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Hanioka N, Isobe T, Saito K, Nagaoka K, Mori Y, Jinno H, Ohkawara S, Tanaka-Kagawa T. Glucuronidation of tizoxanide, an active metabolite of nitazoxanide, in liver and small intestine: Species differences in humans, monkeys, dogs, rats, and mice and responsible UDP-glucuronosyltransferase isoforms in humans. Comp Biochem Physiol C Toxicol Pharmacol 2024; 283:109962. [PMID: 38889874 DOI: 10.1016/j.cbpc.2024.109962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 06/20/2024]
Abstract
Tizoxanide (TZX) is an active metabolite of nitazoxanide (NTZ) originally developed as an antiparasitic agent, and is predominantly metabolized into TZX glucuronide. In the present study, TZX glucuronidation by the liver and intestinal microsomes of humans, monkeys, dogs, rats, and mice, and recombinant human UDP-glucuronosyltransferase (UGT) were examined. The kinetics of TZX glucuronidation by the liver and intestinal microsomes followed the Michaelis-Menten or biphasic model, with species-specific variations in the intrinsic clearance (CLint). Rats and mice exhibited the highest CLint values for liver microsomes, while mice and rats were the highest for intestinal microsomes. Among human UGTs, UGT1A1 and UGT1A8 demonstrated significant glucuronidation activity. Estradiol and emodin inhibited TZX glucuronidation activities in the human liver and intestinal microsomes in a dose-dependent manner, with emodin showing stronger inhibition in the intestinal microsomes. These results suggest that the roles of UGT enzymes in TZX glucuronidation in the liver and small intestine differ extensively across species and that UGT1A1 and/or UGT1A8 mainly contribute to the metabolism and elimination of TZX in humans. This study presents the relevant and novel-appreciative report on TZX metabolism catalyzed by UGT enzymes, which may aid in the assessment of the antiparasitic, antibacterial, and antiviral activities of NTZ for the treatment of various infections.
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Affiliation(s)
- Nobumitsu Hanioka
- Department of Health Pharmacy, Yokohama University of Pharmacy, 601 Matano-cho, Totsuka-ku, Yokohama 245-0066, Japan.
| | - Takashi Isobe
- Department of Health Pharmacy, Yokohama University of Pharmacy, 601 Matano-cho, Totsuka-ku, Yokohama 245-0066, Japan
| | - Keita Saito
- School of Pharmacy, Shujitsu University, 1-6-1 Nishigawara, Naka-ku, Okayama 703-8516, Japan
| | - Kenjiro Nagaoka
- College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-cho, Matsuyama 790-8578, Japan
| | - Yoko Mori
- Division of Environmental Chemistry, Ntional Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki-ku, Kawasaki 210-9501, Japan
| | - Hideto Jinno
- Faculty of Pharmacy, Meijo University, 150 Yagotoyama, Tempaku-ku, Nagoya 468-8503, Japan
| | - Susumu Ohkawara
- Department of Health Pharmacy, Yokohama University of Pharmacy, 601 Matano-cho, Totsuka-ku, Yokohama 245-0066, Japan
| | - Toshiko Tanaka-Kagawa
- Department of Health Pharmacy, Yokohama University of Pharmacy, 601 Matano-cho, Totsuka-ku, Yokohama 245-0066, Japan
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A comparative analysis of machine learning approaches to predict C. difficile infection in hospitalized patients. Am J Infect Control 2022; 50:250-257. [PMID: 35067382 DOI: 10.1016/j.ajic.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Interventions to better prevent or manage Clostridioides difficile infection (CDI) may significantly reduce morbidity, mortality, and healthcare spending. METHODS We present a retrospective study using electronic health record data from over 700 United States hospitals. A subset of hospitals was used to develop machine learning algorithms (MLAs); the remaining hospitals served as an external test set. Three MLAs were evaluated: gradient-boosted decision trees (XGBoost), Deep Long Short Term Memory neural network, and one-dimensional convolutional neural network. MLA performance was evaluated with area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, diagnostic odds ratios and likelihood ratios. RESULTS The development dataset contained 13,664,840 inpatient encounters with 80,046 CDI encounters; the external dataset contained 1,149,088 inpatient encounters with 7,107 CDI encounters. The highest AUROCs were achieved for XGB, Deep Long Short Term Memory neural network, and one-dimensional convolutional neural network via abstaining from use of specialized training techniques, resampling in isolation, and resampling and output bias in combination, respectively. XGBoost achieved the highest AUROC. CONCLUSIONS MLAs can predict future CDI in hospitalized patients using just 6 hours of data. In clinical practice, a machine-learning based tool may support prophylactic measures, earlier diagnosis, and more timely implementation of infection control measures.
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Esposito G, Nobile N, Gigli S, Seguella L, Pesce M, d’Alessandro A, Bruzzese E, Capoccia E, Steardo L, Cuomo R, Sarnelli G. Rifaximin Improves Clostridium difficile Toxin A-Induced Toxicity in Caco-2 Cells by the PXR-Dependent TLR4/MyD88/NF-κB Pathway. Front Pharmacol 2016; 7:120. [PMID: 27242527 PMCID: PMC4860461 DOI: 10.3389/fphar.2016.00120] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/25/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clostridium difficile infections (CDIs) caused by Clostridium difficile toxin A (TcdA) lead to severe ulceration, inflammation and bleeding of the colon, and are difficult to treat. AIM The study aimed to evaluate the effect of rifaximin on TcdA-induced apoptosis in intestinal epithelial cells and investigate the role of PXR in its mechanism of action. METHODS Caco-2 cells were incubated with TcdA and treated with rifaximin (0.1-10 μM) with or without ketoconazole (10 μM). The transepithelial electrical resistance (TEER) and viability of the treated cells was determined. Also, the expression of zona occludens-1 (ZO-1), toll-like receptor 4 (TLR4), Bcl-2-associated X protein (Bax), transforming growth factor-β-activated kinase-1 (TAK1), myeloid differentiation factor 88 (MyD88), and nuclear factor-kappaB (NF-κB) was determined. RESULTS Rifaximin treatment (0.1, 1.0, and 10 μM) caused a significant and concentration-dependent increase in the TEER of Caco-2 cells (360, 480, and 680% vs. TcdA treatment) 24 h after the treatment and improved their viability (61, 79, and 105%). Treatment also concentration-dependently decreased the expression of Bax protein (-29, -65, and -77%) and increased the expression of ZO-1 (25, 54, and 87%) and occludin (71, 114, and 262%) versus TcdA treatment. The expression of TLR4 (-33, -50, and -75%), MyD88 (-29, -60, and -81%) and TAK1 (-37, -63, and -79%) were also reduced with rifaximin versus TcdA treatment. Ketoconazole treatment inhibited these effects. CONCLUSION Rifaximin improved TcdA-induced toxicity in Caco-2 cells by the PXR-dependent TLR4/MyD88/NF-κB pathway mechanism, and may be useful in the treatment of CDIs.
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Affiliation(s)
- Giuseppe Esposito
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Nicola Nobile
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Stefano Gigli
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Luisa Seguella
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Marcella Pesce
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
| | | | - Eugenia Bruzzese
- Department of Translational Medical Science, University of Naples Federico IINaples, Italy
| | - Elena Capoccia
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Luca Steardo
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of RomeRome, Italy
| | - Rosario Cuomo
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples Federico IINaples, Italy
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Polyclonal Antibody Therapies for Clostridium difficile Infection. Antibodies (Basel) 2014. [DOI: 10.3390/antib3040272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Somvanshi VS, Ellis BL, Hu Y, Aroian RV. Nitazoxanide: nematicidal mode of action and drug combination studies. Mol Biochem Parasitol 2014; 193:1-8. [PMID: 24412397 PMCID: PMC3972318 DOI: 10.1016/j.molbiopara.2013.12.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 12/03/2013] [Accepted: 12/17/2013] [Indexed: 11/18/2022]
Abstract
Intestinal nematodes or roundworms (aka soil-transmitted helminths or STHs) cause great disease. They infect upwards of two billion people, leading to high morbidity and a range of health problems, especially in infected children and pregnant women. Development of resistance to the two main classes of drugs used to treat intestinal nematode infections of humans has been reported. To fight STH infections, we need new and more effective drugs and ways to improve the efficacy of the old drugs. One promising alternative drug is nitazoxanide (NTZ). NTZ, approved for treating human protozoan infections, was serendipitously shown to have therapeutic activity against STHs. However, its mechanism of action against nematodes is not known. Using the laboratory nematode Caenorhabditis elegans, we show that NTZ acts on the nematodes through avr-14, an alpha-type subunit of a glutamate-gated chloride ion channel known for its role in ivermectin susceptibility. In addition, a forward genetic screen to select C. elegans mutants resistant to NTZ resulted in isolation of two NTZ resistant mutants that are not in avr-14, suggesting that additional mechanisms are involved in resistance to NTZ. We found that NTZ combines synergistically with other classes of anthelmintic drugs, i.e. albendazole and pyrantel, making it a good candidate for further studies on its use in drug combination therapy of STH infections. Given NTZ acts against a wide range of nematode parasites, our findings also validate avr-14 as an excellent target for pan-STH therapy.
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Affiliation(s)
- Vishal S Somvanshi
- Section of Cell and Developmental Biology, Division of Biological Sciences, University of California San Diego, La Jolla, CA, USA
| | - Brian L Ellis
- Section of Cell and Developmental Biology, Division of Biological Sciences, University of California San Diego, La Jolla, CA, USA
| | - Yan Hu
- Section of Cell and Developmental Biology, Division of Biological Sciences, University of California San Diego, La Jolla, CA, USA
| | - Raffi V Aroian
- Section of Cell and Developmental Biology, Division of Biological Sciences, University of California San Diego, La Jolla, CA, USA.
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Howerton A, Patra M, Abel-Santos E. A new strategy for the prevention of Clostridium difficile infection. J Infect Dis 2013; 207:1498-504. [PMID: 23420906 DOI: 10.1093/infdis/jit068] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a leading cause of antibiotic-associated diarrhea. The infective form of C. difficile is the spore, but the vegetative bacterium causes the disease. Because C. difficile spore germination is required for symptomatic infection, antigermination approaches could lead to the prevention of CDI. We recently reported that CamSA, a bile salt analog, inhibits C. difficile spore germination in vitro. METHODS Mice infected with massive inocula of C. difficile spores were treated with different concentrations of CamSA and monitored for CDI signs. C. difficile spore and vegetative cells were counted in feces from infected mice. RESULTS A single 50-mg/kg dose of CamSA prevented CDI in mice without any observable toxicity. Lower CamSA doses resulted in delayed CDI onset and less severe signs of disease. Ingested C. difficile spores were quantitatively recovered from feces of CamSA-protected mice. CONCLUSIONS Our results support a mechanism whereby the antigermination effect of CamSA is responsible for preventing CDI signs. This approach represents a new paradigm in CDI treatment. Instead of further compromising the microbiota of CDI patients with strong antibiotics, antigermination therapy could serve as a microbiota surrogate to curtail C. difficile colonization of antibiotic-treated patients.
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Affiliation(s)
- Amber Howerton
- Department of Chemistry, University of Nevada, Las Vegas, NV 89154, USA
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Abstract
Metronidazole is a treatment of choice for several types of infections, but coexisting conditions or concomitant medications may preclude its use. Although tinidazole, a newer nitroimidazole, may be an option in cases where drug interactions make the use of metronidazole inadvisable, similar absolute contraindications exist. In situations where nitroimidazole use is contraindicated or inadvisable, clinicians may have difficulty deciding on efficacious treatment options. For the treatment of trichomoniasis, alternatives include furazolidone, clotrimazole, nonoxynol-9 or paromomycin. Alternatives for bacterial vaginosis include clindamycin topically or systemically. For giardiasis, alternative options include paromomycin, nitazoxanide or the antihelminthic benzimidazoles. Alternatives for Clostridium difficile are varied, including oral vancomycin, nitazoxanide and rifaximin. Although options are limited, alternative therapies for treatment of patients with absolute contraindications to the nitroimidazole antibiotics are available.
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Eiland EH. Activities of aClostridium difficileinfection reduction team. Am J Health Syst Pharm 2011; 68:1298, 1300-1. [PMID: 21719589 DOI: 10.2146/ajhp100664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Edward H. Eiland
- Department of Pharmacy Huntsville Hospital System 101 Sivley Road Huntsville, AL 35801
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Hedge DD, Strain JD, Heins JR, Farver DK. New advances in the treatment of Clostridium difficile infection (CDI). Ther Clin Risk Manag 2011; 4:949-64. [PMID: 19209277 PMCID: PMC2621401 DOI: 10.2147/tcrm.s3145] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Clostridium difficile infections (CDI) have increased in frequency throughout the world. In addition to an increase in frequency, recent CDI epidemics have been linked to a hypervirulent C. difficile strain resulting in greater severity of disease. Although most mild to moderate cases of CDI continue to respond to metronidazole or vancomycin, refractory and recurrent cases of CDI may require alternative therapies. This review provides a brief overview of CDI and summarizes studies involving alternative antibiotics, toxin binders, probiotics, and immunological therapies that can be considered for treatment of acute and recurrent CDI in severe and refractory situations.
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Affiliation(s)
- Dennis D Hedge
- South Dakota State University College of Pharmacy, Brookings, SD 57007, USA
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Tannous G, Neff G, Kemmer N. Therapeutic Success of Rifaximin for Clostridium difficile Infection Refractory to Metronidazole and Vancomycin. Case Rep Gastroenterol 2010; 4:404-409. [PMID: 21060709 PMCID: PMC2975008 DOI: 10.1159/000320685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
We report the case of a 46-year-old white male with confirmed Clostridium difficile infection for >4 weeks after fluoroquinolone therapy. The patient received two courses of metronidazole 500 mg three times daily (t.i.d.) during which time diarrhea resolved; however, symptoms recurred 14-15 days after treatment termination. He received a 2-week course of vancomycin 125 mg four times daily, with symptoms recurring 10 days after treatment conclusion. The patient then received a pulsed tapering schedule of vancomycin with adjunctive Saccharomyces boulardii. Diarrhea recurred 12 days after treatment completion. He received rifaximin 400 mg t.i.d. while hospitalized for diarrhea-associated complications. Symptoms resolved within 24 h. The patient received a 4-week regimen of rifaximin 400 mg orally t.i.d. after discharge. No further episodes of diarrhea were reported within 6 months after treatment termination. The present case supports the potential benefit of rifaximin for the treatment of recurrent Clostridium difficile infection.
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Affiliation(s)
- George Tannous
- Department of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Wingfield T, Gallimore CI, Xerry J, Gray JJ, Klapper P, Guiver M, Blanchard TJ. Chronic norovirus infection in an HIV-positive patient with persistent diarrhoea: a novel cause. J Clin Virol 2010; 49:219-22. [PMID: 20863753 DOI: 10.1016/j.jcv.2010.07.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/26/2010] [Accepted: 07/30/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Tom Wingfield
- The Monsall Unit, Infectious Diseases and Tropical Medicine Department, North Manchester General Hospital, Manchester, UK.
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Abstract
Clostridium difficile is a gram-positive, spore-forming, toxin-producing anaerobic bacillus identified as the causal agent of a variety of manifestations typically isolated to the colon, but in its severe form, it can lead to sepsis and death. C. difficile infection due to a toxin gene variant strain (BI/NAP1) has been identified at the center of outbreaks and has resulted in increased mortality. Many questions remain as to how this strain appeared so quickly and has harmed or killed so many patients. We present a review of C. difficile infection, discussing its clinical presentation, diagnosis, management, and prevention.
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Chen X, Katchar K, Goldsmith JD, Nanthakumar N, Cheknis A, Gerding DN, Kelly CP. A mouse model of Clostridium difficile-associated disease. Gastroenterology 2008; 135:1984-92. [PMID: 18848941 DOI: 10.1053/j.gastro.2008.09.002] [Citation(s) in RCA: 378] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 08/26/2008] [Accepted: 09/04/2008] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Infection with Clostridium difficile causes nosocomial antibiotic-associated diarrhea and colitis. Hamsters historically have been used to investigate disease pathogenesis and treatment, but are not ideal models because of the lack of hamster-specific reagents and genetically modified animals, and because they develop fulminant disease. The aim of this study was to establish a mouse model of antibiotic-induced C. difficile-associated disease (CDAD) that more closely resembles human disease. METHODS C57BL/6 mice were exposed to a mixture of antibiotics (kanamycin, gentamicin, colistin, metronidazole, and vancomycin) for 3 days. Two days later, they were given injections of clindamycin and then challenged 1 day later with different doses of C. difficile. RESULTS Mice that were exposed to antibiotics and then challenged with C. difficile developed diarrhea and lost weight. Disease severity varied from fulminant to minimal in accordance with the challenge dose. Typical histologic features of CDAD were evident. Oral vancomycin prevented CDAD in all mice, but 68% died from colitis after treatment was discontinued. All animals that survived an initial episode of CDAD showed no evidence of diarrhea or colitis after subsequent rechallenge with C. difficile. Different strains of C. difficile tested in the model showed different levels of virulence in mice. CONCLUSIONS We have developed a mouse model of CDAD that closely represents the human disease. In light of the recent substantial increases in CDAD incidence and severity, this model will be valuable in testing new treatments, examining disease pathogenesis, and elucidating mechanisms of protective immunity.
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Affiliation(s)
- Xinhua Chen
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- Ciarán P Kelly
- Gastroenterology Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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Salnikova MS, Joshi SB, Howard Rytting J, Warny M, Russell Middaugh C. Physical Characterization of Clostridium Difficile Toxins and Toxoids: Effect of the Formaldehyde Crosslinking on Thermal Stability. J Pharm Sci 2008; 97:3735-52. [DOI: 10.1002/jps.21261] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
In this issue of the Journal, an article by Pepin et al. documents the shifting sands of the modern-day Clostridium difficile epidemic as seen in Quebec. Pepin and coauthors' observation that the superior activity of vancomycin over metronidazole has been lost since the emergence there of the hypervirulent strain NAP1/027 in 2003 has implications for the future treatment of C. difficile-associated diarrhea (CDAD). This editorial explores these, particularly in complicated cases and high-risk populations.
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Kause JB. Drugs Causing Diarrhoea and Antidiarrhoeals in the Intensive Care Unit (ICU). J Intensive Care Soc 2007. [DOI: 10.1177/175114370700800310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Juliane B Kause
- SpR Intensive Care Medicine and Acute Medicine Southampton General Hospital Tremona Road Southampton SO16 6SD
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Emerson CR. Clostridium difficile—Associated Diarrhea, an Emerging Epidemic: Therapeutic Options. J Pharm Pract 2007. [DOI: 10.1177/0897190007302892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Clostridum difficile—associated disease (CDAD) is the leading cause of infectious diarrhea and is associated with considerable morbidity and mortality. The incidence is estimated to range from 3.4 to 8.4 cases per 1000 hospital admissions, and it has become a growing problem at many institutions. Treatment options for CDAD are limited due to a paucity of new pharmacologic agents and studies examining other potential treatments. Historically oral metronidazole and oral vancomycin have been used as first-line agents in the treating CDAD, however recent reports of treatment failure and recurrence with these agents have surfaced. These reports illustrate a need for novel pharmacologic agents and a thorough review of currently available agents that may have activity against C difficile. Available data on the treatment of CDAD were extracted and reviewed to outline the appropriate management of CDAD.
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Affiliation(s)
- Christopher R. Emerson
- Department of Veterans Affairs, New York Harbor Healthcare System, 800 Poly Place, Brooklyn, NY 11209
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