Antibiotic-induced vitamin K deficiency and the role of the presence of intestinal flora.

Cephalosporin antibiotics with N-methyl-thio-tetrazole (NMTT) side chains have been known to be associated with the development of hypoprothrombinemia. However, it has not been fully established whether these symptoms are induced by an inhibition of vitamin K production by intestinal microorganisms or by an inhibitory action of these antibiotics on endogenous vitamin K metabolism. Therefore, an attempt has been made to clarify the above-mentioned ambiguity by using germfree mice in which primary vitamin K deficiency can be established within a short experimental period. Germfree (GF) and conventional (CV) ICR male mice, 8-13 weeks old were used in this experiment. Vitamin K deficient (Def) and menaquinone-4 supplemented diet (MK-4) were fed to the mice in both rearing conditions. In the antibiotic-treated group, sodium latamoxef (LMOX, 300 mg/kg B.W./day) was intraperitoneally administered once a day, and in the control group the same volume of saline (Saline) was administered. Severe vitamin K deficient symptoms were observed in the GF-K-Def-LMOX group, and both prothrombin time (PT) and activated-partial thromboplastin time (APTT) values were prolonged on the 8th day of the experimental period compared with the GF-K-Def-Saline group. Furthermore the mortality rate of GF-K-Def-LMOX group was comparatively higher than that of the Saline group. This study has provided evidence that vitamin K deficiency is amplified by an administration of LMOX even in the absence of intestinal flora.

Vitamin K-reversible hypoprothrombinemia in rats: comparison of hypoprothrombinemic changes in various strains of rats caused by vitamin K deficiency and antibiotic treatment.

Hypoprothrombinemic changes were compared in rats fed various vitamin K-deficient diets. Changes such as prolongation of prothrombin time and activated partial thromboplastin time, decrease in plasma levels of prothrombin and clotting factor VII, and increase in plasma descarboxyprothrombin, appeared in rats maintained on vitamin K-deficient diet, but in rats on ordinary diet (vitamin K-sufficient diet). As the development of hypoprothrombinemia was not significantly different among animals fed various vitamin K-deficient diets, the blood coagulation parameters were concluded to be regulated only by the vitamin K level. Following the development of hypoprothrombinemia, hemorrhaging in various organs was detected in vitamin K-deficient rats, with strain differences in the severity of hemorrhage; Fischer and Wistar strains were more sensitive than the Sprague Dawley strain. Administration of a beta-lactam antibiotic, latamoxef (LMOX), to vitamin K-deficient rats led to enhancement of the hypoprothrombinemic conditions, but LMOX-associated changes in plasma enzyme levels were not detected.

Depression of liver microsomal vitamin K epoxide reductase activity associated with antibiotic-induced coagulopathy.

Hypoprothrombinemic changes in blood coagulation parameters, such as prolongation of prothrombin time, increase in the level of plasma protein induced by vitamin K absence, and decrease in plasma prothrombin level, were detected in rats fed a vitamin K-deficient diet. These changes were enhanced by the administration of beta-lactam antibiotics containing N-methyltetrazolethiol, thiadiazolethiol or methyl-thiadiazolethiol. Microsomal vitamin K epoxide reductase activity was suppressed with the maximum effect at 1-2 days after the treatment and with recovery, thereafter, gradually to the normal level after 5-7 days. Hypoprothrombinemic alterations in blood coagulation parameters following a single administration of antibiotic to vitamin K-deficient rats were somewhat delayed compared with the change in the epoxide reductase activity, but the effects of the antibiotic on both blood coagulation parameters and the enzyme activity disappeared completely 7 days after the antibiotic treatment. Antibiotic-induced depression of the epoxide reductase activity was observed even in the vitamin K sufficient rats, although the hypoprothrombinemic changes in the blood coagulation parameters did not develop. Vitamin K administration could normalize the blood coagulation parameters in the hypoprothrombinemic rats caused by treatment with the antibiotics but without recovery of the decreased epoxide reductase activity. These results suggest that some antibiotics inhibit liver microsomal vitamin K epoxide reductase, which causes hypoprothrombinemia to develop under vitamin K-deficient conditions.

Vitamin K reversible hypoprothrombinemia in rats. II. Efficacy of vitamin K on latamoxef-induced coagulopathy in rats.

Feeding of a vitamin K-deficient diet caused the development of hypoprothrombinemic changes in rats such as prolongation of prothrombin time (PT) and activated partial thromboplastin time (APTT), decreases in plasma prothrombin and clotting factor VII levels, and an increase in the descarboxyprothrombin (PIVKA) level in both plasma and liver. Successive administrations of latamoxef (LMOX) to the vitamin K-deficient rats resulted in the further enhancement of these changes. After the development of hypoprothrombinemia with LMOX, a single subcutaneous injection of vitamin K1 normalized most of these abnormalities in blood coagulation parameters within 6 hr. When vitamin K was given at 200 micrograms/kg, PT, APTT and the plasma PIVKA level showed normal values for at least 8 days even when the animals were fed a vitamin K-deficient diet and treated with LMOX during the recovery period. The amount of vitamin K required to maintain most of the blood coagulation parameters in the normal range was about 3 micrograms/kg/day. The plasma level of vitamin K was higher than 0.3-0.5 ng/ml when the blood coagulation parameters were maintained in the normal range.

Studies on the nephrotoxicity of aminoglycoside antibiotics and protection from these effects. (5). Interaction of tobramycin with latamoxef in vitro.

Interaction of tobramycin (TOB) with latamoxef (LMOX) was studied in vitro. Solutions containing TOB alone, LMOX alone or both of these compounds in varying molar ratios (TOB:LMOX = 1:1, 1:2, 1:4 and 2:1) were incubated at 37 degrees C for 0.5, 1, 3 and 5 h after adjusting to pH 7.4. Aliquots sampled at a suitable time were subjected to paper electrophoresis (PE) and thin layer chromatography (TLC). In PE, the spots of TOB and LMOX were observed as single spots on the cathode and anode sides, respectively. However, the spot associated with TOB overlapped with that associated with LMOX on the cathode side when aliquots of the solution containing both TOB and LMOX were analyzed. It seemed that the degree of overlapping became stronger with an increase in incubation time, and there were no spots corresponding to TOB alone in the mixture of TOB-LMOX (1:4). TLC analysis showed that the spot of LMOX radiated fluorescence with Rf value 0.38. On the other hand, in the mixtures, there was a definite decrease in fluorescence of LMOX at the position of Rf value 0.38, compared with that of LMOX alone. Furthermore, the spot associated with LMOX, which overlapped with that associated with TOB, also appeared at the origin on the TLC plate. The ultraviolet spectrum of the mixture of TOB-LMOX (1:2) showed a decrease in the intensity of absorption of LMOX at 268 nm. These interactions between TOB and LMOX were also observed in rat serum and its filtrate in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cefonicid and other cephalosporin antibiotics on male sexual development in rats.

The purpose of this study was to determine whether cefonicid, a cephalosporin antibiotic with a modified N-methylthiotetrazole (MTT) side chain, caused testicular toxicity when subcutaneously administered to Sprague-Dawley male rats from days 6 to 36 postpartum at doses of 50 to 1,000 mg/kg per day. Moxalactam (a cephamycin antibiotic which will be referred to as a cephalosporin for convenience throughout), which contains the MTT side chain, was used as a positive control and was administered at 100 to 1,000 mg/kg per day, and cephalothin, which lacks an MTT side chain, was used as the negative control at 1,000 mg/kg per day. Moxalactam caused a significant reduction in testicular and seminal vesicle weights in 37-day-old animals, and histological examination revealed bilateral multifocal atrophy of the seminiferous tubules at all dose levels. Animals reared to reproductive maturity had significant deficits in fertility, and histological examination revealed multifocal or diffuse atrophy of the seminiferous tubules at all doses with a severity greater than that observed in the 37-day-old animals. The histological findings were confirmed by marked reductions in testicular sperm production rates and cauda epididymal sperm numbers. Cephalothin and cefonicid had no treatment-related adverse effects on the sexual maturation of prepubertal, juvenile, or adult males. The absence (in cephalothin) or modification (in cefonicid) of the MTT side chain was not associated with adverse reproductive effects. The relevance of these findings to humans in prenatal and prepubertal stages of life cannot be determined at this time.

Effect of the topical application of some newer antibiotics on the cerebral cortex.

Five currently used antibiotics--moxalactam, cefotaxime, cefoperazone, metronidazole, and piperacillin--and bacitracin were compared for epileptogenetic effect against penicillin G as a standard when applied directly to cat cerebral cortex. Piperacillin was half as epileptogenic as penicillin. Moxalactam, cefotaxime, and cefoperazone showed epileptogenicity one-fourth to one-eighth that of penicillin on a milligram per cubic centimetre basis. Neither metronidazole nor bacitracin produced any focal seizure activity at the highest concentrations tested. Some of the newer cephalosporin antibiotics may have a significant risk of inducing seizure activity if high concentrations come in direct contact with neocortical tissue.

Studies on the nephrotoxicity of aminoglycoside antibiotics and protection from these effects (4). Effects of tobramycin alone and in combination with latamoxef on the stability of rat kidney lysosomal membranes.

Effects of tobramycin (TOB) alone and in combination with latamoxef (LMOX) on the stability of rat kidney lysosomal membranes were investigated. Rats were injected with doses of TOB (90 mg/kg/day, s.c.) alone. LMOX (2,000 mg/kg/day, s.c.) alone or TOB (90 mg/kg/day, s.c.) and LMOX (2,000 mg/kg/day, s.c.) for 5 consecutive days. The rat kidney lysosomes were isolated on the 1st, 3rd and 5th days and incubated in a 0.25 M sucrose solution containing 1 mM EDTA (pH 7.0) at 37 degrees C for 20 min. After incubation, the activity of N-acetyl-beta-D-glucosaminidase (NAG) released from lysosomes was measured, and the percent NAG release was calculated as an index of the stability of lysosomal membranes. The percent releases of NAG from lysosomes of TOB alone-treated rats were 40 and 50% greater than those of normal rats on the 1st and 3rd days, respectively. On the other hand, treatment with TOB and LMOX suppressed the NAG release from lysosomes with TOB alone by about 80 to 100%. There were insignificant slight increases in the percent NAG release in LMOX alone-treated rats on the 3rd and 5th days. In addition, the in vitro study indicated that incubation of the lysosomal fraction from kidneys of normal rats with TOB (30 micrograms/ml) significantly increased the NAG release, compared with that of the non-treated lysosomal fraction. However, the preincubated mixture of TOB (30 micrograms/ml) and LMOX (50 micrograms/ml) in vitro significantly suppressed the release of NAG from lysosomes by 85%. These results suggest that the suppression of the releases of NAG from lysosomes by the combination of TOB with LMOX may contribute to the protective effect of LMOX against TOB nephrotoxicity.

Moxalactam retinal toxicity.

Moxalactam disodium is a new third-generation semisynthetic, broad-spectrum, cephalosporin-like antibiotic for parenteral administration. Topical, subconjunctival, and intravenous administration provide poor concentration in the vitreous. To determine its toxicity in intravitreal administration, we injected comparative doses directly into the vitreous cavity of 21 rabbits. With doses of 1.25 mg or less there was no toxic damage to the retina. With a dose of 2.5 mg, early degeneration of photoreceptors was seen after three months. With higher doses (5 and 10 mg) there were major histopathologic and electroretinographic changes. These results suggest the feasibility of employing moxalactam in the treatment of acute, severe, fulminant bacterial endophthalmitis.

Production of hypoprothrombinemia by moxalactam and 1-methyl-5-thiotetrazole in rats.

To determine whether the hypoprothrombinemia associated with antibiotics containing a 1-methyl-5-thiotetrazole (MTT) group is a result of the presence of the MTT group, rats were maintained on a vitamin K-deficient diet for 10 days and then received either intravenous moxalactam or cefotaxime or oral MTT for two additional days. MTT and moxalactam, which contains the MTT group, prolonged prothrombin time. Cefotaxime, which lacks the MTT group, had no effect.

Evaluation of lamoxactam in the treatment of severe bacterial infections.

We investigated the clinical efficiency and safety of lamoxactam for treatment of 28 episodes of infection in 26 adult patients (15 males and 11 females) whose ages ranged from 17 to 83 years (mean 48.7). 4 patients had 'ultimately fatal diseases' and the remaining 22 had 'nonfatal diseases'. The clinical condition at the beginning of treatment was 'critical' or 'poor' in 15 cases. Episodes of infection treated were: 14 intraabdominal, 9 bacteremia, 5 nephro-urinary, 3 osteomyelitis, and a miscellaneous group including pneumonia, soft tissue, parameningeal focus and infected V-P shunt. A total of 34 microorganisms were responsible for 25 episodes of infection. 15 and 10 episodes were mono- and polymicrobial, respectively. Isolated microorganisms included 13 aerobic facultative gram-negative bacillus, 5 facultative gram-positive cocci, and 16 anaerobes. Total dosage of lamoxactam administered by patient ranged from 24 to 234 g (mean 57.6 g), and mean duration of therapy was 15.2 days (range 8-42 days). The overall rate of clinical response to lamoxactam was excellent, amounting to 84% of episodes and 91% of patients. Local and general tolerance was good, and lamoxactam had to be discontinued only once during therapy due to an episode of neutropenia. Enterococcal colonization (5 of 26 patients, 19%) and superinfections (3 of 26 cases, 11.5%) were undesirably frequent in our patients. Lamoxactam seems to be an effective and safe single-agent therapy for many bacterial infections. The possibility of enterococcal colonization and superinfections should be monitored, specially in patients with urinary or intraabdominal infections.