Tissue penetration of clindamycin in diabetic foot infections

Oral Antibiotics for Bacteremia and Infective Endocarditis: Current Evidence and Future Perspectives

Bacteremia and endocarditis are two clinical syndromes that, for decades, were managed exclusively with parenteral antimicrobials, irrespective of a given patient's clinical condition, causative pathogen, or its antibiotic susceptibility profile. This clinical approach, however, was based on low-quality data and outdated expert opinions. When a patient's condition has improved, gastrointestinal absorption is not compromised, and an oral antibiotic regimen reaching adequate serum concentrations is available, a switch to oral antibacterials can be applied. Although available evidence has reduced the timing of the oral switch in bacteremia to three days/until clinical improvement, there are only scarce data regarding less than 10-day intravenous antibiotic therapy in endocarditis. Many standard or studied oral antimicrobial dosages are smaller than the approved doses for parenteral administration, which is a risk factor for treatment failure; in addition, the gastrointestinal barrier may affect drug bioavailability, especially when the causative pathogen has a minimum inhibitory concentration that is close to the susceptibility breakpoint. A considerable number of patients infected by such near-breakpoint strains may not be potential candidates for oral step-down therapy to non-highly bioavailable antibiotics like beta-lactams; different breakpoints should be determined for this setting. This review will focus on summarizing findings about pathogen-specific tailoring of oral step-down therapy for bacteremia and endocarditis, but will also present laboratory and clinical data about antibiotics such as beta-lactams, linezolid, and fosfomycin that should be studied more in order to elucidate their role and optimal dosage in this context.

Arterial leg ulcers-Bacterial patterns, antimicrobial resistance and clinical characteristics, a retrospective single-centre cohort, 2012-2021

OBJECTIVE

Severe wound infections in patients with peripheral artery disease (PAD) are common, potentially life- and limb-threatening, and difficult to treat. Evidence on patients with infected leg ulcers in PAD is scarce. This study aims to provide insight into the microbiological patterns and antimicrobial resistance (AMR) of specific pathogens in patients with arterial leg ulcers.

METHODS AND DESIGN

In this retrospective, consecutive, single-centre study 16,553 patients underwent an endovascular revascularization procedure between 2012 and 2021. Of these, 1,142 patients had PAD Rutherford category 5 or 6 with infected leg ulcers. Logistic regression was used to identify risk factors for Staphylococcus aureus-associated infections.

RESULTS

A total of 3,431 bacterial isolates were detected, of which 2,335 (68.1%) bacterial isolates were gram-positive and 1,096 (31.9%) were gram-negative species. The most prevalent bacteria were S. aureus (18.6%), Enterococcus faecalis (9.1%) and S. epidermidis (7.8%). Pseudomonas aeruginosa (5.6%), Proteus mirabilis (3.7%) and Escherichia coli (3.4%). The resistance of S. aureus isolates to clindamycin was 11.0%. Resistance to oxacillin was rare (1.5%). P. aeruginosa is frequently resistant to ciprofloxacin (14.4%) whilst intrinsically resistant to trimethoprim/sulfamethoxazole. P. mirabilis and E. coli were frequently resistant to both ciprofloxacin (7.3; 20.7%) and trimethoprim/sulfamethoxazole (24.6; 22.6%), respectively. Resistance to amoxicillin/clavulanic acid was high among E. coli isolates (36.8%). Multi-drug resistance (MDR) was rare among S. aureus and P. aeruginosa isolates. In contrast, the proportion of MDR was high in E. coli isolates. End-stage renal disease was independently positively associated with S. aureus identification (p = .042).

CONCLUSION

S. aureus was the most common pathogen in arterial leg ulcers with end-stage renal disease being an independent risk factor. Clindamycin resistance was common, making empirical therapy likely to fail. Isolated E. coli species had a high proportion of MDR.

Repurposing of existing antibiotics for the treatment of diabetes mellitus

Proline specific serine protease enzyme, dipeptidyl peptidase IV (DPP-4) has become a promising target for diabetes, as it stops glucagon-like peptide 1 (GLP-1) from becoming inactive, resulting in higher levels of active GLP-1. This lowers glucose levels by increasing insulin secretion and decreasing glucagon secretion. DPP-4 is also linked to a higher BMI and a 0.7 to 1% reduction in HbA1c. Currently available DPP-4 inhibitor drugs showed less promising anti-diabetic activity as this class associated with many side effects due to non-selectivity and therefore searching on more potent DPP-4 inhibitors are still ongoing. In our present study, we investigate the inhibition of DPP-4 through a series of antibiotic compounds which were previously reported to be used in diabetic foot infections and compared with existing DPP-4 inhibitors. To obtain this objective, three-dimensional crystal structure of DPP-4 was retrieved from the protein data bank (PDB id: 1 × 70). A systematic computational method combining molecular docking, MM-GBSA binding energy calculation, MD simulations, MM-PBSA binding free energy calculations and ADME were used to find best DPP-4 inhibitor. Molecular docking results revealed that clindamycin has a higher affinity towards the catalytic sides of DPP-4 and built solid hydrophobic and polar interactions with the amino acids involved in the binding region of DPP-4, such as S1 subsite, S2 subsite and S2 extensive subsite. MD simulations results showed clindamycin as potent virtual hit and suggested that it binds with DPP-4 in competitive manner, which virtually indicate that besides antibiotic activity clindamycin has anti-diabetic activity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40203-021-00118-6.

Patterns of bacterial culture and antimicrobial susceptibility test results for dogs with retrobulbar abscesses: 133 cases (2002-2019)

OBJECTIVE

To evaluate patterns of bacterial culture and antimicrobial susceptibility test results for dogs with retrobulbar abscesses and generate recommendations for empirical antimicrobial selection.

ANIMALS

133 dogs examined between 2002 and 2019.

PROCEDURES

Records were retrospectively reviewed to determine type of bacterial culture, number and type of bacterial isolates, antimicrobial susceptibility test results, concurrent and recent antimicrobial exposure, effect of culture results on antimicrobial regimen, and outcome.

RESULTS

Aerobic culture alone was performed in 37 dogs, and aerobic and anaerobic culture was performed in 96 dogs. Isolates were recovered from 96 dogs, with multiple isolates recovered from 54 (56%) of those dogs. Of the 69 dogs for which both aerobic and anaerobic culture was performed and at least 1 isolate was obtained, 34 (49%) had purely aerobic infections, 15 (22%) had mixed aerobic and anaerobic infections, and 20 (29%) had purely anaerobic infections. Pasteurella spp (n = 26), Streptococcus spp (20), and Escherichia coli (12) were the most common aerobic isolates. Bacteroides spp (n = 22), Actinomyces spp (10), and Fusobacterium (10) spp were the most common anaerobic isolates. Susceptibility test results led to changes in the antimicrobial regimen in 37 of 80 (46%) dogs. Of the 76 dogs for which outcome information was available, 78 (97%) recovered.

CLINICAL RELEVANCE

Multipathogen and anaerobic infections were common in dogs with retrobulbar abscesses. Susceptibility data supported the use of amoxicillin-clavulanate or a combination of clindamycin and enrofloxacin as first-line treatments. Additional study is needed to characterize anaerobic antimicrobial susceptibilities and to compare results of susceptibility testing with in vivo responses to antimicrobial administration.

Antibiotics in Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

Cotrimoxazole and clindamycin in skin and soft tissue infections

PURPOSE OF REVIEW

The aim of this study was to present recent microbiological, experimental, clinical and tolerance data for cotrimoxazole and clindamycin in the specific field of skin and soft tissue infections (SSTIs).

RECENT FINDINGS

Staphylococcus aureus and streptococci remain the leading cause of SSTIs. Cotrimoxazole is a good anti-Gram-positive agent with preserved activity against methicillin-susceptible and methicillin-resistant S. aureus (MRSA) and streptococci. Although clindamycin has good methicillin-susceptible S. aureus activity, a growing number of resistant MRSA and streptococci have been reported. Strong experimental data support the antitoxin activity of clindamycin, but clinical observations remain scarce. Several recent randomized trials involving cotrimoxazole and/or clindamycin demonstrate the efficacy and tolerance of both drugs. The oral formulation of both drugs may facilitate the implementation of early switch and early discharge protocols in clinical practice.

SUMMARY

Recent publications demonstrate that cotrimoxazole and clindamycin remain reliable and realistic therapeutic approaches for SSTIs.

Development of a Novel Collagen Wound Model To Simulate the Activity and Distribution of Antimicrobials in Soft Tissue during Diabetic Foot Infection

Diabetes has major implications for public health, with diabetic foot ulcers (DFUs) being responsible for significant morbidity and mortality. A key factor in the development of nonhealing ulcers is infection, which often leads to the development of biofilm, gangrene, and amputation. A novel approach to treating DFUs is the local release of antibiotics from calcium sulfate beads. We have developed a novel model system to study and compare the release and efficacy of antibiotics released locally, using collagen as a substrate for biofilm growth and incorporating serum to mimic the biochemical complexity of the wound environment. We found that our soft-tissue model supports the growth of a robust Pseudomonas aeruginosa biofilm, and that this was completely eradicated by the introduction of calcium sulfate beads loaded with tobramycin or gentamicin. The model also enabled us to measure the concentration of these antibiotics at different distances from the beads and in simulated wound fluid bathing the collagen matrix. We additionally found that a multidrug-resistant Staphylococcus aureus biofilm, nonsusceptible to antibiotics, nonetheless showed an almost 1-log drop in viable counts when exposed to calcium sulfate beads combined with antibiotics. Together, these data suggest that locally applied antibiotics combined with calcium sulfate provide surprising efficacy in diabetic foot infections and offer an effective alternative approach to infection management. Our study additionally establishes our new system as a biochemically and histologically relevant model that may be used to study the effectiveness of a range of therapies locally or systemically for infected DFUs.

Diagnosis and management of infection in the diabetic foot

Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.

2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Concentration-dependent effects of antimicrobials on Staphylococcus aureus toxin-mediated cytokine production from peripheral blood mononuclear cells

BACKGROUND

Toxins contribute to the pathogenicity of Staphylococcus aureus infections by inducing a dysregulated inflammatory response. This study evaluated the impact of anti-staphylococcal antibiotic exposures over an increasing concentration range on cytokine production from peripheral blood mononuclear cells (PBMCs) after S. aureus toxin exposures.

METHODS

Human PBMCs were suspended in complete Roswell Park Memorial Institute (RPMI) 1640 medium with 10% fetal bovine serum at 10(6) cells/mL with 100 ng/mL S. aureus toxic shock syndrome toxin-1 (TSST-1), staphylococcal enterotoxin A (SEA), α-toxin or Panton-Valentine leucocidin (PVL). Vancomycin, trimethoprim/sulfamethoxazole, tigecycline, daptomycin, linezolid, clindamycin and azithromycin were added at a concentration range of 0.5-100 mg/L. Cytokine [interleukin-1β (IL-1β), IL-6, IL-8, interferon-γ (IFN-γ) and tumour necrosis factor-α (TNF-α)] concentrations were measured in duplicate by ELISA following exposure and were compared with response with toxin alone.

RESULTS

At concentrations approximating serum C(max), tigecycline decreased IL-6 by 52%-57% and IFN-γ production by 43%-53% compared with toxin alone (P ≤ 0.05) and linezolid inhibited TNF-α by 12%-35% and IL-8 by 25%-42% (P ≤ 0.02). However, trimethoprim/sulfamethoxazole increased TNF-α and IL-8 production (P = 0.002). Clindamycin, daptomycin, vancomycin and azithromycin had no consistent significant effect at approximate serum C(max) concentrations. All antibiotics had a concentration-dependent effect on cytokine production, with tigecycline, clindamycin and trimethoprim/sulfamethoxazole being the most potent inhibitors of cytokine production at concentrations exceeding 25 mg/L.

CONCLUSIONS

S. aureus toxins stimulate production of inflammatory cytokines in PBMCs. Antimicrobials with high tissue penetration, including tigecycline, clindamycin, trimethoprim/sulfamethoxazole and linezolid, reduced cytokine production, which, along with their antimicrobial effects, may have importance in the therapeutic outcome of severe infections.

Continuous clindamycin infusion, an innovative approach to treating bone and joint infections

The feasibility, safety, and efficacy of prolonged, continuous, intravenous clindamycin therapy were retrospectively evaluated for 70 patients treated for bone and joint infections, 40% of whom were treated as outpatients. The median treatment duration was 40 days, the median daily clindamycin dose was 2,400 mg, and three moderate-grade adverse events occurred. The median serum clindamycin concentrations on days 3 to 14 and days 8 to 28 were 5 and 6.2 mg/liter, respectively; the median concentration was significantly lower (P < 0.02) in patients treated with rifampin (5.3 mg/liter) than in those not treated with rifampin (8.9 mg/liter). Among 53 patients with a median follow-up of 30 months (range, 24 to 53 months), 49 (92%) were considered cured (1 patient had a relapse, and 3 patients had reinfections).

Current recommendations in the management of osteomyelitis of the hand and wrist

Management of osteomyelitis of the hand and wrist is a multidisciplinary and individualized process. A rational approach to management includes careful consideration of the pathogenesis, microbiology, diagnostic options, and surgical and medical treatment of this disease.

Diagnosis and treatment of diabetic foot infections

EXECUTIVE SUMMARY: 1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic Gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture before starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic Gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 12 weeks usually suffices, but some require an additional 12 weeks; for moderate and severe infections, usually 24 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 46 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to 1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II). 19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).

Separation and characterization of clindamycin and related impurities in bulk drug by high-performance liquid chromatography-electrospray tandem mass spectrometry

A simple high-performance liquid-electrospray ionization tandem mass spectrometric (HPLC-ESI-MSn) method has been developed for the rapid identification of clindamycin and its related minor impurities in bulk drug. The ESI-MSn results obtained allowed us to propose plausible schemes for their fragmentations, which were confirmed further by electrospray ionization Fourier transform ion cyclotron resonance mass spectrometry (ESI-FTICR-MS) using collision-induced dissociation (CID) method at high mass resolution. The positive ESI-MS/MS of clindamycin and its derivative compounds showed some diagnostic fragments, such as the neutral losses of H2O, HCl, methanethiol and 2-methylthio-ethenol, and the residue of 3-propyl-N-methylpyrrolidine and 3-ethyl-N-methylpyrrolidine, which are specific and useful for the identification of the lincosamide antibiotics and related impurities. According to the fragmentation mechanism of mass spectrometry and HPLC-UV-ESI-MSn data, six impurities of clindamycin have been identified on-line. Additionally, the positive ion mode extracted ion current (EIC) method has been used to separate and identify these lincosamide compounds.

Simple method for the assay of clindamycin in human plasma by reversed-phase high-performance liquid chromatography with UV detector

A rapid and simple high-performance liquid chromatography (HPLC) method was developed and validated for the quantification of clindamycin in human plasma. After precipitation with 50% trichloroacetic acid (TCA) containing the internal standard, propranolol, the analysis of the clindamycin level in the plasma samples was carried out using a reverse-phase cyano (CN) column with ultraviolet detection (204 nm). The chromatographic separation was accomplished with an isocratic mobile phase consisting of acetonitrile-distilled water-7.6 mm tetramethylammonium chloride (TMA) (60:40:0.075, v/v/v), adjusted to pH 3.2. The proposed method was specific and sensitive with a lower limit of quantitation (LLOQ) of 0.2 microg/mL. This HPLC method was validated by examining the precision and accuracy for inter- and intraday analysis in the concentration range 0.2-20.0 microg/mL. The relative standard deviations (RSD) in the inter- and intraday validation were 6.1-14.9 and 6.0-16.1%, respectively. In the stability test, clindamycin was found to be stable in human plasma during the storage and assay procedure. The present HPLC method was applied to the analysis of samples taken up to 12 h after a single oral administration of clindamycin in healthy volunteers.

A new HPLC/UV method for the determination of clindamycin in dog blood serum

A new HPLC method for the quantitative determination of clindamycin in dog blood serum at levels down to 80 ng/ml has been developed. Samples were deproteinised with acetonitrile and clindamycin was extracted with dichloromethane. Chromatographic analysis was carried out on a C(18) reversed-phase analytical column in the presence of tetra-n-butylammonium hydrogen sulfate (TBA), as an ion-pairing agent. UV detector wavelength was set at 195 nm. The assay was validated for a concentration range from 80 to 6000 ng/ml serum. Good linearity was observed in the entire concentration range. The limit of quantification (LOQ) was 80 ng/ml and the limit of detection (LOD) was 60 ng/ml. Regression of accuracy data yielded an overall mean recovery value (+/-S.E.M.) of 93.98+/-0.42%, while precision data revealed coefficient of variation (CV (%)) values lower than 4.41%. The method was successfully applied to determine drug concentrations in serum samples from dogs that had been orally administered clindamycin hydrochloride.

Pharmacotherapy of lower limb diabetic ulcers

OBJECTIVE

To discuss the pathophysiology, microbiology, and pharmacotherapy of lower extremity (LE) diabetic ulcers.

DATA SOURCES

A MEDLINE search from 1966 to April 1999 was conducted. The search was limited to humans and English-language journals. Key search words included "diabetic ulcer," "fluoroquinolones," "beta-lactam," "hyperbaric oxygen," "diabetes mellitus," "diabetic foot," and "growth factor."

STUDY SELECTION

Randomized and nonrandomized studies were selected for review. Results of randomized, placebo-controlled studies were emphasized more than nonrandomized results.

DATA SYNTHESIS

LE ulcers are a common cause of hospitalization, and cause significant morbidity and mortality. Staphylococcus aureus is the most common pathogen in non-limb-threatening infections; Gram-negative bacteria and anaerobes are most prevalent in limb-threatening and life-threatening infections. Oral antibiotic therapy may be used in non-limb-threatening infections, if adequate response is achieved in 24-48 hours; otherwise, intravenous antibiotics should be started. Intravenous antibiotics should be the initial therapy for limb-threatening or life- threatening ulcers. Antimicrobial therapy of at least 10-14 days has been effective in treating LE ulcers in the absence of osteomyelitis. Growth factors offer another treatment alternative, although only becaplermin is currently approved for diabetic ulcers.

CONCLUSION

Antibiotic therapy has been effective for the treatment of LE diabetic ulcers. However, further studies are required to identify optimal antibiotics and dosage regimens. Growth factors may have a role but additional research is needed to determine when best to initiate this therapy.

Evidence-based antibiotic therapy of diabetic foot infections

In addition to proper cleansing, debridement and local wound care, foot infections in diabetic patients require carefully selected antibiotic therapy. Serious infections necessitate hospitalization for initial parenteral broad-spectrum antibiotic therapy. Appropriately selected patients with mild infections can be treated as outpatients with oral (or even topical) therapy. Initial antibiotic selection is usually empirical, but definitive therapy may be modified based on culture results and the clinical response. Therapy should nearly always be active against staphylococci and streptococci, with broader-spectrum agents indicated if Gram-negative or anaerobic organisms are likely. In infected foot tissues levels of most antibiotics, except fluoroquinolones, are often subtherapeutic. The duration of therapy ranges from a week (for mild soft tissue infections) to over 6 weeks (for osteomyelitis). Recent antibiotic trials have shown that several intravenously or orally administered agents are effective in treating these infections, with no one agent or combination emerging as optimal. Suggested regimens based on the severity of infection are provided.

A Current Approach to Diabetic Foot Infections

Foot infections are a common, complex, and serious problem in diabetic patients. Infections usually begin in foot ulcers, which are associated with neuropathy, vasculopathy, and various metabolic disturbances. These infections are potentially limb and sometimes life threatening. Etiologic agents are usually aerobic gram-positive cocci, but chronic or serious infections often contain gram-negative rods and anaerobes. Chronic infections can lead to contiguous bone infection. Diagnosing osteomyelitis may require imaging studies (especially magnetic resonance imaging) and occasionally bone biopsy. In addition to proper cleansing, debridement, and local wound care, diabetic foot infections require carefully selected antibiotic therapy. Serious infections necessitate hospitalization for initial parenteral broad-spectrum antibiotic therapy, but appropriately selected patients with mild infections can be treated as outpatients with oral (or even topical) agents. Initial antibiotic selection is usually empiric; modifications may be needed based on the results of properly obtained cultures and the clinical response. Therapy should be active against staphylococci and streptococci, with broader-spectrum agents indicated if polymicrobial infection is likely. Levels of most antibiotics, except fluoroquinolones, are often subtherapeutic in infected foot tissues. The duration of therapy ranges from a week (for mild soft tissue infections) to over 6 weeks (for osteomyelitis). No single antibiotic agent or combination has proven to be optimal. With appropriate local, surgical, and antimicrobial therapy, most diabetic foot infections can now be successfully treated.

Determination of clindamycin in human plasma by high-performance liquid chromatography using coupled columns

A rapid automated method has been developed for the determination of clindamycin, a lincosamide antibiotic, in human plasma. Coupled column HPLC was used after precipitation of plasma proteins with a saturated ammonium sulfate solution. As a first step, the drug and internal standard were trapped on a precolumn of LiChrospher 60RP-select B. A reversed-phase Nucleosil 100 C18 HD column then separated drug and internal standard from each other and from remaining plasma components. The assay was validated in the range 0.2-10.0 micrograms ml-1 plasma. The results obtained for accuracy, intra- and inter-day precision complied very well with the generally accepted criteria for bioanalytical assays.

Tissue concentrations after a single-dose, orally administered ofloxacin in patients with diabetic foot infections

We studied the penetration of orally administered ofloxacin at the site of diabetes-related foot infections in patients with a planned debridement of the lesion. A total of nine patients received 800 mg of oral ofloxacin 120 to 150 minutes before surgery. During surgery, vital margin tissue and a serum sample were obtained. Serum and tissue concentrations of ofloxacin were measured. From seven patients sufficient amounts of tissue were obtained. Mean serum concentration was 7.0+/-3.5 mg/liter; mean tissue concentrations was 11.5+/-8.4 mg/kg. Mean serum and tissue concentrations exceed the minimal inhibitory concentration90 (MIC90) of commonly involved pathogens. This indicates that orally administered ofloxacin can be an effective treatment for infected diabetic foot lesions.

Clindamycin resistance among erythromycin-resistant Streptococcus pneumoniae

The increasing proportion of Streptococcus pneumoniae isolates with reduced susceptibility to penicillin has created an urgent need for therapeutic alternatives to some beta-lactam agents. Clindamycin is an antimicrobial agent with excellent bioavailability after oral administration which has been considered for the therapy of community-acquired pneumococcal otitis media. Using the Etest methodology, we have studied the in vitro susceptibility of 59 erythromycin-resistant strains of S. pneumoniae to clindamycin, penicillin, trimethoprim-sulfamethoxazole, and rifampin. The study also addressed the impact of the susceptibility test medium [Mueller-Hinton (MH) vs IsoSensitest (Iso), both 5% blood supplement] on the results. A total of 20 isolates (37%) displayed constitutive clindamycin resistance on Iso blood agar, compared with only 11 (22%) on MH blood agar. The remaining nine strains found to be clindamycin susceptible on MH manifested resistance only with erythromycin induction. Resistance to penicillin, rifampin, and trimethoprim-sulfamethoxazole in erythromycin-resistant isolates was 83%, 2%, and 85%-89% (medium dependent), respectively. These results indicate that the choice of susceptibility test medium affects the expression (constitutive or inducible) of macrolide-lincosamide-streptogramin (MLS) resistance in S. pneumoniae. In addition, the common assumption that erythromycin resistance in S. pneumoniae implies clindamycin resistance may need to be reconsidered and routine susceptibility tests (including induction if MH medium is used) should be considered for MLS-class drugs.

Distribution of systemically administered ampicillin, benzylpenicillin, and flucloxacillin in excisional wounds in diabetic and normal rats and effects of local topical vasodilator treatment

The present study assessed the suitability of the streptozotocin-treated diabetic rat as a model for the study of diabetes-impaired wound healing. The distribution of three antibiotics, ampicillin, benzylpenicillin, and flucloxacillin, in wound and adjacent tissue sites on the abdomens and legs of normal and diabetic rats was determined 30 min after intravenous administration of a single bolus containing 50 mg of all three antibiotics per kg of body weight. Tissue/plasma ratios showed that antibiotic tissue penetration appeared to be related to protein binding. The treatment of wound sites with vasodilators (1% solution) to increase local blood flow and antibiotic delivery to the site was then determined and appeared to be more effective with endothelium-independent sodium nitroprusside than with endothelium-dependent acetylcholine in diabetic rats. These results suggest that coadministration of topical vasodilators to wound sites in neuropathic diabetic patients undergoing antibiotic therapy for infected ulcers could increase antibiotic delivery to wound tissue sites.

Effects of macro- and microcirculatory functions on ceftriaxone concentrations in tissues of patients with stage IV peripheral arterial occlusive disease

The objective of the study was to determine the ceftriaxone levels achievable within lesions (toe or forefoot area) in patients with septic gangrene and to investigate the relationship between macro- and microcirculatory parameters and antibiotic concentration. Fifteen patients with severe chronic peripheral occlusive disease received an intravenous injection of 2 g of ceftriaxone. Antibiotic levels in venous and capillary blood and in an exudative part of the lesion were measured. Macrocirculatory functions were assessed by Doppler sonography, plethysmography, and angiography; microcirculatory functions were assessed by quantitative capillaroscopy and fluorescence video microscopy. The mean antibiotic concentrations measured between 4 and 8 h after injection were 92 +/- 26 micrograms/ml in venous blood and 84 +/- 46 micrograms/ml in capillary blood. The concentration in tissue reached its maximum 4 h after injection; the average concentration at between 2 and 8 h was 95 +/- 55 micrograms/ml. Only dynamic capillary parameters showed significant (P < 0.01) correlations to antibiotic levels in tissue. Significantly (P < 0.01) higher levels in tissue were observed in patients with adequate microcirculatory functions (138 +/- 48 micrograms/ml) than in patients with poor microcirculatory function (51 +/- 26 micrograms/ml). Microcirculatory dysfunction appears to be the limiting factor for tissue antibiotic levels. However, even those patients with poor microcirculatory function showed tissue antibiotic levels that were above the MICs for the pathogens most frequently isolated from gangrenous lesions. Therefore, intravenous application was found to be adequate and additional measures such as intra-arterial therapy or Bier's occlusion are basically unnecessary. Our finding that microcirculatory function is the limiting factor for the tissue antibiotic concentration is corroborated by computations based on a three-compartment model.