Performance of the fractional maximal effect method: comparative interaction studies of ciprofloxacin and protein synthesis inhibitors

Demonstration of in vitro antagonism between fusidic acid and quinolones

Fusidic acid is an antibiotic active against staphylococci and other bacterial pathogens. It is used in the treatment of staphylococcal infections usually in combination with other antibacterial agents. Reports of the clinical effects of antimicrobial combinations containing fusidic acid have been somewhat inconsistent. The aim of this study was to investigate the in vitro antagonism of fusidic acid and quinolones. Twenty-six staphylococci strains isolated from various clinical samples were tested. After detecting the diameter of the zone of inhibition around fusidic acid, levofloxacin, ciprofloxacin, ofloxacin and moxifloxacin for each strain, in vitro antagonism between fusidic acid and each quinolone was investigated using disk approximation. In all 26 strains, quinolones and fusidic acid were antagonist in vitro. The reason for this antagonistic effect and its clinical implications are not known. However, care should be exercised in prescribing quinolones and fusidic acid in combination.

Antimicrobial activities of clarithromycin, gatifloxacin and sitafloxacin, in combination with various antimycobacterial drugs against extracellular and intramacrophage Mycobacterium avium complex

We studied the activities of clarithromycin and fluoroquinolones (gatifloxacin, sitafloxacin, levofloxacin) in combination with other antimycobacterial drugs against extracellular and intramacrophage Mycobacterium avium complex (MAC). Clarithromycin potentiated the activities of rifampicin and rifalazil against both extracellular and intramacrophage MAC. In contrast, all the test quinolones exhibited antagonistic effects against extracellular MAC when combined with either clarithromycin or rifamycins. Such an antagonism was not observed for the activity of these combinations against intramacrophage MAC. Combined effects were observed with combinations of these fluoroquinolones with either ethambutol or streptomycin. Similar profiles were seen for the activities of two-drug combinations of clarithromycin or fluoroquinolones with other drugs against intramacrophage MAC isolated from pulmonary and disseminated MAC infections.

Pharmacokinetic and pharmacodynamic interactions between intravenous ciprofloxacin and oral ferrous sulfate

Changes in oral bioavailability and in vitro antimicrobial activity have been the focus of many previous interaction studies for metal cations and quinolones. This study is the first to examine the possibility of an interaction in the systemic circulation using ciprofloxacin and ferrous sulfate as representative interactants in a rat model, and to determine the changes, if any, in the pharmacokinetics and pharmacodynamics of the antibiotic. To minimize direct physical interaction in the gastrointestinal (GI) tract, the current study design required the male Sprague Dawley rats (220-240 g) to be dosed with 100 mg/kg of oral ferrous sulfate and 5 mg/kg of intravenous ciprofloxacin. Control animals received only intravenous ciprofloxacin. Blood and urine samples were collected over time for quantitation of ciprofloxacin independently by both HPLC (H) and microbiological (M) assays. Results showed that the disposition of ciprofloxacin in control animals was biexponential with a mean (+/-SD) terminal elimination half-life (t(1/2,lambda z)) of 0.93+/-0.30 h. A large apparent volume of distribution (V(d,lambda z): 6.96+/-1.56 L/kg) was observed. In addition, concentration vs. time profiles generated by both assays were similar. When the antibiotic was dosed with oral iron, parameter estimates generated by HPLC appeared to show a wider distribution and a longer elimination of ciprofloxacin; mean V(d,lambda z) and t(1/2,lambda z) estimates increased by 2- and 4-fold, respectively. Relative to controls, antibiotic exposure (AUC(0-infinity) was also significantly higher (p<0.05) in the presence of iron (1.89+/-0.15 vs. 1.00+/-0.39 mg/h/L). A strong assay dependency was observed for ciprofloxacin concentrations observed post-distribution; the respective M/H ratios for AUC(0-infinity) and urinary recovery were 1.1 and 0.9 for controls and 0.7 and 0.5 for animals receiving oral iron. This iron related reduction in antimicrobial activity was in clear contrast to the higher exposure and longer t(1/2,lambda z) of the antibiotic. In conclusion, concomitant oral iron dosing induced significant changes in the pharmacokinetics/pharmacodynamics of intravenous ciprofloxacin.

New pharmacodynamic parameters for antimicrobial agents

The application of pharmacodynamic theories to antimicrobial chemotherapy has greatly improved the prediction of the time course of activity expressed by antibiotics. Being a major component of the antibiotic-bacterium interaction system, pharmacodynamics, when properly integrated with the pharmacokinetics established for the antibiotic, allow better evaluation of the dosage regimen in conjunction with its clinical response. Before this approach becomes effective, detailed background information on the complex antibiotic-bacterium interactions have to be secured. To achieve this, proper characterization of a time-kill curve is a prerequisite. The use of susceptibility endpoints such as the MIC with respect to the antibiotic concentrations achievable in vivo represent the conventional approach to clinical dosing of antimicrobial agents, i.e. by maintaining concentrations above the MIC. Recently, a number of surrogate markers have been proposed by combining suitable pharmacokinetic parameters and susceptibility data, e.g. peak/MIC ratio, AUC>MIC, time above MIC, AUIC etc. to enhance the prediction of clinical outcomes. Attempts have been made to apply these pharmacokinetic/pharmacodynamic markers to antibiotics of the same class as well as to antibiotics from different classes. This review aims to discuss the various microbial dynamic responses in relation to antibiotic exposure and the development of different pharmacokinetic/pharmacodynamic markers for use in current antimicrobial chemotherapy.

Achieving an optimal outcome in the treatment of infections. The role of clinical pharmacokinetics and pharmacodynamics of antimicrobials

Over the past few decades, the importance of applying pharmacokinetic principles to the design of drug regimens has been increasingly recognised by clinicians. From the perspective of antimicrobial chemotherapy, an improvement in clinical outcome and/or a reduction in toxicity are of primary interest. Before application of these pharmacokinetic theories can be effective, the interrelationships between antimicrobial, pathogen and host factors must be clearly defined. Information regarding the pharmacokinetics of the antimicrobial and the quantification of pathogen susceptibility is required. Even though susceptibility end-points such as minimum inhibitory concentration (MIC) and minimum bactericidal concentration are widely employed, they do not provide any information on dynamic changes of bacterial densities. In this regard, time-kill studies can provide more basic knowledge of the complex bacterial responses to the antimicrobial. Better prediction of these responses can be afforded by the use of mathematical models. More recently, various surrogate end-points employing a combination of suitable pharmacokinetic parameters and susceptibility data, for example the ratio of peak concentration to MIC, the area under the concentration-time curve above the MIC (AUC > MIC), the time above the MIC, or the area under the inhibitory curve (AUIC), have been suggested for better prediction of the activity of different classes of antimicrobials. To allow more extensive investigations of the contribution of pharmacokinetics to the pharmacodynamics of antimicrobials, various in vitro kinetic models have been developed. However, certain limitations exist, and it is necessary to avoid over-interpretation of the data generated by these models. Two important microbial dynamic responses, postantibiotic effect and resistance selection, must be further explored before the full impact of pharmacokinetics on antimicrobial chemotherapy can be depicted. The present paper aims at discussing all the relevant factors and provides some pertinent information on the use of pharmacokinetic-pharmacodynamic principles in antimicrobial therapy.