The Antibacterial Effects of Ciprofloxacin and Trovafloxacin Against Streptococcus Pneumoniae in an in Vitro Dynamic Model

ORIGINAL ARTICLE

The antibacterial effects of ciprofloxacin and trovafloxacin against Streptococcus pneumoniae in an in vitro dynamic model

Cliri Microbiol ItEfect 1999; 5: 13-15

Matthew O'Brien Thy Quacli2, Deborah Gilbert', Michael N. Dudley3 arid Stephen H. Ziniier ',','

'Brown University, Providence; 'Roger Williams Medical Center, Providence; 3Antiinfective Pharmacology Research Unit, University of Rhode Island College of Pharmacy, Ingston, and 'Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA

Objective: To determine whether the newer fluoroquinolone antibiotics such as trovafloxacin posses enhanced activity against Gram-positive organisms, including Streptococcus pneumoniae, because the clinical activity of older quinolones against pneumococci has been questioned. Methods: In this study, the bactericidal activities of ciprofloxacin and trovafloxacin against six strains of penicillin- resistant and -sensitive strains of Streptococcus pneumoniae were compared using an in vitro model that simutates human pharmacokinetics. Ciprofloxacin was administered at 750 rng every 12 h, higher than the usual daily dose of 500 mg twice a day. Trovafloxacin was administered at 300 mg every 24 h for the six strains and at 200 mg every 24 h for three of the strains. Results: The single 300-mg dose of trovafloxacin killed five of the six strains in 4 h, with no bacterial regrowth. Ciprofloxacin reduced the initial inoculum by 3-5 logs by 24 h. Although the 300-mg dose of trovafloxacin more rapidly eradicated susceptible strains, the activity of trovafloxacin at 200 mg every 24 h was similar to that of ciprofloxacin at 750 mg every 12 h against the three strains tested. Conclusion: Trovafloxacin (and ciprofloxacin at high doses) eradicates susceptible strains of pneumococci in an in vitro dynamic model. Key words: Streptococcus pneumoniae, trovafloxacin, ciprofloxacin, in vitro model

INTRODUCTION with a long elimination half-life and enhanced activity against Gram-positive cocci, including Staphylococcus Over the past several years, penicillin-resistant pneumo- uureus, Streptococcus pyogenes, and both penicillin-suscep- cocci (PRP) have been isolated from infected patients tible and -resistant strains of Streptococcus pneurnoriiae [3]. with increasing frequency [ 11. These organisms are In this study, the pharmacodynamics of trova- often resistant to macrolides, azalides and some cephalo- floxacin were compared to those of ciprofloxacin using sporins [?I. Trovafloxacin is a new fluoronaphthyridone an in vitro dynamic model of infection. This model simulates human pharmacokinetics and exposes bacteria to changing concentrations of antibiotic that mimic the Corresponding author and reprint requests: human pharmacology of the drug. With a half-life of Stephen H. Zinner, 825 Chalkstone Avenue, Providence, 10-12 h, trovafloxacin can be administered orally once RI 02908, USA a day and results in a C,,,,, of 2.2 mg/L at a 200-mg Tel: +401 456 2074 Fax: +401 456 6839 dose and 3.3 mg/L at 300 mg. The usual dose of E-mail: [email protected] ciprofloxacin is 500 mg every 12 h, but it was studied Accepted 8 June 1998 here at the higher dose of 750 mg every 12 h [4].

12 O‘Brien et al: Trovafloxacin and ciprofloxacin versus pneurnococci 13

Table 1 Ciprofloxacin, trovafloxacin, penicillin and erythromycin susceptibility of the tested strains

Ciprofloxacin Trovafloxacin Penicillin Erythromycin Strain MIC/MBC (mg/L) MIC/MBC (mg/L) MIC/MBC (mg/L) MICIMBC (mg/L)

Streptococcus pueumoniae 31 90 1.0/ 1.o 0.125/0.25 2.0/’7.0 (R) 64/128 (R) Sfreptococcus pneurnoniac 5056A 1.0/2.0 0.125/0.25 8/8 (R) 6-1/13 (K) Sfreptococcus ptieumoniae 9741 1.0/1 .o 0.125/0.25 0.015/O.015 (S) 0.03/0.06 (S) Streptococcus pneumonide 669 1 1.0/2.0 0.125/0.25 7.W1 (R) 0.06/0.125 (S) Strtpcorcus pneumoiiiae 2309A 1.0/2.0 0.125/0.25 8/8 (R) 0.06/0.115 (S) Strrptococrus przeurnotiiae 18032 32/64 1.0/2.O 0.03/0.03 (S) 0.03/0.06 (S)

R, resistant; S. susceptible.

MATERIALS AND METHODS Bacterial counts on samples from the peripheral compartment were determined by filtration-plating. Six strains of pneumococci (Table 1) were selected from The concentrations of both antibiotics in the two clinical isolates (courtesy of John Lonks). The MICs compartments were determined by bioassay [6]. For and MBCs of ciprofloxacin, trovafloxacin, penicillin ciprofloxacin, well-plates seeded with Eschevichicz coli and erythromycin, as well as penicillin and erythro- ATCC 25922 were used, and plates used to determine mycin susceptibility phenotypes are presented in Table trovafloxacin concentrations contained Bacillus subtilis 1. These strains were introduced into a two-compart- spores. Pharmacokinetic parameters were calculated ment artificial capillary model that simulates human using trapezoidal and regression methods (Holford pharmacokinetics in vitro [5]. NHG, MKMODEL, Version 3, Biosoft, 1990). The model consists of a central compartnient which mimics ‘serum’ concentrations and six hio- reactor artificial capillary chambers (Unisyn Fibertech Corporation, San Diego, California, USA) connected 3.5 in series which constitute the peripheral compartment. 3 The antibiotic is introduced into the central compart- 2.5 ment at time zero to simulate an oral dose. At the end of a 60-min infusion, the concentration of the drug 2 reaches a maximum analogous to the C,,, achieved 1.5 after absorption of drug into the circulation. To further 1 miniic human pharmacokinetics, the concentration of 0.5 drug decreases as sterile, antibiotic-free Mueller- Hinton broth is infused at a rate equal to the drug 0 elimination rate (half-life). The changing concentra- 0 6 12 18 24 30 tions of antibiotic are pumped to the six hioreactors of (a) Time after dose (h) the peripheral Compartment, where they diffuse 3.0 through the capillary walls to contact the bacteria. Ciprofloxacin was administered to mimic 750 mg every 2.5 12 h, and trovafloxacin dosing simulated 300 nig every 2.0 at a 34 h. Three strains were also studied trovafloxacin 1.5 dose of 200 mg every 24 h. I.o Log-phase bacteria were used at initial inocula that ranged from 2 x 10’ to 5 x 10h colony-forming 0.5

units/mL. The peripheral compartments were sampled 0.0 every 3 h for 24 h (except for hour 16 or 18), yielding 0 6 12 18 24 30 a mixture of bacteria and antibiotic, the relative (b) Time after dose (h) proportions of which are constantly changing. The Figure 1 Time course of central compartment antibiotic central compartment was sampled hourly for the first concentrations: (a) ciprofloxacin simulated at 750 nig every 8 h and then subsequently every 2 h. The central 12 h; (b) trovafloxacin simulated at 300 mg (W) and compartment remains sterile during these experiments. 200 mg (+) every 21 h. 14 Clinical Microbiology and Infection, Volume 5 Number 1, January 1999

9.00

8.00

7.00 J E 6.00 3 5 5.00 u) 4 4.00

3.00

2.00

1.oo

0.00 0 6 12 18 24 30 Time (h)

+2309A +3190 -A- 5056A *6691 -I- 9742 --+18032

Figure 2 Mean of duplicate bacterial counts for six strains of Streptococcus pneurnoniae exposed to simulated trovafloxacin dosing at 300 mg every 24 h in an in vitro dynamic model.

._..

0 6 12 18 24 30 Time (h)

+2309A +3190 +5056A ~6691+9742 -18032

Figure 3 Mean of duplicate bacterial counts for the same six strains of Streptococcus pneurnoniae as in Figure 2 exposed to simulated ciprofloxacin dosing at 750 mg every 12 h in an in vitro dynamic model. O'Brien et al: Trovafloxacin and ciprofloxacin versus pneumococci 15

."."" , DISCUSSION

J 8.00 -- E The new fluoronaphthyridone trovafloxacin demon- 3 LL strated more coniplete eradication of penicillin- 0 resistant and -sensitive strains of Streptoroccur pneurnorziae P) 0 -I tested in the pharmacokinetic model compared to the older fluoroquinolone ciprofloxacin. Trovafloxacin "."" 1 killed five of the six pneumococcal strains in 4 h at a 0 6 12 18 24 30 simulated oral dose of 300 mg every 24 h. Cipro- Time (h) floxacin at the higher than usual dose of 750 mg every (a) --c 2309A +6691 --I8032 12 h eradicated three strains by 24 h and reduced the inoculum of two other strains by 3-5 logs. However, trovafloxacin and ciprofloxacin at 750 mg every 12 h performed similarly against three strains tested at the 10.00 , I lower trovafloxacin dose of 2OOmg every 34 h. -I 8.00 Incidentally, this is the dose that is recommended clinically. It is unlikely that antibiotic carryover could explain these data, as the concentrations of drugs 4.00 rn 0 exposed to bacteria are reduced by dilution in the -I 2.00 central Compartment and back-diffusion from the peripheral compartment in the model. Also, niultiple serial dilutions and filterings are performed on samples withdrawn from the peripheral chamber. In other

(b) --c 2309A +6691 ti8032 experiments in progress, bacteria exposed to single simulated doses in the in vitro model are capable of regrowth if the observation period is longer than 24 h. Figure 4 Mean of duplicate bacterial counts for three Trovafloxacin is known to be more active in vitro strains of Stvcptococcirs pncumoniae exposed to simulated against penicillin-resistant pneuniococci than macro- trovafloxacin dosing at 200 ing every 2.1 h (a) and to lides, p-lactmi antibiotics and trimethoprini- ciprofloxacin dosing at 7.50 rng every 12 h (b). sulfamethoxazole 131. Although ciprofloxacin was not initially approved for the treatment of pneuniococcal infections, it has recently been approved for use in the treatment of respiratory infections. The data presented RESULTS here suggest that the higher dose of ciprofloxacin provides similar results to a 200-nig simulated dose of The time courses of central compartment concen- trovafloxacin in the in vitro dynamic model used. The trations of ciprofloxacin and trovafloxacin are shown in clinical activity of these drugs should be compared in Figure 1, and the time courses of bacterial killing are clinical studies with appropriate doses. shown in Figures 2-4. Bacterial growth in the absence References of antibiotic showed an increase from 5.81-6.46 log 1. Applebaum PC. Enmerging resistance to antimicrobial agents in CFU at 0 h to 8.3-9.63 log CFU at 8 h. gram-positive bacteria. Drug 1996; 51 (suppl 1): 1-5. As noted above, Streptococctrs prieurnoniac 18( )32 was 2. Thomson KS, Chartrand SA, Sanders CC, Block SL. Trova- not susceptible to ciprofloxacin; its MIC of 32 mg/L floxacin, a new fluoroquinolone with potent activity against Streptococas pneumoniar. Antimicrob Agents Chemother 1997; was considerably higher than the MIC<,(,of 0.25 mg/L 41: 478-80. for trovafloxacin (MIC 1 mg/L). Neither antibiotic 3. Morrissey I. Bactericidal activity of trovafloxacin (CP-99,219). effectively eradicated this strain. Trovafloxacin at J Antimicrob Chenmother 19%; 38: 1061-6. 300 mg every 34 h killed all five other strains by 6 h, 4. Teng K, Harris SC, Nix DE, Schentag JJ, Foulcis G, Liston TE. independent of penicillin susceptibility, and regrowth Pharmacokinetics and safety of trovafloxacin (CX-99,219), a new quinolone antibiotic, following adniinistration of single oral did not occur (Figure 2). Ciprofloxacin at 750 mg every doses to healthy male volunteers. J Antimicrob Chemother 12 h also killed three strains within 12 h and reduced 1995; 36: 385-94. the inoculum of the other two by 3-4 logs (Figure 3). 5. Blaser J, Stone HH, Zinner SH. Two compartment kinetic model When tested at a trovafloxacin dose of 200 mg every with multiple artificial capillary unit5. J Antimicrob Chemother 2-1 h, the three strains behaved similarly to both this 1985; 15(~~ppl.A): 131-7. 6. Barry AL. Procedure for testing antimicrobial agents in agar drug and ciprofloxacin, although strain 6691 was not media: theoretical considerations. In Lorian V, ed. Antibiotics in completely killed by the latter drug (Figure 4). laboratory medicine. Baltimorr: Williams 8( Wikins, 1986: 1-26.