Clinical pharmacokinetics of quinupristin/dalfopristin

Quinupristin/dalfopristin is a streptogramin antibacterial with a wide spectrum of Gram-positive antibacterial activity. The drug has minimal oral absorption and is administered intravenously as a fixed 30 : 70 ratio of quinupristin to dalfopristin. A linear relationship has been observed between the dose administered and maximum plasma concentrations. Single-dose administration of 7.5 mg/kg produced a maximal plasma concentration of 2.3-2.7 mg/L for quinupristin and 6.1-8.2 mg/L for dalfopristin. The area under the concentration-time curve (AUC) obtained with the same dose was 2.7-3.3 and 6.5-7.7 mg. h/L for quinupristin and dalfopristin, respectively. Repeated administration results in 13-21% increases in maximum plasma concentrations and 21-26% increases in AUC for both quinupristin and dalfopristin. Quinupristin and dalfopristin exhibit steady-state volumes of distribution of 0.46-0.54 and 0.24-0.30 L/kg, respectively. Quinupristin exhibits higher protein binding (55-78%) than dalfopristin (11-26%), though both entities distribute well into tissues. Concentrations exceeding those in blood have been reported for the kidney, liver, spleen, salivary glands and white blood cells of primates. Extravascular penetration, as measured in blister fluid, is 40-80%. Both quinupristin and dalfopristin are extensively metabolised via nonenzymatic reactions. Quinupristin is conjugated to form two active compounds, a cysteine moiety and a glutathione moiety. Dalfopristin is hydrolysed to the active metabolite pristinamycin IIA. The metabolites exert antibacterial activity similar to that of the parent compounds. Quinupristin/dalfopristin is excreted primarily in the faeces (75-77%), with lesser renal excretion (15-19%). The elimination half-lives of quinupristin and dalfopristin are similar, and are 0.7-1.3 hours after single doses. The metabolites have slightly longer half-lives, ranging from 1.2 to 1.8 hours. With repeated doses, plasma clearance of quinupristin and dalfopristin is reduced by approximately 20% compared with single doses, resulting in clearances of 0.7-0.8 L/h/kg. Saturable protein binding has been hypothesised as a causative mechanism. Quinupristin/dalfopristin is an inhibitor of cytochrome P450 3A4, resulting in multiple drug interactions. Ciclosporin AUC increased by 5-222% when coadministered with quinupristin/dalfopristin. Careful monitoring of patients receiving drugs that are substrates of cytochrome P450 3A4 is suggested.Quinupristin/dalfopristin is administered at 7.5 mg/kg every 8-12 hours, depending upon the severity of infection. The pharmacodynamic parameter linked with antibacterial activity for quinupristin/dalfopristin appears to be the ratio of AUC to the minimal inhibitory concentration. The additional activity of a prolonged post-antibiotic effect may also be important for efficacy.     

奎奴普丁/达福普汀对革兰氏阳性球菌的体外抗菌活性

目的 体外测定奎奴普丁／达福普汀(QD)抗革兰氏阳性球菌的活性并与万古霉素(VCM)和替考拉宁(TEC)敏感性结果比较。方法 收集2001年6月～2002年8月间本院临床分离的270株革兰氏阳性菌株，采用K—B法测定细菌药敏。结果 QD对甲氧西林敏感或耐药的金黄色葡萄球菌(MSSA，MRSA)、甲氧西林敏感的凝固酶阴性葡萄球菌(MSCNS)、屎肠球菌和链球菌的抗菌性活性与VCM和TEC相同，敏感率均为100％；QD对粪肠球菌和甲氧西林耐药的凝固酶阴性葡萄球菌的抗菌活性(分别为19．5％和94．8％)不如VCM(100．0％和100．0％)和TEC(92．7％和97．9％)。结论 QD对MRSA、MSSA、MSCNS、屎肠球菌和链球菌具强大抗菌活性。     

Pharmacokinetics of quinupristin/ dalfopristin in patients with severe chronic renal insufficiency

OBJECTIVE: To compare the pharmacokinetic profile of a single intravenous injection of quinupristin/dalfopristin, a new injectable streptogramin, in healthy young individuals and patients with severe chronic renal insufficiency. A secondary objective was to assess the relative tolerability of this dose in these patients compared with healthy individuals. PATIENTS AND PARTICIPANTS: 13 patients with severe chronic renal insufficiency (creatinine clearance 6 to 28 ml/min/1.73m2) were individually matched for gender, bodyweight and age to a healthy volunteer. METHODS: Participants received a single dose of quinupristin/dalfopristin 7.5 mg/kg bodyweight as a continuous 1-hour intravenous infusion, followed by serial blood sampling. RESULTS: The disposition profile of unchanged quinupristin was similar in the 2 groups. However, the elimination of quinupristin derivatives in patients with renal impairment tended to be decreased: mean peak plasma drug concentration (Cmax) and area under the concentration-time curve from zero to infinity (AUCinfinity) of quinupristin plus its active derivatives were about 1.4 times higher in the patients with renal impairment compared with healthy volunteers. The mean Cmax and AUCinfinity of both unchanged dalfopristin and dalfopristin plus its active derivatives were about 1.3 times higher in renally impaired patients than in healthy volunteers. Adverse events were generally mild and transient. No severe or serious adverse events were reported and no participants prematurely discontinued the study. Venous tolerability tended to be better in healthy volunteers than in the patients with renal impairment. CONCLUSION: These results suggest that no formal reduction in the dosage of quinupristin/dalfopristin is necessary in patients with severe chronic renal impairment.     

In vitro activity of daptomycin against clinical isolates with reduced susceptibilities to linezolid and quinupristin/dalfopristin

An initiative was taken to determine the in vitro activity of daptomycin against 85 Gram-positive isolates with reduced susceptibilities to linezolid and quinupristin/dalfopristin. Daptomycin had potent activity against all strains, with a Staphylococcus spp. minimum inhibitory concentration (MIC) < or =2 microg/mL and an Enterococcus spp. MIC < or =8 microg/mL. Resistance to linezolid and quinupristin/dalfopristin appears to be independent of reduced susceptibility to daptomycin.     

Linezolid and quinupristin/dalfopristin: novel antibiotics for gram-positive infections of the skin

With the continuing development of clinical drug resistance among bacteria, the need for new, effective agents to treat multi-drug-resistant Gram-positive infections remains important. With treatment options limited, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives. This review focuses on agents newly introduced and FDA-approved for the treatment of skin and skin structure infections: linezolid and quinupristin/dalfopristin.     

Efficacy of quinupristin/dalfopristin versus vancomycin, alone or in combination with rifampicin, against methicillin-resistant Staphylococcus aureus in a rabbit arthritis model

We compared the efficacy of quinupristin/dalfopristin versus vancomycin, alone or in combination with rifampicin, in a rabbit model of methicillin-resistant Staphylococcus aureus-induced arthritis. Vancomycin, alone or in combination with rifampicin, and quinupristin/dalfopristin+rifampicin were significantly more effective than quinupristin/dalfopristin alone.     

Evaluation of quinupristin/dalfopristin (Synercid) and RPR 106972 stability in susceptibility testing media

In response to conflicting reports on the chemical stability of quinupristin/dalfopristin, a study was designed to assess the in vitro longevity and effects of media and storage conditions on this streptogramin combination. Broth microdilution trays containing parenteral (quinupristin/dalfopristin) and oral (RPR 106 972) streptogramin combinations as well as pristinomycin components (P-I and P-II) were preincubated at 35°C for 12–72 h before inoculation with control strains (Streptococcus pneumoniae ATCC 49 619, Haemophilus influenzae ATCC 49 247, Enterococcus faecalis ATCC 29 212, Staphylococcus aureus ATCC 29 213) and five clinical isolates with various drug resistance phenotypes. Overall, the mean quinupristin/dalfopristin activity loss was 24%/12 h, 41%/18 h, 43%/24 h, 69%/48 h and 79%/72 h with no detected loss of potency when measured by E. faecalis until 18 h. RPR 106 972 mean activity loss was 6%/12 h, 19%/18 h, 19%/24 h, 56%/48 h and 71%/72 h with no loss of potency as measured by S. aureus until 48 h. Overall, P-I components had greater stability as compared with P-II for both drug combinations. Bioassays showed similar trends in decreased activity. Bioassay differences among media types were only significant (>3 mm; greater loss of potency) for haemophilus test media for both P-II components at 72 h. The presence of an organism in the medium had no effect on stability assay results. The effect of storage temperature (4, 25°C) on quinupristin/dalfopristin and RPR 106 972 stability was also detrimental to drug potency indicating the requirement for rigid quality assurance for streptogramin diagnostic reagents when determining activity by reference or standardized susceptibility tests.     

抗革兰阳性耐药菌的新型头孢菌素类抗生素头孢洛林酯

头孢洛林酯是新型注射给药的广谱头孢菌素类抗生素,对革兰阳性菌,包括耐甲氧西林金黄色葡萄球菌(MRSA)和多药耐药肺炎链球菌(MDRSP)以及常见革兰阴性菌具有杀菌活性。2010年10月29日,美国FDA批准其用于治疗成人社区获得性细菌肺炎(CABP)和急性细菌皮肤和皮肤结构感染(ABSSSI),包括MRSA的感染。文中对其抗菌活性、药动学/药效学、临床疗效、不良反应等做一综述。     

Multiple-dose pharmacokinetics and safety of two regimens of quinupristin/dalfopristin (Synercid) in healthy volunteers

Quinupristin/dalfopristin (Q/D) is a novel streptogramin antibiotic for the treatment of severe gram-positive infections. The purpose of this open, nonrandomized, parallel-group, phase I trial was to evaluate Q/D pharmacokinetics after single and repeated doses under the two different dosing regimens corresponding to the effective doses and to evaluate tolerability. Two groups of 10 healthy volunteers received multiple 1-hour intravenous infusions of 7.5 mg/kg Q/D either every 8 or 12 hours for 4 or 5 days, respectively. Plasma concentrations of Q, D, and metabolites were determined using high-performance liquid chromatography and selective microbiological assays. The two regimens q8h and q12h lead to the same disposition profile after single and repeated administration. Single-dose data confirmed the high plasma clearances of Q and D (about 0.90 l/h/kg) obtained previously. Unchanged drugs were the main components in plasma, with each of the three metabolites representing about 20% (in terms of the AUC ratio) of the parent drugs. Comparable steady-state concentrations were reached from day 2 of both regimens. A similar moderate increase in Cmax and AUC (about 20%) of parent drugs was observed between the first and last day of treatment. This phenomenon, which was also observed for the metabolites, was not expected considering the short terminal disposition half-lives of the parent drugs and trough plasma concentrations of all components mostly below the limits of quantitation at steady state, whatever the dosing regimen. The clearances of parent drugs at steady state were about 20% lower as compared with that observed following the first drug administration (statistically significant difference). No trend suggesting a treatment effect on any laboratory parameter, vital signs, or electrocardiographic parameters was identified. However, 80% of subjects reported venous adverse events probably related to treatment.     

Antimicrobial activity in vitro of cefaclor, a new oral cephalosporin

The antimicrobial activity of cefaclor, a new orally administered cephalosporin derivative, was studied in vitro against a variety of Gram-positive and Gram-negative clinical isolates. Both penicillin-resistant and penicillin-susceptible strains of Staphylococcus aureus were susceptible to cefaclor, with mean MICs of 1.44 and 0.93 microgram/ml, respectively. However, the MBC for penicillin-resistant S. aureus was higher than that for the penicillin-susceptible strains. All strains of Streptococcus pyogenes, Streptococcus viridans, and Streptococcus pneumoniae tested were highly susceptible to cefaclor; all strains of Streptococcus faecalis were highly resistant to cefaclor. Strains of Escherichia coli, Klebsiella sp., Proteus mirabilis, and Hemophilus influenzae were susceptible to cefaclor. Eighty per cent of strains of H. influenzae were inhibited by 5 micrograms/ml of cefaclor. Most strains of Enterobacter sp., indole-positive Proteus, Pseudomonas sp., and Serratia sp. were resistant to cefaclor.     

Antimicrobial activity of sulbactam/cefoperazone. Comparison with other new cephems

Antimicrobial activities of sulbactam/cefoperazone (SBT/CPZ) against 50 fresh clinical isolates of Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Citrobacter freundii, Enterobacter spp., Serratia marcescens, Proteus mirabilis, Proteus vulgaris and Pseudomonas aeruginosa were compared to those of CPZ, Cefotiam (CTM), Cefotaxime (CTX) and Latamoxef (LMOX). Minimal inhibitory concentrations (MIC's) of SBT and CPZ mixed in a ratio of 1:1 were determined by the dilution method using Mueller-Hinton agar and expressed by absolute concentrations of CPZ. Antimicrobial activities of SBT/CPZ against principally penicillinase (PCase) producing bacteria, i.e., S. aureus, E. coli, K. pneumoniae, P. mirabilis, were superior to those of CPZ alone. The presence of SBT in concentrations around 0.39 approximately 1.56 micrograms/ml clearly enhanced CPZ's antimicrobial activities against these PCase producing strains. The synergistic antimicrobial effects of SBT in combination with CPZ were less pronounced against principally cephalosporinase (CEPase) producing bacteria, i.e., C. freundii, Enterobacter spp., S. marcescens, P. vulgaris, and P. aeruginosa, and exerted with SBT at concentrations around 3.13 approximately 12.5 micrograms/ml. Comparative antimicrobial activities indicated by MIC80's of tested agents showed that SBT/CPZ had more stable activities against bacteria ranging from Gram-positive to Gram-negative bacteria than CTM, CTX and LMOX. MIC's of SBT/CPZ were higher than 25 micrograms/ml against 8% of S. aureus, 18% of C. freundii, 10% of Enterobacter spp., 26% of S. marcescens, 2% of P. vulgaris, and 18% of P. aeruginosa. These resistant strains against which the addition of SBT showed no synergism, may possess other mechanism of resistance than beta-lactamase production. It is concluded that the presence of CPZ resistant strains is an actual current problem and not an imaginary future problem, and that the number of resistant strains against other new cephems which have different chemical structure from CPZ is increasing. When these present bacteriological environments are considered, the appearance of SBT/CPZ in the clinical practice is timely and meaningful.     

In vitro antimicrobial activity of cefpirome, a new cephalosporin with a broad antimicrobial spectrum

The in vitro activity of cefpirome (HR 810), a new cephalosporin antibiotic having a 2,3-cyclopentenopyridine group in the 3-position side chain, was compared with in vitro activities of 5 other cephalosporins. HR 810 showed a broad spectrum of antimicrobial activity against Gram-positive and Gram-negative bacteria when tested using 71 standard strains and 876 clinical isolates. HR 810 inhibited 70% of the clinically isolated Staphylococcus aureus and Staphylococcus epidermidis strains when used at 0.59-0.84 microgram/ml, 2- to 25-fold lower than values of reference antibiotics, and the compound was also highly effective against Enterococcus faecalis which is relatively resistant to most of the existing cephem antibiotics. The activity of HR 810 against Enterobacteriaceae members (11 species), based on its minimal inhibitory concentrations inhibiting 90% of bacterial growth (MIC90S), was the highest among the cephalosporins used. Especially against Enterobacter species and Citrobacter freundii, the MIC90S of the compound were 4- to 64-fold lower than the values of the other antibiotics. Against Pseudomonas aeruginosa, HR 810 was as active as cefoperazone, an antipseudomonal agent. The minimal bactericidal concentrations (MBCs) of HR 810 were equal to or only 2-fold greater than the MICs for most of 12 standard strains tested. The compound markedly decreased viable bacterial counts at its MICs, thus showing strong bactericidal activities. The in vitro activity of HR 810 was not affected by pH or human serum content of agar media, but the activity against Gram-negative bacteria was lowered as the inoculum size increased.     

Antimicrobial activity of a new series of benzimidazole derivatives

Due to antimicrobial importance of benzimidazoles and hydrazones, some benzimidazolehydrazone compounds were synthesized to screen their antimicrobial activity. Structures of the synthesized compounds were elucidated by ¹H-NMR, IR and ES-MS spectral data and elemental analysis. The synthesized benzimidazole-hydrazones exhibited very weak antibacterial activity. However, antifungal activity of some of the synthesized compounds was very notable against Candida species. The compounds displaying important antifungal activity were screened for their toxicity. Artemia salina 96-well assay was used to determine cytotoxicity of the compounds. Tested compounds exhibited toxicity to different extents (LD₅₀ = 126.33−368.72 μg/mL). Nevertheless, determination of 3–14 folds higher LD₅₀ than minimum inhibitory concentration is a significant finding, which demonstrates that the compounds display antifungal activity at non-toxic concentration.     

Antimicrobial activity of new coumarin derivatives

A preliminary exploration of coumarin analogs as novel antimicrobial agents was carried out to determine the basic features of the structure responsible for the observed biological activity. The substituents ester or carboxylic acid on the coumarin ring were needed to have potent inhibitory activity against both Gram-positive and Gram-negative bacteria. The presence of phenolic hydroxyl group and/or carboxylic acid was necessary to possess higher activity against Helicobacter pylori.     

PS-5, a new beta-lactam antibiotic. II. Antimicrobial activity.

PS-5, a new beta-lactam antibiotic, has relatively potent antimicrobial activity against Gram-positive and Gram-negative bacteria, especially the Enterobacter groups, Serratia marcescens, the Proteus groups and Klebsiella pneumoniae. The activity of PS-5 against many beta-lactamase-producing organisms is greater than that of cefoxitin or cefazolin. PS-5 has good therapeutic activity in mice infected with Staphylococcus aureus Smith or Enterobacter cloacae 45.     

A re-emerging class of antimicrobial agents: streptogramins (quinupristin/dalfopristin) in the management of multiresistant gram-positive nosocomial cocci in hospital setting

Multiresistant gram-positive cocci, including Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus faecalis and Enterococcus faecium, are emerging pathogens in the setting of immunocompromised, hospitalized patients, especially when surgery or invasive procedures are of concern, and patients are admitted in intensive care units. The spectrum of antimicrobial compounds available for an effective treatment of these infection is significantly threatened by the emerging and spread of glycopeptide-resistant strains. Quinupristin/dalfopristin is a novel streptogramine association, which represents an effective response to most of these problems, due to its innovative mechanim of action, its maintained activity against multiresistant pathogens, and its possibility of synergistic activity with other compounds. Problems related to the epidemiology of multiresistant gram-positive infection, potential clinical indications of quinupristin/dalfopristin, and updated data on efficacy and tolerability of this compound and its derivatives, are outlined on the ground of a review of available literature evidences.