Determination of ticarcillin levels in serum by high-pressure liquid chromatography

Temocillin (6 g daily) in critically ill patients: continuous infusion versus three times daily administration

OBJECTIVES

The growing incidence of infections caused by Enterobacteriaceae producing ESBLs has led to increased use of carbapenems. Temocillin, which resists most β-lactamases, may be a useful alternative. The aim of this study was to assess the pharmacokinetics and target attainment rates of 6 g of temocillin daily divided into three administrations every 8 h (three times daily) or administered by continuous infusion in critically ill patients.

PATIENTS AND METHODS

This was a prospective, two-centre, randomized, controlled study in patients with intra-abdominal or lower respiratory tract infections caused by Enterobacteriaceae.

RESULTS

Thirty-two patients were included and analysed for clinical efficacy, and pharmacokinetics were measured in 29 of them. Four patients undergoing continuous veno-venous haemofiltration (CVVH) were analysed separately. Mean, median and range of percentages of the dosing interval during which the free drug concentration remained >16 mg/L were 76.4, 98 and 18.7-98.9 in patients treated three times daily and 98.9, 89.7 and 36.4-99.9 in patients with continuous infusion, respectively. Clinical cure rates were 79% and 93% in each of these groups, respectively (not significant). Patients with CVVH received a daily dose of 750 mg given by continuous infusion and had a mean free drug concentration of only 13.8 ± 1.9 mg/L. No adverse event attributable to temocillin was observed.

CONCLUSIONS

Temocillin (6 g daily) given by continuous infusion allows a larger proportion of critically ill patients to have free drug serum concentrations covering infections caused by Enterobacteriaceae with an MIC of 16 mg/L compared with administration three times daily. Clinical efficacy compared with carbapenems in documented severe infections needs to be further studied.

Continuous versus intermittent infusion of temocillin, a directed spectrum penicillin for intensive care patients with nosocomial pneumonia: stability, compatibility, population pharmacokinetic studies and breakpoint selection

BACKGROUND AND AIMS

Temocillin, a 6alpha-methoxy-penicillin stable towards most beta-lactamases (including extended-spectrum beta-lactamase), is presented as an alternative to carbapenems for susceptible Enterobacteriaceae in microbiological surveys. We aimed at documenting its potential clinical usefulness in intensive care (IC) patients using pharmacokinetic/pharmacodynamic approaches applied to conventional (twice daily) and continuous infusion (CI) modes of administration.

METHODS

(i) In vitro evaluation of temocillin stability and compatibility with other drugs under conditions pertinent of CI in IC patients; (ii) pharmacokinetic study in patients treated by CI (4 g/day; n = 6) versus [twice daily (2 g every 12 h); n = 6]; (iii) population pharmacokinetic analysis of twice daily with Monte Carlo simulations to determine 95% probability of target attainment (PTA(95)) versus MIC (based on time above MIC > or = 40% for measured free drug).

RESULTS

Temocillin was stable at 37 degrees C in 8.34% solutions for 24 h and compatible with flucloxacillin and aminoglycosides, but not with several other antibiotic and non-antibiotic drugs. With CI, stable total serum concentrations were 73.5 +/- 3.0 mg/L (SEM) and free concentration 29.3 +/- 2.8 mg/L. With twice daily, Cmax (total drug) was 147 +/- 12.3 mg/L (SEM; free drug: 50.3 +/- 15.8 mg/L), lowest trough (total drug) 12.3 mg/L, and PTA(95) (free drug) obtained for MIC < or = 8 mg/L.

CONCLUSIONS

Temocillin (4 g/day) by CI yields stable free serum concentrations above the current breakpoint (16 mg/L), although individual variations may suggest lowering the breakpoint to 8 mg/L (as for twice daily) unless the daily dose or the frequency of administration is increased.

Simultaneous determination of ticarcillin and clavulanate in rabbit serum and tissue cage fluid by liquid chromatography

A gradient elution HPLC method with a wavelength switch technique was developed to simultaneously analyze the beta-lactam ticarcillin and the beta-lactamase inhibitor clavulanate in rabbit serum and tissue cage fluid (TCF). A C18 reversed-phase column with a programmable UV detector changing the wavelength from 218 to 254 nm at 9 min was used for chromatographic separation. The mobile phase consisted of acetonitrile, phosphate buffer and tetrabutylammonium hydrogen sulfate by following a gradient elution program at a flow-rate of 1 ml/min. Sample processing was carried out with liquid-liquid extraction. Good linearity, recoveries, precision and accuracy were obtained. The ranges of the standard curves were 1-100 microg/ml for ticarcillin, and 0.2-20 microg/ml for clavulanate. This assay has been successfully applied to analyze ticarcillin and clavulanate in rabbit serum and tissue cage fluid samples from a pharmacokinetic study.

Determination of ticarcillin epimers in plasma and urine with high-performance liquid chromatography

A high-performance liquid chromatogaphic method was developed for determining the concentrations of ticarcillin (TIPC) epimers in human plasma and urine. Samples were prepared for HPLC analysis with a solid-phase extraction method and the concentrations of TIPC epimers were determined using reversed-phase HPLC. The mobile phase was a mixture of 0.005 M phosphate buffer (pH 7.0) and methanol (12:1, v/v) with a flow-rate of 1.0 ml/min. TIPC epimers were detected at 254 nm. Baseline separation of the two epimers was observed for both plasma and urine samples with a detection limit of ca. 1 microg/ml with a S/N ratio of 3. No peaks interfering with either of the TIPC epimers were observed on the HPLC chromatograms for blank plasma and urine. The recovery was more than 80% for both plasma and urine samples. C.V. values for intra- and inter-day variabilities were 0.9-2.1 and 1.1-6.4%, respectively, at concentrations ranging between 5 and 200 microg/ml. The present method was used to determine the concentrations of TIPC epimers in plasma and urine following intravenous injection of TIPC to a human volunteer. It was found that both epimers were actively secreted into urine and that the secretion of TIPC was not stereoselective. Plasma protein binding was also measured, which revealed stereoselective binding of TIPC in human plasma.

Pharmacokinetic-based ticarcillin/clavulanic acid dose recommendations for infants and children

The pharmacokinetic characteristics of ticarcillin and clavulanic acid were determined after the first dose (n = 22) and again under steady-state conditions (n = 16) in a group of infants and children. Study subjects ranged in age from 1 month to 9.3 years; all but 3 study patients were 6 months of age or older. Each patient received 50 mg of ticarcillin and 1.7 mg of clavulanic acid (30:1 ratio) per kg of body weight given intravenously every 4 hours. Elimination half-life, steady-state volume of distribution, and body clearance averaged 1.1 hours, 0.22 L/kg, and 2.7 mL/min/kg, respectively, for ticarcillin, and 0.9 hours, 0.4 L/kg, and 6.2 mL/min/kg, respectively, for clavulanic acid. A total of 71% of the ticarcillin and 50% of the clavulanic acid dose were excreted unchanged in the urine over the 4-hour sampling period. Corresponding renal clearances averaged 2.1 and 3.2 mL/min/kg for ticarcillin and clavulanic acid, respectively. No differences were observed between first dose and steady-state evaluations in the pharmacokinetic behavior of either agent. In contrast, the pharmacokinetic behavior of clavulanic acid was significantly different from that observed for ticarcillin. These pharmacokinetic data combined with known in vitro susceptibilities of important clinical pathogens support a dose of 80 mg of ticarcillin and 2.7 mg/kg clavulanic acid per kg body weight given as a fixed dose combination every 8 hours for the treatment of most systemic infections that occur outside the central nervous system.

Correlation between activity of beta-lactam agents in vitro and bacteriological outcome in acute pulmonary exacerbations of cystic fibrosis

A study was conducted to determine whether a direct relationship exists between beta-lactam and/or aminoglycoside activity measured in vitro and bacteriological outcome in acute pulmonary exacerbations of cystic fibrosis. Twenty-seven patients, aged between 6 months and 24 years (mean age 10 1/2 years), were included in the study and received 41 i.v. courses of a beta-lactam agent combined with an aminoglycoside. A total of 63 Pseudomonas aeruginosa strains were found in sputum taken on admission at densities exceeding 10(6) cfu/g of sputum. For each episode, the serum inhibitory quotient (SIQ) and the serum bactericidal quotient (SBQ) of the beta-lactam agent and of the aminoglycoside administered were determined for the Pseudomonas aeruginosa isolate(s). The SIQs and SBQs were calculated by dividing the average peak serum levels achievable in the patients by the minimal inhibitory concentrations and minimal bactericidal concentrations, respectively. The SIQs and SBQs were compared to bacteriological outcome. Bacteriological success was defined as a decrease of 2 log10 counts or more in the Pseudomonas aeruginosa density in sputum between days 0 and 7 of therapy. The SIQ and SBQ of beta-lactam agents were good predictors of bacteriological outcome: SIQs of < 1:16 were 100% predictive of failure (chi 2 28; p < 0.001) and of > or = 1:64 were 92.9% predictive of success (chi 2 35.68; p < 0.001); SBQs of < 1:8 were 100% predictive of failure (chi 2 42.78; p < 0.001) and of > or = 1:32 were 95.8% predictive of success (chi 2 31.5; p < 0.001). Aminoglycoside SIQs and SBQs were not predictive of outcome.

Determination of ticarcillin in human plasma and in urine by reversed-phase LC

A liquid chromatographic assay for ticarcillin (ticar.) in plasma and urine is described. For analysis, the internal standard cefoperazone (cfp) is dissolved in acetonitrile, which is used for precipitating the protein. The supernatant is evaporated, reconstituted in running mobile phase and injected directly onto the reversed-phase C18 column, with detection at 205 nm. The mobile phase is composed of water-acetonitrile-o-phosphoric acid-tetramethylammonium chloride (TMA). Coefficients of variation for reproducibility were in the range of 2.2-15.5% for extra-low, low, medium and high controls. Limits of detection were 0.5 microgram ml-1 for plasma and 1 microgram ml-1 for urine. No interference from other cephalosporins or other antibiotics was noted. This liquid chromatographic assay is simple, accurate, requires no extraction and overcomes previous problems related to the drug's peak splitting due to isomerization.

Development and validation of an LC method for the quantitation of carbenicillin in human serum

An LC method for the quantitation of carbenicillin in human serum has been developed and validated. After protein precipitation with acetonitrile and evaporation, the residue was taken up by citric acid at pH 1.9. Carbenicillin and the internal standard (I.S.), piperacillin, were extracted with ethyl acetate, evaporated to dryness and reconstituted with a buffer solution. The separation of carbenicillin,, the I.S., and matrix peaks was achieved on a Microsorb C18, 3 microns column with a mobile phase of acetonitrile-tetrabutylammonium-phosphate buffer (pH* 6.6). The detection was by UV at 208 nm. The run time was 8 min. The established linearity range was 0.25-20 microgram ml-1 (r2 > 0.99) with a limit of quantitation of 0.25 microgram ml-1. Interday precision (RSD) and bias over the entire range were 1.1-6.9% and -1.83 to +2.80%, respectively. The interday precision (RSD) and bias for the QC samples at 0.75, 3.0 and 12 micrograms ml-1 were 5.9-7.9% and -2.80 to +2.30%, respectively. Stabilities of on-system, bench top, freeze-thaw cycles and sample storage were established.

Effect of the silica support of bonded reversed-phase columns on chromatography of some antibiotic compounds

Chromatographic behavior of three types of antibiotics was investigated on bonded C18 and polymeric reversed-phase columns. With penicillins with carboxylic acid functions only, retention and separations on the two types of columns were similar. beta-Lactam antibiotics with basic functions did not give as sharp peaks on the C18 column unless a silanol blocking agent, tetramethyl ammonium chloride (TMA) was added. In 0.01 M orthophosphoric acid-acetonitrile, tetracyclines were separated on the polymeric reversed-phase columns, but not on the C18 columns. With addition of TMA, results on C18 and polymeric reversed-phase columns were nearly identical. Addition of an ion pair also improved separations on the C18 columns, but not as much as TMA. Interaction with the silica support of C18 columns was used to separate tylosin from interferences in extracts of biological materials. The results demonstrate the importance of interactions with the silica support in chromatography of basic antibiotics on C18 packings. These interactions can be either beneficial or detrimental to separations, depending on the conditions used.