Levofloxacin: a review of its use in the treatment of bacterial infections in the United States

Practical guidance on the prevention and management of infection in multiple myeloma patients: A case-based approach

The risk of infection in multiple myeloma patients is significant, due to immune dysfunction secondary to myeloma, immunosenescence and age-related comorbidities, given the elderly myeloma patient demographic. Newer treatments, despite providing unprecedented improvements in disease-control, have further elevated infection risk. This risk is so substantial that we are approaching a period where a subset of older myeloma patients may be more likely to die secondary to infectious complications imposed by redirected T-cell therapy rather than from myeloma. As a result, it is essential to provide myeloma patients with the appropriate prophylaxis and monitoring against infection. In this review, we discuss disease-related, patient-related and treatment-related reasons for the increased infection risk in myeloma patients, and how to both prevent and manage this risk through creating a dynamic, infection prevention plan that is personalised to the individual patient.

Clinical Utility of Polymerase Chain Reaction (PCR) in Diagnosing and Managing Bacterial Infections: A Case Series of Three Patients With Acinetobacter baumannii

This case series highlights the critical role of polymerase chain reaction (PCR) in diagnosing and managing bacterial infections in dermatology. We present three cases of patients with the same bacterial infection, identified through PCR, and discuss the implications for treatment. The series highlights the advantages of PCR over traditional culture methods, emphasizing its ability to deliver rapid, accurate diagnoses and facilitate targeted therapeutic interventions. Unlike cultures, which can be time-consuming, PCR provides a quicker and more precise identification of pathogens. Additionally, we outline the cost-saving potential of PCR, as its efficiency in pinpointing infections can reduce the need for broad-spectrum antibiotics, minimize unnecessary diagnostic procedures, and shorten the duration of patient illness, thereby contributing to overall healthcare savings.

Levofloxacin Preventive Treatment in Children Exposed to MDR Tuberculosis

BACKGROUND

Worldwide, approximately 2 million children younger than 15 years of age are infected with multidrug-resistant (MDR) Mycobacterium tuberculosis, with MDR tuberculosis developing in approximately 30,000 annually. Evidence from randomized, controlled trials on tuberculosis preventive treatment in persons exposed to MDR tuberculosis is lacking.

METHODS

In this community-based, multisite, double-blind, cluster-randomized, placebo-controlled trial in South Africa, we assessed the efficacy and safety of levofloxacin as preventive treatment in children with household exposure to an adult with bacteriologically confirmed MDR pulmonary tuberculosis. Children younger than 5 years of age were eligible for inclusion regardless of interferon-γ release assay result or human immunodeficiency virus (HIV) status, and children 5 to 17 years of age were eligible if they had a positive interferon-γ release assay or HIV infection. Households were randomly assigned to a trial regimen, and children in the household received levofloxacin or placebo once daily for 24 weeks. The primary efficacy end point was incident tuberculosis, which included death from tuberculosis, by week 48 after randomization. The primary safety end point was any adverse event of grade 3 or higher during the treatment period that was at least possibly related to the trial regimen.

RESULTS

Of 922 participants from 497 households, 453 were assigned to receive levofloxacin and 469 to placebo; 91.0% of the participants were younger than 5 years of age. At least 80% of the assigned doses of levofloxacin or placebo were received by 86% of the participants in each trial group. By week 48, tuberculosis had developed in 5 participants (1.1%) in the levofloxacin group and in 12 participants (2.6%) in the placebo group (hazard ratio, 0.44; 95% confidence interval [CI], 0.15 to 1.25). The results of sensitivity analyses were consistent with those of the primary analysis. Grade 3 or higher adverse events during the treatment period that were considered to be at least possibly related to the trial regimen occurred in 4 participants in the levofloxacin group and in 8 participants in the placebo group (hazard ratio, 0.52; 95% CI, 0.16 to 1.71). Grade 2 tendonitis occurred in 1 child in the levofloxacin group.

CONCLUSIONS

Although preventive treatment with levofloxacin led to a lower incidence of tuberculosis than placebo among children with household exposure to MDR tuberculosis, the difference was not significant. (Supported by Unitaid and others; TB-CHAMP ISRCTN Registry number, ISRCTN92634082.).

Antibiotics versus Non-Antibiotic in the treatment of Aspiration Pneumonia: analysis of the MIMIC-IV database

BACKGROUND

Aspiration pneumonia (AP) is a common complication in the intensive care unit (ICU), which is associated with significantly increased morbidity and mortality and has a significant impact on patient prognosis. Antibiotics are commonly used in the clinical treatment of AP. However, the prognostic impact of antibiotics on patients with AP has not been adequately characterized. The purpose of this study is to illustrate the relationship between the use of antibiotics and in-hospital mortality of AP patients, as well as to analyze the effects of different antibiotic treatment regimens on the prognosis of the patients, and to further understand the distribution of pathogens and drug resistance in AP patients, so as to provide guidance information for the rational use of medication for patients in the clinic.

METHODS

Clinical data of AP patients were extracted from the MIMIC-IV database. Statistical methods included multivariate logistic regression, propensity score matching (PSM), and inverse probability weighting (IPW) based on propensity scores to ensure the robustness of the findings. In addition, the characteristics of the medications used by patients with AP were described using statistical graphs and tables.

RESULTS

A total of 4132 patients with AP were included. In-hospital mortality was significantly lower in the group using antibiotics compared to the group not using antibiotics (odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.27- 0.71, P = 0.001). Furthermore, in the group using mechanical ventilation (MV), antibiotics use significantly reduced in-hospital mortality (OR = 0.30, 95% CI 0.15-0.57, P < 0.001). Vancomycin and cephalosporins are the most commonly used antibiotics to treat AP. Specifically, vancomycin in combination with piperacillin-tazobactam was used most frequently with 396 cases. The highest survival rate (97.6\%) was observed in patients treated with levofloxacin combined with metronidazole. Additionally, vancomycin combined with piperacillin-tazobactam had many inflammation related features that differed significantly from those in patients who did not receive medication.

CONCLUSIONS

Antibiotics use is closely associated with lower in-hospital mortality in ICU patients with AP. Moreover, understanding antibiotics use, the composition of pathogenic bacteria, and the rates of drug resistance in patients with AP can aid in disease prevention and prompt infection control.

Integrating 3,4-Dihydro-2H-1,4-oxazine into Peptides as a Modification: Silver Triflate-Catalyzed Cyclization of N-Propargyl N-Sulfonyl Amino Alcohols for SPPS Applications

We present a methodology yielding 3,4-dihydro-2H-1,4-oxazine by cyclization of N-propargyl N-sulfonyl amino alcohols using silver triflate as a catalyst at ambient temperature. Additionally, we showcase the applicability of this methodology in solid phase peptide synthesis (SPPS) to introduce the oxazine heterocyclic ring into short peptides containing serine and threonine. Notably, Rink amide resin supported the on-resin formation of 3,4-dihydro-2H-1,4-oxazine, while 2-CTC resin facilitated the oxazine formation in a one-pot process involving peptide cleavage, deprotection, and subsequent C-O ring formation, thus offering a versatile method for the late-stage modification of peptides.

Recent efforts in the development of glycoconjugate vaccine and available treatment for tuberculosis

Tuberculosis (TB) continues to pose a grave threat to global health, despite relentless eradication efforts. In 1882, Robert Koch discovered that Mycobacterium tuberculosis (Mtb) is the bacterium responsible for causing tuberculosis. It is a fact that tuberculosis has claimed the lives of more than one billion people in the last few decades. It is imperative that we must take immediate and effective action to increase resources for TB research and treatment. Effective TB treatments demand an extensive investment of both time and finances, often requiring 6-9 months of rigorous antibiotic therapy. The most efficient way to control tuberculosis is by receiving a childhood Bacillus Calmette-Guérin (BCG) vaccination. Despite years of research on vaccine development, we still do not have any new approved vaccine for tuberculosis, except BCG, which is partially effective in young children. This review discusses briefly the available treatment for tuberculosis and remarkable advancements in glycoconjugate-based TB vaccine developments in recent years (2013-2024) and offers valuable direction for future research priorities.

Fluconazole and levofloxacin prophylaxis are ineffective strategies for preventing infections in acute myeloid leukemia patients undergoing chemotherapy

INTRODUCTION

Acute myeloid leukemia patients are at high risk for infections, which contribute to increased mortality rates of up to 70%. The use of antimicrobial prophylaxis has been shown to significantly lower rates of infection. Therefore, this retrospective study aimed to evaluate the effect of two agents that showed effective results in the literature, levofloxacin and fluconazole, as prophylaxis strategies in AML patients.

METHODOLOGY

A total of 85 AML patients' medical records treated with a 7+3 induction chemotherapy protocol in the Cancer Hospital of Uberlândia from 2017 to 2021 were screened and their data was collected. Within these patients, groups for analysis were created based on whether the acting physician included an antibacterial or antifungal prophylaxis protocol during induction. Contingency tables with χ² and odds ratio tests were realized to verify associations between prophylaxis and infection. Additionally, Kaplan-Meier curves with Cox regression were developed to analyze survival.

RESULTS

The use of prophylaxis with either fluconazole or levofloxacin did not lower rates of infection, as those who with prophylaxis did not demonstrate significant differences when compared to those without (20.3-29.7%, and 12.3-23.3%, respectively). Patients who suffered a bacterial infection during induction were shown to have lower overall survival, with a similar trend seen in fungal infections.

CONCLUSION

Bacterial and fungal infections were associated with higher rates of induction mortality and lower overall survival, and prophylaxis using fluconazole and levofloxacin did not present any significant difference in preventing these infections in this study, contrasting results found in the literature. The individuality of each treatment center should be taken into consideration and future studies should be realized to better determine the most effective methods and agents for prophylaxis.

Biodegradation and antimicrobial capability-induced heavy metal resistance of the marine-derived actinomycetes Nocardia harenae JJB5 and Amycolatopsis marina JJB11

Currently, heavy metal-resistant (HMR) marine actinomycetes have attracted much attention worldwide due to their unique capabilities. In this study, 27 marine-derived actinomycetes were isolated from coastal beaches in the Arabian Gulf of Al-Jubail in Saudi Arabia and screened for resistance to 100 mg/L of the heavy metals Cd2+, Cr6+, Cu2+, Fe2+, Pb2+, and Ni2+ using different assay techniques. Six isolates were selected as HMRs, of which two isolates, JJB5 and JJB11, exhibited the highest maximum tolerance concentrations (200- > 300 mg/L). Both isolates were the highest among six-HMR screened for their biodegradation potential of plastics low-density polyethylene, polystyrene, and polyvinyl chloride, recording the highest weight loss (15 ± 1.22 - 65 ± 1.2%) in their thin films. They also showed the highest biodegradability of the pesticides acetamiprid, chlordane, hexachlorocyclohexane, indoxacarb and lindane, indicating promising removal capacities (95.70-100%) for acetamiprid and indoxacarb using HPLC analysis. Additionally, the cell-free filtrate (CFF) of both isolates displayed the highest antimicrobial activity among the six-HMR screened against a variety of microbial test strains, recording the highest inhibition zone diameters (13.76 ± 0.66 - 26.0 ± 1.13 mm). GC‒MS analyses of the ethyl acetate extract of their CFFs revealed the presence of diverse chemical compounds with a multitude of remarkable biological activities. Based on their spore morphology and wall-chemotype, they were assigned to the nocardioform-actinomycetes. Furthermore, their phenotypic characteristics, together with 16S rRNA gene sequencing (OR121525-OR121526), revealed them as Nocardia harenae JJB5 and Amycolatopsis marina JJB11. Our results suggest that marine HMR actinomycetes are promising candidates for various biotechnological applications.

Bimetallic Coordination Polymers: Synthesis and Applications in Biosensing and Biomedicine

Bimetallic coordination polymers (CPs) have two different metal ions as connecting nodes in their polymer structure. The synthesis methods of bimetallic CPs are mainly categorized into the one-pot method and post-synthesis modifications according to various needs. Compared with monometallic CPs, bimetallic CPs have synergistic effects and excellent properties, such as higher gas adsorption rate, more efficient catalytic properties, stronger luminescent properties, and more stable loading platforms, which have been widely applied in the fields of gas adsorption, catalysis, energy storage as well as conversion, and biosensing. In recent years, the study of bimetallic CPs synergized with cancer drugs and functional nanomaterials for the therapy of cancer has increasingly attracted the attention of scientists. This review presents the research progress of bimetallic CPs in biosensing and biomedicine in the last five years and provides a perspective for their future development.

Refashioning of the drug-properties of fluoroquinolone through the synthesis of a levofloxacin-imidazole cobalt (II) complex and its interaction studies on with DNA and BSA biopolymers, antimicrobial and cytotoxic studies on breast cancer cell lines

Levofloxacin (HLVX), a quinolone antimicrobial agent, when deprotonated (LVX-) behaves as a bidentate ligand, and it coordinates to Co2+ through the pyridone oxygen and the carboxylate oxygen. Along with two imidazole (ImH) ligands, levofloxacin forms a Co(II)-Levofloxacin-imidazole complex, [CoCl(LVX)(ImH)2(H2O)]·3H2O (abbreviated henceforth as CoLevim) which was isolated and characterized by 1H and 13C NMR spectroscopy, UV-visible and FT-IR spectroscopy, powder X-ray diffraction and thermal analysis methods. CoLevim shows promise in its antimicrobial activities when tested against microorganisms (Bacillus cereus, Bacillus subtilis, Listeria monocytogenes, Staphylococcus aureus, Salmonella typhimurium and Escherichia coli). Fluorescence competitive studies with ethidium bromide (EB) revealed that CoLevim can compete with EB and displace it to bind to CT-DNA through intercalative binding mode. In addition, CoLevim exhibited a good binding propensity to BSA proteins with relatively high binding constants. The antioxidant activities of the free ligands and CoLevim were determined in vitro using ABTS+ radical (TEAC assay). The Co-complex showed a better antioxidant capacity with inhibitory concentrations (IC50) of 40 μM than the free ligands. CoLevim also showed noteworthy apoptotic potential and behaved as an efficient resistant modifying agent when its antiproliferative potential was examined by MTT assay using the breast cancer cell lines (MCF7, MCF7Dox/R and MCF7Pacli/R cells).

A validated eco-friendly HPLC-FLD for analysis of the first approved antiviral remdesivir with other potential add-on therapies for COVID-19 in human plasma and pharmaceuticals

It is crucial to have a reliable and sensitive method for separating common drugs used in SARS-CoV-2 pneumonia treatment protocols for ongoing treatment and upcoming investigations. This study presents an HPLC-FLD approach to analyze three co-administered medicines - remdesivir (RDV), hydroxychloroquine sulphate (HCQ), and levofloxacin hemihydrate (LVX) - in their pure forms, pharmaceutical preparations, and spiked human plasma. The HPLC-FLD analysis was conducted using a Symmetry® C18 column (100 mm × 4.6 mm ID, 3.5 μm particle size) at 40 °C, with (A) an aqueous mixture of 0.02 M phosphate buffer and 0.2% heptane-1-sulphonic acid sodium solutions (50 : 50) adjusted to pH 3, (B) acetonitrile, and (C) methanol as the mobile phase. The injection volume was 10 μL, and the flow rate was 1.5 mL min-1. The detection was done using a multi-wavelength excitation and emission fluorescence detector, with individual optimization for each drug. The drug separation time was less than 10 minutes, and the method showed sensitive and wide linearity ranges for all medicines, with r2 values of more than 0.999. The impact of the mobile phase pH and flow rate on suitability parameters (retention time and number of theoretical plates) was studied. The method was found to be environmentally friendly based on GAPI and AGREE metrics. The validity of the method was evaluated following ICH and FDA guidelines.

Acute pancreatitis associated with the antibiotic levofloxacin: A rare case report

Drug-induced acute pancreatitis is a potentially ignored diagnosis that must be precisely valued. Drug-induced acute pancreatitis can be considered the third common cause of acute pancreatitis after ruling out alcohol and gallstones. Levofloxacin belongs to a class of fluoroquinolone antibiotics used for treating various infections. Besides photosensitivity and liver toxicity, levofloxacin can induce acute pancreatitis, although rarely described. We highlight a case of acute pancreatitis in a female induced by levofloxacin. She presented with typical signs and symptoms of acute pancreatitis and had been taking levofloxacin for urinary tract infections for the last 3 days. After ruling out all other possible causes, her clinical picture, laboratory results, and imaging findings confirmed acute pancreatitis induced by levofloxacin.

Retrospective analysis of risk factors for levofloxacin-induced liver injury

Levofloxacin is used as a first-line drug for the treatment of Legionella pneumonia. However, the relatively high incidence of drug-induced liver injury (DILI) remains a clinical problem. Based on the available patient data, this study aimed to identify the risk factors for DILI before levofloxacin administration. Multiple logistic regression analyses suggested that male sex (odds ratio [OR], 6.975; 95% confidence interval [CI], 1.737-28.000; p = 0.006), elevated C-reactive protein level (OR, 1.182; 95% CI, 1.089-1.283; p = 0.0006), and high haemoglobin level (OR, 1.640; 95% CI, 1.226-2.195; p = 0.001) before administration of levofloxacin were risk factors for DILI. Possible treatment with alternative drugs should be considered in male patients with elevated C-reactive protein and haemoglobin levels. Moreover, close monitoring of liver function tests when levofloxacin is administered may prevent the development and severity of DILI.

Levofloxacin-Fatty Acid Systems: Dual Enhancement Through Deep Eutectic Formation and Solubilization for Pharmaceutical Potential and Antibacterial Activity

Fatty acids, including medium-chain saturated and polyunsaturated fatty acids, are known for their broad health benefits, including antimicrobial activity. Through their green properties, deep eutectic systems have been heralded as having the potential to be at the forefront of pharmaceutical applications. In this work, capric acid and geranic acid, two examples of medium-chain saturated and polyunsaturated fatty acids, were employed to enhance the pharmaceutical properties and the antibacterial activity of levofloxacin. To this end, levofloxacin formulations with either capric or geranic acid were prepared and characterized using appropriate techniques. Levofloxacin was utilized to create innovative deep eutectic systems in conjunction with capric acid at three different molar ratios: 1:9, 2:8 and 3:7. This was confirmed through a rigorous analysis involving nuclear magnetic resonance, infrared spectroscopy and differential scanning calorimetry. Furthermore, it is noteworthy that geranic acid demonstrated an impressive threefold improvement in levofloxacin's solubility compared to its solubility in aqueous solutions. The antibacterial activity of the novel combinations of levofloxacin with either fatty acid was evaluated using a checkerboard titration assay. Gratifyingly, both formulations exhibited synergistic effects against a panel of levofloxacin-sensitive and resistant Gram-negative bacteria. In conclusion, the observed superior antibacterial activity of levofloxacin illuminates the potential use of fatty acid-based formulations and deep eutectic systems as green and innovative strategies to combat the global antimicrobial resistance problem.

A Rare Case of Levofloxacin-Induced Acute Pancreatitis: Case Report and Literature Review

Diagnosing acute pancreatitis induced by any drug is often overlooked and warrants careful evaluation. Drug-induced acute pancreatitis is relatively rare, and diagnosis of exclusion after ruling out alcohol, gallstones, hypertriglyceridemia, and intervention. Levofloxacin, a class of fluoroquinolones, is generally recommended against various bacterial infections. While levofloxacin is mainly known for its potential side effects, such as photosensitivity and liver toxicity, it can also rarely induce acute pancreatitis. We report a case of acute pancreatitis in a female patient precipitated by levofloxacin. The patient exhibited typical manifestations of acute pancreatitis and had been taking levofloxacin for a urinary tract infection over the past three days. After ruling out other possible causes, her clinical presentation, laboratory results, and imaging findings confirmed levofloxacin-induced acute pancreatitis.

Safety and Efficacy of Nemonoxacin vs Levofloxacin in Patients With Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Randomized Control Trials

Community-acquired pneumonia is a leading cause of morbidity and mortality throughout the world, which incurs significant healthcare costs. The aim of his meta-analysis is to assess the clinical efficacy and safety of a novel non-fluorinated quinolone, nemonoxacin, compared with levofloxacin in treating community-acquired pneumonia (CAP). A recursive literature search was conducted using PubMed, Google Scholar, and Scopus up to August 2022. All randomized clinical trials comparing nemonoxacin to levofloxacin for community-acquired pneumonia were included. The patients selected for this study had mild to moderate CAP. Each individual received treatment with either nemonoxacin (500 mg or 750 mg) or levofloxacin (500 mg) for a duration of 3-10 days. Four randomized control trials with a total of 1955 patients were included. Nemonoxacin and levofloxacin were found to have similar clinical cure rates in the treatment of CAP. There were no significant differences reported in the treatment-emergent adverse events between the two drugs (RR=0.95, 95% CI: 0.86, 1.08, I²=0%). However, the most frequent symptoms exhibited were gastrointestinal system-related. Both the dosages (500 mg and 750 mg) of nemonoxacin were found to have similar efficacy as that of levofloxacin. Our meta-analysis indicates that nemonoxacin is a well-tolerated and effective antibiotic therapy for the treatment of community-acquired pneumonia (CAP), with clinical success rates comparable to those of levofloxacin. Furthermore, the adverse effects associated with nemonoxacin are generally mild. Therefore, both the 500 mg and 750 mg dosages of nemonoxacin can be recommended as appropriate antibiotic therapy regimens for the treatment of CAP.

Ring-Opening Cyclization (ROC) of Aziridines with Propargyl Alcohols: Synthesis of 3,4-Dihydro-2H-1,4-oxazines

Activated aziridines react with propargyl alcohols in the presence of Zn(OTf)₂ as the Lewis acid catalyst following an S_N2-type ring-opening mechanism to furnish the corresponding amino ether derivatives. Those amino ethers further undergo intramolecular hydroamination via 6-exo-dig cyclization in the presence of Zn(OTf)₂ as the catalyst and tetrabutylammonium triflate salt as an additive under one-pot two-step reaction conditions. However, for nonracemic examples, ring-opening and cyclization steps were conducted under two-pot conditions. The reaction works well without any additional solvents. The final 3,4-dihydro-2H-1,4-oxazine products were obtained with 13 to 84% yield and 78 to 98% enantiomeric excess (for nonracemic examples).

Substrate-Controlled Product Divergence in Iron(III)-Catalyzed Reactions of Propargylic Alcohols: Easy Access to Spiro-indenyl 1,4-Benzoxazines and 2-(2,2-Diarylvinyl)quinoxalines

We report herein unprecedented cascade reactions of O-propargyl-N-tosyl-amino phenols with 10 mol% FeCl₃ in DCE at room temperature for 0.67-3 h to form spiro-indenyl 1,4-benzoxazines with 38-89 % yield. Replacing the substrates' oxygen atom by a N-tosylimine group followed by treatment with the same catalyst and solvent at 80 °C produced 2-(2,2-diarylvinyl)quinoxalines in 12-20 h with up to 62 % yield. Mechanistic understanding provided an insight into the transformations. The use of simple substrates and an environmentally benign low-cost catalyst, broad substrate scope and tolerance of diverse functional groups makes the methodology inherently attractive.

Application of Multi-Layered Temperature-Responsive Polymer Brushes Coating on Titanium Surface to Inhibit Biofilm Associated Infection in Orthopedic Surgery

Infection associated with biomedical implants remains the main cause of failure, leading to reoperation after orthopedic surgery. Orthopedic infections are characterized by microbial biofilm formation on the implant surface, which makes it challenging to diagnose and treat. One potential method to prevent and treat such complications is to deliver a sufficient dose of antibiotics at the onset of infection. This strategy can be realized by coating the implant with thermoregulatory polymers and triggering the release of antibiotics during the acute phase of infection. We developed a multi-layered temperature-responsive polymer brush (MLTRPB) coating that can release antibiotics once the temperature reaches a lower critical solution temperature (LCST). The coating system was developed using copolymers composed of diethylene glycol methyl ether methacrylate and 2-hydroxyethyl methacrylate by alternatively fabricating monomers layer by layer on the titanium surface. LCST was set to the temperature of 38-40 °C, a local temperature that can be reached during infection. The antibiotic elution characteristics were investigated, and the antimicrobial efficacy was tested against S. aureus species (Xen29 ATCC 29 213) using one to four layers of MLTRPB. Both in vitro and in vivo assessments demonstrated preventive effects when more than four layers of the coating were applied, ensuring promising antibacterial effects of the MLTRPB coating.

Helicobacter Pylori: A Review of Current Treatment Options in Clinical Practice

BACKGROUND

When prescribing antibiotics, infection eradication rates, local resistance rates, and cost should be among the most essential considerations. Helicobacter pylori is among the most common infections worldwide, and it can lead to burdensome sequela for the patient and the healthcare system, without appropriate treatment. Due to constantly fluctuating resistance rates, regimens must be constantly assessed to ensure effectiveness.

METHODS

This was a narrative review. The sources for this review are as follows: searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Helicobacter pylori, Treatment Options, Clinical Practice.

RESULTS

Multiple antibiotics are prescribed as part of the regimen to thwart high resistance rates. This can lead to unwanted adverse reactions and adherence issues, due to the amount and timing of medication administration, which also may contribute to resistance. Single-capsule combination capsules have reached the market to ease this concern, but brand-only may be problematic for patient affordability. Due to the previously mentioned factors, effectiveness and affordability must be equally considered.

CONCLUSIONS

This review will utilize guidelines to discuss current treatment options and give cost considerations to elicit the most effective regimen for the patient.

Short- and Long-Term Effects of Different Antibiotics on the Gut Microbiota and Cytokines Level in Mice

BACKGROUND

Antibiotics are the first line of treatment for infectious diseases. However, their overuse can increase the spread of drug-resistant bacteria. The present study analyzed the impact of different types of antibiotics on the gut microbiome and cytokines level of mice.

METHODS

A total of five groups of 8-week-old male BALB/c mice (n = 35) were treated with piperacillin-tazobactam (TZP), ceftriaxone (CRO), tigecycline (TGC), levofloxacin (LEV) or normal saline (Ctrl), respectively, for up to 4 weeks. Fecal samples were analyzed by bacterial 16S rRNA gene sequencing for bacterial identification. Blood samples were used for the determination of 23 serum cytokines using multiplex immunoassay.

RESULTS

Exposure to antibiotics was shown to affect the normal weight gain of mice. Significant changes in gut composition caused by TZP, CRO and TGC treatment included the decreased abundance of Bacteroidetes (p < 0.01), Muribaculaceae (p < 0.01) and Lachnospiraceae (p < 0.01), and the increased abundance of Proteobacteria (p < 0.05), Enterobacteriaceae (including Klebsiella and Enterobacter) (p < 0.01) and Enterococcaceae (including Enterococcus) (p < 0.01). After 4-week treatment, the TZP, CRO and LEV groups had significantly lower concentrations of several serum cytokines. Correlation analysis of the top 30 bacterial genera and cytokines showed that Enterococcus and Klebsiella were strongly positively correlated with tumor necrosis factor-α (TNF-α), interleukins (IL) IL-12p70 and IL-1β. Desulfovibrio, Candidatus Saccharimonas, norank_f__norank_o__Clostridia_UCG-014, Lactobacillus, and Roseburia were strongly negatively correlated with these cytokines.

CONCLUSION

This study demonstrates the effects of various antibiotics on the intestinal microflora and immune status of mice. Compared with TZP, CRO and TGC, LEV had minimal impact on the gut microbiota. In addition to TGC, long-term TZP, CRO and LEV intervention can lead to a decrease in serum cytokine levels, which may depend on the intestinal microflora, antibiotic used and the duration of treatment.

Presentation and Management of a Complex Orbital Apex Syndrome From Penetrating Mechanical Spring Hook: A Case Report

Our case report demonstrates the management of a unique penetrating orbital injury. The intraorbital foreign body was an approximately 22 cm long metal dishwasher spring hook lodged into the left orbital apex. An ophthalmological check-up a couple of weeks following the removal surgery discerned the patient had an unprecedented case of orbital apex syndrome. We present this unique case so physicians, medical students, and other emergency and medical professionals can learn about the diagnostic, surgical, and multidisciplinary management necessary to achieve a favorable clinical outcome.

Biotransformation of the Fluoroquinolone, Levofloxacin, by the White-Rot Fungus Coriolopsis gallica

The wastewater from hospitals, pharmaceutical industries and more generally human and animal dejections leads to environmental releases of antibiotics that cause severe problems for all living organisms. The aim of this study was to investigate the capacity of three fungal strains to biotransform the fluoroquinolone levofloxacin. The degradation processes were analyzed in solid and liquid media. Among the three fungal strains tested, Coriolopsis gallica strain CLBE55 (BRFM 3473) showed the highest removal efficiency, with a 15% decrease in antibiogram zone of inhibition for Escherichia coli cultured in solid medium and 25% degradation of the antibiotic in liquid medium based on high-performance liquid chromatography (HPLC). Proteomic analysis suggested that laccases and dye-decolorizing peroxidases such as extracellular enzymes could be involved in levofloxacin degradation, with a putative major role for laccases. Degradation products were proposed based on mass spectrometry analysis, and annotation suggested that the main product of biotransformation of levofloxacin by Coriolopsis gallica is an N-oxidized derivative.

Synthesis and Application of Levofloxacin–Tin Complexes as New Photostabilizers for Polyvinyl Chloride

Polyvinyl chloride (PVC) is a synthetic polymer with a wide range of applications with impact on our daily life. It can undergo photodegradation with toxic products that are hazardous to both human health and the environment. In addition, photodegradation shortens the useful lifetime of the material. Elongation of the effective lifespan of PVC is, therefore, a salient area of research. Recently, a lot of attention has been directed toward the design, preparation, and usage of new additives that are capable of reducing the photodecomposition of PVC. This work investigates the synthesis of new levofloxacin-tin complexes and their potential exploitation against the photodecomposition of PVC. Several levofloxacin-tin complexes have been synthesized, in high yields, by a simple procedure and characterized. The potential use of the additives as photostabilizers for PVC has been investigated through the determination of weight loss, molecular weight depression, formation of fragments containing carbonyl and alkene groups, and surface morphology of irradiated PVC films. The results show that the new additives are effective in reducing the photodegradation of PVC. The new levofloxacin-tin complexes act as absorbers of ultraviolet light and quenchers of highly reactive species such as free radicals produced during photodegradation. They are more effective photostabilizers compared with organotin complexes previously reported. The complexes containing aromatic substituents were more effective than those counterparts having aliphatic residues.

Clinical and Microbiological Efficacy of Adjunctive Systemic Quinolones to Mechanical Therapy in Periodontitis: A Systematic Review of the Literature

OBJECTIVES

To assess the clinical and microbiological efficacy of systemic quinolones adjunctive to mechanical therapy in periodontitis patients. Materials and Methods. A systematic review of the scientific literature was carried out. The search scheme comprised the Scopus, PubMed/MEDLINE, SCIELO (Scientific Electronic Library Online), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) databases, together with the gray literature. MeSH terms and keywords were utilized to explore publications in all idioms. Only randomized clinical trials (RCTs) that met the selection criteria were included.

RESULTS

A total of 4 RCTs were selected. These RCTs found superior clinical and microbiological efficacy of adjunctive systemic moxifloxacin (MOX) and levofloxacin (LV) compared to subgingival debridement plus placebo. Improvements in PD and CAL were 2.4 ± 0.8 mm and 2.7 ± 0.9 mm for LV, and 1.5 ± 0.5 mm and 1.8 ± 0.5 mm for MOX, respectively. After six months of follow-up, adjunctive MOX reduced the presence of Aggregatibacter actinomycetemcomitans to imperceptible levels, while LV markedly reduced this microorganism. Some adverse events were reported in the LV group and none in the MOX group.

CONCLUSIONS

Adjunctive MOX and LV improve probing depth and clinical attachment level compared with subgingival debridement alone in patients with periodontitis. The efficacy of these quinolones against A. actinomycetemcomitans was also superior.

Recent applications of quinolinium salts in the synthesis of annulated heterocycles

Quinoline derivatives are frequently found in natural products and biologically active compounds, however, construction of quinoline fused polyheterocycles is the challenging goal in synthetic organic chemistry. In this regard, quinolinium salts meet the demand to a great level, as they can be synthesized readily and employed effectively for the rapid construction of condensed heterocyclic core. The present review focuses on recent (2015-2021) applications of different quinolinium salts that react with suitable partners to access diverse annulated products. Most of the reactions discussed here involve easily available starting materials, operationally simple, high atom efficiency and environmentally benign. Mechanistic aspects of representative transformations have also been highlighted for better understanding of reaction pathway.

Ab initio molecular dynamics simulations and experimental speciation study of levofloxacin under different pH conditions

Levofloxacin is an extensively employed broad-spectrum antibiotic belonging to the fluoroquinolone class. Despite the extremely wide usage of levofloxacin for a plethora of diseases, the molecular characterization of this antibiotic appears quite poor in the literature. Moreover, the acid-base properties of levofloxacin - crucial for the design of efficient removal techniques from wastewaters - have never extensively been investigated so far. Here we report on a study on the behavior of levofloxacin under standard and diverse pH conditions in liquid water by synergistically employing static quantum-mechanical calculations along with experimental speciation studies. Furthermore, with the aim of characterizing the dynamics of the water solvation shells as well as the protonation and deprotonation mechanisms, here we present the unprecedented quantum-based simulation of levofloxacin in aqueous environments by means of state-of-the-art density-functional-theory-based molecular dynamics. This way, we prove the cooperative role played by the aqueous hydration shells in assisting the proton transfer events and, more importantly, the key place held by the nitrogen atom binding the methyl group of levofloxacin in accepting excess protons eventually present in water. Finally, we also quantify the energetic contribution associated with the presence of a H-bond internal to levofloxacin which, on the one hand, stabilizes the ground-state molecular structure of this antibiotic and, on the other, hinders the first deprotonation step of this fluoroquinolone. Among other things, the synergistic employment of quantum-based calculations and speciation experiments reported here paves the way toward the development of targeted removal approaches of drugs from wastewaters.

Adverse Event Profile During the Treatment of Helicobacter pylori: A Real-World Experience of 22,000 Patients From the European Registry on H. pylori Management (Hp-EuReg)

INTRODUCTION

The safety of Helicobacter pylori eradication treatments and to what extent adverse events (AEs) influence therapeutic compliance in clinical practice are hardly known. Our aim was to assess the frequency, type, intensity, and duration of AEs, and their impact on compliance, for the most frequently used treatments in the "European Registry on Helicobacter pylori management."

METHODS

Systematic prospective noninterventional registry of the clinical practice of European gastroenterologists (27 countries, 300 investigators) on the management of H. pylori infection in routine clinical practice. All prescribed eradication treatments and their corresponding safety profile were recorded. AEs were classified depending on the intensity of symptoms as mild/moderate/severe and as serious AEs. All data were subject to quality control.

RESULTS

The different treatments prescribed to 22,492 patients caused at least 1 AE in 23% of the cases; the classic bismuth-based quadruple therapy was the worst tolerated (37% of AEs). Taste disturbance (7%), diarrhea (7%), nausea (6%), and abdominal pain (3%) were the most frequent AEs. The majority of AEs were mild (57%), 6% were severe, and only 0.08% were serious, with an average duration of 7 days. The treatment compliance rate was 97%. Only 1.3% of the patients discontinued treatment due to AEs. Longer treatment durations were significantly associated with a higher incidence of AEs in standard triple, concomitant, bismuth quadruple, and levofloxacin triple or quadruple therapies.

DISCUSSION

Helicobacter pylori eradication treatment frequently induces AEs, although they are usually mild and of limited duration. Their appearance does not interfere significantly with treatment compliance.

Drug Release from Thermo-Responsive Polymer Brush Coatings to Control Bacterial Colonization and Biofilm Growth on Titanium Implants

Despite decades of biomedical advances, the colonization of implant devices with bacterial biofilms is still a leading cause of implant failure. Clearly, new strategies and materials that suppress both initial and later stage bacterial colonization are required in this context. Ideal would be the implementation of a bactericidal functionality in the implants that is temporally and spatially triggered in an autonomous fashion at the infection site. Herein, the fabrication and validation of functional titanium-based implants with triggered antibiotic release function afforded via an intelligent polymer coating is reported. In particular, thermo-responsive poly(di(ethylene glycol) methyl ether methacrylate) (PDEGMA) brushes on titanium implants synthesized via a surface-initiated atom transfer radical polymerization with activators regenerated through the electron transfer technique (ARGET ATRP) allows for a controlled and thermally triggered release of the antibiotic levofloxacin at the wound site. Antibiotic loaded brushes are investigated as a function of thickness, loading capacity for antibiotics, and temperature. At temperatures of the infection site >37 °C the lower critical solution temperature behavior of the brushes afforded the triggered release. Hence, in addition to the known antifouling effects, the PDEGMA coating ensured enhanced bactericidal effects, as demonstrated in initial in vivo tests with rodents infected with Staphylococcus aureus.

Clinical Impact of the Revised 2019 CLSI Levofloxacin Breakpoints in Patients with Enterobacterales Bacteremia

The Clinical and Laboratory Standards Institute (CLSI) revised the fluoroquinolone MIC breakpoints for Enterobacterales in 2019, based on pharmacokinetic/pharmacodynamic analyses. However, clinical evidence supporting these breakpoint revisions is limited. A retrospective study was conducted at 3 hospitals in Taiwan between January 2017 and March 2019. Patients treated with levofloxacin for bacteremia caused by members of the Enterobacterales with high MICs (1 or 2 μg/ml; levofloxacin susceptible by pre-2019 CLSI breakpoints) were compared with those with low-MIC bacteremia (≤0.5 μg/ml; levofloxacin susceptible by 2019 CLSI breakpoints) to assess therapeutic effectiveness by multivariable logistic regression. The primary outcome was 30-day mortality, and the secondary outcome was the emergence of levofloxacin-resistant isolates within 90 days after levofloxacin initiation. A total of 308 patients were eligible for the study. Kaplan-Meier analysis showed that patients infected with high-MIC isolates (n = 63) had a significantly lower survival rate than those infected with low-MIC isolates (n = 245) (P = 0.001). Multivariable logistic regression revealed that high levofloxacin MIC was a predictor of 30-day mortality (odds ratio [OR], 6.05; 95% confidence interval [CI], 1.51 to 24.18; P = 0.011). We consistently found similar results in a propensity score-matched cohort (OR, 5.38; 95% CI, 1.06 to 27.39; P = 0.043). The emergence of levofloxacin-resistant isolates was more common in the high-MIC group than the low-MIC group (25.0% versus 7.5%; P = 0.065). An estimated area under the concentration-time curve/MIC ratio of ≥87 was significantly associated with better survival (P = 0.002). In conclusion, patients infected with isolates with levofloxacin MICs within the pre-2019 CLSI susceptible range of 1 or 2 μg/ml exhibited higher mortality than those infected with isolates with MICs of ≤0.5 μg/ml.

Polyvinyl Chloride Modified Carbon Paste Electrodes for Sensitive Determination of Levofloxacin Drug in Serum, Urine, and Pharmaceutical Formulations

Levofloxacin (LF) is a medically important antibiotic drug that is used to treat a variety of bacterial infections. In this study, three highly sensitive and selective carbon paste electrodes (CPEs) were fabricated for potentiometric determination of the LF drug: (i) CPEs filled with carbon paste (referred to as CPE); (ii) CPE coated (drop-casted) with ion-selective PVC membrane (referred to as C-CPE); (iii) CPE filled with carbon paste modified with a plasticizer (PVC/cyclohexanone) (referenced as P-CPE). The CPE was formulated from graphite (Gr, 44.0%) and reduced graphene oxide (rGO, 3.0%) as the carbon source, tricresyl phosphate (TCP, 47.0%) as the plasticizer; sodium tetrakis[3,5-bis(trifluoromethyl)phenyl] borate (St-TFPMB, 1.0%) as the ion exchanger; and levofloxacinium-tetraphenylborate (LF-TPB, 5.0%) as the lipophilic ion pair. It showed a sub-Nernstian slope of 49.3 mV decade⁻¹ within the LF concentration range 1.0 × 10⁻² M to 1.0 × 10⁻⁵ M, with a detection limit of 1.0 × 10⁻⁵ M. The PVC coated electrode (C-CPE) showed improved sensitivity (in terms of slope, equal to 50.2 mV decade⁻¹) compared to CPEs. After the incorporation of PVC paste on the modified CPE (P-CPE), the sensitivity increased at 53.5 mV decade⁻¹, indicating such improvement. The selectivity coefficient (log KLF2+,Fe+3pot.) against different interfering species (Na⁺, K⁺, NH⁴⁺, Ca²⁺, Al³⁺, Fe³⁺, Glycine, Glucose, Maltose, Lactose) were significantly improved by one to three orders of magnitudes in the case of C-CPE and P-CPE, compared to CPEs. The modification with the PVC membrane coating significantly improved the response time and solubility of the LF-TPB within the electrode matrix and increased the lifetime. The constructed sensors were successfully applied for LF determination in pharmaceutical preparation (Levoxin^® 500 mg), spiked urine, and serum samples with high accuracy and precision.

Liposomes as a Nanoplatform to Improve the Delivery of Antibiotics into Staphylococcus aureus Biofilms

Staphylococcus aureus biofilm-associated infections are a major public health concern. Current therapies are hampered by reduced penetration of antibiotics through biofilm and low accumulation levels at infected sites, requiring prolonged usage. To overcome these, repurposing antibiotics in combination with nanotechnological platforms is one of the most appealing fast-track and cost-effective approaches. In the present work, we assessed the potential therapeutic benefit of three antibiotics, vancomycin, levofloxacin and rifabutin (RFB), through their incorporation in liposomes. Free RFB displayed the utmost antibacterial effect with MIC and MBIC₅₀ below 0.006 µg/mL towards a methicillin susceptible S. aureus (MSSA). RFB was selected for further in vitro studies and the influence of different lipid compositions on bacterial biofilm interactions was evaluated. Although positively charged RFB liposomes displayed the highest interaction with MSSA biofilms, RFB incorporated in negatively charged liposomes displayed lower MBIC₅₀ values in comparison to the antibiotic in the free form. Preliminary safety assessment on all RFB formulations towards osteoblast and fibroblast cell lines demonstrated that a reduction on cell viability was only observed for the positively charged liposomes. Overall, negatively charged RFB liposomes are a promising approach against biofilm S. aureus infections and further in vivo studies should be performed.

Effect of the Short-Term Use of Fluoroquinolone and β-Lactam Antibiotics on Mouse Gut Microbiota

BACKGROUND

Antibiotics play an important role in the treatment of infectious diseases. However, the overuse of antibiotics increases the spread of drug-resistant bacteria and causes dysbiosis of the intestinal microbiota. Few studies have addressed the longitudinal effects of antibiotics on the microbiome and host immunity.

MATERIALS AND METHODS

In this study, the short-term effect of fluoroquinolone (levofloxacin) and β-lactam antibiotics (meropenem, cefoperazone/sulbactam, and aztreonam) on the gut microbiota of mice was evaluated by 16S rRNA gene sequencing. The susceptibility of Bifidobacterium longum, Lactobacillus lactis, Enterococcus faecium, and Clostridium butyricum to these antimicrobial agents was assessed using the disc diffusion method.

RESULTS

Our results showed that 4-day antibiotic exposure significantly reduced the alpha and beta diversity of gut bacteria and increased serum inflammatory cytokines, and these changes persisted long after antibiotic withdrawal and did not return to pre-treatment levels. Nonetheless, the bacterial community composition tended to return to pre-treatment levels after discontinuing treatment. The tested probiotic strains were resistant to aztreonam but were sensitive to meropenem and cefoperazone/sulbactam.

CONCLUSION

Short-term antibiotic treatment led to significant changes in the intestinal flora with a tendency to recover. The antibiotics had different effects on the intestinal microbial community and probiotic strains. This study provides guidance for the concomitant use of probiotics and antibiotics, and the results emphasize the importance of using broad-spectrum antibiotics responsibly to prevent the long-term disruption of the native microbiota.

Prescribed drugs containing nitrogen heterocycles: an overview

Heteroatoms as well as heterocyclic scaffolds are frequently present as the common cores in a plethora of active pharmaceuticals natural products. Statistically, more than 85% of all biologically active compounds are heterocycles or comprise a heterocycle and most frequently, nitrogen heterocycles as a backbone in their complex structures. These facts disclose and emphasize the vital role of heterocycles in modern drug design and drug discovery. In this review, we try to present a comprehensive overview of top prescribed drugs containing nitrogen heterocycles, describing their pharmacological properties, medical applications and their selected synthetic pathways. It is worth mentioning that the reported examples are actually limited to current top selling drugs, being or containing N-heterocycles and their synthetic information has been extracted from both scientific journals and the wider patent literature.

Herb-drug interaction: The effect of Polygonum capitatum extract on pharmacokinetics of levofloxacin in rats

Polygonum capitatum is a traditional medicinal plant of the Miao people and has been used to treat a variety of urological disorders in China for many years. Preparations made from water-soluble P. capitatum extracts, Relinqing® granules, are often used in combination with levofloxacin to treat urinary tract infections, and have demonstrated better clinical efficacy than either drug alone. As there is no information on the pharmacokinetics of both drugs after co-administration, a sensitive and reliable ultra-performance liquid chromatography-tandem mass spectrometry method was developed and validated to study the potential herb-drug interactions between P. capitatum and levofloxacin. This analytical method delivered high levels of specificity, recovery, accuracy, precision and preserved sample stability. When applied to study pharmacokinetic interactions after oral co-administration of P. capitatum extract (1.86 g kg^-1) and levofloxacin (42 mg kg^-1) in rats, the results indicated significant reductions in C_max and AUC_0-24h of levofloxacin, and significant increases in MRT, T_max, CLz/F and Vz/F. Moreover, pretreatment with P. capitatum extract orally did not alter the intravenous pharmacokinetics of levofloxacin. Combined and compared oral pharmacokinetic parameters, suggesting that the interacting targets might localized in the intestine during absorption. Overall, the results revealed a potential herb-drug interaction between P. capitatum and levofloxacin.

Synthesis, biological evaluation and QSAR studies of new thieno[2,3-d]pyrimidin-4(3H)-one derivatives as antimicrobial and antifungal agents

A series of new thieno[2,3-d]pyrimidin-4(3H)-one derivatives were synthesized and evaluated for their activity against four gram-positive and four gram-negative bacterial and eight fungal species. The majority of the compounds exhibited excellent antimicrobial and antifungal activity, being more potent than the control compounds. Compound 22, bearing a m-methoxyphenyl group and an ethylenediamine side chain anchored at C-2 of the thienopyrimidinone core, is the most potent antibacterial compound with broad antimicrobial activity with MIC values in the range of 0.05-0.13 mM, being 6 to 15 fold more potent than the controls, streptomycin and ampicillin. Furthermore, compounds 14 and 15 which bear a p-chlorophenyl and m-methoxyphenyl group, respectively, and share a 2-(2-mercaptoethoxy)ethan-1-ol side chain showed the best antifungal activity, being 10-15 times more potent than ketoconazole or bifonazole with MIC values 0.013-0.026 and 0.027 mM, respectively. Especially in the case of compound 15 the low MIC values were accompanied by excellent MFC values ranging from 0.056 to 0.058 mM. Evaluation of toxicity in vitro on HFL-1 human embryonic primary cells and in vivo in the nematode C. elegans revealed no toxic effects for both compounds 15 and 22 tested at the MIC concentrations. Ligand-based similarity search and molecular docking predicted that the antibacterial activity of analogue 22 is related to inhibition of the topoisomerase II DNA gyrase enzyme and the antifungal activity of compound 15 to CYP51 lanosterol demethylase enzyme. R-Group analysis as a means of computational structure activity relationship tool, highlighted the compounds' crucial pharmacophore features and their impact on the antibacterial and antifungal activity. The presence of a N-methyl piperidine ring fused to the thienopyrimidinone core plays an important role in both activities.

Optimization Strategies Aimed to Increase the Efficacy of Helicobacter pylori Eradication Therapies with Quinolones

H. pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. Fluoroquinolones such as levofloxacin, or more recently moxifloxacin or sitafloxacin, are efficacious alternatives to standard antibiotics for H. pylori eradication. The aim of the present review is to summarize the role of quinolone-based eradication therapies, mainly focusing on the optimization strategies aimed to increase their efficacy. Several meta-analyses have shown that, after failure of a first-line eradication treatment, a levofloxacin-containing rescue regimen is at least equally effective, and better tolerated, than the generally recommended bismuth quadruple regimen. Compliance with the levofloxacin regimens is excellent, and the safety profile is favourable. Higher cure rates have been reported with longer treatments (>10-14 days), and 500 mg levofloxacin daily is the recommended dose. Adding bismuth to the standard triple regimen (PPI-amoxicillin-levofloxacin) has been associated with encouraging results. Unfortunately, resistance to quinolones is easily acquired and is increasing in most countries, being associated with a decrease in the eradication rate of H. pylori. In summary, a quinolone (mainly levofloxacin)-containing regimen is an encouraging second-line (or even third-line) strategy, and a safe and simple alternative to bismuth quadruple therapy in patients whose previous H. pylori eradication therapy has failed.

Project IDentif.AI: Harnessing Artificial Intelligence to Rapidly Optimize Combination Therapy Development for Infectious Disease Intervention

In 2019/2020, the emergence of coronavirus disease 2019 (COVID-19) resulted in rapid increases in infection rates as well as patient mortality. Treatment options addressing COVID-19 included drug repurposing, investigational therapies such as remdesivir, and vaccine development. Combination therapy based on drug repurposing is among the most widely pursued of these efforts. Multi-drug regimens are traditionally designed by selecting drugs based on their mechanism of action. This is followed by dose-finding to achieve drug synergy. This approach is widely-used for drug development and repurposing. Realizing synergistic combinations, however, is a substantially different outcome compared to globally optimizing combination therapy, which realizes the best possible treatment outcome by a set of candidate therapies and doses toward a disease indication. To address this challenge, the results of Project IDentif.AI (Identifying Infectious Disease Combination Therapy with Artificial Intelligence) are reported. An AI-based platform is used to interrogate a massive 12 drug/dose parameter space, rapidly identifying actionable combination therapies that optimally inhibit A549 lung cell infection by vesicular stomatitis virus within three days of project start. Importantly, a sevenfold difference in efficacy is observed between the top-ranked combination being optimally and sub-optimally dosed, demonstrating the critical importance of ideal drug and dose identification. This platform is disease indication and disease mechanism-agnostic, and potentially applicable to the systematic N-of-1 and population-wide design of highly efficacious and tolerable clinical regimens. This work also discusses key factors ranging from healthcare economics to global health policy that may serve to drive the broader deployment of this platform to address COVID-19 and future pandemics.

Successes and Challenges: Inhaled Treatment Approaches Using Magnetic Nanoparticles in Cystic Fibrosis

Magnetic nanoparticles have been largely applied to increase the efficacy of antibiotics due to passive accumulation provided by enhancing permeability and retention, which is essential for the treatment of lung infections. Recurring lung infections such as in the life-shortening genetic disease cystic fibrosis (CF) are a major problem. The recent advent of the CF modulator drug ivacaftor, alone or in combination with lumacaftor or tezacaftor, has enabled systemic treatment of the majority of patients. Magnetic nanoparticles (MNPs) show unique properties such as biocompatibility and biodegradability as well as magnetic and heat-medicated characteristics. These properties make them suitable to be used as drug carriers and hyperthermia-based agents. Hyperthermia is a promising approach for the thermal activation therapy of several diseases, including pulmonary diseases. The benefits of delivering CF drugs via inhalation using MNPs as drug carriers afford application of sufficient therapeutic dosages directly to the primary target site, while avoiding potential suboptimal pharmacokinetics/pharmacodynamics and minimizing the risks of systemic toxicity. This review explores the multidisciplinary approach of using MNPs as vehicles of drug delivery. Additionally, we highlight advantages such as increased drug concentration at disease site, minimized drug loss and the possibility of specific cell targeting, while addressing major challenges for this emerging field.

Antimicrobial Resistance Gene Prevalence in a Population of Patients with Advanced Dementia Is Related to Specific Pathobionts

Long-term care facilities are significant reservoirs of antimicrobial-resistant organisms, and patients with advanced dementia are particularly vulnerable to multidrug-resistant organism (MDRO) acquisition and antimicrobial overuse. In this study, we longitudinally examined a group of patients with advanced dementia using metagenomic sequencing. We found significant inter- and intra-subject heterogeneity in microbiota composition, suggesting temporal instability. We also observed a link between the antimicrobial resistance gene density in a sample and the relative abundances of several pathobionts, particularly Escherichia coli, Proteus mirabilis, and Enterococcus faecalis, and used this relationship to predict resistance gene density in samples from additional subjects. Furthermore, we used metagenomic assembly to demonstrate that these pathobionts had higher resistance gene content than many gut commensals. Given the frequency and abundances at which these pathobionts were found in this population and the underlying vulnerability to MDRO of patients with advanced dementia, attention to microbial blooms of these species may be warranted.

Efficacy and safety of levofloxacin as a treatment for complicated urinary tract infections and pyelonephritis

INTRODUCTION

Urinary tract infections (UTIs) are among the most common causes of sepsis presenting to hospitals. Treating complicated UTIs is extremely important due to their potential mortality. Levofloxacin is a fluoroquinolone antibacterial that has become one of the cornerstones of antibiotic therapy of complicated UTIs and pyelonephritis since its introduction in the 1990s because of its exceptional pharmacokinetic (PK) and pharmacodynamic (PD) profile. However, the emergence of widespread fluoroquinolone resistance over the past decade has prompted investigators to reexamine its place in the treatment of UTI.

AREAS COVERED

This literature review summarizes data about the efficacy and the tolerability of levofloxacin in treating complicated UTIs and pyelonephritis.

EXPERT OPINION

In the early 2000s, fluoroquinolones became the most commonly prescribed antibiotic in the US. Since then, the resistance rate of Escherichia coli to fluoroquinolones has increased, largely hampering the use of this class of drugs. These data, in association with emerging data about inappropriate prescription and toxicity, have limited its clinical use. For these reasons, a judicious use of levofloxacin and other fluoroquinolones and a careful implementation of infection control procedures are the main available tools for the management of UTIs and pyelonephritis.

Azithromycin plus β-lactam versus levofloxacin plus β-lactam for severe community-acquired pneumonia: A retrospective nationwide database analysis

Previous studies showed potential benefits of macrolide combined with β-lactam for severe community-acquired pneumonia (CAP). However, it remains inconclusive whether macrolide plus β-lactam is superior to respiratory fluoroquinolone plus β-lactam for patients with severe CAP. Using a nationwide inpatient database in Japan, we performed propensity score matching and inverse probability of treatment weighting (IPTW) to compare 28-day mortality and in-hospital mortality between azithromycin plus β-lactam and levofloxacin plus β-lactam for severe CAP patients admitted to hospital between July 2010 and March 2015. We identified 1,999 patients with severe pneumonia who received azithromycin plus β-lactam (n = 840) or levofloxacin plus β-lactam (n = 1,159) within 2 days after admission. Five-hundred sixty propensity score-matched pairs showed no significant differences between azithromycin plus β-lactam and levofloxacin plus β-lactam in 28-day mortality and in-hospital mortality (19.3% vs. 20.7%, p = 0.601 and 24.8% vs. 26.8%, p = 0.495, respectively). IPTW analysis also showed no significant differences between azithromycin plus β-lactam and levofloxacin plus β-lactam in 28-day mortality (risk difference, -3.5% [95% confidence interval, -8.8% to 1.7%] and in-hospital mortality (risk difference, -3.6%; 95% confidence interval, -9.4% to 2.1%). In conclusion, there were no significant differences in 28-day mortality and in-hospital mortality between azithromycin plus β-lactam and levofloxacin plus β-lactam for severe CAP patients.

Levofloxacin-Associated Neurotoxicity in a Patient with a High Concentration of Levofloxacin in the Blood and Cerebrospinal Fluid

Neurotoxicity is a rare and intolerable adverse effect associated with levofloxacin therapy, whose diagnosis has mostly been reported based on medical history rather than quantitative measures in the blood. We report a 68-year-old man with levofloxacin-associated encephalopathy and myoclonus with high levels of levofloxacin in the blood and cerebrospinal fluid. After hemodialysis, these decreased, and his symptoms rapidly improved. An electroencephalogram was also normal. This case showed the concentration of levofloxacin to be clearly related to levofloxacin-associated neurotoxicity. Therefore, an estimation of its concentration may contribute to accurate diagnosis.