Evidence of active transport of benzyl-14C-penicillin from cerebrospinal fluid to blood

Relevance in biology and mechanisms of immune and treatment evasion of Treponema pallidum

INTRODUCTION

During syphilis a compelling fight is engaged between the host's humoral and cellular immune responses that work to eliminate the infection and Treponema pallidum (T. pallidum) that manages to evade eradication and cause chronic infection. Different mechanisms are utilized by treponemes to overcome immunological response. Although penicillin (BPG) proved to be effective in quelling the early manifestations of the disease and consequently its contagiousness, questions remain about its ability to prevent the late complications and to provide a microbiological eradication in vivo. In fact, both serological and microbiological failures have been reported following conventional treatment.

EVIDENCE ACQUISITION

We reviewed some biologic properties of T. pallidum in order to establish a relationship with the persistence of the infection and the alleged treatment resistance.

EVIDENCE SYNTHESIS

The host humoral response, sometimes, may not protect completely against T. pallidum and accounts for the persistent infection and tertiary damages. In fact, the cell mediated response during infection may be downregulate in response to pathogen-derived molecules, or indirectly by generating Treg cells. It is also possible that there are strain types of T. pallidum with higher ability of evasion determining neurosyphilis. In addition, apart the impressive results that BPG has made on the syphilis cutaneous lesions, concerns still remain on its efficacy in preventing late complications.

CONCLUSIONS

Understanding the biology of the T. pallidum may help researchers in this field to develop future target therapies in order to prevent persistent infection and progression of the disease.

Drug efflux transporters in the CNS

The central nervous system (CNS) contains important cellular barriers that maintain homeostasis by protecting the brain from circulating toxins and through the elimination of toxic metabolites generated in the brain. The barriers that limit the concentration of toxins and xenobiotics in the interstitial fluids of the CNS are the capillary endothelial cells of the blood-brain barrier (BBB) and the epithelial cells of the blood-cerebrospinal fluid barrier (BCSFB). Both of these barriers have cellular tight junctions and express transport systems which serve to actively transport nutrients into the brain, and actively efflux toxic metabolites and xenobiotics out of the brain. This review will focus on the expression and function of selected drug efflux transporters in these two barriers, specifically the multidrug resistance transporter, p-glycoprotein, and various organic anion transporters, such as multidrug resistance-associated proteins, organic anion transporter polypeptides, and organic anion transporters. These transport systems are increasingly recognized as important determinants of drug distribution to, and elimination from, different compartments of the CNS. Consequences of drug efflux transporters in barriers of the CNS include limiting the distribution of substrates that are beneficial to treat CNS diseases, and increasing the possibility of drug-drug interactions that may lead to untoward toxicities. Therefore, the study of these transporters is important in examining the various determinants of drug delivery to the CNS.

The impact of efflux transporters in the brain on the development of drugs for CNS disorders

The development of drugs to treat disorders of the CNS requires consideration of achievable brain concentrations. Factors that influence the brain concentrations of drugs include the rate of transport into the brain across the blood-brain barrier (BBB), metabolic stability of the drug, and active transport out of the brain by efflux mechanisms. To date, three classes of transporter have been implicated in the efflux of drugs from the brain: multidrug resistance transporters, monocarboxylic acid transporters, and organic ion transporters. Each of the three classes comprises multiple transporters, each of which has multiple substrates, and the combined substrate profile of these transporters includes a large number of commonly used drugs. This system of transporters may therefore provide a mechanism through which the penetration of CNS-targeted drugs into the brain is effectively minimised. The action of these efflux transporters at the BBB may be reflected in the clinic as the minimal effectiveness of drugs targeted at CNS disorders, including HIV dementia, epilepsy, CNS-based pain, meningitis and brain cancers. Therefore, modulation of these efflux transporters by design of inhibitors and/or design of compounds that have minimal affinity for these transporters may well enhance the treatment of intractable CNS disorders.

Pharmacokinetics and pharmacodynamics of antibiotics in meningitis

The penetration of antimicrobials into the CSF is dependent on lipid solubility, molecular size, capillary and choroid plexus efflux pumps, protein binding, and the degree of inflammation. Penicillins, certain cephalosporins, carbapenems, fluoroquinolones, vancomycin, and rifampin provide the highest ratios of CSF levels to the MBC for common infecting organisms. For beta-lactam antibiotics, it is the duration of time that CSF concentrations exceed the MBC that determines the rate of bactericidal activity. It appears that levels should exceed the MBC for more than 50% of the dosing interval. The peak/MBC and AUC/MBC ratios are important determinants of efficacy for aminoglycosides and fluoroquinolones. Once-daily dosing of aminoglycosides is as effective as multiple-daily dosing regimens in experimental meningitis, probably because of drug-induced prolonged persistent effects. Fluoroquinolones do not produce as prolonged persistent effects and are slightly less effective when administered once daily. Although steroid use can reduce the penetration and decrease the bactericidal activity of some antimicrobials, such as vancomycin, in experimental meningitis, the clinical impact of steroid use in human meningitis is still unclear.

Effect of para-aminohippurate on the efflux of valproic acid from the central nervous system of the rabbit

Recently we investigated the mechanisms mediating the transport of valproic acid (VPA) between blood and brain. In one study efflux of valproic acid (VPA) from rabbit brain was inhibited by probenecid. Efflux of VPA decreased when probenecid was given intravenously but not when probenecid was given by ventriculocisternal (VC) perfusion indicating that the major site of probenecid-sensitive transport was at the brain capillary endothelium and not at the choroid plexus. In another study VPA transport into rat brain was inhibited by para-aminohippurate (PAH). The purpose of the present study were to determine (a) if the efflux of VPA from rabbit brain was also inhibited by PAH, and (b) whether efflux of VPA could occur at the choroid plexus via an PAH-selective transport system. Six control rabbits received VPA by intravenous infusion and tracer concentrations of [3H]VPA and [14C]PAH by VC perfusion. Rabbits in the PAH group (n = 6) received identical treatment with VPA, tracer concentrations of [3H]VPA and [14C]PAH and, in addition, received 20 mM PAH by VC perfusion. PAH had no effect on the VC extraction ratio of [3H]VPA or the steady-state brain concentration of intravenously administered VPA. It is concluded that the efflux of VPA at the rabbit blood-brain barrier is mediated by a transporter different from the PAH-like transporter responsible for the uptake of VPA into rat brain. In addition, the finding that VC perfusion with PAH had no effect on the VC extraction of [3H]VPA provides further evidence that the choroid plexus plays a negligible role in removal of VPA from the CNS.

Pharmacokinetic quantification of the exchange of drugs between blood and cerebrospinal fluid in man

Various parameters which may be useful in quantification of drug transit from blood into CSF and vice versa after a short duration infusion are compared here by recalculating previously published data from our group. Due to the slower entry into and elimination from the CSF compartment as compared to the central compartment, the ratio of drug concentrations in CSF and serum sampled at the same time increase with time after an infusion. Therefore, concentration quotients of simultaneously drawn blood and CSF are inadequate to characterise CSF penetration. The ratio of the areas under the concentration-time curves in a body fluid and serum (AUCbody fluid/AUCs) is an established measure to quantify overall penetration from the central into a peripheral compartment. AUCCSF/AUCs is closely correlated with the quotient of the maximum CSF and serum concentrations (CmaxCSF/CmaxS) (rs = 0.87, n = 42, P < 0.001) and with the rate constant of distribution in CSF (CLin/VCSF) (rs = 0.80, n = 42, P < 0.001). Since CmaxCSF/CmaxS depends on the mode of drug administration, it is suggested that AUCCSF/AUCs be used to quantify overall drug transit into CSF. CLin/VCSF is of use when CSF can only be sampled once, or when the velocity of the transit of a drug into CSF is to be described. The CSF exit rate constant (CLout/VCSF) characterises elimination from CSF independent of the elimination from serum and may be applied to estimate the formation rate of CSF; in the present study it averaged 20 ml/h.

Solubilization and stabilization of a benzylpenicillin chemical delivery system by 2-hydroxypropyl-beta-cyclodextrin

A dihydropyridine----pyridinium salt redox carrier-based chemical delivery system for benzylpenicillin (1) was complexed with 2-hydroxypropyl-beta-cyclodextrin (HPCD). The solubility of the lipophilic 1, which is incompatible with aqueous formulations, was dramatically increased and showed a linear dependency on the HPCD concentration. The degree of incorporation was 20 mg of 1 per g of complex. The stability study of 1 in various pH buffers indicated the base-catalyzed hydrolysis of the acyloxyalkyl linkage and the hydration of the 5,6 double bond of the dihydropyridine as the main degradation processes. The overall loss of 1, which follows first-order kinetics, was not influenced by changes in ionic strength and elimination of oxygen from the reaction medium. The HPCD complex of 1, which has a stability constant of 720-940 M-1, stabilized the chemical delivery system. The influence of the temperature on the stability of 1 is also discussed.

Interaction between benzylpenicillin and thiopental in the central nervous system of the male rat

The effect of benzylpenicillin (BPC) pretreatment on the kinetics and brain sensitivity for thiopental was studied in male rats using a previously developed electroencephalgrafic (EEG) threshold method. Thiopental was infused intravenously with constant infusion rate. The rats were killed by decapitation immediately after the first burst suppression of 1 sec. or more (the silent second) which was observed in the EEG-record during the infusion. Thiopental concentration in serum and in different brain regions was determined by a high pressure liquid chromatografic method. After pretreatment with 0.9 g/kg of BPC the dose of thiopental needed to induce the silent second was significantly reduced (-20 per cent) when compared with saline treated controls. The serum concentration was also reduced (-30 per cent) after this BPC pretreatment but the concentrations in the different brain regions were the same in both groups. After pretreatment with 1.2 g/kg of BPC almost all animals had convulsions, the dose needed to obtain the silent second was very much reduced and there were reduced concentrations of thiopental in the different brain regions. After both doses of BPC high negative correlations were found between BPC concentrations in brain tissue and thiopental concentrations in hippocampus and brainstem indicating an interaction between the drugs. The most probable site of this interaction is the organic acid transport system out of the CNS which could be used by both substances. Lipid solubility is not the only factor involved in the distribution of thiopental in the rat brain.

Quinine reduces noxious cochlear effects of furosemide and ethacrynic acid

Endocochlear potential (EP) and eighth nerve action potential (AP) were measured in chinchillas. We investigated the interaction of quinine with the loop diuretics furosemide and ethacrynic acid to determine whether the cochlear effects of these agents are attenuated by pretreatment with quinine. Animals were injected with either furosemide, 25 mg/kg intravenously (IV), or ethacrynic acid, 15 mg/kg IV. Control animals injected without pretreatment were found to have a large decrease in EP, with a decrease of compound action potentials (CAP) amplitude and an elevation of CAP threshold. Animals pretreated with quinine, 25 mg/kg, were found to have a significantly smaller reduction of EP and CAP amplitude following injection of either diuretic. No significant differences in urine volumes were noted between experimental and control groups. Quinine is known to cause nonspecific changes in the membranes of epithelial cells, which may cause alterations of the transport of organic anions by such tissues. Such an effect on epithelial cells in the cochlea may cause reduced uptake of loop diuretics in this organ, resulting in reduced toxicity.

Neurotoxicity of beta-lactam antibiotics. Experimental kinetic and neurophysiological studies

The neurotoxic potential of intravenous administered benzylpenicillin (BPC) was studied in rabbits with intact blood-CNS barriers and rabbits with experimental E. coli meningitis. At onset of epileptogenic EEG activity or seizures, serum, CSF and brain tissue were collected for assay of BPC. Based on the fact that, in tissues, BPC seems to remain extracellularly, brain concentrations of BPC were expressed as brain tissue fluid (BTF) levels, calculated as 10x the concentration in whole brain tissue. Neurotoxicity could be precipitated in all rabbits. In normal rabbits BTF levels of BPC were considerably higher than those in CSF indicating a better penetration across the blood-brain barrier (BBB). BPC penetrated better to CSF and BTF in meningitic rabbits than in normal controls, suggesting some degree of damage of the BBB concomitant with meningeal inflammation. E. coli meningitis did not increase the neurotoxicity of BPC. In control rabbits the intracisternal injection of saline resulted in some degree of pleocytosis. Unmanipulated animals are therefore preferable as controls. Epileptogenic EEG-changes was the most precise of the two variables used for demonstration of neurotoxicity. EEG-changes were therefore used as neurotoxicity criterion in the following rabbit experiments. To evaluate the effect of uraemia alone and uraemia plus meningitis on the neurotoxity of BPC in rabbits, cephaloridine was used to induce uraemia. Meningitis was induced by intracisternal inoculation of a cephalosporin resistant strain of E. cloacae. Untreated rabbits were used as controls. Uraemia resulted in increased BTF penetration of BPC, possibly explained by permeability changes in the BBB and/or decreased binding of BPC to albumin. Uraemia did not result in increased penetration of BPC into the CSF of non-meningitic rabbits. Uraemic non-meningitic rabbits had the highest BTF levels of BPC at the criterion, indicating that cephaloridine-induced renal failure increased the epileptogenic threshold in these rabbits. The combination of uraemia and meningitis increased the neurotoxicity of BPC since the criterion was reached at considerably lower BTF levels of BPC. Meningitis, either alone or together with uraemia, did not increase the neurotoxicity in comparison to control rabbits. Higher BTF levels of BPC were found in meningitic rabbits than in controls with intact blood-CNS barriers at onset of EEG-changes. In all groups of rabbits there was a pronounced variability of BPC levels in the CSF while the intra-group variations in BTF levels were much smaller. Thus, BTF and not CSF levels were decisive for the neurotoxicity of BPC.(ABSTRACT TRUNCATED AT 400 WORDS)

Susceptibility of relatively penicillin-resistant Streptococcus pneumoniae to newer cephalosporin antibiotics

Antimicrobial susceptibilities were performed at the Centers for Disease Control on 3400 Streptococcus pneumoniae isolates that were collected during a national survey of serotype-distribution of pneumococci found in normally sterile body fluids. The results showed 126 isolates (3.7%) to be relatively resistant to penicillin (RPR). The RPR strains were tested for susceptibility to cefuroxime, ceftriaxone, cefotaxime, cefamandole, cefaclor, ceftazidime, and moxalactam. These newer generation cephalosporin drugs were tested either because of their ability to penetrate into the cerebrospinal fluid (CSF) or for their activity against pneumococci. Three hundred ninety-one pneumococci were tested with 179 resistant to at least one antimicrobial. The RPR strains were not categorically resistant to the cephalosporins but were fourfold more resistant to them than were the penicillin-susceptible strains. The three most effective antimicrobials in the study for RPR were cefuroxime, cefotaxime, and ceftriaxone [corrected]. Each gave MICs that were attainable in CSF for RPR. Fifty percent of the RPR were inhibited by 0.06 mg/ml and 90% by 0.25 micrograms/ml of these antimicrobials. The least effective were cefaclor, moxalactam, and ceftazidime.

Diurnal oscillations of CSF valproate in monkey

Valproate (VPA) was administered to four rhesus monkeys by constant-rate intravenous infusion for two weeks under controlled conditions. Plasma and CSF samples were collected for a period of 27 hours at 3-hour intervals during steady-state and post-infusion periods. The mean correlation coefficient between total plasma and CSF VPA concentrations was found to be 0.78 +/- 0.09. The CSF VPA levels reflected the changes in free VPA in plasma but the two were not equivalent. Diurnal fluctuations in CSF VPA concentration were similar to those found in plasma but the inter-animal variation was greater in CSF than in plasma.

Gram-negative bacillary meningitis

The incidence of gram-negative bacillary meningitis has increased significantly in the past two decades. Approximately two thirds of all reported cases have occurred after neurosurgical procedures. With the development of the newer cephalosporins, the overall mortality rate has decreased from 40 to 80 per cent to 10 to 20 per cent.

Rationale for optimal dosing of beta-lactam antibiotics in therapy for bacterial meningitis

This review considers the five major principles governing optimal dosing of beta-lactam antibiotics in therapy for bacterial meningitis: off the entry of passage of antibiotics into CSF, (2) the antimicrobial activity of beta-lactams within the purulent CSF in vivo, (3) the bactericidal activity within the CSF, (4) the route and mode of drug administration together with the postantibiotic effect, and (5) the duration of therapy. Special attention is paid to the third principle, bactericidal activity within the CSF, employing the model of the newer, third-generation cephalosporins used in the treatment of meningitis caused by gram-negative aerobic bacilli.

Pharmacokinetics of capacity-limited tissue distribution of methicillin in rabbits

Single-dose and steady-state studies were carried out in rabbits to characterize the pharmacokinetics of methicillin elimination and tissue distribution. Serum methicillin concentrations after single doses exhibited a biexponential decline with a mean terminal half-life of 27 +/- 5 min. Steady-state volume of distribution (Vdss) decreased twofold as doses increased from 5 to 125 mg/kg, while total clearance was consistent over this dosage range. During steady-state infusions of 8.7-87.2 mg/kg/h, the serum and extravascular fluid concentrations increased in proportion to dose, while clearance remained constant. Methicillin tissue concentrations did not increase in proportion to dose and serum concentration, and the Vdss measured from tissue recovery decreased as dosage and serum concentrations increased. Central compartment volume and serum protein binding did not change. The cause of the dose-dependent change in Vdss was a capacity-limited uptake of methicillin into essentially all nonexcretory tissues. This process was described by a partial physiological pharmacokinetic model based on the actual weights or volumes of the rabbit tissues. Distribution into extracellular fluids was assumed to be complete, while entry into cellular, nonexcretory tissue became capacity limited as the Km (17.2 micrograms/mL) was exceeded. The result was a decline in Vdss with increasing serum concentrations to a limiting value which approached the volume of the central space (Vc) and was similar to the extracellular water volume of the rabbit (0.17 L/kg). In the dosage range where total clearance was independent of serum concentration, the distribution of methicillin was concentration dependent and could be predicted by equations derived from the Michaelis-Menten equation.

Accumulation of peptide Tyr-D-Ala-Gly by choroid plexus during ventriculocisternal perfusion of rat brain

Accumulation of Tyr-D-Ala-Gly (TAG) in choroid plexus was studied with ventriculocisternal perfusion of anesthetized rats. The choroid plexus of the lateral ventricles and the fourth ventricle accumulated TAG against a concentration gradient with regards to cerebrospinal fluid (CSF) but not plasma. This accumulation was inhibited by some metabolic inhibitors and peptides which had the same effect on accumulation of TAG in isolated choroid plexus. These results indicate that the active transport of TAG is present in the epithelium facing CSF. This active accumulation was affected by morphine. Reserpine, which is a chemical denervation of sympathetic nerves has no effect on the active accumulation of TAG. Thus, all these results suggest that, in vivo accumulation of TAG in choroid plexus during ventriculocisternal perfusion is similar to in vitro accumulation of TAG in isolated plexus.

Clinical pharmacokinetics of cerebrospinal fluid

The distribution of drugs into the cerebrospinal fluid has long been considered a challenging field of investigation in 2 major respects: (a) understanding how the physicochemical properties (molecular weight, pKa, plasma protein binding) of various molecules influence their movements across such a specific structure as the blood-brain barrier; and (b) defining the relationship between cerebrospinal fluid concentrations of various drugs and their central (side) effects. An attempt has been made to review the very dispersed information presently available to offer a clinically orientated picture of this area of pharmacokinetics. Drugs acting on the central nervous system (benzodiazepines, tricyclic antidepressants, anticonvulsants, opioids), antibacterial agents, cardiovascular drugs (beta-adrenoceptor blockers and digoxin), antineoplastic drugs (mainly methotrexate), and other miscellaneous agents (corticosteroids, cimetidine, methylxanthines) are reviewed. The available evidence seems to support the conclusion that only for methotrexate and antibacterial agents does knowledge of cerebrospinal fluid pharmacokinetics have direct therapeutic implications, while the mosaic of information available for other drugs does little more than provide a partially satisfactory picture.

Dose-dependent pharmacokinetics of mezlocillin in relation to renal impairment

The dose dependence of mezlocillin pharmacokinetics was examined in relation to renal function after intravenous doses of 1 and 5 g in 16 subjects with various degrees of renal impairment. Dose and time-average model-independent physiological parameters were calculated from plasma concentration and urinary excretion data. Lack of superimposition of plasma concentration profiles occurred between dosage levels with a twofold exaggeration of areas under the curve produced between doses of 1 and 5 g. Decreased plasma clearances at the higher dose were caused partly by nonlinear renal clearance, but more markedly by dose dependence in nonrenal clearances. At each dosage level, these parameters were examined in relation to creatinine clearances. Plasma and renal clearances exhibited a typical linear correlation with creatinine clearance for each dose level. However, nonrenal clearances demonstrated a linear relationship with creatinine clearance at the 1-g dose, but apparent saturation of this pathway produced lower and relatively constant nonrenal clearance values at the 5-g dose. Mezlocillin pharmacokinetics are thus influenced by both dose and renal function over the dosage range of 1 to 5 g. Saturation in renal clearance and probably in biliary clearance explains the unusual disposition characteristics of mezlocillin observed in this and previously reported studies.

Treatment of bacterial meningitis in children without intravenous fluids

It would be easier and cheaper, and there would be less risk of cerebral oedema, if bacterial meningitis could be adequately treated without the intravenous administration of fluid. Fifty children with bacterial meningitis were treated with intramuscular injections of benzyl penicillin, probenecid given orally and chloramphenicol palmitate suspension given orally, and the outcome was evaluated prospectively. Seven (14%) of the 50 children died. In a control group of 50 children with bacterial meningitis treated with the intravenous administration of benzyl penicillin and chloramphenicol sodium succinate, the outcome was determined retrospectively. Twelve (24%) of the 50 children died. The difference in mortality rate was 10% +/- 15.7% (+/- 2 SE), which is not significant. Except in the rare case of a child with shock or persistent vomiting, bacterial meningitis can be effectively treated with six-hourly intramuscular injections of penicillin, and probenecid and chloramphenicol given orally.

Antimicrobial penetration into cerebrospinal fluid

The complex physiology of the blood-brain barrier and the characteristics of an antimicrobial which govern its distribution into the brain are poorly understood. Likewise, available data regarding CSF antimicrobial concentrations after extra-CNS administration, as tabulated in this review, are inadequate. Because of the potentially dire consequences that result from inappropriately treated CNS infections, large cooperative studies using standardized methodology are needed. Suggestions for such methods are outlined.

Treatment of bacterial infections of the central nervous system

Antimicrobial agents for the treatment of bacterial meningitis and other pyogenic intracranial infections have now been in use for approximately 45 years. The last decade, however, has been a period of tremendous advances in knowledge of the pharmacokinetics and other characteristics of the available drugs. The identification of factors that affect their in vivo metabolism and excretion, the importance of drug interactions, and the development of methods for estimation of serum and cerebrospinal fluid levels have added both complexity and sophistication to the clinical utilization of the antimicrobial agents. The number of available antimicrobials has expanded greatly during recent years, although the penicillins, chloramphenicol, and the aminoglycosides remain the mainstay of antibiotic treatment in the majority of cases of bacterial infection of the central nervous system.

Effect of meningitis and probenecid on the penetration of vancomycin into cerebrospinal fluid in rabbits

This study examined the effects of experimental pneumococcal meningitis and probenecid administration on the penetration of parenterally administered vancomycin into cerebrospinal fluid in rabbits. Bacterial killing was also examined in infected animals. Meningitis was induced by intracisternal inoculation of Streptococcus pneumoniae. Vancomycin was administered in a loading dose followed by a continuous intravenous infusion for 6 h. Serum and cerebrospinal fluid samples were obtained at 0, 2, 4, and 6 h for antibiotic assays and quantitative cultures. Meningitis significantly enhanced the penetration of vancomycin into cerebrospinal fluid, but probenecid administration had no effect. In normal rabbits, at 6 h the mean percent penetration (cerebrospinal fluid concentration/serum concentration x 100%) +/- the standard deviation was 1.9 +/- 0.9% in the nonprobenecid group (n = 10) and 1.9 +/- 1.1% in the probenecid group (n = 9). In rabbits with experimental pneumococcal meningitis, the mean percent penetration at 6 h was 3.9 +/- 2.6% in the nonprobenecid group (n = 11) and 4.3 +/- 2.1% in the probenecid group (n = 9). Mean bacterial titers in the cerebrospinal fluid of infected animals decreased by more than 3.0 log 10 colony-forming units per ml in both the nonprobenecid and the probenecid groups.

Tissue distribution and metabolism of drugs VI: Effect of second drugs on pancreatic distribution and insulin-releasing activity of sulfonylureas in perfused rat pancreas

The distribution of sulfonylureas and their insulin-releasing potency as a pharmacological response were studied in isolated perfused rat pancreas. Sulfonylurea concentrations in the perfused pancreas in the presence or absence of a second drug were determined after perfusion for 15 min. Sulfonylureas could be distributed throughout the pancreas readily, and the tissue sulfonylurea concentration was reduced by the addition of sulfaphenazole, sulfadimethoxine, and salicylic acid. The insulin secretion rate stimulated by tolbutamide also was reduced by these three drugs; sulfanilamide, which could not displace the tolbutamide distribution, did not affect the tolbutamide-mediated secretion of insulin. These results document the importance of drug concentration in the tissue or receptor site with regard to insulin secretion and show that the sulfonylurea-mediated secretion of insulin can be modified easily by concomitant perfusion of a second drug that displaces sulfonylurea in the pancreas. These findings suggest that the drug interaction at the target organ or receptor site should be understood to provide adequate drug therapy.

A pharmacologic evaluation of penicillin in children with purulent meningitis

We undertook a prospective study of the pharmacokinetics of penicillin G (administered intravenously every four hours for a total of b50,000 U per kilogram per day) in the cerebrospinal fluid of children with purulent meningitis. Both the absolute mean cerebrospinal-fluid penicillin concentration (0.8, 0.7 and 0.3 microgram per milliliter) and the percentage of the simultaneous serum penicillin concentration measurable in the cerebrospinal fluid (18.4, 9.9, 4.9 per cent) declined on the first, fifth and 10th days of therapy, respectively. A mean peak cerebrospinal-fluid penicillin concentration of 0.96 micrograms per milliliter was measured at least transiently on all three study days. This pharmacokinetic pattern correlated with the return of cerebrospinal-fluid protein concentration toward normal (P less than 0.01). Penicillin G in the dosage studied is adequate therapy for most streptococcal and meningococcal meningitis in children; an increased dosage may be necessary when the minimal inhibitory concentration of penicillin to the etiologic agent is unusually high.

Effect of probenecid on cerebrospinal fluid concentrations of penicillin and cephalosporin derivatives

Probenecid may elevate the cerebrospinal fluid (CSF) concentration of penicillin G by inhibiting the excretion of organic acids from CSF. We have studied this phenomenon with various penicillin and cephalosporin derivatives. Penicillin concentrations were determined in rabbits under steady-state conditions before and after intravenous probenecid administration. With both low-dose and high-dose probenecid, CSF penicillin levels increased two to three times as did CSF concentration as a percentage of serum level. The same probenecid effect was consistently demonstrated in animals with experimental pneumococcal meningitis. Probenecid likewise increased the CSF concentration of ampicillin, carbenicillin, nafcillin, cephacatrile, and cefazolin. Probenecid may prove useful in certain bacterial infections where high CSF antibiotic levels are necessary.

Inhibition of penicillin transport from the cerebrospinal fluid after intracisternal inoculation of bacteria

The effect of intracisternal inoculation of bacteria on the choroid plexus system, which transports penicillin from cerebrospinal fluid (CSF) to blood, was studied in vitro and in vivo. Meningeal and choroid plexus inflammations as well as CSF pleocytosis were induced in rabbits with intracisternal inoculations of Hemophilus influenzae or Staphylococcus aureus. At various times after bacterial inoculation, the choroid plexuses of the inoculated rabbits were removed and incubated in artificial CSF containing [(14)C]penicillin. The ability of the choroid plexuses to accumulate pencillin in vitro was measured and was found to be depressed as compared with controls. This depression of choroid plexus uptake reversed with resolution of the inflammatory process. In vivo on the day after intracisternal inoculation of Hemophilus influenzae, a decrease in the disappearance of penicillin relative to inulin in the inoculated rabbits (as compared to the controls) was observed when [(14)C]penicillin and [(3)H]inulin were injected intraventricularly and cisternal CSF was sampled 2 h later. This decrease could not be explained by penicillin binding to the CSF exudate. However, the choroid plexus transport system for penicillin was only partially depressed in those inoculated rabbits with bacterially induced inflammation, since in vitro the choroid plexuses could still accumulate penicillin and in vivo CSF penicillin levels could be further increased with probenecid pretreatment. These results suggest that CSF penicillin levels are increased in this model due to three factors: a depression of active efflux of penicillin from the CSF, an increase in permeability to penicillin of inflamed meninges, and, less significantly, by CSF binding of penicillin.