SummaryAntibodies to factor VIII (inhibitors) are usually produced at the beginning of treatment with factor VIII and are rare in multitransfused patients. Such antibodies are deemed to be patient-related, as supported by the description of a number of associated risk factors. However, a second category of inhibitors has recently been identified, namely antibodies occurring in multitransfused patients as a result of exposure to a particular factor VIII concentrate. A first outbreak of product-related inhibitors was recently described. The present paper describes the second well-documented occurrence of such inhibitors.Eight out of 140 multitransfused patients with severe haemophilia A developed an inhibitor to factor VIII shortly after changing treatment to a double-virus inactivated plasma-derived factor VIII concentrate. In addition to solvent-detergent treatment, this concentrate was pasteurised at 63° C for 10 hours. Exposure to the pasteurised product before inhibitor detection ranged from 9 to 45 days. Inhibitor titers varied between 2.2 and 60 Bethesda Units and recovery of transfused factor VIII ranged from 0.21 to 0.68 (expressed as IU/dl factor VIII rise per IU/kg administered). In contrast to usual inhibitors in haemophilia A patients, these product-related inhibitors showed complex inhibition kinetics. They were found specific for the factor VIII light chain. The inhibitors gradually declined when exposure to the pasteurised product was stopped, despite further treatment with other factor VIII concentrates. The present data stress the importance of carefully monitored clinical studies, both in previously treated and previously untreated patients, before introduction of a new or modified clotting factor concentrate.

The streptogramins and related antibiotics (the lincosamides and macrolides) (MLS) are important inhibitors of bacterial protein synthesis. The key reaction in this process is the formation of a peptide bond between the growing peptide chain (peptidyl-tRNA) linked to the P-site of the 50S ribosome and aminoacyl-tRNA linked to the A site. This reaction is catalysed by the peptidyl transferase catalytic centre of the 50S ribosome. Type A and B streptogramins in particular have been shown to block this reaction through the inhibition of substrate attachment to the A and P sites and inhibition of peptide chain elongation. Synergy between type A and B components results from conformational changes imposed upon the peptidyl transferase centre by type A compounds and by inhibition of both early and late stages of protein synthesis. The conformational change increases ribosomal affinity for type B streptogramins. Microbial resistance to the MLSB antibiotics is largely attributable to mutations of rRNA bases, producing conformational changes in the peptidyl transferase centre. This can result in resistance to a single inhibitor or to a group of antibiotics (MLSB). The activity of type A streptogramin is retained thus explaining the improved inhibitory action of the combined streptogramins against macrolide and lincosamide-resistant strains. However, the development of resistance to the streptogramins may be less of a problem because of the synergic effect of type A and B compounds which has also been demonstrated in strains resistant to MLSB i.e., high level resistance to the combined streptogramins is only likely when type A streptogramin resistance determinants are present along with type B streptogramin resistance determinants.

By testing all donations as pools of 480 by un-nested PCR, and resolving positive pools to identify the responsible donations, it is possible to ensure that the viral load in fractionation pools (5000 donations) remains < 10(3) IU/ml, compatible with the efficacy of inactivation procedures and complying with Food and Drug Administration (FDA) recommendations.

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Synergimycins A and B act synergistically in vivo; the mixture of the two compounds is more powerful than the individual components and their combined action is irreversible. Type A (virginiamycin M, VM-like) components inactivate the donor and acceptor sites of peptidyltransferase, thus interfering with the corresponding functions of the enzyme. They block two of the peptide chain elongation steps: aminoacyl-tRNA (AA-tRNA) binding to the A site of ribosomes, and peptide bond formation with peptidyl-tRNA (pep-tRNA) at the P site. A tight (non-exchangeable) linkage of tRNA derivatives with the two ribosomal sites requires a stable interaction of their aminoacyl component with peptidyltransferase. Such interaction is prevented by VM, hence the release of AA-tRNA from the A site and of pep-tRNA from the P site upon translocation; ultracentrifugally unstable particles (60S) are thus formed. A new model for peptidyltransferase has been proposed, to account for the interference of VM with the two sites of the enzyme. The action of this antibiotic is partly due to its presence on the ribosome, and partly to the conformational alterations triggered by its binding. Type B synergimycins (VS-like) and the related 14-membered macrolides (erythromycin) have a more complex action, as revealed by copolymer-based models of cell-free protein synthesis. These antibiotics produce an inhibition of peptide bond formation, and a release of incomplete peptide chains, which processes are both template-dependent (i.e. linked to the polymerization of basic amino acids and proline). The functional interference of VS with peptidyltransferase is explained by the location of the corresponding binding site at the base of the central protuberance of 50S subunits. When ribosome.VS complexes are incubated with erythromycin, the former antibiotic is replaced by the latter; such a replacement does not occur in the presence of VM, which reduces ribosome affinity for macrolides and increases that for type B synergimycins. A study of these complex ribosomal interactions by stopped-flow spectrofluorimetry had allowed a mapping of the binding sites for the MLS antibiotics (macrolides, lincosamides, type B synergimycins) within the peptidyltransferase domain. The active component of these binding sites is represented by segments (loop V and domain II) of 23S rRNA, as indicated by protection and mutation mapping experiments, L proteins increasing the affinity of fixation and its specificity.