E. Bergogne-Berezin, G. Berthelot, H. Kale, C. Morel
Penetration of Ampicillin into Human Bronchial Secretions Summary: Ampicillin concentrations in serum and bronchial secretions after oral administration of bacampicillin were evaluated. Twenty-eight hospitalized patients with acute bronchopulmonary infections received a single dose of 800 mg of bacampicillin. Samples of bronchial secretions were obtained during diagnostic' bronchoscopy and blood samples were drawn simultaneously. Significant concentrations of ampicillin were found in bronchial secretions, the peak level, reached after approximately two hours, being 0.27 ~tg/ml on an average, The penetration of ampicillin into the bronchial secretions after the administration of bacampicitlin could be correlated with the degree of bronchial inflammation, as illustrated either by macroscopic purulence or protein concentration in the secretions. The results suggest that bacampicillin is a useful drug in acute bronchopulmonary infections. Zusammenfassung: Penetration yon Ampicillin in das Bronchialsekret beim Menschen. Die Ampicillinkonzentrationen im Serum und im Bronchialsekret wurden nach oraler Gabe von Bacampicillin bestimmt. Achtundzwanzig hospitalisierte Patienten mit akuten bronchopulmonalen Infektionen erhielten eine Einzeldosis von 800 mg Bacampicillin. Proben yon Bronchialsekret wurden w~ihrend einer diagnostischen Bronchoskopie gewonnen, gleichzeitig wurden Blutproben abgenommen. In den Bronchialsekreten wurden signifikante Ampicillinkonzentrationen gefunden; der Spitzenspiegel der nach etwa zwei Stunden erreicht wurde, betrug dabei im Mittel 0,27 ~tg/mt. Die Penetration yon Ampicitlin in das Bronchialsekret nach Gabe von Bacampicillin scbien mit dem Grad der bronchialen Entztindung korreliert zu sein, der an der makroskopisch erkennbaren Purulenz oder der Eiweil3konzentration des Sekrets bemessen wurde. Die Ergebnisse lassen annehmen, dab Bacampicillin ein geeignetes Medikament zur Behandlung yon akuten bronchopulmonalen Infektionen darstellt. Introduction
Bacampicillin, a new type of hydrolyzable ester of ampicillin, is rapidly transformed in vivo to ampicillin (1). Bacampicillin releases ampicillin during the absorption process in the gastrointestinal tract. The rapid and high peak serum concentrations obtained warrant a good penetration of the drug into body-fluids and tissues. T h e penetration of active drug into the site of infection is of primary importance for the o u t c o m e of the t r e a t m e n t of bacterial b r o n c h o p u l m o nary infections. The penetration of antibiotics into the tissues of the b r o n c h o p u l m o n a r y tract can be illustrated by the concentrations of active drug as m e a s u r e d in bronchial secretions (2, 3). Experience shows that the concentrations in bronchial secretions vary b e t w e e n and even within different groups of antibiotics (4, 5). A s penicillins are often used for the t r e a t m e n t of b r o n c h o p u l m o n a r y infections, we d e e m e d it interesting to study the penetration of ampicillin into bronchial secretions after administration of the new ampicillin derivative bacampicillin. In order to evaluate the degree of bronchial inflammation and its possible correlation with the drug concentrations, two criteria of inflammation were used: the macroscopic purulence and the con-
centration of proteins in same samples of bronchial secretions. Materials and M e t h o d s
Patients: Twenty-eight hospitalized patients with acute bronchopulmonary infections such as pneumonia and bronchitis were given a single oral dose of 800 mg of bacampicillin. Because of underlying diseases such as lung cancer, all patients underwent diagnostic bronchoscopy. Samples: Blood samples were drawn 0.5, 1, 2, 3 and 4 hours after administration of bacampiciUin, and samples of bronchial secretions were obtained during bronchoscopy after 2 and 4 hours. Macroscopic purulence and the concentration of protein in the bronchial secretions were estimated immediately. All samples for microbiological assay were however stored at - 20°C until analyzed. Macroscopic purulence was evaluated according to the following rating scale as described by May (6): (+) = 25% purulence (+ +) = 50% purulence ( + + + ) = 75% purulence ( + + + + ) = 1 0 0 % purulence The protein concentration was measured by the use of sulfosalieytic acid (Exton reagent). Microbiological assay: The bronchial secretions were rendered more fluid by addition of Digest Eur after defreezing, allowing better diffusion of antibiotic in the culture medium. Assays were done by the z[gar diffusion method as described by Grove and Randall (7). Oxoid Antibiotic Medium 2 (pH 6.6) was used as test medium and Bacillus subtilis IP 5832 as test organism. Steel cylinders were used as wells for the test samples and standard dilutions. An ampicillin standard in horse serum in a two-fold dilution series ranging from 0.03 to 64 ~tg/ml was run parallell to the test samples, both test samples and standard being run in quadruplicate and allotted to random positions on the assay plate. After overnight incubation at 37°C, the zone diameters were measured and the ampicillin concentrations estimated by plotting against the standard curve. Results
The ampicillin concentrations obtained in serum and bronchial secretions at various times after the administration of 800 mg of bacampicillin are given in Table 1. The peak serum level, occurring half-an-hour after administration, averaged 8 lag/ml, whereas the m a x i m u m concentration in bronchial secretions was 0.27 ~tg/ml on an average and was seen two hours after administration of the drug. The bronchial secretion/serum concentration ratio increased f r o m 2.5 to 6.0 per cent b e t w e e n 1-1.5 and 3--4 hours after administration. Individual values for findings in the bronchial secretions, i. e. macroscopic purulence, proProf. E. Bergogne-Berezin, Dr. G. Berthelot, Dr. H. Kale, Department of Microbiology, H6spital BICHAT, 170 Boulevard Ney, 75 877 Paris Cedex 18, France; Dr. C. Morel, Department of Microbiology C. H. R. Caen, Avenue Georges Clemenceau, 14 033 Caen Cedex, France.
Infection 7 (1979) Suppl. 5
S 463
E, Bergogne-Berezin et al,: Penetration of Ampicitlin into Bronchial Secretions Table t:Ampiciltin concentrations (gg/ml)in serum andbronchial secretions. Hours after administration
Serum
0.5 1-1.5 2-2.5 3-4
Mean
Range
8.0 5.9 4.0 2.0
4.0 -10.0 2.0 -16.0 1.5 - 9.0 0.95-4,0
Bronchial secretions Mean Range 0.15 0.27 0.13
Ratio* B/S
0.06-0.33 2.5% 0.06-0.62 5.5% 0.0~0.286.0%
* Ratio between the concentrations in serum and bronchial secretions.
Table 2: Findings in bronchial secretions.
Purulence + + + + + + + + + + + + + + + + + +
+ + + + + +
+ + + + +
+ + + + +
+ + + +
+ + + +
Protein concentration (g/l)
Ampicillin concent-ration (gg/ml)
1.0 0.8 1.4 0.20 1.0 O.20 0.20
0.125 0.125 0.125 0.06 0.06 0.125 0.125
0.25 0.55 1,9 1.0 0.4 1.0
0.25 0.06 0,06 0,06 0.28 0.06
3.4 1.0 5.8 6.7 7.0
0.125 0.06 0.21 0.28 0,06
9.4 7.0
0.25 0.21
t e i n c o n c e n t r a t i o n s a n d ampicillin c o n c e n t r a t i o n s are s h o w n in T a b l e 2. A s c a n b e seen f r o m t h e table, t h e dispersion of t h e ampicillin c o n c e n t r a t i o n s is r a t h e r wide with v a r y i n g d e g r e e s of b r o n c h i a l i n f l a m m a t i o n as illust r a t e d by p u r u l e n c e a n d p r o t e i n c o n t e n t of t h e secretions. A t r e n d t o w a r d s h i g h e r ampicillin c o n c e n t r a t i o n s in cases with m o r e p r o n o u n c e d i n f l a m m a t i o n is h o w e v e r discernible.
S 464
Infection 7 (1979) Suppl. 5
Discussion
T h e m e a s u r e m e n t of ampicillin c o n c e n t r a t i o n s in i n f e c t e d b r o n c h i a l secretions a f t e r a d m i n i s t r a t i o n of b a c a m p i c i l l i n s h o u l d give r e l e v a n t i n f o r m a t i o n for t h e r a p y with this n e w p r o - d r u g in b r o n c h o p u l m o n a r y infections. T h e m e a n levels of ampiciUin s e r u m a n d b r o n c h i a l secretions f o u n d in this s t u d y after t h e a d m i n i s t r a t i o n of 800 m g of b a c a m p i c i l l i n w e r e c o n s i d e r a b l y h i g h e r c o m p a r e d with t h o s e a t t a i n e d after a dose of 1 g of ampicillin in a n earlier study (4). T h i s difference c a n b e e x p l a i n e d b y t h e fact t h a t bacampicillin is m o r e lipophilic t h a n ampicillin, thus b e i n g m o r e rapidly a n d c o m p l e t e l y a b s o r b e d (1). It is weil k n o w n t h a t t h e p a s s a g e of antibiotics t h r o u g h t h e b l o o d - b r o n c h o / a l v e o l a r b a r r i e r is e n h a n c e d d u r i n g inflamm a t i o n (5). This study also shows t h a t t h e antibiotic p e n e t r a t i o n after bacampicillin a d m i n i s t r a t i o n is i n c r e a s e d as m u c h with a h i g h d e g r e e of p u r u l e n c e as w i t h high c o n c e n t r a t i o n s of p r o t e i n in t h e b r o n c h i a l secretions, a fact w h i c h m a y b e of i m p o r t a n c e for t h e t h e r a p e u t i c o u t c o m e . T h e ampieillin c o n c e n t r a t i o n s a t t a i n e d in b r o n c h i a l secretions in o u r study s e e m a d e q u a t e to inhibit t h e most c u r r e n t p a t h o g e n i c bacteria, e . g . g r a m positive cocci a n d n o n p e n i c i l l i n a s e - f o r m i n g Haemophilus influenzae.
Literature 1. Bodin, iV. 0., EkstrOm, B., Forsgren, U., Jalar, L. P., Ramsay, C. H., Magni, L., Sjrberg, B.: Bacampicillin: a new orally well absorbed derivative of ampicillin. Antimicrob. Agents Chemother. 8 (1975) 518-525. 2. Barza, M., Weinstein, L.: Penetration of antibiotics into fibrin in vivo. I-Comparison of penetration of ampicillin into fibrin clots, abscesses and "Interstitial fluid". J. Infect. Dis. (1974) 59-65. 3. May, J. R., Delves, D. M.: Treatment of chronic bronchitis with ampicillin. Some pharmacological observations. Lancet I (1965) 929-933. 4. Bergogne-Berezin, E., Lambert-Zechovsky, N., Kale, H.: Etude pharmacocinrtique comparative de divers antibiotiques darts les srcrrtions bronchiques. Med. Mal. Infect. 6 (1976) 4 134-137. 5. Pennington, J. E.: Kinetics of penetration and clearance of antibiotics in respiratory secretions: In: Kirkpatriek, C. H., Reynolds, H. Y. (ed): Immunologic and infectious reactions in the lung. Marcel Dekker Inc., New York, 1976. 6. May, J. R., May, D. S.: Bacteriology of sputum in chronic bronchitis. Tubercle 44 (1963) 162. 7. Grove, D. C., Randall, W. A.: Assay methods of antibiotics. Medical Encyclopedia, New York, 1955.
Penetration of Ampicillin into Human Bronchial Secretions Summary: Ampicillin concentrations in serum and bronchial secretions after oral administration of bacampicillin were evaluated. Twenty-eight hospitalized patients with acute bronchopulmonary infections received a single dose of 800 mg of bacampicillin. Samples of bronchial secretions were obtained during diagnostic' bronchoscopy and blood samples were drawn simultaneously. Significant concentrations of ampicillin were found in bronchial secretions, the peak level, reached after approximately two hours, being 0.27 ~tg/ml on an average, The penetration of ampicillin into the bronchial secretions after the administration of bacampicitlin could be correlated with the degree of bronchial inflammation, as illustrated either by macroscopic purulence or protein concentration in the secretions. The results suggest that bacampicillin is a useful drug in acute bronchopulmonary infections. Zusammenfassung: Penetration yon Ampicillin in das Bronchialsekret beim Menschen. Die Ampicillinkonzentrationen im Serum und im Bronchialsekret wurden nach oraler Gabe von Bacampicillin bestimmt. Achtundzwanzig hospitalisierte Patienten mit akuten bronchopulmonalen Infektionen erhielten eine Einzeldosis von 800 mg Bacampicillin. Proben yon Bronchialsekret wurden w~ihrend einer diagnostischen Bronchoskopie gewonnen, gleichzeitig wurden Blutproben abgenommen. In den Bronchialsekreten wurden signifikante Ampicillinkonzentrationen gefunden; der Spitzenspiegel der nach etwa zwei Stunden erreicht wurde, betrug dabei im Mittel 0,27 ~tg/mt. Die Penetration yon Ampicitlin in das Bronchialsekret nach Gabe von Bacampicillin scbien mit dem Grad der bronchialen Entztindung korreliert zu sein, der an der makroskopisch erkennbaren Purulenz oder der Eiweil3konzentration des Sekrets bemessen wurde. Die Ergebnisse lassen annehmen, dab Bacampicillin ein geeignetes Medikament zur Behandlung yon akuten bronchopulmonalen Infektionen darstellt. Introduction
Bacampicillin, a new type of hydrolyzable ester of ampicillin, is rapidly transformed in vivo to ampicillin (1). Bacampicillin releases ampicillin during the absorption process in the gastrointestinal tract. The rapid and high peak serum concentrations obtained warrant a good penetration of the drug into body-fluids and tissues. T h e penetration of active drug into the site of infection is of primary importance for the o u t c o m e of the t r e a t m e n t of bacterial b r o n c h o p u l m o nary infections. The penetration of antibiotics into the tissues of the b r o n c h o p u l m o n a r y tract can be illustrated by the concentrations of active drug as m e a s u r e d in bronchial secretions (2, 3). Experience shows that the concentrations in bronchial secretions vary b e t w e e n and even within different groups of antibiotics (4, 5). A s penicillins are often used for the t r e a t m e n t of b r o n c h o p u l m o n a r y infections, we d e e m e d it interesting to study the penetration of ampicillin into bronchial secretions after administration of the new ampicillin derivative bacampicillin. In order to evaluate the degree of bronchial inflammation and its possible correlation with the drug concentrations, two criteria of inflammation were used: the macroscopic purulence and the con-
centration of proteins in same samples of bronchial secretions. Materials and M e t h o d s
Patients: Twenty-eight hospitalized patients with acute bronchopulmonary infections such as pneumonia and bronchitis were given a single oral dose of 800 mg of bacampicillin. Because of underlying diseases such as lung cancer, all patients underwent diagnostic bronchoscopy. Samples: Blood samples were drawn 0.5, 1, 2, 3 and 4 hours after administration of bacampiciUin, and samples of bronchial secretions were obtained during bronchoscopy after 2 and 4 hours. Macroscopic purulence and the concentration of protein in the bronchial secretions were estimated immediately. All samples for microbiological assay were however stored at - 20°C until analyzed. Macroscopic purulence was evaluated according to the following rating scale as described by May (6): (+) = 25% purulence (+ +) = 50% purulence ( + + + ) = 75% purulence ( + + + + ) = 1 0 0 % purulence The protein concentration was measured by the use of sulfosalieytic acid (Exton reagent). Microbiological assay: The bronchial secretions were rendered more fluid by addition of Digest Eur after defreezing, allowing better diffusion of antibiotic in the culture medium. Assays were done by the z[gar diffusion method as described by Grove and Randall (7). Oxoid Antibiotic Medium 2 (pH 6.6) was used as test medium and Bacillus subtilis IP 5832 as test organism. Steel cylinders were used as wells for the test samples and standard dilutions. An ampicillin standard in horse serum in a two-fold dilution series ranging from 0.03 to 64 ~tg/ml was run parallell to the test samples, both test samples and standard being run in quadruplicate and allotted to random positions on the assay plate. After overnight incubation at 37°C, the zone diameters were measured and the ampicillin concentrations estimated by plotting against the standard curve. Results
The ampicillin concentrations obtained in serum and bronchial secretions at various times after the administration of 800 mg of bacampicillin are given in Table 1. The peak serum level, occurring half-an-hour after administration, averaged 8 lag/ml, whereas the m a x i m u m concentration in bronchial secretions was 0.27 ~tg/ml on an average and was seen two hours after administration of the drug. The bronchial secretion/serum concentration ratio increased f r o m 2.5 to 6.0 per cent b e t w e e n 1-1.5 and 3--4 hours after administration. Individual values for findings in the bronchial secretions, i. e. macroscopic purulence, proProf. E. Bergogne-Berezin, Dr. G. Berthelot, Dr. H. Kale, Department of Microbiology, H6spital BICHAT, 170 Boulevard Ney, 75 877 Paris Cedex 18, France; Dr. C. Morel, Department of Microbiology C. H. R. Caen, Avenue Georges Clemenceau, 14 033 Caen Cedex, France.
Infection 7 (1979) Suppl. 5
S 463
E, Bergogne-Berezin et al,: Penetration of Ampicitlin into Bronchial Secretions Table t:Ampiciltin concentrations (gg/ml)in serum andbronchial secretions. Hours after administration
Serum
0.5 1-1.5 2-2.5 3-4
Mean
Range
8.0 5.9 4.0 2.0
4.0 -10.0 2.0 -16.0 1.5 - 9.0 0.95-4,0
Bronchial secretions Mean Range 0.15 0.27 0.13
Ratio* B/S
0.06-0.33 2.5% 0.06-0.62 5.5% 0.0~0.286.0%
* Ratio between the concentrations in serum and bronchial secretions.
Table 2: Findings in bronchial secretions.
Purulence + + + + + + + + + + + + + + + + + +
+ + + + + +
+ + + + +
+ + + + +
+ + + +
+ + + +
Protein concentration (g/l)
Ampicillin concent-ration (gg/ml)
1.0 0.8 1.4 0.20 1.0 O.20 0.20
0.125 0.125 0.125 0.06 0.06 0.125 0.125
0.25 0.55 1,9 1.0 0.4 1.0
0.25 0.06 0,06 0,06 0.28 0.06
3.4 1.0 5.8 6.7 7.0
0.125 0.06 0.21 0.28 0,06
9.4 7.0
0.25 0.21
t e i n c o n c e n t r a t i o n s a n d ampicillin c o n c e n t r a t i o n s are s h o w n in T a b l e 2. A s c a n b e seen f r o m t h e table, t h e dispersion of t h e ampicillin c o n c e n t r a t i o n s is r a t h e r wide with v a r y i n g d e g r e e s of b r o n c h i a l i n f l a m m a t i o n as illust r a t e d by p u r u l e n c e a n d p r o t e i n c o n t e n t of t h e secretions. A t r e n d t o w a r d s h i g h e r ampicillin c o n c e n t r a t i o n s in cases with m o r e p r o n o u n c e d i n f l a m m a t i o n is h o w e v e r discernible.
S 464
Infection 7 (1979) Suppl. 5
Discussion
T h e m e a s u r e m e n t of ampicillin c o n c e n t r a t i o n s in i n f e c t e d b r o n c h i a l secretions a f t e r a d m i n i s t r a t i o n of b a c a m p i c i l l i n s h o u l d give r e l e v a n t i n f o r m a t i o n for t h e r a p y with this n e w p r o - d r u g in b r o n c h o p u l m o n a r y infections. T h e m e a n levels of ampiciUin s e r u m a n d b r o n c h i a l secretions f o u n d in this s t u d y after t h e a d m i n i s t r a t i o n of 800 m g of b a c a m p i c i l l i n w e r e c o n s i d e r a b l y h i g h e r c o m p a r e d with t h o s e a t t a i n e d after a dose of 1 g of ampicillin in a n earlier study (4). T h i s difference c a n b e e x p l a i n e d b y t h e fact t h a t bacampicillin is m o r e lipophilic t h a n ampicillin, thus b e i n g m o r e rapidly a n d c o m p l e t e l y a b s o r b e d (1). It is weil k n o w n t h a t t h e p a s s a g e of antibiotics t h r o u g h t h e b l o o d - b r o n c h o / a l v e o l a r b a r r i e r is e n h a n c e d d u r i n g inflamm a t i o n (5). This study also shows t h a t t h e antibiotic p e n e t r a t i o n after bacampicillin a d m i n i s t r a t i o n is i n c r e a s e d as m u c h with a h i g h d e g r e e of p u r u l e n c e as w i t h high c o n c e n t r a t i o n s of p r o t e i n in t h e b r o n c h i a l secretions, a fact w h i c h m a y b e of i m p o r t a n c e for t h e t h e r a p e u t i c o u t c o m e . T h e ampieillin c o n c e n t r a t i o n s a t t a i n e d in b r o n c h i a l secretions in o u r study s e e m a d e q u a t e to inhibit t h e most c u r r e n t p a t h o g e n i c bacteria, e . g . g r a m positive cocci a n d n o n p e n i c i l l i n a s e - f o r m i n g Haemophilus influenzae.
Literature 1. Bodin, iV. 0., EkstrOm, B., Forsgren, U., Jalar, L. P., Ramsay, C. H., Magni, L., Sjrberg, B.: Bacampicillin: a new orally well absorbed derivative of ampicillin. Antimicrob. Agents Chemother. 8 (1975) 518-525. 2. Barza, M., Weinstein, L.: Penetration of antibiotics into fibrin in vivo. I-Comparison of penetration of ampicillin into fibrin clots, abscesses and "Interstitial fluid". J. Infect. Dis. (1974) 59-65. 3. May, J. R., Delves, D. M.: Treatment of chronic bronchitis with ampicillin. Some pharmacological observations. Lancet I (1965) 929-933. 4. Bergogne-Berezin, E., Lambert-Zechovsky, N., Kale, H.: Etude pharmacocinrtique comparative de divers antibiotiques darts les srcrrtions bronchiques. Med. Mal. Infect. 6 (1976) 4 134-137. 5. Pennington, J. E.: Kinetics of penetration and clearance of antibiotics in respiratory secretions: In: Kirkpatriek, C. H., Reynolds, H. Y. (ed): Immunologic and infectious reactions in the lung. Marcel Dekker Inc., New York, 1976. 6. May, J. R., May, D. S.: Bacteriology of sputum in chronic bronchitis. Tubercle 44 (1963) 162. 7. Grove, D. C., Randall, W. A.: Assay methods of antibiotics. Medical Encyclopedia, New York, 1955.
