Antimicrobial activity of DV-7751a, a new fluoroquinolone

Emerging fluoroquinolone-resistance for common clinically important gram-negative bacteria in Taiwan

The in vitro antimicrobial activity of the three most commonly used fluoroquinolones (norfloxacin, ofloxacin and ciprofloxacin) was measured for 2235 isolates of seven common pathogenic gram-negative bacteria. Collected from a major teaching hospital in Taiwan during the years 1985-86, 1989-90, and 1996-97, the samples were evaluated using the agar dilution method. The overall susceptibility to fluoroquinolones has decreased rapidly after the wide use of these antimicrobial agents. Isolates of Escherichia coli and Morganella morganii proved quite susceptible to the fluoroquinolones until 1996. By 1996-97, 20% of the bacteria had become resistant to the fluoroquinolones. Activity against Klebsiella pneumoniae and Proteus mirabilis remained excellent, however, with more than 90% of the isolates susceptible during the survey period. Interestingly, some strains of Serratia marcescens and Pseudomonas aeruginosa were demonstrating in vitro resistance even before the fluoroquinolones were launched in Taiwan. This resistance increased rapidly, with around 20-30% of S. marcescens isolates fluoroquinolone-resistant by 1996-1997. After the introduction of the fluoroquinolones, resistance was demonstrated for about 15% of the P. aeruginosa isolates, and 20% of Enterobacter cloacae isolates, with the susceptibility rate remaining steady state through the 1990s. Different pulsed-field gel electrophoresis patterns have been demonstrated for most fluoroquinolone-resistant isolates, suggesting that the increased resistance was not due to the spread of a single clone. We conclude a trend of increasing fluoroquinolone resistance for many common gram-negative bacteria in Taiwan, especially in recent years. Appropriate use of the new fluoroquinolones should be encouraged in order to prevent the rapid emergence and increase of fluoroquinolone-resistant bacteria.

The new fluoroquinolones: A critical review

OBJECTIVE

This paper reviews the literature available on the new fluoroquinolones - clinafloxacin, gatifloxacin, grepafloxacin, levofloxacin, moxifloxacin, sparfloxacin and trovafloxacin - to compare these agents with each other and contrast them with ciprofloxacin, an older fluoroquinolone.

DATA SELECTION

Published papers used were obtained by searching MEDLINE for articles published between 1994 and 1998, inclusive. References of published papers were also obtained and reviewed. Abstracts from scientific proceedings were reviewed.

DATA EXTRACTION

Due to the limited data available on several of the agents, criteria for study inclusion in the in vitro, pharmacokinetics and in vivo sections were not restrictive.

DATA SYNTHESIS

The new fluoroquinolones offer excellent Gram-negative bacillary activity and improved Gram-positive activity (eg, against Streptococcus pneumoniae and Staphylococcus aureus) over ciprofloxacin. Clinafloxacin, gatifloxacin, moxifloxacin, sparfloxacin and trovafloxacin display improved activity against anaerobes (eg, Bacteriodes fragilis). All of the new fluoroquinolones have a longer serum half-life than ciprofloxacin (allowing for once daily dosing), and several are eliminated predominantly by nonrenal means. No clinical trials are available comparing the new fluoroquinolones with each other. Clinical trials comparing the new fluoroquinolones with standard therapy have demonstrated good efficacy in a variety of infections. Their adverse effect profile is similar to that of ciprofloxacin. Clinafloxacin and sparfloxacin cause a high incidence of phototoxicity (1.5% to 14% and 2% to 11.7%, respectively), grepafloxacin causes a high incidence of taste perversion (9% to 17%) and trovafloxacin causes a high incidence of dizziness (11%). They all interact with metal ion-containing drugs (eg, antacids), and clinafloxacin and grepafloxacin interact with theophylline. The new fluoroquinolones are expensive; however, their use may result in savings in situations where, because of their potent and broad spectrum of activity, they can be used orally in place of intravenous antibiotics.

CONCLUSIONS

The new fluoroquinolones offer advantages over ciprofloxacin in terms of improved in vitro activity and pharmacokinetics. Whether these advantages translate into improved clinical outcomes is presently unknown. The new fluoroquinolones have the potential to emerge as important therapeutic agents in the treatment of respiratory tract and genitourinary tract infections.

Trovafloxacin: a new fluoroquinolone

OBJECTIVE

To review the pharmacology, antimicrobial activity, pharmacokinetics, clinical efficacy, and safety of trovafloxacin.

DATA SOURCES

A MEDLINE search (January 1966-April 1998) was conducted for relevant literature using the terms CP-99,219, CP-116,519, trovafloxacin, and alatrofloxacin. Abstracts published by the American Society of Microbiology during 1995-1997 meetings were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

All in vitro, animal, and human studies were reviewed for the antimicrobial activity, pharmacokinetics, efficacy, and safety of trovafloxacin.

DATA SYNTHESIS

Trovafloxacin is a new fluoroquinolone with enhanced activity against gram-positive and anaerobic microorganisms. The oral bioavailability under fasting conditions is approximately 88%. The elimination half-life of trovafloxacin is approximately 10 hours. Less than 10% of trovafloxacin is eliminated unchanged in the urine. Trovafloxacin is effective in the treatment of community-acquired pneumonia and nosocomial pneumonia with cure rates of > 90% and 77%, respectively. Trovafloxacin is comparable with ceftriaxone in the treatment of meningococcal meningitis in children; each produces a cure rate of approximately 90%. In treatment of uncomplicated urinary tract infection, both ciprofloxacin and trovafloxacin achieve an eradication rate of > or = 93%. Trovafloxacin is similar to ofloxacin in the treatment of urogenital Chlamydia trachomatis and acute exacerbations of chronic bronchitis, with clinical success in 97% of patients with each drug. The common adverse effects of trovafloxacin include dizziness, headache, and gastrointestinal intolerance.

CONCLUSIONS

The advantages of once-daily dosing and enhanced activity of trovafloxacin against gram-positive and anaerobic organisms may expand its use over available fluoroquinolones. Further studies are needed to define its role in the treatment of various infectious diseases.

Urinary excretion and bactericidal activities of a single oral dose of 400 milligrams of fleroxacin versus a single oral dose of 800 milligrams of pefloxacin in healthy volunteers

Twelve healthy volunteers participated in this randomized crossover study to compare the concentrations and recovery levels of fleroxacin and pefloxacin in urine and to assess their bactericidal activities against 12 strains of urinary pathogens with different susceptibilities over a wide range of MICs. The volunteers received a single oral dose of 400 mg of fleroxacin or 800 mg of pefloxacin. The mean cumulative renal excretion of unchanged fleroxacin, N-demethyl-fleroxacin, and N-oxide-fleroxacin accounted for 67, 7, and 6% of the total dose, respectively. The total urinary recovery of pefloxacin and the active metabolite norfloxacin was 34%. In the time-kill and the urinary bactericidal titer (UBT) studies, only the subjects' urine not supplemented with broth was used. With most tested organisms and both quinolones it took more than 8 h to achieve a reduction in CFU of 99.9% (3 log units). Overall, there was a good correlation between UBTs and MICs for the strains. Against Escherichia coli ATCC 25922 the median UBTs were similar for both antibiotics and at least 1:8 for 96 h; against the E. coli strain for which the MIC was 0.5 microgram/ml the UBT was at least 1:4 for 48 h. The UBTs of both drugs against Klebsiella pneumoniae were at least 1:16 for 72 h. The UBTs for Staphylococcus aureus (the MIC for which was 16 micrograms/ml) of both antibiotics were low, and in some of the samples, no bactericidal titers were observed. UBTs for Proteus mirabilis of pefloxacin are significantly higher than those of fleroxacin. For Pseudomonas aeruginosa the median UBTs were present for the 24-to-48-h interval. The same is true for Enterococcus faecalis. Against Staphylococcus saprophyticus, UBTs were present for at least 48 h with both quinolones. Overall, a single oral dose of 400 mg of fleroxacin exhibits UBTs comparable to those of 800 mg of pefloxacin. Therefore, it may be expected that half of the dose of fleroxacin gives comparable results in the treatment of urinary tract infections; this should be substantiated in comparative clinical trials.

Inhibitory activities of quinolones against DNA gyrase and topoisomerase IV purified from Staphylococcus aureus

In order to clarify the mechanism of action of quinolones against Staphylococcus aureus, GrlA and GrlB proteins of topoisomerase IV encoded by genes with or without mutations were purified separately as fusion proteins with maltose-binding protein in Escherichia coli. The reconstituted enzymes showed ATP-dependent decatenation and relaxing activities but had no supercoiling activity. The inhibitory effects of quinolones on the decatenation activity of topoisomerase IV were determined by quantitative electrophoresis with kinetoplast DNA as a substrate. The 50% inhibitory concentrations (IC50s) of levofloxacin, DR-3354, DU-6859a, DV-7751a, ciprofloxacin, sparfloxacin, and tosufloxacin against topoisomerase IV of S. aureus FDA 209-P were 2.3, 97, 0.45, 1.5, 2.5, 7.4, and 1.8 microg/ml, respectively, and were correlated well with their MICs. The IC50s of these drugs were from 2 to 20 times lower than those for the DNA gyrase. These results support genetic evidence that the primary target of new quinolones is topoisomerase IV in quinolone-susceptible strains of S. aureus. Three altered proteins of topoisomerase IV containing Ser-->Phe changes at codon 80 or Glu-->Lys changes at codon 84 of grlA, or both, were also purified. The inhibitory activities of quinolones against the topoisomerase IV which contained a single amino acid change were from 8 to 95 times weaker than those against the nonaltered enzyme. These results suggest that the mutations in the corresponding genes confer quinolone resistance.

Sparfloxacin worldwide in vitro literature: isolate data available through 1994

Sparfloxacin is a piperazinyl, cyclopropyl-fluoroquinolone with broad-spectrum antibacterial activity. Compared to other quinolones, sparfloxacin displays improved activity against a variety of pathogens including Staphylococcus, Streptococcus, Enterococcus, Chlamydia, Mycoplasma, Ureaplasma, and Mycobacteria species. Other susceptible organism group include Haemophilus, Legionella, Moraxella, Neisseria, Aeromonas, Acinetobacter, Bordetella, Brucella, Campylobacter, Gardnerella, and Helicobacter species. Most Enterobacteriaceae are also susceptible, whereas most isolates of Pseudomonas aeruginosa are not. Sparfloxacin is bactericidal. Activity is generally stable to variations of inoculum, pH, and cation concentration, and it is unchanged in the presence of 5% sodium cholate or 70% human serum. Susceptibility to the drug is diminished in urine. Cross-resistance, although incomplete, has been documented with other quinolones, but not with other antimicrobic classes.

Activity of two novel fluoroquinolones (DU-6859a and DV-7751a) tested against glycopeptide-resistant enterococcal isolates

Two novel fluoroquinolones, DU-6859a and DV-7751a, were compared with three peer compounds (ciprofloxacin, levofloxacin, and ofloxacin) by testing 150 strains of enterococci that were resistant to vancomycin. Standardized methods recommended by the National Committee for Clinical Laboratory Standards were used for all minimum inhibitory concentration tests, and DU-6859a was additionally tested by the standardized disk diffusion procedure (5-mu g disks). The rank order of the fluoroquinolone spectrums against these Enterococcus spp. isolates was DU-6859a (71.3% of strains inhibited at < or = 2 mu g/ml) > DV-7751a (38.7%) > levofloxacin (33.3%) > ofloxacin (32.0%) > ciprofloxacin (3.3%). Using previously proposed break point zone diameters of > or = 16 mm (susceptible) and < or = 12 mm (resistant), the DU-6859a disk diffusion tests for these glycopeptide-resistant organisms were without false-susceptible or false-resistant error (81.3% absolute agreement). These results indicate that among the investigational and currently marketed fluoroquinolones, DU-6859a appears to have the greatest potential value in the therapy of Enterococcus spp. strains that are resistant to the glycopeptides and many other therapeutic agents.

Pharmacokinetics and tolerance of a new fluoroquinolone antimicrobial drug after single oral doses in healthy volunteers

1. The pharmacokinetics and tolerance of DV-7751a were investigated in healthy male Caucasian volunteers after single oral doses (100, 200, 400 and 800 mg). 2. DV-7751a was rapidly absorbed in the fasted state. The mean maximum concentration in plasma (Cmax) ranged from 0.27 to 1.98 micrograms/ml for the 100-800-mg dose and the mean time to reach Cmax (tmax) ranged from 1.1 to 1.9 h. The terminal half-life ranged from 8.75 to 10.0 h. A good linear correlation (r = 0.974) was found between doses from 100 to 800 mg and the resulting area under the concentration-time curve (AUC). The plasma protein binding of the drug was in the range of 57-65%. 3. Within 48 h, the cumulative urinary excretion of unchanged drug amounted to 22.0-26.8% of the dose administered. Faecal recovery of the drug up to 72 h after the 400-mg dose was about 12% of the dose given. 4. Adverse events thought to be possibly related to the drug included headache, rash, leg cramp, diarrhoea, abdominal pain, CNS depression and dizziness. DV-7751a, however, was well tolerated with no serious adverse events at any doses and all subjects completed the study. No drug crystals were observed in the urine.

In vitro evaluation of DV-7751a, a new fluoroquinolone with an enhanced spectrum of activity against gram-positive aerobic organisms and anaerobes

DV-7751a is an investigational fluoroquinolone with improved spectrum and potency against gram-positive bacteria. We studied the in vitro activity of this compound against 771 recent clinical isolates by the reference agar and broth microdilution methods. Its activity was compared with those of ciprofloxacin, levofloxacin, and ofloxacin and with those of ceftazidime, oxacillin, and gentamicin where relevant. DV-7751a was four- to eightfold more active than the comparison fluoroquinolones against Enterococcus spp. (including vancomycin-resistant strains), Staphylococcus spp. (including oxacillin-resistant Staphylococcus aureus), Streptococcus spp., other gram-positive pathogens, and some anaerobes. The DV-7751a activity against most gram-negative species was similar to that of ofloxacin and ciprofloxacin. DV-7751a appears to be a candidate for the therapy of some mixed-flora infections and the treatment of bacteria resistant to the current fluoroquinolones.

Determination of a new fluoroquinolone antimicrobial agent, (S)-10-[(S)-(8-amino-6-azaspiro d3,4]octan-6-yl)]-9-fluoro-2, 3-dihydro-3-methyl-7-oxo-7H-pyrido[1,2,3-de][1,4]benzoxazine-6- carboxylic acid hemihydrate, DV-7751a, in human serum and urine using solid-phase extraction and high-performance liquid chromatography with fluorescence detection

A high-performance liquid chromatographic method for the determination of a new fluoroquinolone antimicrobial agent, (S)-10-[(S)-(8-amino-6-azaspiro[3,4]octan-6-yl)]-9-fluoro-2,3- dihydro-3-methyl-7-oxo-7H-pyrido[1,2,3-de][1,4]benzoxazine-6-carboxylic acid hemihydrate (DV-7751a, I) in human serum and urine has been developed. Compound I and the internal standard were extracted from serum and urine by means of Bond Elut C8 LRC column. The extracts were chromatographed on a reversed-phase Inertsil ODS-2 column using tetrahydrofuran-50 mM KH2PO4 (pH2)-1 M ammonium acetate (19:81:1, v/v) as the mobile phase at a flow-rate of 1.0 ml/min. Fluorescence detection at an excitation wavelength of 305 nm and an emission wavelength of 530 nm resulted in a limit of quantitation of 0.0098 microgram/ml for serum and 0.098 microgram/ml for urine. The method showed satisfactory sensitivity, precision, accuracy, recovery and selectivity. Stability studies showed that I was stable in serum and urine for at least 1 month at -20 degrees C and for at least 48 h at room temperature.

In vitro activity of fluoroquinolones against gram-positive bacteria

This paper reviews the in vitro activities of several newer fluoroquinolone antimicrobials that exhibit enhanced potency against Gram-positive bacteria. Several of these agents demonstrate 10-fold greater activity than older members of this class against Staphylococcus aureus and inhibit [minimum inhibitory concentration (MIC90) values < or = 2 mg/L] many isolates resistant to ciprofloxacin or ofloxacin. Markedly enhanced activity is also noted against Streptococcus pneumoniae, 90% of isolates being inhibited at concentrations 10- to 100-fold lower than those of the older agents. Enterococci also exhibit greater susceptibility to several of the newer fluoroquinolones, although relative cross-resistance with the earlier drugs is noted. As determined by dilution techniques, the new fluoroquinolones generally demonstrate bactericidal activity at concentrations at or near their MIC values. The activities of the new compounds described here are decreased at low pH, but are not affected by the addition of up to 50% human serum to the test medium. Resistance is rarely detected (frequency < 10(-9)) when high density bacterial suspensions are plated in the presence of 4 times the MIC of these compounds. However, colonies displaying relative resistance to the new agents can be selected by serial passage in incremental antimicrobial concentrations.

Comparison of inhibition of Escherichia coli topoisomerase IV by quinolones with DNA gyrase inhibition

In order to examine the inhibitory activities of quinolones against topoisomerase IV, both subunits of this enzyme, ParC and ParE, were purified from Escherichia coli. The specific activity of topoisomerase IV decatenation was found to be more than five times greater than that of topoisomerase IV relaxation. Thus, the decatenation activity of topoisomerase IV seems the most relevant activity for use in studies of drug inhibition of this enzyme. Although topoisomerase IV was less sensitive to quinolones than DNA gyrase, the 50% inhibitory concentrations for decatenation were significantly lower than those for type I topoisomerases. Moreover, there was a positive correlation between the inhibitory activity against topoisomerase IV decatenation and that for DNA gyrase supercoiling. These results imply that topoisomerase IV could be a target for the quinolones in intact bacteria and that quinolones could inhibit not only supercoiling of DNA gyrase but also decatenation of topoisomerase IV when high concentrations of drug exist in bacterial cells.