The Staphylococcus epidermidis genes icaABC are involved in the synthesis of the polysaccharide intercellular adhesin (PIA), which is located mainly on the cell surface, as shown by immunofluorescence studies with PIA-specific antiserum. PIA was shown to be a linear beta-1,6-linked glucosaminoglycan composed of at least 130 2-deoxy-2-amino-D-glucopyranosyl residues of which 80-85% are N-acetylated, the rest being non-N-acetylated and positively charged. A transposon insertion in the icaABC gene cluster (ica, intercellular adhesion) led to the loss of several traits, such as the ability to form a biofilm on a polystyrene surface, cell aggregation, and PIA production. The mutant could be complemented by transformation with the icaABC-carrying plasmid pCN27. Transfer of pCN27 into the heterologous host Staphylococcus carnosus led to the formation of large cell aggregates, the formation of a biofilm on a glass surface, and PIA expression. The nucleotide sequence of icaABC suggests that the three genes are organized in an operon and that they are co-transcribed from the mapped icaA promoter. IcaA contains four potential transmembrane helices, indicative of a membrane location. The deduced IcaA sequence shows similarity to those of polysaccharide-polymerizing enzymes, the most pronounced being with a Rhizobium meliloti N-acetylglucosaminyltransferase involved in lipo-chitin biosynthesis (22.5% overall identity and 37.4% overall similarity). This similarity suggests that IcaA has N-acetylglucosaminyltransferase activity in the formation of the beta-1, 6-linked N-acetyl-D-glucosaminyl polymer. IcaB is secreted into the medium and contains a typical signal peptide. IcaC is hydrophobic and contains six predicted transmembrane helices distributed over its entire length, typical for an integral membrane protein. Neither IcaB nor IcaC shares similarity with known proteins, and their function is unknown. Inactivation of icaA, icaB, or icaC in pCN27 led to the complete loss of the intercellular adhesion phenotype in S. carnosus, suggesting that all three genes are involved in intercellular adhesion, PIA expression, and translocation.

The polysaccharide intercellular adhesin (PIA) is an important factor in the colonization of medical devices by Staphylococcus epidermidis. The genes encoding PIA production are organized in the icaADBC (intercellular adhesion) operon. To study the function of the individual genes, we have established an in vitro assay with UDP-N-acetylglucosamine, the substrate for PIA biosynthesis, and analyzed the products by thin-layer chromatography and mass spectrometry. IcaA alone exhibited a low N-acetylglucosaminyltransferase activity and represents the catalytic enzyme. Coexpression of icaA with icaD led to a significant increase in activity. The newly identified icaD gene is located between icaA and icaB and overlaps both genes. N-Acetylglucosamine oligomers produced by IcaAD reached a maximal length of 20 residues. Only when icaA and icaD were expressed together with icaC were oligomer chains that react with PIA-specific antiserum synthesized. IcaA and IcaD are located in the cytoplasmic membrane, and IcaC also has all the structural features of an integral membrane protein. These results indicate a close interaction between IcaA, IcaD, and IcaC. Tunicamycin and bacitracin did not affect the in vitro synthesis of PIA intermediates or the complete PIA biosynthesis in vivo, suggesting that a undecaprenyl phosphate carrier is not involved. IcaAD represents a novel protein combination among ␤-glycosyltransferases.In recent years, Staphylococcus epidermidis has emerged as a frequent cause of nosocomial infections in association with indwelling medical devices such as intravascular catheters, cerebrospinal fluid shunts, prosthetic heart valves, prosthetic joints, artificial pacemakers, and chronic ambulatory peritoneal dialysis catheters (reviewed in Refs. 1 and 2). The virulence of S. epidermidis in these infections is thought to be based on its ability to colonize medical devices by forming a biofilm composed of multilayered cell clusters embedded in a slime matrix (3). As shown by electron microscopy studies, surface colonization takes place in two steps (4). The first step is primary adhesion of some bacteria, which is followed by proliferation of the cells to multilayered clusters. Factors reported to contribute to primary attachment of S. epidermidis cells to a polymer surface include unspecific hydrophobic interactions (5, 6), a capsular polysaccharide/adhesin (PS/A) (7, 8), proteinaceous cell-surface antigens (SSP-1 and SSP-2) (9, 10), and the autolysin AtlE identified by our group (11).A characteristic feature of the second phase of biofilm formation is intercellular adhesion, which results in the formation of large cell clusters by clinical S. epidermidis strains. This reaction is associated with the production of the polysaccharide intercellular adhesin (PIA) 1 located at the cell surface (12). PIA consists of two structurally related homoglycans, polysaccharides I and II, composed of at least 130 2-deoxy-2-amino-Dglucopyranosyl residues that are mostly (Ͼ80%) N-acetylated. The residues are ␤-1,6-linked (13), ...

Transvenous unipolar active can defibrillation systems have proven to be effective in treating ventricular tachyarrhythmias. However, a further reduction of ventricular defibrillation thresholds (V-DFT) would increase the longevity, reduce the size of pulse generators, and help to avoid additional leads in patients with inacceptable high V-DFTs. In a finite difference computer model, the extension of the right ventricular (RV) defibrillation coil into the low right atrium led to a 40% reduction of unipolar V-DFT. To evaluate this finding, we conducted a prospective, randomized study in 11 patients receiving an ICD. Extension of the RV electrode was simulated by adding a second coil placed in the low right atrium with the same polarity. Using a binary search protocol, V-DFT was determined with and without the additional electrode in each patient. Total shock impedance was significantly lower in the two coil (low RA) configuration, compared to the single coil (RV) configuration. Corresponding values were 49.9 +/- 6.7 Ohm and 61.1 +/- 9.3 Ohm, respectively (P < 0.01, paired t-test). However, there was no reduction, but even a nonsignificant increase in V-DFTs. Mean V-DFT in the RV configuration was 12.0 +/- 5.6 J and 16.3 +/- 7.8 J in the low RA configuration (P = 0.09, paired t-test). Despite a reduction in total impedance, the addition of a defibrillation coil in the low right atrium does not reduce ventricular defibrillation thresholds.