A retrospective study of the efficacy and safety of levofloxacin in children with severe infection

Objectives

Levofloxacin is widely used because of its broad-spectrum antimicrobial activity and convenient dosing schedule. However, the relevance of its use in children remains to be investigated. The purpose of this study is to investigate the efficacy and safety of levofloxacin use in children with severe infections.

Methods

We conducted a retrospective observational study of patients <18 years of age who received levofloxacin intravenously in the Pediatric Intensive Care Unit (PICU) of our hospital during the period between 2021 and 2022. Patient demographics, course characteristics, clinical effectiveness, and adverse event correlations were extracted through a retrospective tabular review.

Results

We included 25 patients treated with 28 courses of levofloxacin. The mean age of these children treated with levofloxacin was 4.41 years. Conversion of pathogenic microbiological test results to negative after levofloxacin treatment was detected in 11 courses (39.29%). A decrease in inflammatory markers, white blood cell or C-reactive protein counts, was detected in 18 courses (64.29%). A total of 57 adverse events occurred during the treatment period, of which 21 were possibly related to levofloxacin and no adverse events were probably related to levofloxacin.

Conclusion

The effectiveness of levofloxacin use in children with serious infections is promising, especially for the treatment of multidrug-resistant bacteria. Adverse events occurring during the initiation of levofloxacin therapy in children are reported to be relatively common, but in this study, only a small percentage of them were possibly related to levofloxacin, and none of them were highly possibly related to levofloxacin.

[Should fluoroquinolones be feared during pregnancy and breastfeeding?]

Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin and moxifloxacin) are antibiotics which pharmacological and therapeutic advantages resulted in a large use, now restricted because of resistances emergence and adverse effect risk. For pregnant or breastfeeding women they still are a cause of concern, based on the joint toxicity described in children directly treated, thus limiting their use in these populations. However, the data about exposed pregnancies published over time have not so far confirm these fears and allow, when a fluoroquinolone is clearly indicated, not to deprive pregnant patients of the therapeutic benefit of these important antibiotics and to envisage their use whatever the term of the pregnancy, within the current scope of their prescription. During breastfeeding the use of some of them can be considered.

Association of Outpatient Oral Macrolide Use With Sensorineural Hearing Loss in Children, Adolescents, and Young Adults

Importance

Prior publications have reported the sporadic development of sensorineural hearing loss (SNHL) after intravenous or high-dose macrolide therapy for adults with comorbid conditions, but investigations of the auditory effect of oral outpatient dosing for children, adolescents, and young adults have been limited.

Objective

To determine whether broad-based outpatient use of oral macrolide therapy is associated with increased risk of pediatric SNHL through nationally representative analyses.

Design, Setting, and Participants

A retrospective case-control study of 875 matched pairs of children, adolescents, and young adults was performed, matching on age, sex, and the time elapsed since prescription date. All eligible pediatric patients were included, with matched control participants from the TRICARE US military health insurance system who were evaluated between October 1, 2009, and September 30, 2014.

Exposures

Oral outpatient macrolide treatment compared with penicillin use among pediatric patients.

Main Outcomes and Measures

The clinical outcome of interest was SNHL in children, adolescents, and young adults. Multivariable conditional logistic regression was used to compare the risk of prior macrolide exposure with penicillin exposure, adjusted for other risk factors and potential confounders. Four time frames between exposure and diagnosis were additionally assessed.

Results

There were 875 eligible matched pairs of children, adolescents, and young adults included. The mean (SD) age of the participants was 5.7 (4.9) years; 1082 participants were male (62%), 58 were Asian (3%), 254 were Black (15%), 1152 were White (66%), and 286 were of Native American and other (no further breakdown was available in the TRICARE database) race and ethnicity (16%). In multivariable analysis, participants who had SNHL had increased odds of having received a macrolide prescription compared with a penicillin prescription when all time frames from exposure were included (adjusted odds ratio, 1.31; 95% CI, 1.05-1.64). There were significantly higher odds of macrolide exposure than penicillin exposure when diagnosis and testing occurred more than 180 days after antibiotic exposure (adjusted odds ratio, 1.79; 95% CI, 1.23-2.60).

Conclusions and Relevance

In this case-control study of a nationally representative patient population, findings suggest that children, adolescents, and young adults with SNHL had increased odds of outpatient oral macrolide use compared with penicillin use, particularly when having received a diagnosis more than 180 days after exposure. Further study of the association of macrolides with SNHL in children, adolescents, and young adults is warranted.

Pharmacotherapy for Bordetella pertussis infection. II. A synthesis of clinical sciences

Despite the plethora of studies that have examined laboratory susceptibility testing for Bordetella pertussis, assessments of treatment have lagged far behind both in quality and quantity. Macrolides and trimethoprim/sulfamethoxazole historically served the needs of both treatment and prevention, albeit there is still controversy about the degree of protection measured both bacteriologically and clinically. As high-level macrolide resistance has emerged in some geographic regions and since macrolides have been the mainstay of therapy, alternative antibiotics need to be defined for pertussis. In vitro susceptibility testing suggests the potential for several alternatives to macrolides, including trimethoprim/sulfamethoxazole, specific β-lactam agents, chloramphenicol, some quinolones and possibly some tetracyclines. For the latter antibiotics, more clinical studies for treatment and prophylaxis are required in to order to establish bacteriological-clinical correlates for outcome. In the interim, if the clinical circumstances mandate the use of proposed interim alternatives to macrolides, outcomes should be assessed with test of cure by culture, since genetic amplification technologies do not discriminate bacterial viability. Whereas there may be debate in regard to using placebo or macrolides as the controls for alternative antibiotic therapy in geographies where most B. pertussis isolates are antibiotic-susceptible, both placebo and macrolide controls should be assessed along with alternative antibiotics in well-designed controlled studies in regions pressured by macrolide resistance. Outcomes of clinical response and epidemiological patterns of disease should continue to be monitored given the degree of macrolide resistance that is emerging.

Anti-infective treatment of purulent meningitis caused by carbapenem-resistant Klebsiella pneumoniae in a newborn: a case report

The widespread use of carbapenems has caused a notable spread of carbapenem-resistant Klebsiella pneumoniae (CRKP). The incidence of CRKP-associated infections is rising significantly in neonatal intensive care units (NICUs), which poses a grave challenge to clinical treatment. This paper is to highlight the drug treatment of CRKP with purulent meningitis in children and explore the safety of levofloxacin in children. We retrospectively analyzed the clinical data of combination therapy with levofloxacin and aztreonam in a newborn with purulent meningitis caused by CRKP. As clinical pharmacists, we evaluated the risks and benefits of quinolones for anti-infective treatment in newborns, helped clinicians adjust the anti-infective protocol of levofloxacin combined with aztreonam and provided pharmaceutical care throughout the course of treatment. In the end, the child had no fever, no dyspnea, and no obvious abnormalities in brain color Doppler ultrasound. The intracranial infection was finally controlled, and the child improved and was discharged, with no apparent neurological, skeletal, joint, tendon, or cardiac adverse events. For newborns with CRKP-associated purulent meningitis, fluoroquinolones combined with other drugs such as polymyxin, tigecycline, aminoglycosides, minocycline, that Klebsiella pneumoniae is susceptible to (when no safe and effective anti-infective alternatives are available) can reduce the mortality rate of newborns with purulent meningitis caused by carbapenem-resistant gram-negative bacteria. We analyzed the drug resistance mechanisms of CRKP, the selection of antibiotic agents, the safety of quinolones in children, the permeability of the blood-brain barrier to quinolones, and the selection of the quinolone dose. Personalized combination therapy improves treatment outcomes and reduces adverse reactions, especially in patients with resistant bacteria infection.

Multidrug-resistant organisms in urinary tract infections in children

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

Genotypic and phenotypic characterization of Mycobacterium tuberculosis resistance against fluoroquinolones in the northeast of Iran

BACKGROUND

Fluoroquinolones are broad-spectrum antibiotics that are recommended, and increasingly important, for the treatment of multidrug-resistant tuberculosis (MDR-TB). Resistance to fluoroquinolones is caused by mutations in the Quinolone Resistance Determining Region (QRDR) of gyrA and gyrB genes of Mycobacterium tuberculosis. In this study, we characterized the phenotypic and genotypic resistance to fluoroquinolones for the first time in northeast Iran.

METHODS

A total of 123 Mycobacterium tuberculosis isolates, including 111 clinical and 12 collected multidrug-resistant isolates were studied. Also, 19 WHO quality control strains were included in the study. The phenotypic susceptibility was determined by the proportion method on Löwenstein-Jensen medium. The molecular cause of resistance to the fluoroquinolone drugs ofloxacin and levofloxacin was investigated by sequencing of the QRDR region of the gyrA and gyrB genes.

RESULTS

Among 123 isolates, six (4.8%) were fluoroquinolone-resistant according to phenotypic methods, and genotypically three of them had a mutation at codon 94 of the gyrA gene (Asp→ Gly) which was earlier reported to cause resistance. All three remaining phenotypically resistant isolates had a nucleotide change in codon 95. No mutations were found in the gyrB gene. Five of the 19 WHO quality control strains, were phenotypically fluoroquinolone-resistant, four of them were genotypically resistant with mutations at codon 90, 91 of the gyrA gene and one resistant strain had no detected mutation.

CONCLUSIONS

Mutation at codon 94 of the gyrA gene, was the main cause of fluoroquinolone resistance among M. tuberculosis isolates in our region. In 3/6 fluoroquinolone-resistant isolates, no mutations were found in either gyrA or gyrB. Therefore, it can be concluded that various other factors may lead to fluoroquinolone resistance, such as active efflux pumps, decreased cell wall permeability, and drug inactivation.

Enoxacin inhibits proliferation and invasion of human osteosarcoma cells and reduces bone tumour volume in a murine xenograft model

Osteosarcoma is the most prevalent primary bone malignancy in children and adolescents. Neoadjuvant chemotherapy combined with surgical resection, the current standard treatment of osteosarcoma, is associated with a 5-year survival rate of only ~70%. Therefore, it is necessary to identify new, more effective treatment strategies for patients with this lethal disease. Enoxacin is a highly effective broad-spectrum fluoroquinolone antibiotic with low toxicity. The drug inhibits the growth and metastasis of numerous tumour types, but its efficacy has not been studied in osteosarcoma. This study assessed the antitumour effects of enoxacin in osteosarcoma 143B cells and in a murine tumour xenograft model. Enoxacin inhibited the proliferation, invasion and migration of 143B cells, as well as inducing their apoptosis. These effects were thought to be mediated by downregulation of Bcl-xL, Bxl-2, matrix metalloproteinase (MMP)2 and MMP9 expression. Enoxacin also significantly impaired the growth of bone tumours in nude mice without affecting their liver or kidney function, or blood cell count. Collectively, these results indicate that enoxacin is a promising new drug for osteosarcoma that warrants further evaluation in clinical studies.

Quinolones for sepsis. A protocol for a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

BACKGROUND

Sepsis is a relatively common and deadly condition that constitutes a major challenge to the modern health care system. Quinolones are sometimes used in combination with beta-lactam antibiotics for sepsis, but no former systematic review has assessed the benefits and harms of quinolones in patients with sepsis.

METHODS

We will perform a systematic review with meta-analysis and trial sequential analysis including randomised clinical trials assessing the effects of quinolones as add on therapy to usual care in children and adults with sepsis. For the assessment of harms, we will also include quasi-randomised studies and observational studies identified during our searches for randomised clinical trials.

DISCUSSION

This systematic review will clarify if there is evidence to support quinolones being part of the standard treatment for sepsis.

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.

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada

INTRODUCTION

Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

OBJECTIVE

We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada.

METHODS

Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests.

RESULTS

From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases.

CONCLUSIONS

Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.

[Profile of bacterial resistance in pediatric urinary tract infections in 2014]

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

Safety Concerns Surrounding Quinolone Use in Children

Fluoroquinolones are highly effective antibiotics with many desirable pharmacokinetic and pharmacodynamic properties including high bioavailability, large volume of distribution, and a broad spectrum of antimicrobial activity. Despite their attractive profile as anti-infective agents, their use in children is limited, primarily due to safety concerns. In this review we highlight the pharmacological properties of fluoroquinolones and describe their current use in pediatrics. In addition, we provide a comprehensive assessment of the safety data associated with fluoroquinolone use in children. Although permanent or destructive arthropathy remains a significant concern, currently available data demonstrate that arthralgia and arthropathy are relatively uncommon in children and resolve following cessation of fluoroquinolone exposure without resulting in long-term sequelae. The concern for safety and risk of adverse events associated with pediatric fluoroquinolone use is likely driving the limited prescribing of this drug class in pediatrics. However, in adults, fluoroquinolones are the most commonly prescribed broad-spectrum antibiotics, resulting in the development of drug-resistant bacteria that can be challenging to treat effectively. The consequence of misuse and overuse of fluoroquinolones leading to drug resistance is a greater, but frequently overlooked, safety concern that applies to both children and adults and one that should be considered at the point of prescribing.

Discovery and structure-activity relationships of a novel isothiazolone class of bacterial type II topoisomerase inhibitors

There is an urgent and unmet medical need for new antibacterial drugs that tackle infections caused by multidrug-resistant (MDR) pathogens. During the course of our wider efforts to discover and exploit novel mechanism of action antibacterials, we have identified a novel series of isothiazolone based inhibitors of bacterial type II topoisomerase. Compounds from the class displayed excellent activity against both Gram-positive and Gram-negative bacteria with encouraging activity against a panel of MDR clinical Escherichia coli isolates when compared to ciprofloxacin. Representative compounds also displayed a promising in vitro safety profile.