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A RESEARCH REPORT SUBMITTED TO THE FACULTY OF HEALTH SCIENCES, UNIVERSITY OF WITWATERSRAND, JOHANNESBURG, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PHARMACY IN CLINICAL PHARMACY 2004 / The purpose of the study was to evaluate the use of cefotaxime with the idea of improving its use within the hospital. Improving the use of cefotaxime could result in a change in the proportion spent from the pharmacy budget. More importantly a change in prescribing patterns of this drug could also result in a reduction in resistant patterns of cefotaxime. / IT2018

A 27-year-old Peruvian woman living with human immunodeficiency virus (HIV) in clinical stage B3 and not on antiretroviral therapy presented with a ten-day history of fever, chills, night sweats and a two-day history of skin lesions. On physical examination, several erythematous-purplish lesions were found on the face and legs. Meningococcal infection was suspected and ceftriaxone was started. Blood culture grew nontyphoidal Salmonella enterica. A biopsy of the skin lesions showed leukocytoclastic vasculitis (LCV); therefore, corticosteroids were added. After two weeks of antibiotic and corticosteroid treatment, the lesions had resolved, but they recurred two days after treatment with prednisone was stopped. Corticosteroids and combination antiretroviral therapy were started simultaneously and the lesions resolved without recurrence. HIV infection has been associated with higher rates of skin lesions in salmonellosis. LCV has been described both in the setting of HIV infection and salmonellosis. However, our review of the literature found no previous cases of LCV in concurrent HIV and salmonellosis. / Revisión por pares / Revisión por pares

Antibiotic resistance is one of the most serious medical problems in the world. To counteract the increase in antibiotic resistance, new rapid and effective analytical methods are needed. To effectively treat infections in critically ill patients, optimal antibiotic dosages are required. DrugLog® is an instrument that uses a spectrophotometric method to analyze antibiotics in plasma in the wavelength range 200-800 nm. The aim of this study was to do a method validation of the instrument DrugLog®.     The study material that was used was whole blood from healthy donor and routine citrate plasma samples from the laboratory. The precision of the method and stability of plasma, the best way to filtrate lipids from plasma and four antibiotics (meropenem, cefotaxime, vancomycin, piperacillin/tazobactam) were investigated.     The precision of the method, measured as CV% was less than 0.62 and stability plasma showed a CV% of 135.74 after 24 h in room temperature. The stability for the different antibiotics after 24 h in room temperature showed a CV% of 8.11 for meropenem, 40.80 for vancomycin, 16.55 for cefotaxime and 2.92 for the combination antibiotic piperacillin/tazobactam. It was also determined that bacterial filter was the best way to remove lipids from plasma.     In conclusion DrugLog® is a suitable instrument to analyze concentration of antibiotics in patients during antibiotic treatment, however further validations are needed.

Pour exercer leur effet princeps, les médicaments doivent atteindre des concentrations nécessaires et suffisantes à leur site d'action tout en évitant la survenue d'effets indésirables. Les antibiotiques sont utilisés pour le traitement d'infection cérébroméningées dont la cible bactériologique se situe dans le liquide céphalorachidien (LCR) ou le liquide extracellulaire cérébral (LEC) un site d'action cérébral qui constitue aussi une cible pour des effets secondaires. La distribution de médicament dans le cerveau et le LCR est limitée par la présence des barrières hémato-encéphalique (BHE) et hématoliquidienne (BHL). De plus, des mécanismes d'efflux diminuent les concentrations tissulaires des médicaments. Pour optimiser l'usage des antibiotiques et diminuer les effets indésirables, il est important d'obtenir des informations pharmacocinétiques tissulaires. Le recueil de LEC par microdialyse cérébrale et le prélèvement de LCR permettent chez des patients de réanimation la comparaison des concentrations libres de médicament. Ce travail constitue une étude de la distribution dans le plasma, le LCR et le LEC de deux antibiotiques : le céfotaxime et le métronidazole. Des patients (après un traumatisme crânien ou un accident vasculaire) ont été traités par céfotaxime et métronidazole pour une pneumopathie. Quatre études pharmacocinétiques ont été réalisées à l'équilibre par microdialyse cérébrale (n=11) pour le recueil du LEC ou par prélèvement de LCR (n=9) par une dérivation ventriculaire externe. Les résultats ont montré que le métronidazole diffusait totalement dans les deux milieux alors que la diffusion du céfotaxime était limitée, probablement en raison de phénomènes d'efflux. / To exert their effect while avoiding adverse events, drugs must reach sufficient concentrations in their site of action. Antibiotics are used for treating infection that bacterial target is in the cerebrospinal fluid (CSF) or brain extracellular fluid (ECF) which is also a target for adverse events. Drug distribution in the brain and CSF may be limited by the presence of the blood-brain barrier (BBB) and blood-CSF barrier (BCSFB). In addition, efflux mechanisms may decrease tissue concentrations of drugs.To optimize the use of antibiotics and reduce adverse events, it is important to obtain tissue pharmacokinetics. Collecting ECF samples via brain microdialysis and CSF samples via external ventricular drain in critically ill patients allow comparison of free drug concentrations. This work is a study of the distribution in plasma, CSF and ECF of two antibiotics, cefotaxime and metronidazole.Patients (after a head injury or stroke) were treated with cefotaxime and metronidazole for pneumonia. Four pharmacokinetic studies were performed at equilibrium by brain microdialysis (n = 11) for collecting ECF or CSF samples (n = 9) by an external ventricular drain. The results showed that metronidazole distributes extensively in both ECF and CSF while the diffusion of cefotaxime was limited, probably due to efflux transporters.

TEM and SHV β-lactamases are the most prevalent β-lactamases among Gram-negative bacteria. The introduction and widespread use of expanded-spectrum antibiotics, particularly third generation cephalosporins, has led to the evolution of bacterial strains expressing extended spectrum β-lactamases (ESBLs). ESBLs emerge by genetic point mutation from non-extended spectrum precursors. It was found that multiple β-lactamase families within single isolates complicate the process of detecting the resistance status of isolate using non-quantitative DNA diagnostic methods. Preliminary phenotypic characterisation of probable β-lactamase enzyme family types present in 100 isolates from the Asia-Pacific and South African locales showed that single isolates frequently contained multiple β-lactamase families. SHV, TEM, AMPC and CTX-M β-lactamase families were detected in these isolates using PCR detection methods. Ninety-eight percent of all isolates tested contained as least one β-lactamase gene, with up to four to β-lactamase gene families found to co-exist in single isolates. Kinetic PCR methods for interrogating the polymorphic sites at blaSHV codons 238 & 240 and blaTEM codons 164, 238, 240 as well as promoter polymorphism were developed. A high proportion of blaSHV 238 and 240 mutant alleles was found to correlate with cefotaxime, ceftazidime and aztreonam resistance levels. In an attempt to understand the molecular basis for the co-existence of multiple blaSHV alleles within single isolates, the blaSHV promoter region was cloned from one ESBL expressing isolate. Experimental results showed that blaSHV can exist downstream of two different promoters within a single isolate. Both promoters have previously been reported, and differ by the presence or absence of IS26, which results in a change in the transcription initiation site. The blaSHV gene copy numbers in cis with the different promoters were measured, and it was found that the copy number of the IS26::blaSHV promoter was positively correlated with resistance levels. Cloning and analysis of PCR products showed that different blaSHV variants existed in cis with promoters in individual isolates. However, mutant genes were more abundant downstream of the IS26 promoter. There were no ESBL+ isolates without this promoter. It was concluded that blaSHV in cis with the IS26 promoter is located on an amplifiable replicon, and the presence of the IS26 insertion may facilitate the acquisition of an ESBL+ phenotype. To further confirm the role of IS26 in resistance acquisition, ESBL negative isolates were subjected to serial passage in vitro evolution experiments and fluctuation assays. Results confirm that the insertion of the IS26 element upstream of blaSHV is positively correlated with the ability to exhibit an ESBL phenotype, when such isolates also contain the critical G238S substitution. It was also found that IS26 can catalyse the duplication and mobilisation of blaSHV within an isolate. Fluctuation experiments have shown that the frequency at which such genomic events occur resulting in ESBL phenotypes is extremely low and requires many generations of selection under sub-lethal conditions. A survey of a geographically diverse set of isolates has shown that IS26-blaSHV was found in all of the bacterial populations surveyed. However, it does not appear to be exclusively associated with SHV-mediated ESBL production.

Le développement des méthodes de séquençage de nouvelle génération a permis d’approfondir les connaissances sur le rôle des communautés bactériennes commensales pour la santé de leur hôte, et l’impact négatif de la perturbation de leur équilibre. Les antibiotiques sont les principaux perturbateurs de cet équilibre, mais leur impact n’a pas été quantifié précisément.Nous avons quantifié la relation entre les concentrations fécales d’antibiotiques et la perturbation de la diversité bactérienne au sein du microbiote intestinal, et modélisé le lien entre la perte de diversité bactérienne et la probabilité de décès dans un modèle animal de colite à Clostridium difficile induite par les antibiotiques. Nous avons montré que l’indice de diversité de Shannon et la distance UniFac non pondérée étaient les indices de diversité qui étaient le plus prédictif du décès dans ce modèle d’infection.Chez des volontaires sains, nous avons développé un modèle mathématique semimécanistique de l’évolution de la diversité au sein du microbiote, mesurée par deux indices de diversité, après perturbation antibiotique, et quantifié la relation entre l’exposition individuelle plasmatique et fécale à un antibiotique, et son effet sur la perturbation de la diversité bactérienne au cours du temps. Nous avons également analysé le rôle de la voie d’élimination des antibiotiques pour la limitation de l’impact d’un antibiotique sur le microbiote. Ces travaux nous ont permis de montrer que le microbiote intestinal présente une grande sensibilité aux antibiotiques, et que la voie d’élimination ne semble de ce fait pas jouer un rôle prépondérant dans la perspective de limiter l’impact des antibiotiques sur le microbiote intestinal. / The development of next generation sequencing broadened our knowledge on the role of commensal bacterial communities on their host’s health, and the negative impact of their disruption. Antibiotics are the main disrupting factor, but their impact has not been precisely quantified.We quantified the relationship between antibiotic fecal concentrations and the loss of bacterial diversity in the intestinal microbiota, and modelled the link between the loss of diversity and mortality in a hamster model of antibiotic-induced Clostridium difficile infection. We showed that the Shannon diversity index and the unweighted UniFrac distance are the 2 indices that best predict mortality in this model. In healthy volunteers, we developed a semi-mechanistic model of the evolution over time of bacterial diversity – measured by two indices – after an antibiotic perturbation, and quantified the relationship between antibiotic concentrations in plasma and feces and the loss of bacterial diversity in the intestinal microbiota. We also analyzed the role of the antibiotic elimination pathway in the reduction of their impact on the microbiota. In this work, we showed that the intestinal microbiota is highly susceptible to antibiotics, and that the elimination route doesn’t have a major role, in the perspective of limiting antibiotics’ impact on the intestinal microbiota.

Infections in critically ill patients are a problem for the healthcare system and at any one time, 70 % of all intensive care unit (ICU) patients are treated with antibiotics. Antibiotics bind toproteins in the blood, but only unbound drug can diffuse over capillary membranes and bindto the targeted receptor. Standard protein binding percentages for antibiotics have been developed from studies on healthy volunteers and dosing regimens for patients are adapted accordingly. The determination of the total concentration of antibiotics in patients’ bloodsamples is, based on the standard percentages, ordinarily representative for the pharmacological effect of the antibiotic. However, certain conditions that are common incritically ill patients can alter protein binding percentages, resulting in a larger or smaller unbound fraction. This in turn can result in toxicity or therapeutic failure. The aim of this project was to develop an analytical method for the determination of the unbound concentration of the Beta-Lactam antibiotics cefotaxime, flucloxacillin, cloxacillin and piperacillin in plasma. A method was successfully developed using ultrafiltration for the extraction of unbound analytes and ultra high performance liquid chromatography tandem mass spectrometry, UHPLC-MS/MS, for their quantification. The method was partly validated according to the European Medicines Agency’s guidelines on bioanalytical method validation. / Kritiskt sjuka patienter med infektioner är en börda för sjukvården och 70 % av alla patienter på intensivvårdsavdelningar är ordinerade antibiotika. Antibiotika binder till proteiner i blodet, men enbart den icke-proteinbundna (fria) fraktionen kan diffundera över kapillära membran och binda till receptorer. Standardproteinbindningsgrad för olika antibiotika har utvecklats från studier på friska frivilliga och doseringen av läkemedlen är anpassade därefter. Den totala koncentrationen av antibiotika i patienters blod är vanligen representativ för den farmakologiska effekten. Dock kan vissa sjukdomar påverka proteinbindningsgraden vilket resulterar i en större eller mindre mängd fria antibiotika i blodcirkulationen. Det här kan i sintur resultera i toxicitet eller otillräcklig effekt av läkemedlet. Syftet med det här projektet var att utveckla en analytisk metod för att bestämma den fria koncentrationen av Beta-Lactam antibiotikan cefotaxim, flukloxacillin, kloxacillin och piperacillin i plasma. En metod utvecklades med ultrafiltrering för extraktion av den fria fraktionen och högupplösande vätskekromatografi och tandem masspektrometri, UHPLCMS/MS, för kvantifiering av analyterna. Metoden validerades delvis enligt den Europeiska Läkemedelsmyndighetens riktlinjer för bioanalytisk metodvalidering.

A transformação genética possibilita a introdução de genes de interesse nos genomas, podendo assim ser empregada na tentativa de melhorar características agronômicas e florestais. No entanto, para a obtenção de plantas transgênicas são necessários protocolos eficientes de regeneração de plantas in vitro. Em teca, dados sobre cultura de tecidos são escassos, havendo a necessidade de determinar condições ótimas para a mesma. Com isso, o trabalho teve por objetivos estudar a organogênese in vitro de teca visando desenvolver um método de regeneração eficiente, avaliar condições para o processo de transformação e testar a susceptibilidade da lagarta Hyblaea puera a toxinas produzidas pelo Bacillus thuringiensis. Foram avaliadas a influência de TDZ e BAP na indução da competência organogenética em hipocótilos, nó cotiledonar e cotilédones de teca. Os biorreguladores AIB, BAP, NAA e GA3 foram utilizados na regeneração de segmentos de hipocótilo, nó cotiledonar, raiz, epicótilo e cotilédone. Antibióticos supressores de Agrobacterium tumefaciens e a higromicina (seleção de células transgênicas), foram também avaliados. Finalmente, testes com o inseticida biológico DipelTM e esporos de B. thuringiensis crescidos em laboratório foram realizados com as lagartas de Hyblaea puera. Na aquisição de competência organogenética o TDZ proporcionou um aumento de 46% na regeneração e o BAP 26% quando comparados ao controle. Para a organogênese in vitro foi avaliado um máximo de 70% de regeneração em nó cotiledonares em meio MS adicionado de 1 mg.L-1 de BAP + 0,5 mg.L-1 de GA3. Entretanto, em outras concentrações dos meios de regeneração hipocótilos, raiz, cotilédones e epicótilos tiveram máximas frequências de regeneração em torno de 60%, 60%, 30% e 10%, respectivamente. Os antibióticos supressores da Agrobacterium tumefaciens tiveram efeitos diferentes para cada explante. Timentin e cefotaxima na concentração de 300 mg.L-1 aumentaram o número de brotos em hipocótilos e nó cotiledonar em 1,6 e 2,0 vezes, respectivamente. Em cotilédone esses antibióticos tiveram efeitos negativos no número de brotos. Carbenicilina em todas as doses influenciou negativamente a regeneração em todos os explantes utilizados. A higromicina a 2,5 mg.L-1 inibe em 100% a regeneração de cotilédones, nó cotiledonar e hipocótilo. Os ínstares mais novos de H. puera são susceptíveis tanto ao produto comercial DipelTM quanto aos esporos crescidos em laboratório, apresentando 100% de mortalidade a concentrações de 2x105 UFC após 24 horas de ingestão. Mostrando assim seu potencial na transgenia visando à expressão de genes de Bt para a resistência a insetos. Os resultados apresentados nesse trabalho contribuem para o ganho de informação sobre os fatores que influenciam a organogênese desta espécie, bem como, definir parâmetros que possam ser utilizados em experimentos futuros visando à transformação genética da espécie. / Genetic transformation allows the introduction of genes in host genomes and can therefore be used to improve forestry and agronomic traits like insect resistence. However, efficient plant regeneration protocols are necessary to obtain transgenic plants. Thus far, information about in vitro teak (Tectona grandis L. f) organogenesis is scarce. Therefore, the aims of this study were: develop an efficient protocol for in vitro organogenesis of teak, assess conditions for its genetic transformation and test the susceptibility of the caterpillar Hyblaea puera to toxins produced by Bacillus thuringiensis. We evaluated the influence of TDZ and BAP on the induction of organogenic competence in hypocotyl, cotyledonary nodes and cotyledons. Growth regulators IBA, BAP, NAA and GA3 were used in the regeneration of the hypocotyl, cotyledonary node, root, epicotyl and cotyledon. Antibiotics for suppression of Agrobacterium tumefacien (timentin, cefotaxime and carbenicillin) and for selection of transgenic cells (hygromycin) were also evaluated. Finally, tests with the biological insecticide DipelTM and spores of B. thuringiensis grown in laboratory were performed with the caterpillar of Hyblaea puera. TDZ increases 46% the regeneration frequency and BAP 26% when compared to controls. Cotyledonary nodes showed the best regeneration frequency (70%) growing on MS medium added of 1 mg.L-1 BAP + 0.5 mg.L-1 GA3. Hypocotyls, roots, cotyledons and epicotyls presented variable frequency of regeneration (60%, 60%, 30%, and 10% respectively) growing on distinct concentrations of grown regulators. We tested three antibiotics (timentin, cefotaxime, and carbenicillin) to suppress A. tumefaciens in vitro growth and they presented different effects on the organogenesis of each explants used in this study. Timentin and cefotaxime at concentration of 300 mg.L-1 increased the number of buds on hypocotyls and cotyledonary nodes. Conversely, these antibiotics had negative effects on the number of shoots of cotyledonary explants. Carbenicillin at all doses presented a negative influence on regeneration of all explants. Hygromycin at concentration of 2.5 mg.L-1 inhibits 100% of regeneration of cotyledons, cotyledonary nodes, and hypocotyls. The young instars of H. puera are susceptible to likely both commercial product DipelTM and spores grown in the laboratory, presented 100% mortality at concentrations of 2x105 CFU after 24 hours of ingestion. These findings suggest its potential to be used in teak transgenic approaches for insect resistance. Our results contribute to information about factors that influence the organogenesis of this specie, as well as define parameters that can be used in future experiments aimed at the genetic transformation of the specie.

A transformação genética possibilita a introdução de genes de interesse nos genomas, podendo assim ser empregada na tentativa de melhorar características agronômicas e florestais. No entanto, para a obtenção de plantas transgênicas são necessários protocolos eficientes de regeneração de plantas in vitro. Em teca, dados sobre cultura de tecidos são escassos, havendo a necessidade de determinar condições ótimas para a mesma. Com isso, o trabalho teve por objetivos estudar a organogênese in vitro de teca visando desenvolver um método de regeneração eficiente, avaliar condições para o processo de transformação e testar a susceptibilidade da lagarta Hyblaea puera a toxinas produzidas pelo Bacillus thuringiensis. Foram avaliadas a influência de TDZ e BAP na indução da competência organogenética em hipocótilos, nó cotiledonar e cotilédones de teca. Os biorreguladores AIB, BAP, NAA e GA3 foram utilizados na regeneração de segmentos de hipocótilo, nó cotiledonar, raiz, epicótilo e cotilédone. Antibióticos supressores de Agrobacterium tumefaciens e a higromicina (seleção de células transgênicas), foram também avaliados. Finalmente, testes com o inseticida biológico DipelTM e esporos de B. thuringiensis crescidos em laboratório foram realizados com as lagartas de Hyblaea puera. Na aquisição de competência organogenética o TDZ proporcionou um aumento de 46% na regeneração e o BAP 26% quando comparados ao controle. Para a organogênese in vitro foi avaliado um máximo de 70% de regeneração em nó cotiledonares em meio MS adicionado de 1 mg.L-1 de BAP + 0,5 mg.L-1 de GA3. Entretanto, em outras concentrações dos meios de regeneração hipocótilos, raiz, cotilédones e epicótilos tiveram máximas frequências de regeneração em torno de 60%, 60%, 30% e 10%, respectivamente. Os antibióticos supressores da Agrobacterium tumefaciens tiveram efeitos diferentes para cada explante. Timentin e cefotaxima na concentração de 300 mg.L-1 aumentaram o número de brotos em hipocótilos e nó cotiledonar em 1,6 e 2,0 vezes, respectivamente. Em cotilédone esses antibióticos tiveram efeitos negativos no número de brotos. Carbenicilina em todas as doses influenciou negativamente a regeneração em todos os explantes utilizados. A higromicina a 2,5 mg.L-1 inibe em 100% a regeneração de cotilédones, nó cotiledonar e hipocótilo. Os ínstares mais novos de H. puera são susceptíveis tanto ao produto comercial DipelTM quanto aos esporos crescidos em laboratório, apresentando 100% de mortalidade a concentrações de 2x105 UFC após 24 horas de ingestão. Mostrando assim seu potencial na transgenia visando à expressão de genes de Bt para a resistência a insetos. Os resultados apresentados nesse trabalho contribuem para o ganho de informação sobre os fatores que influenciam a organogênese desta espécie, bem como, definir parâmetros que possam ser utilizados em experimentos futuros visando à transformação genética da espécie. / Genetic transformation allows the introduction of genes in host genomes and can therefore be used to improve forestry and agronomic traits like insect resistence. However, efficient plant regeneration protocols are necessary to obtain transgenic plants. Thus far, information about in vitro teak (Tectona grandis L. f) organogenesis is scarce. Therefore, the aims of this study were: develop an efficient protocol for in vitro organogenesis of teak, assess conditions for its genetic transformation and test the susceptibility of the caterpillar Hyblaea puera to toxins produced by Bacillus thuringiensis. We evaluated the influence of TDZ and BAP on the induction of organogenic competence in hypocotyl, cotyledonary nodes and cotyledons. Growth regulators IBA, BAP, NAA and GA3 were used in the regeneration of the hypocotyl, cotyledonary node, root, epicotyl and cotyledon. Antibiotics for suppression of Agrobacterium tumefacien (timentin, cefotaxime and carbenicillin) and for selection of transgenic cells (hygromycin) were also evaluated. Finally, tests with the biological insecticide DipelTM and spores of B. thuringiensis grown in laboratory were performed with the caterpillar of Hyblaea puera. TDZ increases 46% the regeneration frequency and BAP 26% when compared to controls. Cotyledonary nodes showed the best regeneration frequency (70%) growing on MS medium added of 1 mg.L-1 BAP + 0.5 mg.L-1 GA3. Hypocotyls, roots, cotyledons and epicotyls presented variable frequency of regeneration (60%, 60%, 30%, and 10% respectively) growing on distinct concentrations of grown regulators. We tested three antibiotics (timentin, cefotaxime, and carbenicillin) to suppress A. tumefaciens in vitro growth and they presented different effects on the organogenesis of each explants used in this study. Timentin and cefotaxime at concentration of 300 mg.L-1 increased the number of buds on hypocotyls and cotyledonary nodes. Conversely, these antibiotics had negative effects on the number of shoots of cotyledonary explants. Carbenicillin at all doses presented a negative influence on regeneration of all explants. Hygromycin at concentration of 2.5 mg.L-1 inhibits 100% of regeneration of cotyledons, cotyledonary nodes, and hypocotyls. The young instars of H. puera are susceptible to likely both commercial product DipelTM and spores grown in the laboratory, presented 100% mortality at concentrations of 2x105 CFU after 24 hours of ingestion. These findings suggest its potential to be used in teak transgenic approaches for insect resistance. Our results contribute to information about factors that influence the organogenesis of this specie, as well as define parameters that can be used in future experiments aimed at the genetic transformation of the specie.