Cefoperazone: A review of its in vitro antimicrobial activity, pharmacological properties and therapeutic efficacy

Multicenter study on clinical outcomes and poor prognostic factors in patients with Klebsiella pneumoniae bacteremia receiving cefoperazone/sulbactam treatment

BACKGROUND

Infections caused by Klebsiella pneumoniae are common and result in high mortality rates. In vitro studies demonstrated the potency of cefoperazone/sulbactam (CPZ/SUL) against Klebsiella pneumoniae. However, the clinical efficacy of CPZ/SUL for the treatment of K. pneumoniae bacteremia has not been studied.

OBJECTIVES

This study aimed to associate the clinical outcomes of patients with bacteremia with the minimal inhibitory concentrations (MICs) of CPZ/SUL against the causative K. pneumoniae isolates.

METHODS

This multicenter, retrospective study was conducted in Taiwan between July 2017 and April 2021. Patients with K. pneumoniae bacteremia treated with CPZ/SUL were enrolled in this study. CPZ/SUL MICs were determined using the agar dilution method. Data on the patients' clinical outcomes and characteristics were collected and analyzed.

RESULTS

In total, 201 patients were enrolled. Among the causative K. pneumoniae isolates, 180 (89.5%) were susceptible to CPZ/SUL. Most patients (n = 156, 77.6%) had favorable outcomes. The 30-day mortality rate was 11.9% (n = 24). Multivariate risk analyses showed that higher APACHE II score (Odds Ratio [OR], 1.14; Confidence Interval [CI], 1.07-1.21; p < 0.001), metastatic tumors (OR, 5.76; CI, 2.31-14.40; p < 0.001), and causative K. pneumoniae CPZ/SUL MICs > 16 µg/ml (OR, 4.30; CI, 1.50-12.27; p = 0.006) were independently associated with unfavorable outcomes.

CONCLUSION

Patients with K. pneumoniae bacteremia treated with CPZ/SUL at a ratio 1:1 had favorable outcomes when the CPZ/SUL MICs were ≤ 16 µg/ml. Patients with higher APACHE II scores and metastatic tumors had unfavorable outcomes.

Novel Siderophore Cephalosporin and Combinations of Cephalosporins with β-Lactamase Inhibitors as an Advancement in Treatment of Ventilator-Associated Pneumonia

In an era of increasing antibiotic resistance among pathogens, the treatment options for infectious diseases are diminishing. One of the clinical groups especially vulnerable to this threat are patients who are hospitalized in intensive care units due to ventilator-associated pneumonia caused by multidrug-resistant/extensively drug-resistant Gram-negative bacteria. In order to prevent the exhaustion of therapeutic options for this life-threatening condition, there is an urgent need for new pharmaceuticals. Novel β-lactam antibiotics, including combinations of cephalosporins with β-lactamase inhibitors, are proposed as a solution to this escalating problem. The unique mechanism of action, distinctive to this new group of siderophore cephalosporins, can overcome multidrug resistance, which is raising high expectations. In this review, we present the summarized results of clinical trials, in vitro studies, and case studies on the therapeutic efficacy of cefoperazone-sulbactam, ceftolozane-tazobactam, ceftazidime-avibactam, and cefiderocol in the treatment of ventilator-associated pneumonia. We demonstrate that treatment strategies based on siderophore cephalosporins and combinations of β-lactams with β-lactamases inhibitors show comparable or higher clinical efficacy than those used with classic pharmaceuticals, like carbapenems, colistin, or tigecycline, and are often associated with a lower risk of adverse events.

Combined PK/PD Index May Be a More Appropriate PK/PD Index for Cefoperazone/Sulbactam against Acinetobacter baumannii in Patients with Hospital-Acquired Pneumonia

Cefoperazone/sulbactam (CPZ/SUL) is a β-lactam and β-lactamase inhibitor combination therapy for the treatment of respiratory tract infections. Using data from a prospective, multiple-center, open-label clinical trial in 54 patients with hospital-acquired pneumonia or ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii (Ab), we showed that a combined PK/PD index %(T > MICcpz*T > MICsul) is a more appropriate PK/PD index against Ab, compared to the PK/PD index (%T > MIC) for a single drug. For a 2 h infusion, the PK/PD cutoff of CPZ/SUL (2 g/1 g, q8h) for clinical and microbiological efficacy was 4/2 and 1/0.5 mg/L, respectively. The corresponding cumulative fraction of response was 46.5% and 25.3%, respectively. Results based on the combined PK/PD index were quite similar to that based on the joint probability of target attainment. The two drugs have interaction from the viewpoint of PK/PD. When the dose of one drug was too high, the PK/PD cutoff was often determined by another drug in which the dose was maintained. In most cases, sulbactam exerted the main effect against infection by Ab in the complex CPZ/SUL, which was similar to the literature reports. When the MIC of CPZ was 8, 16, or 32 mg/L, a CPZ/SUL 2 g/1 g (q8h), 2 g/2 g (q8h), or 2 g/2 g (q6h) (infusion was all 3 h) was recommended, respectively. A clinical efficacy and safety study to confirm simulation results is warranted.

Discovery and Development of Antibacterial Agents: Fortuitous and Designed

Today, antibacterial drug resistance has turned into a significant public health issue. Repeated intake, suboptimal and/or unnecessary use of antibiotics, and, additionally, the transfer of resistance genes are the critical elements that make microorganisms resistant to conventional antibiotics. A substantial number of antibacterials that were successfully utilized earlier for prophylaxis and therapeutic purposes have been rendered inadequate due to this phenomenon. Therefore, the exploration of new molecules has become a continuous endeavour. Many such molecules are at various stages of investigation. A surprisingly high number of new molecules are currently in the stage of phase 3 clinical trials. A few new agents have been commercialized in the last decade. These include solithromycin, plazomicin, lefamulin, omadacycline, eravacycline, delafloxacin, zabofloxacin, finafloxacin, nemonoxacin, gepotidacin, zoliflodacin, cefiderocol, BAL30072, avycaz, zerbaxa, vabomere, relebactam, tedizolid, cadazolid, sutezolid, triclosan and afabiacin. This article aims to review the investigational and recently approved antibacterials with a focus on their structure, mechanisms of action/resistance, and spectrum of activity. Delving deep, their success or otherwise in various phases of clinical trials is also discussed while attributing the same to various causal factors.

Non-responder phenotype reveals apparent microbiome-wide antibiotic tolerance in the murine gut

Broad spectrum antibiotics cause both transient and lasting damage to the ecology of the gut microbiome. Antibiotic-induced loss of gut bacterial diversity has been linked to susceptibility to enteric infections. Prior work on subtherapeutic antibiotic treatment in humans and non-human animals has suggested that entire gut communities may exhibit tolerance phenotypes. In this study, we validate the existence of these community tolerance phenotypes in the murine gut and explore how antibiotic treatment duration or a diet enriched in antimicrobial phytochemicals might influence the frequency of this phenotype. Almost a third of mice exhibited whole-community tolerance to a high dose of the β-lactam antibiotic cefoperazone, independent of antibiotic treatment duration or dietary phytochemical amendment. We observed few compositional differences between non-responder microbiota during antibiotic treatment and the untreated control microbiota. However, gene expression was vastly different between non-responder microbiota and controls during treatment, with non-responder communities showing an upregulation of antimicrobial tolerance genes, like efflux transporters, and a down-regulation of central metabolism. Future work should focus on what specific host- or microbiome-associated factors are responsible for tipping communities between responder and non-responder phenotypes so that we might learn to harness this phenomenon to protect our microbiota from routine antibiotic treatment.

Discovery of COVID-19 Inhibitors Targeting the SARS-CoV-2 Nsp13 Helicase

The raging COVID-19 pandemic caused by SARS-CoV-2 has infected tens of millions of people and killed several hundred thousand patients worldwide. Currently, there are no effective drugs or vaccines available for treating coronavirus infections. In this study, we have focused on the SARS-CoV-2 helicase (Nsp13), which is critical for viral replication and the most conserved nonstructural protein within the coronavirus family. Using homology modeling that couples published electron-density with molecular dynamics (MD)-based structural refinements, we generated structural models of the SARS-CoV-2 helicase in its apo- and ATP/RNA-bound conformations. We performed virtual screening of ∼970 000 chemical compounds against the ATP-binding site to identify potential inhibitors. Herein, we report docking hits of approved human drugs targeting the ATP-binding site. Importantly, two of our top drug hits have significant activity in inhibiting purified recombinant SARS-CoV-2 helicase, providing hope that these drugs can be potentially repurposed for the treatment of COVID-19.

Discovery of COVID-19 Inhibitors Targeting the SARS-CoV2 Nsp13 Helicase

The raging COVID-19 pandemic caused by SARS-CoV2 has infected millions of people and killed several hundred thousand patients worldwide. Currently, there are no effective drugs or vaccines available for treating coronavirus infections. In this study, we have focused on the SARS-CoV2 helicase (Nsp13), which is critical for viral replication and the most conserved non-structural protein within the coronavirus family. Using homology modeling and molecular dynamics approaches, we generated structural models of the SARS-CoV2 helicase in its apo- and ATP/RNA-bound conformations. We performed virtual screening of ~970,000 chemical compounds against the ATP binding site to identify potential inhibitors. Herein, we report docking hits of approved human drugs targeting the ATP binding site. Importantly, two of our top drug hits have significant activity in inhibiting purified recombinant SARS-CoV-2 helicase, providing hope that these drugs can be potentially repurposed for the treatment of COVID-19.

Use of cefoperazone/sulbactam in neonates

BACKGROUND

Neonates are at high risk for nosocomial infections due to multidrug-resistant pathogens. The use of β-lactamase inhibitors in combination with β-lactam antibiotics broadens the antimicrobial spectrum. Cefoperazone/sulbactam is used in children but there are limited data on its usage in neonates. The purpose of the present study was therefore to evaluate the use of cefoperazone/sulbactam in the treatment of neonatal infections caused by multidrug-resistant pathogens.

METHODS

The records of neonates who were hospitalized and who received cefoperazone/sulbactam were reviewed.

RESULTS

There were 90 infants who received cefoperazone/sulbactam. A pathogen could be isolated in 41 (45.6%) of the infants. In total, 17.1% of isolated pathogens were resistant to cefoperazone/sulbactam. Side-effects were seen in four of the infants. Two infants had cholestasis, one infant had neutropenia and one had superinfection with candida.

CONCLUSION

Cefoperazone/sulbactam can be used in the treatment of nosocomial infections caused by multidrug-resistant pathogens in neonates.

Pharmacokinetics of cephalosporins in the neonate: a review

The aim of this work was to review the published data on the pharmacokinetics of cephalosporins in neonates to provide a critical analysis of the literature as a useful tool for physicians. The bibliographic search was performed for articles published up to December 3, 2010, using PubMed. In addition, the book Neofax: A Manual of Drugs Used in Neonatal Care by Young and Mangum was consulted. The cephalosporins are mainly eliminated by the kidneys, and their elimination rates are reduced at birth. As a consequence, clearance is reduced and t1/2 is more prolonged in the neonate than in more mature infants. The neonate's substantial body water content creates a large volume of distribution (Vd) of cephalosporins, as these drugs are fairly water soluble. Postnatal development is an important factor in the maturation of the neonate, and as postnatal age proceeds, the clearance of cephalosporins increases. The maturation of the kidney governs the pharmacokinetics of cephalosporins in the infant. Clearance and t1/2 are influenced by development, and this must be taken into consideration when planning a cephalosporin dosage regimen for the neonate.

Cefotaxime and desacetylcefotaxime antimicrobial interactions. The clinical relevance of enhanced activity: a review

This presentation reviews 15 years of in vitro, pharmacokinetic, and clinical data concerning the active metabolite of cefotaxime sodium, desacetylcefotaxime. This principle metabolite maintains an antimicrobial activity and spectrum superior to so-called "second-generation" cephalosporins, plus it has an extended serum elimination half-life. Furthermore, it penetrates well into various important body compartments. The metabolite enhances cefotaxime potency by additive or synergistic antimicrobial interactions that can significantly reduce cefotaxime minimum inhibitory concentrations (MICs) among oxacillin-susceptible staphylococci, Streptococcus species including pneumococci resistant to penicillin, anaerobes, enteric bacilli, Pseudomonas aeruginosa, and when tested in human serum, some enterococci. The high activity of cefotaxime alone and the contributions of desacetylcefotaxime to the drug's total antimicrobial value must be considered in reestablishing correct dosing of this "third-generation" cephalosporin. Physicians should use cefotaxime susceptibility tests to direct appropriate, cost-effective dosing and the selection of co-drugs when needed. Moreover, empiric cefotaxime regimen doses should also be reduced for some infections at sites where expected pathogen MICs remain low (< or = 2 micrograms/ml).

Novel galactose single point method as a measure of residual liver function: example of cefoperazone kinetics in patients with liver cirrhosis

A novel, simple, clinically useful quantitative liver function test, called the galactose single point (GSP) method, was developed to assess residual liver function by measuring galactose blood concentration 1 hour after galactose was administered (0.5 g/kg). This method was applied to the study of cefoperazone kinetics in patients with hepatic cirrhosis. To study the influence of hepatic cirrhosis on the residual liver function and the correlation between the residual liver function and the pharmacokinetics of cefoperazone, a dose of 1 g of cefoperazone was administered to 11 healthy volunteers and 12 patients with liver cirrhosis. The GSP method, the galactose elimination capacity (GEC) test, and the modified galactose elimination capacity (MGEC) test were done for each volunteer and patient to measure residual liver function. The galactose concentrations were determined enzymatically. Cefoperazone was administered intravenously, and blood and urine samples were collected at appropriate intervals after drug administration. All blood and urine samples were stored at -30 degrees C until high-performance liquid chromatography analysis. Cefoperazone plasma concentrations were much higher in cirrhosis patients than in normal subjects at all times. The elimination half-life, hepatic clearance, mean residence time, and renal clearance of cirrhosis patients differed significantly from those of healthy volunteers. The plasma protein binding was unaltered in both groups. Urinary excretion of cefoperazone was significantly increased in cirrhosis patients (23.95 +/- 5.06% for normal men and 51.09 +/- 11.50% in cirrhosis patients). Hepatic clearance, fraction excreted in urine, and total clearance significantly correlated with GSP, GEC, and MGEC (P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of chronic lobular hepatitis on pharmacokinetics of cefoperazone--a novel galactose single-point method as a measure of residual liver function

Cefoperazone is a semisynthetic cephalosporin antibiotic containing a piperazine side chain, which results in antipseudomonal activity. Unlike the other cephalosporins, it is mainly cleared by the liver (60-80%) and it may be more sensitive to changes in the liver function and/or plasma protein binding than other cephalosporins, which are not primarily cleared by the liver. In order to study the influence of chronic lobular hepatitis on the pharmacokinetics of cefoperazone, a dose of 1 g of cefoperazone was administered to 11 normal, healthy volunteers and 16 subjects with chronic lobular hepatitis. In each volunteer or patient, a novel galactose single-point (GSP) method, the galactose elimination capacity (GEC) test, and the modified galactose elimination capacity (MGEC) test were also performed as a measure of residual liver function. Cefoperazone was administered intravenously over a period of 3-5 min. Blood and urine samples were collected at appropriate intervals after drug administration and stored at -30 degrees C until high-pressure liquid chromatographic (HPLC) analysis. The cefoperazone hepatic clearance, mean residence time, and renal clearance in hepatitis patients were significantly different from those of normal healthy volunteers, whereas the plasma protein binding was unaltered between the two groups. Urinary excretion of cefoperazone showed a highly significant increase in patients, 23.95 +/- 5.06% and 37.54 +/- 13.61% for normal men and hepatitis patients respectively. Hepatic clearance and fraction excreted in urine significantly correlated with values of GSP and MGEC respectively (p < 0.05). These results suggest (i) cefoperazone kinetics was significantly altered in patients with chronic lobular hepatitis; (ii) GSP, a novel simple, clinically useful quantitative liver function test, can predict the cefoperazone hepatic clearance in patients with liver dysfunction.

Steady-state pharmacokinetics of cefoperazone and sulbactam in patients with acute appendicitis

OBJECTIVE

To determine the steady-state pharmacokinetics of intravenously administered cefoperazone and sulbactam when given in combination to patients with acute appendicitis.

METHODS

Six patients with normal renal and hepatic function received cefoperazone 2 g with sulbactam 1 g prior to appendectomy and then every 12 hours. Serial blood samples were collected after each patient received at least three doses of cefoperazone/sulbactam.

RESULTS

Cefoperazone and sulbactam could be best described by a two-compartment model. Mean +/- SD values for cefoperazone steady-state volume of distribution (Vssd), elimination half-life (t1/2 beta), clearance (Cl), and area under the curve (AUC0-t) were 19.8 +/- 8.0 L, 3.97 +/- 1.06 h, 62.6 +/- 16.3 mL/min, and 556.9 +/- 122.0 mg.h/L, respectively. Sulbactam Vssd, t1/2 beta, Cl, and AUC0-t were 34.7 +/- 13.9 L, 1.39 +/- 0.4 h, 288.6 +/- 68.2 mL/min, and 64.8 +/- 24.5 mg.h/L, respectively.

CONCLUSIONS

Compared with data from healthy volunteers, cefoperazone exhibited a decreased Cl and increased Vssd and t1/2 beta in patients with acute appendicitis. An increased Vssd also was observed for sulbactam. The disposition of cefoperazone/sulbactam is altered in this group of patients; however, these changes are not likely to warrant a dosage reduction.

New insights into the activity of third-generation cephalosporins against pneumonia-causing bacteria

Over 300 isolates representing all pathogens causing greater than or equal to 4% of nosocomial or outpatient pneumonias were tested against currently used third-generation cephalosporins (cefotaxime, desacetylcefotaxime, ceftriaxone, ceftazidime, cefoperazone, and ceftizoxime) to determine differences in activity and effects of physiologic host and pharmacokinetic properties. Prevalent drug resistances were represented and tests were performed by reference methods of the National Committee for Clinical Laboratory Standards. Spectrums and potency of cefotaxime, desacetylcefotaxime, ceftriaxone, and ceftizoxime were most similar, but cefotaxime plus desacetylcefotaxime at in vivo ratios increased the cefotaxime spectrum (anaerobes and Pseudomonas) and potency. Ceftizoxime was least active because of current reduced activity against some Staphylococcus spp. and Pseudomonas aeruginosa. Ceftriaxone potency was adversely affected (greater than or equal to 4-fold decrease) by serum protein binding, thus reducing its susceptibility spectrum for pathogens with greater than or equal to 4 micrograms/ml minimum inhibitory concentrations (MICs) and a 10.6% reduced spectrum overall. Ceftazidime provided poorest coverage against the significant and clinically increasing Gram-positive cocci and did not significantly inhibit aspiration pneumonia causing anaerobic strains. Ceftazidime and cefoperazone were more active against pseudomonas, but they were most labile to newer extended-spectrum beta-lactamases. On empiric balance, the third-generation cephalosporins continue to provide the best therapeutic spectrum, particularly those favorably influenced by host factors (proteins and metabolism). These third-generation cephalosporin differences become more important since some agents (ceftazidime) have readily selected type-I enzyme mutants among intensive-care-unit respiratory tract pathogens at our institution. Cost containment will also influence drug choices for some third-generation cephalosporins, usually favoring the earliest introduced compounds such as cefotaxime.

Pharmacological properties of cephalosporins

The cephalosporins differ in the substituents attached at the 3 and/or 7 positions of the molecule. Very schematically, substitution at C3 mainly modifies the overall pharmacokinetic properties whereas substitution at position 7 influences the antibacterial characteristics. When using the more common "generation" system for classification, three generations can be distinguished on the basis of their antibacterial spectrum, potency, and their stability to beta-lactamases. The first generation cephalosporins have similar antibacterial and pharmacokinetic characteristics. C3-esterified cephalosporins (e.g. cephalothin and cephapirin) are significantly metabolized. The so-called second generation cephalosporins exhibit only minor differences with respect to the pharmacokinetic properties in contrast to the third generation cephalosporins. The apparent volumes of distribution of most cephalosporins range between seven and 20 1, indicating that they mainly stay in the extracellular space. Plasma protein binding is variable from compound to compound. Generally, the major route of elimination of most cephalosporins is via the kidney except for cefoperazone and ceftriaxone which are both excreted to a large extent by the biliary route. With the exception of cefonicid, cefotetan and cefriaxone, which have longer elimination half-lives (i.e. 4.5, 3.5 and around eight hours), all other cephalosporins have a half-life ranging from 0.5 to 2.5 hours. The pattern of adverse reactions is comparable for all the cephalosporins although there are slight differences in both the incidence and the type of reactions. The major categories of adverse reactions are gastrointestinal, dermatologic, hypersensitivity, haematologic, hepatic, renal as well as CNS effects. Alcohol intolerance (antabus-like effect) can occur when cephalosporins containing the NMTT moiety are administered concomitantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of the intestinal flora of mice by parenteral treatment with broad-spectrum cephalosporins

A study was performed to determine the effect of parenteral treatment with four broad-spectrum cephalosporins (cefoperazone, ceftriaxone, ceftazidime, and cefepime) on the number of aerobic gram-negative rods and on the outgrowth of Candida albicans and a multiresistant strain of Citrobacter freundii in the feces of mice. The estimated fractions of a parenteral dose that were excreted into the gastrointestinal tract were 0.37 for cefoperazone, 0.11 for ceftriaxone, 0.03 for ceftazidime, and 0.002 for cefepime. All four cephalosporins significantly decreased the number of aerobic gram-negative rods in the feces, and virtually all gram-negative rods were eliminated at high doses of cefoperazone, ceftazidime, and ceftriaxone. Furthermore, at high doses these three compounds led to a significant increase of the outgrowth of resistant Citrobacter freundii. The outgrowth of Candida albicans was increased at high doses of cefoperazone and ceftriaxone, whereas ceftazidime and cefepime did not have this effect. The most profound changes in the gastrointestinal ecology were observed during treatment with high doses of cefoperazone. The results suggest that the colonization resistance of the gastrointestinal tract can be substantially decreased by parenteral treatment with cefoperazone and, to a lesser extent, with ceftriaxone and ceftazidime.

Pathophysiologic basis for the use of third-generation cephalosporins

After 10 years of use, the third-generation cephalosporins remain excellent antibiotics. They have superior activity against selected streptococcal species compared with other cephalosporins, and superior activity against Haemophilus, Neisseria, Branhamella, and other less common oral gram-negative aerobic species. Despite a very broad spectrum of activity, the third-generation cephalosporins, like all other cephalosporins, have only poor activity against enterococci, Listeria, Corynebacterium jekeium, and methicillin-resistant staphylococci. Over the past 10 years, the activity of the third-generation cephalosporins against Escherichia coli, Klebsiella, Proteus, Providencia, Serratia, Haemophilus, and Neisseria has remained excellent. Equally as important, though perhaps less well recognized, is the activity of some of these agents against mouth anaerobic species and the anaerobic Bacteroides and Clostridium spp. of the pelvic area. At present, there are two main threats to the continued use of the third-generation cephalosporins. These are the increasing number of infections due to Enterobacter spp., which constitutively produce large amounts of a beta-lactamase that hydrolyzes cephalosporins, and the recent appearance of Klebsiella spp. in many parts of the world that possess new plasmid-mediated beta-lactamases that destroy cefotaxime, ceftazidime, and related third-generation parenteral cephalosporins. Correlation of pharmacologic properties with in vitro activity provides information as to reasonable dosage regimens for the third-generation cephalosporins. For most serious infections cefotaxime, ceftizoxime, and ceftazidime should be given three times a day provided that the patient has relatively normal renal function. Ceftriaxone can be administered once daily in less severe infections. The use of lower doses or less frequent dosing with cefotaxime, ceftizoxime, or ceftazidime is recommended in aged patients whose renal function is impaired. The unique interaction of cefotaxime with its active metabolite, desacetylcefotaxime, allows cefotaxime to be administered less frequently than three times a day in selected anaerobic infections. Correlation of the antibacterial activity and pharmacology of cephalosporins will help us to tailor their use more appropriately, so that the third-generation cephalosporins will remain useful antimicrobial agents for a further decade.

Cefoperazone therapy of bacterial meningitis: a clinical trial

Sixteen hospitalized patients, aged between 10 and 76 years (mean: 34.3 years), with bacterial meningitis were treated i.v. with cefoperazone at daily doses of 4.5 g to 9 g. In two cases ampicillin was given in combination with cefoperazone during the last four days and the first five days of treatment, respectively. The following organisms were isolated: Neisseria meningitidis (n = 9), Haemophilus influenzae (n = 3), Escherichia coli (n = 2), Streptococcus pneumoniae (n = 2). Fourteen patients completely recovered from infection and the pathogens were eradicated; the treatment failed in only two patients and both were cured with alternative treatment. Furthermore, in 11 patients cefoperazone serum and CSF levels were determined four times during the first week of treatment (1st, 3rd, 5th and 7th days). No important side effects were recorded.

Perioperative antibiotic prophylaxis for transurethral resection of the prostate: is it justifiable?

The role of perioperative antimicrobial prophylaxis in transurethral resection of the prostate remains controversial. A total of 110 patients with preoperative sterile urine undergoing transurethral resection of the prostate was included in this open, prospective and randomized study to compare the prophylactic role of cefoperazone to no antibiotic prophylaxis. Patients were well matched between the 2 groups on all essential characteristics and risk factors at baseline. Owing to the strict selection criteria and aseptic measures used, the low incidence of postoperative urinary tract infections in the control group (1.8 per cent) compared to none in the cefoperazone group made conclusions and generalization limited due to sample size. In view of the extremely low infection rate it is doubtful that antibiotic prophylaxis had any beneficial role in this selected population.

A review of cephalosporin metabolism: a lesson to be learned for future chemotherapy

The historical background information concerning the metabolism of cephalosporins and selected other antiinfectives was reviewed as a preface to discussion concerning desacetyl-cefotaxime (dCTX), a metabolite of cefotaxime (CTX) sodium. Cephalothin and cephapirin were metabolized at the 3-position to less active desacetyl forms. However, the parent drugs and their metabolites interact in a favorable manner resulting in dominant additive or synergist inhibition of susceptible bacterial pathogens. Similarly, CTX plus dCTX have been described as being synergist in their activity against greater than 70% of Enterobacteriaceae or staphylococci and greater than 80% of anaerobic bacteria. Antagonism was rare with only two species and of no clinical significance. More recently, reported studies showed enhanced activity of CTX/dCTX against pathogens producing meningitis compared to ceftriaxone and other contemporary therapeutic agents. The dCTX compound was classified as a drug with a potency superior to a "second-generation" cephalosporin and possessed greater beta-lactamase stability against some enzymes compared to CTX. These features may explain low reported rates of superinfections and adverse side-effects, including resistance arising on chemotherapy. Physicians are cautioned to take into account the potential favorable effects of drug metabolites on antimicrobial spectrum, potency and applied pharmacokinetics. In the case of CTX/dCTX, the laboratory results for CTX will always underestimate its value or potency because of the contribution of the metabolite.

Cefoperazone in the treatment of infections in cancer patients

Cefoperazone appears to be one of the cephalosporins with the most promise in granulocytopenic patients, regardless of whether it is used in combination or as monotherapy. It has the broad spectrum of antimicrobial activity necessary to inhibit the organisms commonly encountered in patients with cancer, as well as the ability to achieve high serum levels for sustained periods of time. Administration of cefoperazone should provide effective therapy in the overall management of most infections encountered in patients with neoplastic diseases.

In vitro antimicrobial spectrum, occurrence of synergy, and recommendations for dilution susceptibility testing concentrations of the cefoperazone-sulbactam combination

Broth microdilution tests and an antimicrobial interaction (synergy) studies using various combinations of cefoperazone and sulbactam were performed in an effort to determine the most appropriate in vitro dilution test system. The test results with cefoperazone and sulbactam were categorized as synergistic (complete or partial) for nearly 80% of the strains isolated from clinical trial patients. The results indicate that the cefoperazone-sulbactam fixed ratio (2:1) maximized the cefoperazone spectrum of activity and best approximated the parenteral formulation of the drug. The cefoperazone-sulbactam combination had a greater antimicrobial activity than did the other comparison beta-lactams, except for imipenem, tested against strains of the family Enterobacteriaceae. To be consistent with the National Committee for Clinical Laboratory Standards interpretive breakpoints for cefoperazone alone, the following MIC breakpoints should be applied to the combination (2:1 ratio): less than or equal to 16/8 micrograms/ml, susceptible; 32/16 micrograms/ml, moderately susceptible; and greater than or equal to 64/32 micrograms/ml, resistant.

Cephalosporin, carbapenem, and monobactam antibiotics

Cephalosporin and related antibiotics are highly effective bactericidal agents of relatively low toxicity. The spectrum of activity varies with the drug but is usually broad. The first-generation cephalosporins, and especially cefazolin, are most active against sensitive staphylococci and streptococci. Most second-generation (except cefoxitin) and third-generation cephalosporins show substantial activity against Haemophilus influenzae. All cephalosporins (except cefsulodin) are active against Klebsiella, Escherichia coli, and Proteus mirabilis, whereas only the third-generation agents have pronounced activity against the other Enterobacteriaceae. Imipenem (a carbapenem) is active against essentially all pathogenic organisms, but aztreonam (a monobactam) is active against only aerobic gram-negative bacilli. Advantages associated with some of the new cephalosporins are once-daily administration and high cerebrospinal fluid levels. With the development of new cephalosporins, however, new toxicities have become apparent, and superinfections and induction of resistance have become greater problems. The cephalosporins are among the most expensive antibiotics in use today; thus, use of these expensive agents must be justified by lower toxicity, greater efficacy, or both in comparison with drugs of more reasonable cost.

In vitro antimicrobial activity of cefoperazone-sulbactam combinations against 554 clinical isolates including a review and beta-lactamase studies

Cefoperazone was tested against 554 clinical isolates alone and with sulbactam in three combinations. The addition of sulbactam in low concentrations (less than or equal to 4 micrograms/ml) improved the spectrum of cefoperazone principally against gram-negative bacilli such as Acinetobacter species, some Pseudomonas species, and beta-lactamase-positive Enterobacteriaceae. Nearly all of the spectrum increase was achieved at a sulbactam level of less than or equal to 2 micrograms/ml. Sulbactam was found to be an effective antimicrobial agent against Acinetobacter species (MIC50, 1.0 microgram/ml), Pseudomonas acidovorans (MIC50, 2.0 micrograms/ml), Neisseria gonorrhoeae (MIC50, less than or equal to 0.5 microgram/ml), and N. meningitidis (MIC50, less than or equal to 0.5 microgram/ml). Sulbactam had a higher affinity and binding constant for the plasmid-mediated beta-lactamases such as TEM-1 and TEM-2 compared to cefoperazone (greater than or equal to 10-fold difference). This finding was important as cefoperazone can be hydrolyzed at a moderate rate by the highly efficient TEM enzymes (less than 2% of clinical Escherichia coli isolates). Sulbactam increased the susceptibility (less than or equal to 16 micrograms/ml) of 220 isolates of Enterobacteriaceae to cefoperazone from 88.6 to 96.3% when 4.0 micrograms/ml of sulbactam was added. The cefoperazone antimicrobial activity was also increased against the nonenteric bacilli from a 69.5 to a 87.4% total inhibition. MICs among cefoperazone-susceptible gram-negative and gram-positive strains were routinely decreased 2- to 32-fold, as calculated from MIC90 results. Therefore, sulbactam should predictably increase the antimicrobial spectrum and clinical effectiveness of cefoperazone against nosocomial and other pathogens such as the plasmid-containing enteric bacilli, Bacteroides species and Acinetobacter species, and possibly provide the opportunity to reduce dosage schedules for infecting species already susceptible to cefoperazone alone.

Pharmacokinetic evaluation of cefoperazone in infants

The pharmacokinetics of cefoperazone were evaluated in 25 infants (mean age, 26 days) after intramuscular and intravenous routes of administration. The levels in blood that were achieved were severalfold higher than those required to inhibit common pathogens. The mean half-life of 240 min was one-half of that observed in 1- to 2-day-old infants but about twice that seen in adults. Further evaluation is needed to study the efficacy of the drug in infants and children.

Pharmacokinetics of cefaronide, ceftriaxone and cefoperazone in sheep

The pharmacokinetics of cefaronide (16 gm/kg dose), ceftriaxone and cefoperazone (47 gm/kg dose), after intravenous (i.v.) administration were determined in six Merino ewes. The mean values for terminal half life, steady state volume of distribution Vd(ss), renal clearance (ClR) and total body clearance (ClB) for cefaronide were 1.5 h, 0.39 l/kg, 0.06 l/h/kg and 0.16 l/h/kg, for ceftriaxone; 1.7 h, 0.30 l/kg, 0.08 l/h/kg, and 0.22 l/h/kg, and 0.7 h, 0.16 l/kg, 0.02 l/h/kg and 0.16 l/h/kg for cefoperazone, respectively. After 5.5 h, approximately 42% cefaronide, and after 8 h, approximately 37% ceftriaxone and 13% cefoperazone, was excreted in urine. The non-renal elimination of ceftriaxone and cefoperazone appeared to be more rapid in sheep than is reported in man. Cefaronide was excreted largely unchanged in the urine of sheep. Therefore, the elimination of cefaronide in sheep was similar to that found in man. Cefaronide was well distributed in sheep, whereas ceftriaxone and cefoperazone appeared to be distributed to a lesser degree. These findings underline the different disposition of drugs in different species.

Clinical pharmacokinetics of the third generation cephalosporins

At the present time, the third generation cephalosporins that are already on the market or close to this point include cefsulodin, cefotaxime, cefoperazone, latamoxef, ceftriaxone, ceftazidime, ceftizoxime and cefotetan. Other newer compounds are also under development but have not been included in this review. None of the third generation compounds is suitable for oral administration and, accordingly, their pharmacokinetics have been studied only after intravenous and intramuscular administration. Microbiological assays and HPLC methods have been used for the measurement of plasma/serum, urine, bile and cerebrospinal fluid (CSF) concentrations. As found with cefotaxime, microbiological assays should only be used when the full metabolite spectrum of a particular drug is known, as otherwise, the presence of microbiologically active metabolites may lead to erroneous conclusions. Under normal conditions, the major route of elimination is via the kidneys for cefsulodin, latamoxef, ceftazidime, ceftizoxime and cefotetan. In contrast, cefoperazone is mainly eliminated in the bile, whereas cefotaxime and ceftriaxone depend both on the liver and the kidneys for their elimination. With the exception of ceftriaxone, which has a longer elimination half-life (i.e. around 8 hours), all the other third generation cephalosporins have a t1/2 ranging between 1.5 and 2.5 hours. Plasma protein binding is variable from one compound to another. However, the clinical relevance of this parameter is not clearly established since tissue penetration also depends on the relative affinity of the drug for tissue components. Third generation cephalosporins seem to penetrate adequately into the CSF and, thus pharmacokinetically appear to be appropriate agents for the treatment of meningitis. The degree of modification of pharmacokinetic parameters by renal insufficiency or hepatic diseases depends, as for other drugs, on the extent to which the compound is excreted via the kidneys or the liver. The third generation cephalosporins have been extensively studied under these conditions and recommendations for dosage modification in special circumstances are available for most of them. The pharmacokinetics of some third generation cephalosporins may be modified in neonates and elderly patients. Accordingly, their use at the extremes of age must be accompanied by a closer than usual clinical monitoring of the patient. From a clinical point of view, the third generation cephalosporins possess reliable pharmacokinetic properties.(ABSTRACT TRUNCATED AT 400 WORDS)

Single-drug versus combination empirical therapy for gram-negative bacillary infections in febrile cancer patients with and without granulocytopenia

Empirical therapy with cefoperazone was compared with cefoperazone plus amikacin in granulocytopenic and nongranulocytopenic febrile patients. In nonneutropenic patients the overall response rate to cefoperazone was 88%; 10 of 12 gram-negative bacteremic patients were cured. Cefoperazone plus amikacin resulted in an 88% overall response rate and cured 14 of 15 patients with bacteremia. In neutropenic patients the overall response rate was 77% with cefoperazone alone and 73% with cefoperazone plus amikacin; the cure rates for gram-negative bacteremias were 8 of 11 and 6 of 12 patients, respectively. Our findings support the concept of single-drug empirical therapy with cefoperazone in febrile cancer patients, whether granulocytopenic or not, especially when gram-negative bacteremias are predominantly caused by Escherichia coli or Klebsiella species. The issue of Pseudomonas spp. and other more resistant pathogens needs further assessment with a larger number of patients.

Susceptibility of anaerobic bacteria from several French hospitals to three major antibiotics

The in vitro activity of cefoxitin was compared with those of metronidazole and clindamycin against 322 strains of anaerobic bacteria collected from several hospitals during 1982 and tested by an agar dilution method. Metronidazole and cefoxitin inhibited at least 89% of strains tested, whereas clindamycin was less active.

Lack of interference of five new beta-lactam antibiotics with serum creatinine determination

Several cephalosporins falsely elevate creatinine concentration as determined by the Jaffé reaction. We studied the in vitro effect of various concentrations of cefoperazone, ceftizoxime, ceftriaxone, ceftazidime, and azthreonam on the creatinine determination in serum, using both a manual and an automated technique. No false elevation or change in baseline creatinine concentration could be observed with any of the five antibiotics. With the use of large concentrations in serum of these beta-lactam antibiotics, we can estimate their lack of interference with creatinine determination in urine as well. Therefore, there is no need to relate the timing of blood (and urine) sampling for creatinine assay to dosage of these antibiotics.

Intraabdominal infections in the elderly

Biliary sepsis, appendicitis, diverticulitis, and intraabdominal abscess are intraabdominal infections that are especially relevant to the elderly population. Diagnostic delays, reluctance to perform surgery, presence of underlying disease, and postoperative complications contribute to the higher morbidity and mortality rates seen for elderly patients with these infections.

Drug prescribing in renal failure: dosing guidelines for adults

The data base for rational guidelines to safe, efficacious drug prescribing in adults with renal insufficiency are presented in tabular form. Current medical literature was extensively surveyed to provide as much specific information as possible. When information is lacking, however, recommendations are based on pharmacokinetic variables in normal subjects. Nephrotoxicity, important adverse effects, and special considerations in renal patients are noted. Adjustments are suggested for hemodialysis and peritoneal dialysis when appropriate.

Antimicrobial activity and other in vitro properties of cefoperazone A, the principal metabolite of cefoperazone sodium

Cefoperazone A, the principal metabolite of cefoperazone, was found to have an antimicrobial activity ranging from slightly below to 16-fold less than that of the parent drug. Like cefoperazone, the metabolite is bactericidal, penetrates well into bacterial cells, and has moderate beta-lactamase stability, some strains of members of the family Enterobacteriaceae produce an inoculum effect on the metabolite activity.

Pharmacokinetics of cefoperazone in full-term and premature neonates

The pharmacokinetics of cefoperazone were evaluated in 28 newborn infants who were being treated for sepsis. A dose of 50 mg/kg was administered intravenously on days 0 to 2 in all, with a second dose administered on days 5 to 7 in 14 infants. Cerebrospinal fluid penetration was also studied in seven neonates. The mean peak concentration of cefoperazone in the serum of premature infants less than 33 weeks of gestational age, 159 (standard deviation, +/- 22) micrograms/ml, was higher than concentrations in premature infants 33 to 36 weeks of age and full-term infants (110 +/- 41 and 109 +/- 29 micrograms/ml, respectively). The mean concentrations 24 h after dosage were similar in all three groups, 13 to 17 micrograms/ml. The mean serum half-lives were similar in the three subgroups and ranged from 7 to 9 h. After the dose at 5 to 7 days, mean blood levels in the subgroups at 0.5 h were 149, 112, and 112 micrograms/ml; 24-h levels ranged from 9 to 12 micrograms/ml. The mean serum half-lives ranged from 5 to 7 h. Cerebrospinal fluid levels in patients with meningitis ranged from 2.8 to 9.5 micrograms/ml and in patients without meningitis from 1 to 7 micrograms/ml. Peak blood levels were 15 to 1,000 times higher than the 90% minimal inhibitory concentration of common pathogens found in newborns. These observations support the potential efficacy of cefoperazone in treatment of infections, including meningitis, in newborn infants.

Cefoperazone (Cefobid, Pfizer)

Cefoperazone is a new beta-lactam antibiotic that possesses a broad spectrum of activity against gram-positive and gram-negative organisms. Cefoperazone differs from all previous cephalosporins in that it has exceptional activity against P. aeruginosa. The other distinguishing feature of cefoperazone is its high rate of biliary excretion, which will allow for treatment of biliary tract infections. Renal elimination accounts for only 20 percent of the agent's elimination; dosage modification is not necessary in decreased renal function. The clinical response rate of infections to cefoperazone is similar to that of moxalactam, cefotaxime, or the cephalosporins in general. The overall incidence of side effects was 14 percent in U.S. trials, with skin rash, fever, or urticaria occurring in 1 percent; phlebitis and injection-site pain in 2 percent; and diarrhea in 5 percent. As with the other third-generation cephalosporins, cefoperazone requires close scrutiny because of its expected high cost and the lack of comparative trials with standard antibiotic regimens.

Antimicrobial activity, pharmacokinetics, adverse reactions, and therapeutic indications of cefoperazone

Cefoperazone is a parenteral cephalosporin antibiotic that is pending approval by the U. S. Food and Drug Administration. Compared to most other cephalosporins cefoperazone has a greatly expanded spectrum of bactericidal activity that encompasses most aerobic gram-positive bacteria except enterococci, most aerobic gram-negative bacteria, including a majority of Pseudomonas aeruginosa strains, and a number of pathogenic anaerobic bacteria. Its long serum half-life, approximately two hours, permits a twelve hourly dosing schedule. No dosage modification is required in patients with renal insufficiency, and only minor modification is needed in patients with hepatic insufficiency or biliary obstruction. Clinical trials have established cefoperazone's efficacy in lower respiratory tract infections, urinary tract infections, and a variety of other bacterial infections. Adverse reactions have been infrequent, and few serious reactions have been identified. Cefoperazone is a promising new agent for the treatment of gram-negative bacillary and polymicrobial infections, especially in settings that require empiric therapy.