ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Apr. 1998, p. 984986 0066-4804/98/$04.

000 Copyright 1998, American Society for Microbiology

Vol. 42, No. 4

In Vitro Activity of Levooxacin against a Selected Group of Anaerobic Bacteria Isolated from Skin and Soft Tissue Infections
HANNAH M. WEXLER,1,2* ERIC MOLITORIS,1 DENISE MOLITORIS,2 1,2,3,4 AND SYDNEY M. FINEGOLD Medical3 and Research2 Services Veterans Administration Medical Center, West Los Angeles, Wadsworth Division, Los Angeles, California 90073, and Departments of Medicine1 and Microbiology and Immunology,4 UCLA School of Medicine, Los Angeles, California 90024
Received 3 July 1997/Returned for modication 13 October 1997/Accepted 5 January 1998

The in vitro activity of levooxacin was compared to the activities of ooxacin, ciprooxacin, ampicillinsulbactam (2:1), cefoxitin, and metronidazole for a selected group of anaerobes (n 175) isolated from skin and soft tissue infections by using the National Committee for Clinical Laboratory Standards-approved Wadsworth method. Ampicillin-sulbactam and cefoxitin inhibited 99% of the strains of this select group, levooxacin and ooxacin inhibited 73 and 50%, respectively, at 2 g/ml, and ciprooxacin inhibited 51% at 1 g/ml. The geometric mean MIC of levooxacin was lower than those of ooxacin and ciprooxacin for every group except Veillonella.

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Fluoroquinolones have become important agents in the therapeutic arsenal for a wide range of infections. Their utility for anaerobic infections, however, is thought to be limited. Most of the quinolone agents introduced over the past several years, including ciprooxacin, lomeoxacin, noroxacin, peoxacin, enoxacin, cinoxacin, and ooxacin, have had only limited activity against anaerobes (3, 5, 8, 10, 11, 16, 17) and have had particularly poor activity against the Bacteroides fragilis group organisms. Variable activity against Prevotella species, such as the Prevotella melaninogenica and Prevotella oralis group, and against Bacteroides ureolyticus has been reported (10). Levooxacin, the optically active l isomer of ooxacin, is a tricyclic uoroquinolone with a methyl group at the C-3 position in the oxazine ring. Levooxacin is two- to fourfold more active than ooxacin in vitro and possesses similar pharmacokinetic properties (13). It can be useful to describe the antibacterial efcacy of agents against organisms found in a specic clinical setting. Documentation of the association of particular anaerobic species with specic infections, along with information on their antimicrobial susceptibility patterns, is helpful both to the laboratory scientist in identication protocols and to the clinician prescribing antimicrobial therapy. Rather than aiming at the entire anaerobic population, empiric therapy can be directed against the organism(s) most likely to be present. Our laboratory performed such a study on organisms isolated from skin and soft tissue infections. The purpose of this study was to evaluate the in vitro activity of levooxacin and other agents against clinical isolates from these infections. (Results of this study were presented at the 36th Interscience Conference on Antimicrobial Agents and Chemotherapy, 15 to 18 September 1996.) The bacteriologic data from this study have been published

* Corresponding author. Mailing address: Microbial Diseases Research Laboratory, Bldg. 304, Room E3-224, VA Wadsworth Medical Center 691/151J, Los Angeles, CA 90073. Phone: (310) 268-3404. Fax: (310) 268-4458. E-mail: hwexler@ucla.edu. 984

in detail (14); the susceptibility data are presented here. Briefly, cutaneous or subcutaneous abscesses (86 specimens) of intravenous-drug users (IVDUs) were cultured and results were compared with those for abscesses (74 specimens) of patients with no history of intravenous drug use (non-IVDUs). The IVDU abscesses yielded 173 aerobes and 131 anaerobes. Specimens (n 160) were primarily from upper extremity (n 83, 52%), lower extremity (n 36, 22%), and buttock and perirectal (n 18, 11%) locations. Staphylococcus aureus was the most common aerobe isolated (50% of the specimens yielded this isolate), followed by Streptococcus milleri (46%). The commonly encountered anaerobes were Fusobacterium nucleatum (17% of the specimens yielded this isolate), pigmented Prevotella species (22%), Peptostreptococcus micros (17%), Actinomyces odontolyticus (15%), and Veillonella species (13%). The non-IVDU isolates included 116 aerobes and 106 anaerobes. S. aureus was isolated from 53% of these specimens, followed by coagulase-negative staphylococci (19%), S. milleri (19%), and Streptococcus pyogenes (16%). The main groups of anaerobes were Peptostreptococcus species (35% of the specimens yielded this isolate), Bacteroides species (19%), and gram-positive bacilli (31%). Overall, 67% of the IVDU isolates were of oral origin, compared with 25% of the nonIVDU isolates. Of the specimens from IVDUs and nonIVDUs, 48 and 67%, respectively, yielded only aerobes, and 2 and 4%, respectively, yielded only anaerobes. Sixty-four percent of the patients had one or more -lactamase-producing organisms (14). Anaerobic bacteria used in this study were isolated from the skin and soft tissue infections described above and were identied according to established procedures (9, 15). MICs were determined by an agar dilution technique described previously (15) by using an inoculum of 105 CFU and brucella base-laked blood agar. Plates were incubated in an anaerobic chamber (Anaerobe Systems, San Jose, Calif.) for 48 h at 37C. The MIC was dened as the lowest concentration of antimicrobial resulting in no growth, a haze, one discrete colony or multiple tiny colonies, or a marked change in the appearance of growth compared to the control plate (in the case of persistent light

VOL. 42, 1998 TABLE 1. Activities of antimicrobial agents against anaerobic organisms
Organism (no. of isolates) and antimicrobial agent MIC (g/ml) Range 50% 90%

NOTES TABLE 1Continued

Organism (no. of isolates) and antimicrobial agent MIC (g/ml) Range 50%

985

90%

B. fragilis (6) Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Other B. fragilis group species (6)a Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Other Bacteroides species (10)b Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Clostridium species (10)c Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Peptostreptococcus species (37)d Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Gram-positive (non-spore-forming) rods (35)e Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin F. nucleatum (18) Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Prevotella species (43)f Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin Veillonella species (10) Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin

0.54 816 24 12 0.51 22 0.516 216 416 18 0.51 216 0.250.25 11 0.128 0.124 0.121 0.128 0.250.25 164 0.1232 0.1216 0.121 0.2532 0.128 18 0.1232 0.1216 0.122 0.2532

1 8 4 1 0.5 2 1 8 8 1 0.5 2 0.25 1 2 2 0.25 4 0.25 1 2 1 0.12 2 0.25 1 0.5 0.5 0.25 0.5 0.25 1 4 2 1 8 0.25 8 32 8 0.5 16 0.25 1 8 16 1 16

Total (175) Ampicillin-sulbactam Cefoxitin Ciprooxacin Levooxacin Metronidazole Ooxacin

0.1216 164 0.1232 0.1216 0.1264 0.1232

0.25 1 1 1 0.5 1

1 4 8 4 8 8

a Includes B. distasonis (one isolate), B. ovatus (one isolate), B. thetaiotaomicron (two isolates), and B. vulgatus (two isolates). b Includes B. levii and B. ureolyticus (ve isolates each). c Includes C. cadaveris (one isolate), C. innocuum (one isolate), C. malenominatum (one isolate), C. oroticum (one isolate), C. perfringens (one isolate), C. sordellii (three isolates), C. sporogenes (one isolate), and a Clostridium species (one isolate). d Includes P. anaerobius (3 isolates), P. asaccharolyticus (4 isolates), P. magnus (7 isolates), P. micros (18 isolates), P. prevotii (4 isolates), and a Peptostreptococcus species (1 isolate). e Includes Actinomyces odontolyticum (nine isolates), Actinomyces species (ve isolates), Eubacterium limosum (one isolate), Eubacterium nodatum (one isolate), a Eubacterium species (three isolates), Lactobacillus jensenii (two isolates), Lactobacillus species (nine isolates), Propionibacterium acnes (four isolates), and a Propionibacterium species (one isolate). f Includes P. bivia (three isolates), P. buccae (seven isolates), P. denticola (two isolates), P. disiens (one isolate), P. intermedia (eight isolates), P. loescheii (eight isolates), P. melaninogenica (eight isolates), P. oralis (one isolate), P. oris (one isolate), and Prevotella species (four isolates).

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0.250.5 12 0.1216 0.124 0.1264 0.128 0.254 11 0.54 0.51 0.120.5 12 0.124 18 0.516 0.516 0.122 132 0.250.5 14 0.128 0.128 0.252 0.2516

0.25 1 1 0.5 8 1 0.25 1 2 1 0.12 2 0.25 1 2 1 0.5 1 0.25 1 0.12 0.25 1 0.5

0.25 2 16 4 64 8 0.25 1 2 1 0.25 2 2 4 8 4 1 8 0.25 4 0.12 0.5 2 1

Continued

[slight] growth) (12). Reference strains of B. fragilis (ATCC 25285) and Bacteroides thetaiotaomicron (ATCC 29741) were used as controls in each test. Antimicrobial agents were obtained as powders from the indicated companies: ampicillinsulbactam from Pzer Pharmaceuticals, New York, N.Y.; cefoxitin from Merck Sharp and Dohme, Rahway, N.J.; ciprooxacin from Miles Pharmaceuticals, West Haven, Conn.; ooxacin and levooxacin from R. W. Johnson, Raritan, N.J.; and metronidazole from Sigma, St. Louis, Mo. National Committee for Clinical Laboratory Standards-approved breakpoints for anaerobic bacteria are established for ampicillin-sulbactam (8 g/ml for the susceptible category, 16 g/ml for the intermediate category), cefoxitin (16 g/ml for the susceptible category, 32 g/ml for the intermediate category), and metronidazole (8 g/ml for the susceptible category, 16 g/ml for the intermediate category). Results are shown in Tables 1 and 2. Levooxacin was the most active quinolone against B. fragilis, inhibiting 83% of the strains at 2 g/ml (compared to 0% inhibition for both ciprooxacin and ooxacin). However, at 4 g/ml, both levooxacin and ooxacin inhibited 100% of the strains. (The difference between the results at 2 g/ml may be due to the 1-twofolddilution error inherent in this technique.) Ciprooxacin inhibited only 33% of the strains at 2 g/ml. Levooxacin was much more active than the other two quinolones against F. nucleatum (18 strains), inhibiting all of the tested strains at breakpoint compared to 22 and 17% of strains inhibited by ooxacin and ciprooxacin, respectively. Ooxacin inhibited 100% of the strains at 4 g/ml and ciprooxacin inhibited 94% at 2 g/ml. For all the anaerobes tested, levooxacin was more active than ooxacin at 2 g/ml (73 versus 50% of strains inhibited) and at 4 g/ml (81 versus 74%). Ciprooxacin, in comparison, inhibited 51% of all anaerobes at 1 g/ml. The MIC at which 90% of the isolates are inhibited (MIC90) of levooxacin was 1 twofold dilution lower than those of ciprooxacin and ooxacin (and the levooxacin breakpoint for aerobes is 2 g/ml while the ciprooxacin breakpoint is 1 g/ml). The geometric mean

986

NOTES TABLE 2. Geometric mean MICs of uoroquinolone agents for anaerobic bacteria
Organism (no. of strains) MIC (g/ml) of: Levooxacin Ooxacin Ciprooxacin

ANTIMICROB. AGENTS CHEMOTHER.

B. fragilis (6) Other B. fragilis group species (6) Other Bacteroides species (10) Clostridium species (9) F. nucleatum (18) Peptostreptococcus species (37) Gram-positive (non-spore-forming) rods (35) Prevotella species (43) Veillonella species (10)

1.1 2.2 0.7 1 0.86 0.69 0.69 1 0.4

2 4.5 1.4 1.5 1.7 1.3 1.7 1.9 0.76

3.2 9 0.98 1.4 1.8 0.96 1.5 1.7 0.18

against certain groups of anaerobes will need conrmatory clinical data to support their use as therapeutic options against infections involving anaerobes. Levooxacin has good activity against certain groups of anaerobic isolates (non-B. fragilis Bacteroides species, Veillonella species, Prevotella species, and Porphyromonas species), and its utility in specic anaerobic clinical infections warrants further study.
This work was supported in part by R. W. Johnson and in part by VA Medical Research Funds.
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MIC of levooxacin was lower than those of ooxacin and ciprooxacin for every group of anaerobes except Veillonella species (10) and ranged from 0.4 to 2.2 g/ml. In general, the MICs of levooxacin were 1 to 2 doubling dilutions lower than those of ooxacin, a result that has been reported by other investigators as well (1). There have been a limited number of studies of the in vitro efcacy of levooxacin against anaerobes. In one study of clinical isolates, levooxacin was effective against B. fragilis (15 strains) (MIC90, 1 g/ml) and Clostridium perfringens (5 strains) (MIC90, 0.25 g/ml); the MIC90 was 4 g/ml for Clostridium difcile (5 strains). The activities of ciprooxacin and sparoxacin were comparable in this study and the newer agents DU 6859 and trovaoxacin (CP 99,219) were more effective (2). In another study of fresh clinical isolates collected from laboratories around the United States from 1990 to 1991 the MIC90 of levooxacin was 2.0 g/ml for B. fragilis (n 39), compared to 8.0 g/ml for ooxacin and ciprooxacin. The MIC90s of the three agents for Peptostreptococcus were 8.0, 16.0 and 4.0 g/ ml, respectively (6). Weighted mean MICs were calculated for several quinolones from multiple published studies (4); all isolates were from hospital or community sources, and at least three studies were used to calculate the mean MICs. The mean MICs of levooxacin, ooxacin, and ciprooxacin, respectively (weighted to reect the number of strains tested in the different studies), were as follows: for B. fragilis, 3.5, 6.5, and 14.9 g/ml; for C. difcile, 5.0, 12.5, and 14.4 g/ml; for C. perfringens, 0.75, 1.2, and 2.5 g/ml; and for Peptostreptococcus, 4.6, 9.4, and 5.6 g/ml (4). In a study of 194 aerobic and anaerobic strains isolated from bite wound infections (primarily oral or skin isolates) (7), levooxacin was active against all aerobic isolates (MIC90, 1.0 g/ml). Among the anaerobes isolated, levooxacin was active against 90% of Peptostreptococcus strains and against most of the Prevotella, Porphyromonas, and Bacteroides spp. (MIC90, 4.0 g/ml; no higher MICs were seen). Levooxacin was less active against the fusobacteria (MIC90, 64 g/ml). Quinolones with improved antianaerobic activity are being developed. The promising in vitro activity of these agents

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