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Eleftheriotis G, Marangos M, Lagadinou M, Bhagani S, Assimakopoulos SF. Oral Antibiotics for Bacteremia and Infective Endocarditis: Current Evidence and Future Perspectives. Microorganisms 2023; 11:3004. [PMID: 38138148 PMCID: PMC10745436 DOI: 10.3390/microorganisms11123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
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 This clinical approach, however, was based on low-quality data and outdated expert opinions.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.
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Affiliation(s)
- Gerasimos Eleftheriotis
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Markos Marangos
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Maria Lagadinou
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
| | - Sanjay Bhagani
- Department of Infectious Diseases and HIV Medicine, Royal Free London NHS Foundation Trust, London NW3 2QG, UK;
| | - Stelios F. Assimakopoulos
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504 Patras, Greece; (G.E.); (M.M.); (M.L.)
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Flateau C, Riazi A, Cassard B, Camus M, Diamantis S. Streptococcal and enterococcal endocarditis: time for individualized antibiotherapy? J Antimicrob Chemother 2021; 76:3073-3076. [PMID: 34486671 DOI: 10.1093/jac/dkab333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Recommendations for the treatment of streptococcal and enterococcal endocarditis are based on old efficacy studies, but the starting doses have never been reassessed and are associated with significant adverse events. Based on data from other serious infections, we suggest that maintaining a concentration of β-lactams higher than 4-6 times the responsible bacteria MIC 100% of the time in the heart of the vegetation would be a pertinent therapeutic objective. The data point to a diffusion gradient of β-lactams in the vegetation. Yet, so far as is known, the ratio of antibiotic concentration at steady state between plasma and vegetation cannot be completely determined. Answering this crucial question would make it possible for each patient to have a targeted β-lactam plasma concentration, according to the MIC for the responsible bacteria. This would lead the way to personalized antibiotherapy and allow a safe switch to oral medication.
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Affiliation(s)
- Clara Flateau
- Department of Tropical and Infectious Diseases, Groupe Hospitalier Sud Ile de France (GHSIF), Melun, France
| | - Adélie Riazi
- Hospital Pharmacy, Groupe Hospitalier Sud Ile de France (GHSIF), Melun, France
| | - Bruno Cassard
- Hospital Pharmacy, Groupe Hospitalier Sud Ile de France (GHSIF), Melun, France
| | - Maryse Camus
- Hospital Pharmacy, Groupe Hospitalier Sud Ile de France (GHSIF), Melun, France
| | - Sylvain Diamantis
- Department of Tropical and Infectious Diseases, Groupe Hospitalier Sud Ile de France (GHSIF), Melun, France
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Purohit TJ, Hanning SM, Amirapu S, Wu Z. Rectal bioavailability of amoxicillin sodium in rabbits: Effects of suppository base and drug dose. J Control Release 2021; 338:858-869. [PMID: 34534590 DOI: 10.1016/j.jconrel.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/30/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
In this paper, rectal absorption and tissue tolerance of amoxicillin sodium (AS) suppositories prepared in a hydrophilic base, polyethylene glycol (PEG) or lipophilic base, Suppocire® NA 15 (SNA 15), were investigated. Following in vitro characterization, including drug distribution in the suppository bases, drug-base interactions and drug release, pharmacokinetics were investigated in rabbits to determine absolute bioavailability (F) at two dose levels (100 mg and 200 mg). Both types of suppositories were found uniform in weight and content. Powder X-ray diffraction (XRD) and differential scanning calorimetry indicated that AS existed as solid dispersion or anhydrous crystalline dispersion in both suppositories at different ratios without changing melting points of the bases. This was supported by Fourier transform infrared (FTIR) spectroscopy and scanning electron microscopy conjugated with energy dispersive X-ray (SEM/EDX). In dissolution medium, melting and spreading of SNA 15 and dissolution of PEG suppositories accounted for their different drug release kinetics and mean dissolution time (MDT). A rapid and complete amoxicillin absorption (F close to 100%) with a double peak pharmacokinetic profile was observed alongside minimal signs of tissue irritation in rabbits treated with SNA 15 suppositories at both dose levels. In contrast, the F of amoxicillin from PEG suppositories was 59%, increasing to 77.3% as AS dose doubled from 100 mg to 200 mg, reflected in the slower release predominately controlled by erosion of the base. An in vitro - in vivo correlation was observed (MDT vs F; p < 0.01). AS was stable in SNA 15 suppositories at least for three months at 20 ± 0.2 °C. This research highlighted the advantages of SNA 15 suppositories over the PEG suppositories in providing rapid and complete rectal absorption of AS and tissue compatibility.
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Affiliation(s)
- Trusha J Purohit
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Sara M Hanning
- School of Pharmacy, The University of Auckland, Auckland, New Zealand.
| | - Satya Amirapu
- Department of Anatomy and Medical Imaging, The University of Auckland, New Zealand
| | - Zimei Wu
- School of Pharmacy, The University of Auckland, Auckland, New Zealand.
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Hofsäss MA, Dressman J. Evaluation of Differences in Dosage Form Performance of Generics Using BCS-Based Biowaiver Specifications and Biopharmaceutical Modeling–Case Examples Amoxicillin and Doxycycline. J Pharm Sci 2020; 109:2437-2453. [DOI: 10.1016/j.xphs.2020.04.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/12/2022]
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A Phase 1 Pharmacokinetic and Safety Study of Extended-Duration, High-dose Cefixime for Cephalosporin-resistant Neisseria gonorrhoeae in the Pharynx. Sex Transm Dis 2019; 45:677-683. [PMID: 29624558 DOI: 10.1097/olq.0000000000000844] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no fully oral recommended treatment regimens for gonorrhea. Inadequately treated pharyngeal gonococcal infections are a likely reservoir for transmission and development of antimicrobial resistance. We sought to determine an oral cefixime dosing regimen that would theoretically treat pharyngeal infections by gonococci with minimum inhibitory concentrations 0.5 μg/mL. METHODS We conducted an open-label, nonrandomized, phase I pharmacokinetic and safety study of cefixime in 25 healthy male and female volunteers divided into 4 dosing cohorts (cohort A, 400 mg; cohort B, 800 mg; cohort C, 1200 mg; and cohort D, 800 mg every 8 hours × 3 doses [total dose 2400 mg]) with a target serum concentration of at least 2.0 μg/mL for more than 20 hours. Cefixime concentrations from serum and pharyngeal fluid were determined with use of a validated liquid chromatography-tandem mass spectrometry assay. Safety measures included laboratories, physical examinations, and symptom diaries. RESULTS None of the single-dose regimens attained the target concentration; however, 50% of subjects in cohort D attained the target concentration. Variation in absorption and protein binding contributed to differences in concentrations. Pharyngeal fluid concentrations were negligible. The single-dose regimens were well tolerated; the multidose regimen resulted in mild to moderate gastrointestinal symptoms in 43% of subjects. CONCLUSIONS None of the dosing regimens achieved the target concentration. However, the proposed theoretical target was extrapolated from penicillin data; there are no empirically derived pharmacokinetic/pharmacodynamic criteria for pharyngeal gonorrhea. Under alternative cephalosporin-specific therapeutic goals, the multidose regimen may be effective, although the absence of cefixime in pharyngeal fluid is concerning. A clinical trial evaluating efficacy and defining pharmacokinetic/pharmacodynamic outcomes may be warranted.
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Montanha MC, Dos Santos Magon TF, de Souza Alcantara C, Simões CF, Silva SRB, Kuroda CM, Yamada SS, de Oliveira LES, Nasser D, Junior NN, Mazucheli J, Diniz A, Paixão PJPA, Kimura E. Reduced bioavailability of oral amoxicillin tablets compared to suspensions in Roux-en-Y gastric bypass bariatric subjects. Br J Clin Pharmacol 2019; 85:2118-2125. [PMID: 31215676 DOI: 10.1111/bcp.14023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/20/2019] [Accepted: 06/02/2019] [Indexed: 12/31/2022] Open
Abstract
AIMS To evaluate the relative bioavailability of oral amoxicillin (AMX) tablets in comparison to AMX suspension in Roux-en-Y gastric bypass bariatric subjects. METHODS A randomized, double-blind, cross-over study was performed on the bioavailability of oral AMX tablets and suspension in Roux-en-Y gastric bypass subjects operated at least 3 months previously . Doses of 875 mg of the AMX tablet or 800 mg of the AMX suspension were given to all the subjects, allowing a washout of 7 days between the periods. Blood samples were collected at 0, 0.25, 0.5, 1, 1.5, 2, 4, 6 and 8 hours after drug administration and the AMX levels were quantified by liquid chromatography coupled with triple quadrupole tandem mass spectrometry. The pharmacokinetic parameters were calculated by noncompartmental analysis, normalized to an 875 mg dose and the bioavailability of the AMX from the tablets was compared to that from the suspension formulation. RESULTS Twenty subjects aged 42.65 ± 7.21 years and with a body mass index of 29.88 ± 4.36 kg/m2 were enrolled in the study. The maximum AMX plasma concentration of the tablets and the suspension (normalized to 875 mg) were 7.42 ± 2.99 mg/L and 8.73 ± 3.26 mg/L (90% confidence interval of 70.71-99.11), and the total area under the curve from time zero to infinity were 23.10 ± 7.41 mg.h/L and 27.59 ± 8.32 mg.h/L (90% confidence interval of 71.25-97.32), respectively. CONCLUSION The tablets presented a lower bioavailability than the suspension formulation and the total absorbed amount of AMX in these subjects was lower in comparison to the standard AMX absorption rates in nonbariatric subjects, regardless of the formulation.
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Affiliation(s)
- Maiara Camotti Montanha
- Postgraduate Program in Biosciences and Physiopathology (PBF), Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | | | - Conrado de Souza Alcantara
- Postgraduate Program in Biosciences and Physiopathology (PBF), Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Caroline Ferraz Simões
- Postgraduate Program in Physical Education, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Sandra Regina Bin Silva
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Cristina Megumi Kuroda
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Sérgio Seiji Yamada
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | | | - Daoud Nasser
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Nelson Nardo Junior
- Department of Physical Education, Centre for Multiprofessional Studies of Obesity (NEMO), Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Josmar Mazucheli
- Department of Statistics, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Andrea Diniz
- Department of Pharmacy, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | | | - Elza Kimura
- Postgraduate Program in Biosciences and Physiopathology (PBF), Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Postgraduate Program in Food Science (PPC), Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Department of Pharmacy, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
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Fatima A, Jiyad Shaikh M, Zahid H, Younus I, Abdul Khaliq S, Khalid F. Clinical Pharmacokinetics of Clavulanic Acid, a Novel β- Lactamase Isolated from Streptomyces clavuligerus and Its Variability. Med Chem 2019. [DOI: 10.5772/intechopen.79409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Charoo NA, Rahman Z, Ali AA. Is the demonstration of bioequivalence for clavulanic acid required in amoxicillin-clavulanic acid orally administered immediate-release products? J Pharm Pharmacol 2018; 70:883-892. [PMID: 29633270 DOI: 10.1111/jphp.12920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/11/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Bioequivalence (BE) criteria for amoxicillin-clavulanic acid (Co-amoxiclav) oral formulations are based on 90% confidence interval for both amoxicillin and clavulanic acid. The aim of this work is to explore the relevance of demonstrating BE of clavulanic acid in Co-amoxiclav oral formulations and also to assess the impact on safety and efficacy of product due to bioinequivalent clavulanic acid. METHODS AND KEY FINDINGS The subtherapeutic levels of clavulanic acid would continue to exert their action against β-lactamases due to postβ-lactamase inhibitor effect. Additionally, only minute quantities are required to inhibit β-lactamases. Majority of adverse effects associated with Co-amoxiclav are of less serious nature, therefore, risk due to suprabioavailable clavulanic acid was determined to be low. 'Very rapid clavulanic acid release' in in vitro dissolution test would ensure that clinically significant differences between test and reference formulations if any are detected in advance. As an additional risk mitigation strategy, WHO recommends qualitative and quantitative composition similarity between test and reference formulations to ensure excipients do not adversely impact bioavailability. CONCLUSIONS Co-amoxiclav with non-bioequivalent clavulanic acid, but bioequivalent amoxicillin would still achieve its therapeutic objectives without exposing patients to unwanted adverse effects. Therefore, the current regulatory criterion of demonstrating BE of clavulanic acid appears conservative.
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Affiliation(s)
- Naseem A Charoo
- Zeino Pharma LLC, Khalifa Industrial Zone, Abu Dhabi, United Arab Emirates
| | - Ziyaur Rahman
- Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, Texas A&M University, College Station, TX, USA
| | - Areeg Anwer Ali
- RAK College of Pharmaceutical Sciences, RAK Medical & Health Sciences University, Ras Al Khaimah, United Arab Emirates
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Thambavita D, Galappatthy P, Mannapperuma U, Jayakody L, Cristofoletti R, Abrahamsson B, Groot DW, Langguth P, Mehta M, Parr A, Polli JE, Shah VP, Dressman J. Biowaiver Monograph for Immediate-Release Solid Oral Dosage Forms: Amoxicillin Trihydrate. J Pharm Sci 2017; 106:2930-2945. [PMID: 28483422 DOI: 10.1016/j.xphs.2017.04.068] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/18/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
Literature and experimental data relevant to waiver of in vivo bioequivalence (BE) testing for the approval of immediate-release solid oral dosage forms containing amoxicillin trihydrate are reviewed. Solubility and permeability characteristics according to the Biopharmaceutics Classification System (BCS), therapeutic uses, therapeutic index, excipient interactions, as well as dissolution and BE and bioavailability studies were taken into consideration. Solubility and permeability studies indicate that amoxicillin doses up to 875 mg belong to BCS class I, whereas 1000 mg belongs to BCS class II and doses of more than 1000 mg belong to BCS class IV. Considering all aspects, the biowaiver procedure can be recommended for solid oral products of amoxicillin trihydrate immediate-release preparations containing amoxicillin as the single active pharmaceutical ingredient at dose strengths of 875 mg or less, provided (a) only the excipients listed in this monograph are used, and only in their usual amounts, (b) the biowaiver study is performed according to the World Health Organization-, U.S. Food and Drug Administration-, or European Medicines Agency-recommended method using the innovator as the comparator, and (c) results comply with criteria for "very rapidly dissolving" or "similarly rapidly dissolving." Products containing other excipients and those containing more than 875 mg amoxicillin per unit should be subjected to an in vivo BE study.
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Affiliation(s)
- Dhanusha Thambavita
- Department of Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo 08, Sri Lanka
| | - Priyadarshani Galappatthy
- Department of Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo 08, Sri Lanka
| | - Uthpali Mannapperuma
- Department of Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo 08, Sri Lanka
| | - Lal Jayakody
- Department of Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo 08, Sri Lanka
| | - Rodrigo Cristofoletti
- Division of Bioequivalence, Brazilian Health Surveillance Agency (Anvisa), Brasilia, Brazil
| | | | - Dirk W Groot
- RIVM (National Institute for Public Health and the Environment), Bilthoven, The Netherlands
| | - Peter Langguth
- Pharmaceutical Technology and Biopharmaceutics, Institute of Pharmacy and Biochemistry, Johannes Gutenberg-University, Mainz, Germany
| | - Mehul Mehta
- Division of Clinical Pharmacology, Centre for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland 20993
| | - Alan Parr
- BioCeutics LLC, Cary, North Carolina 28594
| | - James E Polli
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland 21201
| | - Vinod P Shah
- International Pharmaceutical Federation (FIP), The Hague, The Netherlands
| | - Jennifer Dressman
- Institute of Pharmaceutical Technology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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Prado TM, Cincotto FH, Moraes FC, Machado SA. Electrochemical Sensor-Based Ruthenium Nanoparticles on Reduced Graphene Oxide for the Simultaneous Determination of Ethinylestradiol and Amoxicillin. ELECTROANAL 2017. [DOI: 10.1002/elan.201700014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Thiago M. Prado
- Institute of Chemistry of São Carlos; University of São Paulo; São Carlos, SP Brazil
| | | | - Fernando C. Moraes
- Chemistry Department; Federal University of São Carlos; São Carlos, SP Brazil
| | - Sergio A.S. Machado
- Institute of Chemistry of São Carlos; University of São Paulo; São Carlos, SP Brazil
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11
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de Velde F, de Winter BCM, Koch BCP, van Gelder T, Mouton JW. Non-linear absorption pharmacokinetics of amoxicillin: consequences for dosing regimens and clinical breakpoints. J Antimicrob Chemother 2016; 71:2909-17. [PMID: 27330071 DOI: 10.1093/jac/dkw226] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/13/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe the population pharmacokinetics of oral amoxicillin and to compare the PTA of current dosing regimens. METHODS Two groups, each with 14 healthy male volunteers, received oral amoxicillin/clavulanic acid tablets on two separate days 1 week apart. One group received 875/125 mg twice daily and 500/125 mg three times daily and the other group 500/125 mg twice daily and 250/125 mg three times daily. A total of 1428 amoxicillin blood samples were collected before and after administration. We analysed the concentration-time profiles using a non-compartmental pharmacokinetic method (PKSolver) and a population pharmacokinetic method (NONMEM). The PTA was computed using Monte Carlo simulations for several dosing regimens. RESULTS AUC0-24 and Cmax increased non-linearly with dose. The final model included the following components: Savic's transit compartment model, Michaelis-Menten absorption, two distribution compartments and first-order elimination. The mean central volume of distribution was 27.7 L and mean clearance was 21.3 L/h. We included variability for the central volume of distribution (34.4%), clearance (25.8%), transit compartment model parameters and Michaelis-Menten absorption parameters. For 40% fT>MIC and >97.5% PTA, the breakpoints were 0.125 mg/L (500 mg twice daily), 0.25 mg/L (250 mg three times daily and 875 mg twice daily), 0.5 mg/L (500 mg three times daily) and 1 mg/L (750, 875 or 1000 mg three times daily and 500 mg four times daily). CONCLUSIONS The amoxicillin absorption rate appears to be saturable. The PTAs of high-dose as well as twice-daily regimens are less favourable than regimens with lower doses and higher frequency.
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Affiliation(s)
- Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
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12
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GODOY C, CASTELLS G, MARTÍ G, CAPECE BPS, PÉREZ F, COLOM H, CRISTÒFOL C. Influence of a pig respiratory disease on the pharmacokinetic behaviour of amoxicillin after oral ad libitum administration in medicated feed. J Vet Pharmacol Ther 2010; 34:265-76. [DOI: 10.1111/j.1365-2885.2010.01220.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Petri N, Lennernäs H. In Vivo
Permeability Studies in the Gastrointestinal Tract of Humans. ACTA ACUST UNITED AC 2009. [DOI: 10.1002/9783527623860.ch9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pichichero ME, Reed MD. Variations in amoxicillin pharmacokinetic/pharmacodynamic parameters may explain treatment failures in acute otitis media. Paediatr Drugs 2009; 11:243-9. [PMID: 19566108 DOI: 10.2165/00148581-200911040-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pharmacokinetic/pharmacodynamic (PK/PD) modeling and Monte Carlo simulations suggest that amoxicillin should rarely fail as therapy for Streptococcus pneumoniae and Haemophilus influenzae acute otitis media (AOM) infections except when the S. pneumoniae are highly penicillin resistant or the H. influenzae are beta-lactamase producing. However, important and not infrequent exceptions to this expectation have been described. The objective of this review was to define the biologic variations in amoxicillin PK/PD parameters for the treatment of AOM in children and assess whether these variations could explain why the commonly employed amoxicillin PK/PD model is imperfect in predicting outcome for every patient in this clinical setting. To this end, a literature search of MEDLINE (1966-2006) and EMBASE (1974-2006) was conducted to identify studies that evaluated ampicillin or amoxicillin intestinal absorption, serum concentrations, and/or middle ear fluid (MEF) concentrations. Analysis of studies identified for review showed that the intestinal bioavailability of amoxicillin depends on passive diffusion and a saturable 'pump' mechanism that produces variable serum concentrations of the antibacterial agent. Indeed, substantial differences from patient to patient in serum (5- to 30-fold) and MEF (up to 20-fold) concentrations of amoxicillin occur following oral administration, and 15-35% of children have no detectable amoxicillin in MEF. These findings suggest that variability in PK/PD parameters may impact amoxicillin concentrations in serum and MEF, possibly explaining some AOM treatment failures.
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Affiliation(s)
- Michael E Pichichero
- Rochester General Research Institute, Legacy Pediatric Group, Rochester, New York, USA.
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15
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Kerč J, Opara J. A new amoxicillin/clavulanate therapeutic system: Preparation, in vitro and pharmacokinetic evaluation. Int J Pharm 2007; 335:106-113. [PMID: 17141985 DOI: 10.1016/j.ijpharm.2006.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 10/27/2006] [Accepted: 11/01/2006] [Indexed: 11/25/2022]
Abstract
A new peroral amoxicillin/clavulanate therapeutic system composed of immediate release tablet and controlled release floating capsule was developed and evaluated by in vivo bioavailability study. Pharmacokinetic (PK) parameters for amoxicillin and clavulanic acid of the new therapeutic systems: AUCt, AUCi, (AUCt/AUCi), Cmax, Tmax, kel, T(1/2) and additionally for amoxicillin T(4) and T(2) were calculated from the plasma levels. The study confirmed enhanced pharmacokinetic parameters of a newly developed therapeutic system containing 1500 mg of amoxicillin and 125 mg of clavulanic acid. Prolonged time over MIC of amoxicillin in relation to a regular immediate release amoxicillin/clavulanate formulation was confirmed.
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Affiliation(s)
- Janez Kerč
- Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Verovškova 57, 1526 Ljubljana, Slovenia.
| | - Jerneja Opara
- Lek Pharmaceuticals d.d., Sandoz Development Center Slovenia, Verovškova 57, 1526 Ljubljana, Slovenia
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Denes E. [Antibiotherapy for acute CAP in adults]. Med Mal Infect 2006; 36:718-33. [PMID: 17092678 DOI: 10.1016/j.medmal.2006.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 07/21/2006] [Indexed: 11/16/2022]
Abstract
Community acquired pneumonia is one of the most frequent infections. With time, bacterial epidemiology and bacterial resistance evolve and new antibiotics become available. So an up-date on adequate antibiotic use is necessary. We reviewed the epidemiology of pneumonia and the evolution of bacterial resistance. We also collected data on new antibiotics which can be used for this infection such as levofloxacin, moxifloxacin, telithromycin, and pristinamycin. All these drugs are effective on bacteria involved in pneumonia. At this time, only few Streptococcus pneumoniae strains have developed resistance to these drugs. However, resistance to fluoroquinolones is not easily detected with common laboratory techniques. There is no effectiveness difference between the 2 new fluoroquinolones (levofloxacin, moxifloxacin) in clinical studies. However, in bacteriological and pharmacological studies, moxifloxacin seems to be more effective than levofloxacin (500 mg/day). For the treatment of pneumonia due to Legionella pneumophila, fluoroquinolones are now widely recommended. For Streptococcus pneumonia, amoxicillin remain the drug of choice, even for bacteria with a decreased susceptibility to penicillin. The importance of treating atypical pathogens remains to be documented.
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Affiliation(s)
- E Denes
- Service de maladies infectieuses et tropicales, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
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17
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Sánchez Navarro A. New formulations of amoxicillin/clavulanic acid: a pharmacokinetic and pharmacodynamic review. Clin Pharmacokinet 2006; 44:1097-115. [PMID: 16231964 DOI: 10.2165/00003088-200544110-00001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The pharmacokinetic properties of amoxicillin and clavulanic acid when used alone or in combination are extensively reviewed and discussed in this article. The reported data support a nonlinear absorption process for amoxicillin. Saturable transport mechanisms, limited solubility and the existence of an absorption window are possibly involved in the gastrointestinal absorption of this antibacterial, all leading to a decrease in the peak plasma concentration (Cmax)/dose ratio, a prolongation of the time to reach Cmax, and broad variability for high doses of amoxicillin. Data available in the literature also suggest a possible interaction between amoxicillin and clavulanic acid that might decrease the absolute bioavailability of clavulanic acid. In the present review the intrinsic pharmacodynamics of each drug, together with the synergism produced by the amoxicillin/clavulanic acid association, are also reviewed and analysed. Not only beta-lactamase-producing strains, but also Streptococcus pneumoniae strains, seem to be more efficiently eradicated by the association of amoxicillin and clavulanic acid, and a relevant post-antibacterial effect and post-beta-lactamase inhibitor effect are likely to operate when amoxicillin is administered together with clavulanic acid. The principles of pharmacokinetic/pharmacodynamic analysis applied to amoxicillin are reviewed, with special emphasis being placed on the results obtained from in vitro studies and animal models regarding the new pharmacokinetically enhanced formulation. Theoretical considerations concerning the efficacy of this formulation provided by the application of pharmacokinetic/pharmacodynamic analysis to the scarce pharmacokinetic data available are also included. The broad pharmacokinetic variability of both amoxicillin and clavulanic acid, particularly when administered together and at high doses of amoxicillin, is highlighted and the interest in considering this aspect to improve predictions based on pharmacokinetic/pharmacodynamic analyses for the new formulations is indicated. Methodological recommendations such as the Monte Carlo simulation are proposed in order to obtain more realistic predictions in clinical practice.
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18
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Garau J. Role of beta-lactam agents in the treatment of community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2005; 24:83-99. [PMID: 15696306 DOI: 10.1007/s10096-005-1287-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Community-acquired pneumonia (CAP) is a common illness associated with high rates of morbidity and mortality worldwide. The beta-lactam antibacterial agents have been the mainstay of therapy for CAP for over four decades and remain as first-line therapy. However, the impact of the substantial prevalence of resistance seen among the common respiratory pathogens, particularly penicillin and macrolide resistance among Streptococcus pneumoniae, is now an area for concern. CAP treatment guidelines often recommend the use of a macrolide or fluoroquinolone in conjunction with, or as an alternative to, beta-lactam agents, but whether this is necessary is uncertain. This review outlines the historical use of beta-lactam antibacterial agents in the treatment of CAP along with their ongoing therapeutic utility.
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Affiliation(s)
- J Garau
- Department of Medicine, Hospital Mutua de Terrassa, Plaza Dr Robert 5, 08221 Terrassa, Barcelona, Spain.
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19
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Groppo FC, Simões RP, Ramacciato JC, Rehder V, de Andrade ED, Mattos-Filho TR. Effect of sodium diclofenac on serum and tissue concentration of amoxicillin and on staphylococcal infection. Biol Pharm Bull 2004; 27:52-5. [PMID: 14709898 DOI: 10.1248/bpb.27.52] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effect of sodium diclofenac on serum and tissue amoxicillin concentration as well as their effect against staphylococcal infection was observed. Four polyurethane sponges were placed in the back of thirty rats. After 14 d, two granulomatous tissues received 0.5 ml of 10(8) cfu/ml (Staphylococcus aureus). Two days later, the rats were divided into five groups: group 1 received amoxicillin 50 mg/kg/p.o., group 2 received amoxicillin 25 mg/kg/p.o., group 3 received sodium diclofenac 2.5 mg/kg/i.m. and amoxicillin 50 mg/kg/p.o., group 4 received sodium diclofenac 2.5 mg/kg/i.m., and group 5 (control group) received NaCl 1 ml/p.o. After six hours of drug administration, blood serum (10 microl) and noninfected granulomatous tissues were placed on Mueller-Hinton agar inoculated with 10(8) cfu/ml (S. aureus). Infected tissues were dispersed in a sonic system and were spread (10 microl) on salt mannitol agar. Microorganisms were counted and the inhibition zones were measured after 18 h of incubation at 37 degrees C. Amoxicillin tissue concentration was 6.27 microg/g for group 1, 2.18 microg/g for group 2, and 0.72 microg/g for group 3. The serum concentrations were 11.56 microg/ml for group 1, 5.36 microg/ml for group 2, and 1.34 microg/ml for group 3. No differences were observed among group 1, 2, and 3 regarding staphylococci counts (Kruskall-Wallis test p>0.05). Group 4 reduced (p<0.05) staphylococci counts comparing to group 5. It was concluded that sodium diclofenac reduced serum and tissue amoxicillin concentration and, even in large doses, amoxicillin was not effective in eradicating the staphylococcal infection after 6 h of administration.
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Affiliation(s)
- Francisco Carlos Groppo
- Department of Pharmacology, Anaesthesiology and Therapeutics-Piracicaba Dentistry School, Campinas State University, Av. Limeira 901, Bairro Areiao, Piracicaba, São Paulo, Brazil.
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20
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Vree TB, Dammers E, Van Duuren E. Variable absorption of clavulanic acid after an oral dose of 25 mg/kg of Clavubactin and Synulox in healthy dogs. J Vet Pharmacol Ther 2003; 26:165-71. [PMID: 12755899 DOI: 10.1046/j.1365-2885.2003.00476.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The aims of this investigation were to calculate the pharmacokinetic parameters and to identify parameters, based on individual plasma concentration-time curves of amoxicillin and clavulanic acid in dogs, that may govern the observed differences in absorption of both drugs. The evaluation was based on the data from plasma concentration-time curves obtained following a single dose in an open, randomized, two-way crossover study involving 24 male Beagle dogs treated with two Amoxi-Clav formulations (A Clavubactin and B Synulox, each with 200/50 mg). Plasma amoxicillin and clavulanic acid concentrations were determined using validated bioassay methods. The half-life of elimination of amoxicillin was 1.5 h (t1/2 = 1.52 +/- 0.19 h, Cmax = 11.4 +/- 2.74 microg/mL), and that of clavulanic acid 0.76 h (t1/2 = 0.71 +/- 0.23 h, Cmax = 2.06 +/- 1.05 microg/mL). There was a fivefold variation in the AUCt of clavulanic acid for both formulations, while the AUCt of amoxicillin varied by a factor of 2. The mean ratio of the AUCt amoxicillin : clavulanic acid was 12.7 +/- 3.65 for formulation A and 11.8 +/- 5.22 for formulation B (P = 0.51).
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Affiliation(s)
- T B Vree
- Institute for Anaesthesiology, University Medical Center Sint Radboud, Nijmegen, The Netherlands.
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21
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Lennernäs H, Knutson L, Knutson T, Hussain A, Lesko L, Salmonson T, Amidon GL. The effect of amiloride on the in vivo effective permeability of amoxicillin in human jejunum: experience from a regional perfusion technique. Eur J Pharm Sci 2002; 15:271-7. [PMID: 11923059 DOI: 10.1016/s0928-0987(02)00005-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this human intestinal perfusion study (in vivo) was twofold. Firstly, we aimed to determine the effective in vivo jejunal permeability (P(eff)) of amoxicillin and to classify it according to the Biopharmaceutics Classification System (BCS). Secondly, we investigated the acute effect of amiloride on the jejunal P(eff) of amoxicillin. Amoxicillin, a beta-lactam antibiotic, has been reported to be absorbed across the intestinal mucosa by both passive diffusion and active transport. A regional single-pass perfusion of the jejunum was performed using a Loc-I-Gut perfusion tube in 14 healthy volunteers. Each perfusion lasted for 200 min and was divided into two periods of 100 min each. The concentration of amoxicillin entering the jejunal segment was 300 mg/l in both periods, and amiloride, an inhibitor of the Na+/H+ exchanger, was added at 25 mg/l in period 2. The concentrations of amoxicillin and amiloride in the outlet jejunal perfusate were measured with two different HPLC-methods. Antipyrine and [14C]PEG 4000 were added as internal standards to the perfusion solution. Amiloride had no significant effect on the jejunal P(eff) of amoxicillin. The human in vivo jejunal P(eff) for amoxicillin was 0.34+/-0.11 x 10(-4) and 0.46+/-0.12 x 10(-4) cm/s in periods 1 and 2, respectively. The high jejunal P(eff) for amiloride was 1.63+/-0.51 x 10(-4) cm/s which predicts an intestinal absorption of more than 90%. Following the BCS amoxicillin was classified as a low P(eff) drug, and amiloride had no acute effect on the in vivo jejunal P(eff) of amoxicillin.
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Affiliation(s)
- H Lennernäs
- Department of Pharmacy, Box 580, BMC, Uppsala University, S-751 23, Sweden.
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Charles BG, Preechagoon Y, Lee TC, Steer PA, Flenady VJ, Debuse N. Population pharmacokinetics of intravenous amoxicillin in very low birth weight infants. J Pharm Sci 1997; 86:1288-92. [PMID: 9383742 DOI: 10.1021/js970068l] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The population pharmacokinetics of amoxicillin were determined in 40 very premature infants (< or = 32 week gestational age, < 1500 g birth weight) who were receiving intravenous amoxicillin (50 mg/ kg, every 12 h) during the first days after birth. Serum amoxicillin concentrations were measured by HPLC. Clearance (CL) and volume of distribution (Vd) were modeled alone and under the influence of demographic and clinical covariates with a 1-compartment model with first-order elimination. The final population models with influential covariates were: CL(L/h) = 0.0000610 x body weight (g) and CL (L/h) = 0.0000805 x body weight (g), for infants also receiving gentamicin and not receiving gentamicin, respectively; Vd(L) = 0.678. The interpatient standard deviation (SD) for CL was 0.0351 L/h, and for Vd was 0.365 L. The intrapatient variability (SD) among observed and model-predicted serum concentrations was 13.7 mg/L. Evaluation of the predictive performance of this model in another group of infants (n = 16) indicated statistically insignificant bias (p > 0.05) of 3 mg/L among pairs of observed and Bayesian-predicted amoxicillin concentrations. The average population CL was smaller, but the average Vd and terminal half-life (t1/2) were larger than previously reported for healthy adults.
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Affiliation(s)
- B G Charles
- School of Pharmacy, University of Queensland, St. Lucia, Australia
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