JID 1990;162 (October)
Correspondence
Safety of Immune Globulin Preparations with Regard to Human Immunodeficiency Virus
Reprints or correspondence: Dr. Michael B. Rodell, Armour Pharmaceutical Company, 920A Harvest Dr., Suite 200, Blue Bell, PA 19422. The Journal of Infectious Diseases 1990;162:997 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0041$01.00
Enhancement of Coxsackievirus B3 Replication in Vero Cells by Indomethacin COLLEAGUES-Indomethacin has been shown, in a murine model, to increase coxsackievirus B3 (CB3) titers in the heart (104.78 ± 0.71 vs. 10 3.4 ± 0.35 TCID 50 ) , enhance mortality (4/15 vs, 0/34), and increase the incidence of severe myocarditis (46.7% vs. 3.2 %) [1]. The basis for this augmentation of CB3 virulence has not been elucidated. One possible mechanism is that indomethacin may stimulate virus replication leading to higher viral titers and worsening of virusinduced tissue damage. This hypothesis is supported by the findings of Walz-Cicconi and Weller [2], who reported similar effects of salicylates on varicella zoster replication. We examined this hypothesis by evaluating the effects of indomethacin on CB3 growth in Vero cell monolayers. Indomethacin was obtained from Merck Sharp & Dohme (West Point, PA) in powder form and prepared in suspension as previously described [1]. Briefly, it was diluted in distilled water (37.5 mg of indomethacin in 5 ml of water) and added to 6.75 ml of water containing 12 mg of sodium carbonate. The suspension was then agitated for 10 min, diluted 1:100 in distilled water, and filtered through
Reprints or correspondence: Dr. Riad Khatib, Grace Hospital, 18700 Meyers Road, Detroit, MI 48235. The Journal of Infectious Diseases 1990;162:997-998 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0042$01.00
The Cohn process is designed to concentrate IgG antibodies present in a plasma pool; the efficacy of immune globulins depends on this. The presence of anti-HIV in immune globulins, even if such products are derived from units of plasma shown negative for this marker, can occur if a sufficient number of units contain levels of anti-HIV below the detection capability of test reagents. The antibody concentration inherent in the fractionation process could also concentrate circulating anti-HIV. However, the presence of anti-HIV in globulins, if it does occur, should not be equated with any potential for the transmission ofHIV itself. Furthermore, it is our understanding that test reagents for the determination of anti-HIV are intended for use in testing of plasma or serum samples; they are not calibrated for final product testing, since qualified product-based positive and negative controls do not exist.
Michael B. Rodell and Garrett E. Bergman Armour Pharmaceutical Company, Blue Bell, Pennsylvania
References 1. Hausler WJ Jr, Swack NS, Ramirez MT. Additional commercial gammaglobulin preparations found with antibody to human immunodeficiency virus. J Infect Dis 1990;161:153 2. Wells MA, Wittek AE, Epstein JS, Marcus-Sekura C, Daniel S, Tankersley DL, Preston MS, Quinnan GV Jr. Inactivation and partition of human T-cell lymphotrophic virus, type III, during ethanol fractionation of plasma. Transfusion 1986;26:210-213
a 0.45-JLm microfilter for sterilization. Drug concentration was then measured spectrophotometrically and found to be O.OOt M. Additional dilutions were made in MEM supplemented with 10% fetal calf serum (FCS) to reach desired concentration. Vero cells (1()4 cells/ml) were planted on 6-well tissue culture plates in MEM supplemented with 10% FCS, with or without indomethacin, at logarithmic concentrations of 10- 4-10-8 M (higher concentrations were found to be toxic to the monolayers). They were incubated at 37°C in 5 % CO 2 for 72 h to allow time for monolayers to be confluent; then medium was discarded and monolayers washed twice with MEM. CB3, Nancy strain, with known passage history [1] was inoculated in quadruplicate at an MOl ofO.OOt and 0.005 (a higher MOl resulted in too many plaques to count). After incubation for 2 h at 37°C, the cells were washed three times and overlaid with MEM supplemented with 5 % FCS and 0.5 % methylcellulose. Plates were then reincubated for 72 h; plaques were then counted and averaged. An enhancement index was calculated by dividing the average number of plaques at a given drug concentration by the average number of plaques in control wells. Any index >2 was considered positive. Table 1 shows the results of these experiments. Indomethacin clearly stimulated CB3 replication in Vero cells. At an MOl of 0.005, the enhancement index was positive in the presence of 10- 5 or 10- 4 M drug. Also, at both concentrations, the number of viral plaques were significantly higher (P < .05, using the rank sum test). At an MOl of O.OOt, indomethacin enhancement was more evident. Thus, the enhancement index was higher and positive at lower drug concentrations. Moreover, the number of plaques was significantly higher
Downloaded from http://jid.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
COLLEAGUES-Hausler et al. [1] reported on determining the presence of antibody to human immunodeficiency virus (anti-HIV) in commercial gammaglobulin preparations. The products they evaluated had been produced in Spain by manufacturers not licensed by the Center for Biologics Evaluation and Research (CBER), US Food and Drug Administration; consequently, materials produced by these manufacturers cannot be distributed in this country. Unstated, and perhaps unknown, by the authors is whether the units of plasma used in the production of these immune globulin preparations had been tested and found negative for anti- HIV before pooling and fractionation. Investigators at CBER previously found [2] that the Cohn alcohol fractionation techniques used by licensed US fractionators in producing immune globulin preparations are capable of removing or inactivating significant quantities of HIV in challenge experiments, thereby rendering these products safe relative to transmission of this virus.
997
998
Correspondence
Table 1. Effects of indomethacin on coxsackievirus B3 replication in Vero cell mono layers. Experiment
2
Indomethacin concentration
(logro M)
0.001
0 10- 7 10- 6 10- 5 10- 4 0 10- 8 10- 7 10- 6 10- 5 10- 4
0.005
Enhancement Viral titers index (mean pfu ± 2 SO) 1.76 2.67 9.34 6.34 13.7 7.25 9.00 10.00 11.00 16.25 32.75
± 0.58 ± 2.51 ± 1.53 ± 0.58 ± 2.1 ± 2.63 ± 2.45 ± 1.42
± 0.00 ± 4.35 ± 7.54
1.5 5.3 3.6 7.8 1.2 1.4 1.5 2.2 4.9
in the presence of 10- 4 , 10-5 , or 10-6 M drug (P < .05 by rank sum test). These findings demonstrated a dose-dependent stimulation of CB3 replication by indomethacin. The mechanism of this enhancement
Ciprofloxacin in the Treatment of Helicobacter pylori in Patients with Gastritis and Peptic Ulcer COLLEAGUEs-Ciprofloxacin and other quinolone antibiotics are highly active against Helicobacter pylori (formerly Campylobacter pylori [il) in vitro [2] with MIC90 ranging from 0.06 to 2.0 ILg/ml for ciprofloxacin. Ciprofloxacin has good tissue penetration [3] and retains moderate activity at acid pH [4]. Despite these potential advantages, preliminary studies using ofloxacin [5], norfloxacin [6], and ciprofloxacin [3, 7] have not demonstrated consistent or longlived eradication of the organism and resistant organisms have developed in some patients. We evaluated the effectiveness of ciprofloxacin in eradicating H. pylori from the gastric antrum in patients with endoscopically documented gastritis or peptic ulceration and tested for the development of quinolone resistance. Twoendoscopic biopsies, taken from the gastric antrum away from any ulcer in patients with endoscopic peptic ulceration or gastritis, were submitted for routine histopathologic examination, culture, and urease slant test. Patients with positive cultures were treated with ciprofloxacin (Miles Pharmaceuticals, West Haven, CT), 500 mg by mouth twice daily for 21 days. Treat-
Presented in part: 29th Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston, September 1989. This study was approved by the University of California, San Francisco, Committee on Human Research; written informed consent was obtained before endoscopy. Grant support: Miles Pharmaceuticals (087-033-01). Reprints or correspondence: Dr. John P. Cello, Gastroenterology 3C-19, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. The Journal of Infectious Diseases 1990;162:998-999 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0043$01.00
is unclear. However, since prostaglandins have been shown to inhibit the replication of many viruses [3], it is possible that indomethacin increases CB3 titers by suppressing prostaglandin synthesis, leading to a lack of prostaglandin inhibition of virus replication. Whatever the mechanism, these findings may at least partly explain the basis for deleterious effects of indomethacin in CB3 murine myocarditis.
Riad Khatib, Milagros :Po Reyes, and Frederick E. Smith Department of Medicine, Grace Hospital and J-Jizyne State University, Detroit, Michigan
References 1. Rezkalla S, Khatib G, Khatib R. Coxsackievirus B3 murine myocarditis. Deleterious effects of nonsteroidal anti-inflammatory agents. J Lab Clin Med 1986;117:393-395 2. Walz-Cicconi MA, Weller TM. Dose-related effect of acetylsalicylic acid on replication of varicella zoster in vitro. Proc Nat! Acad Sci USA 1984;81:5223-5226 3. Santoro MG; Jaffe B, Paez E, Esteban M. The relationship between the antiviral action of interferon and prostaglandins in virus-infected murine cells. Biochem Biophys Res Comrnun 1983;116:442-448
ment with histamine- (Hz) receptor antagonists (i.e., famotidine, 40 mg by mouth daily) was allowed; however, bismuth-containing compounds, other antibiotics, and antacids were avoided. Endoscopy was repeated at the end of antibiotic therapy and 3 weeks later and biopsies were taken from the gastric antrum for histopathologic examination and culture. Part of one biopsy specimen was homogenized in 0.5 ml of sterile saline and plated onto brain-heart infusion (BHI) agar supplemented with 7 % horse blood, 1% isovitex (Difco Laboratories, Detroit), 3 ILglml vancomycin, and 1 pglml amphotericin. The plates were incubated at 37°C in a microaerophilic atmosphere using BBC Campy pack and gas jar (Becton Dickinson, Cockeysville, MD) for 3-5 days. Small gray colonies were tested for urease activity and Gram's reaction. H. pylori were identified as ureasepositive, gram-negative curved rods. Minimum inhibitory concentration for ciprofloxacin was determined by the agar dilution method using BHI supplemented with 7 % horse blood and 1% isovitex. Seventy-six patients with endoscopic gastritis, gastric ulcer, or duodenal ulcer were screened for the presence of H. pylori in antral tissue. Thirty patients (39 %) had positive tissue specimen cultures confirmed by urease production, Gram's reaction, and Giemsa staining. Eight patients with positive cultures were enrolled in the study. Seven patients completed 21 days oftherapy; one completed 14 days (table 1). Three had negative cultures at the completion of 21 days of therapy, but no patient had a negative culture 21 days after therapy was completed although a culture specimen was misplaced for one but histologic examination revealed the presence of H. pylori. MICs for the patients before therapy ranged from 0.12 to 2.0 ILg/ml with an MIC90 of 0.5 JLg/ml. MICs at the end of therapy for five isolates ranged from 4.0 to 16.0 JLg/ml. MICs for six isolates 21 days after the completion oftherapy ranged from 0.25 to 8.0 ILgiml. Three patients had a negative culture and histologic examination for H. pylori at the completion of therapy (21 days) and positive cultures 3 weeks later (42 days). Two patients had a twofold increase in the MIC (one tube dilution) and the other had a fourfold increase in
Downloaded from http://jid.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
MOl
JID 1990;162 (October)
Correspondence
Safety of Immune Globulin Preparations with Regard to Human Immunodeficiency Virus
Reprints or correspondence: Dr. Michael B. Rodell, Armour Pharmaceutical Company, 920A Harvest Dr., Suite 200, Blue Bell, PA 19422. The Journal of Infectious Diseases 1990;162:997 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0041$01.00
Enhancement of Coxsackievirus B3 Replication in Vero Cells by Indomethacin COLLEAGUES-Indomethacin has been shown, in a murine model, to increase coxsackievirus B3 (CB3) titers in the heart (104.78 ± 0.71 vs. 10 3.4 ± 0.35 TCID 50 ) , enhance mortality (4/15 vs, 0/34), and increase the incidence of severe myocarditis (46.7% vs. 3.2 %) [1]. The basis for this augmentation of CB3 virulence has not been elucidated. One possible mechanism is that indomethacin may stimulate virus replication leading to higher viral titers and worsening of virusinduced tissue damage. This hypothesis is supported by the findings of Walz-Cicconi and Weller [2], who reported similar effects of salicylates on varicella zoster replication. We examined this hypothesis by evaluating the effects of indomethacin on CB3 growth in Vero cell monolayers. Indomethacin was obtained from Merck Sharp & Dohme (West Point, PA) in powder form and prepared in suspension as previously described [1]. Briefly, it was diluted in distilled water (37.5 mg of indomethacin in 5 ml of water) and added to 6.75 ml of water containing 12 mg of sodium carbonate. The suspension was then agitated for 10 min, diluted 1:100 in distilled water, and filtered through
Reprints or correspondence: Dr. Riad Khatib, Grace Hospital, 18700 Meyers Road, Detroit, MI 48235. The Journal of Infectious Diseases 1990;162:997-998 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0042$01.00
The Cohn process is designed to concentrate IgG antibodies present in a plasma pool; the efficacy of immune globulins depends on this. The presence of anti-HIV in immune globulins, even if such products are derived from units of plasma shown negative for this marker, can occur if a sufficient number of units contain levels of anti-HIV below the detection capability of test reagents. The antibody concentration inherent in the fractionation process could also concentrate circulating anti-HIV. However, the presence of anti-HIV in globulins, if it does occur, should not be equated with any potential for the transmission ofHIV itself. Furthermore, it is our understanding that test reagents for the determination of anti-HIV are intended for use in testing of plasma or serum samples; they are not calibrated for final product testing, since qualified product-based positive and negative controls do not exist.
Michael B. Rodell and Garrett E. Bergman Armour Pharmaceutical Company, Blue Bell, Pennsylvania
References 1. Hausler WJ Jr, Swack NS, Ramirez MT. Additional commercial gammaglobulin preparations found with antibody to human immunodeficiency virus. J Infect Dis 1990;161:153 2. Wells MA, Wittek AE, Epstein JS, Marcus-Sekura C, Daniel S, Tankersley DL, Preston MS, Quinnan GV Jr. Inactivation and partition of human T-cell lymphotrophic virus, type III, during ethanol fractionation of plasma. Transfusion 1986;26:210-213
a 0.45-JLm microfilter for sterilization. Drug concentration was then measured spectrophotometrically and found to be O.OOt M. Additional dilutions were made in MEM supplemented with 10% fetal calf serum (FCS) to reach desired concentration. Vero cells (1()4 cells/ml) were planted on 6-well tissue culture plates in MEM supplemented with 10% FCS, with or without indomethacin, at logarithmic concentrations of 10- 4-10-8 M (higher concentrations were found to be toxic to the monolayers). They were incubated at 37°C in 5 % CO 2 for 72 h to allow time for monolayers to be confluent; then medium was discarded and monolayers washed twice with MEM. CB3, Nancy strain, with known passage history [1] was inoculated in quadruplicate at an MOl ofO.OOt and 0.005 (a higher MOl resulted in too many plaques to count). After incubation for 2 h at 37°C, the cells were washed three times and overlaid with MEM supplemented with 5 % FCS and 0.5 % methylcellulose. Plates were then reincubated for 72 h; plaques were then counted and averaged. An enhancement index was calculated by dividing the average number of plaques at a given drug concentration by the average number of plaques in control wells. Any index >2 was considered positive. Table 1 shows the results of these experiments. Indomethacin clearly stimulated CB3 replication in Vero cells. At an MOl of 0.005, the enhancement index was positive in the presence of 10- 5 or 10- 4 M drug. Also, at both concentrations, the number of viral plaques were significantly higher (P < .05, using the rank sum test). At an MOl of O.OOt, indomethacin enhancement was more evident. Thus, the enhancement index was higher and positive at lower drug concentrations. Moreover, the number of plaques was significantly higher
Downloaded from http://jid.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
COLLEAGUES-Hausler et al. [1] reported on determining the presence of antibody to human immunodeficiency virus (anti-HIV) in commercial gammaglobulin preparations. The products they evaluated had been produced in Spain by manufacturers not licensed by the Center for Biologics Evaluation and Research (CBER), US Food and Drug Administration; consequently, materials produced by these manufacturers cannot be distributed in this country. Unstated, and perhaps unknown, by the authors is whether the units of plasma used in the production of these immune globulin preparations had been tested and found negative for anti- HIV before pooling and fractionation. Investigators at CBER previously found [2] that the Cohn alcohol fractionation techniques used by licensed US fractionators in producing immune globulin preparations are capable of removing or inactivating significant quantities of HIV in challenge experiments, thereby rendering these products safe relative to transmission of this virus.
997
998
Correspondence
Table 1. Effects of indomethacin on coxsackievirus B3 replication in Vero cell mono layers. Experiment
2
Indomethacin concentration
(logro M)
0.001
0 10- 7 10- 6 10- 5 10- 4 0 10- 8 10- 7 10- 6 10- 5 10- 4
0.005
Enhancement Viral titers index (mean pfu ± 2 SO) 1.76 2.67 9.34 6.34 13.7 7.25 9.00 10.00 11.00 16.25 32.75
± 0.58 ± 2.51 ± 1.53 ± 0.58 ± 2.1 ± 2.63 ± 2.45 ± 1.42
± 0.00 ± 4.35 ± 7.54
1.5 5.3 3.6 7.8 1.2 1.4 1.5 2.2 4.9
in the presence of 10- 4 , 10-5 , or 10-6 M drug (P < .05 by rank sum test). These findings demonstrated a dose-dependent stimulation of CB3 replication by indomethacin. The mechanism of this enhancement
Ciprofloxacin in the Treatment of Helicobacter pylori in Patients with Gastritis and Peptic Ulcer COLLEAGUEs-Ciprofloxacin and other quinolone antibiotics are highly active against Helicobacter pylori (formerly Campylobacter pylori [il) in vitro [2] with MIC90 ranging from 0.06 to 2.0 ILg/ml for ciprofloxacin. Ciprofloxacin has good tissue penetration [3] and retains moderate activity at acid pH [4]. Despite these potential advantages, preliminary studies using ofloxacin [5], norfloxacin [6], and ciprofloxacin [3, 7] have not demonstrated consistent or longlived eradication of the organism and resistant organisms have developed in some patients. We evaluated the effectiveness of ciprofloxacin in eradicating H. pylori from the gastric antrum in patients with endoscopically documented gastritis or peptic ulceration and tested for the development of quinolone resistance. Twoendoscopic biopsies, taken from the gastric antrum away from any ulcer in patients with endoscopic peptic ulceration or gastritis, were submitted for routine histopathologic examination, culture, and urease slant test. Patients with positive cultures were treated with ciprofloxacin (Miles Pharmaceuticals, West Haven, CT), 500 mg by mouth twice daily for 21 days. Treat-
Presented in part: 29th Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston, September 1989. This study was approved by the University of California, San Francisco, Committee on Human Research; written informed consent was obtained before endoscopy. Grant support: Miles Pharmaceuticals (087-033-01). Reprints or correspondence: Dr. John P. Cello, Gastroenterology 3C-19, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. The Journal of Infectious Diseases 1990;162:998-999 © 1990 by The University of Chicago. All rights reserved. 0022-1899/90/6204-0043$01.00
is unclear. However, since prostaglandins have been shown to inhibit the replication of many viruses [3], it is possible that indomethacin increases CB3 titers by suppressing prostaglandin synthesis, leading to a lack of prostaglandin inhibition of virus replication. Whatever the mechanism, these findings may at least partly explain the basis for deleterious effects of indomethacin in CB3 murine myocarditis.
Riad Khatib, Milagros :Po Reyes, and Frederick E. Smith Department of Medicine, Grace Hospital and J-Jizyne State University, Detroit, Michigan
References 1. Rezkalla S, Khatib G, Khatib R. Coxsackievirus B3 murine myocarditis. Deleterious effects of nonsteroidal anti-inflammatory agents. J Lab Clin Med 1986;117:393-395 2. Walz-Cicconi MA, Weller TM. Dose-related effect of acetylsalicylic acid on replication of varicella zoster in vitro. Proc Nat! Acad Sci USA 1984;81:5223-5226 3. Santoro MG; Jaffe B, Paez E, Esteban M. The relationship between the antiviral action of interferon and prostaglandins in virus-infected murine cells. Biochem Biophys Res Comrnun 1983;116:442-448
ment with histamine- (Hz) receptor antagonists (i.e., famotidine, 40 mg by mouth daily) was allowed; however, bismuth-containing compounds, other antibiotics, and antacids were avoided. Endoscopy was repeated at the end of antibiotic therapy and 3 weeks later and biopsies were taken from the gastric antrum for histopathologic examination and culture. Part of one biopsy specimen was homogenized in 0.5 ml of sterile saline and plated onto brain-heart infusion (BHI) agar supplemented with 7 % horse blood, 1% isovitex (Difco Laboratories, Detroit), 3 ILglml vancomycin, and 1 pglml amphotericin. The plates were incubated at 37°C in a microaerophilic atmosphere using BBC Campy pack and gas jar (Becton Dickinson, Cockeysville, MD) for 3-5 days. Small gray colonies were tested for urease activity and Gram's reaction. H. pylori were identified as ureasepositive, gram-negative curved rods. Minimum inhibitory concentration for ciprofloxacin was determined by the agar dilution method using BHI supplemented with 7 % horse blood and 1% isovitex. Seventy-six patients with endoscopic gastritis, gastric ulcer, or duodenal ulcer were screened for the presence of H. pylori in antral tissue. Thirty patients (39 %) had positive tissue specimen cultures confirmed by urease production, Gram's reaction, and Giemsa staining. Eight patients with positive cultures were enrolled in the study. Seven patients completed 21 days oftherapy; one completed 14 days (table 1). Three had negative cultures at the completion of 21 days of therapy, but no patient had a negative culture 21 days after therapy was completed although a culture specimen was misplaced for one but histologic examination revealed the presence of H. pylori. MICs for the patients before therapy ranged from 0.12 to 2.0 ILg/ml with an MIC90 of 0.5 JLg/ml. MICs at the end of therapy for five isolates ranged from 4.0 to 16.0 JLg/ml. MICs for six isolates 21 days after the completion oftherapy ranged from 0.25 to 8.0 ILgiml. Three patients had a negative culture and histologic examination for H. pylori at the completion of therapy (21 days) and positive cultures 3 weeks later (42 days). Two patients had a twofold increase in the MIC (one tube dilution) and the other had a fourfold increase in
Downloaded from http://jid.oxfordjournals.org/ at University of Bath Library & Learning Centre on June 8, 2015
MOl
JID 1990;162 (October)
