Efficacy of antimicrobial therapy in the compromised host : an experimental study

For many years it has been recognized that patients with impaired host defense mechanisms due to hemoproliferative malignancy or its treatment are subject to episodes of fulminating, often lethal bacterial infection. The proper management of these infections is a problem, because antimicrobial agents which are known to be effective in the normal host, lose, at least partially, their efficacy in these patients. Therapeutic failures occur despite the organisms usual sensitivity. As a consequence, the use of combinations of antimicrobial drugs have been recommended for presumptive treatment of these life-threatening infections when the identity and susceptibility of the causative bacteria are unknown. The high risk of infectious complications in these patients may be due to impairment of their defense mechanisms. This in turn is the consequence of the malignant process itself. The immune system and its functions are involved in many aspects of malignancies, especially in hematological malignancies. These each have a characteristic pattern of immunodeficiencies. For example, hematological malignancies may suppress humoral and cellular immunity and cause neutropenia or an impaired neutrophil function. Also the antineoplastic therapy by radiation and/or chemotherapeutic agents, interferes with specific and nonspecific host defense functions.Met het dierexperimenteel onderzoek, beschreven in dit proefschrift, wordt getracht meer inzicht te geven in de relatie tussen afweerfactoren en de werkzaamheid van antibiotica bij het bestrijden van bacteriele infecties. In de klinische geneeskunde wordt men in toenemende mate geconfronteerd met patienten die lijden aan aanwijsbare vormen van weerstandsvermindering, bijvoorbeeld als gevolg van maligniteiten en de behandelingen daarvan (bestraling of chemotherapie). Ernstige infekties komen als gevolg hiervan frekwent voor en hebben niet zelden een fataal verloop omdat de antimicrobiele therapie die werkzaam is bij de normale gastheer, in deze patienten vaak geheel of gedeeltelijk faalt. Verschillende factoren dragen gelijktijdig bij aan de vermindering van de weerstand. Maligniteiten en chemotherapeutische behandelingen kunnen aanleiding geven tot onderdrukking van humorale of cellulaire immuniteit, alsook vermindering van het aantal of de funktie van polymorphonucleaire leukocyten (PMN). Een tweetal vragen komcn naar voren. Ten eerste, in welke mate is de werkzaamheid van een antibioticum therapie afhankelijk van weerstandsfactoren van de gastheer? Ten tweede, kan een verzwaring van het antibioticum therapieschema het gemis aan eigen afweerfactoren geheel of gedeeltelijk compenseren? Omdat de klinische situatie weinig ruimte biedt voor de bestudering van deze vragen, is gekozen voor een dierexperimentele benadering waarbij het mogelijk is weerstandsfactoren selectief weg te nemen. Door middel van de studies beschreven in de hoofdstukken 1-5 proberen wij een bijdrage te leveren aan de beantwoording van deze vragen. Door de keuze van de experimentele infecties, veroorzaakt door Streptococcus pneumoniae of Listeria monocytogenes, was het mogelijk de relatieve betekenis van afweerfactoren afzonderlijk voor de werkzaarnheid van antibiotica te bestudere

Enhanced localization of liposomes with prolonged blood circulation time in infected lung tissue

Abstract In an experimental model of unilateral pneumonia caused by Klebsiella pneumoniea in rats we investigated whether intravenous administration of liposomes with prolonged blood circulation time resulted in significant localization of liosomes in infected lung tissu. Liposomes (100 nm) composed of hydrogenated phosphatidylinositol:hydrogenated phosphatidylcholine:cholesterol (mola ratio, 1:10:5) radiolabeled with gallium-67-deferoxamine showed relatively long blood circulation time. The degree of localization of these long circulating liposomes in the infected lef lung was significantly higher compared to that of localization of 110 nm egg phosphatidylglycerol:egg phosphatidylcholine:cholesterol (molar ratio, 1:10:5) liposomes which exhibited relatively short blood circulation time. At 16 h after administration of the long circulating liposomes (when 10% of the injected dose was still present in the bloodstream) localization of liposomes in the infected left lung was increased up to 10-fold compared to the left lung of uninfected rats, and appeared to be highly correlated with the intensity of the infection. In the uninfected right lung the localization of long circulating liposomes was not increased. The degree of localization of liposomes in the infected tissue is dependent on the residence time of liposomes in the blood compartment. The extent of localization of long circulating liposomes in infected tissue appeared to be dependent on the liposomal dose administered

Liposomes as delivery systems in the prevention and treatment of infectious diseases

Research on the potential application of liposomes in the prevention and treatment of infectious diseases has focussed on improvement of the therapeutic index of antimicrobial drugs and immunomodulators and on stimulation of the immune response to otherwise weak antigens in vaccines composed of purified micro-organism subunits. In this review current approaches in this field are outlined. The improved therapeutic index of antimicrobial drugs after encapsulation in liposomes is a result of enhanced drug delivery to infected tissue or infected cells and/or a reduction of drug toxicity of potentially toxic antibiotics. Liposomal encapsulation of immunomodulators that activate macrophages aims at reducing the toxicity of these agents and targeting them to the cells of the mononuclear phagocyte system in order to increase the nonspecific resistance of the host against infections. Studies on the immunogenicity of liposomal antigens have demonstrated that liposomes can potentiate the humoral and cell mediated immunity to a variety of antigens

Administration of liposomal agents and blood clearance capacity of the mononuclear phagocyte system

As liposomes are cleared from the circulation to a substantial extent by the phagocytic cells of the mononuclear phagocyte system (MPS), there is a question whether administration of liposome-based therapeutic agents interferes with clearance of infectious organisms by the MPS from blood. In the present study, at first the effect of administration of three types of empty liposomes (devoid of drug), differing in blood residence time, on carbon clearance and bacterial clearance from blood was studied with mice. Classical liposomes (LIP A) and placebo liposomes with lipid composition as in AmBisome (LIP B) or as in Doxil (LIP C) were used. Liposomes were administered intravenously as a single dose. Second, the effect of multiple-dose administration of AmBisome on bacterial blood clearance was studied with rats. AmBisome was administered with two different dosage schedules. The blood clearance capacity of the MPS was monitored at different time points after the last liposome injection. It was shown that the carbon blood clearance capacity of the MPS was impaired only at a high lipid dose of empty classical liposomes. The bacterial blood clearance capacity was never impaired, not even after prolonged treatment with AmBisome administered in a clinically relevant regimen

Mild Staphylococcus aureus skin infection improves the course of subsequent endogenous S. aureus bacteremia in mice

Staphylococcus aureus carriers with S. aureus bacteremia may have a reduced mortality risk compared to non-carriers. A role for the immune system is suggested. Here, we study in mice the effect of mild S. aureus skin infection prior to endogenous or exogenous S. aureus bacteremia, and evaluate protection in relation to anti-staphylococcal antibody levels. Skin infections once or twice by a clinical S. aureus isolate (isolate P) or S. aureus strain 8325-4 were induced in mice free of S. aureus and anti-staphylococcal antibodies. Five weeks later, immunoglobulin G (IgG) levels in blood against 25 S. aureus antigens were determined, and LD50 or LD100 bacteremia caused by S. aureus isolate P was induced. S. aureus skin infections led to elevated levels of anti-staphylococcal IgG in blood. One skin infection improved the course of subsequent severe endogenous bacteremia only. A second skin infection further improved animal survival rate, which was associated with increased pre-bacteremia IgG levels against Efb, IsaA, LukD, LukE, Nuc, PrsA and WTA. In conclusion, S. aureus isolate P skin infection in mice reduces the severity of subsequent endogenous S. aureus bacteremia only. Although cellular immune effects cannot be rules out, anti-staphylococcal IgG against specified antigens may contribute to this effect

Liposomal amphotericin B (AmBisome) reduces dissemination of infection as compared with amphotericin B deoxycholate (Fungizone) in a rate model of pulmonary aspergillosis

The efficacy of AmBisome, a liposomal formulation of amphotericin B, was compared with that of Fungizone (amphotericin B desoxycholate), in a rat model of unilateral, pulmonary aspergillosis. Repeated administration of cyclophosphamide resulted in persistent, severe granulocytopenia. The left lung was inoculated with a conidial suspension of Aspergillus fumigatus, thus establishing an unilateral infection. Antifungal treatment was started 40 h after fungal inoculation, at which time mycelial disease was confirmed by histological examination. Both Fungizone 1 mg/kg and AmBisome 10 mg/kg resulted in increased survival in terms of delayed as well as reduced mortality. Quantitative cultures of lung tissue showed that only AmBisome 10 mg/kg resulted in reduction of the number of fungal cfus in the inoculated left lung. Compared with Fungizone, both AmBisome 1 mg/kg/day and AmBisome 10 mg/kg/day significantly prevented dissemination from the infected left lung to the right lung. In addition, both AmBisome regimens reduced hepatosplenic dissemination, and the 10 m/kg dosage fully prevented this complication. In conclusion, when compared with Fungizone, in this model AmBisome is more effective in reducing dissemination of unilateral, pulmonary aspergillosis, even when given in relatively low dosage. Such low dosages may have a place in prophylactic settings

Sterically stabilized amphotericin B-liposomes: Toxicity and biodistribution in mice

In this study it was investigated whether long-circulating amphotericin B (AMB) containing liposomes could be prepared by incorporation of polyethylene glycol (1900) derivatized distearoylphosphatidylethanolamine (PEG-DSPE), and whether the incorporation of PEG-DSPE affected toxicity and biodistribution of the preparation in mice. Toxicity of two formulations of liposomes containing both PEG-DSPE and AMB (PEG-AMB-LIP, types 1 and 2) was compared with that of AMB-liposomes without PEG-DSPE (AMB-LIP) as well as that of MB-deoxycholate (AMB-DOC). The maximum tolerated dosage (MTD) of AMB-DOC, expressed in terms of death during treatment for 5 consecutive days or significant increases in the parameters used to monitor renal and hepatic functions, was 0.8 mg/kg per day. AMB-LIP were the least toxic, the MTD being 11 mg/kg per day. The formulation with AMB complexed to DSPG (PEG-AMB-LIP type 1) was as toxic as AMB-DOC. This PEG-AMB-LIP formulation was omitted from further studies on biodistribution. With AMB complexed to PEG-DSPE (PEG-AMB-LIP type 2) toxicity was substantially reduced, resulting in a MTD of 9 mg/kg per day. Biodistribution of radiolabeled PEG-AMB-LIP type 2 was compared with that of AMB-LIP. Blood residence time of PEG-AMB-LIP type 2 was prolonged as compared to AMB-LIP; For PEG-AMB-LIP type 2 at 24 h after administration 30% of the injected dosage of AMB in intact liposomes was circulating versus 6% for AMB-LIP

Involvement of T cells in enhanced resistance to Klebsiella pneumoniae septicemia in mice treated with liposome-encapsulated muramyl tripeptide phosphatidylethanolamine or gamma interferon

We have previously shown that prophylactic administration of the liposome-encapsulated immunomodulating agents muramyl tripeptide phosphatidylethanolamine (MTPPE) and gamma interferon (IFN-gamma) results in strongly increased survival of mice from a normally lethal septicemia with Klebsiella pneumoniae. It was anticipated that the treatment acts on macrophages and nonspecifically augments host resistance to various infections. In the present study, we provide evidence for a key role for T cells in host defense potentiation by the liposomal immunomodulators toward K. pneumoniae septicemia. It is shown that both CD4 and CD8 cells are important in immunomodulation, most likely due to production of IFN-gamma. Depletion of circulating IFN-gamma resulted in strong reduction of the antimicrobial host defense activation. Administration of interleukin-10 resulted in decreased antimicrobial host defense activation by liposomal immunomodulators. Moreover, administration of liposomal immunomodulators was shown to induce predominantly T-helper type 1 (Th1) cell populations in the spleen. These findings indicate that immunomodulation with liposomal MTPPE and IFN-gamma favors Th1 and NK cell activation