CHEMOTHERAPY NOV Fig.1 Combined effect of drug A and drug B Fig. 2 MICs of CEPs (LMOX, CZX, CMX, CPZ) against 27 strains (inoculum size 106 CFU/

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CHEMOTHERAPY NOV. 1987 Fig.1 Combined effect of drug A and drug B Fig. 2 MICs of CEPs (LMOX, CZX, CMX, CPZ) against 27 strains (inoculum size 106 CFU/ml) of S. marcescens + Visible growth No visible growth FIC (Fractional inhibitory concentrationi index MIC of drott combined with drug B / MIC of d A alone (MIC)ƒÊg/ml MIC of dnue B combined with drug A / MIC of drwe B alone

VOL.35 NO.11 CHEMOTHERAPY Fig.3 MICs of AGs (GM, AMK, TOB, NTL) against 27 strains of S. marcescens (inoculum size 106 CFU/ ml) Table 1 Combined effects of Ĉ- lactams, and GM or AMK against 27 strains of S. marcescens (inoadtan size, 106/ ml)

CHEMOTHERAPY NOV. 1987 Table 2 Combined effects of CEP. and AGs azalnet 27 strains of S. marcescons (inoculum size, 106/ ml) Fig.4 Sensitivity distribution of GM alone or combined with LMOX (27 strains of S. marcescens, inoculum size 106/ ml)

VOL.35 NO.11 CHEMOTHERAPY Table 3 Combined effect. of Ĉ- lactams, and GM or AMK (106 CFU/ ml) Fig. 5 Killing curves of CZX combined with GM against S. marcescens No. 10 strain Fig.6 Killing curves of CZX combined with AMK against S. marcescens No.10 strain

CHEMOTHERAPY NOV. 1987 Fig. 7 Killing curves of LMQX combined with GM against S. marcescens No.10 strain Fig.B Killing curves. of CPZ combined with GM or AMK against S. marcescens No. 10 strain Table 4 Correspondence between MICs (HIA, 106/ ml) and MBCs (HIB)

VOL.35 NO.11 CHEMOTHERAPY Fig. 9 Killing curves of LMOX combined with GM against S. marcescens IFO 12648 Fig.11 Killing curves of CZX combined with GM or AMK against S. marcescens IFO 12848 Fig. 10 Killing curves of LMOX combined GM against S. marcescens IFO 12648 with

CHEMOTHERAPY NOV. 1987 Fig.12 Combined effects of LMOX and GM against S. marcescens No.6 and No.12 strains S.marcesccens No. 6 strain S.marrcescens No. 12 strain Fig.13 MIC of GM: 400ƒÊg/ml MIC of LMOX: 12.5ƒÊg/ml FIC index: 0.312 Killing curves of LMOX combined with GM against S. marcescens No. 6 and No. 12 strains MIC of GM: 3.13ƒÊg/ml MIC of LMOX: 12.5ƒÊg/ml FIC index: 0.258 Fig.14 Killing curves of CZX combined with GM against S. marcescens No. 10 strain and IFO 12648

CHEMOTHERAPY Scanning electron micrographs of S. marcescens IFO 12648 exposed to a combination of CPZ 1/ 16 MIC and GM I II MIC a) control + GM 1/ 16 MIC (MIC; 100ƒÊg/ ml) for 0.5 hour c) CCI 1/ 16 MIC+ GM 1/ 16 MIC for 1 hour

CHEMOTHERAPY NOV 1987 Fig. 16 Scanning electron mierographs of S. marcencens No.10 strain exposed to a combination of CZX 1/ 4 MIC and GM 1/ 16 MIC (a), or GM 1 MIC alone (b) for 1 hour a) CZX 1/ 4 MIC (MIC; 6.25 Đg/ ml) + GM 1/ 16 MIC (MIC; 6.25 Đg/ ml) b) GM 1 MIC alone (MIC; 6.25 Đg/ml) for 1 hour for 1 hour

VOL.35 NO.11 CHEMOTHERAPY

CHEMOTHERAPY NOV. 1987 6) ANDERSON, E. T.; L. S. YOUNG& W. L. HEWITT: Antimicrobial synergism in the therapy of gram- negative rod bacteremia. Chemotherapy 24: 45 `54, 1978 16) HUNTER, T. H.: The treatment of subacute bacterial endocarditis with antibiotics. Am. J. Med. 1: 83 `92, 1946 17) HUNTER, T. H.: Use of streptomycin in treatment of bacterial endocarditis. J. Med. Am. 2: 436 `442, 1947 18) WEINSTEIN, R. J.: L. S. YOUNG& W. L. HEWITT: Comparison of methods for assessing in

VOL.35 NO.11 CHEMOTHERAPY vitro antibiotic synergism against Pseudomonas end Serratia. J, Lab. Cli. Med. 86: 853 `862, 1975 19) ANDRIOLE, V. T.: Antibiotic synergy in experimental infection with Pseadomonas. II. The effect of carbenicillin, cephalothin, or cephanone combined with tobramycin or gentamicin. J. Inf. Dis. 129: 124 `133, 1974 20) DOUGHERTY, P. F.; D. W. YOTTER& T. R. MATTHEWS : Microdilution transfer plate technique for determining in vitro synergy of antimicrobial agents. Antimicr. Agents Chemother. 11: 225 `228, 1977 21) GARROD, L. P.& P. M. WATERWORTH : Methods of testing combined antibiotic bactericidal action and significance of the result. J. Clin. Petho. 15: 328 `338, 1962 22) MOELLERING, R. C.& D. J. KROGSTAD : Combinations of Antibiotics. Mechanisms of Interaction against Bacteria. In "Antibiotics in Laboratory Medicine. Ed., V. LORIAN, pp. 298 `341, 1980 WEINSTEIN, J.& 23) A. R. C. MOELLERING: Penicillin and gentamicin therapy for enterococcal infection. JAMA 223: 1030 `1032, 1973 24) KLASTERSKY, J. ; C. HENSGENS& F. M. CARPEN- - TIER: Comparative effectiveness of combinations of amikacin with penicillin G and amikacin with carbenicillin in Gram-negative septicemia : Double- blind clinical trial. J. Infe. Dis. 134- S: 433 `440, 1976 25) KLASTERSKY, J. et al.: Significance of antimicrobial synergism for the outcome of Gram negative sepsis. Amer. J. Med. Sci. 273(2): 157 `167, 1977 26) EORTC project group: Three antibiotic regimens in the treatment of infection in febrile granulocytopenic patients with cancer. J. Infe. Dis. 137(1): 14 `29, 1978 27) SCHIMPFF, S.; W. SATTERLEE, V. M. YOUNG & A. SERPICK : Empiric therapy with carbenicillin and gentamicin for febrile patients with cancer and granulocytopenia. New Eng. J. Med. 284: 1061 `1065, 1971 28) RAHAL, J. J. Jr.: Antibiotic combinations ; The clinical relevance of synergy and antagonism. Medicine 57: 179 `195, 1978 29) POGWI2D, S. M.& S. A. LERNER: In vitro activity of gentamicin, amikacin, and netilmicin alone and in combination with carbenicillin against S. marcescens. Antimicr. Agents. Chemother. 10: 878 `884, 1976 32) NAKAzAwA, S.; T. NISHINO, M. OTSUKI, M. NAKAO& T. NOMURA: Bacteriological studies on the combined action of aminoglycoside antibiotics and synthetic penicillins against Pseudomonas aeruginosa. J. Antibiotics 27: 989 `491, 1974 33) MOELLERING, R. C.: Antimicrobial synergism- An elusive concept. J. Inf. Dis. 140: 639 `441, 1979 34) JAWETZ, E.& 7.5. GUNNISON: An experimen. tal basis of combined antibiotic action. JAMA 150: 693 `695, 1952 36) EmoN, G. B. ; S. SINGER& G. H. Hrrau.s: Antagonists of nucleic acid derivatives. VII. Synergism in combinations of biochemically related antimetabolites. J. Biol. Chem. 208: 477 `488, 1952 38) REYES, M. P. et al.: Synergy between carbenicillin and an aminoglycoside against P. aeruginosa isolated from patients with endocarditis and sensitivity of isolates to normal human serum. J. Infe. Dis. 140(2): 192 ` 202, 1979 39) MCLAUGHLIN, J. E.& D. S. REEVES: Clinical and laboratory evidence for inactivation of gentamicin by carbenicillin. Lancet Feb. 6: 261 `264, 1971 40) PICKERING, L. K.& P. GEARHART: Effect of time and concentration upon interaction between gentamicin, tobramycin, netilmicin, or amikacin and carbenicillin or ticarcillin. Antimicrob. Agents Chemother. 15: 592 ` 596, 1979 41) YOUNG, L. S.; G. DECKER& W. L. HEWITT: Interaction of gentamicin by carbenicillin in the urinary tract. Chemotherapy 20: 212 ` 220, 1974 42) WEIBERT, R. T.& W. F. KEANE: Carbenicillin, gentamicin interaction in acute renal failure. Amer. 2. Hosp. Pharm. 34: 1137 `1139, 1977

CHEMOTHERAPY NOV. 1987 COMBINED THERAPY WITH ANTIBIOTICS IN VITRO SYNERGISTIC EFFECTS OF Ĉ- LACTAMS AND AMINOGLYCOSIDES AGAINST S. MARCESCENS MOTOSHI KAWAHARA Department of Urology, Faculty of Medicine, Kagoshima University, Kagoshima (Director Prof. Y.OHI) The purpose of this study was to examine the fractional inhibitory concentration (FIC) index ofĈ -lactams and aminoglycosides (AG.) against S. marcescens. The correlation between growth curves and morphological changes in the bacteria was also clarified at sub- MIC levels. In vitro activities of 27 kinds of combination of 10 Ĉ- lactams and 4 AGs against 27 strains of S. marcescens isolated from patients with urinary tract infections and S. marcescens strain IFO 12648 were studied using the checkerboard method. Combination of so- called third- generation cephems (CEPs) and AGs seemed to enhance the bactericidal effect against almost all strains tested. Growth curves of these strains and the standard strain were studied after addition of each drug at sub- MIC level. The initial inoculum size was 10,405 CFU/ ml. Scanning electron microscopic (SEM) observations were also performed. Synergistic inhibitory rates and minimum FIC indices were LMOX 89% (0.241), CZX 74% (0.322), CPZ 82% (0.310), all in combination with GM; and LMOX 74% (0.359), CZX 78% (0.385) and CPZ 63% (0.384) with AMK. A bactericidal effect of LMOX with GM against S. marcescens No.10 strain (minimum FIC index; 0.125) was observed after adding 1/ 2 and 1/ 4 MIC, respectively. After incubation with 1/ 8 and 1/ 16 MIC, respectively, for 8 hours, viable bacteria decreased to 1/ 10 to 1/ 100 of the controls. With each 1/ 16 MIC of CZX and GM (minimum FIC index ; 0.065) the standard strait was suppressed to 1/ 100 to 1/1,000 of the controls 8 hours later. SEM demonstrated prominent bacteriolysis and/ or filament formation after combination of sub- MICs in comparison with a single regimen. Although the minimum FIC indices did not always coincide with antibacterial synergism, growth curve tests always reflected morphological changes as far as sub- MIC combinations of the thirdgeneration CEPs and AGs were concerned.

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