Comparative anti-staphylococcal effects of gemifloxacin and trovafloxacin in an in vitro dynamic model in terms of AUC/MIC and dose relationships

Gemifloxacin for the treatment of respiratory tract infections: in vitro susceptibility, pharmacokinetics and pharmacodynamics, clinical efficacy, and safety

Gemifloxacin is a synthetic fluoroquinolone antimicrobial agent exhibiting potent activity against most gram-negative and gram-positive organisms, such as the important community-acquired respiratory pathogens Streptococcus pneumoniae (including multidrug-resistant S. pneumoniae), Haemophilus influenzae , and Moraxella catarrhalis . The agent's mechanism of action involves dual targeting of two essential bacterial enzymes: DNA gyrase and topoisomerase IV. Gemifloxacin was approved by the Food and Drug Administration in April 2003 for treatment of community-acquired pneumonia and acute bacterial exacerbation of chronic bronchitis. The drug has an oral bioavailability of approximately 71%. Approximately 20-35% of gemifloxacin is excreted unchanged in the urine after 24 hours. The elimination half-life of gemifloxacin is 6-8 hours in patients with normal renal function, supporting once-daily dosing. The 24-hour free-drug area under the plasma concentration-time curve:minimum inhibitory concentration ratio (fAUC(0-24):MIC) associated with efficacy, based on results from in vitro and animal models of infection, is approximately 30. With a mean fAUC(0-24) of approximately 3 microg*hour/ml (35% of total AUC(0-24) of 8.4) and a median S. pneumoniae MIC for 90% of tested strains of 0.03, a fAUC(0-24):MIC ratio of 100 would be expected after standard dosing (320 mg once/day). In clinical studies involving both hospitalized and outpatient populations, gemifloxacin has been highly effective in the treatment of community-acquired pneumonia and acute exacerbation of chronic bronchitis. Clinical success rates ranged from 93.9-95.9% in patients with community-acquired pneumonia and 96.1-97.5% in those with acute exacerbation of chronic bronchitis. Gemifloxacin is well tolerated; the frequency of adverse events with this agent is low. Most adverse events are mild-to-moderate in severity, with diarrhea (< 4%), nausea and rash (< 3%), and headache (< 2%) most commonly reported. Drug interactions with gemifloxacin are not common, although absorption is greatly reduced when given with divalent and trivalent cation-containing compounds, such as antacids. Due to its potent activity against many common gram-positive and gram-negative respiratory pathogens, its proven clinical efficacy, and its favorable safety profile, gemifloxacin is a highly effective empiric treatment for community-acquired lower respiratory tract infections.

Fluoroquinolone AUIC break points and the link to bacterial killing rates. Part 1: In vitro and animal models

OBJECTIVE

To review in vitro and animal model studies with fluoroquinolones and the pharmacokinetic and pharmacodynamic relationships that are predictive of clinical and microbiologic outcomes and resistance. Data on fluoroquinolones are summarized and examine the premise that a single area under the inhibitory concentration-time curve (AUIC) target >125 may be used for all fluoroquinolones with concentration-dependent killing actions and against all target organisms.

DATA SOURCES

Primary articles were identified by MEDLINE search (1966-February 2002) and through secondary sources.

STUDY SELECTION AND DATA EXTRACTION

All of the articles identified from the data sources were evaluated, and all information deemed relevant was included.

DATA SYNTHESIS

The fluoroquinolones exhibit concentration-dependent killing. This effect clearly depends on concentrations achieved, and outcomes depend on endpoints established by individual investigators. With AUIC values <60, the actions of fluoroquinolones are essentially bacteriostatic; any observed bacterial killing is the combined effect of low concentrations in relation to minimum inhibitory concentration and the action of host factors such as neutrophils and macrophages. AUIC values >100 but <250 yield bacterial killing at a slow rate, but usually by day 7 of treatment. AUICs >250 produce rapid killing, and bacterial eradication occurs within 24 hours. Disagreements regarding target endpoints are the expected consequences of comparing microbial and clinical outcomes across animal models, in vitro experiments, and humans when the endpoints are clearly not equivalent. Careful attention to time-related events, such as speed of bacterial killing, versus global endpoints, such as bacteriologic cure, allows optimal break points to be defined.

CONCLUSIONS

Evidence from in vitro and animal models favors the use of AUIC values >250 for rapid bactericidal action, regardless of whether the organism is gram-negative or gram-positive.

Species-independent pharmacodynamics of gemifloxacin and ciprofloxacin with Haemophilus influenzae and Moraxella catarrhalis in an in vitro dynamic model

To demonstrate the antimicrobial effects of the different pharmacokinetics of gemifloxacin and ciprofloxacin, the pharmacodynamics of gemifloxacin and ciprofloxacin were studied using two clinical isolates each of Haemophilus influenzae and Moraxella catarrhalis. Monoexponentially decreasing concentrations of gemifloxacin (single dose, half-life 7.4 h) and ciprofloxacin (two 12-h doses, half-life 4 h) were simulated in an in vitro dynamic model over 8-fold ranges of the area under the curve (AUC)-to-MIC ratio: from 56 to 466 and 112-932 h, respectively. With each quinolone, log-linear relationships were established between the intensity of the antimicrobial effect (I(E)) and AUC/MIC. The I(E)-log AUC/MIC plots were bacterial strain- and species-independent and the gemifloxacin and ciprofloxacin plots were not superimposable. To generalize the findings obtained with the studied organisms, the effects of gemifloxacin and ciprofloxacin on hypothetical strains of H. influenzae and M. catarrhalis with MICs equal to the respective MIC(90)s were predicted. Based on these predictions, the AUC/MIC(90)s of 320 mg gemifloxacin (800 h with H. influenzae and 400 h with M. catarrhalis) may be 31-34% more efficient than those of 2 x 500 mg ciprofloxacin (730 and 365 h, respectively). These data suggest greater efficacy of gemifloxacin against H. influenzae and M. catarrhalis relative to ciprofloxacin at clinically achievable AUC/MIC ratios.