Penetration of lincomycin ('Lincocin') and clindamycin ('Dalacin C') into the synovial cavity in rheumatoid arthritis

The mysteries of target site concentrations of antibiotics in bone and joint infections: what is known? A narrative review

INTRODUCTION

Currently, antibiotic treatment is often a standard dosing regimen in bone and joint infections (BJI). However, it remains unknown if exposure at the target-site is adequate. The aim of this review is to gain more insight in the relationship between the target site concentration of antibiotic and the minimal inhibitory concentration to target the bacteria in bone and joint infections (BJI).

AREAS COVERED

A literature search was performed by Erasmus MC Medical library. Bone, bone tissue and synovial concentration of antibiotics were covered in humans. In addition, we reported number of patients, dose, sampling method, analytical method and tissue and plasma concentrations. We used the epidemiological cut-off value (ECOFF) values of the targeted micro-organisms. If more than 3 publications were available on the antibiotic, we graphically presented ECOFFS values against reported antibiotic concentrations.

EXPERT OPINION

For most antibiotics the literature is sparse. In addition, a lot of variable and total antibiotic concentrations are published. Ciprofloxacin, cefazolin, cefuroxime, vancomycin and linezolid seem to have adequate average exposure if correlating total concentration to ECOFF, when standard dosing is used. With regards to other antibiotics, results are inconclusive. More extensive pharmacokinetic/pharmacodynamic modeling in BJI is needed.

Antibiotic penetration into bone and joints: An updated review

Treatment of bone and joint infections can be challenging as antibiotics should penetrate through the rigid bone structure and into the synovial space. Several pharmacokinetic studies measured the extent of penetration of different antibiotics into bone and joint tissues. This review discusses the results of these studies and compares them with minimum inhibitory concentrations (MIC) of common pathogens implicated in bone and joint infections in order to determine which antibiotics may have a greater potential in the treatment of such infections. Clinical outcomes were also evaluated as data were available. More than 30 antibiotics were evaluated. Overall, most antibiotics, including amoxicillin, piperacillin/tazobactam, cloxacillin, cephalosporins, carbapenems, aztreonam, aminoglycosides, fluoroquinolones, doxycycline, vancomycin, linezolid, daptomycin, clindamycin, trimethoprim/sulfamethoxazole, fosfomycin, rifampin, dalbavancin, and oritavancin, showed good penetration into bone and joint tissues reaching concentrations exceeding the MIC₉₀ and/or MIC breakpoints of common bone and joint infections pathogens. Few exceptions include penicillin and metronidazole which showed a lower than optimum penetration into bones, and the latter as well as flucloxacillin had poor profiles in terms of joint space penetration. Of note, studies on joint space penetration were fewer than studies on bone tissue penetration. Although clinical studies in osteomyelitis and septic arthritis are not available for all of the evaluated antibiotics, these pharmacokinetic results indicate that agents with good penetration profiles would have a potential utilization in such infections.

Concentrations of some antibiotics in synovial fluid after oral administration, with special reference to antistaphylococcal activity

One of 4 antibiotics with antistaphylococcal activity was given in a conventional oral dose for one day to each of 20 hospitalised patients with synovial effusion of a knee joint requiring aspiration. Serial synchronous samples of serum and synovial fluid (SF) were taken over 36 hours through indwelling cannulae. No morbidity was experienced either during or after this procedure. Satisfactory antistaphylococcal concentrations in SF were achieved with sodium fusidate (500 mg 8 hourly) and amoxycillin (250 mg 8 hourly). Cephradine (500 mg 6 hourly) frequently failed to reach the minimum inhibitory concentration for Staphylococcus aureus in the SF, and flucloxacillin (250 mg 6 hourly) was unpredictable in its penetration of the synovial space. Wide interpatient variation of both serum and SF concentrations was found. Our results indicate that sodium fusidate is an appropriate early treatment for a nonresistant staphylococcal joint infection. Amoxycillin is a suitable alternative or second antistaphylococcal drug and would also be appropriate initial therapy when the infecting organism is unknown. We strongly recommend that SF antibiotic concentrations be measured, to ensure adequate penetration of the synovial cavity, in the treatment of septic arthritis.

Treatment of Nongonococcal bacterial septic arthritis

Septic arthritis carries significant morbidity and mortality, necessitating prompt, appropriate therapy with joint fluid aspiration, intravenous antibiotics, and occasionally, surgical intervention. The initial choice of antimicrobial agent is guided by the results of synovial fluid gram stain, by identification of the pathogenesis of the primary focus, or by epidemiologic factors. Adequacy of therapy is assessed by serial synovial fluid white blood cell counts and by determining antimicrobial concentrations in the joint space. The goal of treatment is a clinically normal and sterile joint. Factors that may affect antimicrobial joint penetration include the degree of joint tissue inflammation, the degree of drug protein binding, and the chemical characteristics of the drug. Perhaps most important in determining the extent of joint penetration are factors that may affect serum antibiotic concentrations, for example, dose, route of administration, volume of distribution, but rate of elimination.

Serum and peritoneal fluid concentrations of clindamycin and lincomycin in the mouse

Serum concentrations of drug were obtained at various times after intramuscular dosing of healthy mice with either clindamycin or lincomycin hydrochlorides. Washings from the peritoneal cavity were taken at the same time as the serum samples. Changes in drug concentration in the peritoneal fluid with time mimic those for the serum, but concentrations in peritoneal fluid are much greater than the corresponding serum concentrations. The total volume of peritoneal fluid was estimated to be 0.05 ml.

Plasma, bone, hip capsule, synovial and drain fluid concentrations of lincomycin during total hip replacement

1 Lincomycin (600 mg) was given 6 h preoperatively by intramuscular injection, as an intravenous infusion over 30 min and for 72 h postoperatively in twelve patients having total hip replacement. 2 The plasma, bone, hip capsule, synovial and drain fluid concentrations of lincomycin were almost always above the M.I.C. of lincomycin against penicillinase producing Staphylococcus aureus. 3 There was a good correlation between the estimated concentrations of lincomycin in bone by the grinding and agitation methods of analysis. 4 Two patients developed pseudomembranous colitis after parenteral lincomycin.