In vitro evaluation of josamycin, spiramycin, and erythromycin against Rickettsia rickettsii and R. conorii

Treatment of Tick-Borne Diseases

OBJECTIVE:

To review the data regarding the pharmacotherapy of Lyme disease, Rocky Mountain spotted fever (RMSF), and the human ehrlichioses.

DATA SOURCES:

English-language literature was identified via MEDLINE (1966–January 2002) using the keywords Lyme disease, Rocky Mountain spotted fever, and ehrlichiosis. Textbooks and other pertinent resources were also reviewed.

STUDY SELECTION AND DATA EXTRACTION:

All articles identified through the data sources above were evaluated and reviewed if pertinent to the objective.

DATA SYNTHESIS:

Tick-borne diseases are the most common vector-transmitted diseases in North America. Each disease causes significant morbidity and, in the case of RMSF, mortality if patients go untreated. If the disease syndromes are recognized early and treatment is initiated, complications are greatly reduced. Doxycycline is active against each of the causative organisms, simplifying empiric treatment.

CONCLUSIONS:

Effective pharmacotherapy exists to treat each of these diseases, assuming diagnosis is made quickly. The β-lactam and tetracycline antibiotics appear to be the most effective therapy for Lyme disease. The tetracyclines, but not the β-lactams, are effective for RMSF and the human ehrlichioses. Since Borrelia burgdorferi and the human granulocytic ehrlichiosis agent are becoming more common coinfecting pathogens, tetracycline or doxycycline should be considered the drugs of choice for patients from endemic areas where exposure to both pathogens may have occurred. Doxycycline is the preferred agent because of decreased frequency of administration and adverse effects.

Randomized Trial of Clarithromycin for Mediterranean Spotted Fever

The classic antibiotic treatment for Mediterranean spotted fever (MSF) is based on tetracyclines or chloramphenicol, but chloramphenicol's bone marrow toxicity makes tetracyclines the treatment of choice. However, it is convenient to have alternatives available for patients who are allergic to tetracyclines, pregnant women, and children <8 years old. We conducted a randomized clinical trial to compare clarithromycin with doxycycline or josamycin in the treatment of MSF. Forty patients were evaluated (23 male; mean age, 39.87 years); 13 patients were aged <14 years. Seventeen patients received clarithromycin, and 23 received doxycycline or josamycin. The interval between the onset of symptoms and the start of treatment was 4.04 ± 1.70 days in the clarithromycin group versus 4.11 ± 1.60 days in the doxycycline/josamycin group (P = not significant [NS]). Time to the disappearance of fever after treatment was 2.67 ± 1.55 days in the clarithromycin group versus 2.22 ± 1.35 days in the doxycycline/josamycin (P = NS). The symptoms had disappeared at 4.70 ± 2.25 days in the clarithromycin group versus at 4.75 ± 3.08 days in the doxycycline/josamycin (P = NS). There were no adverse reactions to treatment or relapses in either group. In conclusion, clarithromycin is a good alternative to doxycycline or josamycin in the treatment of MSF.

Use of the plaque assay for testing the antibiotic susceptibility of intracellular bacteria

The plaque assay was first described for titration of bacterial inoculums and clonal isolation, and was later adapted for testing antibiotics susceptibility and to study virulence factors and motility of bacteria. Over time, the sensitivity and reproducibility of the technique has been improved. Usually, the number of plaques is counted; however, the recent development of informatics tools has stimulated interest in the quantification of plaque size. Owing to this new approach, the plaque assay has been used to characterize the host cell response when infected cells are treated with antimicrobial agents. It was found that statins prevented cell lesions following rickettsial infection; in other studies, some antibiotics were found to cause apoptosis of host cells, suggesting a toxic activity. Here, we present an overview of the plaque assay as it has been used to investigate intracellular bacteria.

Treatment of Rickettsia spp. infections: a review

Human rickettsioses caused by intracellular bacteria of the genus Rickettsia are distributed worldwide and are transmitted by arthropod vectors such as ticks, fleas, mites and lice. They have a wide range of manifestations from benign to life-threatening diseases. Mortality rates of up to 30% have been reported for some rickettsioses. Here, the authors will review in vitro and human studies of the various compounds that have been used for the treatment of Rickettsia spp. infections. The authors will also provide recommendations for the treatment of spotted fever and typhus group rickettsioses.

Clarithromycin versus azithromycin in the treatment of Mediterranean spotted fever in children: a randomized controlled trial

We conducted an open-label randomized controlled trial to compare the efficacy and safety of clarithromycin (15/mg/kg/day in 2 divided doses for 7 days) with those of azithromycin (10 mg/kg/day in 1 dose for 3 days) in the treatment of children with Mediterranean spotted fever. Until now, there has not been a gold-standard therapy for this rickettsial disease in children. Eighty-seven children were randomized to receive 1 of the 2 drugs. The mean time to defervescence (+/- standard deviation) was 46.2+/-36.4 h in the clarithromycin group and 39.3+/-31.3 h in the azithromycin group. These differences were not statistically significant and both drugs were equally well-tolerated. Clarithromycin and azithromycin could be acceptable therapeutic alternatives to chloramphenicol and tetracyclines for children aged < or =8 years with Mediterranean spotted fever. Azithromycin, because it has a long half-life, offers the advantages of administration in a single daily dose and a shorter duration of therapy, which could increase compliance in children.

In vitro susceptibilities of 27 rickettsiae to 13 antimicrobials

The MICs of 13 antibiotics (doxycycline, thiamphenicol, rifampin, amoxicillin, gentamicin, co-trimoxazole, ciprofloxacin, pefloxacin, ofloxacin, erythromycin, josamycin, clarithromycin, and pristinamycin) were determined for 27 available rickettsial species or strains. We used two in vitro cell culture methods described previously: the plaque assay and the microplaque colorimetric assay. Our results confirm the susceptibilities of rickettsiae to doxycycline, thiamphenicol, and fluoroquinolones. Beta-lactams, aminoglycosides, and cotrimoxazole were not active. Typhus group rickettsiae were susceptible to all macrolides tested, whereas the spotted fever group rickettsiae, R. bellii, and R. canada were more resistant, with josamycin, a safe alternative for the treatment of Mediterranean spotted fever, being the most effective compound. Strain Bar 29, R. massiliae, R. montana, R. aeschlimannii, and R. rhipicephali, which are members of the same phylogenetic subgroup, were more resistant to rifampin than the other rickettsiae tested. Heterogeneity in susceptibility to rifampin, which we report for the first time, may explain in vivo discrepancies in the effectiveness of this antibiotic for the treatment of rickettsial diseases. We hypothesize that rifampin resistance and erythromycin susceptibility may reflect a divergence during the evolution of rickettsiae.

In vitro susceptibilities of Bartonella henselae, B. quintana, B. elizabethae, Rickettsia rickettsii, R. conorii, R. akari, and R. prowazekii to macrolide antibiotics as determined by immunofluorescent-antibody analysis of infected Vero cell monolayers

The in vitro susceptibilities of Bartonella (Rochalimaea) henselae, B. quintana, B. elizabethae, Rickettsia akari, R. conorii, R. prowazekii, and R. rickettsii to different concentrations of azithromycin, clarithromycin, dirithromycin, erythromycin, and roxithromycin in Vero cell cultures were evaluated. Bartonella and Rickettsia spp. were allowed to initiate infection of the antibiotic-free Vero cell monolayers, which were maintained in 16-chamber microscope slides in the absence of antibiotics at 32 degrees C in a CO2-enriched atmosphere. The monolayers were then incubated for 3 h to allow for initial host cell intracellular penetration by infecting species. After inoculation, inocula were replaced and tested with media containing 12 different concentrations of each antibiotic in replicate (10 wells of each antibiotic dilution) for each species, and the monolayers were reincubated. Tetracycline served as the control. Growth status of Bartonella spp. and Rickettsia spp. was determined by evaluation of immunofluorescent staining bacilli. Five days later, when antibiotic-free, control-infected cell monolayers demonstrated significant fluorescence, media were removed for all cell monolayers, the monolayers were fixed, and all specimens were stained with standard indirect immunofluorescent antibody reagents. Fluorescent foci were enumerated by counting such foci on random fields visualized with an epifluorescence microscope. The extent of antibiotic-induced focus inhibition was recorded for each dilution of antibiotic and compared with that of an antibiotic-negative control. Effective antibiotic dilution endpoints for inhibition of Bartonella and Rickettsia proliferation, as judged by absence of increase of significant fluorescence (as compared with no-growth controls), were enumerated by determining the number of cell culture chambers at various antibiotic dilutions that were negative or positive for significant Bartonella- or Rickettsia-specific fluorescence. All of the macrolide agents tested were readily active against all three Bartonella organisms, and azithromycin, clarithromycin, and roxithromycin may have potential in the treatment of Rickettsia infections. Animal model-based clinical trials are warranted to define the specific treatment role of the newer macrolide antibiotics.

In vitro and in vivo antibiotic susceptibilities of ELB rickettsiae

The activities of doxycycline, rifampin, chloramphenicol, and erythromycin against ELB rickettsiae (Rickettsia azadi) were determined by dye uptake and plaque assays. Plaque formation in Vero cells was inhibited by 0.12 microgram of doxycycline per ml. The data presented demonstrate the susceptibility of ELB rickettsiae to commonly used antibiotics for the treatment of rickettsial diseases.

In vitro susceptibilities of spotted fever group rickettsiae and Coxiella burnetti to clarithromycin

The in vitro bacteriostatic activity of clarithromycin, a new macrolide derivative, against Rickettsia rickettsii, Rickettsia conorii, and "Rickettsia israeli" was determined by the plaque assay and the dye uptake assay. Both bacteriostatic and bactericidal activities of clarithromycin against the Nine Mile, Q212, Priscilla, and ME9 strains of Coxiella burnetti were evaluated by using three cell culture systems. Clarithromycin showed improved antibacterial activity compared with that of erythromycin. A bacteriostatic activity was obtained at concentrations below the reported maximum concentration of clarithromycin in human serum (about 4 micrograms/ml) for all tested rickettsiae. MICs ranged from 1 to 2 micrograms/ml for the three Rickettsia species and from 1 to 4 micrograms/ml for the C. burnetti strains. No bactericidal activity against C. burnetti was obtained when clarithromycin was used at 4 micrograms/ml.

Antibiotic treatment of rickettsiosis, recent advances and current concepts

The author reviews the recent advances in the treatment of Mediterranean Spotted Fever and Q fever. In mediterranean spotted fever (M.S.F.), in vitro and preliminary in vivo data support the place of quinolones and josamycin in the treatment of M.S.F. In children josamycin could become the first choice drug as well as in pregnant woman. In Q fever chronic disease should be treated using a combination of antibiotic (doxycycline + quinolones) for a minimum of 3 years.

In vitro susceptibilities of Coxiella burnetii, Rickettsia rickettsii, and Rickettsia conorii to the fluoroquinolone sparfloxacin

In vitro susceptibilities of Rickettsia rickettsii, Rickettsia conorii, and Coxiella burnetii to the new fluoroquinolone sparfloxacin (AT-4140; RP 64206) were determined. Plaque and dye uptake assays were used to measure the MICs against R. rickettsii and R. conorii. The susceptibilities of C. burnetii Nine Mile and Q 212 were determined in two acute-infection models and in two chronic-infection models. The MICs were 0.125 to 0.25 microgram/ml for R. rickettsii and 0.25 to 0.5 microgram/ml for R. conorii. Sparfloxacin (1 microgram/ml) cured cells recently infected with C. burnetii Nine Mile and Q 212 within 4 to 9 days and cured multiplying, persistently infected cells within 10 days. As previously described with other fluoroquinolones (D. Raoult, M. Drancourt, and G. Vestris, Antimicrob. Agents Chemother. 34:1512-1514, 1990), sparfloxacin failed to cure cells persistently infected with C. burnetii and blocked from dividing with cycloheximide. As determined by the dye uptake assay, no cellular toxicity was noted with sparfloxacin at up to 128 micrograms/ml. These results are consistent with those previously obtained with fluoroquinolones (D. Raoult, M. Yeaman, and O. Baca, Rev. Infect. Dis. 11[Suppl. 5]:S986, 1989), although sparfloxacin may be slightly more active.

Rocky Mountain spotted fever

Rocky Mountain spotted fever is an endemic tickborne disease found throughout the United States and other regions of the world. Exposure may result in a spectrum of disease from subclinical infection to severe or fatal multiorgan collapse. The disease is maintained in nature in Ixodid tick vectors and their hosts. The most important ticks in the United States are Dermacentor variabilis and Dermacentor andersoni. Small mammals are the natural reservoirs in the wild. Dogs become infected when a tick harboring Rickettsia rickettsii feeds on the dog. Dogs do not develop sufficient rickettsemia to act as a reservoir in the transmission of Rickettsia rickettsii. Thus, although dogs act as sentinels to the presence of the disease, they cannot directly transmit infection. Signs in early stages of disease often are nonspecific. The most characteristic laboratory abnormality is thrombocytopenia, but serologic testing is necessary for confirmation of infection. Tetracycline and chloramphenicol are effective antibiotics to treat infection. Treatment should continue for 14 to 21 days to allow host immune defenses to develop and eradicate the organism. Prevention requires avoidance of tick-infested areas and rapid removal of ticks should exposure occur.

Randomized trial of doxycycline versus josamycin for Mediterranean spotted fever

We undertook a randomized clinical trial comparing therapeutic efficacy of the 1-day doxycycline regimen with the 5-day josamycin regimen for Mediterranean spotted fever. All 59 patients recovered uneventfully, and results did not significantly differ between the two schedules. One-day doxycycline therapy is an effective, easy, and inexpensive treatment. Josamycin is a useful therapeutic alternative that may be particularly convenient for pregnant women and patients with a history of allergy to tetracyclines.

Antibiotic susceptibility of rickettsia and treatment of rickettsioses

The author describes the in vitro data for antibiotic susceptibility of Rickettsia and Coxiella burnetti. Tetracyclines are still the first antibiotic choice in spotted fevers, typhus and Q fever. In spotted fever a shortened treatment is suggested and the place of macrolide antibiotics, such as Josamycin, in treating children may be evaluated. In Q fever, according to the new biological data, an association of tetracyclines and Rifampin or Quinolones is suggested.

In vitro susceptibilities of Rickettsia rickettsii and Rickettsia conorii to roxithromycin and pristinamycin

In vitro susceptibilities of Rickettsia rickettsii and Rickettsia conorii to roxithromycin, pristinamycin, and the pristinamycin compounds, P1 and P2, were determined by a dye uptake assay and a plaque assay. The MICs were 1 microgram/ml for roxithromycin, 2 micrograms/ml for pristinamycin, greater than 256 micrograms/ml for P1, and 2 micrograms/ml for P2. Compounds P1 and P2 did not share synergetic activity. The toxicity of each compound was determined by a dye uptake assay. Toxic concentrations were 128 micrograms/ml for roxithromycin, 32 micrograms/ml for pristinamycin, greater than 256 micrograms/ml for P1, and 32 micrograms/ml for P2. Roxithromycin and pristinamycin could be useful in the treatment of Rocky Mountain spotted fever and Mediterranean spotted fever.