Fluoroquinolones in the management of community-acquired pneumonia in primary care

Refashioning of the drug-properties of fluoroquinolone through the synthesis of a levofloxacin-imidazole cobalt (II) complex and its interaction studies on with DNA and BSA biopolymers, antimicrobial and cytotoxic studies on breast cancer cell lines

Levofloxacin (HLVX), a quinolone antimicrobial agent, when deprotonated (LVX-) behaves as a bidentate ligand, and it coordinates to Co2+ through the pyridone oxygen and the carboxylate oxygen. Along with two imidazole (ImH) ligands, levofloxacin forms a Co(II)-Levofloxacin-imidazole complex, [CoCl(LVX)(ImH)2(H2O)]·3H2O (abbreviated henceforth as CoLevim) which was isolated and characterized by 1H and 13C NMR spectroscopy, UV-visible and FT-IR spectroscopy, powder X-ray diffraction and thermal analysis methods. CoLevim shows promise in its antimicrobial activities when tested against microorganisms (Bacillus cereus, Bacillus subtilis, Listeria monocytogenes, Staphylococcus aureus, Salmonella typhimurium and Escherichia coli). Fluorescence competitive studies with ethidium bromide (EB) revealed that CoLevim can compete with EB and displace it to bind to CT-DNA through intercalative binding mode. In addition, CoLevim exhibited a good binding propensity to BSA proteins with relatively high binding constants. The antioxidant activities of the free ligands and CoLevim were determined in vitro using ABTS+ radical (TEAC assay). The Co-complex showed a better antioxidant capacity with inhibitory concentrations (IC50) of 40 μM than the free ligands. CoLevim also showed noteworthy apoptotic potential and behaved as an efficient resistant modifying agent when its antiproliferative potential was examined by MTT assay using the breast cancer cell lines (MCF7, MCF7Dox/R and MCF7Pacli/R cells).

Levofloxacin and Amikacin Adsorption on Nanodiamonds: Mechanism and Application Prospects

This research is focused on the adsorption modification of detonation nanodiamond surfaces with antibiotics for their further use as smart materials for cardiovascular surgery purposes, namely as bioprostheses modifiers. Tritium-labeled amikacin and levofloxacin were used as tracers for the adsorption process control. We found that nanodiamonds form adsorption complexes with levofloxacin via physical adsorption, while in the case of amikacin, electrostatic attraction contributes to the formation of more stable complexes, even in the presence of electrolytes and desorbing agents (models of biological fluids). Antimicrobial characterization of nanodiamond–levofloxacin and nanodiamond–amikacin complexes indicates a reduction in the dose of antibiotics that is used as an antimicrobial agent. Therefore, the use of biomaterial based on DND complexes with antibiotics as the basis of bioprostheses will allow one either to avoid or significantly reduce the duration and intensity of antibiotics use in the postoperative period, which is critically important from the viewpoint of the development of antibiotic resistance in pathogens.

Characterization on the toxic mechanism of two fluoroquinolones to trypsin by spectroscopic and computational methods

Ciprofloxacin (CPFX) and enrofloxacin (ENFX), two of the most widely used fluoroquinolones (FQs), pose a great threat to humans and the ecosystem. In this study, the toxic mechanisms between the two FQs and trypsin were evaluated by means of multiple spectroscopic methods, as well as molecular docking. During the fluorescence investigations, both FQs quenched the intrinsic fluorescence of trypsin effectively, which was due to the formation of moderately strong complexes (mainly through van der Waals forces and hydrogen bonds). The binding of two FQs not only caused the conformational and micro-environmental changes of trypsin, but also changed its molecular activity; shown by the UV-Visible absorption spectroscopy, synchronous fluorescence spectroscopy, and functional tests. The established methods in this work can help to comprehensively understand the transport of FQs in the human body.

Development and validation of a fast micro-extraction by packed sorbent UHPLC-PDA method for the simultaneous determination of linezolid and ciprofloxacin in human plasma from patients with hospital-acquired pneumonia

An ultra high-performance liquid chromatographic (UHPLC) method with PDA detection was developed and validated for the simultaneous quantification of linezolid and ciprofloxacin in human plasma and applied in hospital acquired pneumonia patients (HAP). The method uses a semi-automated microextraction by packed sorbent for sample preparation. All parameters in the extraction step (pH, sample volume, sample dilution and number of aspiration - ejection cycles) and in the desorption step (percentage of acetonitrile in the solvent of elution and number of aspirations of elution solvent through the device) were statistically significant when the recovery was used as response. The method showed good linearity with correlation coefficients, r²>0.9995 for the two drugs, as well as high precision (RSD%<9.77% in each case), accuracy ranged from -6.2% to +8.2. The limit of quantification of the two drugs was established at 0.01 and 0.02μg/mL for ciprofloxacin and linezolid, respectively. Linezolid, ciprofloxacin and internal standard were extracted from human plasma with a mean recovery ranging from 92.4% to 97.4%. During validation, the concentrations of linezolid and ciprofloxacin were found to be stable after 3 freeze-thaw cycles and for at least 24h after extraction. This method will subsequently be used to quantify the drugs dosage in patients with HAP to establish if the dosage regimen given is sufficient to eradicate the infection at the target site.

Development of hemiacetal esterified levofloxacin to prevent chelation with metal-containing drugs

OBJECTIVES

To avoid the chelate formation between levofloxacin (LVFX) and aluminium hydroxide in gastrointestinal tract, an ethoxycarbonyl 1-ethyl hemiacetal ester of levofloxacin (LVFX-EHE) was synthesised as a prodrug.

METHODS

The effects of aluminium hydroxide on the bioavailability of LVFX following oral administration of LVFX-EHE were investigated in rats. Furthermore, the effects of aluminium hydroxide on small intestinal absorption of LVFX and LVFX-EHE when subjected to a hydrolysis experiment using in situ everted gut sac were investigated, and the minimal inhibitory concentrations (MICs) of LVFX and LVFX-EHE for various intestinal bacteria were measured.

KEY FINDINGS

When LVFX-EHE was co-administered with and without aluminium hydroxide, the AUC_{0-4 h} values of LVFX hydrolysed from LVFX-EHE were similar to that of LVFX alone. In everted gut sac experiments, LVFX-EHE was efficiently absorbed even in the presence of aluminium ions after 1 h of incubation, whereas the absorption of LVFX decreased significantly in the presence of aluminium ions. MIC values of LVFX-EHE were far higher than LVFX.

CONCLUSIONS

This study suggests the benefit of ethoxycarbonyl 1-ethyl hemiacetal esterification of the carboxyl group of new quinolone as a prodrug which is able to avoid chelate formation.

GSH Induced Controlled Release of Levofloxacin from a Purpose-Built Prodrug: Luminescence Response for Probing the Drug Release in Escherichia coli and Staphylococcus aureus

Fluoroquinolones are third-generation broad spectrum bactericidal antibiotics and work against both Gram-positive and Gram-negative bacteria. Levofloxacin (L), a fluoroquinolone, is widely used in anti-infective chemotherapy and treatment of urinary tract infection and pneumonia. The main pathogen for urinary tract infections is Escherichia coli, and Streptococcus pneumoniae is responsible for pneumonia, predominantly a lower respiratory tract infection. Poor permeability of L leads to the use of higher dose of this drug and excess drug in the outer cellular fluid leads to central nervous system (CNS) abnormality. One way to counter this is to improve the lipophilicity of the drug molecule, and accordingly, we have synthesized two new Levofloxacin derivatives, which participated in the spatiotemporal release of drug via disulfide bond cleavage induced by glutathione (GSH). Recent studies with Streptococcus mutants suggest that it is localized in epithelial lining fluid (ELF) of the normal lower respiratory tract and the effective [GSH] in ELF is ∼430 μM. E. coli typically cause urinary tract infections and the concentration of GSH in porcine bladder epithelium is reported as 0.6 mM for a healthy human. Thus, for the present study we have chosen two important bacteria (Gram + ve and Gram - ve), which are operational in regions having high extracellular GSH concentration. Interestingly, this supports our design of new lipophilic Levofloxacin based prodrugs, which released effective drug on reaction with GSH. Higher lipophilicity favored improved uptake of the prodrugs. Site specific release of the drug (L) could be achieved following a glutathione mediated biochemical transformation process through cleavage of a disulfide bond of these purpose-built prodrugs. Further, appropriate design helped us to demonstrate that it is possible also to control the kinetics of the drug release from respective prodrugs. Associated luminescence enhancement helps in probing the release of the drug from the prodrug in bacteria and helps in elucidating the mechanistic pathway of the transformation. Such an example is scarce in the contemporary literature.

Bacterial Infections in the Elderly Patient: Focus on Sitafloxacin

Sitafloxacin (DU-6859a) is a new-generation oral fluoroquinolone with in vitro activity against a broad range of Gram-positive and -negative bacteria, including anaerobic bacteria, as well as against atypical bacterial pathogens. Particularly in Japan this antibiotic was approved in 2008 for treatment of a number of bacterial infections caused by Gram-positive cocci and Gram-negative cocci and rods, including anaerobia atypical bacterial pathogens. As compared to oral levofloxacin sitafloxacin was non-inferior in the treatment of community-acquired pneumonia and non-inferior in the treatment of complicated urinary tract infections, according to the results of randomized, double-blind, multicentre, non-inferiority trials. Non-comparative studies demonstrated the efficacy of oral sitafloxacin in otorhinolaryngological infections, urethritis in men, cervicitis in women and odontogenic infections. Most common adverse reactions were gastrointestinal disorders and laboratory abnormalities in patients receiving oral sitafloxacin; diarrhea and liver enzyme elevations were among the common. In the Japanese population sitafloxacin covers broad spectrum of bacteria as compared to carbapenems, whereas in the Caucasians its use is currently limited due to the potential for ultraviolet A phototoxicity. Sitafloxacin is a promising therapeutic agent which merits further investigation in randomized clinical trials of elderly patients.

Does empirical treatment of community-acquired pneumonia with fluoroquinolones delay tuberculosis treatment and result in fluoroquinolone resistance in Mycobacterium tuberculosis? Controversies and solutions

The role of fluoroquinolones (FQs) as empirical therapy for community-acquired pneumonia (CAP) remains controversial in countries with high tuberculosis (TB) endemicity owing to the possibility of delayed TB diagnosis and treatment and the emergence of FQ resistance in Mycobacterium tuberculosis. Although the rates of macrolide-resistant Streptococcus pneumoniae and amoxicillin/clavulanic acid-resistant Haemophilus influenzae have risen to alarming levels, the rates of respiratory FQ (RFQ) resistance amongst these isolates remain relatively low. It is reported that ca. 1–7% of CAP cases are re-diagnosed as pulmonary TB in Asian countries. A longer duration (≥7 days) of symptoms, a history of night sweats, lack of fever (>38 °C), infection involving the upper lobe, presence of cavitary infiltrates, opacity in the lower lung without the presence of air, low total white blood cell count and the presence of lymphopenia are predictive of pulmonary TB. Amongst patients with CAP who reside in TB-endemic countries who are suspected of having TB, imaging studies as well as aggressive microbiological investigations need to be performed early on. Previous exposure to a FQ for >10 days in patients with TB is associated with the emergence of FQ-resistant M. tuberculosis isolates. However, rates of M. tuberculosis isolates with FQ resistance are significantly higher amongst multidrug-resistant M. tuberculosis isolates than amongst susceptible isolates. Consequently, in Taiwan and also in other countries with TB endemicity, a short-course (5-day) regimen of a RFQ is still recommended for empirical therapy for CAP patients if the patient is at low risk for TB.

Prevalence of and Risk Factors for Levofloxacin-Resistant E. coli Isolated from Outpatients with Urinary Tract Infection

Purpose

Levofloxacin has been widely used because of its broad spectrum and excellent penetration of the prostate. But levofloxacin-resistant Escherichia coli (E.coli) has been reported all over the world. We analyzed the annual levofloxacin resistance of E. coli and its risk factors.

Materials and Methods

From 2005 to 2009, we retrospectively analyzed patients who had undergone a urine analysis and a urine culture at the Outpatient Section of the Department of Urology of Kwangju Christian Hospital. Among them, we chose 509 patients infected by E. coli and evaluated the resistance rate to levofloxacin and its risk factors.

Results

The annual rates of levofloxacin resistance of E. coli were 29.49% in 2005, 26.51% in 2006, 40.21% in 2007, 43.20% in 2008, and 31.75% in 2009. A close correlation with the resistance rate was shown in cases that had underlying neurogenic bladder (p=0.002, odds ratio [OR]=4.236), a history of ciprofloxacin (p<0.001, OR=3.753) and levofloxacin (p<0.001, OR=2.996) administration for at least 48 hours in the past year, urolithiasis (p=0.003, OR=3.317), and older age (p<0.001, OR=1.027).

Conclusions

This study from 2005 to 2009 showed that the levofloxacin resistance rates of E. coli were high at over 25%. The risk factors that affected the levofloxacin resistance rates of E. coli were underlying neurogenic bladder, ciprofloxacin administration history, urolithiasis, levofloxacin administration history, and older age. Levofloxacin should be prescribed cautiously in patients with these risk factors until the pathogen is identified.