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Quinolones and False-Positive Urine Screening for Opiates by Immunoassay Technology

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Quinolones and False-Positive Urine Screening for Opiates by Immunoassay Technology TOWARD OPTIMAL LABORATORY USE Quinolones and False-Positive Urine Screening for Opiates by Immunoassay Technology Lindsey R. Baden, MD Context Millions of assays are performed each year to monitor for substance abuse Gary Horowitz, MD in various settings. When common medications cross-react with frequently used test- Helen Jacoby, MD ing assays, false-positive results can lead to invalid conclusions. Objective To evaluate cross-reactivity of quinolone antimicrobials in common opi- George M. Eliopoulos, MD ate screening assays and to assess the in vivo implications of this phenomenon. Design, Setting, and Participants The reactivity of 13 quinolones (levofloxa- N RESPONSE TO PUBLIC CONCERNS cin, ofloxacin, pefloxacin, enoxacin, moxifloxacin, gatifloxacin, trovafloxacin, spar- regarding use of illicit drugs, ran- floxacin, lomefloxacin, ciprofloxacin, clinafloxacin, norfloxacin, and nalidixic acid) dom drug testing has become a com- was tested in 5 commercial opiate screening assays from September 1998 to March mon practice for employees in the 1999. In 6 healthy volunteers, we confirmed the cross-reactivity of levofloxacin or Iworkplace, for individuals incarcerated ofloxacin with these opiate screening assays. or under suspicion by the criminal jus- Main Outcome Measure Opiate assay activity (threshold for positive result, 300 tice system, and in other circum- ng/mL of morphine). 1 stances. This practice has been sanc- Results Nine of the quinolones caused assay results above the threshold for a positive tioned by legislation and affirmed by result in at least 1 of the assays. Four of the assay systems caused false-positive results court decisions, including the US for at least 1 quinolone. Eleven of the 13 compounds caused some opiate activity by at Supreme Court.2-6 In general, samples are least 1 assay system. At least 1 compound caused opiate assay activity in all 5 assay sys- usually subjected to screening by rela- tems. Levofloxacin, ofloxacin, and pefloxacin were most likely to lead to a false- tively inexpensive, rapid, and reliable positive opiate result. Positive results were obtained in urine from all 6 volunteers. immunoassays, with samples testing Conclusion Greater attention to the cross-reactivity of quinolones with immunoas- positive requiring confirmation by an says for opiates is needed to minimize the potential for invalid test interpretation. alternative method. When such strict pro- JAMA. 2001;286:3115-3119 www.jama.com tocols are followed, false-positive screen- ing test results do not cause problems. methods (as would be required in le- Meatherall and Dai9 reported in 1997 It is now widely appreciated that im- gal settings) when there is a question that ofloxacin could result in a false- munoassays are extremely reliable and about the validity of screening results. positive test result for opiates by the have relatively few false-positive re- For this reason, information concern- EMIT [enzyme multiplied immunoas- sults. As a result, at least for some ap- ing therapeutic use of possible cross- say technique] II assay (Syva, San Jose, plications, it has been advocated that reacting prescription medications Calif). However, this fact does not ap- confirmation is not necessary.7,8 Thus, should assist authorities in testing and pear to be widely known among clini- as testing expands beyond the strictly ultimately help the individual who is cians. We encountered a patient in controlled legal arenas, there is a pos- being tested. whom a false-positive urine screening sibility that positive results will be acted Author Affiliations: Departments of Medicine (Drs a speaker and consultant for Bayer and Ortho McNeil on in the absence of confirmatory test- Baden, Jacoby, and Eliopoulos) and Pathology (Dr Pharmaceuticals, and a consultant for Merck, Warner- ing. Such is the case in most hospital Horowitz), Beth Israel Deaconess Medical Center, Har- Lambert/Parke-Davis, and Abbott Laboratories. vard Medical School, Boston, Mass. Corresponding Author and Reprints: Lindsey R. Baden, laboratories, and thus it becomes im- Financial Disclosures: Dr Baden has received fellow- MD, Division of Infectious Diseases, Brigham and portant for clinicians to know that false- ship support from Pfizer and is participating in a multi- Women’s Hospital, 15 Francis St, PBB-A400, Boston, center clinical trial with Merck. Dr Eliopoulos has served MA 02115 (e-mail: [email protected]). positive test results do occur and to re- as a consultant and speaker and has received research Toward Optimal Laboratory Use Section Editor: quest confirmatory testing by alternative contract funding from Aventis Pharmaceuticals, has been David H. Mark, MD, MPH, Contributing Editor. ©2001 American Medical Association. All rights reserved. (Reprinted) JAMA, December 26, 2001—Vol 286, No. 24 3115 Downloaded From: https://jamanetwork.com/ on 09/27/2021 FALSE-POSITIVE URINE SCREENING FOR OPIATES test for opiates during therapy with le- [cloned enzyme donor immunoassay] With approval from the Committee vofloxacin nearly resulted in his ejec- reagents (Microgenics, Concord, on Human Studies and informed con- tion from a drug-treatment center. As Calif), which were run on Hitachi sent from the participants, in 1999, 6 a result, we examined systematically the 912 analyzer (Roche Diagnostics), (4) healthy volunteers were given a single propensity of various quinolones to Roche Abuscreen OnLine reagents oral dose of antibiotic (3 received 500 cause false-positive reactions for opi- (Roche Diagnostics), which were run mg of levofloxacin and 3 received 400 ates using 5 major commercially avail- on the Dimension XL analyzer (Dade mg of ofloxacin) and urine samples were able screening assays. Behring, Newark, Del), and (5) Beck- collected at approximately 6-hour in- man opiate reagents, which were run tervals for the following 48 hours. These METHODS on the Synchron CX analyzer (Beck- samples were analyzed for opiates by the Thirteen quinolones (levofloxacin, man Instruments, Brea, Calif). EMIT II 717 system. Select samples were ofloxacin, pefloxacin, enoxacin, moxi- For those samples that tested posi- run on the other 4 assay systems. floxacin, gatifloxacin, trovafloxacin me- tive in a given assay at the lowest con- sylate, sparfloxacin, lomefloxacin, centration (600 µg/mL), further dilu- RESULTS ciprofloxacin hydrochloride, clinafloxa- tions were performed to determine the Assay Cross-Reactivity cin, norfloxacin, and nalidixic acid) approximate lowest concentration that The results of the screening assays for were either provided by the manufac- would test positive. Controls with mor- the 13 quinolones tested in vitro are turer or purchased from a biologic com- phine concentrations of 0, 225, 300, and shown in TABLE 1. A concentration of pany. All antibiotics were made soluble 375 ng/mL were run simultaneously on 300 ng/mL of morphine was set as the as per standard techniques10 to a con- each assay. All assays were run in ac- positive threshold, as previously sug- centration of 5000 µg/mL to ensure we cordance with the manufacturers’ rec- gested by the Department of Health and exceeded possible in vivo urinary lev- ommendations. Specifically, the thresh- Human Services and widely used by els and dilutions to concentrations of old for a positive result was set at 300 clinical laboratories.11-14 By conven- approximately 1700 µg/mL and 600 ng/mL of morphine, and samples with tion, a value of 250 ng/mL would be con- µg/mL were made. error messages not amenable to trouble- sidered a negative value for opiates, al- These samples were then analyzed shooting protocols were not run on di- though substantial opiate activity above by 5 different commercial immunoas- lution (as recommended by manufac- baseline (0 ng/mL) is present. The fol- says: (1) EMIT II reagents, which turers). A more detailed investigation lowing quinolones cross-reacted to cause were run on Hitachi 717 analyzer of the dose-response curves for ofloxa- a positive test result for opiates at con- (Roche Diagnostics, Indianapolis, cin and levofloxacin was performed centrations assayed: levofloxacin and Ind), (2) AxSYM fluorescence polar- with the EMIT II 717 system, span- ofloxacin (using Abbott AxSYM, ization immunoassay (Abbott Labora- ning the range of concentrations from CEDIA, EMIT II, and Roche OnLine as- tories, Abbott Park, Ill), (3) CEDIA 5000 µg/mL to 0.005 µg/mL. says), pefloxacin (using CEDIA, EMIT Table 1. Expected Urinary Concentration of Quinolones and the Concentration Required for Immunoassay Activity* Quinolone Concentration Causing Assay Positivity for Opiates, µg/mL In Vivo Peak Urinary Concentration Abbott Quinolone With Standard Dosing, µg/mL† AxSYM CEDIA EMIT II Roche Synchron Levofloxacin 1000 1700-5000 60-200 140 200-600 S Ofloxacin 400 1700-5000 60-200 140 200-600 S Pefloxacin 40 S 60-200 600-1700 200-600 N Enoxacin 8 S 1700-5000 600-1700 S N Gatifloxacin 300-400 S S 600-1700 S N Lomefloxacin 300 N S S 1700-5000 N Moxifloxacin 69 N S S 1700-5000 N Sparfloxacin 12 N S S S N Ciprofloxacin 400 N S S 1700-5000 N Clinafloxacin 147 N S S N N Norfloxacin 400 N S S 1700-5000 N Trovafloxacin 12 N N N N N Nalidixic acid 1000 N N N N N *Expected urinary concentrations of quinolones and concentrations triggering a positive result for the different assays are demonstrated. Levofloxacin and ofloxacin would be expected to trigger a positive opiate assay by the EMIT II, CEDIA, and Roche OnLine assays. Several of the quinolones cause demonstrable assay activity, but below the threshold concentration for assay positivity. S indicates signal detected at maximum concentration tested, but below the threshold value, may contibute in an additive fashion with other cross-reacting compounds; N, no signal detected at maximum concentration tested. See the “Methods” section for details about the assays. †Data obtained from several sources.15-25 3116 JAMA, December 26, 2001—Vol 286, No. 24 (Reprinted) ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 FALSE-POSITIVE URINE SCREENING FOR OPIATES II, and Roche OnLine assays), enoxa- Figure 1.
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