The activity in vitro and in vivo of a new imidazole antifungal, ketoconazole.
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Biomedical subjects
Publications and source records attributed to F C Odds.
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The extracellular acid proteinase of Candida albicans was purified from culture filtrates by a single-column chromatographic step. The purity of the enzyme and its unique antigenic properties were confirmed by polyacrylamide-gel electrophoresis and by reaction with homologous and heterologous anti-sera. The purified enzyme (PP), which was a carboxyl proteinase, contained mannan as an integral part of the molecule. C. albicans proteinase was detected in experimental candida kidney lesions by indirect immunoflourescence. Precipitating antibodies to PP and to cytoplasmic extract (CE) were detected in sera from rabbits with chronic, experimental, systemic candidosis; however precipitins to PP were not found in sera from infected rabbits in which tissue invasion was prevented by antifungal treatment. In retrospective tests with sera from healthy subjects and from patients with and without proven systemic candidosis a qualitative distinction between true and false-positive precipitins to PP was not found; however, whereas 72% of sera from proven cases of deep-seated candida infection had anti-PP titres greater than 4 and greater than or equal to anti-CE titres, these same quantitative criteria were met by only 15% of sera from patients for whom information of a diagnosis of candidosis was not available. The purified proteinase was therefore a more specific antigen than the widely used cytoplasmic extract for detection of antibodies in cases of candidosis.
The frequencies of the carriage of yeast pathogens and of serum precipitins to a variety of candida antigens among 254 patients generally tended to increase with the length of the patient's stay in hospital. This trend was observed even though none of the patients investigated showed signs or symptoms of superficial or systemic candidosis. The extent of the general trend varied considerably between subgroups of patients within the general categories of 'surgical' and 'nonsurgical' inpatients. Increases in both frequencies and quantities of yeasts in the mouth were most evident postoperatively among patients who underwent open-heart surgery and among nonsurgical patients who received antibiotics or steroids in hospital. The frequency of precipitins to Candida albicans cytoplasmic antigens in the absence of candidosis rose overall from 11% of 217 sera obtained within 24 hours of admission to 35% of 85 sera obtained five to 11 days after admission or operation. These 'false positive' antibodies were thought to arise after transient yeast overgrowth in the gut at the time of an acute illness or immediately after surgery. The study adds further data to documented examples of 'false positive' candida antibodies and indicates the need for care in the diagnostic interpretation of candida precipitin test results among groups of patients at risk of yeast overgrowth during their hospital stay.
A system of 10 agar plate tests allowed presumptive identification of Candida albicans and differentiation of up to 512 strain types within the species. The yeast isolates were tested for acid and salt tolerance, proteinase production, resistance to 5-fluorocytosine and safranine, and assimilation of urea, sorbose, citrate and glycine. Media were inoculated semiquantitatively with a multiple-pronged device so that 55 yeasts and 5 reference strains could be printed on each plate at once. The results for the 9 strain differentiation tests were arranged in 3 groups to allow simple designation of types by 3-digit numbers. Mouth and vaginal samples from 85 patients and healthy volunteers yielded to 45 different strain types, of which types 153, 157 and 357 were the most prevalent. The reproducibility of the system was good, if attention was paid to the precision which the media were prepared and inoculated. The effect of test variables, including incubation temperature, medium pH and inoculum size, was assessed. Work is presently in progress to extend the system for presumptive identification of other clinically important Candida spp. and differentiation of their strain types.
The end points of tube dilution tests for minimal inhibitory concentrations of miconazole and flucytosine against Candida albicans were difficult to evaluate because partial inhibition was noted over a wide range of antifungal concentrations. This problem was not encountered with amphotericin B. Partial inhibition of Candida arose because of reductions in yeast growth rate and of cell yield. Different sizes of yeast inocula were differentially inhibited by the same concentration of antifungal agent. An in vitro apparatus was described in which miconazole formulated as commercial creams, pessaries and medicated tampons for intravaginal application could be assessed for its inhibitory action in vitro.
The pH reactions, ultraviolet spectra and phosphorus content of solutions of a variety of commercially available peptones all indicated, predictably, considerable differences in the chemical composition of the peptones. The effects of these differences on the outcome of experiments with Candida albicans grown in different peptone media was investigated. The fungus produced germ tubes equally effectively on all such media provided that the inoculum was kept to 10(6) blastospores/ml or less. However, expression of inducible enzyme activities in C. albicans varied extensively from peptone to peptone; there was, for example, an inverse relationship between the inorganic phosphorus content of peptones and the amount of acid phosphomonoesterase detectable in intact blastospores. The results indicated that use of different peptones in "Sabouraud's" media by different laboratories may account for some, but not all, published instances of irreproducibility of experiments with C. albicans.
The prevalence of oral yeasts and humoral precipitating antibodies to candida was estimated in 204 unselected diabetic patients (172 outpatients and 32 inpatients). Yeasts, mainly Candida albicans, were isolated from the mouths of 41% of the outpatients and precipitins were found in 17.5% although none of the patients had clinically overt candidiasis. The extent of oral yeast colonisation and incidence of antibodies was not related to their antidiabetic treatment or to the duration of their diabetes. It was, however, related to the blood glucose and urine sugar levels at the time they were sampled, the highest incidence being among the diabetic inpatients with high blood glucose levels at the time of sampling and the lowest among outpatients with normal blood glucose levels at the time of sampling. There was no such correlation when diabetic control over the previous 12-month period was considered.
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The optimum conditions for detection of Candida precipitins by double diffusion and counter immunoelectrophoresis have been established. Counter immunoelectrophoresis was shown to be more sensitive than double diffusion, and its application to routine tests for Candida precipitins to cytoplasmic antigen is recommended.
A medium that initially produced filaments from almost all of its Candida albicans blastospore inoculum contained 1% mycological peptone and 0.2% glucose, final pH 7.4-7.5. The medium was inoculated to 10-6 cells/ml and incubated at 40 degrees C. Reversion to secondary blastospores began at a mean of 2.4 h after inoculation. The patterns of utilization of growth nutrients during optimal mycelial growth showed no correlation with the events of filamentation.
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The filamentous growth cycle in C. albicans was resistant to changes in environment brought about either by the serial transfer of growing cells to fresh nutrients or by sudden changes of temperature after the first h of growth. In further experiments older culture filtrates, exhausted of their ability to induce mycelial growth, were reactivated by addition of fresh nutrients or water. The data provided evidence against the existence of both a mycelial stimulatory and inhibitory compound in the growth medium. It is concluded that although the environment initially dictates what proportion of blastospores are committed to filamentation it has no further effect on the process.
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The antigenicity of the two growth phases of Candida albicans has been compared by using crossed immunoelectrophoresis and double-diffusion techniques. Qualitative and quantitative differences in antigenic composition between the phases have been revealed and moreover a specific mycelial antigenic component demonstrated.It is postulated that the use of specific mycelial antigens for routine diagnostic precipitin testing in patients with suspected systemic candidiasis would give more reliable results than at present obtained with yeast cell antigens.
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