Rebamipide is a mucoprotective agent commonly used to prevent nonsteriodal anti-inflammatory drug-induced gastrointenstinal side effects [1]. Human plasma and urine analysis of rebamipide utilizing high performance liquid chromatography (HPLC) have been reported [2]. Recently, we reported on the plasma levels of rebamipide in presense or absence of celecoxib or diclofenac in rats [3] using a modified HPLC method of detection developed by Jeoung et al. [4]. To tailor the method towards use in urinary rebamipide extraction and analysis, the following modifications were made:To compensate for high concentrations of rebamipide found in urine, a new rebamipide stock solution was prepared with a final concentration of 50,000 ng/mL.Rat urine calibration standards were obtained within the range of 50-1000 ng/mL and 1000-50,000 ng/mL.Plasma samples were replaced with urine samples.

Yes / Mutations in the gyrase genes cause fluoroquinolone resistance in Mycobacterium tuberculosis. However, the predictive value of these markers for clinical outcomes in patients with MDR-TB is unknown to date. The objective of this study was to determine molecular markers and breakpoints predicting second-line treatment outcomes in M. tuberculosis patients treated with fourth-generation fluoroquinolones. We analysed treatment outcome data in relation to the gyrA and gyrB sequences and MICs of ofloxacin, gatifloxacin and moxifloxacin for pretreatment M. tuberculosis isolates from 181 MDR-TB patients in Bangladesh whose isolates were susceptible to injectable drugs. The gyrA 90Val, 94Gly and 94Ala mutations were most frequent, with the highest resistance levels for 94Gly mutants. Increased pretreatment resistance levels (>2 mg/L), related to specific mutations, were associated with lower cure percentages, with no cure in patients whose isolates were resistant to gatifloxacin at 4 mg/L. Any gyrA 94 mutation, except 94Ala, predicted a significantly lower proportion of cure compared with all other gyrA mutations taken together (all non-94 mutants + 94Ala) [OR = 4.3 (95% CI 1.4-13.0)]. The difference in treatment outcome was not explained by resistance to the other drugs. Our study suggests that gyrA mutations at position 94, other than Ala, predict high-level resistance to gatifloxacin and moxifloxacin, as well as poor treatment outcome, in MDR-TB patients in whom an injectable agent is still effective.

Together with the current antibiotic resistance crisis, bacterial persistence appears to play an increasingly important role in the frequent failure of antibiotic treatments. Persister cells are rare bacteria that transiently become drug tolerant, allowing them to survive lethal concentrations of bactericidal antibiotics. Upon antibiotic removal, persister cells are able to resume growth and give rise to a new bacterial population as sensitive to the antibiotic as the original population. Interest in persister cells seriously increased in the past few years as these phenotypic variants were shown to be involved in the recalcitrance of chronic infections, such as tuberculosis and pneumonia and in the well-known biofilm tolerance to antibiotics. Persistence has therefore been extensively studied throughout the last decade, which led to the discovery of large variety of different molecular mechanisms involved in persisters formation. However, the specific physiology of bacterial persisters remains elusive up to now, mainly because of the transient nature and the low frequencies of persister cells in growing bacterial cultures. This work aims to gain a better understanding of the physiology of Escherichia coli persisters by combining population analyses with single-cell observations.In the first part of this thesis, we developed an experimental method allowing for measuring persistence with increased reproducibility. The method was further refined, which allowed us to observe four distinct phases in the ofloxacin time-kill curve, suggesting the existence of a tolerance continuum at the population level at treatment time. Characterization of these four phases notably revealed that the growth rate and the intrinsic antibiotic susceptibility of the strain define the number of surviving cells at the onset of the persistence phase, while persister cells survival mainly relies on active stress responses (SOS and stringent responses in particular).We next investigated the molecular mechanisms underlying the well-known correlation between persistence and the growth rate. Interestingly, we showed that the growth rate determines the number of survival cells at the onset of the persistent phase, whereas it does not affect the death rate of persister cells during antibiotic treatment. Furthermore, slow growth was shown to influence survival to ofloxacin independently of the replication rate, thereby suggesting that target inactivation solely cannot explain this correlation. However, our preliminary data indicate that ppGpp induction upon ofloxacin exposure substantially increases in slow growing bacterial populations, supporting a model in which slow growth would allow bacteria to respond faster to the antibiotic treatment, thereby generating more persisters than fast growing bacterial populations.Finally, both population and single-cell analyses were performed to assess the influence of the SOS response on persistence to ofloxacin. Firstly, population analyses revealed that the SOS response is required for survival of both sensitive and persister cells, but only during recovery, after ofloxacin removal, presumably allowing cells to induce SOS-dependent DNA repair pathways, required to deal with the accumulated ofloxacin-induced DNA lesions. The SOS response therefore appears as a good target for anti-persisters strategies, as shown by the 100-fold decrease in persistence upon co-treatment of a bacterial population with an SOS-inhibitor and ofloxacin. Secondly, single-cell analyses revealed that persister cells sustain similar DNA damages than sensitive cells upon ofloxacin treatment and induce SulA- and SOS-independent filamentation upon antibiotic removal, probably reflecting the presence of remaining cleaved complexes, formed during ofloxacin exposure. Importantly, we showed filamentation to occur in persister cells upon ampicillin treatment as well, thereby suggesting these filaments to be part of a more general survival pathway, which molecular basis remains unknown. / Doctorat en Sciences / info:eu-repo/semantics/nonPublished

I performed two randomised controlled trials (RCTs) to determine the best treatments for enteric fever in Kathmandu, Nepal, an area with a high proportion of nalidixic acid resistant S. Typhi and S. Paratyphi A isolates. I recruited 844 patients with suspected enteric fever to compare chloramphenicol versus gatifloxacin. 352 patients were culture confirmed. 14/175 patients treated with chloramphenicol and 12/177 patients treated with gatifloxacin experienced treatment failure (HR=0.86 (95% CI 0.40 to 1.86), p=0.70). The median times to fever clearance were 3.95 and 3.90 days, respectively (HR=1.06 [CI 0.86 to 1.32], p=0.59). The second RCT compared ofloxacin versus gatifloxacin and recruited 627 patients. Of the 170 patients infected with nalidixic acid resistant strains, the number of patients with treatment failure was 6/83 in the ofloxacin group and 5/87 in the gatifloxacin group (Hazard Ratio, HR=0.81, 95% CI 0.25 to 2.65; p=0.73); the median times to fever clearance were 4.7 and 3.3 days respectively (HR=1.59 [CI 1.16 to 2.18], p=0.004). I compared conventional blood culture against an electricity free culture approach. 66 of 304 patients with suspected enteric fever were positive for S. Typhi or S. Paratyphi A, 55 (85%) isolates were identified by the conventional blood culture and 60 (92%) isolates were identified by the experimental method. The percentages of positive and negative agreement for diagnosis of enteric fever were 90.9% and 96.0%, respectively. This electricity free blood culture system may have utility in resource-limited settings or potentially in disaster relief and refugee camps. I performed a literature review of RCTs of enteric fever which showed that trial design varied greatly. I was interested in the perspective of patients and what they regarded as cure. 1,481 patients were interviewed at the start of treatment, 860 (58%) reported that the resolution of fever would mean cure to them. At the completion of treatment, 877/1,448 (60.6%) reported that they felt cured when fever was completely gone. We suggest that fever clearance time is the best surrogate for clinical cure in patients with enteric fever and should be used as the primary outcome in future RCTs for the treatment of enteric fever.

Magister Pharmaceuticae - MPharm / Many studies have investigated the pharmacokinetics of anti-tuberculosis drugs in patients infected with tuberculosis. However, little is known about the pharmacokinetics of the drugs that are used in the treatment of multi-drug resistant tuberculosis (MDRTB).Therefore, the objective of the present study was to investigate the steady state concentrations and the pharmacokinetics of ofloxacin, one of the drugs used in the treatment of MDR-TB in patients infected with MDR-TB and patients with MDR-TB co-infected with HIV Plasma samples were drawn at different times over 24 hours after ofloxacin oral administration. For the determination of ofloxacin plasma concentrations, the liquid chromatography coupled with mass spectrometry analysis method was used.The method was validated over a concentration range of 0.1-10 μg/ml. The lower limit of ofloxacin detection was 0.05μg/ml, while the lower limit of quantification was 0.1μg/ml. The response was linear over the range used with a mean recovery of 97.6%. Ofloxacin peak was well separated at a retention time of 9.6 minutes.The pharmacokinetic parameters obtained were presented as mean ± standard deviation(SD). The peak concentration of ofloxacin (Cmax) was 4.71± 2.27 μg/ml occurred at Tmax 3±1.29 hours after ofloxacin oral administration. The mean (±SD) for the area under the concentration-time curve (AUC0-24) and the area under the concentration-time curve(AUC0-∞) were 68.8±42.61 μg/ml.hr and 91.93±76.86 μg/ml.hr, respectively. Ofloxacin distributed widely with a mean (±SD) volume of distribution (Vd) 2.77±1.16 L/kg and it was eliminated with a mean (±SD) total clearance rate of 0.27±0.25 L/hr/kg. Ofloxacin mean (±SD) half-life was 9.55± 4.69 hours and mean (±SD) of the mean residence time (MRT) was 1512± 6.59 hours.In summary, compared with the previous findings in the literature, ofloxacin pharmacokinetic was altered in MDR-TB patients with or without HIV co-infection.The AUC and Cmax were reduced, while the half-life and the time to reach the peak concentration were prolonged. This suggests that, both the rate and the extent of ofloxacin absorption were decreased. Furthermore, ofloxacin was highly eliminated in patients, which may be related to the altered liver function in this group of patients.Further studies investigating the effect of HIV, liver and kidney dysfunctions on ofloxacin pharmacokinetics are recommended in large number of patients infected with MDR-TB.in addition to the therapeutic drug monitoring to maintain the desired concentration of ofloxacin in the patients.