See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/21395602

Antibiotic tissue penetration and its relevance: Models of tissue penetration and
their meaning

Article  in  Antimicrobial Agents and Chemotherapy · November 1991

DOI: 10.1128/AAC.35.10.1947 · Source: PubMed

CITATIONS READS
118 334

5 authors, including:

David Nix Charles A Peloquin

The University of Northampton University of Florida
143 PUBLICATIONS   5,634 CITATIONS    380 PUBLICATIONS   12,143 CITATIONS   

SEE PROFILE SEE PROFILE

Jerome J Schentag
University at Buffalo, The State University of New York
410 PUBLICATIONS   18,890 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Critical Path to TB Drug Regimens (CPTR) View project

Pharmacokinetics of First-Line Antituberculosis Drugs Using WHO Revised Dosage in Children With Tuberculosis With and Without HIV Coinfection View project

All content following this page was uploaded by Jerome J Schentag on 03 November 2014.

The user has requested enhancement of the downloaded file.

ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Oct. 1991, p. 1947-1952
0066-4804/91/101947-06$02.00/0
Copyright © 1991, American Society for Microbiology
MINIREVIEWS
Antibiotic Tissue Penetration and Its Relevance: Models of Tissue
Penetration and Their Meaning
DAVID E. NIX,* S. DIANE GOODWIN, CHARLES A. PELOQUIN, DENISE L. ROTELLA,
AND JEROME J. SCHENTAG
Center for Clinical Pharmacy Research, School of Pharmacy, The State University of New York at Buffalo,
and The Clinical Pharmacokinetics Laboratory, Millard Fillmore Hospital, Buffalo, New York 14209-1194
Tissue penetration regulates the clinical effectiveness and
toxic potential of antibacterial agents. At first glance, the
concept of tissue penetration appears simplistic; however,
many concepts are often misunderstood. Knowledge of
tissue distribution principles is essential before making com-
parisons between agents.
Traditional pharmacokinetic data analysis yields an anti-
biotic concentration-versus-time curve that is descriptive of
drug behavior in plasma or serum (5, 11, 50). Early pharma-
cokinetic studies derived the parameter apparent volume of
distribution as the primary mathematical expression of anti-
biotic tissue distribution. This parameter is approximated by
dividing the dose by the peak concentration in serum follow-
ing intravenous bolus administration. As a calculated pro-
portionality constant, volume of distribution considers dis-
tribution between organs and tissues to be homogeneous.
Actual measurements of concentrations of aminoglycosides
and 3-lactams in tissues reveal uneven tissue distribution.
Tissue/serum ratios of these compounds are less than 1:1 for
most body sites, excluding the excretory organs (40, 41, 47,
52). It became a general belief that bacteria which cause
tissue infections are exposed to lower antibiotic concentra-
tions than are those found simultaneously in blood. This
conclusion rationalized the use of higher antibacterial dos-
ages to treat infections of organs and tissues (26). Studies
showing that sites such as cerebrospinal fluid (34) and
abscess cavities (3) had drug concentrations lower than
those in blood reinforced the contention of lower antibiotic
concentrations at extravascular infection sites. Subsequent
studies which demonstrated low concentrations in extravas-
cular fluid models (8, 18, 64) further emphasized this hypoth-
esis. Furthermore, studies proposed that protein binding
inhibited extravascular penetration (2, 11, 22, 39) and im-
plied that antibiotics highly bound to serum proteins had to
be used at higher dosages to be as effective as antibiotics
exhibiting low serum protein binding (2, 11, 26).
In contrast, some antibiotics had the ability to concentrate
at body tissue sites. These antibiotics were thought to be
effective at lower dosages. However, these high concentra-
tions could also be associated with organ toxicity, as was the
case with the high tissue/serum ratios of aminoglycosides,
for which concentrations in the kidneys (46, 49) or perilymph
(51) were related to the development of toxicity. The high
local concentrations of aminoglycosides were not always
adverse, as correlations were also observed between con-
centrations in tissues and aminoglycoside efficacy against
*
Corresponding author.
1947
Vol. 35, No. 10
infections such as pyelonephritis (13, 20). Modeling of such
uneven tissue distribution required multicompartmental
pharmacokinetic models (48).
In view of these complex and often confusing data,
investigators and clinicians readily accepted the premise of
poor correlation between concentrations in tissues and in-
fection response (26, 33). Dosages of 1-lactams escalated, in
part to offset perceived defects in their tissue penetration. In
the case of the aminoglycosides, maximum dosages were
limited by toxicity, so combination therapy was advocated
to compensate for perceptions of poor tissue penetration.
There were other reasons for the poor activity of aminogly-
cosides, including binding to leukocytes and necrotic debris
at the site (27, 56), antagonism by relative anaerobiosis (38,
57), and antagonism by metal cations in urine (32). The end
result of all these factors was an escalation of dosages to the
point of greater toxicity and then rapid acceptance of com-
bination therapy.
To fully illustrate the importance and relevance of tissue
antibiotic distribution, we will outline the principles involved
in measuring or calculating the extravascular penetration of
antibiotics. We will demonstrate why tissue/serum ratios can
be misleading when used to predict antibacterial effects.
In the companion paper (33a), we will establish conditions
under which homogenate tissue/serum ratios may accurately
reflect concentrations at the site of action. Various factors
that affect extravascular penetration, such as protein bind-
ing, will be discussed. Also, we will interpret tissue penetra-
tion data with respect to the concentration of drug reaching
the site of infection. Finally, similarities and differences in
fluid and tissue drug distributions among quinolones, 1-lac-
tams, and aminoglycosides will be considered.
Bacterial distribution during infections: the concept of
target sites. It is generally assumed that most bacterial
infections occur in what is considered the extracellular or
interstitial space (1, 42, 43, 58). Bacteria attach to the
surfaces of host cells as well as to any artificial surface on
which nutrients and metabolic products are available (35).
Mechanisms for bacterial adhesion have been the subject of
many studies (4, 9, 58). Infection causes damage to host
tissues via metabolic products, toxins, or enzymes which are
produced by the bacteria or via products of the inflammatory
reaction of the host, such as lysosomal enzymes and tumor
necrosis factor. There is a consensus that antibiotics should
be present in the extracellular fluid (ECF) to be effective in
treating bacterial infections. The unanswered questions re-
late to how much and how long. Early work by Eagle et al.
advanced the concept that the effective concentration in
tissue is directly related to the effective concentration in
1948 MINIREVIEWS
blood (12). They demonstrated that the minimally effective
serum penicillin concentration required to treat streptococci
in vivo was the same as the MBC in vitro (12). Thus, they
contended that the concentration in serum approximated the
concentration at the biophase. Since penicillin remains out-
side the cell, as long as bacteria also remain outside the cell,
there should be a favorable outcome.
In contrast, intracellular penetration of antibiotics is pre-
sumably a major determinant of response in the treatment of
microorganisms that can survive ingestion by phagocytes.
Examples include Legionella pneumophila, Mycobacterium
tuberculosis, Listeria monocytogenes, and Staphylococcus
aureus (23, 65). Antibiotics effective against these organisms
not only must be able to enter phagocytes but also must
possess antibacterial activity within cells. Clindamycin,
erythromycin, rifampin, and the fluoroquinolones are able to
penetrate polymorphonuclear leukocytes (15, 23, 24, 30, 31,
37). However, in studies of intracellular activity, clindamy-
cin and erythromycin have often failed to significantly re-
duce the number of intraphagocytic S. aureus cells (21).
Rifampin, on the other hand, has produced significant intra-
cellular staphylococcal killing (31). Ciprofloxacin is also
active in some applications of this model. Discrepancy
among drugs is a consequence of differences in antibiotic
activity (revealed as MBC differences) and differences in
binding (21). Measurement of intracellular antibiotic concen-
trations is usually based on total cell-associated drug. The
antibiotic may be bound tightly to membrane, cytoplasmic,
or nuclear components or may be ion trapped in lysosomes.
Extensive cell-associated antibiotic does not necessarily
imply that the antibiotic is present at the site at which
intracellular organisms are residing. When antibiotics are
extensively bound to intracellular components, they may be
poorly active in the intracellular environment, even if the
MBC is exceeded by the intracellular concentration (54).
Adverse intracellular conditions, such as an acidic pH, may
shift the profile of antibiotic activity versus concentration.
Aminoglycosides, quinolones, and macrolides are markedly
less active at an acidic pH and are probably impaired in
intracellular activity as a consequence of the low pH in
lysosomes.
Quantitation of antibiotic distribution by use of tissue
homogenates. A variety of methods have been devised for
determining the tissue penetration of antibiotics (5, 19, 44,
60, 61, 63). However, these diverse methods often do not
agree, leading Cars and Ogren to describe the term tissue
penetration as inherently imprecise, misused, and often a
misleading measure of the distribution of an antibiotic in
tissue (7). First, it is essential to define the specific tissue in
question, as antibiotics typically are not distributed evenly
throughout the body. Therefore, a drug may be distributed in
striated muscle very well, with concentrations approaching
those in serum. For the same antibiotic, simultaneous con-
centrations in homogenized brain, lung, or prostate may be
far below those in serum. Furthermore, some tissues or
fluids equilibrate rapidly with the vascular space, while
others (such as ascitic fluids) equilibrate more slowly. Some
slowly equilibrating tissues may act as depot sites for the
antibiotic (such as the kidney for aminoglycosides or bone
for tetracyclines), maintaining persistently high concentra-
tions long after concentrations in plasma have fallen toward
zero (48). Other examples of depot sites are ascitic fluid for
cephalosporins (61) and the perilymph for aminoglycosides
(51).
Concentrations in tissue vary depending on the method
used to measure them (44, 63). Factors which affect these
ANTIMICROB. AGENTS CHEMOTHER.
dose
C )0 0 1 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -1
No drug. (111
D
IF *
C
FIG. 1. Distribution of P-lactams in tissue. The entire dose
remains in the blood (B) and ECF (interstitial fluid [IF]) (20% of the
tissue by weight), and none penetrates intracellularly (C) (80% of the
tissue by weight). After the initial distributive phase, concentrations
of free drug and total drug are similar in blood and ECF, and remain
proportional in these sites as the drug is excreted. Data are modified
from the principles outlined in references 46 and 50.
measurements include the amount of blood in the tissue
sample (28, 60, 62, 63); sample desiccation (7); chemical
degradation of the antibiotic during processing or assaying
(63); destruction of cellular membranes, with the release of
intracellular proteins (7); and improper preparation of stan-
dards (7, 19). Sample collection is also of critical importance.
Ideally, the sample represents one tissue type, rather than a
cross section of different tissue layers. The tissue should
only be excised after the distribution phase of the drug has
been completed (typically 1 to 2 h after a dose) and a steady
state between the vascular space and the tissue in question
has been achieved (16, 17, 55). The latter may require
several doses of the drug, and continuous intravenous infu-
sion to achieve equilibrium is considered the standard for
comparing methods (16).
Finally, the condition of the tissue at the time of study
must be known. Inflammatory reactions within the tissue
will alter the physiochemical environment, thereby enhanc-
ing or diminishing antibiotic uptake. For example, a change
in the local pH results in a decrease in the penetration of
some antibiotics, as seen in chronic prostatitis (36). Changes
in capillary permeability will affect the ability of a drug to
reach some sites of infection. In the case of acute meningitis,
an increase in capillary permeability is associated with an
increase in the cerebrospinal fluid concentrations of a num-
ber of antibiotics, particularly j-lactams (6). Alternatively,
this increase in the cerebrospinal fluid penetration of P-lac-
tams in the presence of inflamed meninges may be explained
TABLE 1. Calculation of tissue drug recovery and tissue/serum
ratios (nonexcretory organs) for p-lactamsa
Tissue Recovery
Concn
Site mass (gg)
Al) (p.g
()
(%)
Blood 4 40.00 0.960
ECF 16 40.00 6.400
Intracellular fluid (solids plus water) 80 0.01 0.008
Total recovery (%) 100
Total recovery (,ug) 7.360
Tissue-to-serum ratio 0.180
a Calculated at a postdistributive concentration in serum of 40 p.g/ml in a
1.0-g tissue homogenate specimen from a person with a hematocrit of 40%o.
Data are modified from references 45 and 50.
VOL. 35, 1991 MINIREVIEWS 1949

dose

.'IF

,~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

LUNG -
0 Ia.

I- Distributed il
FECF and mne
with concentration
at some intraceflular 4
I^ sites
LUJ SPLEEN
LU
4(
* UVER FIG. 3. Distribution of quinolones in tissue. These drugs readily
*-

LU U.
n
* BONE
LU HEART
VI
0
0
2i
.1
a.
0
_i
s0 .1 .2 .3 .4
MEASURED
TISSUE:SERUM RATIO
FIG. 2. Relationship between measured and predicted tissue/
serum ratios for moxalactam. Data are from rabbits given losages
designed to mimic peak concentrations in humans. Samp)lintg of
fluids and tissue was done in the postdistributive phase. Pre( lictions
of tissue/serum ratios were based on the ECF content of eacl
as follows: heart (0.20), muscle (0.06), stomach (0.19), fat (O.t24)u
bone (0.23), liver (0.31), lungs '(0.34), and spleen (0.24). D ata are
adapted from reference 50.
by decreased rate of active drug removal by active tra .nsport
from the cerebrospinal fluid.
Interpret.tion of tissue homogenate drug concentr ations.
The earliest method used to measure tissue pene tration
involved homogenation of whole tissue and measurennent of
the antibiotic concentration. A small- tissue sample is ex-
cised, gently blotted with absorbent paper to remove s urface
blood, and immediately placed in a small preweighe d con-
tainer to prevent evaporation of water. After the ntainer cot
and the sample are weighed, the sample is homogeniized or
frozen for future analysis. Buffers are often added to facili-
tate homogenation and to optimize drug stability. After
homogenization, the sample is centrifuged, and the suiperna-
tant is removed, its volume is recorded, and it is as,sayed.
The concentration in tissue is determined as follows: tissue
concentration (micrograms per gram) = (supernatanit con-
centration x supernatant volume)/weight of tissue saLmple.
The analytical recovery of the drug in the supernataint may
be suboptimal because of drug binding to particulaLte cell
debris or loss of the drug during sample preparatiorn. It is
therefore important to determine the analytical recovvery of
the drug by adding a known amount of the drui g to a
pass through the cell membrane and, by the end of the distributive
phase, are equilibrated both intracellularly (C) and extracellufarly.
Concentrations in blood (B) and ECF (interstitial fluid [IF]} are
equal, and free concentrations inside the cell are probably similar to
blood and ECF concentrations. The intracellular concentration is
likely to be greater than 5:1, bound to free, to achieve the data
shown in Table 2.
representative tissue sample and performing the analytical
procedure. Preferably, all standards should be prepared in
the appropriate tissue homogenate as well.
Antibiotics penetrate different tissue cells to various de-
grees and display variable degrees of binding to cellular
components and proteins. Measurement of the total homoge-
nate concentration does not emphasize this uneven distribu-
5 tion and may confuse the prediction of the effective concen-
tration in tissue. The homogenization procedure disrupts cell
membranes and produces a suspension containing both
intracellular and extracellular fluids and particles. Blood
present in the vessels of the tissue as well as blood contam-
inating the surface is also incorporated into the homogenate.
The concentration of the drug in erythrocytes (RBCs) must
be estimated to correct for blood contamination. Among the
commonly used antibiotics, only the sulfonamides concen-
trate in RBCs; (25) therefore, only these drugs are subject to
substantial error if the blood content of tissue is neglectpd.
Tissue hemoglobin can be measured if a precise estimate of
retained blood is desired (28). It appears that some of the
new antiviral agents (such as ribavirin) may also concentra-
tion in RBCs, so this issue will continVe to be of importance.
As blood represents only 3 to 6% of most tissues, the
presence of blood does not lead to substantial errors in the
estimation of P-lactams, tetracyclines, or aminoglycosides.
The presence of contaminating blood may have three dif-
TABLE 2. Calculation of tissue drug recovery and tissue/serum
ratios (nonexcretory organs) for quinolonesa
Tissue Concn
Recovery
Site mass (,ug/ (Rog)
(% g)
Blood 4.0 4.0 0.16
ECF 16.0 4.0 0.64
Intracellular fluid (water) 53.6 4.0 2.14
Intracellular fluid (solids) 26.4 22.0 5.80
Total weight (%) 100
Total recovery (p.g) 8.75
Tissue-to-serum ratio 2.20
a Calculated at a postdistributive concentration in serum of 4.0 ,ug/ml in a
1.0-g tissue homogenate specimen from a person with a hematocrit of 40%.
Data are adapted from reference 45.
1950 MINIREVIEWS
dose
FIG. 4. Distribution of aminoglycosides in tissue. As with 3-lac-
tams, the entire dose is initially retained in the blood (B) and ECF
(interstitial fluid [IF]). From these compartments the drug slowly
penetrates the cell membrane and binds intracellularly (C). This
active transport mechanism is responsible for very slowly increasing
intracellular concentrations. Intracellular uptake proceeds slowly
and is not an important determinant of central volume distribution.
There is, however, a rapid tissue transport pump for these drugs in
renal proximal tubular cells, and the higher concentrations in the
kidneys are responsible for nephrotoxicity. Data are adapted from
references 45 and 48.
ferent effects, depending on the pattern of distribution of the
drug in tissue. If the concentration of the drug is higher in
RBCs than in tissue, the drug-containing blood may artifi-
cially elevate the concentration in the tissue homogenate.
Sulfonamides are an example. For drugs that are distributed
evenly among plasma, tissue cells, and RBCs (tetracycline,
chloramphenicol, and some 1-lactams), failure to consider
tissue hemoglobin does not cause measurement errors (25).
In cases in which the drug is excluded from tissue cells and
is also not able to penetrate RBCs, blood contamination may
artificially decrease the concentration in the tissue homoge-
nate by adding cell mass without associated drug. Amino-
glyQosides and many of the newer cephalosporins are exam-
ples of this pattern. For these drugs, the maximum error
possible is about 6%.
Regardless of whether retained blood is used to correct the
data, the concentration (in micrograms per gram) in tissue
used to determine the tissue/serum ratio when samples are
taken simultaneously, as follows: tissue/serum ratio = tissue
concentration (micrograms per gram)/serum concentration
(micrograms per gram).
The tissue/serum ratio is dependent on the recovery of a
measurable quantity of antibiotic from the supernatant of a
homogenized tissue sample. This ratio provides no informa-
TABLE 3. Calculation of tissue drug recovery nnd tissue/serum ratios (nonexcretory organs) for aminoglycosidesa
Tissue Single-dose
Site mass
M°0
Bloqd 4.0
ECF 16.0
Intracellular fluid (water) 53.6
Intracellular fluid (solids) 26.4
Total weight 100
Total recovery
Tissue-to-serum ratio
iLg/ml
a Calculated at a postdistributive concentration in serum of 4.0
dose and at steady state). Data are adapted from references 45 and 48.
ANTIMICROB. AGENTS CHEMOTHER.
tion as to the subcellular distribution in the excised tissue.
However, were bacteria distributed evenly in that tissue, the
homogenate would be a useful expression of bacterial anti-
biotic exposure and might be related to the MIC. Many of
the commonly treated gram-negative bacteria may be extra-
cellular and therefore unevenly distributed in a tissue sam-
ple. It is essential to determine whether the distribution of
the antibiotic follows the distribution of the bacteria to
evaluate the tissue/serum ratio in relation to the MIC.
Aminoglycosides, ,B-lactams, and quinolones represent
three classes of antibiotics whose tissue penetration has
been extensively studied with tissue homogenates. Using
these data, we have prepared figures and tables to show how
tissue homogenates reflect activity for each drug. Each
figure describes the distribution of the antibiotic in the
homogenate of excised tissue, and the corresponding table
shows how a tissue/serum ratio in a homogenate can misrep-
resent the biophase concentration. For example, the P-lac-
tams demonstrate uneven distribution patterns because they
are excluded from most cells. They only penetrate cells
when there is a transport system, such as that demonstrated
for cephaloridine in the kidneys (53). Hlowever, these drugs
equilibrate evenly throughout the ECF (Fig. 1) (46, 50). This
is true as long as the capillary wall membrane can be crossed
freely and regardless of whether the fluid is extracellular or
interstitial. Table 1 and Fig. 2 show how this highly com-
partmentalized distribution pattern can yield a low homoge-
nate drug concentration. It is interesting to note that these
calculations even apply to sites such as bone (29), in which
penetration has been felt to be poor by many investigators.
Once again, the fluids in bone are penetrated very well (29).
Quinolones concentrate inside cells (Fig. 3), resulting in
relatively high homogenate drug concentrations (Table 2).
Aminoglycosides (Fig. 4) are similar to P-lactams for the first
dose but steadily approach the tissue/serum ratios of the
quinolones at their final intracellular steady-state concentra-
tions near day 21 of therapy (Table 3).
Prediction of antibiotic tissue penetration by use of homoge-
nate data. Antibiotic tissue/serum ratios were predicted for
nonexcretory organs for each of the classes in Table 1
(P3-lactams), Table 2 (quinolones), and Table 3 (aiminoglyco-
sides). These calculations show how the known composition
of physiologic tissue can be used to estimate the aptibiotic
tissue/serum ratio in a homogenate. The estimates apply to
passive diffusion sites only and not to any site with either
diffusion barriers or active transport. These calculations
generalize some concepts; for example, they assume that
each organ or tissue has the same ratio of ECF to intracel-
lular mass. This may not be the case, as demonstrated by a
slightly different ratio for each site (50). However, if the ECF
Single-dose Steady-state Steady-state
concn recovery concn recovery
(~Lg/g) (ILO 44gml) (,Ig)
4.00 0.096 4.00 0.096
4.00 0.640 4.00 0.640
0.01 0.005 0.01 0.005
0.01 0.003 8.30 2.200
0.740 2.940
0.186 0.730
in a 1.0-g tissue homogenate specimen from a person with a hematocrit of 40%o (for a single
VOL. 35, 1991
of each site is used to calculate the ratio, then measured
tissue/serum ratios agree well with the calculations (50).
Figure 2 shows measured versus predicted tissue/serum
ratios for nonexcretory sites for one P-lactam. The data
shown were calculated by first correcting known differences
between tissues in intracellular fluid and ECF volumes (50).
The estimates in Fig. 2 were thus based on the assumption
that ,B-lactams do not penetrate cells and are confined to
ECF. Since ECF equilibrates rapidly with serum, it was also
assumed that the drug was distributed evenly throughout
these fluids. The latter assumption may not apply for highly
protein-bound drugs because albumin concentrations are
lower in ECF than in serum, but distribution can still be
predicted if the bound fraction is taken into account (10, 14,
59).
Antibiotic concentrations in eliminating organs, such as
the liver or kidneys, may not be predictable on the basis of
only diffusion principles. Knowledge of cellular uptake and
transport processes may be needed to accurately describe
the concentration ratios in the excretory organs.
Value of homogenate data. Overall, homegenates have
done little to clarify the important questions regarding anti-
biotic concentrations at the site of infection. If anything,
they have been misleading for most antibiotics. Provided
that tissue homogenates are prepared at the steady state in
the postdistributive phase of serum decline, the data are not
incorrect. Rather, interpretation of the homogenate ratio
requires another step-correcting the data to reflect the
partitioning of the antibiotic within the compartments of
ECF, intracellular fluid, and interstitial fluid. When this
latter step is taken for both the drug and the bacterial
pathogen, homogenate data can be very useful. The accom-
panying paper (33a) details these principles.
REFERENCES
1. Barza, M., and G. Cuchural. 1985. General principles of antibi-
otic tissue penetration. J. Antimicrob. Chemother. 15(Suppl.
A):59-75.
2. Barza, M., T. Samuelson, and L. Weinstein. 1974. Penetration of
antibiotics into fibrin loci in vivo. II. Comparison of nine
antibiotics: effect of dose and degree of protein binding. J.
Infect. Dis. 129:66-72.
3. Barza, M., and L. Weinstein. 1974. Penetration of antibiotics
into fibrin loci in vivo. I. Comparison of penetration of ampicil-
lin into fibrin clots, abscesses, and interstitial fluid. J. Infect.
Dis. 129:59-65.
4. Beacheyf E. H. 1981. Bacterial adherence: adhesion-receptor
interactions mediating the attachment of bacteria to mucosal
surfaces. J. Infect. Dis. 143:325-345.
5. Bergan, T. 1981. Pharmacokinetics of tissue penetration of
antibiotics. Rev. Infect. Dis. 3:45-66,
6. Bonati, M., J. Kanto, and G. Tognoni. 1982. Clinical pharmaco-
kinetics of cerebrospinal fluid. Clin. Pharmacokinet. 7:312-335.
7. Cars, O., and S. Ogren. 1985. Antibiotic tissue concentrations:
methodological aspects and interpretation of results. Scand. J.
Infect. Dis. 44:7-15.
8. Chishoim, G. D., P. M. Waterworth, J. S. Calnan, and L. P.
Garrod. 1973. Concentrations of antibacterial agents in intersti-
tial fluid. Br. Med. J. 1:569-573.
9. Costerton, J. W., G. G. Geesey, and K.-J. Cheng. 1978. How
bacteria stick. Sci. Am. 238:86-95.
10. Drusano, G. L. 1988. Role of pharmacokinetics in the outcome
of infections. Antimicrob. Agents Chemother. 32:289-297.
11. Drusano, G. L., P. A. Ryan, H. C. Standiford, M. R. Moody, and
S. C. Schimpff. 1988. Integration of selected pharmacologic and
microbiologic properties of three new P-lactam antibiotics: a
hypothesis for rational comparison. Rev. Infect. Dis. 6:357-363.
12. Eagle, H., R. Fleischman, and A. D. Musselman. 1950. The
effective concentrations of penicillin in vitro and in vivo for
MINIREVIEWS 1951
streptococci, pneumococci, and Treponema palladium. J. Bac-
teriol. 59:625-643.
13. Fabre, J., M. Rudhart, P. Blanchard, and C. Regamey. 1976.
Persistence of gentamicin and sisomicin in renal cortex and
medulla compared with other organs and serum of rats. Kidney
Int. 10:444 449.
14. Fleishaker, J. C., and P. J. McNamara. 1985. Performance of a
diffusional clearance model for beta-lactam antimicrobial agents
as influenced by extravascular protein binding and interstitial
fluid kinetics. Antimicrob. Agents Chemother. 28:369-374.
15. Forsgren, A., and A. Bellahsene. 1985. Antibiotic accumulation
in human polymorphonuclear leukocytes and lymphocytes.
Scand. J. Infect. Dis. Suppl. 44:16-23.
16. Gengo, F. M., and J. J. Schentag. 1981. Methicillin distribution
in serum and extravascular fluid and its relevance to normal and
damaged heart valves. Antimicrob. Agents Chemother. 19:836-
841.
17. Gengo, F. M., and J. J. Schentag. 1982. Rate of methicillin
penetration into normal heart valves and experimental en-
docarditis lesions. Antimicrob. Agents Chemother. 21:456-459.
18. Gerding, D. N., W. H. Hall, E. A. Schierl, and R. E. Marion.
1976. Cephalosporin and aminoglycoside concentrations in peri-
toneal capsular fluid in rabbits. Antimicrob. Agents Chemother.
10:902-911.
19. Gerding, D. N., and L. R. Peterson. 1984. Extravascular antibi-
otic penetration: skin and muscle, 389-396. In A. M. Ristuccia
and B. A. Cunha (ed.), Antimicrobial therapy. Raven Press,
New York.
20. Glauser, M. P., J. M. Lyons, and A. I. Braude. 1979. Prevention
of pyelonephritis due to E. coli in rats with gentamicin stored in
kidney tissue. J. Infect. Dis. 139:172-177.
21. Hand, W. L., and N. L. King-Thompson. 1986. Contrasts
between phagocyte antibiotic uptake and subsequent intracellu-
lar bactericidal activity. Antimicrob. Agents Chemother. 29:
135-140.
22. Hoffstedt, B., and M. Walder. 1981. Influence of serum protein
binding and mode of administration on penetration of five
cephalosporins into subcutaneous tissue fluid in humans. Anti-
microb. Agents Chemother. 20:783-786.
23. Horwitz, M. A., and S. C. Silverstein. 1980. Legionnaires'
disease bacterium (Legionella pneumophila) multiplies intracel-
lularly in human monocytes. J. Clin. Invest. 66:441-450.
24. Jacobs, R. F., and C. B. Wilson. 1983. Intracellular penetration
and antimicrobial activity of antibiotics. J. Antimicrob. Chemo-
ther. 12(Suppl. C):13-20.
25. Kornguth, M. L., and C. M. Kunin. 1976. Uptake of antibiotics
by human erythrocytes. J. Infect. Dis. 133:175-184.
26. Kunin, C. M. 1981. Dosage schedules of antimicrobial agents: a
historical review. Rev. Infect. Dis. 3:4-11.
27. Levy, J., A. L. Smith, M. A. Kenny, B. Ramsey, and F. D.
Schoenknecht. 1983. Bioactivity of gentamicin in purulent spu-
tum from patients with cystic fibrosis or bronchiectasis: com-
parison with activity in serum. J. Infect. Dis. 148:1069-1076.
28. Lowry, 0. H., and A. B. Hastings. 1942. Histochemical changes
associated with aging. I. Methods and calculations. J. Biol.
Chem. 143:257-269.
29. Lunke, R. J., R. H. Fitzgerald, and J. A. Washington. 1981.
Pharmacokinetics of cefamandole in osseous tissue. Antimi-
crob. Agents Chemother. 19:851-858.
30. Mandell, G. L. 1973. Interaction of intraleukocytic bacteria and
antibiotics. J. Clin. Invest. 52:1673-1679.
31. Mandell, G. L,, and T. K. Vest. 1972. Killing of intraleukocytic
Staphylococcus aureus by rifampin: in-vitro and in-vivo studies.
J. Infect. Dis. 125:486-490.
32. Minuth, J. N., D. M. Musher, and S. B. Thorsteinsson. 1976.
Inhibition of the antibacterial activity of gentamicin by urine. J.
Infect. Dis. 133:14-21.
33. Neu, H. C. 1981. Current practices in antimicrobial dosing. Rev.
Infect. Dis. 3:12-18.
33a.Nix, D. E., S. D. Goodwin, C. A. Peloquin, D. L. Rotella, and
J. J. Schentag. 1991. Antibiotic tissue penetration and its rele-
vance: impact of tissue penetration on infection response.
Antimicrob. Agents Chemother. 35:1953-1959.
 1
1952 MINIREVIEWS
34. Norrby, R. A. 1978. Review of the penetration of antibiotics into
CSF, and its clinical significance. Scand. J. Infect. Dis. 14:296-
309.
35. Pethica, B. A. 1980. Microbial and cell adhesion, p. 19-45. In
R. C. W. Berkeley, J. M. Lynch, and J. Melling (ed.), Microbial
adhesion to surfaces, p. 19-45. Ellis Horwood Ltd., Chichester,
United Kingdom.
36. Phau, A. 1986. Prostatitis: a continuing enigma. Urol. Clin.
North Anm. 13:695-713.
37. Prokesch, R. C., and W. L. Hand. 1982. Antibiotic entry into
human polymorphonuclear leukocytes. Antimicrob. Agents
Chemother. 21:373-380.
38. Reynolds, A. V., J. M. T. Hamilton-Miller, and W. Brulfitt.
1976. Diminished effect of gentamicin under anaerobic or hy-
percapneic conditions. Lancet i:477-479.
39. Rolinson, G. N. 1980. The significance of protein binding of
antibiotics in antibacterial chemotherapy. J. Antimicrob. Che-
mother. 6:311-317.
40. Rolinson, G. N. 1984. Tissue penetration of antibiotics. J.
Antimicrob. Chemother. 13:593-602.
41. Ryan, D. M., and 0. Cars. 1980. Antibiotic assays in muscle: are
conventional tissue levels misleading as indicators of antibacte-
rial activity? Scand. J. Infect. Dis. 12:307-309.
42. Ryan, D. M., and 0. Cars. 1983. A problem in the interpretation
of P-lactam antibiotic levels in tissues. J. Antimicrob. Chemo-
ther. 12:281-284.
43. Ryan, D. M., 0. Cars, and B. Hoffstedt. 1986. The use of
antibiotic serum levels to predict concentrations in tissues.
Scand. J. Infect. Dis. 18.381-388.
44. Ryan, D. M., B. Hodges, G. R. Spencer, and S. M. Harding.
1982. Simultaneous comparison of three methods for assessing
ceftazidime penetration into extravascular fluid. Antimicrob.
Agents Chemother. 22:995-998.
45. Schentag, J. J., T. J. CumbW, W. J. Jusko, and M. E. Plaut.
1978. Gentamicin tissue accumulation and nephrotoxic reac-
tions. J. Am. Med. Assoc. 240:2067-2069.
46. Schentag, J. J., and F. M. Gengo. 1982. Principles of antibiotic
tissue penetration and guidelines for pharmacokinetic analysis.
Med. Clin. North Am. 66:39-49.
47. Schentag, J. J., W. J. Jusko, M. E. Plaut, T. J. Cumbo, J. W.
Vance, and E. Abrutyn. 1977. Tissue persistence of gentamicin
in man. J. Am. Med. Assoc. 238:327-329.
48. Schentag, J. J., W. J. Jusko, J. W. Vance, T. J. Cumbo, E.
Abrutyn, M. DeLattre, and L. M. Gerbracht. 1977. Gentamicin
disposition and tissue accumulation on multiple dosing. J.
Pharmacokinet. Biopharm. 5:559-577.
49. Schetitag, J. J., G. Lasezkay, T. J. Cumbo, M. E. Plaut, and
W. J. Jusko. 1978. Accumulation pharmacokinetics of tobramy-
cin. Antimicrob. Agents Chemother. 13:649-656.
50. Schentag, J. J., D. J. Swanson, and I. L. Smith. 1985. Dual
individualization: antibiotic dosage calculation from the integra-
tion of in vitro pharmacodynamics and in vivo pharmacokinet-
View publication stats
ANTIMICROB. AGENTS CHEMOTHER.
ics. J. Antimicrob. Chemother. 15(Suppl. A):47-57.
51. Stupp, H., S. Rauch, H. Sous, J. P. Brun, and F. Lagler. 1967.
Kanamycin dosage and levels in ear and other organs. Arch.
Otolaryngol. 86:63-69.
52. Tsuji, A., T. Terasakd, N. Imaeda, K. Nishide, and E. Nakash-
ima. 1985. Effect of extracellular water voltime on the distribu-
tion of kinetics of P-lactam antibiotics as a function of age. J.
Pharmacobiodyn. 8:167-174.
53. Tuine, B. M., C. H. Kuo, J. B. Hdok, C. Y. Hsu, and D. Fravert.
1983. Effects of piperonyl butoxide on cephalosporin nephro-
toxicity in the rabbit. An effect on cephaloridine transport. J.
Pharmacol. Exp. Ther. 224:520-524.
54. Van der Auweka, P., G. Petlkkos, T. Matsumotb, and M.
Husson. 1988. Influence of LY146032 on human polymorphonu-
clear leukocytes in-vivo. J. Antimicrob. Chemother. 21:57-63.
55. Van Etta, L. L., L. R. Peterson, C. E. Fasching, and D. N.
Gerding. 1982. Effect of the ratio of surface area to volume on
the penetration of antibiotics into extravascular spaces in an in
vitro model. J. Infect. Dis. 146:423-428.
56. Vaudatix, P., and F. A. Waldvogel. 1980. Gentamicin inactiva-
tion in purulent exudates: role of cell lysis. J. Infect. Dis.
142:586-593.
57. Verklin, R. M., and G. L. Mandell. 1977. Alteration of effec-
tiveness of antibiotics by anaerobiosis. J. Lab. Clin. Med.
89:65-71.
58. Walker, P. D. and L. K. Nagy. 1980. Adhesion of organisms to
animal tissues, p. 473-494. In R. C. W. Berkeley, J. M. Lynch,
and J. Melling (ed.), Microbial adhesion to surfaces. Ellis
Horwood Ltd., Chichester, United Kingdom.
59. Waterman, N. G., M. J. Raff, L. Scharfenberger, and P. A.
Barnwell. 1976. Protein binding and concentrations of cephalo-
ridine and cefazolin in serum and interstitial fluid of dogs. J.
Infect. Dis. 133:642-647.
60. Whelton, A., and R. L. Stout. 1984. An overview of antibiotic
tissue penetration, p. 365-378. In A. M. Ristuccia and B. A.
Cunha (ed.), Antimicrobial therapy. Raven Press, New York.
61. Wilson, 1). E., T. C. Chalnebe, and M. A. Madoff. 1967. The
passage of cephalothin into and out of ascitic fluid. Am. J. Med.
Sci. 253:449-452:
62. Wise, R. 1983. Protein binding of 1-lactams: the effects on
activity and pharmacology, particularly tissue penetration. II. J.
Antimicrob. Chemother. 12:105-118.
63. Wise, R. 1986. Methods for evaluating the penetration of 1-lac-
tam antibiotics into tissues. Rev. Infect. Dis. 8(Suppl. 3):5303-
5332.
64. Wise, R., A. P. Giilett, B. Cadge, S. R. Durham, and S. Baker.
1980. The influence of protein binding upon tissue fluid levels of
six 3-lactam antibiotics. J. Infect. Dis. 142:77-82.
65. World Health Organization Scientific Group. 1973. Cell-medi-
ated immunity and resistance to infection. Int. Arch. Allergy
Appl. Immunol. 44:589-648.