Subtherapeutic dicloxacillin levels in a neonate: possible mechanisms

Role of biokinetics in risk assessment of drugs and chemicals in children

Whether children incur different risks from xenobiotics than adults will depend on the exposure, biokinetics, and dynamics of compound. In this paper, current knowledge on developmental physiology and possible effects on biokinetics are evaluated and the role of biokinetics in risk assessment both for drugs and chemicals is discussed. It is concluded that most dramatic age-related physiological changes that may affect biokinetics occur in the first 6-12 months of age. The difference in internal exposure between children and adults can generally be predicted from already known developmental physiological differences. However, for risk assessment it will also be necessary to determine whether internal exposure is within the drug's therapeutic window or if it will exceed the NOAEL of a chemical. Furthermore, the effects of internal exposure of potentially harmful compounds on developing organ systems is of utmost importance. However, knowledge on this aspect is very limited. Risk assessment in children could be improved by: (1) application of pediatric PBPK-models in order to gain insight into internal exposure in children, (2) studies in juvenile animals for studying effects on developing systems, and (3) extrapolation of knowledge on the relationship between internal exposure and dynamics for drugs to other chemicals.

Renal transport of antibiotics and nephrotoxicity: a review

The renal excretion of a drug can essentially be divided schematically into three functional processes: glomerular filtration, tubular reabsorption and tubular secretion. When assessing nephrotoxicity, the tubular secretion system, which allows transport of the drug from the blood to the urine via the tubular cells, is particularly important. Historically, two distinct tubular secretion mechanisms have been described for drugs: one via organic cations and the other via organic anions. More recently, a third tubular secretion mechanism has been identified, mediated by P-glycoprotein. In the present review, a number of examples will be given relating to antibiotic-induced kidney damage determined via the tubular reabsorption mechanism (aminoglycosides, amphotericin B) and via the tubular secretion mechanism (cephalosporins, vancomycin), respectively. Drug transport within the tubular cells is the first fundamental stage in the onset of the nephrotoxic process. Knowledge of these concepts is important for the prevention of iatrogenic kidney damage, particularly in patients with underlying disease receiving concomitant treatment with several potentially nephrotoxic molecules.

Comparative study of the effects of some inducers with or without protein binding properties on bioavailability of isoxazolylpenicillins in rats

The effect of various inducers with or without protein binding properties on serum levels and half life of Oxacillin, Cloxacillin and Dicloxacillin was studied. A total of 102 male rats classified in 3 "categories" according to the administered penicillin with 6 groups of rats in each of them were used. Each group was pretreated for 15 days with the following inducers: phenobarbital, diphenylhydantoin, diazepam, chlorpromazine and phenylbutazone. The control groups received saline. The d-glucaric acid concentration in the urine prior to and after the administration of inducers and the liver weight were taken as enzyme induction indices. The results showed a decrease of serum levels and half life of three penicillins with a negative correlation between urine d-glucaric acid and serum penicillin levels. Phenobarbital, diphenylhydantoin and chlorpromazine affected the 3 penicillins in the following statistically significant order: oxacillin, dicloxacillin, cloxacillin. Diazepam affected: cloxacillin, dicloxacillin, oxacillin, and phenylbutazone: dicloxacillin, cloxacillin and oxacillin. However all drugs finally produced a uniform effect on all 3 penicillins in the following decreasing order: phenobarbital (r = -0.910), diphenylhydantoin (r = -0.864), phenylbutazone (r = -0.851), chlorpromazine (r = -0.842) and diazepam (r = -0.821). For all inducers, the effect was most significant for oxacillin (r = -0.869), second most significant for dicloxacillin (r = -0.811) and finally for cloxacillin (r = -0.778). The results suggested an interaction of isoxazolylpenicillins and the above drugs.

Bioavailability of hetacillin in rats after liver enzyme induction by various inducers with or without protein binding properties

The serum levels and the half life of ampicillin derived from Hetacillin after administration of the latter to a total of 61 rats classified in 7 groups were determined. Each of these groups was pre-treated for 15 days with the following inducers; phenobarbital, diphenylhydantoin, diazepam, chlorpromazine and phenylbutazone. The control group received saline. The d-glucaric acid concentration in the urine prior to and after the administration of inducers and the liver weight were taken as enzyme induction indices. Results showed a positive correlation between the indices of induction and the levels of ampicillin originating from hetacillin with a significant correlation coefficient between the serum levels of ampicillin and urine d-glucaric acid for all drugs studied. The different effect of the various drugs indicated that they could be classified into the following two groups: a) those that induced a significant increase of the levels and half life (t1/2) of ampicillin. The effect was significant in decreasing order for phenylbutazone (r = 0,990), diazepam (r = 0,990) and diphenylhydantoin (r = 0,753). b) those which initially resulted in a significant increase of the levels of ampicillin and thereafter in a decrease with a significant shortening of its t1/2 too. The effect was most significant for phenobarbital (r = 0,887) and less so for chlorpromazine (r = 0,800). Only for these two drugs was a significant and actually negative correlation observed between d-glucaric acid and t1/2 that is: phenobarbital (r = -0,967) chlorpromazine (r = -0,752). Results suggest an interaction of Hetacillin and the above inducers.

Development of mechanisms for drug excretion

Renal excretion of many drugs is less in the newborn than what would be predicted in terms of body weight. This is due, in part, to low renal blood flow and glomerular filtration rate during the immediate newborn period. In the first weeks to months of postnatal life, renal vascular resistance decreases and blood flow increases. Subsequently, the glomerular filtration rate increases. During this time, drug elimination may also be affected by qualitative and quantitative differences in binding of drugs to plasma proteins. In addition, drug elimination may be prolonged due to an immature ability in the newborn to transport or metabolize drugs in the kidney. Recent evidence demonstrated that drugs administered pre- or postnatally may alter the rate of renal excretion of drugs in the newborn. Such effects are of great concern to the clinician and underscore the importance of monitoring drug blood levels in these patients. From another perspective, the ability to stimulate drug excretion has been used as a tool to study basic renal physiology. Quantitative patterns of development coupled with the use of substrate stimulation provided evidence for at least three transport systems for organic anions in the proximal tubule. Similar technics provided preliminary data linking drug metabolism and organic anion transport in the proximal tubule, whereas an obligatory, rate-limiting role for ligandin in anion transport could not be established.