Pharmacokinetics and pharmacodynamics of neutrophil-associated ciprofloxacin in humans

Uncertainty and variability in human exposure limits - a chemical-specific approach for ciprofloxacin and methotrexate

Human exposure limits (HELs) for chemicals with a toxicological threshold are traditionally derived using default assessment factors that account for variations in exposure duration, species sensitivity and individual sensitivity. The present paper elaborates a probabilistic approach for human hazard characterization and the derivation of HELs. It extends the framework for evaluating and expressing uncertainty in hazard characterization recently proposed by WHO-IPCS, i.e. by the incorporation of chemical-specific data on human variability in toxicokinetics. The incorporation of human variability in toxicodynamics was based on the variation between adverse outcome pathways (AOPs). Furthermore, sources of interindividual variability and uncertainty are propagated separately throughout the derivation process. The outcome is a two-dimensional human dose distribution that quantifies the population fraction exceeding a pre-selected critical effect level with an estimate of the associated uncertainty. This enables policy makers to set separate standards for the fraction of the population to be protected and the confidence level of the assessment. The main sources of uncertainty in the human dose distribution can be identified in order to plan new research for reducing uncertainty. Additionally, the approach enables quantification of the relative risk for specific subpopulations. The approach is demonstrated for two pharmaceuticals, i.e. the antibiotic ciprofloxacin and the antineoplastic methotrexate. For both substances, the probabilistic HEL is mainly influenced by uncertainty originating from: (1) the point of departure (PoD), (2) extrapolation from sub-acute to chronic toxicity and (3) interspecies extrapolation. However, when assessing the tails of the two-dimensional human dose distributions, i.e. the section relevant for the derivation of human exposure limits, interindividual variability in toxicodynamics also becomes important.

Treatment of Citrobacter kosen Infection with Ciprofloxacin and Cefotaxime in a Preterm Infant

Objective:

To report a case of successful treatment of Citrobacter koseri infection in a preterm infant as a means of challenging the current treatment recommendations on the basis of pharmacodynamic and pharmacokinetic considerations.

Case Summary:

A premature infant was diagnosed with C. koseri sepsis after 3 weeks in intensive care. Concern for meningitis was based on the propensity for central nervous system (CNS) involvement with Citrobacter infection along with new findings of ventriculomegaly and hydrocephalus shown on cranial ultrasound (CUS). The infant was treated with ciprofloxacin 10–20 mg/day and cefotaxime 100 mg/day for 21 days. After treatment, lumbar puncture was normal, follow-up CUS returned to baseline, and the Infant passed a hearing screen after discharge. A favorable outcome was achieved in this case.

Discussion:

Approximately 76% of neonatal patients Infected with C. koseri develop brain abscesses. The mortality rate for meningitis due to Citrobacter sop is approximately 30%, and of the infants who survive, more than 80% have some degree of mental retardation. Third-generation cephalosporins and aminoglycosides are traditional therapies against this infection. The current antibiotic strategies have failed to prevent the high rates of morbidity and mortality associated with Citrobacter infections. A possible basis for these poor outcomes is failure to apply appropriate pharmacokinetic and pharmacodynamic principles in selecting antibiotics that will achieve adequate concentrations to kill the bacteria in granulocytes within the CNS. Based on favorable sensitivity data, penetration into neutrophils and the CNS, and favorable toxicity profiles, ciprofloxacin and meropenem would appear to be the most appropriate antibiotic treatment options for systemic infection or meningitis caused by C. koseri.

Conclusions:

Ciprofloxacin and meropenem should be considered antibiotic treatment options for systemic infection or meningitis caused by G koseri.

Cyclosporin and tacrolimus increase plasma levels of adenosine in kidney transplanted patients

The immunosuppressive agents, cyclosporin (CsA) and tacrolimus (FK506), display cardioprotective activities. The mechanism would consist on the inhibition of the enzyme, adenosine kinase (AK), leading to an increase in adenosine (ADO) levels. ADO, inosine (INO) and nucleotide plasma levels were measured in kidney transplant recipients before and 1, 2, 4, 6 and 8 h after the administration of CsA or FK506. After CsA and FK506 administration, ADO plasma levels significantly increased, reaching a peak level after 2 h (483 +/- 124 and 429 +/- 96 nm, respectively), and then progressively declined. Calculated peak values (t(max)) of ADO were slightly delayed with respect to those of CsA and FK506. Treatment with rapamycin did not influence the phenomenon. The dynamic profile of plasma changes of ADO, nucleotides and INO were consistent with the inhibition of the enzyme, AK. ADO increase may be clinically relevant in terms of anti-ischaemic, tissue protecting, and immunosuppressive activities as well as in terms of nephrotoxicity.

Quinolones alter defense reactions mediated by macrophages

The innate host defense system is regulated in part by the number and activation of the function of neutrophils and macrophages. The immunological effects of a variety of quinolones on host defense functions of macrophage are reported. Ofloxacin (OFLX), lomefloxacin (LFLX), tosufloxacin (TFLX), fleroxacin (FLRX), sparfloxacin (SPFX) and levofloxacin (LVFX) significantly inhibited phagocytosis of Escherichica coli by macrophages. Moreover, TFLX markedly potentiated the expression of the adhesion molecule Mac-1 by macrophages. No significant alteration was detected in the adherence and the expression of adhesion molecule Mac-1 in macrophages treated with the other quinolones. In contrast, OFLX, LFLX, TFLX, and LVFX were effective in significantly increasing the production of hydrogen peroxide, while the other agents did not. These results suggest that the quinolones at a therapeutic concentration differentially affect phagocytosis, adhesion, and the production of hydrogen peroxide by macrophages.

Comparative studies of modulatory effect to the function of rat peritoneal neutrophils treated with new quinolones

Some of the immunological effects of a variety of new quinolones on adhesion, phagocytosis, and production of reactive oxygen intermediators in neutrophils were studied. Ofloxacin, lomefloxacin, fleroxacin, and levofloxacin potentiated the phagocytosis of Escherichia coli in neutrophils. Moreover, lomefloxacin, and sparfloxacin significantly potentiated adhesion of neutrophils. In contrast, tosufloxacin was effective in significantly and persistently potentiating the production of superoxide anion, whereas the other agents markedly inhibited such production. Furthermore, tosufloxacin was effective in significantly potentiating the production of hydrogen peroxide, whereas sparfloxacin markedly inhibited such production. These results suggest that the new quinolones at a therapeutic concentration may affect functions such as phagocytosis, and production of superoxide anion in neutrophils.

Penetration of ciprofloxacin into the interstitial space of inflamed foot lesions in non-insulin-dependent diabetes mellitus patients

Interstitial ciprofloxacin concentrations were measured by microdialysis in inflamed foot lesions of non-insulin-dependent diabetes mellitus patients following intravenous administration of 0. 2 g of ciprofloxacin. Interstitial ciprofloxacin concentrations were significantly lower than corresponding serum concentrations. There was no significant difference in the penetration of ciprofloxacin into inflamed and unaffected tissue (area under the concentration-time curve(infection)/area under the concentration-time curve(unaffected tissue) = 0.99 +/- 0.15 [mean +/- standard error], n = 6). Thus, inflammation appears to have little or no effect on the penetration of ciprofloxacin into tissue.

Possible interaction between new quinolones and immune functions in macrophages

Some of the immunological effects of a variety of new quinolones on chemotaxis and the production of superoxide anion in rat macrophages were studied. All of the new quinolones examined at a dose range of 0.5 to 50 microg/ml significantly inhibited chemotaxis in a dose-dependent manner in rat macrophages. Moreover, the new quinolones at a dose of 0.5 microg/ml were effective in markedly potentiating the generation of superoxide anion. These results indicate that the new quinolones may modulate immune functions in rat macrophages.

Distribution and antimicrobial activity of ciprofloxacin in human soft tissues

Interstitial ciprofloxacin concentrations in soft tissues were measured by microdialysis following intravenous administration of 200 mg to each of eight healthy volunteers. Interstitial ciprofloxacin concentrations were significantly lower than corresponding total serum drug concentrations; the interstitium-to-serum concentration ratios ranged from 0.55 to 0.73. An in vitro simulation based on interstitial pharmacokinetics showed a substantially lower antimicrobial activity than did the simulation based on serum pharmacokinetics. Thus, ciprofloxacin concentrations at the site of effect may be subinhibitory although effective concentrations are attained in serum.

Influence of antimicrobial agents on bactericidal activity of bovine milk polymorphonuclear leukocytes

The influence of nine commonly used antibiotics on the respiratory burst activity of bovine milk polymorphonuclear leukocytes (PMNL) of high yielding cows was studied in vitro. Cellular oxidative activity was quantitated after preincubation with drugs at different concentrations and assayed by a PMA (12,13-phorbol myristate acetate)-induced luminol-enhanced chemiluminescence (CL) technique. All antibiotics except sulphadiazine and enrofloxacin decreased CL at the highest concentration. Enrofloxacin significantly increased CL. Oxytetracycline inhibited CL even at low doses. The decreased CL with danofloxacin and oxytetracycline was mainly induced by their color, which caused absorption of the blue light emitted by luminol. Production of superoxide radicals measured by the cytochrome c reduction assay was lowered by danofloxacin, penicillin and chloramphenicol. The decreased CL with ceftiofur was due to inhibition of myeloperoxidase (MPO) activity and to scavenging of reactive oxygen species. Interference with the MPO-H2O2-halide system was also observed with spiramycin, erythromycin and oxytetracycline, while the latter was also observed with penicillin. The stimulatory effect of enrofloxacin might be due to an improvement of the penetration of luminol into the PMNL or to a stimulation of the production of H2O2. Potentiation of the action of PMA by changing the ratio between bound and free intracellular Ca2+ might also be involved. Our results suggest that many antibiotics may affect neutrophil function at concentrations that may be found in milk immediately after intramammary treatment or at concentrations higher than those found in milk after intramammary treatment.