EFFECTS OF SULFONAMIDES USED IN CONJUNCTION

WITH AZOCHLORAMID IN LOCALIZED INFECTIONS*

REPORT OF TWO CASES

ERWIN NETER, M.D.

Attending Bacteriologist, ChiIdren’s HospitaI

BUFFALO, NEW YORK

S EVERAL successfu1 attempts have been made to increase the efficacy of suIfonamides as chemotherapeutic

agents for the treatment of experimenta infections of animals and naturaI infections of man. For exampIe, it was shown that, both in vitro and in vivo, the antibacteria activity of suIfonamides is enhanced when the environmenta temperature is increased above 37’~. (Wengatz, Boak, and Carpen- ter,’ White,2,3 Spink,4 WeId and MitcheII,” Neter,6 BeIt and FoIkenberg,’ Bang,s and others). The administration of suIfon- amides in conjunction with certain immune sera has been proved to be more effective than treatment with either agent aIone (Branham and RosenthaI,g Branham,lO BuIIowa, Osgood, Bukantz, and[BrownIee,l’ Tager, I2 and others). Likewise, the com- bined use of suIfonamides and specific bacteriophage may yieId favorabIe resuIts in the treatment of staphyIococca1 in- fections according to Zaytzeff-Jern and MeIeney.13v14 In this connection it is interesting to note that in vitro sulfon- amides may inhibit the deveIopment of phage-resistant staphyIococci ( Neter15).

The question presents itseIf as to whether or not increased antimicrobia1 activity can be obtained by the simuItaneous use of two different chemotherapeutic substances. Os- good and his co-workers16 studied the effect of neoarsphenamine plus suIfathiazoIe in marrow cuItures and suggested the com- bined use of these drugs in the treatment of severe infections of man. In vitro experi- ments on the antipneumococca1 activity

of optochin hydrochIoride (ethyIhydro- cupreine hydrochIoride) or beta-hydroxy- ethyIapocupreine dihydrochIoride used in conjunction with suIfapyridine faiIed to revea1 any potentiating effects (Neterl’). In contrast, suIfonamides and azochIor- amid exerted greater bacteriostatic activity in vitro toward hemoIytic streptococcus, pneumococcus, and staphyIococcus than did either compound aIone (Neterls’lg). This observation has since been cor- roborated by SchmeIkes and Wyss.20 GoId- berger21 recentIy presented his extensive observations on the potentiation of the suIfonamides in the IocaI therapy of wounds and surgica1 infections by the use of oxidants. This author observed that suIfaniIamide and suIfathiazoIe pIus azo- chIoramid or LugoI’s soIution exert greater bacteriostatic activity against StaphyIo- coccus aureus in broth than do any of the compounds aIone. SchmeIkes and Wyss20 made the interesting observation that azochIoramid counteracts the antisuIfon- amide activity of para-amino-benzoic acid.

GoIdberger21 obtained favorabIe resuIts

in the treatment of IocaIized infections by the use of suIfonamides, which were potentiated by the simuItaneous adminis- tration of azochIoramid, LugoI’s iodine or zinc peroxide. In order to stimuIate further investigations on the clinica appIications

of such synergistic effects, the folIowing observations are briefly presented :

SuIfonamides in conjunction with azo-’ chIoramid were used in the treatment of

* From the Children’s HospitaI and from the Department of Bacteriology and ImmunoIogy of the University of BuffaIo, School of Medicine, BuffaIo, New York.

69

70 American Journal of Surgery Neter-Localized Infections OcrosnR. r+G?

severa cases of wound infections.* In no instance were toxic effects noted resuking from this therapy. One case is of particular interest:

F. L., a white male, eighteen years of age, suffered from an infection of an old burn. Cultures reveaIed the presence of beta hemo- Iytic streptococcus. The patient was treated with an ointment of suIfaniIamide for eIeven days. FoIIowing this treatment the hemoIytic streptococcus disappeared from the wound; however, the infection persisted and the cuIture reveaIed the presence of StaphyIococcus aureus hemoIyticus, which caused coaguIation of human pIasma and, therefore, has to be con- sidered as a pathogen. SuIfathiazoIe ointment was administered for nineteen days. AI1 cuhures remained positive for pathogenic staphyIococ- cus. SubsequentIy, suIfathiazoIe (I Gm. five times a day) was given by mouth for ten days. Again, staphylococci were recovered. Then, sulfadiazine powder was appIied to the wound for ten days. CuItures &II revealed the presence of pathogenic staphyIococcus. Finally, a SOIU- tion of azochIoramid (0.2 per cent), suIfaniI- amide (2.23 per cent), sodium tetradecyl suIfate (0.1 per cent), and triacetin (97.43 per cent) was appIied to the wound for eight consecutive days. CuItures taken during this period and the foIlowing eight days remained steriIe. However, ten days after this treatment was discontinued, pathogenic staphyIococcus was again recovered. These observations sug- gest that the combined administration of suIfonamides and azochIoramid resuIted in transitory disappearance of staphyIococcus from a wound, a resuIt which was not obtained by IocaI or systemic administration of suI- fonamides alone.

A second observation on the effects of suIfonamides used in conjunction with azochloramid foIIows :

J. G., a white femaIe, two years of age, was admitted to this hospita1 because of pneumonia and ehpyema. The patient was given 15 gr. of suIfadiazine and then 5 gr. every four hours. The temperature dropped from 105’~. to

too%. within two days. On the second day of hospitalization, suIfaniIamide (5 gr. every four

* The soIutions of azochloramid and sulfanilamide were obtained from Wallace & Tiernan Products through the courtesy of Dr. F. C. SchmeIkes.

hours) was substituted for suIfadiazine. This treatment was continued for eighteen days. Chest taps were done frequentIy. The amounts of fluid removed ranged from I cc. to 150 cc., with a tota of approximately 750 cc. The number of viabIe streptococci was determined by means of poured bIood agar pIates; para- aminobenzoic acid was added to the cuIture medium to counteract any growth inhibitory effects from suIfaniIamide. The concentration of free suIfaniIamide in the exudate was also determined. TabIe I summarizes the results of

TABLE I STREPTOCOCCAL EMPYEMA

Date

2-2-42 2-3-42

2-4-42

2-5-42

2-6-42

2-7-42

2-8-42

2-g-42

2-10-42

2-11-42

z-12-42

2-13-42

2-14-42

2-15-42

2-16-42

z-17-42

2-18-42

z-19-42

2-20-42

2-23-42

2-25-42

-

Treat-

Sd Sd

ss S S, AS S

ss S

Z S, AS

;

2 S S

- -

Concentration of SuIfaniIamide

(mg. %) in Empyema Fluid

12.65 9.38 9.2

13.2 12.9 8.52

3.6 . 6.0

9.3 I.”

trace

-

_j_ ,

L

Approximate Number of

Streptococci Per Cc. of

Empyema FIuid

>1,000,000 5,000,000 5,000,000

. 2,400

. 4oo

.

8

1

0

0

0

S = SuIfaniIamide (per OS). Sd = Sulfadiazine (per OS). AS = AzochIoramid-suIfanilamide solution (intra-

pIeuraIIy). . . . . = No determinations carried out.

these investigations. It may be seen from TabIe I that the exudate contained more than I,OOO,OOO viabIe streptococci per cc. in spite of the fact that free suIfaniIamide in concentra- tions ranging from 9.2 to 12.7 mg. per cent was present. Twenty-four hours foIIowing the intrapIeura1 injection of IO cc. of azochIoramid- suIfaniIamide soIution and simuItaneous admin- istration of suIfaniIamide by mouth, the number of coIonies had decreased to 2,400 per

NEW SERIES VOL. LVIII, No. I Neter-Localized Infections American Journal of Surgery 71

cc. From then on, the number of coIonies 3. WHITE, H. J. Peptone-dextrose broth for use in

diminished steadily and, folIowing a second studies of anti-bacterial activity. Proc. Sot.

intrapleural injection of the azochloramid- Exper. Biol. ti Med., 43: 214-216 (Jan.) 1940.

sulfanilamide soIution, the exudate became 4. SPINK, W. W. The bactericidal effect of sulfa-

compIeteIy steriIe. CIinicaIIy, the patient was in niIamide upon pathogenic and non-pathogenic staphylococci. J. Zmmunol., 37: 345-358, rg3g.

very good condition. No operative measures 5. WELD, J. T. and MITCHELL, L. C. Studies on modifi-

except chest taps were carried out. cation of suIfaniIamide in vitro. J. Bact., 38:

The remarkabIe decrease in the number of 335-350, 1939.

viabIe streptococci foIIowing the first intra- 6. NETER. E. Effect of temnerature on bacteriostatic

action of suIfaniIamide upon members of the

pIeura1 injection suggests that this treatment enterococcus group. Proc. Sot. Exper. Biol. ~7

contributed materiaIIv to the steriIization of Med., 43: 52-55, 1940.

the exudate. It is likely that steriIization 7. BELT, E. and FOLKENBERG, A. W. Treatment of

would have occurred also if the second intra- gonorrhea by artiIicia1 fever aIone and in com- bination with SuIfaniIamide. Arch. Pbys. Tberapy,

pIeura1 injection had been omitted. It may be 21: 203-210, 1940.

mentioned that, except for a transitory rise in 8. BANG, F. B. Influence of temperature on suI-

temperature, no toxic effects resuIted from this fathiazole therapv of gonococcal infections.

treatment. It must be pointed out that a con- J. Ural., 47: 2gg-io1, 194%

o. BRANHAM. S. E. and ROSENTHAL. S. M. Studies in siderable degree of pleura1 thickening was

2

chemotherapy. V. SuIphaniIamide, serum, and

present. Whether this is due to the infection combined drug and serum therapy in experi-

itseIf or to the IocaIIy appIied azochloramid- menta1 meningococcus and pneum-&occus infec-

SuIfaniIamide soIution cannot be stated with tions in mice. Pub. Health Rep., 52: 685-695, 1937.

certainty. IO. BRANHAM. S. E. Effects of SuIfanvridine and . I

SuIfaniIamide with and without serum in experi- menta1 meningococcus infection. Pub. Healtb

AIthough these observations do not per- Rep., 55: 12-25, rg4o.

.mit of any far-reaching concIusions, they I I. BULLOWA, J. G. M., OSGOOD, E. E., BUKANTZ, S. C.

and BROWNLEE, I. E. The effect of sulfapyridine

suggest that in certain cases of IocaIized aIone and with serum on pneumococcic pneu-

infections, in which treatment with suIfon- monia and on pneumococcus-infected marrow

amides aIone faiIs to resuIt in cure, the cuItures. Am. J. M. SC., 199: 364-380, 1940.

12. TAGER, M. The therapy of acute staphylococcal

combined administration of suIfonamide infection of mice with antitoxin and sulfonamide

and chIorine compounds such as azochIor- compounds. Yale J. Biol. c?f Med., 13: 237-252,

amid may yieId increased antimicrobial 1940.

13. ZAYTZEFF-JERN, H. and MELENEY, F. L. Effect on

effects. This confirms similar observations bacteriophage of prontyIin, prontosil, sulfa-

of GoIdberger. 21 It is hardIy necessary to pyridine and other antiseptics and dyes used in

point out that a thorough investigation on surgica1 practice. J. Lab. &’ Clin. Med., 24: 1017-1026. Io39.

the possibIe toxic effects resuIting from this 14. ZAYT~EFF-JERN~H. and MELENEY, F. L. The effect

treatment shouId be carried out. In this of SuIfapyridine and suIfaniIamide on staphyIo-

connection it is we11 to keep in mind that cocci and B. coIi and their respective bacterio-

the combined used of sulfonamides and phages. J. Lab. @ Clin. Med., 26: 17561767,

1941.

other drugs may decrease the toxicity of 15. NETER, E. Inhibitory effect of sulfamido com-

the suIfonamide (Bodansky22) or enhance pounds upon development and growth of phage- resistant bacteria. Proc. Sot. Exper. Biol. u

its iI effects (Harned and CoIe23). The Med., 47: 20-23, 1941.

possibIe cIinica1 applications of the syner- 16. OSGOOD. E. E.. JOSKI. J. and BROWNLEE. I. E.

gistic action of suIfonamides and chIorine The superiority of neoarsphenamine and sulfa-

compounds deserve further attention. thiazol in the therapy of staphyIococcus aureus infections in marrow cultures. Surg., Gynec. eY Obst., 71: 445-450, 1940.

17. NETER, E. The combined bacteriostatic action of REFERENCES SuIfapyridine and optochin upon pneumococcus

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C. M. The bactericida1 of suIfaniIamide on the sulfanilamide and azochIoramid upon group A gonococcus in vitro. J. Bact., 35: 36-36, 1938. hemoIytic streptococcus and enterococcus. Proc.

2. WHITE, H. J. ReIationship between temperature Sot. Exper. Biol. 0 Med., 47: 303-305, 1941. and streptococcidal activity of sulfanilamide and 19. NETER, E. An in vitro study on the synergistic sulfapyridine in vitro. J. Bact., 38: 549-562, 1939. action of sulfamido comnounds and azochIoramid

72 Americun Journal of Surgery Neter-Locahzed Infections

upon various pathogenic microorganisms. J. zz. BODANSKY, 0. Reduction of toxicity of 2-sulfan- Pbarmacol. @ Exper. Tberap., 74: 52-60, 1942. itamidopyrimidine (suIfadiazine) by phenylazo-

20. SCHMELKES, F. C. and WYSS, 0. Inactivation of alpha-aIpha-diaminopyridine hydrochIoride sulfonamide inhibitor by azochloramid. Proc. (pyridium) in the mouse. Proc. Sot. Exper. Biol. Sot. Exper. Biol. GY Med., 49: 263-267, 1942. u Med., 49: 216218, 1942.

21. GOLDBERGER, H. A. The potentiation of the 23. HARNED, B. K. and COLE, V. V. A therapeutic incomoatibiIitv between suIfaovridine and aui- sulfonamides in the local therapy of wounds and

surgical infections by the use of oxidants. Am. J. Suv., 56: 343-374, 1942.

I 1..

nine. J. Pbarmacol. CY Exper. Tberap., 74: 42-5 I, 1942.

LOCAL causes of anorexia are mainIy based upon a decreased hydro-

chloric acid secretion. This is particuIarIy evident in carcinoma of the

stomach, chronic gastritis, pernicious anemia, and other conditions with

achlorhydria. It is not an absoIute ruIe but is most evident in the first two.

From “Symptoms in Diagnosis” by Jonathan CampbeII Meakins (Little,

Brown and Company).