Journal of Antimicrobial Chemotherapy (2008) 61, 1328– 1331

doi:10.1093/jac/dkn110
Advance Access publication 18 March 2008

Pharmacokinetics of moxifloxacin in non-inflamed cerebrospinal fluid

of humans: implication for a bactericidal effect

Kyriaki Kanellakopoulou1*, Alexandra Pagoulatou2, Konstantinos Stroumpoulis2,

Marianthi Vafiadou2, Hariklia Kranidioti1, Helen Giamarellou1

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and Evangelos J. Giamarellos-Bourboulis1
1
4th Department of Internal Medicine, University of Athens, Medical School, Athens, Greece; 2Department of
Anaesthesiology, Sismanoglion General Hospital, Athens, Greece

Received 22 September 2007; returned 20 January 2008; revised 3 February 2008; accepted 20 February 2008

Objectives: To evaluate the ability of moxifloxacin to penetrate healthy brain barriers.

Methods: Fifty patients received a single oral dose of 400 mg as an antimicrobial prophylaxis regimen
for a short urological procedure under spinal anaesthesia. Serum and cerebrospinal fluid (CSF) were
sampled at different time intervals post-drug intake and patients were divided into five groups, as
follows: group I: 0.5 –1 h; group II: 1 –2 h; group III: 2– 4 h; group IV: 4 –6 h; and group V: 6 –8 h.
Concentrations of moxifloxacin were estimated after analysis by an HPLC system. Bactericidal activity
of CSF samples of groups III and IV was assessed by a microdilution technique against two penicillin-
resistant isolates of Streptococcus pneumoniae with MICs of moxifloxacin of 0.19 and 0.125 mg/L,
respectively.
Results: Mean CSF concentrations of moxifloxacin of groups I, II, III, IV and V were 0.19, 0.87, 3.00, 4.07
and 1.82 mg/L, respectively. The mean bactericidal activity of CSF of group III was 8 and that of group
IV was 4.
Conclusions: Single oral intake of 400 mg moxifloxacin is accompanied by good penetration through
healthy meninges within 2 –6 h post-dose and reached adequately high levels in human CSF exerting
satisfactory bactericidal activity against penicillin-resistant S. pneumoniae. These results render novel
perspectives for a role of moxifloxacin in CNS infections.

Keywords: penicillin resistance, brain barrier, Streptococcus pneumoniae

Introduction laboratory animals caused by penicillin-resistant S. pneumoniae

and Escherichia coli,4 – 6 data in humans are lacking. The aim of
The transport and diffusion of antimicrobials in the central this study was to evaluate the penetration of moxifloxacin
nervous system (CNS) are strictly controlled by the blood – brain through the blood –brain barrier in the non-inflamed cerebro-
barrier and by the tight junctions between endothelial vascula- spinal fluid (CSF). It was also investigated whether CSF could
ture.1,2 The worldwide spread of isolates of Streptococcus have any bactericidal activity against penicillin-resistant
pneumoniae with reduced susceptibility to penicillin and to S. pneumoniae.
third-generation cephalosporins has led to research efforts for
agents able to achieve therapeutic concentrations in the CNS.
Moxifloxacin is a new quinolone derivative with broad coverage
against Gram-positive cocci, Gram-negative bacteria and atypical Patients and methods
pathogens comprising even penicillin-resistant S. pneumoniae.3
Its high lipophilicity makes moxifloxacin a promising agent for Study design
penetration into the subarachnoid space and the CNS. This was a prospective study performed during the period December
Although, several experimental studies have evaluated the 2001–October 2003. Fifty patients (42 male, 8 female, mean + SD
role of moxifloxacin in the eradication of CNS infections in age 66.5 + 10.6 years) undergoing a scheduled urological operation

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*Corresponding author. Tel: þ30-2105831665; Fax: þ30-2105326446; E-mail: kyrkanel@yahoo.gr

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 Moxifloxacin in CSF
of short duration, i.e. 20–40 min, under spinal anaesthesia were
enrolled. Exclusion criteria were: (i) an ASA (American Society of
Anesthesiologists) score above 2; (ii) absolute platelet count
,150 000/mL and/or international normalized ratio (INR) .1.5; (iii)
presence of any chronic heart, liver, renal or neurological disease; (iv)
history of recent aspirin intake or of hypersensitivity to quinolones;
and (v) intake of any antimicrobial medication in the last 15 days.
The study protocol was approved by the Ethics Committee of
Sismanoglion General Hospital. Patients gave written informed
consent before operation.
Patients received a single oral dose of 400 mg moxifloxacin
(Bayer, Berlin, Germany) as pre-operative chemoprophylaxis and
lumbar puncture was performed for the induction of anaesthesia.
Depending on the time lapsing between drug intake and lumbar
puncture, patients were divided into five groups, with 10 patients in
each group, according to time lapsing since drug intake, as follows:
group I: 0.5 –1 h; group II: 1 –2 h; group III: 2– 4 h; group IV:
4 –6 h; and group V: 6– 8 h. Lumbar puncture was performed under
aseptic conditions at either the L3-L4 or the L4-L5 intervertebral
space with a 25 Gauge Tuohy catheter yielding 1 mL of CSF. At the
same time interval, 4 mL of blood was collected from each patient
after venipuncture under aseptic conditions of the antecubital vein
for the estimation of serum levels of moxifloxacin. Blood was cen-
trifuged. Serum and CSF were stored at 2708C until assayed.
Estimation of drug levels
Concentrations of moxifloxacin were estimated by an HPLC analysis
as previously described7 using ciprofloxacin as an internal standard.
Briefly, 250 mL of sample was diluted with 250 mL of displacing
reagent and centrifuged for 5 min at 2700 g. The displacing reagent
consisted of 0.5% SDS (Merck, Darmstadt, Germany) and 20%
acetonitrile (Merck) in 75 mM sodium phosphate buffer ( pH 7.5).
A 10 mL aliquot of the supernatant was injected into a HPLC
system (Agilent 1100 Series; Agilent Technologies, Waldbronn,
Germany) with the following elution characteristics: Nucleosil
100-5 C18 (4.6 mm  250 mm, 5 mm) column at 378C; mobile
phase consisting of a pH 3.0 buffer composed of 25 mM Na3PO4
and 10 mM SDS, and acetonitrile 99% at a 35/65 ratio with a flow
rate of 1 mL/min; and ultraviolet detection at 293 nm. The retention
time of moxifloxacin was 2.8 min and its concentration was esti-
mated (in mg/L) using a standard curve created with known concen-
trations of moxifloxacin. All determinations were performed in
duplicate. The lower concentration of the standard curve was
0.09 mg/L and the upper concentration was 50 mg/L. The R 2 of the
curve was 0.9997. The inter-day variation of the assay was 0.04%.
Bactericidal activity of CSF
Bactericidal activity of CSF was studied for all samples of groups
III and IV, which were found to have the highest concentrations of
moxifloxacin among the five groups (see below). Two penicillin-
resistant isolates of S. pneumoniae (1035 and 5731) were used. Both
were isolated from blood of two HIV-positive individuals with lobar
pneumonia. They were grown on Columbia agar (Becton–
Dickinson, Sparks, MD, USA) enriched with 5% defibrinated sheep
blood (E&O Laboratories Ltd). MICs of penicillin G, ceftriaxone,
levofloxacin, moxifloxacin and vancomycin were determined by
Etest according to the instructions of the manufacturer (AB Biodisk,
Sole, Sweden). Bactericidal activity of CSF was estimated in a
96-well plate at a final volume of 100 mL per well in Todd Hewitt
broth (Becton– Dickinson) with serial 2-fold dilutions of the CSF
and 1  104 cfu per well. Bactericidal activity was defined as the
1329
lowest CSF dilution killing 99.9% of colonies after 18 h of
incubation at 378C and 5% CO2.
Statistical analysis
Since participants acted as healthy volunteers, the necessary number
for each group was determined according to former publications.8
Concentrations are expressed as means and SDs. Comparisons
between groups were performed by one-way analysis of variance
(ANOVA) with post hoc Bonferroni correction. Correlations
between serum and CSF concentrations were done by Spearman’s
rank of order. Any value of P , 0.05 was considered significant.
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Results
Concentrations of moxifloxacin in serum and CSF of the five
groups of patients are shown in Table 1. No significant corre-
lations were found between serum and CSF concentrations sep-
arately within each of the five groups. The mean CSF to serum
ratio of the concentrations of moxifloxacin was 0.03 for group I,
0.26 for group II, 0.51 for group III, 0.81 for group IV and 0.53
for group V.
The drug was well tolerated by all patients.
MICs of penicillin, ceftriaxone, levofloxacin, moxifloxacin
and vancomycin for isolate 1035 were 1, 0.75, 1, 0.19 and
0.25 mg/L, respectively, and the MICs for isolate 5731 were 1,
1, 2, 0.125 and 0.25 mg/L, respectively. Mean bactericidal
activity of CSF of group III against isolate 1035 was 8 (range
4 – 8) and that against isolate 5731 was 8 (range 4 – 8). Mean
bactericidal activity of CSF of group IV against isolate 1035 was
4 (range 4 – 8) and that against isolate 5731 was 4 (range 4 –8).
Discussion
Penetration of antimicrobials in the subarachnoid space is a lim-
iting factor for the successful management of infections of the
CNS. Moxifloxacin is a novel quinolone derivative with promis-
ing in vitro activity against Gram-positive cocci. This is the first
study in humans providing information on the concentrations of
moxifloxacin in the CSF and on its penetration through the non-
inflamed meninges after a single oral administration. Mean
levels between 3 and 4 mg/L were detected in the CSF 2– 6 h
post-administration. No correlation was detected between serum
Table 1. Concentrations of moxifloxacin in serum and CSF of 50
patients divided into five groups of sampling according to time
lapsing after intake of a single oral dose of 400 mg
Group Serum (mg/L, mean + SD) CSF (mg/L, mean + SD)
I (0.5–1 h) 2.08 + 2.52 0.19 + 0.61
II (1–2 h) 3.37 + 1.61a 0.87 + 1.09a
III (2–4 h) 6.55 + 3.61b 3.00 + 1.84d
IV (4–6 h) 5.49 + 1.72c 4.07 + 1.15d
V (6–8 h) 3.31 + 1.71a 1.82 + 1.15e
P values of comparisons with group I in the same compartment: anot
significant; bP ¼ 0.002; cP ¼ 0.039; dP , 0.0001; eP ¼ 0.007.
 Kanellakopoulou et al.
and CSF levels, probably implying that penetration of moxiflox-
acin through the blood –brain barrier is performed by a mechan-
ism other than simple diffusion.
Hypotheses about a probable role of moxifloxacin in the
therapy of infections of the CNS are based on published data
related to its in vitro activity against bacterial pathogens. Two
large Greek surveys have been published on the in vitro suscep-
tibility of S. pneumoniae. The first9 involved 460 isolates in
winter 2000 and 485 isolates in winter 2003 in Athens, all being
colonizers of the nasopharynx. The second10 reported 780 iso-
lates colonizing the nasopharynx of children ,6 years old in
day-care centres and 89 isolates from patients with lower respir-
atory tract infection. The MIC90 of moxifloxacin for all isolates,
comprising both penicillin-susceptible and penicillin-resistant
isolates, was 0.25 mg/L. The MIC90 for Neisseria meningitidis
is reported to be 0.008 mg/L.11 As a consequence, it may
be hypothesized that the CSF concentration/MIC90 ratio for
S. pneumoniae is almost 16 and for N. meningitidis almost 500
when applying the greatest concentrations of moxifloxacin
achieved in CSF in the present study. In the same context, the
MIC90 for methicillin-resistant Staphylococcus aureus is
reported to be 0.5 mg/L,12 yielding a respective ratio of 8. These
calculations propose that moxifloxacin may be an adequate
alternative either for the management of community-acquired
CNS infections or even for chemoprophylaxis in neurosurgery.
Pharmacodynamics of fluoroquinolones is generally
expressed by the AUC/MIC ratio.13 AUC in the CSF cannot be
calculated in the present study because one single sample was
drawn from each patient. Repeated CSF sampling can only be
performed in patients having external ventriculostomies, which
has been described only for b-lactams in critically ill patients
with meningitis.14,15 CSF sampled 2 and 6 h after drug intake
possessed a significant bactericidal effect on S. pneumoniae.
This finding is consistent with the high ratios of CSF concen-
tration/MIC90 calculated above and renders the hypothesis for a
role of moxifloxacin in CNS infections favourable.
Only one study has been published on the bactericidal
activity of moxifloxacin against both penicillin-susceptible and
penicillin-resistant S. pneumoniae.16 Serum collected from 12
healthy volunteers after administration of a 3 day oral regimen
of moxifloxacin was used. Mean serum bactericidal activity was
32. Taking into account that CSF levels in the present study
were almost half those of serum, it may be postulated that
reported results on the serum bactericidal activity of moxifloxa-
cin are in line with those reported here for CSF. Estimation of
bactericidal activity presents, however, certain limitations that
may be summarized as follows: (i) the time interval between
drug administration and fluid sampling; (ii) the size of the
applied inoculum; and (iii) the applied diluent.17
Concentrations of moxifloxacin in CSF in humans were
assessed in the present study in a setting of absence of menin-
geal inflammation. Previous experimental studies of meningitis
in rabbits caused by S. pneumoniae and E. coli revealed that
penetration of moxifloxacin was very satisfactory through the
inflamed meninges,5,6 reaching concentrations equal to those
reported here. As a consequence, it may be hypothesized that in
the event of meningitis in humans, concentrations of moxifloxa-
cin in CSF could be even higher.
The presented results revealed that oral intake of 400 mg of
moxifloxacin is accompanied by good penetration through
healthy meninges within 2 –6 h post-dose and reached
1330
adequately high levels in human CSF exerting satisfactory
bactericidal activity against penicillin-resistant S. pneumoniae.
Although studies with a larger number of patients may seem
mandatory, these results render novel perspectives for a role of
moxifloxacin in CNS infections.
Funding
The study was funded by Bayer-Hellas S.A.-Primary Care.
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Transparency declarations
None to declare.
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