Quinolone photoallergy: photosensitivity dermatitis induced by systemic administration of photohaptenic drugs

MDR Tuberculosis Treatment

Multidrug-resistant (MDR) tuberculosis (TB), resistant to isoniazid and rifampicin, continues to be one of the most important threats to controlling the TB epidemic. Over the last few years, there have been promising pharmacological advances in the paradigm of MDR TB treatment: new and repurposed drugs have shown excellent bactericidal and sterilizing activity against Mycobacterium tuberculosis and several all-oral short regimens to treat MDR TB have shown promising results. The purpose of this comprehensive review is to summarize the most important drugs currently used to treat MDR TB, the recommended regimens to treat MDR TB, and we also summarize new insights into the treatment of patients with MDR TB.

Photopatch Testing in New Zealand: A 12-Year Retrospective Review

BACKGROUND

Little is known about the common photoallergens in New Zealand, where ultraviolet exposure is particularly high. Availability of photopatch testing is limited because of it being performed in very few tertiary referral and contact dermatitis clinics.

OBJECTIVE

To review the photopatch testing experience in New Zealand.

METHOD

A retrospective review of all patients who underwent photopatch testing at a tertiary referral center in Auckland from 2008 to 2019 was performed.

RESULTS

Seventy patients had photopatch testing over the 12-year period. Of the 58 patients tested using the photoallergen series, 6 (10%) patients had a positive photopatch test reaction, of which 4 were to promethazine and 2 were to benzophenone-3. The most common postpatch diagnosis was endogenous dermatitis (54%), followed by allergic contact dermatitis (21%), photoallergic contact dermatitis (9%), and chronic actinic dermatitis (4%).

CONCLUSIONS

Both patch and photopatch testing are important investigations in patients with suspected photoallergic contact dermatitis. Promethazine and benzophenone-3 were the most frequent and only photoallergens in our population. Promethazine sensitization was via oral exposure, supporting a mechanism of systematized photoallergy to promethazine.

Photoinduced acute exanthematous pustulosis caused by dicloxacillin and exposure to sunlight

Photoinduced acute exanthematous pustulosis is a rare condition; only few cases of photo-AEP have been described previously with drugs such as norfloxacin, ciprofloxacin, and enoxacin. In this case, the reaction is seen after intake of dicloxacillin.

The degradation of levofloxacin in infusions exposed to daylight with an identification of a degradation product with HPLC-MS

In this paper the decomposition product of levofloxacin was identified. Levofloxacin was dissolved in 0.9% NaCl, 5% glucose, and Ringer's solution. The solutions were divided into two batches: the first one was exposed to daylight and the second one was protected from it. The solutions were stored at the room temperature. The qualitative analysis of the degradation product was performed using MS and TOF detectors. The quantitative assay was done by a validated HPLC method. Visual inspection and pH assessment were done. Levofloxacin protected from daylight remained stable in 0.9% NaCl, 5% dextrose, and Ringer's solution. A slight decomposition of the analyte was observed in the solutions exposed to daylight with the fastest decomposition rate in Ringer's solution as compared with 0.9% NaCl and 5% dextrose solutions. The degradation product of levofloxacin detected with MS was levofloxacin N-oxide. Levofloxacin solutions should be protected from direct daylight to maintain drug stability. Levofloxacin N-oxide is formed regardless of the solvent used.

Update on Quinolone Allergy

PURPOSE OF REVIEW

Quinolones are a group of synthetic antibiotics widely use as first-line treatment for many infections. There has been an increase in the incidence of hypersensitivity reactions to quinolones in recent years, likely due to increased prescription. The purpose of this review is to summarize the clinical pictures, the methods used for diagnosing and the management of allergic reactions to quinolones.

RECENT FINDINGS

Allergic reactions to quinolones can be immediate or delayed, being anaphylaxis and maculopapular exanthema respectively the most frequent clinical entities. A precise diagnosis is particularly difficult since clinical history is often unreliable, skin tests can induce false-positive results, and commercial in vitro test are not well validated. Therefore, drug provocation testing is considered the gold standard to establish diagnosis, which is not a risk-free procedure. Cross-reactivity between quinolones is difficult to predict due to the small number of patients included in the few published studies. Moreover, hypersensitivity to quinolones has also been associated with beta-lactam and neuromuscular blocking agent allergies, although further studies are needed to understand the underlying mechanisms. Avoidance of the culprit quinolone is indicated in patients with a diagnosis of hypersensitivity to these drugs. When quinolone treatment is the only therapeutic option available, desensitization is necessary. This review summarizes the complex diagnostic approach and management of allergic reactions to quinolones.

Electronic, structural and vibrational induced effects upon ionization of 2-quinolinone

Using first principle methodologies, we characterize the lowest electronic states of 2-quinolinone(+) cation. The ground state of this ion is of X˜(2)A(″) nature. We deduce the adiabatic ionization energy of 2-quinolinone to be equal 8.249eV using the explicitly correlated coupled cluster level and where zero point vibrational energy, core-valence and scalar relativistic effects are taken into account. We examine also the ionization induced structural changes and vibrational shifts and analyze the electron density differences between the neutral and ionic species. These data show that the formation of 2-quinolinone(+)X˜(2)A(″) from 2-quinolinone affects strongly the HNCO group, whereas the carbon skeletal is perturbed when the upper electronic cationic states are populated. The comparison to 2-pyridone allows the elucidation of the effect of benzene ring fused with this heterocyclic ring. Since quinolones and pyridones are both model systems of DNA bases, these findings might help in understanding the charge redistribution in these biological entities upon ionization.

Development of novel in vitro photosafety assays focused on the Keap1-Nrf2-ARE pathway

Although photoallergens require UV energy for antigen formation, the subsequent immune response is considered to be the same as in ordinary skin sensitization. Therefore, in vitro tests for skin sensitization should also be applicable for photoallergy testing. In this study, we examined whether activation of the Keap1 (Kelch-like ECH-associated protein 1)-Nrf2 (nuclear factor-erythroid 2-related factor 2)-ARE (antioxidant response element) pathway could be used to assess the photoallergenic potential of chemicals, using the reporter cell line AREc32 or KeratinoSens(TM) . First, we identified an appropriate UVA irradiation dose [5 J cm(-2) irradiation in phosphate-buffered saline (PBS)] by investigating the effect of UV irradiation on ARE-dependent gene induction using untreated or 6-methylcoumarin (6-MC)-treated cells. Irradiation of well-known photoallergens under this condition increased ARE-dependent gene expression by more than 50% compared with both vehicle and non-irradiated controls. When the cut-off value for detecting photoallergens was set at 50% induction, the accuracy of predicting photoallergenic/phototoxic chemicals was 70% in AREc32 cells and 67% in KeratinoSens(TM) cells, and the specificity was 100% in each case. We designate these assays as a photo-ARE assay and photo-KeratinoSens(TM) , respectively. Our results suggest that activation of the Keap1-Nrf2-ARE pathway is an effective biomarker for evaluating both photoallergenic and phototoxic potentials. Either of the above tests might be a useful component of a battery of in vitro tests/in silico methods for predicting the photoallergenicity and phototoxicity of chemicals. Copyright © 2015 John Wiley & Sons, Ltd.

Addition of UVA-absorber butyl methoxy dibenzoylmethane to topical ketoprofen formulation reduces ketoprofen-photoallergic reaction

Topical application of ketoprofen (KP) clinically evokes the allergic type of photocontact dermatitis. To avoid this adverse reaction, we investigated the beneficial effect of each ultraviolet (UV) filter that was included in topical ketoprofen formulation. We first tested the inhibitory effects of four UVA filters by a modified local lymph node assay following KP application on the mouse skin and UVA irradiation on the same site. In this assessment, butyl methoxy dibenzoylmethane (BMDBM), when included in KP application, exerted the most effective inhibitory effect on stimulation with KP and UVA. We manufactured topical patch and gel KP applicants containing BMDBM, which retained KP penetration through the skin and KP stability toward UVA. The ability of BMDBM in these formulations to inhibit KP photosensitivity was evaluated by a modified adjuvant and strip method in guinea pigs, and the photoallergic reactions induced by the BMDBM-containing KP applicants were lower than the non-containing ones. It is known that KP has a cross-reactivity with benzophenone upon UVA exposure, but such a photocross-reactivity of BMDBM with KP was not observed in a mouse ear swelling model. The anti-inflammatory effect of the BMDBM-containing KP patch applicant was comparable to the non-containing one. These results suggest that the addition of BMDBM into KP topical formulations is efficacious for inhibition of KP photocontact dermatitis.

Protective effects of platinum nanoparticles against UV-light-induced epidermal inflammation

Intracellular reactive oxygen species (ROS) and apoptosis play important roles in the ultraviolet (UV)-induced inflammatory responses in the skin. Metal nanoparticles have been developed to increase the catalytic activity of metals, which is because of the large surface area of smaller particles. Platinum nanoparticles (nano-Pt) protected by poly acrylic acid were manufactured by reduction with ethanol. A marked increase in ROS production was observed in UV-treated HaCaT keratinocytes cell lines, while a decrease in ROS production was observed in nano-Pt-treated cells. Pretreatment of the cells with nano-Pt also caused a significant inhibition of UVB- and UVC-induced apoptosis. Furthermore, we found that mice treated with nano-Pt gel prior to UV irradiation showed significant inhibition of UVB-induced inflammation and UVA-induced photoallergy compared to UV-irradiated control mice. These results suggest that nano-Pt effectively protects against UV-induced inflammation by decreasing ROS production and inhibiting apoptosis in keratinocytes.

Induction of eosinophil-infiltrating drug photoallergy in mice

BACKGROUND

Drug photoallergy is one of the highly incident adverse effects. Several different histological patterns have been recognized.

OBJECTIVE

To establish a murine model of the eosinophil-infiltrating type of drug photoallergy by using afloqualone (AQ), a representative photosensitive drug.

METHODS

AKR/J mice were sensitized by intraperitoneal injection of afloqualone solution (2mg/kg/mouse) and irradiation of shaved abdomen with ultraviolet A light (UVA) (12J/cm(2)). This sensitization procedure was repeated 2-12 times, and 3 days after the last immunization, mice were challenged by a subcutaneous injection of AQ solution and irradiation of the same site with UVA. The draining lymph node cells (LNCs) were used for transfer and cytokine production studies, and the challenged skin was analyzed for chemokine expression.

RESULTS

More than 10 times of sensitization induced a massive infiltrate of eosinophils and lymphocytes at the challenged site. AKR/J mice were a high responder strain. The sensitivity was transferred with 5-8 x 10(7) immune lymph node and spleen cells into naïve mice. CD4(+) T cells were mainly responsible for this sensitivity, since 1 x 10(7) CD4(+) cells alone induced a high level of sensitivity, but CD8(+) T cells evoked the sensitivity to a lesser degree. Culture supernatants from AQ-photoimmuned lymph node cells contained a higher level of IL-4 and lower interferon-gamma than those from mice immunized with dinitrofluorobenzene. Finally, the skin of AQ-photochallenged site exhibited high expression of CCL24/eotaxin-2, a chemokine for eosinophils.

CONCLUSION

It is suggested that eosinophilic drug photoallergy is mediated by sensitized Th2 cells and locally produced eosinophil-attracting chemokines.

P-glycoprotein (Abcb1) is involved in absorptive drug transport in skin

The purpose of the present study was to investigate the role of P-glycoprotein (P-gp) in drug disposition in skin. The distribution of P-gp substrates (rhodamine 123 and itraconazole) to the skin after administration from the epidermal side was lower in P-gp gene knockout (mdr1a/1b(-/-)) mice than that in wild-type mice. Coadministration of propranolol, a P-gp inhibitor, decreased the distribution of itraconazole to the skin in wild-type mice, but not in mdr1a/1b(-/-) mice. These results suggest that P-gp contributes to the influx (from the epidermal side) of its substrates into skin, although P-gp is generally involved in efflux of drugs from various tissues. This finding was supported by the lower vectorial transport of rhodamine 123 from the epidermal to the hypodermal side in mdr1a/1b(-/-) mice in Ussing-type chamber experiments and by the immunohistochemical localization of P-gp throughout the dermal layer. Distribution of itraconazole after intravenous administration, on the other hand, was higher in mdr1a/1b(-/-) mice than that in wild-type mice, suggesting that P-gp transports this drug from the skin to the circulation. The present findings are the first to demonstrate involvement of P-gp in dermal drug disposition.

UV-Vis Spectrophotometrical and Analytical Methodology for the Determination of Singlet Oxygen in New Antibacterials Drugs

We have determined and quantified spectrophotometrically the capacity of producing reactive oxygen species (ROS) as 1O2 during the photolysis with UV-A light of 5 new synthesized naphthyl ester derivates of well-known quinolone antibacterials (nalidixic acid (1), cinoxacin (2), norfloxacin (3), ciprofloxacin (4) and enoxacin (5)). The ability of the naphthyl ester derivatives (6-10) to generate singlet oxygen were detecting and for the first time quantified by the histidine assay, a sensitive, fast and inexpensive method. The following tendency of generation of singlet oxygen was observed: compounds 7 >10 > 6 > 8 > 9 >> parent drugs 1-5.

Stimulation of Langerhans cells with ketoprofen plus UVA in murine photocontact dermatitis to ketoprofen

BACKGROUND

Ketoprofen (KP) clinically evokes the allergic type of photocontact dermatitis when applied to the skin and irradiated with ultraviolet A (UVA). We have established a murine model of photocontact dermatitis to KP, which is a T cell-mediated delayed type hypersensitivity.

OBJECTIVE

To further explore the mechanism underlying this sensitivity, we investigated whether KP plus UVA activates the antigen-presenting ability of Langerhans cells (LCs).

METHODS

We analyzed the expression of surface molecules on LCs in the murine epidermis treated with KP plus UVA by immunohistochemistry and flow cytometry. Changes in the cytokine expression of epidermal cells from KP-phototreated skin were also examined by real-time PCR.

RESULTS

LCs became larger after treatment with KP plus UVA. The number of LCs was significantly decreased 2-3 days after KP phototreatment and recovered on day 5. A flow cytometric analysis revealed that KP plus UVA increased the percentage of LCs that highly expressed MHC class II, CD86, CD80, CD54 and CD40, whereas neither KP nor UVA alone enhanced the expression. KP phototreatment augmented the expression of I-A and CD86 on LCs in KP and UVA dose-dependent manners. A real-time PCR analysis of KP-phototreated skin showed that the expression of mRNA for IL-1alpha and GM-CSF was immediately increased after treatment.

CONCLUSION

A photosensitizing regimen of KP plus UVA activates LCs at least partly by stimulating keratinocytes to produce cytokines. Two strains of mice (BALB/c and AKR) differ in responsiveness to KP and the difference is not related to the activation of keratinocytes.

Induction of keratinocyte apoptosis by photosensitizing chemicals plus UVA

BACKGROUND

The capacity of photosensitizing chemicals with ultraviolet A light (UVA) to induce apoptosis is one of the methods to assess their phototoxic and potentially photoallergic properties, since apoptotic cells may be easily presented by antigen-presenting cells.

OBJECTIVES

We examined the photoaggravated ability to induce keratinocyte apoptosis of various chemicals that are known as causative agents of photocontact dermatitis and drug photosensitivity involving photoallergic and/or phototoxic mechanisms.

METHODS

HaCaT keratinocytes were incubated with 3,3',4',5-tetrachlorosalicylanilide (TCSA), bithionol, diphenylhydramine, chlorpromazine, 6-methylcoumarin, sparfloxacin, and enoxacin at 10(-7) to 10(-4)M and irradiated with UVA at 4J/cm(2). As positive control, 8-methoxypsoralen (8-MOP) was also tested. Apoptosis and necrosis were evaluated by flow cytometric enumeration of annexin V(+) 7-AAD(-) and annexin V(+) 7-AAD(+) cells, respectively. The expression of apoptosis-related molecules, caspase-3 and poly (ADP-ribose) polymerase (PARP), was tested by flow cytometric and Western blotting analyses.

RESULTS

In a comparison with non-irradiated cells, significant apoptosis was found in TCSA, bithionol, chlorpromazine, sparfloxacin and enoxacin at 10(-4) or 10(-5)M as well as 8-MOP as assessed by both annexin V and active caspase-3 stainings, while necrosis occurred in most of these chemicals at 10(-4)M. Neither apoptosis nor necrosis was seen in diphenylhydramine or 6-methylcoumarin. PARP were activated in HaCaT cells phototreated with TCSA, bithionol and chlorpromazine.

CONCLUSIONS

We suggest that our method is useful for in vitro assessment of phototoxicity and potential photoallergenicity of chemicals.

Antimicrobial safety: focus on fluoroquinolones

BACKGROUND/PURPOSE

Infrequent toxicities associated with certain drugs and drug classes have recently gained much attention from different health-care perspectives. To protect the patient, continued surveillance of safety and tolerability data is essential. Data from preclinical testing, phase 1-3 trials, and postmarketing surveillance may be used to objectively assess the risks associated with a specific drug or family of compounds. This review summarizes safety and tolerability data for the quinolones.

MAIN FINDINGS

The most common adverse events associated with the quinolone class involve the gastrointestinal tract (nausea and diarrhea) and central nervous system (CNS) (headache and dizziness). These adverse events are usually mild and do not require discontinuation of therapy. Uncommon and potentially serious quinolone-related adverse events involve the cardiovascular system (rate-corrected electrocardiographic QT interval prolongation), musculoskeletal system (tendinitis and tendon rupture), endocrine system (glucose homeostasis dysregulation), renal system (crystalluria, interstitial nephritis, and acute renal failure), and the CNS (seizures). Severe idiosyncratic adverse events are specific to individual agents that may share some structural congruity, such as the 1-(2,4)-difluorophenyl group shared by trovafloxacin (associated with hepatitis), temafloxacin (associated with hemolytic-uremic syndrome), and tosufloxacin (associated with eosinophilic pneumonitis). Overall, discontinuation rates from clinical trials were <4% for the currently marketed quinolones. Quinolones with higher discontinuation rates, such as trovafloxacin (7.0%) and grepafloxacin (6.4%), are no longer available for general use.

CONCLUSIONS

The currently marketed quinolones are well tolerated, with safety profiles similar to those of other antimicrobial classes. Although adverse effects are unusual, some, including tendinitis and CNS-related effects, are more common with quinolones than with other antimicrobial classes. Rare adverse effects attributed to some members of the quinolone family (e.g., Torsades de Pointes, hepatotoxicity, and dysglycemias) are more likely to occur in select "susceptible" populations. These adverse events can often be circumvented by avoiding exposure to the specific quinolone. In some cases, the therapeutic value offered by a quinolone may outweigh its potential risks.

Determination of action spectrum for sparfloxacin-photosensitized single-strand breaks in plasmid pBR322 DNA

BACKGROUND

Various drugs have been reported to induce photosensitivity as a side effect. Sparfloxacin (SPFX) is well known to trigger dermatological phototoxicity upon solar radiation exposure.

PURPOSE

To prevent SPFX-induced phototoxicity, we determined the wavelength range responsible for SPFX phototoxicity.

METHODS

The action spectrum for SPFX photosensitization was assessed by the formation of single-strand breaks in plasmid pBR322 DNA.

RESULTS

The wavelengths of light leading to the formation of single-strand breaks were in the ultraviolet A (UVA) and visible ranges. In comparison with the absorption spectrum, we found that SPFX absorption primarily contributed to the action spectrum of single-strand break formation, but it even expanded to the visible range (between 320 and 480 nm) beyond the absorption wavelengths.

CONCLUSION

The findings suggest that protection of skin from short wavelengths of visible light beyond the absorption wavelengths as well as UVA light is of primary importance in prevention against induction of SPFX phototoxicity.

Hypersensitivity reactions to fluoroquinolones

Fluoroquinolone antibiotics cause immediate and delayed hypersensitivity reactions, and may also affect internal organs and circulating blood cells. The underlying pathomechanisms are only partly understood. The extent of cross-reactivity among different quinolones depends on the type of clinical manifestation and its underlying mechanism. Despite recent advances, reliable diagnostic tests are still lacking. Recent studies have shown quinolone-specific IgE in vitro in more than 50% of patients with immediate-type reactions and a considerable cross-reactivity with related compounds. In maculopapular drug exanthems from ciprofloxacin, specific T-cell clones were identified, and cross-reactivity to related compounds was detected in approximately 50% of the clones. From re-exposure studies in patients with exanthems, cross-reactivity appears to be lower. Cellular tests such as lymphocyte transformation tests are currently not very useful. For prick and intradermal skin tests, widely divergent nonirritant test concentrations have been recommended. Desensitization may be possible in selected patients.

Terbium Sensitized Determination of Tosufloxacin Using Electrochemiluminescence Method

A novel method for determination of trace amounts of tosufloxacin (TFLX) based on electrochemiluminescence (ECL) has been developed. The calibration graphs for TFLX were linear in the range of 5.0 x 10(-11)-3.5 x 10(-7) mol/L, with the detection limit of 1.3 x 10(-11) mol/L. Key factors affecting the determination of TFLX were investigated. TFLX amounts in capsule and serum samples were successfully detected by this method. A possible mechanism of energy transfer, and thus the explanation of ECL in the Tb3+-TFLX-Na2S2O4 system are discussed.

Photonucleophilic Aromatic Substitution of 6-Fluoroquinolones in Basic Media: Triplet Quenching by Hydroxide Anion

Photoreaction of 1-ethyl-6-fluoro-7-(1-piperazinyl)-1,4-dihydro-4-oxoquinoline-3-carboxylic acid (norfloxacin, NFX) and other 6-fluoroquinolones in aqueous solution gives rise to the corresponding 6-hydroxy derivatives. Although two mechanisms have been proposed for this photonucleophilic aromatic substitution, direct evidence for any of them is still missing. Obtaining such evidence requires work in basic media, where intramolecular electron transfer from the piperazine ring to the quinolone system is the almost exclusive singlet deactivation pathway. To overcome this problem, the 4'-N-acetyl derivative of norfloxacin (ANFX) has been employed in the present paper due to the lower availability of the N lone pair. The photochemical and photophysical properties of ANFX have been studied in aqueous solutions at pH between 7.4 and 13. As expected, fluorescence of ANFX is not significantly quenched in basic media. Furthermore, the excited triplet state (lambda(max) = 620 nm) reacts with hydroxide anions with a rate constant of (0.3 +/- 0.1) x 10(6) M(-)(1) s(-)(1). This supports a direct attack by hydroxide anions to the excited triplet state with subsequent release of fluoride as the operating mechanism. The fact that the reaction is inhibited by the presence of naproxen (a water-soluble naphthalene derivative) as triplet quencher clearly confirms the mechanistic assignment.

Photochemical properties of ofloxacin involved in oxidative DNA damage: a comparison with rufloxacin

Photodegradation of ofloxacin (OFX) under aerobic conditions gives rise to N-demethylation, mainly involving coupling of radical cation OFX(*)(+ )()with superoxide radical anion. Although H(2)O(2) is produced as a byproduct, oxidative damage to DNA to give 8-OH-dGuo is associated with a type II mechanism. When the photosensitizing potentials of OFX and rufloxacin (RFX) are compared under the same conditions, the latter is shown to produce a much higher degree of DNA oxidation despite the close structural similarity. This is explained by a decrease of the triplet energy when sulfur instead of oxygen is attached to position 8 of the fluoroquinolone ring system. As a consequence, phosphate anions are able to quench OFX triplet but not RFX triplet; this reveals that the reaction medium has a strong influence on the photochemistry of OFX and hence on its photobiological properties.

Photoinduced N-demethylation of rufloxacin and its methyl ester under aerobic conditions

Irradiation of rufloxacin (RF) under aerobic conditions gives rise to N-demethylation of the piperazinyl ring, which is enhanced in aerated D2O. Two primary processes seem to be involved in RF N-demethylation: photoionization from 1RF and singlet oxygen generation from 3RF. Both processes may lead to the same key intermediates, namely, RF*+ and superoxide radical anion; coupling of these intermediates explains N-demethylation of RF via an iminium cation. Formation of the hydrated electron by a monophotonic process (with a quantum yield of 0.09) is detected along with 3RF (with a intersystem-crossing quantum yield phiISC = 0.36) by laser flash photolysis. Studies performed on RF methyl ester give qualitatively similar results.

Quinolone-photoconjugated major histocompatibility complex class II-binding peptides with lysine are antigenic for T cells mediating murine quinolone photoallergy

Fluoroquinolone antibacterial agents cause photosensitivity dermatitis as an adverse effect and can function immunologically as photohapten. In a murine model of quinolone photoallergy, Langerhans cells are photomodified with a systemically given quinolone upon ultraviolet A irradiation of skin and thus present photohaptenic moieties to sensitize and restimulate T cells. The aim of this study is to determine the site of peptides/proteins photobound to quinolones and to assess the T cell antigenicity of quinolone-photocoupled peptides using Langerhans cells as photoadduct-presenting cells. On an amino acid composition analysis, lysine was preferentially degraded in bovine serum albumin that was ultraviolet A-conjugated with a representative quinolone ofloxacin. An affinity chromatographic study using a quinolone photoadduct-specific monoclonal antibody as ligand demonstrated preferential photocoupling of ofloxacin with a lysine-containing peptide. CD4+ T cells were purified from lymph nodes of BALB/c mice sensitized subcutaneously with ofloxacin-photomodified epidermal cells and from those sensitized epicutaneously via barrier-disrupted skin with a major histocompatibility complex class II (I-Ad)-binding, ofloxacin-photoconjugated peptide. These immune T cells proliferated in vitro in response to Langerhans cells loaded with class II-binding, lysine-containing peptides when photomodified with ofloxacin. Furthermore, epicutaneous application of the ofloxacin-photoconjugated peptide was able to prime mice for subsequent elicitation of photoallergy evoked with systemic ofloxacin and ultraviolet A light. This study suggests that lysine affords quinolone photocoupling of peptides and quinolone-photomodified peptides on class II molecules stimulate pathogenetic T cells in quinolone photoallergy.

Antimicrobial safety and tolerability: differences and dilemmas

The adverse drug reactions associated with antimicrobials have become a topic of major importance and concern in the last few years. Antimicrobial toxicity may take many forms, varying from mild, transient phenomena to dramatic, life-threatening events such as seizures or cardiac arrhythmias. We review the toxicity of antimicrobials in general and of the fluoroquinolones in particular and attempt to explain the adverse events by use of structure-adverse event relationships where possible. There are currently 5 main mechanisms that can be invoked to explain antimicrobial toxicity: direct effects, hypersensitivity, changes in microbial flora, drug interactions, and microbial lysis. The adverse drug reactions seen with fluoroquinolones are explained on the basis of these 5 mechanisms. The various organ systems affected by the fluoroquinolones are considered; then individual members of the fluoroquinolone class are reviewed. The unexpected and dramatic problems encountered with temafloxacin and trovafloxacin are discussed as well.

Clinical use of the fluoroquinolones

The appetite for modification to the basic quinolone nucleus has grown logarithmically since the first quinolone was employed in clinical practice. Important structural refinements have led to expanded microbiologic activity, optimal pharmacokinetics, and increased safety profiles. The practicing clinician and researcher may glean considerable information from the quinolone structure with regard to microbiologic spectra and safety before administering these agents to patients. Although some toxicities can be ominously predictable, such as with the so-called high-risk quinolones (e.g., double-halogenated and trifluorinated quinolones), clinicians must rely on animal models of toxicity and clinical trial data to discern other toxicities (e.g., Q-Tc interval prolongation). A few quinolones enjoy a relatively clean safety profile and are well tolerated (e.g., gatifloxacin, levofloxacin, ciprofloxacin). Other quinolones may be associated with significant collateral system toxicity during therapy; however, under certain conditions, albeit rare, their potential for benefit may outweigh the existing risk. Clinafloxacin, for use in the management of lung infections caused by multiply resistant B. cepacia in cystic fibrosis patients, is an example of a risk that may be outweighed by its therapeutic benefit. Because there are many treatment alternatives within the clinician's armamentarium, the obligation is to select the safest, most therapeutically effective, and most cost-effective agent that is available. In addition to increasing mortality and morbidity, the development of toxicity or an adverse event during therapy may compromise the immediate effectiveness of treatment as well as affect the cost of the patient's care significantly. With the immediate abundance of quinolones available for use, the safest, most effective, and best-tolerated agents will likely emerge as the most appropriate therapeutic choices when a quinolone is indicated.

A laser flash photolysis and pulse radiolysis study of primary photochemical processes of flumequine

The 355 nm laser flash photolysis of argon-saturated pH 8 phosphate buffer solutions of the fluoroquinolone antibiotic flumequine produces a transient triplet state with a maximum absorbance at 575 nm where the molar absorptivity is 14,000 M(-1) cm(-1). The quantum yield of triplet formation is 0.9. The transient triplet state is quenched by various Type-1 photodynamic substrates such as tryptophan (TrpH), tyrosine, N-acetylcysteine and 2-deoxyguanosine leading to the formation of the semireduced flumequine species. This semireduced form has been readily identified by pulse radiolysis of argon-saturated pH 8 buffered aqueous solutions by reaction of the hydrated electrons and the CO2*- radicals with flumequine. The absorption maximum of the transient semireduced species is found at 570 nm with a molar absorptivity of 2,500 M(-1) cm(-1). In argon-saturated buffered solutions, the semireduced flumequine species formed by the reaction of the flumequine triplet with TrpH stoichiometrically reduces ferricytochrome C (Cyt Fe3+) under steady state irradiation with ultraviolet-A light. In the presence of oxygen, O2*- is formed but the photoreduction of Cyt Fe3+ by O2*- competes with an oxidizing pathway which involves photo-oxidation products of TrpH.