Efficacy and safety of a novel once-daily extended-release ciprofloxacin tablet formulation for treatment of uncomplicated urinary tract infection in women

Antibiotic Switches in Urinary Tract Infection Are Associated With Atypical Symptoms and Emergent Care

IMPORTANCE

Given worsening global antibiotic resistance, antimicrobial stewardship aims to use the shortest effective duration of the most narrow-spectrum, effective antibiotic for patients with specific urinary symptoms and laboratory testing consistent with urinary tract infection (UTI). Inappropriate treatment and unnecessary antibiotic switching for UTIs harms patients in a multitude of ways.

OBJECTIVE

This study sought to analyze antibiotic treatment failures as measured by antibiotic switching for treatment of UTI in emergent and ambulatory care.

STUDY DESIGN

For this retrospective cohort study, 908 encounters during July 2019 bearing a diagnostic code for UTI/cystitis in a single health care system were reviewed. Urinary and microbiological testing, symptoms endorsed at presentation, and treatments prescribed were extracted from the medical record.

RESULTS

Of 908 patients diagnosed with UTI, 64% of patients (579/908) received antibiotics, 86% of which were empiric. All patients evaluated in emergent care settings were prescribed antibiotics empirically in contrast to 71% of patients in ambulatory settings (P < 0.001). Of patients given antibiotics, 89 of 579 patients (15%, 10% of all 908 patients) were switched to alternative antibiotics within 28 days. Emergent care settings and positive urine cultures were significantly associated with increased antibiotic switching. Patients subjected to switching tended to have higher rates of presenting symptoms inconsistent with UTI.

CONCLUSIONS

Empiric treatment, particularly in an emergent care setting, was frequently inappropriate and associated with increasing rates of antibiotic switching. Given the profound potential contribution to antibiotic resistance, these findings highlight the need for improved diagnostic and prescribing accuracy for UTI.

Oral ciprofloxacin activity against ceftriaxone-resistant Escherichia coli in an in vitro bladder infection model

OBJECTIVES

Pharmacodynamic profiling of oral ciprofloxacin dosing for urinary tract infections caused by ceftriaxone-resistant Escherichia coli isolates with ciprofloxacin MIC ≥ 0.25 mg/L.

BACKGROUND

Urine-specific breakpoints for ciprofloxacin do not exist. However, high urinary concentrations may promote efficacy in isolates with low-level resistance.

METHODS

Ceftriaxone-resistant E. coli urinary isolates were screened for ciprofloxacin susceptibility. Fifteen representative strains were selected and tested using a dynamic bladder infection model. Oral ciprofloxacin dosing was simulated over 3 days (250 mg daily, 500 mg daily, 250 mg 12 hourly, 500 mg 12 hourly and 750 mg 12 hourly). The model was run for 96 h. Primary endpoint was change in bacterial density at 72 h. Secondary endpoints were follow-up change in bacterial density at 96 h and area-under-bacterial-kill-curve. Bacterial response was related to exposure (AUC0-24/MIC; Cmax/MIC). PTA was determined using Monte-Carlo simulation.

RESULTS

Ninety-three clinical isolates demonstrated a trimodal ciprofloxacin MIC distribution (modal MICs at 0.016, 0.25 and 32 mg/L). Fifteen selected clinical isolates (ciprofloxacin MIC 0.25-512 mg/L) had a broad range of quinolone-resistance genes. Following ciprofloxacin exposure, E. coli ATCC 25922 (MIC 0.008 mg/L) was killed in all dosing experiments. Six isolates (MIC ≥ 16 mg/L) regrew in all experiments. Remaining isolates (MIC 0.25-8 mg/L) regrew variably after an initial period of killing, depending on simulated ciprofloxacin dose. A >95% PTA, using AUC0-24/MIC targets, supported 250 mg 12 hourly for susceptible isolates (MIC ≤ 0.25 mg/L). For isolates with MIC ≤ 1 mg/L, 750 mg 12 hourly promoted 3 log10 kill at the end of treatment (72 h), 1 log10 kill at follow-up (96 h) and 90% maximal activity (AUBKC0-96).

CONCLUSIONS

Bladder infection modelling supports oral ciprofloxacin activity against E. coli with low-level resistance (ciprofloxacin MIC ≤ 1 mg/L) when using high dose therapy (750 mg 12 hourly).

Efficacy and safety of quinolones for the treatment of uncomplicated urinary tract infections in women: a network meta-analysis

INTRODUCTION AND HYPOTHESIS

Uncomplicated urinary tract infection (uUTI) is defined as the presence of pathogenic organisms in the urinary tract without anatomical and functional abnormalities, is accompanied by inflammatory leukocytes and cytokines and may or may not develop clinical symptoms. The frequency of uncomplicated urinary tract infection is higher in young women. Several quinolone treatment regimens are available; however, since we do not know which is the best antibiotic regimen for the treatment of this urinary infection, we analyzed the published evidence and conducted a systematic review with network meta-analysis. The aim was to compare and hierarchize quinolones according to their efficacy and safety and to identify the best treatment for uncomplicated urinary tract infection in women through a systematic review with network meta-analysis.

METHODS

Medline, Embase, LILACS, Cochrane CENTRAL and other databases were searched for trials. Bias in the trials was assessed using the Cochrane Collaboration tool. To analyze efficacy and adverse events, for direct comparisons, we obtained risk ratios and 95% confidence intervals by applying a fixed-effects model using tau² and Q² tests to calculate the heterogeneity. For the network meta-analysis, we analyzed the indirect comparisons by Bucher's method.

RESULTS

We included 18 trials (8765 women). For premenopausal women, ofloxacin had a 57% probability of achieving remission but an 83% frequency of adverse events. For postmenopausal women, ofloxacin was 82% more effective for remission, with a 49% frequency of adverse events, compared with other types of quinolones.

CONCLUSIONS

Compared with other quinolones, ofloxacin 200 mg once daily for a treatment duration < 3 days provides the highest clinical and bacteriological remission rates with the lowest relapse and resistance rates for the treatment of women with uUTIs. However, additional trials are needed to confirm our findings, especially when the treatment duration exceeds 3 days.

Diagnosis and treatment of urinary tract infections across age groups

Urinary tract infections are the most common outpatient infections, but predicting the probability of urinary tract infections through symptoms and test results can be complex. The most diagnostic symptoms of urinary tract infections include change in frequency, dysuria, urgency, and presence or absence of vaginal discharge, but urinary tract infections may present differently in older women. Dipstick urinalysis is popular for its availability and usefulness, but results must be interpreted in context of the patient's pretest probability based on symptoms and characteristics. In patients with a high probability of urinary tract infection based on symptoms, negative dipstick urinalysis does not rule out urinary tract infection. Nitrites are likely more sensitive and specific than other dipstick components for urinary tract infection, particularly in the elderly. Positive dipstick testing is likely specific for asymptomatic bacteriuria in pregnancy, but urine culture is still the test of choice. Microscopic urinalysis is likely comparable to dipstick urinalysis as a screening test. Bacteriuria is more specific and sensitive than pyuria for detecting urinary tract infection, even in older women and during pregnancy. Pyuria is commonly found in the absence of infection, particularly in older adults with lower urinary tract symptoms such as incontinence. Positive testing may increase the probability of urinary tract infection, but initiation of treatment should take into account risk of urinary tract infection based on symptoms as well. In cases in which the probability of urinary tract infection is moderate or unclear, urine culture should be performed. Urine culture is the gold standard for detection of urinary tract infection. However, asymptomatic bacteriuria is common, particularly in older women, and should not be treated with antibiotics. Conversely, in symptomatic women, even growth as low as 10² colony-forming unit/mL could reflect infection. Resistance is increasing to fluoroquinolones, beta-lactams, and trimethoprim-sulfamethoxazole. Most uropathogens still display good sensitivity to nitrofurantoin. First-line treatments for urinary tract infection include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%). These antibiotics have minimal collateral damage and resistance. In pregnancy, beta-lactams, nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole can be appropriate treatments. Interpreting the probability of urinary tract infection based on symptoms and testing allows for greater accuracy in diagnosis of urinary tract infection, decreasing overtreatment and encouraging antimicrobial stewardship.

Guía de práctica clínica sobre diagnóstico y tratamiento de infección de vías urinarias no complicada en mujeres adquirida en la comunidad

<p class="p1"><span class="s1">Mediante un proceso de adaptación de guías de práctica clínica se seleccionaron y evaluaron guías de infección de vías urinarias en mujeres premenopáusicas no embarazadas; se identificaron 3 de alta calidad. Con base en las evidencias y las recomendaciones aportadas por estas guías, se realizó un consenso para realizar recomendaciones para personal de salud —médicos, personal de laboratorio y enfermeros— sobre el diagnóstico de las infecciones urinarias —cistitis y pielonefritis—, sus tratamientos y prevención de la recurrencia.</span></p>

A gastroretentive gabapentin formulation for the treatment of painful diabetic peripheral neuropathy: efficacy and tolerability in a double-blind, randomized, controlled clinical trial

AIMS

A randomized, double-blind, placebo-controlled study was conducted in 147 patients to determine the efficacy and safety of a gastroretentive formulation of gabapentin (G-GR) in treating painful diabetic peripheral neuropathy (DPN).

METHODS

Diabetic patients with symmetrical painful symptoms in distal extremities for 1-5 years and a baseline average daily pain (ADP) score of ≥4 received G-GR 3000mg, as a single evening daily dose (G-GR-QD) or a divided dose (G-GR-DD, 1200mg AM/1800mg PM), or placebo for 4 weeks. G-GR was titrated from 300 to 3000mg/day over 2 weeks, followed by 2 additional weeks at 3000mg/day. Efficacy measures included changes from baseline to Week 4 in ADP score and average daily sleep interference score (SIS).

RESULTS

A significantly larger decrease in ADP score was observed in the G-GR-QD dose group compared with placebo (-2.50 versus -1.30; p=0.002). A ≥50% reduction in ADP score was achieved in 34.8% of G-GR-QD recipients compared with 7.8% of placebo recipients (p=0.001). Similar results were observed for changes in SIS. The incidences of dizziness and somnolence, commonly associated with gabapentin, were low.

CONCLUSIONS

Once-daily G-GR was effective and well tolerated for the treatment of pain due to DPN.

Early pain reduction can predict treatment response: results of integrated efficacy analyses of a once-daily gastroretentive formulation of gabapentin in patients with postherpetic neuralgia

OBJECTIVE

The objectives of this study were to identify and determine the validity of early decision criteria following once-daily gastroretentive gabapentin (G-GR) treatment in patients with postherpetic neuralgia (PHN).

DESIGN

In two placebo-controlled studies, 279 patients were randomized to 1,800 mg G-GR and 270 to placebo with the evening meal; patients underwent a 2-week dose titration, followed by 8 weeks of stable dosing, and 1 week of dose tapering. Patients.  Adults with PHN for ≥6 months and an average baseline Numerical Pain Rating Scale (NPRS) score of ≥4 were included in the study.

OUTCOME MEASURES

Percent change from baseline to week 10 in NPRS scores and the percentage of responders (defined as ≥30% reduction in NPRS scores from baseline to week 10) were determined.

METHODS

Patients randomized to G-GR were categorized at each week based on their percent pain reduction up to that week, and for each category, the percentage of week 10 responders was computed. For several early-improvement criteria, the percentage of week 10 responders, odds ratios for achieving week 10 treatment response, sensitivity, and specificity were calculated.

RESULTS

There was a significant positive association between early pain reduction and week 10 treatment response. Pain reduction of <10% at week 5 of G-GR treatment was the best early predictor of lack of endpoint response, with only 8% of these patients moving on to become week 10 treatment responders.

CONCLUSIONS

Early response was a reliable predictor of final response. This approach holds promise for aiding clinicians in decision making regarding the need for alternative or supplemental treatment during G-GR therapy for PHN.

Antibiotic treatment of uncomplicated urinary tract infection in premenopausal women

Uncomplicated urinary tract infections (UTIs) in otherwise healthy premenopausal women are one of the most frequent infections in the community. Therefore any improvement in management will have a high impact not only on the quality of life of the individual patient but also on the health system. In placebo-controlled studies antimicrobial treatment was significantly more effective than placebo, but on the other hand showed more adverse events. The choice of antibiotic depends on the spectrum and susceptibility patterns of the uropathogens, its effectiveness for this indication, its tolerability, its collateral effects and cost. After a systematic literature search, recommendations for empiric treatment of acute uncomplicated cystitis and acute uncomplicated pyelonephritis and for follow-up strategies were developed.

International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.

Efficacy and safety of ciprofloxacin XR 1000 mg once daily versus ciprofloxacin 500 mg twice daily in the treatment of complicated urinary tract infections

The aim of this trial was to compare the efficacy and safety of extended-release ciprofloxacin (CIPRO XR) versus the immediate-release formulation (CIPRO IR) in the treatment of complicated urinary tract infections (UTIs). 212 patients were randomized to CIPRO XR 1,000 mg tablet once daily or CIPROXIN IR 500 mg tablet twice daily. Treatment efficacy was evaluated by bacteriological outcome. Safety was measured by recording adverse events. The rate of bacteriological eradication was 83% in the CIPRO XR group and 75% in the CIPRO IR. the overall incidence of adverse events reported was higher in the CIPRO IR group. The authors conclude that CIPRO XR is a safe and effective treatment for complicated UTIs. Although the limited data available do not consent to support a statistically superior efficacy or safety compared to CIPRO IR, a trend in favor of CIPRO XR is clearly evident in all efficacy and safety variables. CIPRO XR is associated with reduced frequencies of drug-related adverse events compared to CIPRO IR.

Women's views about management and cause of urinary tract infection: qualitative interview study

OBJECTIVES

To explore the views of women with urinary tract infection on the acceptability of different strategies for managing the infection, including delayed use of antibiotics, and the cause of infection.

DESIGN

Qualitative interview study with semistructured one to one interviews within a randomised controlled trial of different management strategies. Analysis drew on some of the principles of constant comparison to generate key themes grounded in reported experiences and understandings.

SETTING

Seven general practices across four counties in southern England.

PARTICIPANTS

21 women presenting to general practices who were taking part in the larger trial.

RESULTS

Women preferred not to take antibiotics and were open to alternative management approaches. With a strategy of "antibiotic delay" some women felt a lack of validation or that they were not listened to by their general practitioner. Women attributed urinary tract infection to lifestyle habits and behaviours, such as poor hygiene, general "negligence," and even a "penalty of growing old."

CONCLUSION

A clear acknowledgment of women's triggers to consult is needed. If women are asked to delay taking antibiotics, the clinician must address the particular worries that women might have and explain the rationale for not using antibiotics immediately.

Ciprofloxacin prolonged-release tablets do not affect warfarin pharmacokinetics and pharmacodynamics

The purpose of this study was to determine whether the pharmacokinetics of warfarin and ciprofloxacin PR (a prolonged-release formulation of ciprofloxacin) were altered after coadministration. Eighteen healthy male volunteers were given a single oral 7.5-mg dose of warfarin, a single oral 500-mg dose of ciprofloxacin PR, or both drugs administered together in a randomized, open-label, 3-way crossover study. Ciprofloxacin concentrations, warfarin (R)- and (S)-enantiomer concentrations, prothrombin time, and activated partial thromboplastin time were measured over 120 hours following study drug administration. There were no significant differences in pharmacokinetic or pharmacodynamic parameters among treatments. A slightly greater value of half-life for (R)-warfarin was observed when coadministered with ciprofloxacin PR compared with warfarin administered alone (52.6 vs 50.1 hours, P = .029). This difference is not considered clinically relevant, because the values remain similar. These results show that warfarin pharmacokinetics and pharmacodynamics are not altered with concomitant administration of ciprofloxacin PR.

Case studies in swelling polymeric gastric retentive tablets

Swelling tablets administered in the fed state have been shown to provide therapeutic advantages in two marketed products, with the duration of delivery characterised with respect to food and tablet size. Metformin extended-release tablets are a diffusion-based swelling tablet demonstrating once-daily efficacy with good gastrointestinal solubility. Ciprofloxacin extended-release tablets are based on an erosional matrix that delivers the drug to the upper gastrointestinal tract over 6 h to provide once-daily efficacy with reduced incidences of nausea and diarrhoea. Furosemide extended-release tablets are another example of an erosional matrix designed to deliver furosemide to the duodenum and upper jejunum over 6 h to provide a more gradual diuresis and naturesis compared with the immediate-release product.

Effect of omeprazole on bioavailability of an oral extended-release formulation of ciprofloxacin

PURPOSE

The effect of omeprazole on the oral bioavailability and urinary exposure of the Depomed formulation of extended-release (ER) ciprofloxacin was studied.

METHODS

A two-way crossover study was conducted in healthy subjects. Subjects received either a single dose of ER ciprofloxacin 1000 mg or a single dose of ER ciprofloxacin 1000 mg following three days of treatment with omeprazole 40 mg. Blood and urine samples were collected over 36 hours, and ciprofloxacin concentrations were determined using high-performance liquid chromatography.

RESULTS

Twenty-seven subjects (16 men, 11 women) received both treatments. The mean maximum concentration, mean area under the plasma-versus-concentration curve, and mean amount of ciprofloxacin excreted in urine were similar between the two treatments and met strict bioequivalence criteria.

CONCLUSION

Omeprazole did not affect the plasma or urinary pharmacokinetics of an oral ER formulation of ciprofloxacin.

The treatment of urinary tract infections and use of ciprofloxacin extended release

Urinary tract infections (UTIs) are one of the most common reasons people seek medical attention. There are > 50% of women who will have at least one UTI during their lifetime and most of these will require a physician visit and antibiotic treatment. The high prevalence continues to the in-patient setting where genitourinary infections are the most common nosocomial infection. The efficient diagnosis and effective treatment of UTIs is a major healthcare concern. Factors such as economic efficiency and emerging resistance are increasingly becoming more important considerations in providing patient care. In out-patient uncomplicated UTIs, Escherichia coli has been implicated in < or = 75-90% of cases. Although the prevalence in the in-patient setting decreases, E. coli is still the most common bacteria identified and present in 21-54% of urinary isolates. Trimethoprim-sulfamethoxazole has been the preferred first-line agent for uncomplicated out-patient UTIs where local resistance is < 10 - 20%. In recent years, resistance has superseded this threshold in most regions of the US and Europe. In these areas with increased resistance, fluoroquinolones have become a common first-line agent. Ciprofloxacin has been one of the most widely used fluoroquinolones and has a well-known safety profile, as well as excellent activity against most of the common uropathogens. Ciprofloxacin extended release (ER) is a recently released once-daily formulation that has been increasingly used with good clinical success. The pharmacokinetic and pharmacodynamic parameters of ciprofloxacin ER are shown to be at least equal to twice-daily ciprofloxacin and may even confer superiority as ciprofloxacin ER achieves a higher maximum serum concentration. This is supported by clinical studies, which have shown at least as effective clinical cure and bacteriological eradication rates. These studies have also demonstrated similar tolerability and side-effect profiles. Ciprofloxacin ER combines traditional ciprofloxacin's proven track record of efficacy and safety with favourable pharmacokinetics and convenient once-daily dosing. Increased patient compliance is associated with decreased treatment failures and can help slow the development of antimicrobial resistance. Economic considerations are also increasingly important and providing convenient and effective treatment leading to high clinical success decreases overall costs.

Ciprofloxacin for the management of urinary tract infection

Urinary tract infections are common, especially among women. A number of agents are available for the treatment of urinary tract infections but emerging resistance to commonly used first-line therapies has impacted the selection of empirical therapy. Ciprofloxacin was the first member of the fluoroquinolone class of antibiotics to be widely available and is effective for the management of urinary tract infections. An extended-release formulation has recently become available that allows once-daily dosing, which may improve patient adherence and convenience. Clinical trials have demonstrated that the extended-release formulation is as effective as the standard formulation in the management of acute uncomplicated cystitis, complicated urinary tract infections and acute uncomplicated pyelonephritis. The pharmacokinetics of the extended-release formulation may offer potential advantages in terms of microbial eradication and clinical response; however, this has yet to be demonstrated in clinical trials. In the USA and western Europe, overall rates of quinolone resistance among common uropathogens have remained low; however, reports of increasing resistance from certain geographical areas are of great concern. Risk factors for resistance are currently poorly defined.

Duration of antibacterial treatment for uncomplicated urinary tract infection in women

BACKGROUND

Uncomplicated urinary tract infection (UTI) is a common disease, occurring frequently in young sexually active women. In the past, seven day antibiotic therapy was recommended while the current practice is to treat uncomplicated UTI for three days.

OBJECTIVES

TO compare the efficacy and safety of three-day antibiotic therapy to multi-day therapy (five days or longer) on relief of symptoms and bacteriuria at short-term and long-term follow-up.

SEARCH STRATEGY

The Cochrane Library (Issue 1, 2004), the Cochrane Renal Group's Register of trials (July 2003), EMBASE (January 1980 to August 2003), and MEDLINE (January 1966 to August 2003) were searched. We scanned references of all included studies and contacted the first or corresponding author of included trials and the pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing three-days oral antibiotic therapy with multi-day therapy (five days and longer) for uncomplicated cystitis in 18 to 65 years old non-pregnant women without signs of upper UTI.

DATA COLLECTION AND ANALYSIS

Data concerning bacteriological and symptomatic failure rates, occurrence of pyelonephritis and adverse effects were extracted independently by two reviewers. Relative risk (RR) and their 95% confidence intervals (CI) were estimated. Outcomes were also extracted by intention-to-treat analysis whenever possible.

MAIN RESULTS

Thirty-two trials (9605 patients) were included. For symptomatic failure rates, no difference between three-day and 5-10 day antibiotic regimen was seen short-term (RR 1.06, 95% CI 0.88 to 1.28) and long-term follow-up (RR 1.09, 95% CI 0.94 to 1.27). Comparison of the bacteriological failure rates showed that three-day therapy was less effective than 5-10 day therapy for the short-term follow-up, however this difference was observed only in the subgroup of trials that used the same antibiotic in the two treatment arms (RR 1.37, 95% CI 1.07 to 1.74, P = 0.01). This difference was more significant at long-term follow-up (RR 1.43, 95% CI 1.19 to 1.73, P = 0.0002). Adverse effects were significantly more common in the 5-10 day treatment group (RR 0.83, 95% CI 0.74 to 0.93, P = 0.0010). Results were consistent for subgroup and sensitivity analyses.

AUTHORS' CONCLUSIONS

Three days of antibiotic therapy is similar to 5-10 days in achieving symptomatic cure during uncomplicated UTI treatment, while the longer treatment is more effective in obtaining bacteriological cure. In spite of the higher rate of adverse effects, treatment for 5-10 days could be considered for treatment of women in whom eradication of bacteriuria is important.