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The important role played by macrolides in the chemotherapy of infectious diseases is well established, but there is still much speculation about their anti-inflammatory potential. A review of in-vitro and ex-vivo studies reported in the literature shows that macrolides have potentially relevant immunomodulatory effects. In-vitro data suggest that erythromycin A derivatives have a direct effect on neutrophil function and the production of cytokines involved in the inflammation cascade. The ex-vivo results indicate that short-term administration of macrolides may enhance the immune response while long-term administration results in immunosuppression. Further research is required to improve our understanding of the therapeutic activity of macrolides.

Macrolide antibiotics are taken up and concentrated by host cells, particularly phagocytes, and are likely candidates to modify cell functions. In this study, we extended our previous work concerning the effect of three 14-membered-ring macrolides (dirithromycin, erythromycin and erythromycylamine) on human neutrophil exocytosis, and found that three other erythromycin A derivatives (roxithromycin, clarithromycin and the azalide, azithromycin) also triggered neutrophil degranulation in a time- and concentration-dependent manner. After 30 min of incubation, the correlation coefficients for concentration-dependence for roxithromycin were 0.885, 0.739 and 0.750 (P < 0.005) and for clarithromycin were 0.795, 0.599, 0.733 (P < 0.02), respectively, for lysozyme, beta-glucuronidase and lactoferrin release. Although the underlying mechanism was not elucidated, these and previous data suggest that intracellular accumulation is a prerequisite. Furthermore, comparison of the characteristics of macrolide-induced exocytosis with those of exocytosis triggered by the synthetic chemotactic stimulus FMLP suggested that different mechanisms are involved. In keeping with this possibility, we showed that combined treatment (macrolides plus FMLP) resulted in totally additive exocytosis of azurophilic but not specific granules. The clinical relevance of our data remains to be ascertained.

Dirithromycin, a new semisynthetic 14-membered-ring macrolide was avidly concentrated by human neutrophils in a time- but not concentration-dependent manner with mean cellular/extracellular, concentration ratios (C/E) of 9 within the first 5 min and up to 47 at 120 min. Erythromycylamine, the hydrolysis product of dirithromycin, was concentrated significantly less by neutrophils, reaching C/E values of 4 and 19 (at 5 and 120 min). A point of interest was the interindividual variability in the antibiotic uptake kinetics; in particular, 7 out of 47 neutrophil samples from different healthy volunteers displayed very slow uptake of both drugs (C/E values at 30 min: dirithromycin, 5.8; erythromycylamine, 4.6). The reason(s) for this is unknown. The uptake of both drugs was decreased at acidic pH and increased at basic pH. Chloroquine, an antimalarial drug which is concentrated in and alkalinizes azurophilic granules, reduced uptake by half. Metabolic inhibitors (2-4 dinitrophenol, sodium fluoride, potassium cyanide and sodium azide) did not impair the uptake of either drug but, interestingly, ouabain, an inhibitor of membrane Na+/K+ ATPase activity, impaired uptake by about 30%. Competitive inhibitors of some transport systems identified on neutrophil membrane (nucleosides, D-glucose and various aminoacids) did not alter the uptake of either drug. Dirithromycin and to a lesser extent, erythromycylamine, reached intracellular concentrations much higher than those required to inhibit the growth of sensitive microorganisms. Although the mechanism of uptake is not clear, one interesting hypothesis involves trapping by protonation into acidic compartments of neutrophils.

Polymorphonuclear neutrophils (PMN) play a prominent role in the host response to infectious diseases. One major bactericidal mechanism used by these cells is the production of reactive oxygen species during what is referred to as the oxidative burst. However, excessive oxidant generation can also be involved in cell and tissue damage associated with severe inflammatory reactions. Macrolide antibiotics are able to penetrate and concentrate within phagocytes and have been successfully used to treat infections due to facultative intracellular pathogens. However, intracellular accumulation of macrolides with possible alkalinization of cellular compartments may interfere with normal cell function. In-vitro and ex-vivo data suggest that macrolides affect various phagocytic functions. This paper presents an overview of the published data concerning the modulation of neutrophil function by macrolides. Preliminary data concerning the in-vitro modulation of the neutrophil oxidative burst by dirithromycin and its metabolite, erythromycylamine, are also discussed.

Cefodizime, a 2-amino-thiazolyl cephalosporin, is reported to display in-vitro, ex-vivo and in-vivo immunomodulatory properties; in particular, it enhances the survival of mice infected with cefodizime-resistant pathogens. We have used an in-vitro model to assess the indirect effect of this drug (compared with other cephalosporins) on the neutrophil (PMN) oxidative response. Pseudomonas aeruginosa was employed as the bacterial target for cefodizime and cefotaxime (MICs greater than 128 mg/l), cefsulodin (MIC 16 mg/l) and ceftazidime (MIC 32 mg/l). After overnight growth in the presence of subinhibitory concentrations of each drug (10 mg/l), the altered filamentous P. aeruginosa induced a stronger oxidative response of PMN than untreated control bacteria. For all cephalosporins this was related to alterations of bacterial structure leading to increased deposits of antibodies and/or complement. Furthermore, increased non-opsonin dependent stimulation of the PMN oxidative burst was obtained; the strongest response was observed with cefodizime-treated P. aeruginosa in the case of low responder PMN, which displayed a deficient response after stimulation by control bacteria. The possibility that cefodizime could enhance this PMN function in opsonin-deficient patients requires further investigation.

Immunomodulation by antibacterial agents shows promise as a novel strategy in the treatment of infectious diseases. Cefodizime, a new oxi-imino-amino-2-thiazolyl cephalosporin, is a particularly good candidate in this context. In-vivo models of experimental infections show that prophylactic administration of cefodizime increases the survival of some strains of mice after challenge with Toxoplasma gondii or Candida albicans; its curative effect in infections due to members of the Enterobacteriaceae is better than that expected from in-vitro MIC determinations relative to other third-generation cephalosporins; this effect is even more marked in immunocompromised animals. Data obtained both in vivo and ex vivo show that cefodizime enhances various immune parameters such as phagocyte function, B lymphocyte responsiveness and delayed hypersensitivity; it may restore natural killer (NK) and phagocyte activity, as well as interleukin 1 (IL-1) and interferon production, in immunocompromised patients and animals. The in-vitro effects of this drug include enhancement of phagocyte bactericidal activity and alteration of bacterial virulence factors. The chemical basis for these various immunomodulatory properties is related to the thio-thiazolyl side-chain at position 3 of the cephem nucleus. To date, the mechanisms underlying the immunomodulatory properties of cefodizime have not been identified clearly, but it is likely that it interferes at different levels of specific and non-specific immune defences.

Cefodizime is a 2-aminothiazolyl cephalosporin for parenteral use. Cefodizime has a bisubstituted thiothiazole moiety in position 3 of the cephem nucleus. The presence of this moiety does not alter the in-vitro antibacterial activity, or safety in animal studies, which are similar to those of cefotaxime, but results in an apparent long elimination half-life in rodents and dogs, and in novel immunological properties.

Josamycin and erythromycin have been compared for their in-vitro interaction with bactericidal killing by human neutrophils. The mechanism of this interaction was studied in two ways. First, the target organisms (Staphylococcus aureus and Pseudomonas aeruginosa) were incubated for 60 min with josamycin, erythromycin or control buffer prior to use in a human polymorphonuclear neutrophil (PMN) killing assay. Second the macrolides were added directly to acellular killing systems mimicking those acting inside the phagolysosome; oxygen-independent systems were obtained from a crude granule extract of PMN and oxygen-dependent systems consisted either of a mixture of xanthine plus xanthine oxidase or of a solution of H2O2. Whereas josamycin-pretreated P. aeruginosa were twice as sensitive to killing by PMN than were control cells, this was not the case for S. aureus. Both oxidant generating systems were more effective in destroying S. aureus in the presence of josamycin (3 and 30 mg/l). Erythromycin showed a similar synergy but only with the xanthine plus xanthine oxidase system. This synergy was observed with neither of the O2-independent systems for S. aureus, nor with any acellular system for P. aeruginosa. These data suggest that at least two kinds of mechanism may explain the bactericidal synergy observed between macrolides and PMN. The first (for macrolide-resistant species such as P. aeruginosa) could be due to alterations in the bacteria by the antibiotics, while the second (for macrolide-sensitive species such as S. aureus) could be based upon an as yet unexplained transformation of the molecules by reactive oxygen species into more "toxic" forms. These differences between josamycin and erythromycin could arise from differences in their chemical structure.

We have compared the in-vitro interactions of quinine and cinchonine, two alkaloids from cinchona bark, with human neutrophil functions. Although these molecules are structurally similar, they induced a quantitatively different depressive effect on neutrophil chemotaxis and oxidative response. Quinine produced the strongest effect at concentrations as low as 10 mg/l, which may be achievable in serum during therapeutic use of this compound. The depression induced by cinchonine was noticeable only at 100 mg/l. Chemotaxis was decreased by about 25% (formyl-methionyl-leucyl-phenylalanine) or 39% (serum) for quinine (100 mg/l) only if a constant concentration of the drug was maintained during the assay while cinchonine had no effect on this PMN function. The greatest impairment was observed for the PMN oxidative burst: this was dose-dependent whatever the stimulus used (phorbol-myristate-acetate or opsonized zymosan). After 30 min incubation in the presence of the drugs, the zymosan-induced chemiluminescence response was decreased by 96% and by 67% with quinine, 100 and 10 mg/l, respectively, and by 62% with cinchonine 100 mg/l. The myeloperoxidase-mediated iodination of PMN was reduced by 100% and 46% with quinine, 100 and 10 mg/l, respectively, whereas cinchonine decreased this function by about 95% at 100 mg/l and 14% at 10 mg/l. Superoxide anion generation was impaired by 94% (quinine 100 mg/l) or 45% (cinchonine 100 mg/l). The relevance to the clinical situation and the possible mechanisms of such effects are discussed.

Josamycin, a 16-membered ring macrolide is concentrated up to 20-fold in phagocytic cells compared with serum. We have studied the in-vitro interaction of this drug with human neutrophils (PMN) bactericidal function by using two strains resistant to this antibiotic, Pseudomonas aeruginosa and Klebsiella pneumoniae, and a sensitive one, Staphylococcus aureus 209P. It was shown that josamycin-pretreated adherent PMN displayed an increased phagocytic activity (about 30 to 40%) for S. aureus or K. pneumoniae, mainly due to the recruitment of an additional phagocytizing subset of PMN. Furthermore, the bacterial killing was enhanced in josamycin-treated PMN in a dose-dependent manner for K. pneumoniae (60-130% increase in the range of concentration 0.1-25 mg/l) and independently of the dose for S. aureus (about 425-460% increase for josamycin 0.1-10 mg/l). P. aeruginosa killing by whole blood was also significantly increased in the presence of 10 and 1 mg/l of josamycin. Other PMN functions were not much altered by josamycin except an enhancement of the formyl-methionyl-leucyl-phenylalanine-induced oxidative response. Chemotaxis was only increased by the presence of a high concentration (100 mg/l) of josamycin. These data suggest that the bactericidal synergy between PMN and josamycin could be related, partly at least, to a direct enhancing effect of josamycin on some PMN functions such as phagocytosis, chemotaxis and FMLP-induced chemiluminescence. On the other hand, alterations of bacteria, either inside the phagolysosome or in the extracellular medium, could lead to an enhanced susceptibility to the phagocytes' microbial mechanisms.

Ceftriaxone, a 2-aminothiazolyl cephalosporin does not alter human neutrophil (PMN) bactericidal function. However, low concentrations of ceftriaxone induce some bacterial strains to be more sensitive to PMN killing. We have studied the effect of a subinhibitory concentration of ceftriaxone (10 mg/l) on Pseudomonas aeruginosa (MIC greater than 128 mg/l). After an overnight exposure to this concentration of ceftriaxone, P. aeruginosa elongated into filaments. PMN killing of ceftriaxone-treated bacteria was better than killing of control bacteria. This enhanced killing was correlated with an increased sensitivity to oxygen-dependent bacterial killing. Furthermore, the altered bacteria induced a greater oxidative response of PMN which was independent of their chemiluminescence response after stimulation by control P. aeruginosa. This increased oxidative burst was attributable to both non-opsonodependent stimulation and to increased deposit of opsonins.

About 0.1% of the sera in human pathology produce a peculiar, cytoplasmic, non-organ- and non-species-specific fluorescence. This may easily be differentiated from the already described anti-organelle antibodies and, more particularly, from the mitochondrial antibodies of primary biliary cirrhosis. Should rat tissues be used in the immunofluorescence test, fluorescence predominates over the first two portions of the renal proximal tubules (P1 and P2) and the mucous neck cells of the stomach. This pattern may be atrributed to mitochondria, and in particular to their inner membranes by fluorescent staining of the ellipsoid region of the rods and cones of the eyes, and by absorption with purified organelles. To distinguish this antibody from the already described mitochondrial antibodies, this one will be called mitochondrial antibody number 5 (M5). The seven carriers of this antibody suffer from systemic lupus erythematosus or autoimmune haemolytic anaemia. In these cases no diseases of the liver were observed, contrary to other classical mitochondrial antibodies.

Ceftriaxone, an amino-2-thiazolyl cephalosporin, has been shown to cooperate in vitro with human neutrophils for the killing of some bacteria. In this work the direct interaction with human leucocyte bactericidal function has been studied. Ceftriaxone (1000 to 1 mg/l) did not alter neutrophil chemotaxis or superoxide anion production. It also did not interfere with the chemiluminescence response of isolated PMN although a paradoxical depressive effect was observed with whole human blood in the case of zymosan stimulation. The killing of Staphylococcus aureus and Klebsiella pneumoniae was not enhanced by ceftriaxone and phagocytosis was significantly depressed only with adherent neutrophils but not when using neutrophils in liquid medium. It is concluded that the synergy observed between leucocyte and ceftriaxone for bacterial killing cannot be related to a direct stimulation of neutrophil functions and should depend on bacterial alteration.

The enhanced bactericidal activity of human neutrophils induced by cefotaxime and cefodizime, two methoxy-imino-amino- 2-thiazolyl cephalosporins, is linked to the cell stimulation of oxygen-dependent and oxygen-independent killing systems, respectively. Cefotaxime enhances both the killing and the oxidative response of neutrophils to opsonized particulate stimuli (bacteria for both activities and opsonized zymosan for the oxidative burst). These effects were not observed with non-opsonized particles (bacteria or zymosan) or soluble stimuli. On the contrary, cefodizime enhances killing of opsonized and non-opsonized bacteria by neutrophils regardless of treatment with phenylbutazone which blocks neutrophil oxidative metabolism. Cefodizime does not universally alter the oxidative burst induced by various stimuli, but has been shown to enhance the bactericidal activity of crude extracts of neutrophil granules. The data suggest that cefodizime and non O2-dependent killing systems of neutrophils cooperate in killing bacteria.

In vitro, cefotaxime and cefodizime enhanced significantly the bactericidal activity of human neutrophils against Staphylococcus aureus P 209 A, but not phagocytosis. The increase was about 150% for cefotaxime and 400% for cefodizime at concentrations as low as 1 mg/l. Furthermore, by two different techniques (NBT and cytochrome C reduction tests) cefotaxime but not cefodizime significantly enhanced superoxide anion production by zymosan-stimulated neutrophils. Other neutrophil functions (chemotaxis and myeloperoxidase-mediated iodination of proteins) were not significantly altered by either antibiotic, even at concentrations as high as 1000 mg/l.

Two bacterial strains (Staphylococcus aureus and Klebsiella pneumoniae) were exposed to subinhibitory concentrations of ceftriaxone. After an overnight culture in presence of 1 MIC of ceftriaxone either in broth or on solid medium S. aureus showed enlarged forms which were better phagocytosed (increase about 40%) and killed (increase about 50%) than control staphylococci. Exposure of K. pneumoniae to 0.1 MIC ceftriaxone resulted in filamentation of bacteria. When grown in the presence of 0.01 MIC, K. pneumoniae did not elongate into filaments but were significantly more phagocytosed (increase about 40%) or killed (increase about 170%) than control bacilli. The mechanism of the greater sensitivity to PMN killing of the altered S. aureus and K. pneumoniae was assessed either with phenylbutazone-treated PMN or by in-vitro exposure to crude granule extracts of PMN. The altered bacteria displayed a significant susceptibility to the non-oxidative killing mechanism while untreated bacteria were unaffected by the non-oxidative system. These data could explain the synergy observed between ceftriaxone and leucocytes in the killing of some micro-organisms.

We have compared the in-vitro interaction of five macrolides (roxithromycin, erythromycin, spiramycin, oleandomycin and josamycin) with human neutrophils (PMN). Only roxithromycin strongly impaired the oxidative burst of PMN assessed by luminol amplified chemiluminescence, superoxide anion generation, and myeloperoxidase-mediated iodination of proteins. This effect was observed only for high concentrations of this drug (100 and 50 mg/l). Furthermore, the sensitivity of PMN to the depressive effect of roxithromycin permitted the definition of two kinds of PMN: in Highly Sensitive (HS)-PMN, the oxidative response was completely abolished while in Moderately Sensitive (MS)-PMN, a decreased, but yet measurable (20-50% of the control), response was obtained. The roxithromycin-induced depression of PMN was time-dependent and partly reversed by washing. Chemotaxis was also impaired by roxithromycin (100 mg/l) but phagocytosis of Klebsiella pneumoniae was unaltered even at high concentrations of the drug. Since roxithromycin displays the highest intracellular uptake, compared with the other macrolides assessed in this study, this could explain the results observed here. The relevance to the clinical situation needs further study. This effect of roxithromycin could be useful to control the inflammatory process associated in certain infectious diseases, in particular if high concentrations of the drug are obtained in tissues.