Contaminated dicloxacillin capsules as the source of an NDM-5/OXA-48-producing Enterobacter hormaechei ST79 outbreak, Denmark and Iceland, 2022 and 2023.

From October 2022 through January 2023, nine patients with NDM-5/OXA-48-carbapenemase-producing Enterobacter hormaechei ST79 were detected in Denmark and subsequently one patient in Iceland. There were no nosocomial links between patients, but they had all been treated with dicloxacillin capsules. An NDM-5/OXA-48-carbapenemase-producing E. hormaechei ST79, identical to patient isolates, was cultured from the surface of dicloxacillin capsules in Denmark, strongly implicating them as the source of the outbreak. Special attention is required to detect the outbreak strain in the microbiology laboratory.

Microdialysis as a tool to determine the local tissue concentration of dicloxacillin in man.

AIMS: The most common pathogen to cause postoperative infections in Denmark is Staphylococcus aureus. Despite using prophylactic antibiotics, infections are still seen. Whether the tissue concentration is above the minimal inhibitory concentration (MIC) for the pathogen is unknown. Thus, the concentration of dicloxacillin in muscle and adipose tissue was measured after intravenous administration, in healthy men. METHODS: MIC for dicloxacillin against S. aureus was determined using the broth macrodilution method. A microdialysis (MD) catheter was placed in the subcutaneous tissue of the abdomen and in the lateral vastus muscle of the thigh of six healthy male volunteers. They were given 2 g dicloxacillin intravenously. Samples from blood and MD fluid were collected. The unbound dicloxacillin was isolated from plasma. Samples were analysed with high performance liquid chromatography (HPLC). RESULTS: The maximum concentration was reached in muscle tissue after 0.5 h and in adipose tissue after 0.8 h. AUC0-6h for the dicloxacillin concentration in adipose tissue was significantly lower when compared to the unbound dicloxacillin concentration in plasma. The dicloxacillin concentration was above the MIC for sensitive S. aureus for a minimum of 2.3 h and a median of 4.1 h in muscle tissue and a minimum of 1.8 h and a median of 3.2 h in adipose tissue. CONCLUSIONS: The unbound dicloxacillin concentration in adipose and muscle tissue remained above the MIC for sensitive S. aureus, for a period sufficient for many orthopaedic procedures. Whether this is true in patients with compromised circulation remains to be investigated.

Combination of thioridazine and dicloxacillin as a possible treatment strategy of staphylococci.

We have previously shown that the phenothiazine, thioridazine, acts in synergy with the beta-lactam antibiotic, dicloxacillin, to kill methicillin-resistant Staphylococcus aureus. In this study, we investigated whether synergy by combining these two drugs could also be observed in vancomycin intermediate susceptible S. aureus (VISA) and methicillin-resistant Staphylococcus epidermidis (MRSE). Synergy was observed in three of four tested VISA strains, suggesting that the thickening of cell wall does not interfere with the effects of thioridazine. In S. epidermidis, no synergy was observed in all tested strains, suggesting that synergy by combining thioridazine and dicloxacillin is isolated to S. aureus species.

Evaluation of water matrix effects, experimental parameters, and the degradation pathway during the TiO2 photocatalytical treatment of the antibiotic dicloxacillin.

The photocalytic degradation of dicloxacillin (DXC) using TiO2 was studied in synthetic and natural waters. The degradation route and the effect of different experimental variables such as pH, applied power, and the initial concentrations of DXC and the catalyst were investigated. The best performances were achieved at a natural pH 5.8 and using 2.0 g L(-1) of TiO2 with 150 W of applied power. The photodegradation process followed Langmuir-Hinshelwood kinetics. The water matrix effect was evaluated in terms of degradation efficiency in the presence of organic compounds (oxalic acid, glucose), Fe(2+) ion and natural water. An increase in degradation was observed when ferrous ion was part of the solution, but the process was inhibited with all evaluated organic compounds. Similarly, inhibition was observed when natural water was used instead of distilled water. The extent of degradation of the process was evaluated following the evolution of chemical oxygen demand (COD), antimicrobial activity (AA), total organic carbon (TOC) and biochemical oxygen demand (BOD5). Total removal of DXC was achieved after 120 min of treatment and 95% mineralization was observed after 480 min of treatment. Additionally, the total removal of antimicrobial activity and a high level of biodegradability were observed after the photocalytical system had been operating for 240 min.

Cephalotin Versus Dicloxacillin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteraemia: A Retrospective Cohort Study.

BACKGROUND: First-line treatments for methicillin-susceptible S. aureus (MSSA) bacteraemia are nafcillin, oxacillin, or cefazolin. Regional shortages of these antibiotics force clinicians to use other options like dicloxacillin and cephalotin. This study aims to describe and compare the safety and efficacy of cephalotin and dicloxacillin for the treatment of MSSA bacteraemia. METHODS: This retrospective study was conducted in a referral centre in Mexico City. We identified MSSA isolates in blood cultures from 1 January 2012 to 31 December 2022. Patients ≥ 18 years of age, with a first episode of MSSA bacteraemia, who received cephalotin or dicloxacillin as the definitive antibiotic treatment, were included. The primary outcome was in-hospital all-cause mortality. RESULTS: We included 202 patients, of which 48% (97/202) received cephalotin as the definitive therapy and 52% (105/202) received dicloxacillin. In-hospital all-cause mortality was 20.7% (42/202). There were no differences in all-cause in-hospital mortality between patients receiving cephalotin or dicloxacillin (20% vs. 21%, p = 0.43), nor in 30-day all-cause mortality (14% vs. 18%, p = 0.57) or 90-day all-cause mortality (24% vs. 22%, p = 0.82). No severe adverse reactions were associated with either antibiotic. CONCLUSIONS: Cephalotin and dicloxacillin were equally effective for treating MSSA bacteraemia, and both showed an adequate safety profile.

Methods for degrading dicloxacillin in water using inorganic peroxides and their combination with UVC- experimental and theoretical aspects.

Antibiotics are currently recognized as environmental pollutants. In this work, the methods involved in the degradation of a ß-lactam antibiotic (i.e., DXC) by treatments based on inorganic peroxides and UVC (e.g., UVC alone, UV-C/H2O2, UVC/peroxymonosulfate, and UVC/peroxydisulfate) are presented. The methodology of computational calculations to obtain frontier orbitals and Fukui indices for DXC, and elucidate the reactive moieties on the target substance is also shown. Finally, the direct oxidation by peroxides and UV-C/H2O2 action to treat DXC in simulated pharmaceutical wastewater are depicted. The chromatographic and theoretical analyses allowed for determining the degrading performance of inorganic peroxides and UVC-based treatments toward the target pollutant in aqueous samples.•Treatments based on inorganic peroxides and UVC as useful methods for degrading the ß-lactam antibiotic dicloxacillin.•Persulfates and UV-C/H2O2 showed high degrading action on the target pharmaceutical.•Methodologies based on theoretical calculations for the identification of reactive moieties on the DXC susceptible to radical attacks are presented.

A phototoxic drug reaction due to topical NSAIDs.

We present a case with a phototoxic reaction following topical use of NSAID. The phototoxic reaction was initially mistaken for cellulitis which led to treatment with dicloxacillin, which led to an exanthematous drug eruption. The patient was treated with topical clobetasol propionate and oral non-sedating antihistamines. Follow-up revealed post-inflammatory hypopigmentation.

Transfer of Dicloxacillin into Human Milk.

Background: Dicloxacillin is a beta-lactam antibiotic that is commonly used in the treatment of lactational mastitis in breastfeeding women. Although penicillins have long been considered safe for breastfeeding mothers and their infants, there is almost no data on the transfer of dicloxacillin into human breast milk despite the fact that it is commonly used for mastitis. Case Report: This study determined the drug concentration-time profile of dicloxacillin in milk samples collected from three lactating mothers consuming 500 mg dicloxacillin taken every 6 hours for treatment of mastitis. Milk levels were measured using liquid chromatography mass spectrometry. The maximum concentration of dicloxacillin in milk was 67.6 ng/mL. The relative infant dose (RID) was calculated to be 0.03%. This value is well below the theoretical level of concern of 10%. Discussion: The limited transfer of dicloxacillin into human milk is probably explained by the high plasma protein binding of dicloxacillin and its subsequent poor penetration into human milk. Conclusion: In this case series, the level of dicloxacillin in milk was found to be very low, and the RID to be only 0.03% of the maternal dose. Although the levels detected were low, dicloxacillin does transfer into breast milk. Caution should be exercised in infants with hypersensitivity to penicillins.

Biosorption of dicloxacillin from pharmaceutical waste water using tannin from Indian almond leaf: Kinetic and equilibrium studies.

This study focused on the use of Indian almond leaf biomass, a local plant widely found in Thailand, on removal of dicloxacillin from pharmaceutical waste water by biosorption. The biosorption characteristics of dicloxacillin were investigated in terms of equilibrium, kinetics and thermodynamics. Optimum biosorption conditions were determined from pH, initial dicloxacillin concentration, biomass dosage, contact time, and temperature. The maximum adsorption capacity was 86.93 % (pH 6.0, 0.1 g/L biomass, dicloxacillin concentration 20 mg/L, contact time 24 h, temperature 283.15 K). The thermodynamic parameters (298.15 K), free energy change, enthalpy change and entropy change were -3475.79 J/mol, -25.36 kJ/mol, and -73.40 J/mol/K, respectively. The best interpretation for the experimental data was given by the Langmuir isotherm with correlation coefficient of 0.965. The results were found to tie in well with pseudo-second-order kinetics. Considering the cost-effectiveness, Indian almond leaf biomass is considered to be suitable to remove dicloxacillin from pharmaceutical waste water.

Effects of Antibiotics on the Intestinal Microbiota of Mice.

Studies on human and mouse gastrointestinal microbiota have correlated the composition of the microbiota to a variety of diseases, as well as proved it vital to prevent colonization with resistant bacteria, a phenomenon known as colonization resistance. Antibiotics dramatically modify the gut community and there are examples of how antibiotic usage lead to colonization with resistant bacteria [e.g., dicloxacillin usage selecting for ESBL-producing E. coli carriage], as shown by Hertz et al. Here, we investigated the impact of five antibiotics [cefotaxime, cefuroxime, dicloxacillin, clindamycin, and ciprofloxacin] on the intestinal microbiota in mice. Five different antibiotics were each given to groups of five mice. The intestinal microbiotas were profiled by use of the IS-pro analysis; a 16S-23S rDNA interspace [IS]-region-based profiling method. For the mice receiving dicloxacillin and clindamycin, we observed dramatic shifts in dominating phyla from day 1 to day 5. Of note, diversity increased, but overall bacterial load decreased. For ciprofloxacin, cefotaxime, and cefuroxime there were few overall changes. We speculate that antibiotics with efficacy against the abundant anaerobes in the gut, particularly Bacteroidetes, can in fact be selected for resistant bacteria, disregarding the spectrum of activity.

Effects of Dicloxacillin on Warfarin Dose in Patients With a Left Ventricular Assist Device.

Patients with a durable, continuous flow left ventricular assist device (CF-LVAD) require anticoagulation with warfarin to prevent thromboembolic events. Driveline infections (DLIs) are a common CF-LVAD complication. A common pathogen implicated in DLI is oxacillin-sensitive Staphylococcus aureus (OSSA), which is effectively treated by oral dicloxacillin. Previous published experiences have observed a significant drug interaction between dicloxacillin and warfarin resulting in decreased international normalized ratio (INR) and increased warfarin dosing requirements. We sought to analyze the effect of dicloxacillin on INR and warfarin dose when used for DLI in our CF-LVAD program. Five of 106 patients having received an CF-LVAD at our institution met the inclusion criteria for this case series. These patients required a mean 51.8% (standard deviation of 29.8%) weekly warfarin dose increase to restore INR to the therapeutic range after the addition of dicloxacillin. Three of the five patients subsequently had their dicloxacillin discontinued, with a mean decrease in weekly warfarin dose of 30.6% (standard deviation of 19.1%). In our experience, when coalesced with prior published reports, an empiric warfarin dose increase of 25% to 33% is reasonable upon initiation of dicloxacillin and an empiric warfarin dose reduction of 10% to 15% is recommended upon discontinuation of dicloxacillin. Close INR follow-up is warranted during and after dicloxacillin treatment.

Fracture Risk Associated with Use of Antibiotics.

BACKGROUND: Data have pointed at an impaired fracture healing with fluoroquinolones and thus potentially a decreased bone biomechanical competence. OBJECTIVES: To study fracture risk associated with antibiotics. METHODS: It is a case control study. There were 124,655 fracture cases and 373,962 age and gender matched controls. The main exposure was use of various groups of antibiotics. Confounder control was performed for social variables, contacts to hospitals and general practitioners, alcoholism and a number of other variables. RESULTS: An increased risk of any fracture (OR =1.45, 95% CI: 1.42 -1.49), hip (1.46, 95% CI: 1.35- 1.58), forearm (1.67, 95% CI: 1.55 -1.80), and spine fractures (1.38, 95% CI: 1.18-1.60) was seen with the use of dicloxacillin and flucloxacillin. There was a dose response relationship for overall risk of fractures, hip, and forearm fractures but not for spine fractures with dicloxacillin and flucloxacillin. None of the other groups of antibiotics against bacteria, tuberculosis, virus, and fungi were systematically associated with any major change in the risk of fractures. CONCLUSION: Dicloxacillin and flucloxacillin seem associated with an increased risk of fractures. The cause for this increase has to be determined but may be related to their use against infections of the bone, the increase thus rather being due to the underlying disease than the drug. Other types of antibiotics especially the fluoroquinolones were not systematically associated with an increased risk of fractures.

Occurrence of antibiotics in mussels and clams from various FAO areas.

Filter feeders, like mussels and clams, are suitable bioindicators of environmental pollution. These shellfish, when destined for human consumption, undergo a depuration step that aims to nullify their pathogenic microorganism load and decrease chemical contamination. Nevertheless, the lack of contamination by drugs may not be guaranteed. Antimicrobials are a class of drugs of particular concern due to the increasing phenomenon of antibiotic resistance. Their use in breeding and aquaculture is a major cause of this. We developed a multiclass method for the HPLC-MS/MS analysis of 29 antimicrobials, validated according to the Commission Decision 2002/657/UE guidelines, and applied it to 50 mussel and 50 clam samples derived from various Food and Agricultural Organisation marine zones. The results obtained, indicate a negligible presence of antibiotics. Just one clam sample showed the presence of oxytetracycline at a concentration slightly higher than the European Union Maximum residue limit set for fish.

Antibiotic use in heavy pigs: Comparison between urine and muscle samples from food chain animals analysed by HPLC-MS/MS.

The antibiotic overuse in zoothechnics, due to prophylactic and therapeutic treatments, or to their growth-promoting activity, is a major cause for the onset of widespread antibiotic resistance. Of particular relevance to this study, is the antibiotic abuse in pig breeding. Despite the comprehensive literature on residue controls in pig muscle, data on pig urine, a non-invasive, on-farm collectable matrix, are lacking. Therefore, we validated an HPLC-MS/MS method to detect 29 antimicrobials from eight classes and applied it to 43 anonymous pig urine and muscle paired samples and fulfilled the parameters in agreement with the Commission Decision 2002/657/UE. The analytical limits were moreover much lower than the maximum residue limits (MRLs) required by the Commission Regulation 37/2010/UE. In the samples, antibiotics were usually detected at higher frequencies and concentrations in urine than muscle. Urine proved a useful tool to detect antibiotic administration and their excessive use in pig farming is depicted.

Safety and pharmacokinetics of dicloxacillin in healthy Chinese volunteers following single and multiple oral doses.

BACKGROUND: Dicloxacillin, a semisynthetic isoxazolyl penicillin antibiotic, has antimicrobial activity against a wide variety of gram-positive bacteria including Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumonia, Streptococcus epidermidis, Streptococcus viridans, Streptococcus agalactiae, and Neisseria meningitidis. The objective of this study was to evaluate the safety and pharmacokinetic profile of dicloxacillin after single and multiple oral dose in healthy Chinese volunteers. METHODS: A single-center, open-label, randomized, two-phase study was conducted in 16 subjects. In the single-dose phase, subjects were randomly assigned to receive single doses of 0.25, 0.5, 1.0, and 2.0 g of dicloxacillin sodium capsule in a 4-way crossover design with a 5-day washout period between administrations. In the multiple-dose phase, subjects were assigned to receive 0.25 or 0.5 g every 6 hours for 3 days in a 2-way crossover design. Plasma and urine pharmacokinetic samples were assayed by a validated high-performance liquid chromatography-tandem mass spectrometry method. Pharmacokinetic parameters were calculated and analyzed statistically. Safety assessments were conducted throughout the study. RESULTS: Following a single oral dose of 0.25-2.0 g dicloxacillin sodium, the maximum plasma drug concentration (Cmax) and the corresponding values for the area under the concentration- time curve from 0 to 10 hours (AUC0-10 h) increased in a dose-proportional manner. The mean elimination half-life (t1/2) was in the range of 1.38-1.71 hours. Dicloxacillin was excreted in its unchanged form via the kidney, with no tendency of accumulation, and varied from 38.65% to 50.10%. No appreciable accumulation of drug occurred with multiple oral doses of dicloxacillin. No serious adverse events were reported. Adverse events were generally mild. CONCLUSION: Dicloxacillin was safe and well tolerated in the volunteers and displayed linear increases in the Cmax and AUC0-10 h values.

Enhancement and inhibition effects of water matrices during the sonochemical degradation of the antibiotic dicloxacillin.

The sonochemical degradation of dicloxacillin (DXC) was studied in both synthetic and natural waters. Degradation routes and the effect of experimental conditions such as pH, initial DXC concentration and ultrasonic power were evaluated. Experiments were carried out with a fixed frequency (600kHz). The best performances were achieved using acidic media (pH=3) and high power (60W). The degradation process showed pseudo-first order kinetics as described by the Okitsu model. To evaluate water matrix effects, substrate degradation, in the presence of Fe(2+) and organic compounds such as glucose and 2-propanol, was studied. A significant improvement was achieved with Fe(2+) (1.0mM). Inhibition of the degradation process was observed at a relatively high concentration of 2-propanol (4.9mM), while glucose did not show any effect. Natural water showed an interesting effect: for a low concentration of DXC (6.4µM), an improvement in the degradation process was observed, while at a higher concentration of DXC (0.43mM), degradation was inhibited. Additionally, the extent of degradation of the process was evaluated through the analysis of chemical oxygen demand (COD), antimicrobial activity, total organic carbon (TOC) and biochemical oxygen demand (BOD5). A 30% removal of COD was achieved after the treatment and no change in the TOC was observed. Antimicrobial activity was eliminated after 360min of ultrasonic treatment. After 480min of treatment, a biodegradable solution was obtained.

Development and Validation of RP-HPLC Method for Simultaneous Estimation of Cefpodoxime Proxetil and Dicloxacillin Sodium in Tablets.

A simple, accurate, rapid and precise reversed-phase high-performance liquid chromatographic method has been developed and validated for simultaneous determination of cefpodoxime proxetil and dicloxacillin sodium in tablet. The chromatographic separation was carried out on kromasil C18 analytical column (250×4.6 mm; 5 µm) with a mixture of acetonitrile:methanol:trifloroacetic acid (0.001%) with pH 6.5 (30:50:20, v/v/v) as mobile phase; at a flow rate of 1.0 ml/min. UV detection was performed at 235 nm. The dicloxacillin sodium and cefpodoxime proxetil were eluted at 1.92 and 3.35 min, respectively. The peaks were eluted with better resolution. Calibration plots were linear over the concentration range 0.5-20 µg/ml for cefpodoxime proxetil (r(2)=0.9996) and 5-50 µg/ml for dicloxacillin sodium (r(2)=0.9987). The method was validated for accuracy, precision, linearity and specificity. The method was very sensitive with limit of detection 0.0726, 0.3685 µg/ml and limit of quantification 0.220, 1.116 µg/ml for cefpodoxime proxetil and dicloxacillin sodium, respectively. The high recovery and low relative standard deviation confirm the suitability of the method for routine determination of cefpodoxime proxetil and dicloxacillin sodium in bulk drug and tablet dosage form.

Validación del método para control de calidad de dicloxacilina sódica en dicloxen cápsulas / Validation of the quality control method for sodium dicloxacillin in Dicloxen capsules

Introducción: la dicloxacilina sódica es un derivado semisintético perteneciente al grupo de las isoxasocil penicilinas que se presenta en suspensión oral y cápsulas. Para el análisis de la materia prima y de estas formas terminadas se recomienda el uso de cromatografía líquida de alta resolución (CLAR), método que no se encuentra disponible en el laboratorio productor de dicloxen cápsulas para el análisis de rutina de este medicamento. Objetivo: desarrollar y validar un método por espectrofotomería UV útil para el control de calidad de dicloxacilina sódica en dicloxen cápsulas. Métodos: se desarrolló un método por espectrofotometría UV directa basado en la determinación de una solución acuosa del analito a 274 nm; el cual fue una modificación del método de identificación establecido en la Farmacopea japonesa, 2011, para la materia prima. Por tratarse de un método modificado se realizó su validación a través de los parámetros linealidad, precisión, exactitud y especificidad frente a los componentes de la formulación dicloxen cápsulas. Resultados: la concentración prefijada en el procedimiento propuesto como 100 por ciento fue de 0,3 mg/mL de analito, lo cual está en correspondencia con la adecuada respuesta medida. En el espectro UV del dicloxacina sódica se observaron dos máximos de absorción, a la lmáxima= 274 nm y a 283 nm. Se seleccionó el valor de l= 274 nm para la cuantificación. Se estableció una metodología analítica muy sencilla que permitiera obtener una solución transparente a partir de la forma terminada, de igual concentración a la solución de referencia. El cumplimiento satisfactorio de todos los criterios de aceptación establecidos para los parámetros especificidad, linealidad, exactitud y precisión permitió demostrar la validez del método en estudio para el control de calidad de dicloxacina sódica en dicloxen cápsulas en el rango de 80 a 120 por ciento. Conclusiones : el método por espectrofotometría UV resulta específico, lineal, exacto y preciso para su aplicación al control de calidad de dicloxacilina sódica en dicloxen cápsulas(AU)

Introduction: sodium dicloxacillin is a semi synthetic derivative of the isoxasocyl penicillin group that may appear in oral suspension form and in caplets. For the analysis of the raw materials and the finished products, it is recommended to use high performance liquid chromatograpy that is an unavailable method at the dicloxen capsule manufacturing lab for the routine analysis of the drug. Objective: to develop and to validate a useful ultraviolet spectrophotometry method for the quality control of sodium dicloxacillin in Dicloxen capsules. Methods: a direct ultraviolet spectrophotometry was developed on the basis of determination of aqueous solution of the analyte at 274 nm distance; the latter was a change from the original detection method set by the Japanese pharmacopeia, 2011 for the raw materials. Since this was a modified method, it had to be validated through parameters such as linearity, precision, accuracy and specificity versus the components of Dicloxen capsule formulation. Results: the preset 100 percent concentration in the suggested procedure was 0.3 mg/mL of analyte, which is in line with the adequate response measured in this test. The ultraviolet spectrum of sodium dicloxacillin showed two maximum absorption values, lmaximun= 274 nm and 283 nm. The choice was l= 274 nm for quantitation. The set analytical methodology was very simple and allowed obtaining a transparent solution from the finished form, which had a concentration value similar to that of the reference solution. The compliance with all the set acceptance criteria for specificity, linearity, accuracy and precision allowed demonstrating the validity of the method under study for the quality control of sodium dicloxacillin in Dicloxen capsules in the 80-120 percent range Conclusions: the ultraviolet spectrophotometry method proved to be specific, linear, accurate and precise for the quality control of sodium dicloxacillin in Dicloxen capsules(AU)