Cefotaxime and ceftriaxone cerebrospinal fluid levels during treatment of bacterial meningitis in children

Cefotaxime (CTX) and ceftriaxone (CRO) were compared for cerebrospinal fluid (CSF) penetration and antimicrobial efficacy in cases of bacterial meningitis in children. This was a comparative study of CRO (100mg/kg once daily) and CTX (50 mg/kg 6 hourly) in the treatment of children with bacterial meningitis. The aetiological agents included Streptococcus pneumoniae (SPn), Haemophilus influenzae type b (Hib) and Neisseria meningitidis (NMen). Minimum inhibitory concentrations (MICs) were measured. In 33 patients from whom a second CSF specimen was obtained, CSF was cultured and assayed for antibiotic concentration. Median MICs of CTX and CRO for SPn, Hib and NMen were 0.01 and 0.01 microg/mL, 0.004 and 0.002 microg/mL and 0.008 and 0.004 microg/mL, respectively. All 33 repeat lumbar puncture specimens were sterile. The lowest CSF level recorded (0.45 microg/mL for CTX) was 45 times the MIC (0.01 microg/mL). The highest levels (24-35 microg/mL for CRO) were up to 8750 times the MIC of the patient's causative organism. A wide range of CSF levels for both antibiotics was observed. Levels varied with post-dose interval and duration of illness. On the basis of these findings, clinicians should be reassured that repeat lumbar puncture is not recommended for the causative organisms in this study (i.e., for Hib, NMen and penicillin/cefotaxime/ceftriaxone fully-susceptible SPn).

Cefotaxime acts synergistically with levofloxacin in experimental meningitis due to penicillin-resistant pneumococci and prevents selection of levofloxacin-resistant mutants in vitro

Cefotaxime, given in two doses (each 100 mg/kg of body weight), produced a good bactericidal activity (-0.47 Deltalog(10) CFU/ml. h) which was comparable to that of levofloxacin (-0.49 Deltalog(10) CFU/ml. h) against a penicillin-resistant pneumococcal strain WB4 in experimental meningitis. Cefotaxime combined with levofloxacin acted synergistically (-1.04 Deltalog(10) CFU/ml. h). Synergy between cefotaxime and levofloxacin was also demonstrated in vitro in time killing assays and with the checkerboard method for two penicillin-resistant strains (WB4 and KR4). Using in vitro cycling experiments, the addition of cefotaxime in sub-MIC concentrations (one-eighth of the MIC) drastically reduced levofloxacin-induced resistance in the same two strains (64-fold increase of the MIC of levofloxacin after 12 cycles versus 2-fold increase of the MIC of levofloxacin combined with cefotaxime). Mutations detected in the genes encoding topoisomerase IV (parC and parE) and gyrase (gyrA and gyrB) confirmed the levofloxacin-induced resistance in both strains. Addition of cefotaxime in low doses was able to suppress levofloxacin-induced resistance.

Prevalence of cefotaxime resistance in group B streptococcus isolates from Osaka, Japan

Streptococcus agalactiae (group B streptococcus; GBS) organisms are a major cause of severe infections, including bacteremia and meningitis in newborns. According to previous reports, GBS organisms are uniformly sensitive to penicillin G (PCG). The susceptibility of 117 strains isolated at Yodogawa Christian Hospital in Osaka, Japan, in 2001 was examined with the WalkAway system, using currently valid National Committee for Clinical Laboratory Standards (NCCLS) interpretive criteria. Twenty-one strains (18%) had intermediate susceptibility and 1 strain (1%) was resistant to PCG. Fifty-one strains (44%) had intermediate susceptibility to ampicillin (ABPC). No ABPC-resistant strain was found. Six GBS strains were selected from the 51 strains showing intermediate susceptibility to ABPC to determine the minimal inhibitory concentrations (MICs). The MICs of the 6 strains were: 1 microgram/ml to ABPC, 0.25 microgram/ml to PCG, 2 micrograms/ml to cefotaxime (CTX), 0.016 microgram/ml to panipenem (PAPM), and more than 4 micrograms/ml to erythromycin (EM). These 6 strains were distinctly resistant to CTX. Peak concentrations in excess of three to ten times the bactericidal concentrations at the site of infection are associated with the best clinical response. In meningitis caused by GBS whose susceptibility is intermediate or resistant to PCG or ABPC, it is difficult to maintain a sufficient therapeutic concentration in cerebrospinal fluid after the administration of these two agents. It is preferable to use PAPM, because the efficacy and safety of PAPM in the treatment of purulent meningitis caused by penicillin-resistant Streptococcus pneumoniae were established in Japan.

Determination of cefotaxime and desacetylcefotaxime in cerebrospinal fluid by solid-phase extraction and high-performance liquid chromatography

A high-performance liquid chromatographic procedure has been developed for the measurement of cefotaxime and desacetylcefotaxime in cerebrospinal fluid. Both compounds were isolated from cerebrospinal fluid samples using solid-phase extraction (SPE). LiChrolut RP-18 (200 mg; 3 ml) columns and a mixture of methanol-phosphate buffer pH 7 (1:1) were applied to elute cefotaxime and its desacetyl metabolite. The separation was performed on a LiChrospher 100RP-18 (5 microm; 250 x 4 mm I.D.) column. The mobile phase consisted of 0.01 M acetate buffer pH 4.8-methanol (85:15), flow-rate was 1.5 ml/min. Cefotaxime and desacetylcefotaxime were detected at a wavelength of 254 nm by UV-Vis detector. The range of concentrations for method calibration and for analytical studies was 1.56-100 microg/ml. The quantitation limit in cerebrospinal fluid was 0.39 microg/ml for cefotaxime and 0.78 microg/ml for desacetylcefotaxime. The extraction recovery from cerebrospinal fluid spiked with cefotaxime and desacetylcefotaxime was 90.4-100.1% and 97.4-102.9%, respectively. The RSDs were below 10.7% for cefotaxime and 6.8% for desacetylcefotaxime. The developed SPE-HPLC method was applied for cefotaxime and desacetylcefotaxime determination in cerebrospinal fluid of children with hydrocephalus after intraventricular administration.

Simultaneous determination of cefotaxime and desacetylcefotaxime in human plasma and cerebrospinal fluid by high-performance liquid chromatography

A simple and sensitive HPLC method for the simultaneous determination of cefotaxime (I) and desacetylcefotaxime (II) in human plasma and cerebrospinal fluid (CSF) is described. The assay involves deproteinisation and subsequent separation on a reversed-phase HPLC column, with ultraviolet detection at 262 nm. Retention times were 6.8 and 2.2 min for cefotaxime and desacetylcefotaxime, respectively. Average recoveries for the analytes were 78% (I) and 88% (II) from both matrices. Linear responses were observed over a wide range (0.58-940 microg/ml for (I) in plasma, 0.80-55.8 microg/ml for (I) in CSF, 0.54-148 microg/ml for (II) in plasma and 0.50-36.0 microg/ml for (II) in CSF).

Kinetic and biochemical analysis of carrier-mediated efflux of drugs through the blood-brain and blood-cerebrospinal fluid barriers: importance in the drug delivery to the brain

In this manuscript, our recent studies on the transporters on the blood-brain barrier and blood-cerebrospinal fluid (CSF) barrier responsible for the excretion of ligands from the central nervous system (CNS) to the blood are summarized. By comparing the brain entry of quinidine in normal and mdr 1a knock out mice, the predominant role of P-glycoprotein in the brain distribution of this compound was demonstrated. In addition to P-glycoprotein, the presence of transporters responsible for the efflux of organic anions from the brain has been suggested by a pharmacokinetic analysis of the CNS distribution of cefodizime, a third generation cephalosporin antibiotic. This suggestion was confirmed by demonstrating the presence of a specific mechanism for the elimination of p-aminohippuric acid from the brain after microinjection into the cerebral hemisphere. In vitro, the energy-dependent luminal preferential efflux of glutathione-bimane was demonstrated in a monolayer of MBEC4 cells which were derived from mouse brain endothelial cells. Studies with isolated membrane vesicles from MBEC4 cells suggested the presence of a primary active transporter(s) for organic anions, and Western blot analysis indicated the presence of multidrug resistance associated protein (MRP1) and/or its related transporters on MBEC4 cells and freshly isolated rat cerebral endothelial cells. The transcellular transport of 17beta estradiol 17beta-D-glucuronide (E(2)17betaG) across the choroid plexus was also demonstrated by examining the efflux of this compound from CSF after intracerebroventricular administration. The functional significance of organic anion transporting polypeptide (oatp-1) on the brush border membrane of the choroid plexus was demonstrated by comparing the uptake of E(2)17betaG into the isolated choroid plexus and oatp-1 transfected COS-7 cells; in addition, reverse transcription-polymerase chain reaction and Western blot analysis indicated the presence of MRP in the choroid plexus. Together with the direction of transcellular transport, the basolateral localization of MRP on the choroid plexus was suggested. By regulating the activity of these efflux transporters, it is possible to improve the brain entry of certain substrates.

Bactericidal activity against intermediately cephalosporin-resistant Streptococcus pneumoniae in cerebrospinal fluid of children with bacterial meningitis treated with high doses of cefotaxime and vancomycin

Cerebrospinal fluid (CSF) was taken from 19 children with bacterial meningitis treated with cefotaxime (300 mg/kg of body weight/day) and vancomycin (60 mg/kg/day). Median levels of drugs in CSF were smaller than expected, as follows: 4.4 microg/ml for cefotaxime, 3.2 microg/ml for desacetylcefotaxime, and 1.7 microg/ml for vancomycin. The median CSF bactericidal titer against an intermediately cefotaxime-resistant pneumococcus was 1:4. Our data suggest at least an additive interaction between the drugs used in this study.

Cerebrospinal fluid bactericidal activity against cephalosporin-resistant Streptococcus pneumoniae in children with meningitis treated with high-dosage cefotaxime

We determined cefotaxime and desacetyl-cefotaxime concentrations in children with bacterial meningitis receiving high-dose cefotaxime (300 mg/kg of body weight/day) and concomitant dexamethasone therapy. The median peak cerebrospinal fluid cefotaxime and desacetyl-cefotaxime concentrations were 4.7 and 8.1 microg/ml, respectively. In vitro bactericidal activity (>99.9% killing in 6 h) was found in 17 (94%), 13 (72%), and 8 (44%) of 18 cerebrospinal fluid specimens against cefotaxime-susceptible, -intermediate (MIC, 1 microg/ml), and -resistant (MIC, 4 microg/ml) strains, respectively. High-dose cefotaxime, while safe, is not reliably sufficient therapy for cephalosporin-nonsusceptible pneumococcal meningitis, and combination therapy is recommended.

Comparative perilymph permeability of cephalosporins and its significance in the treatment and prevention of suppurative labyrinthitis

Cephalosporins are nonototoxic antibiotics that provide excellent coverage for almost all bacteria that can cause suppurative labyrinthitis. In this study we performed comparative perilymph permeability determinations of the three cephalosporins that we deemed to have the most clinical potential in these varied situations. Perilymph pharmacokinetic profiles were established for ceftazidime, cefuroxime, and cefotaxime and its metabolite desacetylcefotaxime in 36 guinea pigs by using the technique of high-performance liquid chromatography. At 1, 2, 3, 4, and 6 hours after intravenous administration of the three cephalosporins at a dose of 100 mg/kg of body weight, ceftazidime consistently exhibited the highest perilymph concentration. Desacetylcefotaxime showed the next highest capacity for penetration into perilymph. Keeping in mind that the choice of drug for the treatment of suppurative labyrinthitis should be based foremost on culture and sensitivity studies, we consider ceftazidime to be the first-line agent for treatment and prevention of both meningogenic labyrinthitis and labyrinthitis complicating acute or chronic otitis media.

High doses of cefotaxime in treatment of adult meningitis due to Streptococcus pneumoniae with decreased susceptibilities to broad-spectrum cephalosporins

We treated nine patients (10 episodes) with meningitis caused by Streptococcus pneumoniae isolates with decreased susceptibilities to broad-spectrum cephalosporins with high doses of cefotaxime (300 mg/kg of body weight per day; maximum dose, 24 g/day). Early adjunctive therapy with dexamethasone was also administered. Cefotaxime MICs were 0.5 (three episodes), 1 (five episodes), and 2 (two episodes) micrograms/ml, and MBCs ranged from 1 to 4 micrograms/ml. Therapy was well tolerated, and all patients experienced prompt clinical improvement. One patient died 8 days after the end of therapy, the central nervous system infection had already been cured, and the remaining patients recovered without relapses.

Passage of cefotaxime and ceftriaxone into cerebrospinal fluid of patients with uninflamed meninges

Cefotaxime and ceftriaxone have proven to be effective in pyogenic infections of the central nervous system. Since in some bacterial central nervous system infections the blood-cerebrospinal fluid (CSF) barrier is either minimally impaired or recovers in the course of the illness, we studied the penetration of both antibiotics in the absence of inflamed meninges. Patients who had undergone external ventriculostomies for noninflammatory occlusive hydrocephalus received either cefotaxime (2 g/30 min) or ceftriaxone (2 g/30 min) to treat extracerebral infections. Serum and CSF were drawn repeatedly after the first dose. With ceftriaxone, they were also drawn after the last dose. The concentrations of cefotaxime, its metabolite desacetylcefotaxime, and ceftriaxone were determined by high-performance liquid chromatography with UV detection. Maximum concentrations of cefotaxime in CSF were reached 0.5 to 8 h (median = 3 h; n = 6) after the end of the infusion and ranged from 0.14 to 1.81 mg/liter (median = 0.44 mg/liter; n = 6). Maximum levels of ceftriaxone in CSF ranging from 0.18 to 1.04 mg/liter (median = 0.43 mg/liter; n = 5) were seen 1 to 16 h (median = 12 h; n = 5) after the infusion. The elimination half-life of cefotaxime in CSF was 5.0 to 26.9 h (median = 9.3 h; n = 5), and that of ceftriaxone was 15.7 to 18.4 h (median = 16.8 h; n = 3). It is concluded that after a single dose of 2 g, maximal concentrations of cefotaxime and ceftriaxone in CSF do not differ substantially. The long elimination half-lives guarantee uniform concentrations in CSF. These concentrations reliably inhibit highly susceptible bacteria but cannot be relied on to inhibit staphylococci and penicillin G-resistant Streptococcus pneumoniae.

In vitro postantibiotic effects following multiple exposures of cefotaxime, ciprofloxacin, and gentamicin against Escherichia coli in pooled human cerebrospinal fluid and Mueller-Hinton broth

Multiple exposures with cefotaxime in either Mueller-Hinton broth or cerebrospinal fluid had no effect on killing or the duration of postantibiotic effect (PAE) in Escherichia coli strains tested. However, upon multiple exposures in Mueller-Hinton broth, ciprofloxacin and gentamicin PAEs significantly decreased with a concomitant reduction in bacterial killing. A reduction in bacterial killing following multiple ciprofloxacin and gentamicin exposures was also seen with cerebrospinal fluid; however, the PAE was maintained.

Pharmacokinetics and cerebrospinal fluid concentrations of cefixime in infants and young children

Limited data are available about cefixime pharmacokinetics and cerebrospinal fluid (CSF) penetration in infants and young children. Ten patients with bacterial meningitis and 8 undergoing CSF shunt placement, aged 2-22 months (mean 9.5 +/- 6.5 months), were given a single dose of cefixime suspension, 8 mg/kg, before undergoing a routine lumbar puncture. Patients were fasted for 2 h before and 2 h after drug administration. Blood samples were collected just before drug administration (0 h) and at 1, 2, 3, 4, 6, 8 h; CSF was obtained at 1-8.8 h after drug administration. Cefixime was measured by a high-performance liquid chromatographic method. The peak serum concentration of cefixime ranged from 0.85 to 6.2 (mean 3.1) micrograms/ml and occurred at 2-8 h (mean 4.5). The area under the serum concentration-time curve ranged from 5.3 to 28.4 micrograms h/ml, and the elimination half-life ranged from 2.6 to 5.6 h. CSF concentrations ranged from 0.02 to 0.57 micrograms/ml. The mean CSF concentration of cefixime was 0.22 micrograms/ml in patients with meningitis and 0.10 microgram/ml in those undergoing shunt placement (p < 0.02). The mean CSF concentration/serum concentration ratio was 11.7 in patients with meningitis compared with 5.4 in those undergoing shunt procedures (p < 0.02). These data indicate that cefixime can be considered as an alternative to other antimicrobials for infants and children with respiratory and urinary tract infections, since the observed peak serum concentration exceeded the minimum inhibitory concentrations of the common pathogens by severalfold.(ABSTRACT TRUNCATED AT 250 WORDS)

Meningoencephalitis due to penicillin-resistant Streptococcus pneumoniae

The case of a 68-year-old man suffering from pneumococcal meningoencephalitis is reported. Antibacterial susceptibility tests revealed a multiply resistant pneumococcal strain. High doses of cefotaxime were necessary to sterilize the cerebrospinal fluid despite the achievement of a satisfactory level of antibiotic in the cerebrospinal fluid with moderate dosage. In France, as well as in many countries, high doses of third-generation cephalosporins such as cefotaxime or ceftriaxone should be administered for the initial therapy of suspected pneumococcal meningitis.

Facilitated transport of cefodizime into the rat central nervous system

The disposition of [14C]cefodizime, a nonmetabolizable analog of cefotaxime, in the central nervous system was studied in control and benzylpenicillin-infused rats using in vivo experimental techniques. After i.v. bolus administration of [14C]cefodizime, a concentration gradient was established from the brain extracellular fluid (ECF) to the cerebrospinal fluid (CSF) (i.e., drug penetration into the CSF after i.v. administration can be accounted for by permeation across the cerebral capillaries and diffusion through the brain ECF and across the ependymal surface into the CSF). Kinetic analysis indicated that the cerebrovascular transfer coefficient for plasma unbound [14C]cefodizime in control rats equaled 5.2 x 10(-5) ml/sec/g brain, a value comparable to that for mannitol. In rats which received an i.v. infusion of benzylpenicillin, the cerebrovascular transfer coefficient for [14C]cefodizime was reduced to approximately 1/15th of the control value, resulting in a reduced central nervous system (brain ECF and CSF)/plasma unbound concentration ratio for this drug. After i.c.v. administration, the efflux of [14C]cefodizime from CSF was comparable to that of [3H]mannitol with a small probenecid-sensitive component and was not affected by treatment with benzylpenicillin. These results indicate that the unidirectional influx of [14C]cefodizime into brain ECF and then into the CSF is facilitated by a mechanism shared with other beta-lactam antibiotics.

Antibiotic concentrations in liquor compared to the minimal inhibitory concentrations of isolates in paediatric bacterial meningitis. The Finnish Study Group

The susceptibilities of 171 bacteria which caused meningitis in 200 children were tested for their susceptibility as minimal inhibitory concentrations (MICs) for the antibiotics used in therapy. These antibiotics were chloramphenicol, ampicillin, cefotaxime and ceftriaxone. The MICs were compared to the minimal concentrations of the drugs seen in the cerebrospinal fluid (CSF) samples. The minimal bacteriostatic capacity (lowest concentration in CSF/MIC) of both cephalosporins was superior to that of chloramphenicol and ampicillin. The correlation of the finding with the speed of liquor sterilization in the treatment groups is discussed.

Treatment of childhood bacterial meningitis

One hundred and eighty-seven children with identified bacterial meningitis were treated with intravenous cefotaxime: 15 patients were neonates, 79 infants, and 93 were aged from 1 to 14 years. Causative organisms were: Neisseria meningitidis in 80 cases, Streptococcus pneumoniae in 41, Haemophilus influenzae in 40, enteric gram-negative bacilli in 20 and Staphylococcus spp. in six. Enteric gram-negative bacilli included: Salmonella spp. in 14 cases, Klebsiella pneumoniae in two, and Escherichia coli, Enterobacter sakazakii and Acinobacter calcoaceticus in one each; in one case the organism was not specified. Daily dose of cefotaxime was 150 to 300 mg/kg. Concomitant treatment with an aminoglycoside was used in seven cases. One hundred and seventy-two patients (92.0%) were cured. Fever persisted for a mean of five days and meningeal signs for a mean of four days. Fifteen (8.0%) patients died: most [13] of them were admitted in coma, and two in shock. Death occurred in the first 48 h in ten cases. Sterilization of CSF was achieved in the first 72 h of treatment in 155 (90.1%) of the cured patients. Cefotaxime was well tolerated. CSF penetration of cefotaxime was evaluated in seven patients: concentrations ranged from 0.499 mg/l to 2.829 mg/l. Based on this clinical study, cefotaxime is an effective and safe drug for the treatment of childhood bacterial meningitis.

Cefotaxime pharmacokinetics and treatment of meningitis in neonates

Pharmacokinetic studies on cefotaxime/desacetylcefotaxime were carried out in very low birth weight newborns (n = 18; 500-1500 g; 28.4 +/- 2.4 weeks gestational age) during the first week of life. We have previously reported that the elimination t 1/2 of cefotaxime (3.4-6.4 h) and desacetylcefotaxime (9.4 h) was longer than previously described in term infants and children. In very low birth weight neonates, a single 50 mg/kg daily dose of cefotaxime may produce accumulation of the metabolite desacetylcefotaxime in serum. In a non-comparative prospective clinical trail, 22 infants (one week - three months) were treated for gram-negative enteric bacillary meningitis with cefotaxime at a dosage of 50 mg/kg/day. The predominant pathogen was Escherichia coli in 14 cases and Enterobacter cloacae in four cases. Cultures of the cerebrospinal fluid obtained 24-48 h after the initiation of treatment were sterile in all subjects. Survival and complication rates of 95% and 19%, respectively, were observed. This compared favorably to previously published experiences with alternative treatment regimens for neonatal gram-negative enteric meningitis. In both the pharmacokinetic and meningitis studies, the safety profile for cefotaxime was excellent with no adverse reactions.

[Experimental study on transferability to cerebrospinal fluid of cefodizime in combination with ampicillin]

A study was done on cefodizime (THR-221, CDZM) in combination with ampicillin (ABPC) for its transferability to cerebrospinal fluid (CSF) of rabbits with experimental meningitis caused by Staphylococcus aureus. Blood and CSF were collected at 15, 30, 45, 60, 90, 120 and 180 minutes after intravenous administration of CDZM at 100 mg/kg to 6 rabbits, ABPC at 100 mg/kg to 4 rabbits and simultaneous administration of both drugs at 100 mg/kg each to 5 rabbits. Drug concentrations were assayed with an high performance liquid chromatography method, and pharmacokinetic parameters were calculated. The comparison revealed no significant difference in concentrations achieved among different groups. Therefore, the mutual transferability of these drugs to CSF was not considered to interact adversely due to the simultaneous administration of both drugs. Accordingly, CDZM may be a candidate of chemotherapeutics in the therapy of purulent meningitis, and it is worthy of further investigations.

[Transferability of cefodizime to cerebrospinal fluid of rabbits with meningitis caused by Staphylococcus aureus]

The transferability of cefodizime (THR-221, CDZM) to cerebrospinal fluid (CSF) was studied employing rabbits with experimental meningitis caused by Staphylococcus aureus. The mean blood concentration was 195 +/- 18.3 micrograms/ml using phosphate buffer solution (PBS) standard and 474 +/- 22.0 micrograms/ml using rabbit serum standard, respectively, at 15 minutes after intravenous administration of the drug at a dose level of 100 mg/kg. The mean concentration in CSF vs. PBS standard was maximum at 60 minutes after administration, and the mean maximum concentration was 8.74 +/- 2.16 micrograms/ml. Pharmacokinetic parameters calculated from those values were as follows, respectively, for PBS standard and rabbit serum standard; Cmax (CSF/serum): 4.48% and 1.84%. AUC (CSF/serum): 6.15% and 2.02% between 15 and 60 minutes, 10.6% and 3.00% between 15 and 120 minutes and 13.4% and 3.48% between 15 and 180 minutes. T 1/2 for CDZM in CSF: 141 minutes in both cases. T 1/2 (CSF/serum): 3.27 and 2.11. Concentrations in CSF determined using an high performance liquid chromatography method in another rabbits were similar to those determined using the bioassay vs. rabbit serum standard. The bioassayed concentration of this drug (AUC (CSF/serum] vs. PBS standard ranked 9th among 23 other beta-lactam antibiotics tested. That is, the drug distributed favorably as compared to other antibiotics, and it may be worthwhile of running clinical trials on this drug in meningitis when antimicrobial potential against main pathogens of meningitis are considered.

Early synergistic killing activity at concentrations attainable in CSF of amoxicillin or cefotaxime and aminoglycosides against Haemophilus influenzae

Rapid eradication of bacteria from the CSF is critical for the outcome of Haemophilus influenzae meningitis in children. In 15 patients studied, the mean H. influenzae colony counts in CSF were 10(5) CFU/ml (range: 10(2) to 10(9) CFU/ml). Time-kill curves were determined for amoxicillin and cefotaxime alone and in combination with gentamicin or amikacin, against 60 clinical isolates of H. influenzae at concentrations equivalent to those found in CSF following systemic administration. Against beta-lactamase-negative strains (n = 44) a bactericidal effect was observed at 18 h for amoxicillin alone, at 5 h for amoxicillin plus aminoglycosides and at 2.5 h for cefotaxime with or without aminoglycosides. Against beta-lactamase-positive strains a bactericidal effect was observed at 18 h for cefotaxime, at 5 h for amoxicillin plus aminoglycosides and at 2.5 h for cefotaxime plus aminoglycosides. It appears that despite low concentrations of gentamicin or amikacin in the CSF, the accelerated killing of H. influenzae provides a rationale for the initial use of the combination of cefotaxime and aminoglycosides in the initial treatment of H. influenzae meningitis.

[Treatment with a cefotaxime-fosfomycin combination of staphylococcal or enterobacterial meningitis in adults]

Thirty-two patients were included in this trial: 22 with staphylococcal meningitis (including 5 methicillin-resistant) and 10 with enterobacterial meningitis. Mean duration of treatment was 14.5 and 15.9 days respectively. The combination was synergistic in vitro against 10 of the 12 strains of Staphylococcus and 5 of the 6 strains of Enterobacteriaceae studied. Bacteriological sterilization occurred in all cases which could be evaluated, and clinical recovery was obtained in 95.2% of patients with staphylococcal meningitis (4 unrelated deaths) and 100% of patients with enterobacterial meningitis (2 deaths). Bactericidal power of the cerebro-spinal fluid, often less than 1/8, was not correlated with effectiveness against Staphylococci. Mean CSF concentrations of cefotaxime, desacetylcefotaxime and fosfomycin on the 2nd and 15th days of treatment were 4, 3.5 and 39.8 mg/l and 2.2, 2.1 and 28.0 mg/l, respectively. Clinical and biological acceptability was satisfactory. There were three cases of superinfection or colonization, by Pseudomonas and Enterobacter.

Pharmacokinetics of cefotaxime and its desacetyl metabolite in plasma and in cerebrospinal fluid

The aim of the study was to investigate the pharmacokinetic modelling of Cefotaxime (CTX) and its main metabolite Desacetyl Cefotaxime (DCTX) which has a less antibacterial activity than the CTX. After intravenous administration of 1g of CTX to 26 patients, the plasma concentrations determined by HPLC showed that the pharmacokinetics of CTX and transformation to DCTX can be described with an open five-compartment model. The implications of this are discussed from the clinical point of view.

[The penetration of cefotaxime into the cerebrospinal fluid. Comparison between acute and chronic stages in intracranial diseases]

Two grams of cefotaxime (CTX) were administrated by drip infusion to 10 patients (11 material) with acute or chronic stage of intracranial diseases. Concentrations of CTX in the serum and the cerebrospinal fluid (CSF) were determined at 15, 30, 60, 120, 240 and 300 minutes after injection. The results obtained were summarized as follows: Serum levels: Peak levels of CTX in sera were 66.2 +/- 10.23 (S.E.) micrograms/ml in the acute stage group (ASG), and 75.7 +/- 31.39 (S.E.) micrograms/ml at 15 minutes after injection in the chronic stage group (CSG). There were no significant difference between the 2 groups. CSF levels: Peak levels of the drug in CSF were 1.35-4.32 micrograms/ml in ASG and 0.18-0.7 microgram/ml in CSG. Average concentration at 60 minutes after injection was 1.11 +/- 0.09 (S.E.) micrograms/ml in ASG and 0.30 +/- 0.08 (S.E.) micrograms/ml in CSG. The value in ASG was significantly higher than the value in CSG by t-test. The ratio between CSF and serum levels: The levels increased as time passed in both groups and the values in ASG were higher than those in CSG at all time points. Average ratios at 60 minutes after injection were 3.85 +/- 0.29 (S.E.)% in ASG and 1.12 +/- 0.50 (S.E.)% in CSG. The value in ASG was significantly higher than that in CSG by t-test. From the above results, it is considered that CTX is useful for the prophylaxis of postoperative infections in intracranial diseases.

[Cefotaxime monotherapy in bacterial meningitis in childhood]

Bacterial meningitis in 20 children was treated with cefotaxime. 17 children received this antibiotic throughout the disease as monotherapy, three were changed to Penicillin G (2) or ampicillin (1), after sensitivity of the pathogen was known, although cefotaxime had been effective. All bacterial isolates were highly susceptible to cefotaxime. All CSF cultures were sterile at second tap, performed 24 to 48 hrs after therapy was started. Cefotaxime and desacetyl-cefotaxime concentrations in CSF, measured by HPLC in 9 patients were in the range of 4 to 34 (average 17.6) mg/l and 2.1 to 82 (average: 15.1) mg/l, representing a CSF-serum ratio of 8 to 74% (average 45.6%) for cefotaxime and 25 to 151% (average: 73.7%) for desacetyl-cefotaxime. Clinical outcome was favourable in 17 patients. There were one death and late neurological deficits in three. Cefotaxime monotherapy is recommended instead of standard therapy with chloramphenicol and/or ampicillin because of superior antibacterial activity, lower toxicity and lesser side-effects for primary meningitis in children caused by N. meningitides, S. pneumoniae, or H. influenzae type b.

Cefotaxime and desacetylcefotaxime pharmacokinetics in infants and children with meningitis

The pharmacokinetics and cerebrospinal fluid (CSF) penetration of cefotaxime (Ctx) and desacetylcefotaxime (dCtx) were evaluated in 13 infants and children with meningitis after dose 6 of Ctx in a multiple-dose intermittent intravenous infusion regimen (50 mg/kg every 6 h). Model-dependent and noncompartmental pharmacokinetic parameters were determined and were found to be congruous. The disposition of both Ctx and dCtx was described adequately by a one-compartment, open model. Noncompartmental pharmacokinetic parameters are reported. The mean Ctx serum concentration at 0.25 h postinfusion was 121.2 micrograms/ml, and the mean CSF concentration at 1 h postinfusion was 6.2 micrograms/ml. The CSF/serum ratio was variable (0 to 20%), with a mean penetration of 10.1%. The mean Ctx elimination half-life, apparent steady-state volume of distribution, and total body clearance were 0.8 h, 0.361 liter/kg, and 0.289 liter/h per kg, respectively. For Ctx, 61% of the dose was excreted unchanged in the urine during the 6-h postinfusion period, and the estimated renal clearance was 0.174 liter/h per kg. No significant correlations were observed between Ctx pharmacokinetic parameters and demographic parameters. The mean peak concentration of dCtx in serum (21.6 micrograms/ml) occurred at approximately 1.5 h postinfusion, and the mean concentration in CSF at 1 h postinfusion was 5.6 micrograms/ml. The CSF/serum ratio was extremely variable (0 to 103%), and the mean penetration was 28.8%. The mean apparent elimination half-life for dCtx was 2.1 h. In infants and children with normal renal function, a 50-mg/kg dose of Ctx administered every 6 h should provide adequate concentrations in serum and CSF in the majority of patients with meningitis.

[Clinical evaluation of cefotiam in the cerebrospinal fluid of patients with ruptured cerebral aneurysms in the acute stage]

The treatment of the patients with ruptured cerebral aneurysm in acute stage is performed by direct neck clipping and cisternal drainages for preventing vasospasm. The cisternal drainage is carried out for 1 to 2 weeks' duration. The cisternal drainage has higher risk for bacterial infections in the cerebrospinal fluid (CSF). In this paper, penetration characteristics of cefotiam (CTM) in CSF were studied. CTM concentrations in CSF were measured at 1, 3 and 6 hours after intravenous drip infusion of CTM (2 g). CTM concentration in cisternal CSF was higher than that of ventricular CSF. The peak concentration in CSF was higher than 0.78 micrograms/ml and obtained at 3 hours after intravenous drip infusion. Our data suggest that CTM is a useful cephalosporin for treatment of meningitis (Staphylococcus aureus, Streptococcus pneumoniae et al.). Apart from meningitis, the higher concentration of CTM in CSF was obtained in the cases with the vasospasm. The result may support that the breakdown of blood brain barrier is induced by the peroxidative substance from the cisternal subarachnoid clots which has the vasospastic activity.

Cefotaxime diffusion into cerebrospinal fluid of children with meningitis

Cefotaxime diffused consistently and in therapeutic levels into the cerebrospinal fluid (CSF) of 13 children successfully treated for bacterial meningitis. CSF cefotaxime levels early (6.0 micrograms/ml) and late (1.2 micrograms/ml) in treatment were severalfold the MBCs for the infecting organisms. After a single 40-mg/kg dose to each of five infants with ventriculostomies, mean CSF levels of cefotaxime were 6.4, 5.7, and 4.5 micrograms/ml at 2, 4, and 6 h, respectively.

[Penetration of cefotaxime into human cerebrospinal fluid]

The penetration of cefotaxime (CTX) into the cerebrospinal fluid (CSF) was monitored to evaluate the prophylactic efficacy of the drug against post-craniotomy infections. Doses ranged from 1 to 2 g were administered to patients with subarachnoid hemorrhage due to the rupture of cerebral aneurysm, traumatic cerebral contusion, or subdural edema accompanied by intracerebral hemorrhage, by intravenous drip infusion over a period of 30 or 60 minutes. CTX readily entered the CSF with concentrations exceeding MICs against the major pathogens occurring after craniotomy. CTX proved to be effective in the prevention of post-craniotomy infections in noninflammatory situations, especially after surgery in the case of cerebral traumas or subarachnoid hemorrhage.

[Cefmenoxime diffusion into cerebrospinal fluid during human purulent meningitis]

We treated 10 patients with bacterial meningitis by 150 mg/kg/day cefmenoxime divided into six intravenous infusions. CSF samples were taken one hour after an IV on the second and fifth days. CSF cefmenoxime determined by microbiologic assay was 8.3 mg/l on days 2 and 5. Every patient recovered without sequelae. In our opinion, these results may support use of cefmenoxime in bacterial meningitis.

New cephalosporins cefotaxime, cefpimizole, BMY 28142, and HR 810 in experimental pneumococcal meningitis in rabbits

Four new cephalosporins, cefotaxime, cefpimizole (U 63196E), BMY 28142, and HR 810 were evaluated in experimental pneumococcal meningitis. Cefotaxime penetrated only moderately into the cerebrospinal fluid of rabbits with meningitis, whereas cefpimizole, BMY 28142, and HR 810 all exhibited unusually good penetration. The bactericidal activity in infected cerebrospinal fluid was comparable for the four drugs.

Cefotaxime in pneumococcal meningitis

Forty-six consecutive patients with pneumococcal meningitis were treated with cefotaxime (CTX). Ages ranged from 1-79 years: 29 adults, six adolescents, six children and five infants. Underlying diseases were found in 38 patients (82.6%). Twenty-six patients (56.5%) were admitted in coma. All isolates were sensitive to CTX, with MICs for 12 strains ranging from 0.01 to 0.08 mg/l. CTX was used as single-drug therapy for 12 to 27 days-mean 15 days. The daily dose of CTX was 200 mg/kg, in four or six equal intravenous doses. CTX penetration into the CSF was studied in four patients. 40 patients (87.0%) were cured. The mortality rate was 13.0%. All dead patients had been admitted in coma. The mortality rate in comatose patients was 23.1%. CSF sterilization was obtained within 72 h after starting treatment, mostly (90.7%) in the first 48 h. No serious side-effects were observed. The study proves that CTX is a safe and very successful therapy for pneumococcal meningitis.

Bactericidal activity of cefotaxime and fosfomycin in cerebrospinal fluid during the treatment of rabbit meningitis experimentally induced by methicillin-resistant Staphylococcus aureus

The purpose of this study was to evaluate the therapeutic effect of cefotaxime (CTX) and fosfomycin (FOS), alone or in combination, in an experimental meningitis, with cerebrospinal fluid (CSF) concentrations of the two antibiotics reproducing those obtained in human CSF during bacterial meningitis. With a dose of 50 mg/kg of CTX and 100 mg/kg of FOS injected i.v. (CTX over 0.5 h and FOS over 3 h), CSF concentrations were comparable to those observed in man. In a series of five rabbits per treatment group, the bacterial population was counted before and after treatment (two doses with a six-hour interval) with CTX, FOS or CTX + FOS (CTX over 0.5 h before the end of FOS infusion). By the 12th hour of treatment, the percentage of bacteria surviving in CSF compared to the initial population was 4.35% for CTX, 0.20% for FOS and 0.19% for CTX + FOS. Thus, it seemed that CTX + FOS was not more active than FOS alone. In another series of four rabbits per group, the bactericidal effect was followed at T0, T6, T12, T24 and T48 after treatment (two doses with a six-hour with a six-hour interval). With CTX, a variable drop in bacterial count from one rabbit to the other occurred during the first 12 h, and then a bacteriostasis followed. With FOS, a quick bactericidal effect was observed during the first 12 h, becoming slower during the following 36 h (0.03% of bacteria surviving at the 48th hour). With CTX and FOS in combination, a quick bactericidal effect was achieved, remaining steady over a 48-hour period (0.001% of bacteria surviving at the 48th hour).

[Value of cefotaxime in gram-negative bacterial meningitis. Apropos of 3 developmental forms in neonates and infants]

Three cases of meningitis with E. coli and H. influenzae are reported. They illustrate the recrudescence and relapse in bacterial meningitis. After the failure of initial antibiotic therapy, the treatment by Cefotaxime allowed a good outcome in all the cases. On account of the bacteriological, pharmacological and clinical data the authors advise using Cefotaxime in first purpose in meningitis with common gram negative bacilli.

Diffusion of ceftriaxone into the cerebrospinal fluid of adults

Fourteen adults, three recovering from bacterial meningitis, were given a single 2 g dose of ceftriaxone or three 2 g doses at 12-hourly intervals. The mean per cent penetration of drug into cerebrospinal fluid (CSF) across uninflamed meninges was 1.5%. These levels, although low, are bactericidal in vitro against most pathogens causing meningitis.

[Study on penetration of cefotiam into the cerebrospinal fluid]

Cefotiam (CTM) is a new cephem antibiotic which has potent activities against Gram-positive and Gram-negative bacteria. We investigated the prophylactic treatment of CTM in orthopedic surgery and the concentrations of CTM Gram-negative in cerebrospinal fluid. The mean serum concentration at 2 hours after the drip infusion of CTM (3 g) was 28.28 +/- 5.48 micrograms/ml, and the mean concentration of CTM in cerebrospinal fluid was 0.58 +/- 0.07 micrograms/ml. From the result of multi-regression analysis in group I (12 cases, over 40 years old) and group II (10 cases, below 39 years old), it was suggested that the factor of age had a marked effect on cerebrospinal fluid concentrations of CTM. (Group I greater than Group II) High concentrations of CTM in cerebrospinal fluid after the 3 g-administration, exceeding the MIC80 for most causative organisms, suggested very useful prophylactic treatment of CTM in orthopedic surgery.

Cefotaxime in the cerebrospinal fluid and serum in patients with purulent meningitis

Cefotaxime concentrations in the cerebrospinal fluid and serum were determined in patients with purulent meningitis by means of a simple, rapid and reproducible method in agar medium. The CSF concentrations of cefotaxime fluctuated around 4 mg/l. The pharmacokinetics of the antibiotic in relation to the integrity of the blood-brain barrier was studied by means of an assay of the albumin and IgG present in the cerebrospinal fluid and in the serum.

Cerebrospinal fluid penetration after combined administration of cefotaxime and ampicillin to rabbits with staphylococcal meningitis

The pharmacokinetics of cefotaxime and ampicillin in the cerebrospinal fluid (CSF) were studied by a HPLC method after administering each of the antibiotics singly or as a mixture to rabbits with experimental meningitis caused by Staphylococcus aureus. The half-lives of cefotaxime and desacetyl-cefotaxime in the serum and of ampicillin in the CSF were found to be significantly shorter in the mixture group than in the respective single administration groups. No other statistically significant differences were observed between the mixture and single administration groups with respect to the maximum concentrations (Cmax) of the antibiotics in the serum and the CSF, to the relative percentage of the Cmax of each antibiotic in the CSF to the Cmax in the serum, and to the relative percentage of the AUC of each antibiotic in the CSF to that in the serum. These results differ from earlier findings that the concentration of ampicillin in the CSF of rabbits was significantly lower in animals concomitantly dosed with latamoxef (moxalactam) and ampicillin than in a group dosed only with ampicillin.

Pharmacokinetics of ceftriaxone in neonates and infants with meningitis

The pharmacokinetics of ceftriaxone was studied in the plasma, urine, and cerebrospinal fluid of seven neonates and seven infants with meningitis. In addition, plasma and urine data were obtained in five neonates and one infant receiving ceftriaxone for other serious infections. All neonates younger than 14 days received daily doses of 50 mg/kg ceftriaxone; all other patients but two received 100 mg/kg. The average weight-corrected values for total body clearance (ClT), volume of distribution (Vdss), and biologic half-life (t 1/2) were 0.37 ml/min/kg, 0.45 L/kg, and 16.2 hours in neonates younger than 1 week; 0.77 ml/min/kg, 0.48 L/kg, and 9.2 hours in neonates older than 1 week; and 1.03 ml/min/kg, 0.39 L/kg, and 7.1 hours in older infants, respectively. There was a significant difference in ClT and t 1/2 between the neonates younger and both neonates older than 1 week, and infants. The Vdss was not significantly different among the three age groups. The average renal clearance in neonates younger than 1 week (0.28 ml/min/kg was 70%, in neonates older than 1 week (0.54 ml/min/kg) was 77%, and in older infants (0.49 ml/min/kg) was 47% of ClT, indicating that nonrenal elimination was less developed in neonates. The quantitation of CSF diffusion of ceftriaxone was assessed by comparison of the areas under the CSF and plasma concentration-time curve. The mean ceftriaxone penetration into the CSF in neonates and infants with bacterial meningitis was 17%. On the other hand, penetration in patients with aseptic meningitis amounted to only 4%. Mean ceftriaxone concentrations in the CSF in patients with bacterial meningitis were 2.8 mg/L after 24 hours, exceeding by many times the minimum inhibitory concentration of the common meningitis pathogens at this time.

[Cerebrospinal fluid diffusion kinetics of cefotaxime and fosfomycin in Staphylococcus aureus meningitis with otorrhea]

A case of post-traumatic meningitis with otorrhea due to Staphylococcus aureus was successfully treated with a cefotaxim-fosfomycin (CTX-FOS) combination. Serial samples of CSF leaking from the ear showed that maximal concentrations of CTX and FOS, 3.24 mg/l and 19.10 mg/l respectively, occurred one hour after the infusion of both antibiotics was terminated. For desacetyl-cefotaxim (D-CTX), maximal concentration (1.24 mg/l) occurred two hours later. These findings suggest that lumber puncture to control maximal penetration of CTX and FOS into CSF should be done one hour after infusion of both antibiotics.

[Diffusion of ceftriaxone in the cerebrospinal and ventricular fluid in the absence of meningeal inflammation]

Spinal and ventricular diffusion of ceftriaxone, measured by HPLC or microbiological assay, is inconsiderable in subjects with healthy meninges.

Concentrations of cefotaxime and the desacetyl metabolite in serum and CSF of patients with meningitis

Thirty-two cases of meningitis (20 caused by Gram-positive or -negative cocci, 7 by Gram-negative bacilli or listeria, and 5 with aseptic meningitis) received cefotaxime, 2 g 8-hourly, in addition to routine therapy. The concentrations of cefotaxime and its desacetyl metabolite in serum and CSF were determined by a high pressure liquid chromotography. Mean concentration of cefotaxime in CSF ranged from 0.8 mg/l (aseptic meningitis), to 6.4 mg/l (Gram-negative and listeria meningitis), and from 0.5 to 5.4 mg/l for the metabolite. The concentrations of both cefotaxime and the derivative demonstrated a correlation with the degree of inflammation (i.e., cell count and protein concentration) and were higher at 3 h after an infusion of antibiotic than at one and two hours. The concentration showed no marked decline on day 10 when signs of inflammation had largely resolved. The concentrations of both the parent compound and the metabolite 3 h after the infusion suggest that, considering the activity and half life of both the dosing might be spaced at 6-8 h intervals.