In vitro activity of linezolid (U-100766) against Haemophilus influenzae measured by three different susceptibility testing methods

Method Development and Validation for the Determination of Linezolid Drug in Human Plasma by Reversed-Phase High-Performance Liquid Chromatography

Objective:

Linezolid is a significant antibiotic used against severe infections initiated by multi-resistant bacterial pathogens.

Method:

Linezolid extraction from plasma is obtained using methanol. Chromatographic separation is achieved isocratically on a C18 column [Zorbax C18, 5 µm particle size, 150 mm ˟ 4.6 mm] making use of a mobile phase of acetonitrile / 0.05 M phosphate buffer, pH = 4.5 (30 : 70 v/v) at a flow rate of 1.2 mL/min with photodiode array detector DAD, at a wavelength of 256 nm.

Method:

Linezolid extraction from plasma is obtained using methanol. Chromatographic separation is achieved isocratically on a C18 column [Zorbax C18, 5 µm particle size, 150 mm ˟ 4.6 mm] making use of a mobile phase of acetonitrile / 0.05 M phosphate buffer, pH = 4.5 (30 : 70 v/v) at a flow rate of 1.2 mL/min with photodiode array detector DAD, at a wavelength of 256 nm.

Results :

The retention time of linezolid was 2.5 min. The analytical method was linear (r2 > 0.998) over the calibration range of 0.30 to 50.0 µg/mL. The extraction recoveries of linezolid range from 71.03 to 91.93 %. The limit of quantification and the limit of detection were 0.112 µg and 0.037 µg, respectively. The RSDs for intraday and interday assays were < 7.77 and 4.32 %, respectively. The intraday and interday accuracies were in the range 80.6-112 % and 77.44-104.85 %, respectively.

Conclusion:

The applied method is precise, accurate and appropriate for pharmacokinetic studies and therapeutic drug monitoring of linezolid in routine clinical practice.

Description and validation of a spectrum score method to measure antimicrobial de-escalation in healthcare associated pneumonia from electronic medical records data

BACKGROUND

Comparison of antimicrobial de-escalation rates between healthcare settings is problematic. To objectively and electronically measure de-escalation a method based upon the spectrum of antimicrobial regimens administered (i.e., spectrum score) was developed.

METHODS

A Delphi process was used to develop applicable concepts. Spectrum scores were created for 27 antimicrobials based upon susceptibility for 19 organisms. National VA susceptibility data was used to estimate microbial spectrum. Susceptibility estimates were converted to ordinal scores, and values for organisms with multi-drug resistance potential were weighted more heavily. Organism scores were summed to create antibiotic-specific spectrum scores and extended mathematically to score multi-antimicrobial regimens. Vignettes were created from antimicrobial regimens administered to 300 patients hospitalized with pneumonia. Daily spectrum scores were calculated for each case. Hospitalization day 4 scores were subtracted from day 2 scores (i.e., spectrum score ∆). A positive spectrum score ∆ defined de-escalation. Experts ranked each pneumonia case on a 7-point Likert scale (Likert >4 indicated de-escalation). Spectrum score ∆s were compared to expert review. Findings were used to identify score deficiencies. Next, 40 pairs of cases were modified to include antimicrobial administration routes. Each pair contained almost similar regimens; however, one contained oral (PO) the other only intravenous (IV) antimicrobials on day 4 of therapy. Experts reviewed cases as described. Spectrum score ∆ credits to account for PO conversion were derived from the mean paired differences in Likert Score. De-escalation status was evaluated in 100 vignettes containing antimicrobial route by different experts and compared to the modified method.

RESULTS

Initial sensitivity and specificity of the spectrum score ∆ to detect expert classified de-escalation events was 86.3 and 96.0%, respectively. In paired cases, the mean (± SD) Likert score was 5.0 (1.5) and 4.6 (1.5) for PO and IV (P = 0.002), respectively. To improve de-escalation event detection, two credits were added to spectrum score ∆s based upon the percentage of antimicrobials administered PO on day 4. The final method, exhibited sensitivity and specificity to detect expert classified de-escalation events of 96.2 and 93.6%, respectively.

CONCLUSIONS

The final spectrum score method exhibited excellent agreement with expert judgments of de-escalation events in pneumonia.

Linezolid update: stable in vitro activity following more than a decade of clinical use and summary of associated resistance mechanisms

Linezolid, approved for clinical use since 2000, has become an important addition to the anti-Gram-positive infection armamentarium. This oxazolidinone drug has in vitro and in vivo activity against essentially all Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The in vitro activity of linezolid was well documented prior to its clinical application, and several ongoing surveillance studies demonstrated consistent and potent results during the subsequent years of clinical use. Emergence of resistance has been limited and associated with invasive procedures, deep organ involvement, presence of foreign material and mainly prolonged therapy. Non-susceptible organisms usually demonstrate alterations in the 23S rRNA target, which remain the main resistance mechanism observed in enterococci; although a few reports have described the detection of cfr-mediated resistance in Enterococcus faecalis. S. aureus isolates non-susceptible to linezolid remain rare in large surveillance studies. Most isolates harbour 23S rRNA mutations; however, cfr-carrying MRSA isolates have been observed in the United States and elsewhere. It is still uncertain whether the occurrences of such isolates are becoming more prevalent. Coagulase-negative isolates (CoNS) resistant to linezolid were uncommon following clinical approval. Surveillance data have indicated that CoNS isolates, mainly Staphylococcus epidermidis, currently account for the majority of Gram-positive organisms displaying elevated MIC results to linezolid. In addition, these isolates frequently demonstrate complex and numerous resistance mechanisms, such as alterations in the ribosomal proteins L3 and/or L4 and/or presence of cfr and/or modifications in 23S rRNA. The knowledge acquired during the past decades on this initially used oxazolidinone has been utilized for developing new candidate agents, such as tedizolid and radezolid, and as linezolid patents soon begin to expire, generic brands will certainly become available. These events will likely establish a new chapter for this successful class of antimicrobial agents.

In vitro activity of linezolid against Clostridium difficile

We examined the in vitro activity of linezolid against Clostridium difficile, including isolates with reduced susceptibility to metronidazole or vancomycin. The MIC at which 50% of the isolates were inhibited (MIC50) and MIC90 were 0.5 and 2 microg/ml, respectively (range, 0.03 to 4 microg/ml). MICs were always <or= 4 microg/ml, and thus, all isolates were considered susceptible.