Omadacycline vs moxifloxacin in adults with community-acquired bacterial pneumonia.

OBJECTIVE: Community-acquired bacterial pneumonia (CABP) is a major clinical burden worldwide. In the phase III OPTIC study (NCT02531438) in CABP, omadacycline was found to be non-inferior to moxifloxacin for investigator-assessed clinical response (IACR) at post-treatment evaluation (PTE, 5-10 days after last dose). This article reports the efficacy findings, as specified in the European Medicines Agency (EMA) guidance. METHODS: Patients were randomized 1:1 to omadacycline 100 mg intravenously (every 12 h for two doses, then every 24 h) with optional transition to 300 mg orally after 3 days, or moxifloxacin 400 mg intravenously (every 24 h) with optional transition to 400 mg orally after 3 days. The total treatment duration was 7-14 days. The primary endpoint for EMA efficacy analysis was IACR at PTE in patients with Pneumonia Patient Outcomes Research Team (PORT) risk class III and IV. RESULTS: In total, 660 patients were randomized as PORT risk class III and IV. Omadacycline was non-inferior to moxifloxacin at PTE. The clinical success rates were 88.4% and 85.2%, respectively [intent-to-treat population; difference 3.3; 97.5% confidence interval (CI) -2.7 to 9.3], and 92.5% and 90.5%, respectively (clinically evaluable population; difference 2.0; 97.5% CI 3.2-7.4). Clinical success rates with omadacycline and moxifloxacin were similar against identified pathogens and across key subgroups. CONCLUSIONS: Omadacycline was non-inferior to moxifloxacin for IACR at PTE, with high clinical success across pathogen types and patient subgroups.

Eravacycline for the treatment of complicated intra-abdominal infections.

Introduction: Complicated intra-abdominal infections (cIAIs) are among the most frequent infections, contributing to significant morbidity and healthcare costs. Several medical needs remain unmet, related to the pharmacokinetic capacities of the available drugs and their limited spectrum of activity for targeting multidrug-resistant Gram-negative and Gram-positive bacteria. Eravacycline, a new synthetic fluorocycline, could have useful properties in cIAIs.Areas covered: The antimicrobial activity of eravacycline against the microorganisms most frequently cultured in cIAIs has been confirmed in worldwide panels of clinical isolates, including enterococci, ESBL-producing Enterobacteriaceae, Acinetobacter baumannii and anaerobes. Pharmacokinetic data demonstrate interesting characteristics with good tissue concentrations including biliary tract and digestive tissues. At a conventional dosage of 1 mg/kg q12h, no adjustment is required on the basis of race or gender, or in elderly (≥ 65 years old) patients, patients with renal impairment or patients undergoing hemodialysis. Phase 2 and 3 trials assessing the clinical efficacy and safety of eravacycline demonstrated non-inferiority versus carbapenems and a good safety profile.Expert opinion: Eravacycline may be particularly suitable for the treatment of cIAIs. Results from clinical trials and real-world data are now expected in specific subgroups of patients to confirm the safety profile and efficacy observed in registration trials.

Assessment of the Physical Compatibility of Eravacycline and Common Parenteral Drugs During Simulated Y-site Administration.

PURPOSE: Eravacycline is a broad-spectrum, intravenous fluorocycline antibiotic approved for the treatment of complicated intra-abdominal infections in adults. A 60-minute infusion is recommended for each infused dose. Compatibility data that may allow convenient Y-site administration of eravacycline with other parenteral medications are unavailable. We aimed to determine the physical compatibility of eravacycline with other intravenous medications by simulated Y-site administration. METHODS: Eravacycline was reconstituted according to published prescribing information and diluted with 0.9% sodium chloride to a concentration of 0.6 mg/mL. Simulated Y-site administration was performed by mixing 5 mL of eravacycline with an equal volume of 51 other intravenous medications, including crystalloid and carbohydrate hydration fluids and 20 antimicrobials. Secondary medications were assessed at the upper range of concentrations considered standard for intravenous infusion. Mixtures underwent visual inspection and turbidity measurement immediately on mixture and at 3 subsequent time points (30, 60, and 120 minutes after admixture), and pH was measured at 60 minutes for comparison with the baseline value of the secondary medication. FINDINGS: Eravacycline was physically compatible with 41 parenteral drugs (80%) by simulated Y-site administration. Incompatibility was observed with albumin, amiodarone hydrochloride, ceftaroline fosamil, colistimethate sodium, furosemide, meropenem, meropenem/vaborbactam, micafungin sodium, propofol, and sodium bicarbonate. IMPLICATIONS: Eravacycline for injection was physically compatible with most parenteral medications assessed. Pharmacists and nurses should be knowledgeable of the observed incompatibilities with eravacycline to prevent the unintentional mixing of incompatible intravenous medications.

Early Clinical Response in Community-acquired Bacterial Pneumonia: From Clinical Endpoint to Clinical Practice.

BACKGROUND: Early clinical response (ECR) is a new endpoint to determine whether a drug should be approved for community-acquired bacterial pneumonia in the United States. The Omadacycline for Pneumonia Treatment In the Community (OPTIC) phase III study demonstrated noninferiority of omadacycline to moxifloxacin using this endpoint. This study describes the performance of the ECR endpoint and clinical stability relative to a posttreatment evaluation (PTE) of clinical success. METHODS: ECR was defined as symptom improvement 72-120 hours after the first dose of study drug (ECR window), no use of rescue antibiotics, and patient survival. Clinical success at PTE was an investigator assessment of success. Clinical stability was defined based on vital sign stabilization, described in the American Thoracic Society and Infectious Diseases Society of America community-acquired pneumonia treatment guidelines. RESULTS: During the ECR window, ECR was achieved in 81.1% and 82.7% of omadacycline and moxifloxacin patients, respectively. Similar numbers of patients achieved clinical stability in each treatment group (omadacycline 74.6%, moxifloxacin 77.6%). The proportion of patients with improved symptoms who were considered clinically stable increased across the ECR window (69.2-77.6% for omadacycline; 68.0-79.7% for moxifloxacin). There was high concordance (>70%) and high positive predictive value (>90%) of ECR and clinical stability with overall clinical success at PTE. CONCLUSIONS: Omadacycline was noninferior to moxifloxacin, based on a new ECR endpoint. Clinical stability was similarly high when measured in the same time frame as ECR. Both ECR and clinical stability showed high concordance and high positive predictive value with clinical success at PTE. CLINICAL TRIALS REGISTRATION: NCT02531438.

Retrospective analysis of a single-center clinical experience toward development of curative treatment of 123 pemphigus patients with a long-term follow-up: efficacy and safety of the multidrug protocol combining intravenous immunoglobulin with the cytotoxic immunosuppressor and mitochondrion-protecting drugs.

BACKGROUND: Pemphigus vulgaris (PV) is a life-long IgG autoantibody-mediated blistering disease affecting the mucosal surfaces lined by the stratified epithelium (oral, nasal, genital) and sometimes also the skin. While corticosteroid treatment is life saving, the high dose and prolonged courses required for disease control are associated with significant adverse effects, including death. Although introduction of rituximab (RTX) provided for a favorable outcome, the high relapse rate, that is, up to 80%, precludes successful use of RTX as a monotherapy. Intravenous immunoglobulin (IVIg) is being increasingly utilized as off-label therapy for a variety of autoimmune and inflammatory diseases, including PV and pemphigus foliaceus (PF). AIMS: The goal of pemphigus research is to develop an effective treatment modality that would allow patients to achieve and maintain a stable clinical remission without the need for additional treatments, or cure. MATERIALS AND METHODS: This article summarizes clinical outcome of 123 pemphigus patients treated with a combination of IVIg, an immunosuppressive cytotoxic drug (ICD) and mitochondrion-protecting drugs in the Blistering Disease Clinic at the University of California, Irvine from 2007 to 2017. RESULTS: The mean time to disease control was 0.2 months and time to complete remission - 1.7 months. Duration of complete remission on drugs until relapse or end of treatment was 19.3 months. The mean duration of complete remission off drugs until relapse was 15.8 months. That until end of follow up was 48.4 months, with a minimum of 14 and a maximum of 91 months. The overall complete remission rate off all drugs was 100%, with 12% overall relapse rate. Most relapses, 8.1 vs. 3.3%, occurred during the time of treatment, compared to posttreatment. No patients had more than a single relapse. The duration of the posttreatment follow-up ranged from 9 to 97 months with a mean of 64.8 months, or 5.4 years. The total number of IVIg cycles ranged from 26 in patients without a relapse to 37 in patients with a relapse. The clinical outcome in patients that received IVIg with RTX or another ICD were found to be very similar. DISCUSSION: Thus, the multidrug IVIg regimen allowed to achieve three principal treatment objectives: (i) rapid control of pemphigus symptoms; (ii) stable disease remission; and (iii) overall safety of treatment. CONCLUSIONS: While the individualized therapeutic approaches to eradicate the autoreactive B cell clones causing disease in each particular PV or PF patient are being developed, all pemphigus patients can benefit from the treatment protocol described in this study.

Combinations of registered drugs reduce treatment times required to deplete Wolbachia in the Litomosoides sigmodontis mouse model.

Filarial parasites can be targeted by antibiotic treatment due to their unique endosymbiotic relationship with Wolbachia bacteria. This finding has led to successful treatment strategies in both, human onchocerciasis and lymphatic filariasis. A 4-6 week treatment course using doxycycline results in long-term sterility and safe macrofilaricidal activity in humans. However, current treatment times and doxycycline contraindications in children and pregnant women preclude widespread administration of doxycycline in public health control programs; therefore, the search for shorter anti-wolbachial regimens is a focus of ongoing research. We have established an in vivo model for compound screening, using mice infected with Litomosoides sigmodontis. We could show that gold standard doxycycline treatment did not only deplete Wolbachia, it also resulted in a larval arrest. In this model, combinations of registered antibiotics were tested for their anti-wolbachial activity. Administration of rifamycins in combination with doxycycline for 7 days successfully depleted Wolbachia by > 2 log (>99% reduction) and thus resulted in a significant reduction of the treatment duration. Using a triple combination of a tetracycline (doxycycline or minocycline), a rifamycin and a fluoroquinolone (moxifloxacin) led to an even greater shortening of the treatment time. Testing all double combinations that could be derived from the triple combinations revealed that the combination of rifapentine (15mg/kg) and moxifloxacin (2 x 200mg/kg) showed the strongest reduction of treatment time in intraperitoneal and also oral administration routes. The rifapentine plus moxifloxacin combination was equivalent to the triple combination with additional doxycycline (>99% Wolbachia reduction). These investigations suggest that it is possible to shorten anti-wolbachial treatment times with combination treatments in order to achieve the target product profile (TPP) requirements for macrofilaricidal drugs of no more than 7-10 days of treatment.

Omadacycline: development of a novel aminomethylcycline antibiotic for treating drug-resistant bacterial infections.

Omadacycline is a first-in-class aminomethylcycline antibiotic that circumvents common tetracycline resistance mechanisms. In vitro omadacycline has potent activity against Gram-positive aerobic bacteria including methicillin-resistant Staphylococcus aureus, penicillin-resistant and multidrug-resistant Streptococcus pneumoniae, and vancomycin-resistant Enterococcus spp. It is also active against common Gram-negative aerobes, some anaerobes and atypical bacteria including Legionella spp. and Chlamydia spp. Ongoing Phase III clinical trials with omadacycline are investigating once daily doses of 100 mg intravenously followed by once-daily doses of 300 mg orally for the treatment of acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. This paper provides an overview of the microbiology, nonclinical evaluations, clinical pharmacology and initial clinical experience with omadacycline.

Eravacycline for the treatment of intra-abdominal infections.

INTRODUCTION: There has been a dramatic increase in the incidence of multidrug-resistant pathogens over the past few years, which highlights the need for new anti-infective therapeutics. Eravacycline is a novel, broad-spectrum synthetic tetracycline indicated for the treatment of severe infections caused by Gram-positive and Gram-negative bacteria. AREAS COVERED: In this review, the authors report eravacycline's pharmacokinetic characteristics and its microbiological spectrum of activity. Furthermore, the authors also highlight the safety and efficacy data from the recent studies on urinary and intra-abdominal infections. EXPERT OPINION: The profile of eravacycline offers several advantages. Indeed, eravacycline has a broad-spectrum activity toward pathogens involved in complicated urinary tract (cUTIs) and intra-abdominal infections (cIAIs), including extended-spectrum beta-lactamase and carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. The availability of an oral formulation supports eravacycline's possible use in sequential therapy. High urinary concentrations favor its use in cUTIs and may reduce the overuse of other antimicrobials that may select resistance, such as carbapenems. Eravacycline efficacy and tolerability have been investigated in a Phase II clinical trial in cIAIs comparing two dosages of eravacycline with ertapenem, showing comparable efficacy among the three arms and a low rate of adverse effects. The results of new Phase III studies are awaited to confirm eravacycline's future applications in severe nosocomial infections.

Characterization of tetracycline resistance genes in Escherichia coli isolated from feedlot cattle administered therapeutic or subtherapeutic levels of tetracycline.

The effect of administering feedlot cattle subtherapeutic levels of chlortetracycline (CT) or CT and therapeutic levels of oxytetracycline (CT-OX) on resistance genotypes in Escherichia coli was investigated. Detection of genes tet(A), tet(B), and tet(C) encoded by tetracycline-resistant isolates (CT, N = 77; CT-OX, N = 99) was performed by multiplex polymerase chain reaction (PCR). Prevalence of tet(A) was similar in isolates across treatment regimes; however, prevalence of tet(B) was lower (18% versus 34%; P < 0.05) and tet(C) was higher (46% versus 28%; P < 0.05) in CT isolates compared with CT-OX isolates. To further characterize selection of resistance genotypes in E. coli, a group of intermediately tetracycline-resistant E. coli (N = 48) was analyzed. The tet(C) gene was present in 92% of these isolates. Copies of tet(C) transcripts, analyzed by real-time PCR, indicated that upregulation did not occur in tetracycline-resistant isolates when compared with intermediately resistant isolates. The minimum inhibitory concentrations of tetracycline, chlortetracycline, and oxytetracycline were also tested on isolates with different resistance genes. The minimum inhibitory concentration was dependent on the tetracycline analogue and the nature of encoded resistance. These data indicate that tetracycline analogues should not be used interchangeably to evaluate resistance and that prevalence of resistance genes in E. coli can vary according to the tetracycline analogue administered to cattle.

Local applications of tetracyclines in endodontics and dental trauma: a review.

Local application of antibiotics within the root canal system may be a more effective mode for delivering the drug. Tetracyclines have been used to remove the smear layer from instrumented root canal walls, for irrigation of retrograde cavities during periapical surgical procedures, and as an intracanal medicament. Substantivity of tetracyclines has been shown for up to at least 12 weeks. BioPure MTAD is effective in removing the smear layer. However, the antimicrobial efficacy against E faecalis of 1.3% NAOCl/MTAD compared with that of the combined alternate use of 5.25% NAOCl and 15% EDTA is still controversial. Substantivity of MTAD has been shown for up to 4 weeks. Furthermore, application of MTAD to 1.3% NAOCl-irrigated dentin may reduce its substantivity. Tetraclean is a mixture of an antibiotic (doxycycline), an acid, and a detergent (like MTAD), with a very low surface tension and high degree efficacy against bacterial biofilms. Ledermix, a glucocorticosteroid-antibiotic compound, due to anti-inflammatory and antiresorptive properties, reduces the inflammatory reaction including clastic-cell mediated resorption, significantly lowers the incidence of replacement resorption, and thus prompts more favorable healing in replanted teeth. A 50:50 mixture of Ledermix paste and Ca(OH)2 has been advocated as an intracanal dressing in cases of infected root canals, pulp necrosis and infection with incomplete root formation (apexification), perforations, inflammatory root resorption, inflammatory periapical bone resorption, and for the treatment of large periapical radiolucent lesions.

Leptospirosis hemorrágica pulmonar / Hemorrhagic pulmonary leptospirosis

La leptospirosis es una enfermedad infecciosa característica de países orientales húmedos. La incidencia en países occidentales es relativamente infrecuente. La enfermedad suele manifestarse de dos formas clínicas principales: la hepato-renal y la pulmonar, generalmente con cierto grado de solapamiento entre ambas.Presentamos un paciente con una presentación severa de leptospirosis hemorrágica pulmonar que en el curso de la enfermedad, presentó un cuadro de embolismo multisistémico (bazo, riñón y sistema nervioso central -SNC-). (AU)

Administration of doxycycline hydrochloride via drinking water to turkeys under laboratory and field conditions.

A series of experiments were carried out in order to determine doxycycline hydrochloride (DoxHCl) plasma levels in 6-wk-old turkeys medicated via drinking water containing DoxHCl at a concentration of 250 mg/L under laboratory and field conditions. Maximal plasma concentration (Cmax) values of 5.7 (+/-1.0) microgram/mL and 4.9 (+/-1.4) micrograms/mL obtained after DoxHCl administration during 2 and 7 d, respectively, were not significantly different. A significant difference was found between the area under the plasma concentration-time profile, calculated between 0 and 168 h (AUC(0-168)), Cmax, and the minimal plasma concentration (Cmin) values obtained after medication with a DoxHCl solution at a concentration of 250 mg/L (431.9 +/- 96.6 micrograms.h/mL, 4.9 +/- 1.4 micrograms/mL and 0.7 +/- 0.3 microgram/mL) and after medication with a DoxHCl solution at a concentration of 750 mg/L (1,176.5 +/- 201.8 micrograms.h/mL, 12.5 +/- 2.7 micrograms/mL and 2.9 +/- 0.4 micrograms/mL), respectively. The increase in body weight was also significantly higher for turkeys medicated with a DoxHCl solution at a concentration of 750 mg/L (83.7 g/d) than for the lower concentration (35.6 g/d). The DoxHCl solution uptake significantly decreased with the increase of DoxHCl concentration. A Cmax value of 1.7 +/- 0.6 micrograms/mL and a Cmin value of 0.5 +/- 0.1 microgram/mL were observed during the field experiment. Water consumption under laboratory conditions was followed for tap water (70 +/- 50 mL/kg.d) and for a DoxHCl solution at a concentration of 250 mg/L supplemented with 1 g anhydrous citric acid/L (119 +/- 6 mL/kg.d) and revealed to be not significantly different. The variability was significantly higher for tap water than for the DoxHCl solution. The stability of the DoxHCl solution containing 1 g citric acid/L over 24 h was 99% expressed as the percentage of the initial concentration.

Tetracyclines suppress matrix metalloproteinase activity in adjuvant arthritis and in combination with flurbiprofen, ameliorate bone damage.

Tetracyclines are potent inhibitors of 2 major matrix metalloproteinases which have been implicated in connective tissue degradation: collagenase and Type IV collagenase/gelatinase. We directly identified these enzyme activities in extracts of inflamed paw tissue from rats with adjuvant arthritis. Oral tetracycline therapy suppressed metalloproteinase activity in arthritic tissue, but even very high doses failed to exhibit substantial antiinflammatory efficacy (reduced joint swelling and paw diameter). Flurbiprofen, a conventional nonsteroidal antiinflammatory drug, reduced inflammatory indices as expected. The combination of the 2 agents administered orally completely inhibited collagenase activity, significantly inhibited gelatinase activity and produced substantial normalization of radiographic joint damage, far greater than either drug alone. Tetracycline inhibition curves in vitro suggest that the collagenase in this tissue is not of fibroblast origin. Tetracycline derivatives might be useful adjuncts to prevention of tissue damage in chronic inflammatory arthritides.

Unsuccessful treatment of non-gonococcal urethritis with rosoxacin provides information on the aetiology of the disease.

In a controlled trial of rosoxacin in patients with non-gonococcal urethritis (NGU), 150 mg of the antibiotic given twice daily for 10 days was compared with 300 mg triple tetracycline (Deteclo) given twice daily for the same period. Only six (19%) of 31 patients treated with rosoxacin were free of urethritis after 10 days; Chlamydia trachomatis was reisolated from 12 (92%) of 13 patients who were chlamydia positive originally, and Ureaplasma urealyticum was reisolated from 12 (80%) of 15 patients who were ureaplasma positive originally. In contrast, 18 (58%) of 31 patients treated with triple tetracycline were cured clinically after 10 days; C trachomatis was not reisolated from any of 10 patients who were chlamydia positive originally, and U urealyticum was reisolated from only three (17%) of 18 patients who were ureaplasma positive originally. These results were consistent with the antimicrobial inactivity of rosoxacin in vitro and they cannot be reconciled with previous reports of successful use of this antibiotic in NGU. Ureaplasmas were isolated more frequently and in larger numbers from chlamydia negative than from chlamydia positive patients, but it is probable that ureaplasmas resistant to tetracycline were not responsible for persistent urethritis.

Tetracyclines in ophthalmology.

Tetracycline and its congeners demonstrate antimicrobial activity against bacteria, Chlamydiae and Toxoplasma gondii. Ophthalmologists can use these drugs to treat bacterial and chlamydial infections, and also for ocular rosacea and similar disorders. Side effects associated with systemic tetracycline use are most commonly related to the gastrointestinal tract and to signs of yeast superinfection. Minocycline use may be limited by its vestibular toxicity. Temporary growth retardation and staining of erupting teeth may occur with oral use of tetracycline in children under 8 years; these drugs should not be given in pregnancy or to young children. Topical tetracycline application yields good tear and aqueous humor concentrations.

The effect of protracted tetracycline treatment on bone growth and maturation.

Mature female rhesus monkeys were used to evaluate the effects of a one-year course of tetracycline (50 mg/kg/day, intramuscularly) on the formation, maturation, and mineralization of mandibular bone. The bones from the treated group contained normal concentrations of calcium (Ca), inorganic phosphorus (Pi), and hydroxyproline (HO-Pr), and the treatment schedule did not alter the distribution (percentage) of total osteons into slightly, moderately, and highly mineralization classes. Tetracycline impairs bone mineralization and the subsequent maturation of the mineral and matrix moieties. The percentage of highly mineralized osteons labeled with tetracycline is subnormal. Density gradient fractionation studies indicate the presence of abnormally high Ca/Pi ratios in the temporally young newly formed bone mineral and somewhat higher ratios in the most mature bone fraction. Protracted tetracycline treatment at high dosages impairs bone growth and maturation in adult rhesus monkeys.