Toxicity of quinolone antimicrobial agents

The Spontaneous Incidence of Neurological Clinical Signs in Preclinical Species Using Cage-side Observations or High-definition Video Monitoring: A Retrospective Analysis

When conducting toxicology studies, the interpretation of drug-related neurological clinical signs such as convulsions, myoclonus/myoclonic jerks, tremors, ataxia, and salivation requires an understanding of the spontaneous incidence of those observations in commonly used laboratory animal species. The spontaneous incidence of central nervous system clinical signs in control animals from a single facility using cage-side observations or high definition video monitoring was retrospectively analyzed. Spontaneous convulsions were observed at low incidence in Beagle dogs and Sprague-Dawley rats but were not identified in cynomolgus monkeys and Göttingen minipigs. Spontaneous myoclonic jerks and muscle twitches were observed at low incidence in Beagle dogs, cynomolgus monkeys, and Sprague-Dawley rats but were not seen in Göttingen minipigs. Spontaneous ataxia/incoordination was identified in all species and generally with a higher incidence when using video monitoring. Salivation and tremors were the two most frequent spontaneous clinical signs and both were observed in all species. Data from the current study unveil potential limitations when using control data obtained from a single study for toxicology interpretation related to low incidence neurological clinical signs while providing historical control data from Beagle dogs, cynomolgus monkeys, Sprague-Dawley rats, and Göttingen minipigs.

Relationship of superoxide dismutase to rotator cuff injury/tear in a rat model

Rotator cuff degeneration is one of the several factors that lead to rotator cuff tears. Oxidative stress and superoxide dismutase have been reported to be related to rotator cuff degeneration; however, the precise mechanism still remains unclear. In this study, we investigated the relationship of oxidative stress and superoxide dismutase to the degeneration of the rotator cuff using rat models. Eighty-four rats were used to create a collagenase-induced rotator cuff injury model (injury model) and a rotator cuff tear model (tear model). The controls were administered saline and had only a deltoid incision, respectively. We evaluated degeneration morphology of the rotator cuff using a degeneration score; dihydroethidium fluorescence intensity, which detects oxidative stress; gene expression; and superoxide dismutase activity. The rotator cuffs in the injury and tear models significantly increased degeneration scores and dihydroethidium fluorescence intensity. On the other hand, gene expression of superoxide dismutase isoform, superoxide dismutase 1, and superoxide dismutase activity were significantly decreased in the injury model but showed no significant difference in the tear model. These findings suggested that superoxide dismutase might not be associated with rotator cuff degeneration after tear but may be involved in degenerative rotator cuff without tear. However, we found that rotator cuff degeneration involves oxidative stress both with and without tear. Based on these findings, it is presumed that different treatments may be appropriate, depending on the state of rotator cuff degeneration, because the mechanisms of the degeneration may be different.

Association of Recurrent Tear After Arthroscopic Rotator Cuff Repair and Superoxide-Induced Oxidative Stress

BACKGROUND

Recurrent tears after arthroscopic rotator cuff repair (ARCR) remain a significant clinical problem. Oxidative stress contributes to the degeneration of the rotator cuff, and a degenerative rotator cuff can lead to recurrent tear after ARCR. However, the correlation between oxidative stress and retear after ARCR is unclear.

PURPOSE

To investigate the correlation between superoxide-induced oxidative stress and recurrent tear after ARCR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 68 patients who underwent ARCR using a suture-bridge technique participated in this study. Specimens were collected from the edge of the torn tendon during surgery. The modified Bonar score was used to evaluate degeneration of the rotator cuff on histological specimens, and fluorescence intensity on dihydroethidium (DHE) staining was used to detect oxidative stress. Superoxide dismutase (SOD) enzyme activity was also measured. The following were used for clinical evaluation: age, tear size on magnetic resonance imaging (MRI) before surgery, Goutallier classification on MRI before surgery, and Japanese Orthopaedic Association score before and 6 months after surgery. After the repaired rotator cuffs were evaluated on MRI 6 months after surgery, the patients were divided into groups: those with a healed rotator cuff (healed group; n = 46) and those with a recurrent tear (retear group; n = 22). The significant differences between the groups were determined with regard to clinical evaluation, modified Bonar score, DHE intensity, and SOD activity. In addition, multivariate logistic regression analysis was performed to investigate risk factors for recurrent tear.

RESULTS

Age, tear size, Goutallier classification, modified Bonar score, DHE intensity, and SOD activity were significantly greater in the retear group than in the healed group, although the Japanese Orthopaedic Association score was not significantly different. Multiple logistic regression analysis demonstrated that age, tear size, and SOD activity were significantly correlated with recurrent tear.

CONCLUSION

In addition to tear size and age, superoxide-induced oxidative stress may be an exacerbating factor for retear after ARCR.

Evaluation of acute cardiorespiratory and hemodynamic changes in perioperative intravenous antimicrobial applications in cats

ABSTRACT The metabolic peculiarities of felines favor an intoxication. Fifty healthy female cats were divided into five groups: PG (placebo group), G2 (cefazolin), G3 (ceftriaxone), G4 (enrofloxacin) and G5 (ampicillin) were used. The parameters evaluated were: total expired carbon dioxide (ETCO2), oxygen saturation in hemoglobin (SpO2), heart rate (HR), respiratory rate (RR), body temperature (BT), systolic, mean and diastolic blood pressure (SBP, mBP and DBP) by invasive method, at T0, 5 (T5), 10 (T10), 15 (T15), 20 (T20), 25 (T25) and 30 (T30) minutes after administration of the treatments. HR presented reduction in G2 compared to PG at all times, except T20, and in G4, T25 and T30 were lower than the T0 values (P<0.05). BT showed increase in the G3 at T0 and T5 and all groups showed reduction in the values of BT relative to T0 (P<0.05). ETCO2 increased in G2 and G5 at all times compared to PG (P<0.05) and there were no differences among the times within each group. It was concluded that ceftriaxone is safer for the prophylactic antimicrobial use in cats, however the other antimicrobials are also indicated, because all the parameters, in all groups, basically did not change over the study and when this occurs it remains in reference interval.

Effects of low levels of the antibiotic ciprofloxacin on the polychaete Hediste diversicolor: biochemical and behavioural effects

The release of pharmaceutical chemicals in the biosphere can have unpredictable ecological consequences, and knowledge concerning their putative toxic effects is still scarce. One example of a widely used pharmaceutical that is present in the aquatic environment is ciprofloxacin. Previous indications suggest that this drug may exert several adverse effects on exposed biota, but the characterization of a full ecotoxicological response to this drug is far from complete, especially in estuarine ecosystems. This work aimed to characterize the acute and chronic effects of ciprofloxacin in the polychaete Hediste diversicolor (Annelida: Polychaeta), exposed to environmentally relevant levels of this drug, close to the real concentrations of this pharmaceutical in surface waters. The adopted toxic endpoints were behavioral parameters, combined with a biomarker-based approach (quantification of the activities of catalase (CAT), glutathione-S-transferase (GSTs), cholinesterases (ChEs), glutathione peroxidase (GPx), and lipid peroxidation levels. Exposure to ciprofloxacin caused effects on behavioural traits, such as an increase in burrowing times and hyperactivity, alongside alterations in biomarkers, including a significant increase in CAT activity following acute exposure. In addition, and after both acute and chronic exposure, lipid peroxidation was reduced, while AChE activities were enhanced. It was possible to ascertain the occurrence of pro-oxidative alterations following exposure to low levels of ciprofloxacin, which were counteracted by the triggering of CAT activity. The meaning of the enhancement of AChE activity is not clear, but it appears to be linked with the observed behavioural changes, and may have been associated with the stimulation of the behavioural traits. These data strongly suggest that the presence of ciprofloxacin in estuarine areas is not without risks, and exposed biota, namely polychaete species, are likely to have their ecological roles affected, thereby compromising the chemical, physical and microbiological stability of sediments, which in turn alters nutrient cycles.

Effects of TNFR1 gene silencing on early apoptosis of marbofloxacin-treated chondrocytes from juvenile dogs

Quinolones (QNs)-induced cartilaginous lesions in juvenile animals by chondrocyte apoptosis is an important toxic effect, which results in the restriction of their use in pediatrics. However, limited data about QNs chondrotoxicity are available for evaluation of the potential toxicity in both animals and human cartilage. To explore whether tumor necrosis factor/its receptor (TNF/TNFR1) signaling pathway is involved in the early apoptosis of marbofloxacin-induced chondrocytes, canine juvenile chondrocytes were treated with 0, 20, 50 and 100 μg/mL marbofloxacin. Results showed that the apoptosis rates of the chondrocytes at 2, 8 and 24 h were significantly increased in a concentration- and time-dependent manner (P <  0.05). The mRNA levels of apoptosis-related factors in TNF/TNFR1 signaling pathways and the protein levels of TNFα and TNFR1 were increased in canine chondrocytes treated with 20-100 μg/mL marbofloxacin (P <  0.05) while TNFR1 gene silencing significantly decreased the chondrocyte apoptosis and inhibited the mRNA expression of TNF/TNFR1 downstream signaling molecules after 100 μg/mL marbofloxacin treatment at 8 h (P <  0.01). It was confirmed that activated TNF/TNFR1 signaling pathway may play a leading role in the early apoptosis of marbofloxacin-induced canine juvenile chondrocytes, which is helpful for clinical estimation or prevention of the risk of QNs.

Ciprofloxacin-induces free radical production in rat cerebral microsomes

In the presence of ciprofloxacin (CPFX), free radical adduct formation was demonstrated in rat cerebral microsomes using a spin trap α-(4-pyridyl-1-oxide)-N-tert-butyl-nitrone by electron spin resonance spectroscopy. Active microsomes, dihydronicotinamide-adenine dinucleotide phosphate, and ciprofloxacin were necessary for the formation of a spin trap/radical adduct. Adduct formation increased dose-dependently at 0.5-1 mM CPFX concentration for 180 min, and 0.3-1 mM concentration level for 240 min. The addition of SKF 525A, ZnCl₂ or desferrioxamine to the incubation system caused complete inhibition of the radical formation. However, pretreatment of microsomal system with superoxide dismutase (SOD) did not induce any protective effect. Induction of lipid peroxidation, and depletion of thiol levels by CPFX were also shown in the system. These results strongly suggested that CPFX produces free radical(s) in the cerebral microsomes of rats.

Assessment of functional nanomaterials in medical applications: can time mend public and occupational health risks related to the products' fate?

Surface coatings are one promising option to prevent bacterial adhesion and biofilm formation given the prevalence of antibiotic resistant bacterial strains. Titanium dioxide (TiO₂) is presently considered to be the only photocatalytic material suitable for commercial use, although the toxicity risks of TiO₂, particularly in its nanoparticulate form, have not been fully addressed. The aim of this study was to determine release of nanoparticles (NPs) from functional materials for medical applications and their aerosol formation. Further, the fate of the material with respect to its product lifetime was investigated. The present study examined the risk of NP exposure since released submicronic and inhalable manufactured nano-objects, their agglomeraates or aggregates containing Ti were detected. The coating of the material magnifies its emission levels when comparing the obtained product properties to those of an uncoated sample. The evolution of release tendecy with the material's time of use shows that release does not vanish upon continuous material losses induced by the release, thus the risk does not diminish with time. Consequently, this nanomaterial TiO₂ needs to be avoided in healthcare settings, or, alternatively, new TiO₂-deposition techniques are required to be developed.

Complications associated with antibiotic administration: neurological adverse events and interference with antiepileptic drugs

Antibiotic use is associated with toxic effects involving the peripheral and central nervous systems and it may interfere with antiepileptic drugs, causing significant variations in their serum levels and activity. Prompt identification of neurological complications during antibiotic therapy is important in order to make appropriate modifications to medication. Characteristics of the drug and the patient, including age and underlying diseases, may favour these complications. The main aim of this study was to review the neurological adverse events that may follow antibiotic administration, the mechanisms that cause them, and the possibility of prevention and treatment. Moreover, the interference of antibiotics with serum levels and the activity of antiepileptic drugs are discussed. The results demonstrate that antibiotic-associated adverse events involving the nervous system are relatively uncommon and are only rarely severe and irreversible, although neurotoxicity has been reported for several antibiotics. Moreover, for patients receiving antiepileptic drugs, monitoring of drug serum levels to avoid the risk of toxicity or inadequate therapy is mandatory during antibiotic treatment. Areas for future research include the effects of combined antibiotic therapies as well as multiple antiepileptic drugs in study populations with an adequate sample size, including neonates and infants, patients with pharmacoresistant epilepsy and elderly patients.

Moxifloxacin-Induced Seizures in an Epileptic Patient

Objective:

To report a patient with seizures probably related to the use of moxifloxacin, a fourth-generation quinolone.

Case Summary:

A 79-year-old white man developed status epilepticus after a 4-day course of moxifloxacin for respiratory infection. He had experienced seizures 2 years before presentation. The patient was currently receiving warfarin, theophylline 400 mg/d, albuterol; furosemide, potassium, and digoxin; and omeprazole for chronic obstructive pulmonary disease, atrial fibrillation with mild heart failure, and heartburn, respectively. He also had moderate renal failure. Despite aggressive therapy, the patient developed progressive respiratory insufficiency and died.

Discussion:

Quinolone use is associated with a variety of central nervous system (CNS) adverse effects in approximately 1–2% of patients. In fact, CNS adverse effects represent the second most frequently encountered form of quinolone toxicity after gastrointestinal involvement. Occasionally, quinolones induce seizures, but, as of October 17, 2003, none have been reported in the literature. Use of the Naranjo probability scale indicated a probable relationship between seizures and moxifloxacin administration in this patient. Seizures may be mediated by CNS stimulation secondary to quinolone binding to γ-aminobutyric acid receptors. Coexisting medical conditions and concurrent medications also facilitate seizure appearance. Risk factors include seizure history, hypokalemia, alkalosis, renal failure, and concomitant treatment with agents that lower the seizure threshold. These factors were not present in this patient except for a prior history of seizures and mild renal failure.

Conclusions:

Seizures with quinolones, albeit rare, need to be considered in certain populations, particularly patients who have had prior seizures, the elderly, patients with renal dysfunction, and patients on multiple medications.

Electrophysiological safety of DW-286a, a novel fluoroquinolone antibiotic agent

Inhibition of the potassium current IKr, and QT prolongation has been known to be associated with drug-induced torsades de pointes arrhythmias (TdP) and sudden cardiac death. We investigated the cardiac electrophysiological effects of DW-286a, a new class of fluoroquinolone antibiotics reported to prolong the QT interval. To investigate the electrophysiological safety of DW-286a, we used conventional microelectrode recording techniques in isolated guinea pig papillary muscles, whole-cell patch clamp techniques in human ether-á-go-go related gene (hERG)-transient transfected Chinese hamster ovary cells, and in vivo electrocardiogram (ECG) measurements in Sprague-Dawley (SD) rats by the use of a telemetry system. DW-286a at 300 μM significantly ( P <0.01) prolonged action potentials at 50% repolarization (APD50) and 90% repolarization (APD90). For IHERG, the IC50 value was 89.00±37.85 μM with a Hill coefficient ( nH) of −0.97 ±0.49. However, when DW-286a was orally administered to conscious SD rats at a high dose (1000 mg/kg), no significant effect on ECG in vivo was detected. From a previous study, we know that concentration at 19.8 μM is the antimicrobial end-point of DW-286a. Therefore, our data suggest that in the electrophysiological aspect, it can be thought that the effective concentrations of DW-286a are between 19.8 and 100 μM (concentration in serum).

In silico and in vitro genotoxicity evaluation of descarboxyl levofloxacin, an impurity in levofloxacin

It is important to establish the safety of impurities in drug substances or drug products. The assessment of genotoxicity of impurities and the determination of acceptable limits for genotoxic impurities was addressed in some recent guidances as a difficult issue. Descarboxyl levofloxacin is an impurity isolated from levofloxacin, which may impose a risk without associated benefit. However, there is insufficient toxic information about descarboxyl levofloxacin. This study investigated the genotoxicity of this impurity by in silico and in vitro methods. We used Derek, a commercial structure-activity relationship software package, as an in silico tool. The results showed that there was a structural alert (quinoline) in this impurity. Then, the in vitro genotoxicity of descarboxyl levofloxacin was investigated by a modified Ames test and by a chromosomal aberration test, using Chinese hamster lung (CHL) cells. Both assays were conducted in the presence or absence of S-9 mix. The results showed that the test impurity was not mutagenic in the Ames test (31.25-500 μg/plate). Whereas there was a statistically significant increase in the number of metaphase CHL cells with structural aberrations at the concentration of 1 mg/mL with S-9 mix, the aberrations rate was 7.5%. It did not significantly increase the number of structural aberration in CHL cells in the presence (at 250 and 500 μg/mL) or absence of S-9 mix. Based on these assays, descarboxyl levofloxacin could be controlled as a nongenotoxic impurity.

Effects of ampicillin/sulbactam and enrofloxacin on the blood pressure of isoflurane anesthetized dogs

A blinded, prospective, randomized crossover study was performed to determine the effects of ampicillin Na/sulbactam Na and enrofloxacin on the blood pressure (BP) of healthy anesthetized dogs. Eight dogs were anesthetized three different times. They randomly received enrofloxacin, ampicillin Na/sulbactam Na, and saline. Systolic, diastolic, and mean arterial BPs (SAP, DAP, and MAP, respectively), heart rate (HR), O2 saturation of hemoglobin, end-tidal CO2 (ETCO2) concentration, inspired isoflurane concentration, end-tidal isoflurane (ETiso) concentration, respiratory rate, electrocardiogram, and body temperature were measured for 20 min prior to administration of treatment, during administration over 30 min, and for 30 min after administration. There was no significant difference in the SAP or ETiso. There was no significant change in the arterial pressure values over time in the enrofloxacin and ampicillin Na/sulbactam Na groups. The control group's MAP increased over time and was increased compared with the enrofloxacin group at times 25, 35, 45, and 55. The statistical difference between the enrofloxacin and the control groups was due to an increase in the MAP in the control group, not a decrease in the enrofloxacin group's BP. Neither enrofloxacin nor ampicillin Na/sulbactam Na caused hypotension in healthy dogs anesthetized with isoflurane and fentanyl.

Relationship of cellular topoisomerase IIα inhibition to cytotoxicity and published genotoxicity of fluoroquinolone antibiotics in V79 cells

Fluoroquinolone (FQ) antibiotics are bacteriocidal through inhibition of the bacterial gyrase and at sufficient concentrations in vitro, they can inhibit the homologous eukaryotic topoisomerase (TOPO) II enzyme. FQ exert a variety of genotoxic effects in mammalian systems through mechanisms not yet established, but which are postulated to involve inhibition of TOPO II enzymes. To assess the relationship of inhibition of cell nuclear TOPO II to cytotoxicity and reported genotoxicity, two FQ, clinafloxacin (CLFX) and lomefloxacin (LOFX), having available genotoxicity data showing substantial differences with CLFX being more potent than LOFX, were selected for study. The relative inhibitory activities of these FQ on nuclear TOPO IIα in cultured Chinese hamster lung fibroblasts (V79 cells) over dose ranges and at equimolar concentrations were assessed by measuring nuclear stabilized cleavage complexes of TOPO IIα-DNA. Cytotoxicity was measured by relative cell counts. Both FQ inhibited V79 cell nuclear TOPO IIα. The lowest-observed-adverse-effect levels for TOPO IIα inhibition were 55 μM for CLFX, and 516 μM for LOFX. The no-observed-adverse-effect-levels were 41 μM for CLFX, and 258 μM for LOFX. At equimolar concentrations (175 μM), CLFX was more potent than LOFX. Likewise, CLFX was more cytotoxic than LOFX. Thus, the two FQ, inhibited TOPO IIα in intact V79 cells, differed in their potencies and exhibited no-observed-adverse-effect levels. These findings are in concordance with published genotoxicity data and observed cytotoxicity.

Genotoxic effect of ciprofloxacin during photolytic decomposition monitored by the in vitro micronucleus test (MNvit) in HepG2 cells

PURPOSE

Ciprofloxacin (CIP), a broad-spectrum, second-generation fluoroquinolone, has frequently been found in hospital wastewaters and effluents of sewage treatment plants. CIP is scarcely biodegradable, has toxic effects on microorganisms and is photosensitive. The aim of this study was to assess the genotoxic potential of CIP in human HepG2 liver cells during photolysis.

METHODS

Photolysis of CIP was performed in aqueous solution by irradiation with an Hg lamp, and transformation products were monitored by HPLC-MS/MS and by the determination of dissolved organic carbon (DOC). The cytotoxicity and genotoxicity of CIP and of the irradiated samples were determined after 24 h of exposure using the WST-1 assay and the in vitro micronucleus (MN) test in HepG2 cells.

RESULTS

The concentration of CIP decreased during photolysis, whereas the content of DOC remained unchanged. CIP and its transformation products were not cytotoxic towards HepG2 cells. A concentration-dependent increase of MN frequencies was observed for the parent compound CIP (lowest observed effect level, 1.2 μmol L(-1)). Furthermore, CIP and the irradiated samples were found to be genotoxic with a significant increase relative to the parent compound after 32 min (P < 0.05). A significant reduction of genotoxicity was found after 2 h of irradiation (P < 0.05).

CONCLUSIONS

Photolytic decomposition of aqueous CIP leads to genotoxic transformation products. This proves that irradiated samples of CIP are able to exert heritable genotoxic effects on human liver cells in vitro. Therefore, photolysis as a technique for wastewater treatment needs to be evaluated in detail in further studies, not only for CIP but in general.

Safety considerations of fluoroquinolones in the elderly: an update

The fluoroquinolones ciprofloxacin, levofloxacin, moxifloxacin and gemifloxacin are widely used for the treatment of various types of bacterial infections. Overall, these antibacterial agents can be considered safe and well tolerated drugs. Comparative studies have evaluated the use of quinolones in elderly and younger populations. Although age per se does not seem to decrease their tolerability, specific adverse effects of the quinolones must be considered when they are chosen for antibacterial treatment. Renal function declines consistently with age and doses of renally excreted quinolones (e.g. ofloxacin, levofloxacin, gatifloxacin) need to be adjusted if a clinically relevant reduction of creatinine clearance is identified. Reactions of the gastrointestinal tract, such as nausea, dyspepsia, vomiting or diarrhoea, are among the most often registered adverse drug reactions during therapy with fluoroquinolones. Treatment with a quinolone causes diarrhoea less frequently than treatment with other classes of antimicrobials. Conflicting data have been published with respect to the incidence of Clostridium difficile-associated diarrhoea in quinolone-treated patients. Hypersensitivity reactions, often manifested on the skin, occur less commonly during therapy with quinolones than, for example, during therapy with beta-lactam antibacterials. Adverse reactions of the CNS are of particular concern in the elderly population. Given the CNS excitatory effects of quinolones, elderly patients should be monitored carefully for such symptoms. It is likely that many signs of possible adverse reactions, such as confusion, weakness, loss of appetite, tremor or depression, are often mistakenly attributed to old age and remain unreported. Quinolones should be used with caution in patients with known or suspected CNS disorders that predispose to seizures (e.g. severe cerebral arteriosclerosis or epilepsy). Quinolones can cause QT interval prolongation. They should be avoided in patients with known prolongation of the QT interval, patients with uncorrected hypokalaemia or hypomagnesaemia and patients receiving class IA (e.g. quinidine, procainamide) or class III (e.g. amiodarone, sotalol) antiarrhythmic agents. Tendinitis and tendon ruptures are recognized as quinolone-induced adverse effects that can occur during treatment or as late as several months after treatment. Chronic renal diseases, concomitant use of corticosteroids and age >60 years are known risk factors for quinolone-induced tendopathies. Overall, the specific adverse-effect profile of quinolones must be considered when they are chosen for treatment of bacterial infections. Because of physiological changes in renal function and when certain co-morbidities are present, some special considerations are necessary when elderly patients are treated with these drugs.

Levofloxacin-induced Achilles tendinitis in a young adult in the absence of predisposing conditions

Fluoroquinolones (FQs) represent a major class of antimicrobials that have a high potential as therapeutic agents. Although FQs are generally safe for the use as antimicrobials, they may induce tendinopathic complications such as tendinitis and tendon rupture. A number of factors have been suggested to further predispose a patient to such injuries. Hitherto, a few published cases on tendon disorders have implicated levofloxacin, a more recently introduced FQ. Here, we report a patient with levofloxacin-induced Achilles tendinitis, who exhibited no known predisposing factors. A 20-year-old man without any history of disease or medication presented with community-acquired pneumonia. Levofloxacin was administered and 3 days later, he complained of pain in the left Achilles tendon and revealed redness and swelling in the area. On suspecting Achilles tendinitis, levofloxacin treatment was discontinued, and the tendinitis subsequently improved. To our knowledge, this is the first case report on FQ-induced Achilles tendinitis in Korea.

The mitochondria targeted antioxidant MitoQ protects against fluoroquinolone-induced oxidative stress and mitochondrial membrane damage in human Achilles tendon cells

Tendinitis and tendon rupture during treatment with fluoroquinolone antibiotics is thought to be mediated via oxidative stress. This study investigated whether ciprofloxacin and moxifloxacin cause oxidative stress and mitochondrial damage in cultured normal human Achilles' tendon cells and whether an antioxidant targeted to mitochondria (MitoQ) would protect against such damage better than a non-mitochondria targeted antioxidant. Human tendon cells from normal Achilles' tendons were exposed to 0-0.3 mM antibiotic for 24 h and 7 days in the presence of 1 microM MitoQ or an untargeted form, idebenone. Both moxifloxacin and ciprofloxacin resulted in up to a 3-fold increase in the rate of oxidation of dichlorodihydrofluorescein, a marker of general oxidative stress in tenocytes (p<0.0001) and loss of mitochondrial membrane permeability (p<0.001). In cells treated with MitoQ the oxidative stress was less and mitochondrial membrane potential was maintained. Mitochondrial damage to tenocytes during fluoroquinolone treatment may be involved in tendinitis and tendon rupture.

Antimycobacterial activities of novel fluoroquinolones

Fifty-one novel 1-(cyclopropyl/2,4-difluorophenyl/t-butyl)-1,4-dihydro-6-fluoro-7-(sub secondary amino)-4-oxoquinoline-3-carboxylic acids were synthesized and evaluated for their antimycobacterial in vitro and in vivo against Mycobacterium tuberculosis H37Rv (MTB), multi-drug resistant Mycobacterium tuberculosis (MDR-TB) and Mycobacterium smegmatis (MC(2)) and also tested for the ability to inhibit the supercoiling activity of DNA gyrase from M. smegmatis. Among the synthesized compounds, 7-(3-(diethylcarbamoyl)piperidin-1-yl)-1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxoquinoline-3-carboxylic acid (7l) was found to be the most active compound in vitro with MIC of 0.09 microM against MTB and MDR-TB respectively. In the in vivo animal model 7l decreased the mycobacterial load in lung and spleen tissues with 2.53- and 4.88-log10 protections respectively at a dose of 50mg/kg body weight.

Potency of DX-619, a novel des-F(6)-quinolone, in haematogenous murine bronchopneumonia caused by methicillin-resistant and vancomycin-intermediate Staphylococcus aureus

In this study, the potency of DX-619, a novel des-fluoro(6)-quinolone agent, was compared with that of vancomycin (VCM) in a murine model of haematogenous bronchopneumonia infection caused by methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-intermediate S. aureus (VISA). The minimum inhibitory concentrations (MICs) of DX-619 and VCM against MRSA were 0.03 microg/mL and 1.0 microg/mL, respectively, whilst the MICs against VISA were 0.125 microg/mL and 8.0 microg/mL, respectively. Treatment with DX-619 resulted in a significant decrease in the number of viable bacteria in the MRSA infection model (mean+/-standard error of the mean for control, VCM and DX-619 groups: 7.97+/-0.32, 7.19+/-0.33 and 2.91+/-0.60 log(10) colony-forming units/lung, respectively). For infection with VISA, mice were pre-treated with cyclophosphamide. The survival rate of mice treated with DX-619 (90% survival) was significantly higher than survival rates in the other two groups (45% both for VCM and control groups; P<0.05). Histopathological examination revealed that inflammatory changes in the DX-619-treated group were less marked than in the other two groups. The parameters in lung tissue for the area under the concentration-time curve/MIC ratio both for MRSA and VISA were higher in the DX-619 group than in the VCM group. Our results emphasise the potency of DX-619 against MRSA and VISA murine haematogenous pulmonary infection.

Ultrastructural changes of the gemifloxacin on Achilles tendon in immature rats: comparison with those of ciproxacin and ofloxacin

Gemifloxacin is a synthetic fluoroquinolone antimicrobial agent that exhibits potent activity against most Gram-negative and Gram-positive organisms, and has a comparatively low chondrotoxic potential in immature animals. This study examined the effects of gemifloxacin on the Achilles tendons in immature Sprague-Dawley rats treated by oral intubation once daily for 5 consecutive days from postnatal week 4 onward at doses of 0 (vehicle), and 600 mg/kg body weight. Ofloxacin or ciprofloxacin were used for comparison. The Achilles tendon specimens were examined by electron microscopy. In comparison with the vehicle-treated controls, there were ultrastructural changes in all samples from the gemifloxacin-, ofloxacin-, and ciprofloxacin-treated rats. Degenerative changes were observed in the tenocytes, and the cells that detached from the extracellular matrix were recognizable. The degree of degenerative changes and the number of degenerated cells in the Achilles tendon were significantly higher in the treated group than in the control group. Moreover, among the quinolone-treated groups, these findings were most significant in the ofloxacin-treated group, and least significant in the gemifloxacin-treated group. It is unclear what these findings mean with respect to the possible risk in juvenile patients treated with gemifloxacin or other quinolones. However, these results show that gemifloxacin causes less changes in the connective tissue structures.

Effect of marbofloxacin on cardiovascular variables in healthy isoflurane-anesthetized dogs

OBJECTIVE

To study the hemodynamic effects of marbofloxacin (MBF) in isoflurane-anesthetized dogs.

ANIMALS

6 healthy 8-month-old Beagles.

PROCEDURE

Anesthesia was induced with sodium thiopental and maintained with isoflurane. Cardiovascular variables were monitored throughout anesthesia. Marbofloxacin was administered by an IV bolus at 2 mg/kg, followed 10 minutes later by an infusion at a rate of 40 mg/kg/h for 30 minutes (total dose, 20 mg/kg). Plasma MBF concentrations were measured by high-performance liquid chromatography.

RESULTS

The mean peak concentration during MBF infusion was 34.2 +/- 6.4 microg/mL. The IV administration of the MBF bolus did not alter any cardiovascular variable in isoflurane-anesthetized dogs. Significant changes were found during infusion when a cumulative dose of 12 mg/kg had been given. The maximal decreases observed at the end of the infusion were 16% in heart rate, 26% in systolic left ventricular pressure, 33% in systolic aortic pressure, 38% in diastolic aortic pressure, 29% in cardiac output, and 12% in QT interval. All dogs recovered rapidly from anesthesia at the end of the experiment.

CONCLUSIONS AND CLINICAL RELEVANCE

MBF may safely be used at 2 mg/kg IV in isoflurane-anesthetized dogs, and significant adverse cardiovascular effects are found only when 6 to 8 times the recommended dose is given.

Safety and Efficacy of Gatifloxacin Therapy for Children with Recurrent Acute Otitis Media (AOM) and/or AOM Treatment Failure

BACKGROUND

Because of concerns about arthrotoxicity, fluoroquinolones are restricted for use in children. This study describes the safety and efficacy of gatifloxacin when used for treatment of children with recurrent acute otitis media (ROM) or acute otitis media (AOM) treatment failure (AOMTF).

METHODS

We performed an analysis of 867 children included in 4 clinical trials who had ROM and/or AOMTF and were treated with gatifloxacin (10 mg/kg once daily for 10 days).

RESULTS

Gatifloxacin had adverse event rates that were similar overall to those of a comparator antibiotic (amoxicillin-clavulanate), except for increased diarrhea in children <2 years old receiving amoxicillin-clavulanate. There was no evidence of arthrotoxicity, hepatotoxicity, alteration of glucose homeostasis, or central nervous system toxicity acutely or during 1 year follow-up in any child. Regarding efficacy, in 2 noncomparative trials, the gatifloxacin cure rate of AOM was 89% (95% confidence interval [CI], 83%-95%) at the test of cure (TOC) visit, 3-10 days after completion of therapy. In 2 comparative trials of gatifloxacin versus amoxicillin-clavulanate, the efficacy of gatifloxacin was 88% (95% CI, 82%-94%). Gatifloxacin led to better clinical outcomes than amoxicillin-clavulanate for AOMTF (91% vs. 81%; P=.029), for AOMTF and age <2 years old (89% vs. 69%; P=.009), and for severe AOM in children <2 years old (90% vs. 75%; P=.012). Among children with AOMTF previously treated with amoxicillin-clavulanate or ceftriaxone injections, gatifloxacin cure rates were high (88% and 75%, respectively).

CONCLUSIONS

Gatifloxacin appears to be safe for children, with no evidence of producing arthrotoxicity in 867 children exposed to the antibiotic when used as treatment for ROM and AOMTF.

Effects of moxifloxacin on QT interval in conscious dogs

Moxifloxacin has been shown to induce QT prolongation in both clinical and preclinical models. However, the ability to observe this effect at clinically relevant concentration in normal conscious dogs has not been reported. The purpose of this study was to investigate the effects of moxifloxacin on the QT interval in conscious, healthy dogs. Four male mongrel dogs were chronically instrumented for the measurement of arterial blood pressure, left ventricular blood pressure, cardiac output, electrocardiograms (ECGs), and body temperature. Animals were administered a 1-h i.v. infusion of moxifloxacin once per day via a catheter in the cephalic vein. Each dog received all doses (0, 1, 10, 25 and 50 mg/kg) in an escalating fashion. Moxifloxacin caused a statistically significant increase in arterial blood pressure at 50 mg/kg. A dose-response effect on QT and QTc prolongation was observed. A statistically significant prolongation in the QT interval was observed at 10, 25 and 50 mg/kg and a prolongation of QTc was observed at 25 and 50 mg/kg. These effects occurred at clinically relevant plasma concentrations. This study demonstrate that a study design with four dogs was sensitive enough to measure moxifloxacin-induced QT prolongation at clinically relevant plasma concentrations.

Structure–phototoxicity relationship in Balb/c mice treated with fluoroquinolone derivatives, followed by ultraviolet-A irradiation

We examined the structure-phototoxicity relationship for fluoroquinolone antimicrobial agents (quinolones) using female albino Balb/c mice. First of all, to obtain an optimum dosage level for induction of phototoxicity, the prototype phototoxicant sparfloxacin was intravenously administered once at 10 mg/kg, 30 mg/kg or 100 mg/kg to female mice, followed immediately by ultraviolet-A (UVA) irradiation for 4 h (21.6J/cm2). The auricular thickness was measured at pre-dose (0 h), 4, 24, 48, 72 and 96 h post-dose, and then the histopathological examination of the auricle was performed. As results, the auricular thickness increased from 30 mg/kg, in conjunction with edema, cellular infiltration, epidermal necrosis and focal loss of the auricle. On the basis of these information, ciprofloxacin, enoxacin, fleroxacin, gatifloxacin, lomefloxacin, norfloxacin and ofloxacin were given intravenously to mice at a fixed dose of 100 mg/kg to compare their potential phototoxicities. Certain quinolones caused the auricular lesions in the following rank order (from lowest to highest): vehicle control (non-phototoxicity)=gatifloxacin=ofloxacin<ciprofloxacin=norfloxacin<enoxacin=fleroxacin<lomefloxacin=sparfloxacin. From the viewpoint of the structure-phototoxicity relationship, quinolones possessing the C-8 substituent with a fluorine or hydrogen and 1,8-naphthyridine derivative evoked phototoxicity in the mouse auricle. These results demonstrate that phototoxicity induced by quinolones would be related to the property of the eighth position.

Safety pharmacology of DW-224a, a novel fluoroquinolone antibiotic agent

To investigate the safety pharmacology of a novel fluoroquinolone antibiotic agent, DW-224a, on the vital functions, we studied its effects on the central nervous system, cardiovascular system and respiratory system. To determine the effects on the central nervous system, we used a modified Irwin's test at each time point after oral administration of DW-224a to mice. In this test, we found that the treatment of test article had no effects on motor activity, behavioral changes, coordination, and sensory/motor reflex responses. The effects of DW-224a on the cardiovascular system were evaluated by the use of a telemetry system in beagle dogs. At 360 min post-DW-224a (100 mg/kg) administration, QT interval prolongation was observed. However, there were no changes in heart rate, blood pressure, and electrocardiogram at all doses and each time points with the exception of QT-interval prolongation as compared to the vehicle treated group. In experiments designed to determine the changes of respiratory function in rats, we found no changes at all doses and time points. We investigated the effects of DW-224a on the human ether-a-go-go-related gene (hERG) mediated potassium currents to evaluate its potential to induce QT interval prolongation. When whole cell patch-clamp electrophysiology was used, DW-224a inhibited hERG currents with IC50 of 218.12 +/- 39.51 microM though its effect was less potent than that of E-4031, a positive control drug. Our data suggested that DW-224a showed no adverse effects on the central nervous system, cardiovascular system, and respiratory system, with the exception of the effect on the QT interval prolongation.

Developmental toxicity assessment of the new ?uoroquinolone antibacterial DW-116 in rabbits

DW-116 is a newly developed fluoroquinolone antibacterial with a broad spectrum against both Gram-positive and Gram-negative bacteria. We have reported recently that DW-116 is embryotoxic and teratogenic in rats. The present study was conducted to investigate the teratogenicity of DW-116, together with maternal toxicity and developmental toxicity using New Zealand White rabbits. The test chemical was administered by gavage to pregnant rabbits from gestational day (GD) 6 through to GD 18 at dose levels of 0, 5, 19.5 and 76.1 mg kg(-1) day(-1). All does were subjected to caesarean section on day 28 of gestation and their foetuses were examined for external, visceral and skeletal abnormalities. In the 76.1 mg kg(-1) group, a minimal maternal toxicity, as evidenced by decreased body weight gain during treatment period, was observed in pregnant rabbits. Significant embryo-foetal toxicity, including increased number of foetal deaths and delayed foetal ossification, was seen. However, no treatment-related morphological changes were detected in foetal external, visceral and skeletal examinations. There were no adverse effects on either pregnant dams or embryo-foetal development at 19.5 and 5 mg kg(-1). It was concluded that administration of DW-116 during the major organogenetic period in rabbits produced decreased maternal body weight gain, increased number of foetal deaths and foetal developmental delay but no evidence of teratogenicity. The no-observed-adverse-effect levels (NOAELs) of DW-116 are considered to be 19.5 mg kg(-1) day(-1) for does and embryo-foetuses, respectively.

Peri- and postnatal developmental toxicity of the fluoroquinolone antibacterial DW-116 in rats

DW-116 is a fluoroquinolone antibacterial developed by Dong-Wha Pharmaceutical Industry Co. The aim of this study is to determine the potential adverse effects of this chemical on pregnancy, delivery and lactation of dams and on peri- and postnatal development of F1 offspring. The test chemical was orally administered to pregnant rats from day 16 of pregnancy, through parturition and throughout the period of lactation up to weaning (postnatal day 21) at dose levels of 0, 10, 50, or 250 mg/kg/day. The progeny were examined at birth and subsequently to weaning. Mortality, body weight change, physical signs of postnatal development (pinna detachment, incisor eruption, fur development, eye opening, testis descent and vaginal opening) and behavioral function (righting reflex, negative geotaxis, grip-strength, pupillary reflex, acoustic startle response, rotating rod test, open field test and water-filled T-maze test) were evaluated. When the exposed offspring reached maturity (11 weeks old) their reproductive capacity was assessed. Maternal toxicity was observed only in the highest dose group and was limited to decreased food consumption during the late stage of pregnancy. However, this change was not observed during the lactation period. There were no adverse effects on mortality, clinical signs, body weight, necropsy findings, organ weight of dams in any treatment group. No adverse effects on the offspring were seen with the low and middle doses tested, but the highest dose increased postnatal mortality. The number of stillborn was also increased at the highest dose but the difference was not statistically significant. Meanwhile, no treatment-related effects were observed in clinical sign, developmental and behavioral landmarks and necropsy findings at any dose levels tested. There were no treatment-related effects on the mating of the F1 generation and resulting F2 offspring. The results of this study indicate that the peri- and postnatal administration of DW-116 to female rats results in an increase in postnatal mortality at a minimally maternotoxic dose, i.e., 250 mg/kg/day. Under the experimental conditions, the no-observed-adverse-effect level for peri- and postnatal developmental toxicity was considered to be 50 mg/kg/day.

General Pharmacology of DW-286a, a New Fluoronaphthyridone Antibiotic: Effects on Central Nervous, Cardiovascular, and Respiratory Systems

DW-286a is a new class of fluoronaphthyridone antibiotic. Its effect on the central nervous system, general behavior, and cardiovascular, respiratory, and other organ systems were studied. The doses given were 30, 50, 100, 150, 300, and 1000 mg/kg and drugs were administered orally. DW-286a did not show any effects on general behavior, motor coordination, analgesic action, seizure and mortality, blood pressure and heart rate, contractile response of isolated guinea pig ileums, and renal function. On the other hand, DW-286a decreased spontaneous locomotor activity from 120 to 240 min after administration at the doses of 300 and 1000 mg/kg and the respiration rate from 30 to 240 min after the administration of doses up to 100 mg/kg. The sleeping time and body temperature were increased significantly in mice at the dose of 1000 mg/kg. DW-286a increased the charcoal transport significantly at doses of 300 and 1000 mg/kg. DW-286a inhibited gastric acid secretion, reduced the volume of the gastric juice and total acidity, and increased the pH dose dependently. Based on the above results, it was concluded that DW-286a affects spontaneous locomotor activity, respiration and body temperature, gastrointestinal transport, gastric secretory action, and hexobarbital sleeping time at high doses.

Developmental toxicity evaluation of the new fluoroquinolone antibacterial DW-116 in rats

We have recently reported that the fluoroquinolone antibacterial DW-116 induces a significant developmental toxicity in rat. The present study was conducted to better understand the teratogenic effects of DW-116 at several developmental toxic doses in rats. DW-116 was orally administered to pregnant rats from gestational day (GD) 6 through 16 at dose levels of 0, 320, 400, and 500 mg/kg/day. All dams were subjected to caesarean section on GD 20 and their fetuses were examined for external, visceral, and skeletal abnormalities. At above 400 mg/kg, severe decreases in maternal body weight gain, food consumption, litter size, fetal weight and placental weight, and severe increases in resorption rate and fetal morphological alterations were observed. At 320 mg/kg, mild decreases in maternal body weight gain, food consumption, fetal weight and placental weight, and mild increases in fetal variations and retardations were observed. These results suggest that DW-116 is embryotoxic at above 320 mg/kg/day and is embryolethal and teratogenic at above 400 mg/kg in pregnant rats and that DW-116 is a selective developmental toxicant in rat conceptuses.

Fluoroquinolones in the elderly: safety considerations

Fluoroquinolones such as ciprofloxacin, levofloxacin, moxifloxacin and gatifloxacin are widely used for the treatment of bacterial infections. Fluoroquinolone-induced adverse effects have not been reported to occur with increased frequency in the elderly, but large trials comparing the tolerability in aged and young individuals are not available. Renal function declines consistently with age and recommendations for dosage changes of renally eliminated fluoroquinolones (ofloxacin, levofloxacin, gatifloxacin) are related to changes in kidney function rather than to age per se. However, during routine clinical work, creatinine clearance data are usually not available; thus it seems more practical to recommend dosage adjustment for elderly individuals in whom low creatinine clearance values can be expected. Reactions of the gastrointestinal tract are the most often observed adverse effects during therapy with fluoroquinolones; however, compared with many other antibacterials, fluoroquinolones are less frequently associated with diarrhoea. Similarly, hypersensitivity reactions, as observed during therapy with penicillins and other beta-lactam agents, occur more rarely during fluoroquinolone therapy. Adverse reactions of the CNS are of particular concern for the elderly population. Elderly patients with impairments of the CNS (e.g. epilepsy, pronounced arteriosclerosis) should be treated with fluoroquinolones only under close supervision. Probably, many signs of possible adverse reactions such as confusion, weakness, loss of appetite, tremor or depression are often mistakenly attributed to old age and remain unreported. Fluoroquinolones can cause QT interval prolongation. Therefore, they should be avoided in patients with known prolongation of the QT interval, patients with uncorrected hypokalaemia or hypomagnesaemia and patients receiving class IA (e.g. quinidine, procainamide) or class III (e.g. amiodarone, sotalol) antiarrhythmic agents. Chondrotoxicity of fluoroquinolones, as observed in immature animals, has led to restricted use in paediatric patients, but there is no indication that similar effects could occur in joint cartilage of adults. Tendinitis and tendon ruptures have occurred in rare cases as late as several months after treatment with some fluoroquinolones. Chronic renal diseases, concomitant use of corticosteroids and age over 60 years have been recognised as risk factors for fluoroquinolone-induced tendon disorders. Overall, the widely used fluoroquinolones discussed in this review are generally well tolerated. Nevertheless, as with all drugs, their specific adverse effect profiles must be considered when they are chosen for treatment of bacterial infections. Because of physiological changes in renal function and in case of certain comorbidities, some special considerations are necessary when fluoroquinolones are used to treat elderly patients.

26-Week repeated oral dose toxicity study of the new quinolone antibacterial DW-116 in Sprague-Dawley rats

The purpose of this study is to investigate the potential subchronic toxicity of DW-116 by a 26-week repeated oral dose in Sprague-Dawley rats. The test article, DW-116, was administered daily by gavage to male and female rats at dose levels of 0, 5, 25 and 125 mg/kg/day. At the end of the treatment period, 12 rats/sex/group were sacrificed, while six extra rats/sex in the vehicle control and highest dose groups were sacrificed after a 4-week recovery. During the test period, clinical signs, mortality, body weights, food and water consumption, ophthalmoscopy, urinalysis, hematology, serum biochemistry, gross findings, organ weights and histopathology were examined. There was no treatment-related mortality. An increase in the incidence of post-dosing salivation was observed in both sexes of the highest dose group. At the scheduled autopsy, an increase in the liver weight was observed in males of the highest dose group in a dose-dependent manner. Hematological investigations revealed a dose-dependent increase in the total white blood cell (WBC) and lymphocyte counts in males treated with the 125 mg/kg dose. Total bilirubin and alanine aminotransferase (ALT) values were also increased in males at the same dose. These effects were completely reversible during the recovery period. There were no adverse effects on body weight, food and water consumption, ophthalmoscopy, urinalysis, necropsy findings and histopathology in any treatment group. Based on these results, it was concluded that the 26-week repeated oral dose of DW-116 caused increases in the liver weight, WBC counts, total bilirubin and ALT values in males at a dose level of 125 mg/kg/day. The target organ was determined to be the liver and WBC in males, but not in females. The no-observed-adverse-effect level (NOAEL) was considered to be 25 mg/kg/day for males and 125 mg/kg/day for females.

Transplacental pharmacokinetics of the new fluoroquinolone DW-116 in pregnant rats

DW-116 is a newly developed fluoroquinolone antibacterial with a broad spectrum against both gram-positive and gram-negative bacteria. Recently, we have reported that DW-116 induces a significant developmental toxicity in rat. The present study was undertaken to characterize the placental transfer and pharmacokinetics of DW-116 in Sprague-Dawley rats. Pregnant females were given a single oral dose of 500-mg [14C]DW-116/kg on gestational day 18. Maternal and fetal tissues were collected at 0.17, 0.5, 1, 2, 4, 8 and 24 h after dosing. The [14C]DW-116-derived radioactivity was rapidly distributed to the fetus and slowly eliminated from the tissue. The radioactivity in both maternal plasma and fetal tissue reached its peak within 1 h and maintained the level of radioactivity up to 16-28% of the peak level until 24 h after dosing. Radioactivity in whole fetus was higher than those in the maternal plasma and placenta. The T(1/2)abs, T(1/2)beta, AUC, Tmax and Cmax in the maternal plasma were approximately 6 min, 13.3 h, 1620 microg h/ml, 0.5 h and 136 microg/ml, respectively. Those in the placenta were approximately 20 min, 12.3 h, 2150 microg h/ml, 1.0 h and 172 microg/ml, respectively. Those in the whole fetus were 13 min, 12.8 h, 2549 microg h/ml, 1 h and 191 microg/ml, respectively. In the amniotic fluid of maternal uterus, the T(1/2)abs, T(1/2)beta, AUC, Tmax and Cmax were approximately 1.3 h, 9.3 h, 2508 microg h/ml, 4.4 h, and 135 microg/ ml, respectively. While DW-116 disappeared biphasically from maternal plasma, whole fetus and placenta, it was eliminated monophasically from amniotic fluid. These results indicate that (1) total radioactivity appeared rapidly in maternal plasma and fetuses; (2) the elimination of total radioactivity is slow; and (3) DW-116 or relevant metabolites could cross the blood-placenta barrier in pregnant rats.

The battle against emerging antibiotic resistance: should fluoroquinolones be used to treat children?

Inappropriate use of antibiotic drugs in humans and animals has led to widespread resistance among microbial pathogens. Resistance is the phenotypic expression corresponding to genetic changes caused by either mutation or acquisition of new genetic information. In some cases, multidrug resistance occurs. Streptococcus pneumoniae is one of the most important respiratory pathogens, playing a major role in both upper and lower respiratory tract infections. Pneumococcal resistance to antimicrobials may be acquired by means of horizontal transfer followed by homologous recombination of genetic material from the normal flora of the human oral cavity or by means of mutation. Resistance to penicillins and macrolides has been increasing for some time, but, recently, fluoroquinolone resistance has become an issue as well. We are concerned that, if fluoroquinolones are approved for use in children, their widespread use will result in rapid emergence of pneumococcal resistance, because children are more often colonized in the nasopharynx with high-density populations of pneumococci than are adults.

Clinical toxicological aspects of fluoroquinolones

Reactions of the gastrointestinal tract and the central nervous system are the most often observed adverse effects during therapy with fluoroquinolones. Pathogenesis of the neurotoxic effects of fluoroquinolones could be related to the activation of the NMDA receptor. Animal experiments as well as clinical experience show that the cardiotoxic potentials of sparfloxacin and grepafloxacin are higher than those of the other fluoroquinolones: they cause QT prolongation at rather low doses thus increasing the risk for severe arrhythmia (torsades de pointes). Phototoxicity has been described for all quinolones, but derivatives with a halogen atom at position 8 show the highest potential for such reactions (e.g. clinafloxacin). Chondrotoxicity of quinolones can affect the articular cartilage and the epiphyseal growth plate in immature animals; the use of these drugs in pediatrics should be restricted to carefully selected indications (such as the use of ciprofloxacin in cystic fibrosis). Tendinitis and tendon ruptures can also be induced by quinolones. Overall, quinolones are as well tolerated as most other anti-microbial agents. However, their specific toxic potentials have to be considered when they are chosen for treatment of bacterial infections.

Effect of antibiotics on in vitro and in vivo avian cartilage degradation

Antibiotics are used in the livestock industry not only to treat disease but also to promote growth and increase feed efficiency in less than ideal sanitary conditions. However, certain antibiotic families utilized in the poultry industry have recently been found to adversely affect bone formation and cartilage metabolism in dogs, rats, and humans. Therefore, the first objective of this study was to determine if certain antibiotics used in the poultry industry would inhibit in vitro cartilage degradation. The second objective was to determine if the antibiotics found to inhibit in vitro cartilage degradation also induced tibial dyschondroplasia in growing broilers. Ten antibiotics were studied by an avian explant culture system that is designed to completely degrade tibiae over 16 days. Lincomycin, tylosin tartrate, gentamicin, erythromycin, and neomycin sulfate did not inhibit degradation at any concentration tested. Doxycycline (200 microg/ml), oxytetracycline (200 microg/ml), enrofloxacin (200 and 400 microg/ml), ceftiofur (400 microg/ml), and salinomycin (10 microg/ml) prevented complete cartilage degradation for up to 30 days in culture. Thus, some of the antibiotics did inhibit cartilage degradation in developing bone. Day-old chicks were then administered the five antibiotics at 25%, 100%, or 400% above their recommended dose levels and raised until 21 days of age. Thiram, a fungicide known to induce experimental tibial dyschondroplasia (TD), was given at 20 ppm. Birds were then killed by cervical dislocation, and each proximal tibiotarsus was visually examined for TD lesions. The results showed that none of these antibiotics significantly induced TD in growing boilers at any concentration tested, whereas birds given 20 ppm thiram had a 92% incidence rate.

A non-arthropathic dose and its disposition following repeated oral administration of ofloxacin, a new quinolone antimicrobial agent, to juvenile dogs

A non-arthropathic dose and disposition of ofloxacin, a potent new quinolone antimicrobial agent, were assessed in male juvenile (3-month-old) dogs, when administered orally at 5, 10 and 20 mg/kg/day once daily for 8 consecutive days. Ofloxacin concentrations in sera and articular cartilages were analyzed by high-performance liquid chromatography (HPLC). Macroscopically, arthropathy characterized by fluid-filled vesicles in articular surface of the humerus and femur was observed in animals receiving 10 and 20 mg/kg/day of ofloxacin, but not in those given 5 mg/kg/day. At 20 mg/kg/day, arthropathy of comparable severity also occurred on day 2. Microscopically, the cavity formation in the middle zone of the articular cartilage was first identified and then necrotic chondrocytes were found numerous around the cavity, followed by appearance of chondrocyte clusters. In pharmacokinetics, peak serum concentration (Cmax) and area under the concentrations (AUC0-24) were increased in a dose-dependent manner. However, no remarkable differences in these two parameters were noted between a single and repeated treatments, suggesting no accumulation of the drug. The articular ofloxacin concentration 2 hr after treatment was approximately 1.8 (day 2) to 2.0 times (day 8) higher than the serum concentration. Based on these results, a non-arthropathic dose of ofloxacin in male juvenile dogs following an 8-day treatment is considered to be 5 mg/kg/ day, and its Cmax, AUC0-24 and articular cartilage concentrations 2 hr after treatment were 3.4 microg/ml, 35.1 microg-hr/m/ and 7.0 microg/g, respectively, under these experimental conditions. Thus, arthropathy due to ofloxacin may be predicted by monitoring serum drug concentration.

Evaluation of quinolone derivatives for antitrypanosomal activity

About 160 fluoroquinolones and derivatives were tested for antitrypanosomal activity in a drug sensitivity assay followed by fluorometric evaluation. The most active quinolone compounds had IC50 values in the range from 100 to 900 ng/ml, while several derivatives were not active at a concentration of 100 microg/ml. In a structure activity relationship study, modification of the quinolones at position R1, R2, R3 and R8 did not influence trypanocidal activity. An exchange of the fluor at position 6 may contribute to an increase in activity but does not entirely control it. Pyrrolidine substituents at position R7 generally were more active than other substituents at this position. Tetracyclic quinolone derivatives were amongst the most active compounds with IC50 values in the range of 0.3-8.8 microg/ml. The in vitro cytotoxicity on HT-29 cells was determined for active compounds with IC50 values below 1 microg/ml. In addition, six drugs with an IC50 below 1 microg/ml and a selectivity index of more than 10 were chosen for in vivo experiments. Dose escalation experiments with a maximum dose of 100 mg/kg/bid were performed in a mouse model without central nervous system involvement. For unknown reasons the in vitro effect of the drugs could not be confirmed in vivo, but the class of compound remains of interest for their mode of action, the low toxicity, pharmacological properties and the availability of a large number of synthesized compounds.

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.

A Risk-Benefit Assessment of Levofloxacin in Respiratory, Skin and Skin Structure, and Urinary Tract Infections

As a class, the quinolone antibacterials can no longer be assumed to be both effective and relatively free of significant adverse effects. Recent safety issues with newer generation fluoroquinolones, and concerns regarding drug-use associated bacterial resistance have made all drugs in this class subject to intense scrutiny and further study. Levofloxacin is a second generation fluoroquinolone with a post marketing history of well tolerated and successful use in a variety of clinical situations. Quinolones as a class cause a variety of adverse effects, including phototoxicity, seizures and other CNS disturbances, tendonitis and arthropathies, gastrointestinal effects, nephrotoxicity, prolonged QTc interval and torsade de pointes, hypo- or hyperglycaemia, and hypersensitivity reactions. Levofloxacin has been involved in only a few case reports of adverse events, which include QTc prolongation, seizures, glucose disturbances, and tendonitis. Levofloxacin has been shown to be effective at dosages of 250mg to 500mg once-daily in clinical trials in the management of acute maxillary sinusitis, acute bacterial exacerbations of chronic bronchitis, community-acquired pneumonia, skin and skin structure infections, and urinary tract infections. There are data suggesting that levofloxacin may promote fluoroquinolone resistance among the Streptococcus pneumoniae, and that clinical failures may result from this therapy. Other data suggest that fluoroquinolones with lower potency against Pseudomonas aeruginosa than ciprofloxacin, such as levofloxacin, may drive class-wide resistance to this pathogen. Levofloxacin is an effective drug in many clinical situations, but its cost is significantly higher than amoxicillin, erythromycin, or first and second generation cefalosporins. Because of the propensity to select for fluoroquinolone resistance in the pneumococcus and potentially other pathogens, levofloxacin should be an alternative agent rather than a drug-of-choice in routine community-acquired respiratory tract, urinary tract, and skin or skin structure infections. In areas with increasing pneumococcal beta-lactam resistance, levofloxacin may be a reasonable empiric therapy in community-acquired respiratory tract infections. Similarly, in patients with risk factors for infectious complications or poor outcome, levofloxacin may be an excellent empiric choice in severe community-acquired respiratory tract infections, urinary tract infections, complicated skin or skin structure infections, and nosocomial respiratory and urinary tract infections. Better clinical data are needed to identify the true place in therapy of the newer fluoroquinolones in common community-acquired and nosocomial infections. Until then, these agents, including levofloxacin, might best be reserved for complicated infections, infection recurrence, and infections caused by beta-lactam or macrolide-resistant pathogens.

Antibiotic side effects

Antibiotic side effects are approached best from an individual agent perspective rather than from a class-related standpoint. As this article indicates, with the exception of drug fevers and drug rashes, most antibiotic side effects are related to individual agents and not class side effects. Clinicians should view antimicrobial side effects as related to each organ system and be aware that more often a nonmicrobial medication is the explanation for the drug side effect rather than the antimicrobial. Nonantimicrobial medications are the most common cause of drug fever; among antimicrobials, beta-lactams and sulfonamides are the most common causes of drug-induced fevers. Antimicrobial side effects have important implications for the patient, legal and economic implications for the hospital, and medicolegal implications for the physician. Antibiotic side effects that prolong hospitalization in today's managed care environment have important economic implications. Clinicians should be familiar with the most common side effects of the most frequently used antimicrobials, to minimize the potential of having adverse reactions occur in patients. Most adverse events related to antimicrobials are reversible rapidly on cessation of the medication. Irreversible toxicities include aminoglycoside-induced ototoxicity, Stevens-Johnson syndrome, and toxicity secondary to nitrofurantoin. The most common acute fatal drug reactions include hypersensitivity reactions resulting in anaphylaxis or the Stevens-Johnson syndrome and fatal hepatic necrosis secondary to trovafloxacin. Clinicians should eliminate the use of drugs associated with chronic or fatal toxicities because multiple therapeutic alternatives exist for virtually every potential infection.

Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro

We studied the inhibitory effects of the fluoroquinolones levofloxacin, ciprofloxacin, and trovafloxacin on growth and extracellular matrix mineralization in MC3T3-E1 osteoblast-like cell cultures. Levofloxacin had the least inhibitory effect on cell growth, with a 50% inhibitory concentration of approximately 80 microg/ml at 48 and 72 hours. Ciprofloxacin had an intermediate degree of inhibition, with a 50% inhibitory concentration of 40 microg/ml at 48 and 72 hours. Trovafloxacin exerted a profound inhibitory effect on cell growth, with a 50% inhibitory concentration of 0.5 microg/ml, lower than clinically achievable serum levels. The decreased cell counts with up to 2.5 microg/ml of trovafloxacin and with up to 40 microg/ml of ciprofloxacin were not associated with decreased rates of 5-bromo-2'-deoxyuridine incorporation per cell. Alatrovafloxacin, the L-alanyl-l-alanine prodrug of trovafloxacin, exerted effects on proliferation and 5-bromo-2'-deoxyuridine incorporation similar to those of the parent compound. The quinolones evaluated also inhibited extracellular matrix mineralization by MC3T3-E1 cells. Treatment of confluent cultures with trovafloxacin, ciprofloxacin, or levofloxacin resulted in strong inhibition of calcium deposition, as determined on day 14 by alizarin red staining and biochemical analysis. The effect was apparent with 2.5-5 microg/ml of each of the three antibiotics tested and progressively increased to more than a 90% decline in the calcium/protein ratio with 20-40 microg/ml antibiotic concentration. Further in vivo studies are advocated to evaluate the relevance of the in vitro cytotoxicity reported here to bone healing in orthopaedic patients.

Toxicity of quinolones

Reactions of the gastrointestinal tract, the CNS and the skin are the most often observed adverse effects during therapy with fluoroquinolones. At least for some of the newer fluoroquinolones a steep dose-response relationship of adverse effects seems to exist. Pathogenesis of the neurotoxic effects of fluoroquinolones is still unknown. Among the newer drugs, trovafloxacin caused mild CNS reactions such as dizziness and lightheadedness in a considerable proportion of patients. Young females seem to be especially sensitive to this effect, which diminishes during treatment or if taken together with food. Cardiotoxic potentials of sparfloxacin and grepafloxacin are higher than those of other fluoroquinolones, but during therapy no clearcut drug-related serious reactions have been reported, apart from a slight prolongation of the QT interval. However, to avoid risks these drugs should not be prescribed to patients with known prolongation of the QT interval (e.g. patients on antiarrhythmics). Phototoxicity has been described for all quinolones, but derivatives with a halogen atom at position 8 show the highest potential for such reactions. Fleroxacin, sparfloxacin, clinafloxacin and lomefloxacin belong to this group of fluoroquinolones. The phototoxic potential of the other new fluoroquinolones is considerably lower, but extensive exposure to UV light should generally be avoided during therapy with all quinolones. Chondrotoxicity of quinolones, as observed in immature animals, can affect articular cartilage and/or the epiphyseal growth plate, depending on the developmental stage. Pathogenesis of chondrotoxicity can probably be explained by the magnesium-chelating properties of these drugs. As juveniles are especially sensitive, use of these drugs in paediatrics should be restricted to carefully selected indications (such as the use of ciprofloxacin in cystic fibrosis). Another manifestation of the toxic effects of quinolones on connective tissue structures are tendopathies. Tendinitis and tendon ruptures have occurred as late as several months after quinolone treatment. Overall, quinolones are well tolerated drugs. Their specific toxic potentials have to be considered when they are chosen for treatment of bacterial infections.

The comparative arthropathy of fluoroquinolones in dogs

1. Fluoroquinolone antibiotics are generally only prescribed to paediatric patients on compassionate grounds. This is because they are known to cause lesions in the cartilage of the major diarthroidal joints in immature experimental animals. As dogs are considered to be the most sensitive species, a series of studies was performed to compare the potential for grepafloxacin (a new fluoroquinolone) to cause arthropathy to that of ofloxacin and ciprofloxacin in juvenile (3 month old) beagles. 2. Grepafloxacin was administered once daily to male juvenile dogs at dosages of up to 100 mg/kg/day (intravenously), 60 mg/kg/day (orally) or 30 mg/kg/day (subcutaneously) for 1 week. Blister formation was observed on the surface of the joints in one of the three animals treated with grepafloxacin intravenously at 100 mg/kg/day. No abnormalities were observed at lower dosages or when grepafloxacin was administered orally or subcutaneously, regardless of dose. In animals treated with ofloxacin or ciprofloxacin at dosages of 10-30 mg/kg/day, blister formation or erosion was observed on the surface of joints regardless of dose or route of administration. 3. Histopathological examination of the joint surfaces of affected animals revealed the loss of cartilaginous matrix and chondrocytes, cavitation within the intermediate zone of cartilage accompanied by cartilage fibrillation or chondrocyte clustering, or loss of the surface layer which covers the cavitation (or loss of outer wall of the cavity). These findings were not present in the absence of grossly observed lesions. 4. Absorption following oral administration of grepafloxacin was low. Examination of plasma concentrations of drug following intravenous administration showed that joint toxicity was seen with ofloxacin and ciprofloxacin at maximum concentrations as low as 3.80 and 4.24 mg/l, respectively, while plasma levels of grepafloxacin of up to 11.95 mg/l failed to cause such lesions. When the concentration of grepafloxacin was 18.69 mg/l a single joint lesion was seen. Following subcutaneous administration of grepafloxacin, systemic exposure (area under the curve) of approximately 1.5 times that seen in man was not associated with joint lesions. However, lesions were noted for ofloxacin and ciprofloxacin treated animals at exposures equal to or below those seen in man. Therefore grepafloxacin appeared to have a relatively low potential for joint toxicity; this was not due to lack of penetration into the synovial fluid.