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Abstract
BACKGROUND Premarketing trials showed the fluoroquinolone agents to have a favorable side-effect profile, with treatment-related adverse events comprising gastrointestinal, central nervous system, and dermatologic effects that were generally mild and reversible on cessation of treatment. However, postmarketing surveillance studies have identified severe adverse events, including severe anaphylaxis, QTc-interval prolongation, and potential cardiotoxicity, associated with 3 quinolone agents that either resulted in the removal of the agent from the market (temafloxacin and grepafloxacin) or significantly restricted its use due to substantial mortality and morbidity associated with liver toxicity (trovafloxacin). To date, there have been no such significant adverse events associated with the older fluoroquinolone agents, including ciprofloxacin, ofloxacin, norfloxacin, and levofloxacin. However, there are fewer data from postmarketing surveillance studies on the most recently approved agents, such as moxifloxacin and gatifloxacin, or agents awaiting approval, such as gemifloxacin. OBJECTIVE This paper examines safety data from the premarketing trials and postmarketing surveillance studies of fluoroquinolones available in the United States. METHODS A MEDLINE search was performed to identify all English-language studies published since 1980 concerning the safety profiles of the fluoroquinolones. CONCLUSIONS The fluoroquinolone antibacterial agents offer broad-spectrum therapy in patients with a variety of infections. Given similar spectra of activity, the choice between quinolones may be based on differences in efficacy and safety or tolerability profiles. Most drug reactions involving these agents are minor and reversible on discontinuing treatment, but adverse effects can be associated with significant mortality and morbidity, as was seen in the case of trovafloxacin and temafloxacin.
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Affiliation(s)
- J Bertino
- Bassett Healthcare, Clinical Pharmacology Research Center, Cooperstown, New York 13326, USA
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Abstract
The second-generation fluoroquinolones have enjoyed successful clinical use for more than 10 years in many countries, and they have a valued and proven record of safety and efficacy. However, deficiencies with respect to gram-positive and anaerobic organisms limit the use of these agents in respiratory, intra-abdominal, and pelvic infections. New, third-generation agents with dramatically increased activity against gram-positive and anaerobic bacteria--notably, Streptococcus pneumoniae and Bacteroides fragilis--have shown high rates of efficacy in pneumonia, bronchitis, and surgical and gynecologic infections. Although most of these new drugs produce similar clinical results, adverse reaction profiles differ and may influence therapeutic choices.
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Affiliation(s)
- P Ball
- 6, Gilchrist Row, St. Andrews, Fife KY16 8XU, Scotland
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Abstract
Postoperative infection remains a complication of surgical procedures, resulting in increased morbidity, mortality, and cost. The frequent polymicrobial etiology and emerging patterns of resistance continue to compromise cure rates. Although quinolones have many attractive properties for the surgical setting, combination therapy is routinely indicated for appropriate coverage. Advanced-generation quinolones, such as trovafloxacin, offer an increased antimicrobial spectrum, including activity against important surgical pathogens, and longer elimination half-lives. These newer agents may be used intravenously or orally as once-daily single-agent therapy for surgical prophylaxis, and in place of combination therapy for complex intra-abdominal and pelvic infections.
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Affiliation(s)
- J A Weigelt
- Department of Surgery, St. Paul-Ramsey Medical Center, University of Minnesota, 55101, USA
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Vincent J, Teng R, Pelletier SM, Willavize SA, Friedman HL. The bioavailability of nasogastric versus tablet-form oral trovafloxacin in healthy subjects. Am J Surg 1998; 176:23S-26S. [PMID: 9935253 DOI: 10.1016/s0002-9610(98)00216-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients in the hospital, as well as those in home care settings, often require nutritional supplementation with enteral feeding solutions. In addition, patients with serious infections who are clinically unstable often cannot maintain adequate intake by mouth and may require an alternative to oral antibiotic administration. However, delivery of crushed oral formulations of drugs via nasogastric tubes is often carried out without adequate bioavailability data, and this method of administration may not always be equivalent to oral drug delivery. METHODS In an open-label, randomized, four-period, four-treatment, cross-over study, 24 healthy volunteers were given one dose of each of the following treatments, with a 7-day wash-out between dosing periods: Treatment A: two 100-mg trovafloxacin tablets given orally with 240 mL water; Treatment B: two crushed 100-mg trovafloxacin tablets suspended in water and administered through a nasogastric tube into the stomach; Treatment C: two crushed 100-mg trovafloxacin tablets suspended in water and administered through a nasogastric tube into the duodenum; or Treatment D: two crushed 100-mg trovafloxacin tablets suspended in water and given through a nasogastric tube into the stomach concomitantly with an enteral feeding solution (240 mL full-strength Osmolite). RESULTS Pharmacokinetic analyses showed that the bioavailability of trovafloxacin after administration of crushed tablets into the stomach with or without concomitant enteral feeding was not significantly different from that of the orally administered whole tablets: the 90% confidence limits of the area under the concentration-time curve (AUC(0-infinity)) for Treatment B versus Treatment A (91.3%, 109.5%) and Treatment D versus Treatment A (91.6%, 109.9%) were well within the bioequivalence criteria of 80% to 125%. Results of analysis of variance (ANOVA) indicated no significant sequence, period, or treatment-by-period interaction effects. Administration of trovafloxacin into the duodenum (Treatment C) resulted in reduced systemic exposure to trovafloxacin, with a 31% decrease in AUC(0-infinity) and a 30% decrease in peak serum concentration (Cmax) compared to oral administration. Time to peak serum concentration (Tmax) was 1.7 hours after oral administration of trovafloxacin and 1.1 hours after administration directly into the stomach or duodenum through a nasogastric tube in the absence of concomitant enteral feeding. All four treatments were well tolerated; no participant discontinued the study due to adverse events and no serious adverse events were reported. CONCLUSIONS These results showed that administration of crushed trovafloxacin tablets through a nasogastric tube into the stomach, with or without concomitant enteral feeding, achieves absorption and tolerability comparable to those of orally administered trovafloxacin tablets.
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Affiliation(s)
- J Vincent
- Pfizer Central Research, Groton, Connecticut 06340, USA
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Roy S, Koltun W, Chatwani A, Martens MG, Dittrich R, Luke DR. Treatment of acute gynecologic infections with trovafloxacin. Trovafloxacin Surgical Group. Am J Surg 1998; 176:67S-73S. [PMID: 9935260 DOI: 10.1016/s0002-9610(98)00223-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Trovafloxacin, a broad-spectrum fourth-generation quinolone with gram-positive and gram-negative aerobic and anaerobic bacterial activity, is available in oral and intravenous formulations. The objective of this prospective, multicenter, double-blind, randomized study was to compare the efficacy of trovafloxacin with that of cefoxitin, an approved drug for treatment of acute gynecologic infections, together with amoxicillin/clavulanic acid as oral follow-on treatment. METHODS Patients with a clinical diagnosis of acute pelvic infection received either intravenous alatrofloxacin with oral trovafloxacin follow-on (trovafloxacin) or a combined regimen of cefoxitin followed by amoxicillin/clavulanic acid for a maximum of 14 days. The primary endpoint was clinical response to therapy on follow-up at day 30. RESULTS Clinical success rates were comparable between the trovafloxacin (n = 107) and comparative (n = 119) groups at study end (90% vs. 86%, respectively; 95% confidence interval, -4.5, 12.5). Among clinically evaluable patients, clinical success rates for infections involving Enterococcus species were higher with trovafloxacin than with the comparative regimen at the end of treatment (96% and 85%) and at study end (96% and 86%). CONCLUSION Intravenous alatrofloxacin followed by oral trovafloxacin for a maximum of 14 days of total therapy was efficacious in the treatment of acute pelvic infections.
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Affiliation(s)
- S Roy
- Women and Children's Hospital, Los Angeles, California 90033, USA
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Weigelt JA, Faro S. Antimicrobial therapy for surgical prophylaxis and for intra-abdominal and gynecologic infections. Am J Surg 1998; 176:1S-3S. [PMID: 9935248 DOI: 10.1016/s0002-9610(98)00211-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- J A Weigelt
- Department of Surgery, St. Paul-Ramsey Medical Center, University of Minnesota, 55101, USA
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Donahue PE, Smith DL, Yellin AE, Mintz SJ, Bur F, Luke DR. Trovafloxacin in the treatment of intra-abdominal infections: results of a double-blind, multicenter comparison with imipenem/cilastatin. Trovafloxacin Surgical Group. Am J Surg 1998; 176:53S-61S. [PMID: 9935258 DOI: 10.1016/s0002-9610(98)00221-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial. METHODS Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30). RESULTS At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups. CONCLUSION Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.
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Affiliation(s)
- P E Donahue
- Cook County Hospital, Chicago, Illinois 60612, USA
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Abstract
BACKGROUND This randomized open-label study assessed the penetration into gynecologic tissues of trovafloxacin, a new broad-spectrum, fourth-generation fluoroquinolone with in vitro activity against anaerobes, gram-positive, gram-negative, and atypical pathogens. METHODS Women undergoing hysterectomy or hysterectomy and adnexectomy received 200 mg trovafloxacin orally before surgery as a single dose or as multiple doses. Samples of genital tract tissue and serum were obtained simultaneously during surgery. RESULTS In the single-dose group, trovafloxacin concentrations in genital tract tissues were measurable for up to 30 hours. Tissue concentrations of trovafloxacin after multiple doses were comparable to those after single doses. Mean tissue: serum concentration ratios after a single dose were greatest in the ovary (1.6 microg/g) and comparable in uterus, myometrium, cervix, and fallopian tubes (0.5 to 0.7 microg/g). Adverse events after a single dose were minor. CONCLUSIONS A daily dose of 200 mg trovafloxacin produces gynecologic tissue concentrations that persist for up to 30 hours at levels necessary to prevent or treat pelvic infections. This dosing regimen is well tolerated.
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Affiliation(s)
- M G Martens
- Obstetrics and Gynecology Department, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA
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Vincent J, Teng R, Dalvie DK, Friedman HL. Pharmacokinetics and metabolism of single oral doses of trovafloxacin. Am J Surg 1998; 176:8S-13S. [PMID: 9935250 DOI: 10.1016/s0002-9610(98)00213-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Trovafloxacin, a new fluoronaphthyridone derivative related to fluoroquinolone antimicrobial drugs, has demonstrated the following characteristics: significant gram-positive and gram-negative activity; significant activity against anaerobes and atypical respiratory pathogens; approximately 11-hour elimination half-life, permitting once-daily administration; and good tissue penetration. Because <10% of an orally administered dose is recovered in urine as unchanged drug, the predominant route of trovafloxacin elimination appears to be nonrenal. The two studies described in this review examined the metabolism and excretion of trovafloxacin and compared the time course and concentrations of trovafloxacin and its metabolites in bile to those in serum. In the first study, four healthy male volunteers received a single, oral 200-mg dose of radiolabeled trovafloxacin. In the second study, three patients with indwelling nasobiliary tubes received a single 200-mg dose of trovafloxacin. Samples of blood, urine, bile, and feces were collected. Trovafloxacin in urine and serum was analyzed by high-performance liquid chromatography (HPLC) with ultraviolet (UV) detection and in bile by HPLC-mass spectroscopy (MS). Levels of the N-acetyl metabolite in bile were determined by HPLC/UV/MS. Metabolites in serum, urine, and feces were determined by reverse-phase HPLC/MS, and radioactivity in these samples was assayed by liquid scintillation counting. In the first study, 63.3% and 23.1% of total radioactivity were recovered in feces and urine, respectively, with most of the radioactivity in urine in the form of the ester glucuronide metabolite (12.8%) and unchanged trovafloxacin (5.9%). Unchanged drug, the N-acetyl metabolite, and the N-sulfate of trovafloxacin accounted for 43.2%, 9.2%, and 3.9%, respectively, of the radioactivity in feces. In the second study, biliary trovafloxacin concentrations were highest between 1.5 and 10 hours postdose, and the maximum concentrations ranged from 18.9 to 37.9 microg/mL. The mean bile:serum ratio of trovafloxacin was 14.9, and the biliary concentration of parent drug was higher than that of its N-acetyl metabolite. In both studies, trovafloxacin was well tolerated, with no discontinuations due to adverse events. The pharmacokinetic profile of trovafloxacin in serum was consistent in healthy subjects and in individuals who had undergone recent hepatobiliary surgery. Trovafloxacin is metabolized primarily by the liver, through phase II metabolism (glucuronidation 13.2%, N-acetylation 10.4%, and N-sulfoconjugation 4.1%); minimal oxidative metabolism was detected. Renal elimination accounted for <10% of the administered dose. The high bile to serum ratio and higher trovafloxacin concentrations relative to metabolite concentrations are consistent with nonrenal elimination. These pharmacokinetic and pharmacodynamic results, together with a broad antimicrobial spectrum, long 11-hour elimination half-life, and low drug-interaction potential, suggest that trovafloxacin may be particularly appropriate for use in the surgical setting.
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Affiliation(s)
- J Vincent
- Department of Clinical Research, Pfizer Central Research, Groton, Connecticut 06340, USA
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Vincent J, Hunt T, Teng R, Robarge L, Willavize SA, Friedman HL. The pharmacokinetic effects of coadministration of morphine and trovafloxacin in healthy subjects. Am J Surg 1998; 176:32S-38S. [PMID: 9935255 DOI: 10.1016/s0002-9610(98)00218-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Morphine and antibiotics are frequently coadministered in the surgical setting. These agents may interact, reducing the efficacy of the antibiotic or increasing the toxicity of morphine. It is therefore important to determine whether antibiotics that might be used for surgical prophylaxis have the potential to change the pharmacokinetics of morphine. It is equally important to learn whether morphine affects the plasma levels of antibiotics and thus may potentially influence their efficacy or tolerability. METHODS This open, randomized, placebo-controlled, three-treatment, three-period cross-over study enrolled 19 healthy volunteers. Oral trovafloxacin (200 mg), a novel fluoroquinolone antibiotic, and intravenous morphine (0.15 mg/kg) were coadministered, and the effects on the pharmacokinetics of each drug and on changes in the pharmacologic action of morphine, estimated from its effects on respiratory rate and level of sedation, were examined. RESULTS When trovafloxacin was coadministered with morphine, the half-life of trovafloxacin was unchanged; however, the ratio of the area under the serum concentration versus time curve (AUC(0-infinity)) estimates for trovafloxacin/morphine versus trovafloxacin/placebo was 63.8% (95% confidence interval [CI], 40.7% to 100.3%), indicating a 36% reduction in the bioavailability of trovafloxacin. The ratio of the mean maximum serum concentration (Cmax) estimates of trovafloxacin for the two treatments was 53.8% (95% CI: 36.1% to 80.1%), indicating a 46% reduction in Cmax. The time to Cmax was delayed by 4 hours. With trovafloxacin coadministration, there were no statistically significant changes in either the mean relative bioavailability of morphine or that of its metabolite, 6beta-glucuronide-morphine. Coadministration of trovafloxacin did not exacerbate the reduction in respiratory rate or increase the number of side effects associated with morphine administration. CONCLUSIONS Coadministration of trovafloxacin and morphine reduces the bioavailability and maximum serum concentrations of trovafloxacin. However, elimination of oral trovafloxacin is not impaired, suggesting that the efficacy of trovafloxacin could be maintained in many patients who receive concomitant morphine. Morphine plasma levels and pharmacologic effects are not significantly altered by coadministration of trovafloxacin. Despite their similar metabolic pathways, the trovafloxacin/morphine combination neither exacerbates the respiratory depressant effects of morphine nor increases the frequency of side effects when compared with placebo/morphine treatment. These results suggest that the efficacy of trovafloxacin may be maintained when coadministered with morphine. Concurrent administration of trovafloxacin and morphine is unlikely to alter the pharmacologic effects of morphine.
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Affiliation(s)
- J Vincent
- Department of Clinical Research, Pfizer Central Research, Groton, Connecticut 06340, USA
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Roy S, Hemsell D, Gordon S, Godwin D, Pearlman M, Luke D. Oral trovafloxacin compared with intravenous cefoxitin in the prevention of bacterial infection after elective vaginal or abdominal hysterectomy for nonmalignant disease. Trovafloxacin Surgical Group. Am J Surg 1998; 176:62S-66S. [PMID: 9935259 DOI: 10.1016/s0002-9610(98)00222-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Trovafloxacin is a new fourth-generation fluoroquinolone whose pharmacokinetics and in vitro activity suggest that it is well suited for antibiotic prophylaxis in elective hysterectomy. METHODS In a randomized, double-blind, multicenter study, parallel groups of women 18 years of age or older received either 200 mg trovafloxacin by mouth and intravenous (i.v.) placebo or 2 g cefoxitin by i.v. infusion and placebo by mouth before elective vaginal or abdominal hysterectomy for nonmalignant disease. RESULTS In the 103 and 97 patients in the trovafloxacin and cefoxitin groups, respectively, who were evaluable for efficacy, the prophylactic success rates at hospital discharge (96% in both groups) and 30 +/- 6 days after hysterectomy (88% and 91% in the trovafloxacin and cefoxitin groups, respectively) were statistically equivalent. Both antibiotics were well tolerated. CONCLUSION A single oral 200 mg dose of trovafloxacin is as effective and safe as a standard cefoxitin parenteral regimen in the prevention of primary bacterial infection after elective vaginal or abdominal hysterectomy for nonmalignant disease.
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Affiliation(s)
- S Roy
- Department of Obstetrics and Gynecology, University of Southern California School of Medicine and Women's and Children's Hospital, Los Angeles 90033, USA
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Milsom JW, Smith DL, Corman ML, Howerton RA, Yellin AE, Luke DR. Double-blind comparison of single-dose alatrofloxacin and cefotetan as prophylaxis of infection following elective colorectal surgery. Trovafloxacin Surgical Group. Am J Surg 1998; 176:46S-52S. [PMID: 9935257 DOI: 10.1016/s0002-9610(98)00220-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Alatrofloxacin, the prodrug of trovafloxacin, is a novel fluoroquinolone antimicrobial agent with a broad spectrum, including activity against gram-positive and gram-negative aerobes and anaerobes. Its pharmacokinetic properties (long half-life, excellent tissue distribution, and good safety profile) suggest a role in surgical prophylaxis. This prospective, multicenter, double-blind trial compared alatrofloxacin with cefotetan, an approved drug for surgical prophylaxis, in reducing postoperative infections. METHODS The efficacy and safety of a single 200-mg intravenous dose of alatrofloxacin were compared to a single 2-g intravenous dose of cefotetan in 492 patients undergoing elective colorectal surgery. The efficacy of alatrofloxacin as a prophylaxis for wound, intra-abdominal, or remote-site postoperative infectious complications was compared with cefotetan in 317 clinically evaluable patients; 161 received alatrofloxacin and 156 received cefotetan. The patients were monitored for infections and safety for 30 days postoperatively. RESULTS No statistically significant between-treatment difference was detected in successful clinical response rates at the end of the study (72% for each group). The incidence of primary wound infections at the time of hospital discharge was also similar: 21% in patients treated with alatrofloxacin and 18% in those treated with cefotetan. Safety, established by the incidence of adverse events, did not differ statistically between the groups. CONCLUSIONS A single intravenous dose of alatrofloxacin given within 4 hours prior to surgery was as effective as an intravenous dose of cefotetan in the prevention of postoperative infectious complications in patients undergoing elective colorectal surgery. The safety profiles of the two medications were similar.
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Affiliation(s)
- J W Milsom
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Ohio, USA
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