Objective To investigate whether symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) is non-inferior to antibiotics in the treatment of uncomplicated lower urinary tract infection (UTI) in women, thus offering an opportunity to reduce antibiotic use in ambulatory care.Design Randomised, double blind, non-inferiority trial.Setting 17 general practices in Switzerland.Participants 253 women with uncomplicated lower UTI were randomly assigned 1:1 to symptomatic treatment with the NSAID diclofenac (n=133) or antibiotic treatment with norfloxacin (n=120). The randomisation sequence was computer generated, stratified by practice, blocked, and concealed using sealed, sequentially numbered drug containers.Main outcome measures The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The prespecified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Analysis was by intention to treat.Results 72/133 (54%) women assigned to diclofenac and 96/120 (80%) assigned to norfloxacin experienced symptom resolution at day 3 (risk difference 27%, 95% confidence interval 15% to 38%, P=0.98 for non-inferiority, P<0.001 for superiority). The median time until resolution of symptoms was four days in the diclofenac group and two days in the norfloxacin group. A total of 82 (62%) women in the diclofenac group and 118 (98%) in the norfloxacin group used antibiotics up to day 30 (risk difference 37%, 28% to 46%, P<0.001 for superiority). Six women in the diclofenac group (5%) but none in the norfloxacin group received a clinical diagnosis of pyelonephritis (P=0.03).Conclusion Diclofenac is inferior to norfloxacin for symptom relief of UTI and is likely to be associated with an increased risk of pyelonephritis, even though it reduces antibiotic use in women with uncomplicated lower UTI.Trial registration ClinicalTrials.gov NCT01039545.
Laboratory-scale batch experiments were developed to investigate the main removal routes for 6 commonly found quinolones (ciprofloxacin, moxifloxacin, norfloxacin, ofloxacin, pipemidic acid, and piromidic acid), in wastewaters from a wastewater treatment plant, at μgL(-1) levels in an aerobic sludge system from a membrane bioreactor (MBR) pilot plant. It was demonstrated that sorption and biotransformation were the main removal routes for the target antibiotics over other possible pathways, as volatilization or hydrolysis, under the experimental conditions. Mass balances indicated that sorption on sludge played a dominant role in the elimination of antibiotics from waters. The sorption coefficient K(d) depended strongly on temperature and on the quinolone type and were higher at lower temperatures and for piperazinylic quinolones. K(d) values were between 516 and 3746Lkg(-1) in the temperature range of 9-38°C. Higher mixed liquor suspended solids (MLSS) increased quinolone removal efficiency mainly by sorption. Quinolone biodegradation constituted a secondary pathway, and could be described by first-order kinetics with degradation-rate constants ranging from 8.0×10(-4)h(-1) to 1.4×10(-2)h(-1) within the same temperature range and MLSS from 7000 to 15,000mgL(-1). Biodegradation depended on the MLSS and temperature, but also on the initial chemical oxygen demand (COD). Higher biodegradation rates were observed at higher MLSS and temperature, as well as at low initial COD. Ciprofloxacin and moxifloxacin registered the highest biodegradation percentages (52.8% and 47.2%, respectively, at 38°C and 15,000mgL(-1) MLSS), which is evidence that, despite the known persistence of this group of antibiotics and removal from waters mainly by sorption, it was possible to improve their removal by biodegradation, with an appropriate selection of conditions and control of process variables, as a preliminary step towards the elimination of these antibiotics from the environment. Further research is needed on the possibilities of removing sorbed antibiotics from sludge.
Microfibrous materials based on poly(l-lactide-co-d,l-lactide) (coPLA) and coPLA/poly(ethylene glycol) (PEG) containing a fluoroquinolone antibiotic: ciprofloxacin hydrochloride (Cipro), levofloxacin hemihydrate (Levo) or moxifloxacin hydrochloride (Moxi) were obtained by electrospinning. The presence of Moxi led to an increase in the conductivity of the coPLA and coPLA/PEG spinning solutions and to the preparation of membranes composed of fibers aligned with the collector rotation direction. The one-step incorporation of the antibiotics in the fibers was confirmed by infrared spectroscopy and fluorescence microscopy. The antibiotics were dispersed in the coPLA or coPLA/PEG polymer matrix and the XRD spectra revealed the presence of crystalline phase characteristic of PEG and of the respective antibiotic. It was found that the release profiles of the antibiotics did not depend on the antibiotic nature but were dependent on the fiber composition. The presence of PEG in the fibers allowed a more rapid antibiotic release within the first 2h of release. The performed microbiological tests with Staphylococcus aureus revealed that the coPLA/Cipro, coPLA/PEG/Cipro, coPLA/Levo, coPLA/PEG/Levo, coPLA/Moxi and coPLA/PEG/Moxi mats inhibited the bacterial growth. In addition, the presence of an antibiotic in the mats led to a substantial decrease in the adhesion of the pathogenic microorganism and in the case of the coPLA/PEG/antibiotic series - to prevention thereof.
A multiresidue analytical procedure for determination of seven fluoroquinolones (marbofloxacin, norfloxacin as internal standard, ciprofloxacin, danofloxacin, enrofloxacin, sarafloxacin and difloxacin), and three quinolones (oxolinic acid, nalidixic acid and flumequine) in eggs is presented. The procedure is based on dispersive solid-phase extraction technique with acetonitrile as extractant. Norfloxacin and ciprofloxacin - d8 were used as internal standards to quantify the (fluoro)quinolones. Analyses were realised by LC-FLD for screening and LC-MS/MS for confirmatory purposes. The whole procedure was evaluated according to the Commission Decision 2002/657/EC. Specificity, decision limit (CCα), detection capacity (CCβ), recovery (absolute and relative), precision (repeatability and reproducibility) were determined during validation process. Recoveries (relative) for the LC-FLD screening determination ranged from 85% to 93%, repeatability and reproducibility were in the range of 5-9% to 9-16%, respectively. CCα and CCβ were 13-37 and 17-43 μg/kg pending on analite. For the LC-MS/MS confirmatory method, the relative recoveries were satisfactory (92-99%) with repeatability and reproducibility in the range of 4-7% to 6-12%, respectively. CCα and CCβ were 3-7 and 7-11 μg/kg depending on the analite. The results of both prepared methods showed these analytical procedures simple, rapid, sensitive and suitable for routine control of eggs.
A sensitive, selective, and efficient method was developed for simultaneous determination of 11 fluoroquinolones (FQs), ciprofloxacin, danofloxacin, difloxacin, enrofloxacin, flumequine, marbofloxacin, norfloxacin, ofloxacin, oxolinic acid, pipemidic acid, and sarafloxacin, in eggs by molecularly imprinted polymer (MIP) and column liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS). Samples were diluted with 50 mM sodium dihydrogen phosphate at pH 7.4, followed by purification with a commercial MIP (SupelMIP SPE-Fluoroquinolones). Recoveries for the 11 quinolones were in the range of 90-106% with intra- and interday relative standard deviation ranging from 1 to 6% and from 3 to 8%, respectively. Limits of detection (LODs) were 0.12-0.85 ng/g, and limits of quantification (LOQs) were 0.36 and 2.59 ng/g, whereas the decision limit (CC(α)) and detection capability (CC(β)) ranged from 0.46 to 3.35 ng/g and from 0.59 to 4.12 ng/g, respectively. The calculated relevant validation parameters are in an acceptable range and in compliance with the requirements of Commission Decision 2002/657/EC. Moreover, a comparison to two other sample treatments [solid-phase extraction (SPE) and solvent extraction] has been carried out. The method was applied to lying hens, Japanese quail, and black-headed gull eggs, in which FQs were not found. The method was also applied to study the depletion of sarafloxacin in eggs.
Fluoroquinolones (FQs) are a class of antibiotics with a broad spectrum of activity, known to disturb bone metabolism. The aim of this work was to characterize the cellular and molecular effects of five FQs (ofloxacin, norfloxacin, ciprofloxacin, levofloxacin and moxifloxacin) in unstimulated and stimulated human osteoclast precursors. Peripheral blood mononuclear cells (PBMC) were cultured in the absence (unstimulated) or in the presence of osteoclastogenic factors (M-CSF and RANKL, stimulated), and were treated with FQs (0.3×10(-9)-10(-3) M), for 21 days. In unstimulated PBMC cultures, FQs (excepting moxifloxacin) exhibited a high osteoclastogenic potential, as shown by a significant increase in the expression of osteoclastic genes, TRAP activity and, specially, number of TRAP-positive multinucleated cells and calcium phosphate resorbing ability, suggesting the presence of mature and functional osteoclasts. Norfloxacin and levofloxacin induced the higher effect, followed by ciprofloxacin and ofloxacin. A decrease on apoptosis and an increase on M-CSF expression might have a possible contribution in the observed cellular behavior. In stimulated PBMC cultures, FQs further increase the osteoclastogenic response induced by M-CSF and RANKL (except ofloxacin). However, the osteoclastogenic response was much lower than that observed in unstimulated PBMC cultures. Both in unstimulated and stimulated PBMC cultures, for most of the FQs, the osteoclastogenic effects were observed in a wide range of concentrations, representative of plasmatic and tissue levels attained in several clinical settings. The various FQs differed on the stimulatory concentration range, the extent of the induced osteoclastogenic response and, also, on the dose- and time-dependent profile. Nevertheless, at high concentrations all the FQs seemed to elicit an increase on apoptosis. Additionally, some differences were noted in the intracellular signaling pathways tested, namely NFkB, MEK and PGE2 production. Results suggest that, considering the inter-individual variability of the FQs pharmacokinetics, the detailed biological profile of each FQ on bone cells is of utmost importance to clarify the effects of these compounds on bone metabolism.
In this study, two analytical approaches were exploited for the resolution of binary mixtures of ciprofloxacin HCl (CIP) or norfloxacin (NOR) and phenazopyridine HCl (PHZ). In the first approach, the amplitudes of the first derivative of the ratio spectra were measured at 267 or 287 nm for CIP and at 268 or 291 nm for NOR. PHZ could be directly determined in the presence of CIP or NOR at 405 nm. The calibration graphs were rectilinear over the ranges of 1.0-16.0 µg/mL for CIP or NOR and 1.0-10.0 µg/mL for PHZ. In the second approach, an accurate, reliable and environmentally nontoxic micellar liquid chromatographic (MLC) method was developed. A good chromatographic separation was achieved using a 150 mm × 4.6 mm i.d., 5 µm particle size Spherisorb ODS-2 column. Eco-friendly mobile phase containing 0.12 M sodium dodecyl sulphate, 0.3% triethylamine and 6% n-butanol in 0.02 M orthophosphoric acid of pH 3.0 was pumped at a flow rate of 1 mL/min. Time programmed UV-detection was applied to allow sensitive determination of the studied drugs. The analytes were eluted without interferences in <10 min. Methocarbamol was used as an internal standard. The MLC method was found to be rectilinear over the concentration range of 0.5-20.0 μg/mL for CIP, NOR or PHZ. These optimized and validated methods were successfully applied for the simultaneous analysis of the studied drugs in their synthetic mixtures and co-formulated tablets. Moreover, the second method was further extended to the determination of these drugs in human urine with direct injection and without any pretreatment.
Ceftazidime-Avibactam Versus Doripenem for the Treatment of Complicated Urinary Tract Infections, Including Acute Pyelonephritis: RECAPTURE, a Phase 3 Randomized Trial Program
- Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
- Published about 2 years ago
The global emergence of carbapenem-resistant Enterobacteriaceae highlights the urgent need to reduce carbapenem dependence. The phase 3 RECAPTURE program compared the efficacy and safety of ceftazidime-avibactam and doripenem in patients with complicated urinary tract infection (cUTI), including acute pyelonephritis.
Risk of Severe Dysglycemia Among Diabetic Patients Receiving Levofloxacin, Ciprofloxacin, or Moxifloxacin in Taiwan
- Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
- Published almost 5 years ago
Background. Observational studies and fatal case reports raise concern about the safety of severe dysglycemia associated with fluoroquinolone use. The objective of this study was to assess the risk of severe dysglycemia among diabetic patients who received different fluoroquinolones. Methods. In a population-based inception cohort study of diabetic patients covering the period from January 2006 to November 2007, outpatient new users of levofloxacin, ciprofloxacin, moxifloxacin, cephalosporins, and macrolides orally were identified. Study events were defined as emergency department visits or hospitalization for dysglycemia within 30 days following the initiation of antibiotic therapy. Results were analyzed with adjusted multinomial propensity score. Results. A total of 78 433 diabetic patients receiving the antibiotics of interest were included in the study. The absolute risk of hyperglycemia per 1000 persons was 6.9 for moxifloxacin and 1.6 for macrolides. In contrast, the risk of hypoglycemia was 10.0 for moxifloxacin and 3.7 for macrolides. The adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of levofloxacin, ciprofloxacin, and moxifloxacin compared with macrolides were 1.75 (1.12-2.73), 1.87 (1.20-2.93), and 2.48 (1.50-4.12), respectively, for hyperglycemia and 1.79 (1.33-2.42), 1.46 (1.07-2.00), and 2.13 (1.44-3.14), respectively, for hypoglycemia. Patients taking moxifloxacin faced a significantly higher risk of hypoglycemia than those receiving ciprofloxacin. A significant increase in the risk of hypoglycemia was also observed among patients receiving moxifloxacin concomitantly with insulin (AOR, 2.28; 95% CI, 1.22-4.24). Conclusions. Diabetics using oral fluoroquinolones faced greater risk of severe dysglycemia. The risk of hypoglycemia varied according to the type of fluoroquinolone administered, and was most commonly associated with moxifloxacin.
Antofloxacin (AFX) is a novel fluoroquinolone that has been approved in China for the treatment of infections caused by a variety of bacterial species. We investigated whether it could be repurposed for the treatment of tuberculosis by studying its in vitro activity. We determined the wild-type and non-wild-type range MICs for AFX as well as ofloxacin (OFX), levofloxacin (LFX), and moxifloxacin (MFX) using the microplate alamar blue assay of 126 clinical Mycobacterial tuberculosis strains from Beijing (China), of which 48 were OFX resistant based on drug-susceptibility testing on Löwenstein-Jensen medium. The MIC distributions were correlated with mutations in the quinolone resistance determining regions of gyrA (Rv0006) and gyrB (Rv0005). Pharmacokinetic/pharmacodynamic (PK/PD) data for AFX were retrieved from the literature. AFX showed lower MIC levels than OFX, but higher than LFX and MFX based on the tentative epidemiological cut-off values (ECOFFs) determined in this study. All strains with non-wild-type MICs to AFX harbored known resistance mutations that also resulted in non-wild-type MICs for LFX and MFX. Moreover, our data suggested that the current critical concentration for OFX for Löwenstein-Jensen that was recently revised by the World Health Organization might be too high, resulting in misclassification of non-wild-type strains with known resistance mutations as wild-type. Based on our exploratory PK/PD calculations, the current dose of AFX is unlikely to be optimal for the treatment of tuberculosis, but higher doses could be effective.