Single-dose antibiotic therapy: what has the past taught us?

Stability of Amoxicillin and Clavulanic Acid in Separate Containers for Administration via a Y-Site

Rationale

With the discovery of new antibiotics diminishing, optimising the administration of existing antibiotics such as amoxicillin-clavulanic acid has become a necessity. At present, the optimal approach for enhancing the effectiveness of time-dependent antibiotics involves extending the time at which antibiotic concentrations are maintained above the minimal inhibitory concentration by prolonging the infusion time. This pharmacodynamic rationale cannot be applied to co-amoxiclav because of poor stability at room temperature. The aim of this study was to establish the shelf-life of amoxicillin and clavulanic acid prepared in separate containers to determine the feasibility of 24-hr continuous infusion therapy.

Methods

A previously developed and validated stability-indicating HPLC method was used to establish the shelf-life of reconstituted amoxicillin and clavulanic acid when prepared in separate containers. Stability at clinical concentration was evaluated at three temperatures. To establish whether there were significant differences at the level of both active ingredients and temperature, results were analysed using analysis of covariance (ANCOVA) to assess differences between the attained slopes of regression.

Results

Data obtained indicated amoxicillin and clavulanic acid stability superior to that previously proposed making it suitable for continuous infusion therapy. Analysis of regression slopes via ANCOVA showed that temperature significantly affected amoxicillin and clavulanic acid stability. Amoxicillin retained 90% of its initial concentration for 80.3 hrs when stored at 4°C, 24.8 hrs at 25°C and 9 hrs when incubated at 37°C. Clavulanic acid retained 90% of its initial concentration for 152 hrs when stored at 4°C, 26 hrs at 25°C and 6.4 hrs when incubated at 37°C.

Conclusion

Amoxicillin and clavulanic acid are suitable for administration via continuous infusion when prepared, stored, and administered in separate containers. Results obtained from this study aid in ameliorating current dosing regimens to optimise antibiotic efficacy; however, more in-depth amoxicillin and clavulanic acid y-site compatibility studies are warranted.

Distribution of ceftiofur into Mannheimia haemolytica-infected tissue chambers and lung after subcutaneous administration of ceftiofur crystalline free acid sterile suspension

The objective of this study was to evaluate the penetration of ceftiofur- and desfuroylceftiofur-related metabolites (DCA) into sterile and infected tissue chambers, lung tissue and disposition of DCA in plasma across four different sacrifice days postdosing. Twelve healthy calves were utilized following implantation with tissue chambers in the paralumbar fossa. Tissue chambers in each calf were randomly inoculated with either Mannheimia haemolytica or sterile PBS. All calves were dosed with ceftiofur crystalline free acid sterile suspension (CCFA-SS) subcutaneously in the ear pinna. Calves were randomly assigned to 4 groups of 3 to be sacrificed on days 3, 5, 7 and 9 postdosing. Prior to euthanasia, plasma and tissue chamber fluid were collected, and immediately following euthanasia, lung tissue samples were obtained from four different anatomical sites DCA concentration analysis. Results of our study found that, in general, DCA concentrations followed a rank order of plasma > infected tissue chamber fluid > noninfected tissue chamber fluid > lung tissue. Data also indicated DCA concentrations remained above the therapeutic threshold of 0.2 microg/mL for plasma and chamber fluid and 0.2 microg/g for lung tissue for at least 7 days post-treatment.

Principles of Antimicrobial Therapy

The most compelling reason for practicing judicious antimicrobial use is to facilitate therapeutic success. The definition of therapeutic success has changed in recent years, however; not only does success include eradication of infection, but it must now include avoidance of resistance. If the goal of antimicrobial therapy is to achieve sufficient concentrations at the site of infection such that the infecting organism is killed, therapy should be successful.

Drugs affecting the respiratory system

Differences in the disposition of drugs among exotic animals is a well-recognized hurdle when treating disease. Differences exist in pharmacokinetics, pharmacodynamics, and disease processes. This article focuses on the principles of treating respiratory tract diseases, with the recognition that not all drugs are indicated for use in all exotic species. The discussion begins with a description of respiratory physiology as it pertains to response to drugs, using the mammalian lung as a template. The role of respiratory defense mechanisms in airway protection and disease is addressed. Drugs used to treat the respiratory tract include the bronchodilators and anti-inflammatory drugs, drugs that modify respiratory secretions (e.g., mucolytics, mucokinetics, and expectorants), antitussive drugs, and decongestants. Aerosolization is an important adjuvant for respiratory therapy as long as precautions are met. Infectious diseases are among the more common respiratory diseases encountered, and the discussion includes a focus on the use of antibiotics for treating respiratory tract infections.

The place of tobramycin in lower respiratory tract infections (LRTI)

The Author provides a review of clinical experience with tobramycin as therapy for lower respiratory tract infections, in comparison to other aminoglycosides, including the pharmacokinetics and toxicity, dwelling on oto- and nephrotoxicity. The article includes a discussion of various dosing regimens of the aminoglycosides, focussing on efficacy and toxicity arising from once-daily administration. The Author then provides a more detailed description of tobramycin's pharmacokinetics, indications for its use, and the possibilities of once-daily dosing, concluding that toxicity is favorably influenced by a single daily administration as well as efficacy, and that patient compliance and reduced hospital costs are other advantages of this regimen.

Considerations in antimicrobial prescribing

Soon after antimicrobial drugs became available, it was recognized that they were being overused and misused. Reasons for concern about the inappropriate use of antimicrobials include the emergence of resistant nosocomial bacteria, which have been identified in every hospital nationwide. The presence of resistant nosocomial bacteria presents the physician with a clinical problem and increases the cost of therapy. It is clear that methods need to be implemented to help physicians improve prescribing of antimicrobial agents. As health care practitioners in all fields strive to make patient care more cost-effective, one observation has become evident: The successfully treated patient consumes fewer resources and subsequently costs the hospital less than an otherwise similar, unsuccessfully treated patient. The goal in the 1990s is to provide optimal, cost-effective care for patients without compromising quality. This goal can be achieved by collaborative efforts of physicians, pharmacists, and microbiologists working together as a team to promote quality patient care.

Parenteral aminoglycoside therapy. Selection, administration and monitoring

Aminoglycosides are potent water-soluble antibiotics, with peak concentration-dependent bactericidal activity against many pathogenic aerobic Gram-negative bacilli and Staphylococcus aureus. For systemic therapy, they must be given parenterally (intravenously or intramuscularly). In the body they remain largely extracellular, but penetration into cerebrospinal fluid and other secretions is meagre. They display trough concentration-dependent reversible nephrotoxicity and The commonly irreversible ototoxicity, which may present after treatment ceases. Gentamicin is the usual all-purpose agent of choice, tobramycin is slightly more effective against Pseudomonas aeruginosa infections, amikacin is the least susceptible to degradation by bacterial enzymes and netilmicin is probably the least toxic. Clinical and drug concentration monitoring have a role in therapy. Aminoglycosides exhibit enduring antibacterial activity (especially against Gram-negative bacilli) many hours after tissue concentrations become negligible. Appreciation of this postantibiotic effect is leading to replacement of conventional multiple daily doses by large single daily doses. The latter regimens confer at least equivalent efficacy and less risk of toxicity (particularly renal). However, single daily dosage may be unsuitable for immunocompromised patients and in those with infective endocarditis, where there is insufficient experience. Cotreatment with beta-lactams is commonly used in order to exploit the synergism between these agents, particularly in enterococcal endocarditis and severe Gram-negative sepsis. Liposomal aminoglycosides are promising parenteral formulations. After being taken up by phagocytes they reach the liver, spleen and sites of inflammation; subsequently they are gradually released. To substantiate the applicability of these hitherto experimental formulations, findings from clinical studies are keenly awaited.