Quinolones in sexually transmitted diseases

Management of Acute Epididymitis: Are European Guidelines Being Followed?

OBJECTIVE

Acute epididymitis is increasing in men aged 35 years or under due to sexually-transmitted Chlamydia trachomatis. This study examines whether Urological surgeons are following European guidelines for the management of acute epididymitis in these patients.

METHODS

A postal questionnaire survey was conducted of specialists in Urology in two regions of the UK.

RESULTS

Of 79 completed replies, 41 (52%) take a detailed sexual history but only 34 (43%) refer patients to a Genitourinary medicine clinic. Quinolones are the most commonly prescribed first-line antibiotic by 56 (71%) respondents, principally ciprofloxacin.

CONCLUSIONS

The current management of acute epididymitis in young men must be improved. Ciprofloxacin is not the optimal antimicrobial for the treatment of urogenital chlamydial infection. We recommend that all such patients be referred to local Genitourinary medicine services for contact-tracing and treatment of their sexual partners.

How, and how efficiently, can we treat Chlamydia trachomatis infections in women?

Several antichlamydial active drugs are available for both non-pregnant and pregnant women, potentially allowing effective prevention of the consequences and transmission of infection. The choice of treatment regimen not only has to consider efficacy, but also side-effects, compliance and the cost of antibiotic drugs. In recent years there have been no significant changes to the guidelines for treating Chlamydia trachomatis infection as no new antibiotic has been included. Inclusion of a new antichlamydial drug in the guidelines must be supported by suitable, randomized trials. Furthermore, how much it will be used in clinical practice will also depend on considerations of a pharmacoeconomic nature.

Chlamydia pneumoniae and atherosclerosis: critical assessment of diagnostic methods and relevance to treatment studies

A number of studies have found that inflammation of the vessel wall plays an essential role in both the initiation and progression of atherosclerosis and erosion and fissure and the eventual rupture of plaques. Chlamydia pneumoniae is one of the infectious agents that have been investigated as possible causes of this inflammation. Initial studies of the association of C. pneumoniae and cardiovascular disease (CVD) were seroepidemiologic, and these were followed by studies in which the organism was identified in vascular tissue from patients with CVD by electron microscopy, PCR and immunocytochemical staining (ICC). C. pneumoniae has also been isolated by culture from vascular tissue in a small number patients. However, no single serologic, PCR, or ICC assay has been used consistently across all studies. The assays used are also not standardized. Recent studies of serologic and PCR assays for diagnosis of C. pneumoniae infection have suggested that there may be substantial interlaboratory variation in the performance of these tests. It now appears that some of the inconsistency of results from study to study may be due, in part, to lack of standardized methods. Although initial seroepidemiologic studies demonstrated a significantly increased risk of adverse cardiac outcome in patients who were seropositive, subsequent prospective studies found either small or no increased risk. In addition to the lack of consistent serologic criteria, recent evaluations have demonstrated inherent problems with performance of the most widely used serologic methods. Most importantly, we do not have a reliable serologic marker for chronic or persistent C. pneumoniae infection.

Clinical applications of quinolones

The quinolone antimicrobials are the class of inhibitors of bacterial topoisomerases that has been developed most fully for clinical use in human medicine. Initial members of the class had their greatest potency against Gram-negative bacteria, but newly developed members have exhibited increased potency against Gram-positive bacteria and soon agents will be available with additional activity against anaerobic bacteria, providing a broad spectrum of potency. After nalidixic acid, the earliest member of the class which was used for treatment of urinary tract infections, the later fluoroquinolone congeners have had sufficient potency, absorption, and distribution into tissue for additional uses in treatment of sexually transmitted diseases, infections of the gastrointestinal tract, respiratory tract, skin, and bones and joints. Tolerability of these agents in usual doses has been good. Acquired bacterial resistance resulting from clinical uses has occurred in particular among staphylococci and Pseudomonas aeruginosa. Intense drug use and ability of resistant pathogens to spread have also contributed to development of resistance in initially more susceptible pathogens such as Escherichia coli and Neisseria gonorrhoeae in certain settings. Preservation of the considerable clinical utility of the quinolone class for the long term will be affected by the extent to which their use is judicious.

Enoxacin: a reappraisal of its clinical efficacy in the treatment of genitourinary tract infections

Enoxacin is a 6-fluoronaphthyridinone antibacterial agent with good in vitro activity against Neisseria gonorrhoeae and most Gram-negative urinary tract pathogens. It is less active in vitro against Acinetobacter spp., Pseudomonas aeruginosa, and most Gram-positive bacteria, than against Gram-negative organisms. Enoxacin is rapidly absorbed, with a high oral bioavailability (87 to 91%). Of the absorbed dose, 44 to 56% is excreted unchanged in the urine, with peak urinary concentrations (>500 mg/L within 4 hours) remaining high (>100 mg/L) for up to 24 hours, sufficient to inhibit most urinary tract pathogens. Single (400 mg) and multiple oral dose regimens (100 to 600 mg twice or 3 times daily for 5 to 14 days) of enoxacin are as effective for the treatment of patients with complicated or uncomplicated urinary tract infections as other antibacterial agents such as amoxicillin, cefuroxime axetil, cotrimoxazole (trimethoprim-sulfamethoxazole) or trimethoprim. Noncomparative data suggest that enoxacin is also an effective agent for the treatment of prostatitis. Single 400 mgoral doses of enoxacin produce >/- 95% bacteriological cure rates in gonococcal infections, comparable to those produced by single intramuscular doses of ceftriaxone 250 mg. Perioperative doses of oral enoxacin 200 mg provide effective prophylaxis against postoperative bacteriuria after transurethral resection of the prostate. Concomitant administration of enoxacin with a number of commonly used therapeutic agents (e.g. antacids, methylxanthines, warfarin) affects the pharmacokinetic properties of either enoxacin or the coadministered agents. Enoxacin is reasonably well tolerated, with the incidence of adverse experiences ranging from 0 to 24%. Adverse events are mainly gastrointestinal, neurological or dermatological and resolve with minimal intervention. Overall, although enoxacin exhibits a number of clinical characteristics that are similar to those of other agents for the treatment of genitourinary tract infections, the advantages offered by this agent generally do not outweigh those of alternative fluoroquinolone agents. Thus, it is likely to prove to be yet another addition to the list of agents available for the management of these infections.

Antibiotic chemotherapy of bacterial sexually transmitted diseases in adults: a review

Treatment regimens for sexually transmitted infections continue to evolve. The natural history of syphilis in HIV-infected patients is leading to more aggressive policies in terms of both investigation and treatment. In particular, treatment protocols for late syphilis, especially neurosyphilis, are under scrutiny. Epidemiological change typified by the spread of penicillinase-producing Neisseria gonorrhoeae (PPNG) has led to a search for new agents to treat gonorrhoea, with a more extensive use of cephalosporin and quinolone antibiotics emerging. The problem of compliance with the antibiotic courses presently required for chlamydial infection may be close to being solved with the development of newer macrolide agents. Single dose azithromycin, although expensive, seems to be as effective as longer courses with other agents. Furthermore, its efficacy in gonococcal infection is also encouraging. Increased understanding of the pathogenesis and natural history of pelvic inflammatory disease (PID) and bacterial vaginosis (BV) has led to rationalization of treatment policies for these conditions.