Relevance of in vitro synergy to therapy: does synergy between diaminopyrimidines and sulphonamides operate at concentrations achievable in urine?
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Bacteria↗
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Synergy of vancomycin with penicillins and cephalosporins against pseudomonas, klebsiella, and serratia.
A model of antibiotic synergy based on a molecular mechanism of action which blocked sequential steps in a single metabolic pathway was tested. Twenty-five strains each of Pseudomonas, Klebsiella, and Serratia were tested in vitro against three different two drug combinations of vancomycin, carbenicillin, or cephalothin. Synergy was observed when vancomycin was combined with either carbenicillin or cephalothin against isolates of Pseudomonas or Serratia, whereas the combination of carbenicillin and cephalothin did not result in significant synergy against these isolates. The presence of synergy was not related to the sensitivity or resistance of the isolates to the drugs in the combination. Synergy was also observed with all three antibiotic combinations against Klebsiella isolates which may be related to enzyme inactivation by one of the drugs in the combination. These observations support the hypothetical model of antibiotic synergy based on sequential blocking of one biochemical pathway.
Carbenicillin↗
Synergy of mecillinam, a beta-amidinopenicillanic acid derivative, combined with beta-lactam antibiotics.
Mecillinam, a beta-amidinopenicillanic acid derivative, was combined with ampicillin, amoxicillin, carbenicillin, cephalothin, cefamandole, and cefoxitin and tested against most members of the Enterobacteriaceae and Pseudomonas. Synergy was demonstrated with selected isolates of most of the organisms tested. Isolates highly susceptible to mecillinam (minimum inhibitory concentration, <0.8 mug/ml) were not synergistically inhibited by addition of another beta-lactam antibiotic. Synergy of mecillinam and a beta-lactamase-resistant penicillin, cloxacillin, was demonstrated. In media of osmolality >10 mOsm or of conductivity >6 mS, mecillinam and beta-lactam antibiotics showed synergy in most instances, whereas at low osmolality and conductivity the activity of mecillinam is so great that synergy cannot be demonstrated. The proportion of mecillinam to beta-lactam antibiotic that will be synergistic ranged from 100:1 to 1:1 to 1:100. Mecillinam did not increase the activity, minimum inhibitory concentration or minimum bactericidal concentration values, of beta-lactam compounds against streptococci, staphylococci, clostridia, listeria, or bacteroides. Synergy was not demonstrated with combinations of mecillinam and aminoglycosides (kanamycin, gentamicin, tobramycin, amikacin), chloramphenicol, tetracycline, or polymyxins.
Azepines↗
In vivo synergy between 6 beta-amidinopenicillanic acid derivatives and other antibiotics.
Both an oral and a parenteral form of a 6beta-amidinopenicillanic acid derivative were found to have appreciable activity against gram-negative bacteria and poor activity against gram-positive bacteria in vivo. When administered orally or parenterally, definite synergy was demonstrated between the amidinopenicillins and ampicillin, amoxicillin, benzylpenicillin, cefazolin, or carbenicillin in infections with a number of gram-negative bacteria, including Klebsiella, Enterobacter, Escherichia, Proteus, Salmonella, and Haemophilus species in mice. Synergy was also observed between the parenteral amidinopenicillin and benzylpenicillin in the Staphylococcus aureus infection but not in infections with other gram-positive organisms. No synergy was demonstrated between the parenteral amidinopenicillin and erythromycin or oxytetracycline in infections with gram-positive or gram-negative organisms. Synergy between the parenteral amidinopenicillin and gentamicin was observed only in the case of Escherichia coli.
Animals↗
Synergy studies with Pseudomonas aeruginosa resistant to gentamicin and/or carbenicillin.
The predictability of synergy with strains of Pseudomonas aeruginosa highly resistant to gentamicin in combination with carbenicillin has been controversial. 30 clinical isolates of P. aeruginosa resistant to gentamicin and/or carbenicillin were tested by checker-board technique. 14 were found to be highly resistant to gentamicin (minimal inhibitory concentration MIC greater than or equal to 128 microgram/ml) and/or carbenicillin (MIC greater than or equal to 512 microgram/ml). Of these 14, 4 isolates showed synergy. 10 of 16 isolates with moderate resistance demonstrated synergy. It is concluded that the level of resistance to gentamicin with P. aeruginosa cannot be used in predicting whether synergy will occur.
Carbenicillin↗
Synergy between T cell-replacing factor and bacterial lipopolysaccharides (LPS) in the primary antibody response in vitro: a model for lipopolysaccharide adjuvant action.
Unfractionated spleen cells, B cells from normal mice, and nu/nu spleen cells respond to the addition of bacterial lipopolysaccharide (LPS) and T-cell-replacing factor (TRF) by production of plaque-forming cells (PFC) in excess of the number expected from the addition of LPS and TRF separately. This synergistic activity is dependent on the presence of the antigen, SRBC. Supernatants of both allogeneic spleen cell mixtures and spleen cells cultured with Con A are effective and synergize best at concentrations suboptimal for their ability to act as TRF alone. Culture supernatants of unstimulated normal or fractionated cell populations are ineffective. Synergy is not dependent on the presence of macrophages in the cultures. Purified LPS free from active contaminants, as well as commercially available LPS, show synergy with TRF. Synergy was seen when TRF was added at initiation of culture or 24 hr later. It is suggested that synergy is the equivalent of LPS adjuvant activity, that the role of T cells in LPS adjuvanticity is that of a conventional cooperating cell, and the LPS acts as an adjuvant by inducing B cells to become more sensitive to T cell helper factors.
Adjuvants, Immunologic↗
The stability of synergy in agonists during the execution of a simple voluntary movement.
The characteristics of muscular synergy between the main elbow flexors (biceps brachii, brachialis, brachoradialis were considered. The activities of these different muscles were recorded simultaneously with surface and wire electrodes. A quantitative analysis of the activity of each of these muscles and of their excitation levels was carried out during movements performed at various velocities and against different inertias. It was shown that: (1) the onset as well as the cessation of activity in the different muscles occur practically simultaneously and independently of the velocity and inertia of the movement; (2) the well-known linear relation between the integrated EMG of biceps brachii and the work can be extended to the other main flexors. This implies that the relation between the activities of the main flexors remains constant whatever the velocity and inertia may be. These results confirm the notion of 'Flexor Equivalent'. They also demonstrate a stability of the synergy between agonist muscles which must be distinguished particularly from the synergy between agonists and antagonists.
Adult↗
A Rapid, simple method for demonstrating synergy of amikacin and penicillin against various microorganisms.
A simple disk diffusion technique with use of triple-layer agar and enzymatic inactivation of penicillin demonstrated synergy between penicillins and aminoglycosides. The method was applied to measurement of the synergistic activity of amikacin and penicillin G against a strain of Streptococcus faecalis sensitive to both drugs, amikacin and ampicillin against a strain of S. faecalis sensitive to amplicillin but resistant to amikacin, and amikacin and carbenicillin against a strain of Proteus mirabilis sensitive to both drugs. The degree of synergy was related to the specific organism tested. For example, syngery of penicillin G and amikacin for S. faecalis could be demonstrated only when the organism was subjected first to the action of penicillin G alone. In addition to providing useful clinical information, the triple-layer technique appears to be a promising tool for the study and understanding of synergy between antimicrobial agents.
Amikacin↗
A method for testing for synergy with any number of agents.
The standard checkerboard titration for detecting synergy between antibiotics is practicable for combinations of two antibiotics, laborious for combinations of three, and not feasible for combinations of four or more. Nevertheless, methods for testing of combinations of several antibiotics are urgently needed because some combinations might be superior to those in use and enable the successful treatment of infections resistant to current therapy. A simple method for measurement of synergy (or antagonism) with combinations of any number of agents has been developed which requires less effort than the standard checkerboard titration of two agents. With this method, the concentrations of each of n agents producing some specified effect (such as minimal inhibitory concentration or minimal bactericidal concentration) are determined. A reference combination made up of 1/n of each of these concentrations is titrated to find a dilution that produces the specified effect. The degree of dilution required is equal to the sum of the fractional inhibitory concentrations (concentration of each agent in combination/concentration of each agent alone) as conventionally determined by checkerboard titrations; sums of less than 1, 1, and greater than 1 indicate synergy, additivity, and antagonism, respectively.
Anti-Bacterial Agents↗
Synergy between carbenicillin and an aminoglycoside (gentamicin or tobramycin) against Pseudomonas aeruginosa isolated from patients with endocarditis and sensitivity of isolates to normal human serum.
Isolates from the blood of 30 patients with endocarditis due to Pseudomonas aeruginosa were tested for synergy between carbenicillin and an aminoglycoside, either gentamicin or tobramycin, by in vitro checkerboard methods in modified (cation-supplemented) Mueller-Hinton broth. Twenty-five of the 30 isolates were affected synergistically. Whether given low (2.5--5 mg/kg) or high (8 mg/kg) doses of aminoglycoside along with 30 g of carbenicillin daily, all of the five patients infected with pseudomonads that were not synergistically affected were refractory to treatment with pseudomonads that were not synergistically affected were refractory to treatment with the carbenicillin-gentamicin combination, whereas the finding of synergy of carbenicillin with gentamicin (or tobramycin) did not assure a medical cure. Tests for synergy between carbenicillin and gentamicin yielded different results in Mueller-Hinton agar than in modified Mueller-Hinton broth. The majority (28) of 30 isolates of endocarditis-producing P. aeruginosa were resistant to the bactericidal effects of 50% pooled normal serum that had been freshly separated. One of the endocarditis-producing strains that was sensitive to 50% serum was resistant to 10% serum. However, sensitivity or resistance to freshly separated, pooled normal human serum did not predict the outcome of antibacterial therapy for pseudomonas endocarditis.
Aminoglycosides↗
Synergy of penicillin-netilmicin combinations against enterococci including strains highly resistant to streptomycin or kanamycin.
The in vitro activity of combinations of penicillin and netilimicin was determined against 20 clinical isolates of enterococci and compared with that obtained in simultaneous tests with penicillin/sisomicin, penicillin/streptomycin, and penicillin/kanamycin. Synergy between the two drugs in each combination was determined by the use of quantitative kill curves and was defined as a killing by the combination at least 100-fold greater than that produced by the most effective drug alone. Penicillin/netilmicin and penicillin/sisomicin combinations were found to be synergistic against the majority of isolates tested, including strains resistant to penicillin/streptomycin or penicillin/kanamycin combinations. This synergy with penicillin could be demonstrated at a concentration of </=7 mug/ml for either netilmicin or sisomicin. Studies on the kinetics of killing produced by these combinations showed the rate and extent of killing to be directly dependent upon the organism's relative susceptibility to the aminoglycoside alone and the aminoglycoside concentration in the combination. Results also indicated that the interaction between penicillin and netilmicin was true synergy; i.e., rapid and complete killing was produced by combinations containing each drug at concentrations insufficient to produce any killing alone, and the killing observed could not be produced by either drug alone at a concentration equivalent to the total drug concentration in the combination. The potential clinical application of this synergistic interaction should be investigated further, especially in view of recent reports showing netilmicin to be considerably less toxic than gentamicin in experimental animals.
Anti-Bacterial Agents↗
Synergy of azlocillin and mezlocillin combined with aminoglycoside antibiotics and cephalosporins.
Synergistic activity between both azlocillin and mezlocillin and aminoglycosides or cefazolin could be demonstrated by checkerboard dilution, isobologram, and killing curve techniques. Azlocillin and mezlocillin combined with gentamicin, netilmicin, or amikacin were synergistic against Escherichia coli, Klebsiella, Citrobacter, Enterobacter, Serratia, and indole-positive Proteus. Synergy was observed with isolates that were susceptible or resistant to azlocillin or mezlocillin. Synergy was seen most often when azlocillin or mezlocillin were combined with amikacin, gentamicin, or netilmicin against Pseudomonas aeruginosa. The combination of mezlocillin and an aminoglycoside produced synergy more often than did carbenicillin plus an aminoglycoside. No antagonism was seen when aminoglycoside antibiotics were combined with azlocillin or mezlocillin. Cefazolin was synergistic against Pseudomonas, Providencia, P. mirabilis, indole-positive Proteus, Citrobacter, Klebsiella, and Escherichia coli, when combined with azlocillin or mezlocillin. However, the combination of either agent with cefazolin was antagonistic when tested against selected indole-positive Proteus and Enterobacter isolates.
Aminoglycosides↗
In vitro studies with Sch 21420 and Sch 22591: activity in comparison with six other aminoglycosides and synergy with penicillin against enterococci.
In vitro tests were performed with Sch 21420 and Sch 22591 to determine (i) their activity in comparison to six other aminoglycosides against 343 clinical isolates, and (ii) whether synergy with penicillin G could be demonstrated with enterococci. In broth dilution tests, Sch 22591 was more active than the seven other aminoglycosides against Staphylococcus aureus, Enterobacteriaceae, and most nonfermenting gram-negative bacilli. Sch 22591 was as active as tobramycin against Pseudomonas aeruginosa. The activity of Sch 21420 was comparable to gentamicin, sisomicin, netilmicin, and tobramycin but greater than amikacin or kanamycin against S. aureus and most genera of Enterobacteriaceae. Sch 21420, amikacin, and kanamycin were (i) more active than the other five aminoglycosides against Proteus rettgeri and Providencia stuartii, but (ii) less active than the other five aminoglycosides against Neisseria gonorrhoeae, enterococci, most nonfermenting gram-negative bacilli, Proteus mirabilis, and Proteus morganii. Studies on the bactericidal activity of Sch 22591 with penicillin indicated a synergistic interaction against enterococci, including strains highly resistant to streptomycin and kanamycin. This could be demonstrated with combinations containing 3.0 to 6.0 mug of Sch 22591 per ml and was comparable to that observed with penicillin/gentamicin. Penicillin plus Sch 21420 (25 mug/ml) also demonstrated synergy against enterococci, including strains highly resistant to streptomycin. However, synergy did not occur against strains highly resistant to kanamycin. These latter results were similar to those obtained in tests with penicillin/kanamycin.
Aminoglycosides↗
Lymphoid cell subpopulations. I. Synergy between lymph node cells and thymocytes in response to alloantigens and mitogens.
Mixtures of isogenic thymocytes (TC) and lymph node cells (LNC) were shown to exhibit synergistic responsiveness to M and H-2 alloantigens in the mixed lymphocyte interaction (MLI). With respect to the kinetics and magnitude of proliferation and effector cell generation, the response occurring in synergizing cultures closely resembled that of optimal numbers of LNC or spleen cells (SC). In addition, the antigen specificity of effector cells generated by synergizing cultures was similar to that of effectors derived from cultures containing optimal numbers of responding SC. LNC-TC mixtures also exhibited synergy in response to the phytomitogens concanavalin A and pokeweed mitogen but not to phytohemagglutinin. Weakly positive synergy was observed in response to bacterial lipopolysaccharide. It is proposed that the phenomenon of synergy is not restricted to cultures containing mixtures of LNC and TC but also occurs in cultures containing optimal numbers of LNC or SC as a result of interactions between subpopulations of lymphocytes contained within these tissues.
Animals↗
The activity of methyl benzoquate and clopidol against Eimeria maxima: synergy and drug resistance.
Synergy between clopidol and methyl benzoquate against Eimeria maxima was shown to be supra-additive. Collateral sensitivity to these drugs could not be demonstrated in resistant lines of this parasite. Resistance to methyl benzoquate and clopidol was not transferred when lines of E. maxima, resistant to the respective drugs, were propagated together. The failure to demonstrate this phenomenon was judged not to be due to synergy between the drugs. Attempts to induce simultaneous was readily acquired by a line of E. maxima resistant to clopidol. Induced resistance to clopidol in a methyl benzoquate-resistant line required numerous passages.
Animals↗
Polymerase-inhibitor drug synergy and mutational signatures in different epithelial cell models of RSVA and hPIV3 infection.
Despite the huge global health burden presented by respiratory viruses, effective broad-spectrum antiviral therapeutic options remain limited. Here we evaluated the antiviral activity of four RNA-dependent RNA polymerase (RdRp) inhibitors, remdesivir, ribavirin, favipiravir, and molnupiravir, as monotherapy or dual-drug combinations against respiratory syncytial virus (subtype A, RSVA) and human parainfluenza (serotype 3, hPIV3) using epithelial cell lines and primary human airway culture models. Remdesivir showed the greatest potency across both viruses, while ribavirin and favipiravir also demonstrated inhibition. Molnupiravir was active against RSVA but not hPIV3. Several dual-drug combinations, including remdesivir-favipiravir, remdesivir-molnupiravir and favipiravir-molnupiravir, produced marked synergy against RSVA, and more limited synergy for hPIV3. Antiviral efficacy was validated in primary airway epithelial cultures, where effective concentrations preserved epithelial integrity and attenuated viral disruption of ciliary function. Across both viruses, increasing antiviral exposure was associated with dose-dependent signature mutagenesis. Antivirals induced significantly higher RSVA mutation burden in the primary airway model. These findings highlight the therapeutic potential of RdRp inhibitor combinations for RSVA and hPIV3, provide mechanistic insight through antiviral-related mutational signatures, and demonstrate advantages of the primary human airway culture model for development of effective multi-drug regimens and broad-spectrum antiviral preparedness.
Journal Article↗
Synergy between sulphonamide and trimethoprim in the presence of pus.
Synergy between sulphadiazine and trimethoprim against Escherichia coli has been demonstrated in culture media not containing lysed horse blood despite the presence of pus or a pus extract which inhibited the action of each drug separately. Synergy may therefore be important where pus is present in vivo.
Culture Media↗
Antibacterial activity and synergy, in vitro and in vivo, of a combination of amoxycillin and flucloxacillin.
The antibacterial activity of a combination of equal parts of amoxycillin and flucloxacillin was compared in vitro and in vivo with that of amoxycillin and flucloxacillin against a range of gram-positive and gram-negative bacteria. The combination generally showed additive effects against bacteria sensitive to the individual penicillins and there was no evidence of antagonism, but synergistic effects were observed between amoxycillin and flucloxacillin against certain amoxycillin-resistant gram-negative bacilli. The extent of synergism varied according to the particular bacterial species under test and synergy was observed only against bacteria with chromosomally-mediated beta-lactamases and not against bacteria with R-factor-mediated beta-lactamases. In general, amoxycillin + flucloxacillin demonstrated activity against experimental mouse infections in good agreement with demonstrated activity against experimental mouse infections in good agreement with its in vitro activity, and synergy was produced against a range of gram-negative bacilli in vivo. The data suggest that clinical trial with amoxycillin + flucloxacillin in the treatment of selected infections including those due to some amoxycillin-resistant bacteria may well be justified.
Amoxicillin↗