Ofloxacin clinical pharmacokinetics

Cerebrospinal fluid concentrations of fluoroquinolones and carbapenems in tuberculosis meningitis

Background: Tuberculosis meningitis (TBM) is the most lethal form of TB. It is difficult to treat in part due to poor or uncertain drug penetration into the central nervous system (CNS). To help fill this knowledge gap, we evaluated the cerebrospinal fluid (CSF) concentrations of fluoroquinolones and carbapenems in patients being treated for TBM. Methods: Serial serum and CSF samples were collected from hospitalized patients being treated for TBM. CSF was collected from routine lumbar punctures between alternating timepoints of 2 and 6 h after drug administration to capture early and late CSF penetration. Rich serum sampling was collected after drug administration on day 28 for non-compartmental analysis. Results: Among 22 patients treated for TBM (8 with confirmed disease), there was high use of fluoroquinolones (levofloxacin, 21; moxifloxacin, 10; ofloxacin, 6) and carbapenems (imipenem, 11; meropenem, 6). Median CSF total concentrations of levofloxacin at 2 and 6 h were 1.34 mg/L and 3.36 mg/L with adjusted CSF/serum ratios of 0.41 and 0.63, respectively. For moxifloxacin, the median CSF total concentrations at 2 and 6 h were 0.78 mg/L and 1.02 mg/L with adjusted CSF/serum ratios of 0.44 and 0.62. Serum and CSF concentrations of moxifloxacin were not affected by rifampin use. Among the 76 CSF samples measured for carbapenem concentrations, 79% were undetectable or below the limit of detection. Conclusion: Fluoroquinolones demonstrated high CSF penetration indicating their potential usefulness for the treatment of TBM. Carbapenems had lower than expected CSF concentrations.

Therapeutic Options for Chlamydia trachomatis Infection: Present and Future

Sexually transmitted infections (STIs), such as Chlamydia trachomatis (Ct) infection, have serious consequences for sexual and reproductive health worldwide. Ct is one of the most common sexually transmitted bacterial infections in the world, with approximately 129 million new cases per year. C. trachomatis is an obligate intracellular Gram-negative bacterium. The infection is usually asymptomatic, notwithstanding, it could also be associated with severe sequels and complications, such as chronic pain, infertility, and gynecologic cancers, and thus there is an urgent need to adequately treat these cases in a timely manner. Consequently, beyond its individual effects, the infection also impacts the economy of the countries where it is prevalent, generating a need to consider the hypothesis of implementing Chlamydia Screening Programs, a decision that, although it is expensive to execute, is a necessary investment that unequivocally will bring financial and social long-term advantages worldwide. To detect Ct infection, there are different methodologies available. Nucleic acid amplification tests, with their high sensitivity and specificity, are currently the first-line tests for the detection of Ct. When replaced by other detection methods, there are more false negative tests, leading to underreported cases and a subsequent underestimation of Ct infection's prevalence. Ct treatment is based on antibiotic prescription, which is highly associated with drug resistance. Therefore, currently, there have been efforts in line with the development of alternative strategies to effectively treat this infection, using a drug repurposing method, as well as a natural treatment approach. In addition, researchers have also made some progress in the Ct vaccine development over the years, despite the fact that it also necessitates more studies in order to finally establish a vaccination plan. In this review, we have focused on the therapeutic options for treating Ct infection, expert recommendations, and major difficulties, while also exploring the possible avenues through which to face this issue, with novel approaches beyond those proposed by the guidelines of Health Organizations.

Fluoroquinolone efflux mediated by ABC transporters

Quinolones and fluoroquinolones are broad spectrum bactericidal drugs, which are widely used in both human and veterinary medicine. These drugs can quite easily enter cells and are often used to treat intracellular pathogens. Some fluoroquinolones have been reported to undergo efflux, which could explain their low bioavailability. There is a growing need to understand resistance mechanisms to quinolones, involving for instance mutations or the action of efflux pumps. Several members of the ATP-binding cassette (ABC) drug efflux transporter family (MDR, MRP, ABCG2) significantly affect the pharmacokinetic disposition of quinolones. Active secretory mechanisms common to all fluoroquinolones have been suggested, as well as competition between fluoroquinolones at transporter sites. For grepafloxacin and its metabolites, MRP2 has been demonstrated to mediate biliary excretion. However, MDR1 is responsible for grepafloxacin intestinal secretion. Recently it has been shown that ciprofloxacin and enrofloxacin are efficiently transported ABCG2 substrates which are actively secreted into milk. It appears that multiple ABC transporters contribute to the overall secretion of fluoroquinolones. The objective of this work is to review the recent advances in insights into ABC transporters and their effects on fluoroquinolone disposition and resistance including data on drug secretion into milk.

Ocular and systemic manifestations after oral administration of a high dose of enrofloxacin in cats

OBJECTIVE

To characterize the effects of oral administration of a high dose of enrofloxacin to cats.

ANIMALS

24 (12 male and 12 female) young healthy cats.

PROCEDURES

Cats were allocated on the basis of sex into 2 groups (4 males and 4 females/ group) from which 3 subgroups for 3 durations (3, 5, or 7 days) of enrofloxacin (50 mg/kg, PO, q 24 h) or control solution (1 mL of water, PO, q 24 h) administration that began on day -1 were created. Funduscopic examinations were performed daily. Electroretinography (ERG) was performed before and every 2 to 3 days after the start of oral administration. Four cats/study group were euthanized on days 3, 5, and 7, and eyes were collected for light and electron microscopic evaluations.

RESULTS

Neurologic, funduscopic, and ERG abnormalities were evident only in cats administered enrofloxacin. Funduscopic changes (granular appearance or graying of the area centralis) were noticed on or before day 3 (after only 3 days of enrofloxacin administration), with subsequent similar changes along the visual streak. Vascular attenuation (between days 2 and 4) and generalized tapetal hyperreflectivity (between days 5 and 7) followed. Reduction in b-wave ERG amplitude preceded funduscopic changes. Morphologic changes in the photoreceptor layers correlated with duration of enrofloxacin administration, with generalized degenerative changes evident after 3 doses.

CONCLUSIONS AND CLINICAL RELEVANCE

The study indicated that a high dose of enrofloxacin (50 mg/kg/d, PO) induced retinal and systemic changes. Enrofloxacin at 10 times the recommended dosage is acutely toxic to the outer retina of clinically normal cats.

Two open-label, randomized, crossover studies assessing the bioequivalence of ofloxacin administered as immediateand extended-release formulations in healthy subjects

BACKGROUND

Ofloxacin is a fluoroquinolone agent available as an immediate-release (IR) tablet formulation administered twice daily. An extended-release (ER) formulation of ofloxacin has been developed for oncedaily administration.

OBJECTIVES

The present studies compared the pharmacokinetic (PK) and safety profiles of the ER and IR formulations of ofloxacin.

METHODS

Based on specific inclusion and exclusion criteria, healthy adult male and female volunteers were selected to receive single and multiple oral doses of ofloxacin ER 400 mg QD and ofloxacin IR 200 mg BID in 2 separate open-label, randomized, crossover studies. Multiple blood samples were collected, and plasma concentrations of ofloxacin were analyzed using a high-throughput liquid chromatography system. PK parameters were calculated using noncompartmental methods. Safety was assessed in the clinical pharmacology unit based on vital signs, electrocardiograms (ECGs), and reported adverse events. The relationship of an adverse event to study drugs (definitely, probably, possibly, remotely, or unrelated) was assessed by the principal investigator.

RESULTS

Forty healthy subjects were included in each study. Thirty-seven subjects (28 men, 9 women; mean age, 37 years; mean weight, 71.2 kg) completed the single-dose study, and 38 subjects (33 men, 5 women; mean age, 36 years; mean weight, 72.2 kg) completed the multiple-dose study. With the exception of 3 black subjects in each study of African-American origin, all subjects in both studies were white. The mean AUC(0-24) values for the ER formulation in the single-and multiple-dose studies (18.6 and 21.4 mg . h/L, respectively) were similar to those for the IR formulation (17.7 and 22.8 mg x h/L), with the 90% CIs falling between 80.0 and 125.0. Mean C(max) values for the ER formulation in the single- and multiple-dose studies (2.02 and 2.12 mg/L) were also similar to those for the IR formulation (1.74 and 1.85 mg/L). Under steady-state conditions, median T(max) values for the ER formulation were significantly longer than those for the IR formulation (5.00 vs 2.00 hours, respectively; P < 0.05). All vital signs and ECGs were within normal ranges during the single- and multipledose studies. Adverse events probably related to study drugs (eg, nausea, loose stools, emesis) were similar in nature and frequency between the 2 formulations. No serious adverse events were reported during either study.

CONCLUSION

In these 2 trials in a selected group of healthy adult male and female volunteers, the ER and IR formulations of ofloxacin displayed a similar rate and extent of bioavailability and comparable safety profiles.

Breast cancer resistance protein (BCRP/ABCG2) transports fluoroquinolone antibiotics and affects their oral availability, pharmacokinetics, and milk secretion

The breast cancer resistance protein (BCRP/ABCG2) is an ATP-binding cassette drug efflux transporter that extrudes xenotoxins from cells in intestine, liver, mammary gland, and other organs, affecting the pharmacological and toxicological behavior of many compounds, including their secretion into the milk. The purpose of this study was to determine whether three widely used fluoroquinolone antibiotics (ciprofloxacin, ofloxacin, and norfloxacin) are substrates of Bcrp1/BCRP and to investigate the possible role of this transporter in the in vivo pharmacokinetic profile of these compounds and their secretion into the milk. Using polarized cell lines, we found that ciprofloxacin, ofloxacin, and norfloxacin are transported by mouse Bcrp1 and human BCRP. In vivo pharmacokinetic studies showed that the ciprofloxacin plasma concentration was more than 2-fold increased in Bcrp1(-/-) compared with wild-type mice (1.77 +/- 0.73 versus 0.85 +/- 0.39 microg/ml, p < 0.01) after oral administration of ciprofloxacin (10 mg/kg). The area under the plasma concentration-time curve in Bcrp1(-/-) mice was 1.5-fold higher than that in wild-type mice (48.63 +/- 5.66 versus 33.10 +/- 4.68 min x microg/ml, p < 0.05) after i.v. administration (10 mg/kg). The milk concentration and milk/plasma ratio of ciprofloxacin were 2-fold higher in wild-type than in Bcrp1(-/-) lactating mice. We conclude that Bcrp1 is one of the determinants for the bioavailability of fluoroquinolones and their secretion into the milk.

The activity of grepafloxacin in two murine models of Mycobacterium avium infection

The activity against Mycobacterium avium complex (MAC) of varying doses of grepafloxacin (GRE; 25 mg/kg, 50 mg/kg, 100 mg/kg, and 200 mg/kg) were compared to clarithromycin (CLA; 100 mg/kg and 200 mg/kg), ethambutol (EMB; 100 mg/kg), and rifabutin (RBT; 10 mg/kg) using an intranasal (IN) infection model compared to an intravenous (IV) infection model. Beige mice (C57BL6/J-Lyst bg J/+) were infected intranasally with about 10(6) organisms and for the IV model about 10(7) organisms. Treatment for both models was started 1 week postinfection and given by gavage 5 days/week for 4 weeks. At the initiation of therapy, an early control group was killed to determine the initial organism load. Three days following the completion of therapy, drug-treated groups of mice and the late control group were killed and the response to therapy measured. The most effective agents were CLA and RBT. GRE and EMB had modest activities in both the IN and the IV models. A matched comparison between IN and IV challenges for each of the agents used revealed greater suppression of MAC in the IN model compared to the IV model.

Pharmacokinetic parameter prediction from drug structure using artificial neural networks

Simple methods for determining the human pharmacokinetics of known and unknown drug-like compounds is a much sought-after goal in the pharmaceutical industry. The current study made use of artificial neural networks (ANNs) for the prediction of clearances, fraction bound to plasma proteins, and volume of distribution of a series of structurally diverse compounds. A number of theoretical descriptors were generated from the drug structures and both automated and manual pruning were used to derive optimal subsets of descriptors for quantitative structure-pharmacokinetic relationship models. Models were trained on one set of compounds and validated with another. Absolute predicted ability was evaluated using a further independent test set of compounds. Correlations for test compounds ranged from 0.855 to 0.992. Predicted values agreed closely with experimental values for total clearance, renal clearance, and volume of distribution, while predictions for protein binding were encouraging. The combination of descriptor generation, ANNs, and the speed and success of this technique compared with conventional methods shows strong potential for use in pharmaceutical product development.

Clinically significant pharmacokinetic interactions between dietary caffeine and medications

Caffeine from dietary sources (mainly coffee, tea and soft drinks) is the most frequently and widely consumed CNS stimulant in the world today. Because of its enormous popularity, the consumption of caffeine is generally thought to be safe and long term caffeine intake may be disregarded as a medical problem. However, it is clear that this compound has many of the features usually associated with a drug of abuse. Furthermore, physicians should be aware of the possible contribution of dietary caffeine to the presenting signs and symptoms of patients. The toxic effects of caffeine are extensions of their pharmacological effects. The most serious caffeine-related CNS effects include seizures and delirium. Other symptoms affecting the cardiovascular system range from moderate increases in heart rate to more severe cardiac arrhythmia. Although tolerance develops to many of the pharmacological effects of caffeine, tolerance may be overwhelmed by the nonlinear accumulation of caffeine when its metabolism becomes saturated. This might occur with high levels of consumption or as the result of a pharmacokinetic interaction between caffeine and over-the-counter or prescription medications. The polycyclic aromatic hydrocarbon-inducible cytochrome P450 (CYP) 1A2 participates in the metabolism of caffeine as well as of a number of clinically important drugs. A number of drugs, including certain selective serotonin reuptake inhibitors (particularly fluvoxamine), antiarrhythmics (mexiletine), antipsychotics (clozapine), psoralens, idrocilamide and phenylpropanolamine, bronchodilators (furafylline and theophylline) and quinolones (enoxacin), have been reported to be potent inhibitors of this isoenzyme. This has important clinical implications, since drugs that are metabolised by, or bind to, the same CYP enzyme have a high potential for pharmacokinetic interactions due to inhibition of drug metabolism. Thus, pharmacokinetic interactions at the CYP1A2 enzyme level may cause toxic effects during concomitant administration of caffeine and certain drugs used for cardiovascular, CNS (an excessive dietary intake of caffeine has also been observed in psychiatric patients), gastrointestinal, infectious, respiratory and skin disorders. Unless a lack of interaction has already been demonstrated for the potentially interacting drug, dietary caffeine intake should be considered when planning, or assessing response to, drug therapy. Some of the reported interactions of caffeine, irrespective of clinical relevance, might inadvertently cause athletes to exceed the urinary caffeine concentration limit set by sports authorities at 12 mg/L. Finally, caffeine is a useful and reliable probe drug for the assessment of CYP1A2 activity, which is of considerable interest for metabolic studies in human populations.

Comparison of in vitro and in vivo release characteristics of sustained release ofloxacin microspheres

The sustained release nature of ofloxacin microspheres--to eradicate bacterial biofilm associated with chronic infections from sensitive strains of bacteria--was determined both in vitro and in vivo. Ofloxacin microspheres were prepared by emulsion solvent evaporation procedure using poly(glycolic acid-co-dl-lactic acid) (PLGA) as the biodegradable polymer. The microspheres were characterized by scanning electron microscopy, in vitro release in an incubator, and in vivo release in the rat subcutaneous model. The microspheres were highly spherical with a very smooth surface. Approximately 45% of the drug was released from microspheres in sizes of 125-250 microns and 250-425 microns in 2 days compared with approximately 22% from microspheres of size range 37-125 microns indicating that surface area of the microspheres did not control the kinetics of in vitro release. However, about 96% of the drug was released from the three different size ranges in 35 days. The in vitro release profile of microspheres of size range 125-250 microns is not significantly different from microspheres in sizes of 250-425 microns. The peak plasma level of ofloxacin in animals that received the drug suspension occurred within 2 hr and was higher than that of the microspheres that occurred by the end of the second day. The plasma of animals that received the free drug was depleted of ofloxacin by the end of the first day, but the drug was sustained above 0.5 microgram/mL in the plasma of animals that received the microspheres for about 3 weeks. The results suggest that biodegradable ofloxacin microspheres can be prepared that release the antibiotic in vivo for about 3 weeks. This should provide a means for continuous treatment of chronic infections in which bacterial biofilm can occur.

Clinical applications of quinolones

The quinolone antimicrobials are the class of inhibitors of bacterial topoisomerases that has been developed most fully for clinical use in human medicine. Initial members of the class had their greatest potency against Gram-negative bacteria, but newly developed members have exhibited increased potency against Gram-positive bacteria and soon agents will be available with additional activity against anaerobic bacteria, providing a broad spectrum of potency. After nalidixic acid, the earliest member of the class which was used for treatment of urinary tract infections, the later fluoroquinolone congeners have had sufficient potency, absorption, and distribution into tissue for additional uses in treatment of sexually transmitted diseases, infections of the gastrointestinal tract, respiratory tract, skin, and bones and joints. Tolerability of these agents in usual doses has been good. Acquired bacterial resistance resulting from clinical uses has occurred in particular among staphylococci and Pseudomonas aeruginosa. Intense drug use and ability of resistant pathogens to spread have also contributed to development of resistance in initially more susceptible pathogens such as Escherichia coli and Neisseria gonorrhoeae in certain settings. Preservation of the considerable clinical utility of the quinolone class for the long term will be affected by the extent to which their use is judicious.

Sequential antimicrobial therapy: pharmacokinetic and pharmacodynamic considerations in sequential therapy

The pharmacodynamic factors important in sequential therapy are largely unknown. This is because most pharmacodynamic investigations concentrate on how bacterial populations respond to first antimicrobial exposures. However, it is likely that for B lactams T>MIC and for quinolones the antimicrobial AUC/MIC ratio will be important. Factors which reduce antimicrobial absorption will impact on these parameters and require further study.

Grepafloxacin: pharmacokinetics and tissue penetration

Pharmacokinetic and tissue penetration studies of grepafloxacin, a new broad-spectrum fluoroquinolone, show that it has useful properties for the treatment of respiratory tract infections. Grepafloxacin has a volume of distribution that is larger than those of many of the other fluoroquinolones and is concentrated in alveolar macrophages, bronchial mucosa and epithelial lining fluid to a greater extent than are certain other fluoroquinolones. Grepafloxacin concentrations achieved in plasma after a 400-mg oral dose are well in excess of those required to inhibit the respiratory pathogens Staphylococcus aureus, Haemophilus influenzae and Moraxella catarrhalis. Streptococcus pneumoniae is also covered for most of the dosing interval, but at normal dose levels grepafloxacin might not inhibit Enterococcus faecalis. The maximum plasma concentrations and area under the concentration---time curve achieved with grepafloxacin suggest that it will be effective for the treatment of community-acquired pneumonia and acute exacerbations of chronic bronchitis. The pharmacokinetics of fluoroquinolones are among their most useful properties. The aim of this paper is to demonstrate whether the differences between grepafloxacin and the other fluoroquinolones are of therapeutic significance.

Pharmacokinetics of grepafloxacin after oral administration of single and repeat doses in healthy young males

The pharmacokinetics of grepafloxacin in healthy male subjects following single oral administration of doses ranging from 200 to 1200 mg, and following repeated oral administration of 400 and 800 mg doses are reported. Plasma levels of grepafloxacin reached a peak within 2 hours (on average) following drug administration and then declined bi-exponentially with concentrations being detectable (> 5 micrograms/L) in the plasma for at least up to 72 hours postdose. The high values for the apparent volume of distribution (5 to 8 L/kg) suggested extensive distribution of grepafloxacin in the tissues. Only a small percentage of the administered dose (ranging from 6% to 9.5%) was recovered in the urine as unchanged grepafloxacin, suggesting that metabolism, rather than urinary excretion, is the major elimination route. The half-life of grepafloxacin was about 12 hours after single doses and about 15 hours after repeat doses. The trough levels increased significantly over the first 3 days of repeat administration; thereafter, the changes were small, with steady-state being reached by the fifth day. The area under the concentration-time curve (AUC24 h) values observed on days 7 and 14 of repeat administration, at each dose level, were similar, suggesting that steady-state is maintained. The area values increased more than proportionally after administration of increasing single and repeat doses, suggesting nonlinear kinetics. The elimination half-life and renal clearance did not change with increasing doses. Saturation in the metabolism of grepafloxacin and possibly in the distribution into a peripheral compartment, as suggested by a decrease in the total plasma clearance and in the apparent volume of distribution, could be the origin of the nonlinear kinetics. However, this deviation from linearity is unlikely to be of clinical significance, since it was very small over the recommended range of therapeutic doses (400 to 600 mg once daily). Compared with other quinolones, grepafloxacin showed the longest half-life and the highest apparent volume of distribution. These features, together with the excellent bactericidal activity of grepafloxacin, support the recommended dosage regimen of grepafloxacin for the treatment of respiratory tract infections and sexually transmitted diseases.

Pharmacokinetics of drugs used in critically ill adults

Critically ill patients exhibit a range of organ dysfunctions and often require treatment with a variety of drugs including sedatives, analgesics, neuromuscular blockers, antimicrobials, inotropes and gastric acid suppressants. Understanding how organ dysfunction can alter the pharmacokinetics of drugs is a vital aspect of therapy in this patient group. Many drugs will need to be given intravenously because of gastrointestinal failure. For those occasions on which the oral route is possible, bioavailability may be altered by hypomotility, changes in gastrointestinal pH and enteral feeding. Hepatic and renal dysfunction are the primary determinants of drug clearance, and hence of steady-state drug concentrations, and of efficacy and toxicity in the individual patient. Oxidative metabolism is the main clearance mechanism for many drugs and there is increasing recognition of the importance of decreased activity of the hepatic cytochrome P450 system in critically ill patients. Renal failure is equally important with both filtration and secretion clearance mechanisms being required for the removal of parent drugs and their active metabolites. Changes in the steady-state volume of distribution are often secondary to renal failure and may lower the effective drug concentrations in the body. Failure of the central nervous system, muscle, the endothelial system and endocrine system may also affect the pharmacokinetics of specific drugs. Time-dependency of alterations in pharmacokinetic parameters is well documented for some drugs. Understanding the underlying pathophysiology in the critically ill and applying pharmacokinetic principles in selection of drug and dose regimen is, therefore, crucial to optimising the pharmacodynamic response and outcome.

Corneal tissue levels of topically applied ofloxacin

PURPOSE

To evaluate the levels of ofloxacin (Ocuflox) in human corneal tissue in patients exposed to various dosing regimens and application methods.

SETTING

Corneal Consultants of Indiana, Indianapolis, Indiana, USA.

METHODS

Forty patients meeting inclusion criteria were recruited from persons scheduled to have penetrating keratoplasty (PKP). Patients were placed into one of two study groups of 20 each based on dosing regimen and application method. The SAS GLM (General Linear Models) procedure was used to test for differences in mean Ocuflox tissue concentration among study groups and for interaction effects of preoperative diagnosis, trephine size, dosing regimen, and corneal integrity.

RESULTS

Corneal tissue concentrations of Ocuflox were elevated significantly by varying drug application methods and dosing schedules before PKP. Eyes receiving medication every 15 minutes for 4 hours had significantly higher levels of Ocuflox than those receiving the drug in six doses over 24 hours before surgery. Ocuflox concentrations exceeded the MIC90 (minimum inhibitory concentration) for key ocular pathogens in essentially all cornea specimens studied.

CONCLUSION

Ocuflox penetration was improved by administering it in a controlled setting at 15 minute intervals over 4 hours. The drug provided high tissue levels in both the cornea and aqueous humor, which together with its broad range of antibacterial coverage, should make it a good choice for prophylactic treatment.

Local absorption kinetics of levofloxacin from intestinal tract into portal vein in conscious rat using portal-venous concentration difference

PURPOSE

The local absorption kinetics of levofloxacin from the intestinal tract was quantitatively evaluated by simultaneously measuring the portal and venous plasma concentrations in a conscious rat.

METHODS

The venous and upper portal blood vessels were cannulated through the jugular and pyloric veins, respectively. After oral or intravenous administration of levofloxacin, portal and venous concentrations of levofloxacin were simultaneously monitored. The absorption rate from the intestine into the portal system was calculated from the portal-venous difference in the plasma concentration of levofloxacin, considering the distribution of levofloxacin into erythrocytes. Portal blood flow rate was newly measured by an electromagnetic flow meter.

RESULTS

There was little portal-venous difference after an intravenous dose of levofloxacin. In contrast, after oral administration, the plasma concentration in the portal vein was constantly higher than that in the jugular vein, demonstrating that this difference was caused by the intestinal absorption of levofloxacin.

CONCLUSIONS

Approximately 90% levofloxacin was absorbed as the intact form from the intestinal tract into the portal system. By considering the bioavailability of levofloxacin in rat, the hepatic extraction ratio in vivo of levofloxacin was estimated to be 30%. The mean local absorption time (Ta) was 1.44 hr which coincided almost with the mean absorption time (MAT).

A guide to the treatment of lower respiratory tract infections

Acute bronchitis is usually a viral infection which, unless there is a special disposition, does not require antibiotic therapy. For the initial oral chemotherapy of bacterial infections of the lower respiratory tract (chronic bronchitis, pneumonia) the effective and well tolerated cephalosporins, macrolides and amoxicillin plus beta-lactamase-inhibitor are recommended. In complicated cases with severe underlying disease, longer history or frequent exacerbations, quinolones should be given if Gram-negative infections are suspected or if initial therapy with other substances has failed. If Legionella, Mycoplasma or Chlamydia spp., so-called 'atypical' pathogens, are involved, macrolide antibiotics are the therapy of first choice. Special attention should be given to the increase in resistance against cotrimoxazole (trimethoprim-sulfamethoxazole) and tetracyclines. In hospitals where primary pneumonias are treated preferentially by intravenous medication, therapy should be switched to oral antibiotics as soon as feasible (follow-up therapy). For severely ill patients with secondary pneumonia and underlying disease, second generation cephalosporins with aminoglycosides, or monotherapy with third generation cephalosporins are recommended. In very severe, high-risk cases, third generation cephalosporins, combinations with high-dosage quinolones or ureidopenicillins plus beta-lactamase-inhibitors are suitable. Future development in the antibiotic treatment of respiratory infections will follow the current trend of lower dosages, with the clear objective of shortening treatment periods and achieving earlier discharge from hospital.

Pharmacodynamics of levofloxacin, ofloxacin, and ciprofloxacin, alone and in combination with rifampin, against methicillin-susceptible and -resistant Staphylococcus aureus in an in vitro infection model

The pharmacodynamic properties of levofloxacin (an optically active isomer of ofloxacin), ofloxacin, and ciprofloxacin, alone and in combination with rifampin, were evaluated over 24 to 48 h against clinical isolates of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA 1199 and MRSA 494, respectively) in an in vitro infection model. The incidence of the emergence of resistance among the test strains was also determined. The fluoroquinolones were administered to simulate dosage regimens of 200 mg, 400 mg given intravenously (i.v.) every 12 h (q12h), and 400 and 800 mg given i.v. q24h. Rifampin was dosed at 600 mg i.v. q24h. Although the MICs and MBCs of the quinolones were similar (< or = 0.49 microgram/ml), levofloxacin was the most potent agent in time-kill studies on the basis of the time required to achieve a 99.9% reduction in the number of log10 CFU per milliliter (e.g., with the regimen of levofloxacin [400 mg q24h, 6.5 h] versus ofloxacin [12.5 h], P < 0.024, and levofloxacin versus ciprofloxacin [6.5 versus 9.0 h], P < 0.0017) against MSSA 1199. The killing activity of levofloxacin was similar to that of ofloxacin against MRSA 494 (time to achieve a 99.9% reduction in the number of log10 CFU per milliliter, 11.1 versus 13.8 h, respectively). Levofloxacin and ofloxacin dosed once daily demonstrated greater bactericidal activity than when they were dosed twice daily against MSSA 1199. Resistance to levofloxacin or ofloxacin was not observed with any dosage regimen. Furthermore, resistance to ofloxacin was not detected when the half-life was reduced from 6 to 3 h. Regrowth and stable resistance (65-fold increase in the MIC for MSSA 1199; 16-fold increase in the MIC for MRSA 494) were noted within 24 h of exposure to ciprofloxacin at 200 mg q12h. Combination therapy with rifampin prevented the emergence of resistance to ciprofloxacin. Neither DNA gyrase alteration nor an energy-dependent efflux process mediated by the norA gene appeared to be responsible for the resistance observed. Our data suggest that with levofloxacin there is a more rapid onset of bactericidal activity than with ofloxacin or ciprofloxacin against MSSA 1199 and that the activity of levofloxacin is similar to that of ofloxacin but better than that of ciprofloxacin against MRSA 494. Resistance was noted only after exposure to the low dose of ciprofloxacin. Resistance to ofloxacin did not develop even when the pharmacokinetics of the drug were set to equal those of ciprofloxacin, suggesting that ofloxacin differs from ciprofloxacin irrespective of time of exposure. The resistance to ciprofloxacin that developed in our vitro model may be mediated by the cfx-ofx locus, which has been shown to be associated with low-level fluoroquinolone resistance. Overall, levofloxacin demonstrated potent bactericidal activity against S. aureus, without the emergence of resistance in our infection model. Quinolones dosed once daily were more effective than equivalent dosages administered twice daily. The addition of rifampin was not synergistic but prevented the emergence of ciprofloxacin resistance.

Activity of levofloxacin in a murine model of tuberculosis

The activity of levofloxacin (LEV) was evaluated in a murine model of tuberculosis. Approximately 10(7) viable Mycobacterium tuberculosis ATCC 35801 were given intravenously to 4-week-old female outbred mice. In a dose-response study, treatment with LEV at 100, 200, and 400 mg/kg of body weight was started 1 day after infection and was given daily for 28 days. Viable cell counts were determined from homogenates of spleens and lungs. A dose-related reduction in organism cell counts in organs was noted for LEV. The activities of LEV at 100, 200, and 300 mg/kg were compared with those of first-line antituberculosis agents. Both isoniazid and rifampin were more active than LEV. There was no difference in activity between LEV and either ethambutol or pyrazinamide against splenic organisms. The activities of ethambutol and LEV at the two higher doses were comparable against lung organisms. LEV at 300 mg/kg was more active than pyrazinamide against lung organisms. The activity of LEV was compared with those of two other quinolones, ofloxacin and sparfloxacin. LEV at 200 mg/kg had more than twofold greater activity than ofloxacin at the same dose. Sparfloxacin at 100 mg/kg was more active than LEV at 200 mg/kg; however, the activities of sparfloxacin at 50 mg/kg and LEV at 200 mg/kg were comparable. The promising activity of LEV in M. tuberculosis-infected mice suggests that it is a good candidate for clinical development as a new antituberculosis agent.

Comparative prophylactic efficacies of ciprofloxacin, ofloxacin, cefazolin, and vancomycin in experimental model of staphylococcal wound infection

Recent shifts in the species and antibiotic resistance patterns of bacteria causing nosocomial infections present new challenges for providing effective prophylaxis in surgery. Traditional regimens lack activity against methicillin-resistant staphylococci and many gram-negative species causing nosocomial infections. The new fluoroquinolones exhibit in vitro activity against many emerging surgical wound pathogens. To determine the potential of this class of antimicrobial agents for use in surgery, we compared the prophylactic efficacies of ciprofloxacin and ofloxacin with those of cefazolin and vancomycin in a guinea pig model of abscess formation. Four Staphylococcus aureus strains, one Staphylococcus epidermidis strain, and one Staphylococcus haemolyticus strain were evaluated. Vancomycin was the most effective prophylactic agent, exhibiting in vivo activity against all strains which was superior or equivalent to those of all other agents tested. Cefazolin was the least effective agent and surpassed the two quinolones in prophylactic efficacy against only one organism, a quinolone- and methicillin-resistant strain of S. aureus. The two quinolones provided excellent protection against infection with all but the quinolone-resistant isolate. The in vivo emergence of quinolone resistance among quinolone-susceptible isolates was not detected. The methicillin-resistant, quinolone-susceptible S. epidermidis and S. haemolyticus isolates were extremely susceptible to prophylaxis, exhibiting 50% infective doses above 4 x 10(6) CFU for seven of the eight antibiotic-strain combinations. We conclude that ciprofloxacin and ofloxacin may be effective antistaphylococcal agents in surgery. The role of these agents remains to be defined, and the definition should include consideration of an adverse effect upon antibiotic resistance patterns of organisms causing nosocomial infections.