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Grepafloxacin in Patients with of Speed in Bacterial Killing

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Grepafloxacin in Patients with of Speed in Bacterial Killing USEO Y·DO OTCO TREATMENT CHALLE NGES IN LRTls Grepafloxacin in patients with ,I acute bacterial exacerbations of chronic bronchitis - A question of speed in bacterial killing Jerome J Schentag Pha1rn D JJ Schentag. Grepafloxacin in patients with acute bacterial exacerbations of chronic bronchitis - A question of speed in bacterial killing. Can J Infect Dis 1998;9(Suppl E): 16E-22E. OBJECTIVE: To characterize the population pharmacokinetics and pharmacodynamics of oral grepanoxacin in patients with acute bacterial exacerbations of chronic bronchitis (ABECB), with particular attention to the speed of bacterial kill­ ing. This was possible because the study design incorporated daily cultures of the patients' sputum. PATIENTS AND METHODS: The study group included 76 patients (43 male, 33 female) between 23 and 81 years of age who were part ofa multicentre, randomized, double-blind, dose-response study. Patients were randomly assigned to re­ ceive oral regimens of grepafloxacin - 200, 400 or 600 mg - each administered once daily for 14 days. Daily cultures and quantitative Gram stains from serial 24 h collections of sputum were used to determine the days co eradication of each strain of bacteria. Grepafloxacin plasma concentration pronles were best fit by a pharmacokinetic model with first order absorption following a lag time between administration of the dose and onset of systemic absorption. Pharmacodynamic analysis was performed for three measures of antibacterial response: probability of bacteriological cure and probability of clinical cure, and lime to eradication. RESULTS: All three measures of response were strongly related to the 24 h area under the inhibitory curve (AUIC) (area under the cu1ve/111inimum inhibitory concentration). Al an AUIC below of 75/serum inhibiting titre (SIT) x 24 h, the per­ centage probability of clinical cure was 71 %; at an AUIC between 75 and l 75, it was 80% (P<0.05); and, at an AUTC above 175, it was 98% (P<O.O l). CONCLUSION: The speed of bacterial killing for grepanoxacin in ABECB patients was highly related co AUIC; values be­ low 75 appear inadequate, and values greater than 175 were optimal. Key Words: Acuce baccerial exacerbations ef chronic bronchiris, Area under che inhibicory cwve. Grepqjloxacin, Pharmacodynamics, Phannacokinerics La grepafloxaci ne chez des patients presentant des exacerbations bacteriennes aigues d'une bronchite chronique - Rapidite de !'eradication bacterienne OBJECTIF : Identifier Jes proprietes pharmacocineliques et pharmacodynamiques de la grepafloxacine ora le chez des patients souffrant d'exacerbations bactcriennes aigues d'une bronchite chronique (EBABC) en portant une attention particuliere a la rapidite de !'eradication des bacteries, ce qui a etc facilite par le protocole de l'etude qui prevoyait des cultures quotidiennes des expectorations chez Jes patients. PATIENTS ET METHODES: La population etudiee regroupait 76 patients (43 hommes, 33 femmes) ages de 23 a 81 ans voir page suivante SUNY, B1!lfalo Clinical Pharmacokinetics Laboratory, Millard Fillmore Healch System, B1!lfalo. Neiv York USA Correspondence: Dr II Schencag, The Clinical Pharmacokinetics Laboratory, Millard Fillmore Healrh Syscem. 3 Gates Circle, B1!lfalo, New York USA 14209. Telephone 7!6-887-4482.Ja.x 716-887-4566. [email protected] 16E Can J Infect Dis Vol 9 Suppl E November/ December 1998 Grepafloxacin in ABECB patients qui panicipaient a une ernde multicentrique. randomisee. a double insu. portant sur le lien dose-reponse. Les patients ont ete assignes aleatoirement a des schemas therapeutiques oraux de grepatloxacine (200. 400 ou 600 mg) administres chacun une fois par jour pendant 14 jours. Les cultures quoridiennes et Jes co lorations de Gram quantitatives provenant de collections d'expectorations de 2.J heures seriees ont servi au calcul du nombre de jours ecoules avant !'eradication de chacune des souches de bacteries. Les profils de concentration plasmarique de grepatloxacine ont ete le mieux ajusres par le biais d'un modele pharmacocinerique qui prevoyait J·effet de premier passage er respectait un delai entre !'administration de la dose et le debut de !'absorption sysremique. L'analyse pharmacodynamique a ete effectuee pour trois parametres de la reponse antibacrerienne : probabilite d'une guerison bacreriologique probabilire de guerison clinique et delai d'eradicarion. RES ULTATS: Les trois mesures de la reponse ont ete en forte correlation avec Jes a ires sous la courbe inhibirrice (ASCl) de 24 h (a ire sous la courbe/concenrrarion minimale inhibirrice). Aune ASCl inferieure a 75/tirre serique inhibireur (TS I) x 24 h. le pourcenrage de probabilite de guerison clinique etait de 71 %; a une ASCl de 75 a 175, ii s·eJevair a 80 % (p < 0,05) er a une ASCl superieure a 175, ii s·eJevait a 98 % (p < 0,01). CONCLUSION: La rapidite d'eradication bacrerienne par la grepatloxacine chez !es patients presentant des EBABC a ere fonemenr li ee a l'ASCI. Les valeurs inferieures a 75 semblenr inadequates er !es valeurs superieures a 175 se sonr revelees oprimales. chievement of an optimal relationship between the tirely renally excreted (6), or ciprofloxacin, which is excreted A pharmacokinetics of f1uoroquinolone antibiotics in the by both pathways (6). patient and the minimum inhibitory concentration (MIC) of Grepaf1oxacin is better suited to the treatment of out­ the infecting organism in that same patient is predictive of patient respirato1y tract infections. We measured the AUICs of eradication of the invading organism ( 1-5). Thus far, studies the new f1uoroquinolone in patients with acute bacterial exac­ have advanced these principles in patients with nosocomial erbations of chronic bronchitis (ABECB). ABECB is a highly lower respiratory tract infections (LRTI). In a study of 73 noso­ suitable model for studies of AUlC versus bacterial eradication comial LRTI patients given intravenous ciprof1oxacin, the op­ (7,8). Serial sputum specimens are readily obtainable in these timal area under the curve (AUC) to MIC ratio, AUC:MIC or area patients. Also, bacterial organisms are found in most patients, under the inhibito1y curve (AUIC), was 125, which approxi­ and the patients are sufficiently ambulatory to allow frequent mates 80% of the AUC to be above the MIC value at dosing in­ returns to the study sites for rigorous blood sampling to char­ tervals of every 8 to 12 h ( 1,4). When the AUIC was above 125, acterize the drugs· pharmacokinetics. There has been little a significantly greater number of these patients were cured study of serial cultures and frequent blood samples in the both microbiologically and clinically. Ciprof1oxacin displayed ABECB population before the present study, so the impact of concentration-dependent bacterial killing in patients. Com­ the disease on either pharmacokinetics or pharmacodynamics pared with the time of bacterial killing at AUIC values above was unknown. The generally prevailing opinion that cultures 125 but less than 250, the time of bacterial eradication at are of little value in ABECB (7,9) did not discourage this exer­ AUIC values exceeding 250 was significantly more rapid cise. Rather, the present study seemed an excellent means to ( 1,2). Nosocomial LRTI pa ti ems below the threshold AUIC determine whether there was a relationship between organism value of 125 have a microbiological failure rate approaching eradication and the outcome of ABECB. lt was clearly neces­ 70% (!). sary to culture microbes from patients more frequently to test In the early phases of clinical antibiotic development, stud­ organism eradication methodology in ABECB patients. The ies of the AUIC of patient populations given a range of doses present report is a summa1y of our previous study of gre­ can assist in the determination of an optimal dosage for pa­ pafloxacin in patients with AECB (10). tients with known infecting pathogens. Furthermore, concen­ trating on the factors that alter the AUIC value in individual PATIENTS AND METHODS patients can explain different outcomes in clinical trial pa­ Patient selection and randomization: Data were collected tients. For example, studies in our LRTI patients demonstrate from three prospective clini.cal trials of grepaf1oxacin for that variability in the clinical and microbiologic response of ABECB. All patients included in this study had frequent spu­ LRTI patients can result from pronounced interpatient differ­ tum cultures and frequent blood samples, the data required for ences in pharmacokinetics. The primary determinants of vari­ the analysis of the relationship between grepafloxacin phar­ ability in pharmacokinelics are typically renal function be­ macokinetics and pharmacodynamics. Patients included in cause it is a determinant of AUC and MIC because it varies this study were l 8 ye·ars of age or more with a diagnosis of between organisms, even within the same species. chronic bronchial disease, including but not limited to chronic The AUIC versus outcome principles developed for cipro­ bronchitis, chronic bronchial asthma, asthmatic bronchitis or floxacin should apply to the new f1uoroquinolone antibiotic bronchiectasis. Each enrolled patient had, superimposed on grepaf1oxacin (OPC-17116). However, there are some factors this underlying disease, an acute bacterial bronchial infection unique to this compound that should be studied. Unlike anti­ characterized by all three of the following: increase in bron­ biotics of this class that we studied previously, grepaf1oxacin chopulmonary symptoms, increase in inflammatory
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