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[Experimental evidence for Mycobacterium tuberculosis persistence in M. tuberculosis-infected H37RV mice in the treatment with 3 first-line drugs (rifampicin, isoniazid, pyrazinamide)].

To detect Mycobacterium tuberculosis (MBT) DNA in the blood and organs of tuberculosis-infected animals treated by the standard regimen including 3 first-line drugs, to assess the cellular reactions of organs of MBT-infected mice, and to evaluate the effect of rifampicin supplemented to the Cornell treatment regimen on the occurrence of endogenous reactivation of a tuberculous process, 150 BALB/c mice were intravenously infected with the MTB H(3)7Rv strain in a dose of 2.5 x 10(4) CFU/mouse and given chemotherapy with 3 drugs: rifampicin, 12 mg/kg body weight, isoniazid, 5 mg/kg, and pyrazinamide, 35 mg/kg. On day 20 of infection 2, 4, and 6 months after treatment and 2 months after termination of 4- and 6-month courses of therapy, the authors made inoculation, impressionsmears from parenchymatous organs stained by the Romanovsky-Gimse method, and conducted polymerase chain reaction for MBT DNA in the blood and organs of mice. The results indicated that supplementation of rifampicin to the Cornell treatment regimen prevented endogenous reactivation of the process, as confirmed by negative inoculations of the organs of the mice left untreated for 2 months. However, detection of MBT DNA and the cytological picture characteristic of tuberculous inflammation in the blood and organs of mice from these groups suggested that an occult tuberculous process was preserved.

Animals↗

Penetration of isoniazid, rifampicin and pyrazinamide in tuberculous pleural effusion and psoas abscess.

SETTING: Tuberculosis Centre, University Medical Centre, Groningen, The Netherlands. OBJECTIVES: To study intralesional concentrations of isoniazid (INH), rifampicin (RMP) and pyrazinamide (PZA) in tuberculous pleural effusions and psoas abscesses, and to compare these to reference serum values and minimal inhibitory concentration (MIC). DESIGN: Intralesional concentrations were measured 2 h after drug administration (six pleural effusions, 10 psoas abscesses). RESULTS: A wide range of concentrations was found for pleural effusions and psoas abscesses. Concentrations were below MIC values in none of 15 patients for INH, in two of 13 for RMP, and in eight of nine for PZA. The Cmax:MIC ratio was always >4 for INH, in four of 13 for RMP, and in none of nine for PZA. In 5/8 patients receiving all three drugs, both RMP and PZA had Cmax:MIC ratios <4, indicating sub-therapeutic drug levels. CONCLUSION: Penetration of INH was always sufficient, penetration of RMP mostly below the desired ratio, and for PZA on average 10 times too low. Five of eight patients on all three drugs had Cmax:MIC ratios <4. This indicates intralesional sub-therapeutic drug levels for RMP and PZA, and local monotherapy with INH. This could induce drug resistance. Drainage as additional therapy seems indicated.

Adolescent↗

Rifampin plus pyrazinamide-induced hepatitis requiring hospitalization in a 30-y-old male with latent tuberculosis.

The case of a 30-y-old male with latent tuberculosis who developed chemical hepatitis requiring hospitalization after 50 d of treatment with rifampin and pyrazinamide is reported. This case justifies the CDC guidelines that were updated on 31 August 2003 advising against the use of this brief regimen for patients with latent tuberculosis due to its risk for hepatotoxicity.

Adult↗

Is the combination of pyrazinamide plus rifampicin safe for treating latent tuberculosis infection in persons not infected by the human immunodeficiency virus?

SETTING: Nine public health care centres in four Spanish cities. OBJECTIVE: To evaluate the efficacy and safety of 2 months of rifampicin (R) plus pyrazinamide (Z) therapy (2RZ) compared with a 6-month course of isoniazid therapy (6H) for treating latent tuberculosis infection (LTBI). DESIGN: Multicentered, randomised, comparative and prospective trial conducted in HIV-seronegative contacts of infectious pulmonary TB cases. RESULTS: Of 352 individuals, 199 received 6H and 153 2RZ; 73% of contacts receiving 6H and 71% receiving 2RZ completed treatment (P = 0.73). Treatment interruption due to hepatotoxicity (ALT/AST > 5 times upper limit of normal) was observed in 10% of contacts in the 2RZ group and in 2.5% of the 6H group (P = 0.007). This higher than expected rate of hepatotoxicity in the 2RZ arm led to premature termination of the study. Severe or fatal liver injury was not detected. Liver function tests normalised after discontinuation of treatment. We conclude that the use of RZ should only be considered when other regimens are unsuitable and intensive monitoring of liver function is feasible.

Adolescent↗

Sterilising action of pyrazinamide in models of dormant and rifampicin-tolerant Mycobacterium tuberculosis.

SETTING: Pyrazinamide (PZA) is an effective sterilising drug in tuberculosis, but its mode of action is controversial. OBJECTIVE: To test the bactericidal activity of 1.56-100 microg/ml PZA in Hu/Coates models of dormant and rifampicin (RMP) tolerant Mycobacterium tuberculosis. METHODS: In model 1, bactericidal activity was tested in pH 5.5 medium against 4-day, 30-day or 100-day static, hypoxic cultures. In models 2 and 3, 100 microg/ml RMP was added to a 100-day culture and PZA was added either during incubation with RMP in model 3, or after resuspension in RMP-free medium in model 2. RESULTS: Model 1: cfu counts on the 100-day and 30-day cultures fell by a maximum of about 1.6 log cfu/ml with increasing culture age, PZA concentration and incubation period, while counts on the 4-day culture showed little change. Model 2: cfu counts at the end of 7 days of recovery showed little bactericidal activity. Model 3: viable bacilli were almost completely eliminated. Bactericidal activity in these models increased with decreasing metabolic bactericidal activity, as measured by the uptake of [3H] uridine into bacterial RNA. CONCLUSION: PZA differs from other anti-tuberculosis drugs in showing greater bactericidal activity the slower the bacillary metabolic activity, hence its great value as a sterilising drug, likely to remain as an effective companion drug with newer sterilising drugs.

Antibiotics, Antitubercular↗

Frequency and implications of pyrazinamide resistance in managing previously treated tuberculosis patients.

OBJECTIVE: To determine the extent of pyrazinamide (PZA) resistance in isolates from previously treated patients from the Western Cape, South Africa. DESIGN: Drug-resistant isolates, isolates resistant to one or more drugs other than PZA (PZA resistance is not routinely determined) (n = 127), and drug-susceptible (n = 47) clinical isolates of Mycobacterium tuberculosis from previously treated patients from the Western Cape were phenotypically (BACTEC MGIT 960) and genotypically (pncA gene sequencing) analysed for PZA resistance. RESULTS: MGIT analysis found that 68 of the 127 drug-resistant isolates were PZA-resistant. Nearly all (63/68) PZA-resistant isolates had diverse nucleotide changes scattered throughout the pncA gene, and five PZA-resistant isolates had no pncA mutations. Of the 47 phenotypically susceptible isolates, 46 were susceptible to PZA, while one isolate was PZA-monoresistant (OR = 53.0, 95% CI = 7.1-396.5). A pncA polymorphism (Thr114Met) that did not confer PZA resistance was also identified. PZA resistance was strongly associated with multidrug-resistant tuberculosis (MDR-TB). CONCLUSION: An alarmingly high proportion of South African drug-resistant M. tuberculosis isolates are PZA-resistant, indicating that PZA should not be relied upon in managing patients with MDR-TB in the Western Cape. A method for the rapid detection of PZA resistance would be beneficial in managing patients with suspected drug resistance.

Antitubercular Agents↗

Rifampicin plus pyrazinamide versus isoniazid for treating latent tuberculosis infection: a meta-analysis.

SETTING: Six trials from Haiti, Mexico, the U.S.A., Brazil, Spain, Zambia and Hong Kong. OBJECTIVE: To evaluate the efficacy and safety of rifampicin plus pyrazinamide (RZ) vs. isoniazid (INH) for the prevention of tuberculosis (TB) among persons with or without human immunodeficiency virus (HIV) infection. DESIGN: Meta-analysis of randomised controlled trials (RCTs) and quasi-RCTs that compared RZ for 2-3 months with INH for 6-12 months. Endpoints were development of active TB, severe adverse effects and death. Treatment effects were summarised as risk difference (RD) with 95% confidence intervals (CI). RESULTS: Three trials conducted in HIV-infected patients and three trials conducted in non-HIV-infected persons were identified. The rates of TB in the RZ group were similar to those in the INH group, whether the subjects were HIV-infected or not (HIV-infected patients: pooled RD = 0%, 95% CI -1-2, P = 0.89; non-HIV-infected persons: pooled RD = 0%, 95% CI -2-1, P = 0.55). There was no difference in mortality between the two treatment groups (HIV-infected patients: pooled RD = -1%, 95% CI -4-2, P = 0.53; non-HIV-infected persons: pooled RD = 0%, 95% CI -1-1, P = 1.00). However, both subgroup analyses showed that a higher incidence of all severe adverse events was associated with 2RZ than INH among non-HIV-infected persons (RD = 29%, 95% CI 13-46, P = 0.0005 vs. RD = 7%, 95% CI 4-10, P < 0.0001). CONCLUSION: RZ is equivalent to INH in terms of efficacy and mortality in the treatment of latent tuberculosis infection. However, this regimen increases the risk of severe adverse effects compared with INH in non-HIV-infected persons.

Antibiotics, Antitubercular↗

[A study of the bacteriophage-based assay for the detection of pyrazinamide resistance in Mycobacterium tuberculosis].

OBJECTIVE: To set up and evaluate the method of phage amplified biologically assay (PhaB) in rapid detection of pyrazinamide (PZA) resistance. METHODS: The PhaB assay was developed and applied in detecting PZA resistance in 108 clinical isolates of Mycobacterium tuberculosis and the results were compared with those of the absolute concentration method. The minimum inhibitory concentration (MIC) was detected for all discrepancy isolates. RESULTS: The results showed that the optimal detecting condition was pH 5.5, PZA 200 microg/ml and 48 h. Of the 108 strains of Mycobacterium tuberculosis, 28 strains were PZA-susceptible and 80 strains were PZA-resistant detected by PhaB; while 32 strains were PZA-susceptible and 76 strains were PZA-resistant by absolute concentration method. Twenty-eight of the 108 strains were PZA-susceptible and 71 were PZA-resistant by the two methods. The concordant isolates of determination of PZA resistance were 99 by the two methods and the concordance rates was 91.7%. There were 9 strains in discordant isolates, of which 7 were the same with MIC method and gene chip in drug susceptibility. If the results of absolute concentration method was the gold standard, the sensitivity, specificity, positive and negative predictive values, as well as accuracy of PhaB assay was 94.7%, 84.8%, 93.4%, 87.5% and 91.7% respectively. CONCLUSION: The PhaB assay can be used as a rapid screening method for detection of drug susceptibility of PZA in clinical isolates of Mycobacterium tuberculosis.

Antitubercular Agents↗

Effect of simultaneous isoniazid administration on pharmacokinetic parameters of pyrazinamide.

Pyrazinamide (PZN) was administered to 10 patients of pulmonary tuberculosis (for 7 consecutive days) each day after an overnight fast. On 8th day serum levels and urinary elimination were measured at 2,4,6 and 8 hours. Simultaneous administration of isoniazid to same patients significantly decreased the peak serum concentration (Cmax). Although, time to peak serum concentration (Tmax) remained unaffected, serum half life (t1/2) prolonged, the elimination rate constant (Kel) and area under serum concentration time curve (AUC) decreased and apparent volume of distribution (Vd) and plasma clearance (Clp) of PZN increased significantly. However, the cumulative per cent dose of PZN excreted in urine was not changed significantly. Although, serum levels of PZN were decreased at 2, 4, 6, and 8 hours, PZN levels remained above minimum effective concentration thereby not affecting the therapeutic status of PZN administered in combination with isoniazid, if PZN is administered in moderate doses.

Adult↗

[Pharmacokinetic aspects of tuberculosis therapy with a fixed combination of rifampicin, isoniazide and pyrazinamide].

The here described investigations show correspondingly that the administration of isoniazid, rifampicin and pyrazinamide in a fixed combination of the administration of the individual substances is bioequivalent under pharmacokinetic aspects. Further investigations on large populations of patients must, however, still confirm whether or not the advantages of the fix combination striven for or theoretically to be expected can be proved in practice.

Biological Availability↗

The disposition of antituberculous drugs in plasma of elderly patients. II. Isoniazid, rifampicin and pyrazinamide.

The pharmacokinetics of isoniazid (INH), rifampicin (RIF) and pyrazinamide (PZA) were studied in 18 elderly patients (67-89 years of age) and 19 young adult patients (19-59 years of age) on the first day and at one month of treatment for pulmonary tuberculosis. Elderly patients exhibited more side effects but there were no age-related changes in the pharmacokinetics of any of the three drugs when used in this combination. The clearance for INH and RIF at steady-state were significantly lower than after first-dose, while that of PZA remained unchanged. At steady-state the clearances for INH and RIF were not characteristic of polymorphic metabolism and auto-enzyme induction, respectively. Elderly patients are more sensitive to antituberculous (anti-TB) drugs; therefore, a modification in the dosage for this patient group should be considered.

Adult↗

[In 76% of patients with active tuberculosis treated with triple therapy (isoniazid-rifampicin-pyrazinamide) cultural conversion precedes microscopic conversion].

The time course of smear and culture conversion was studied in 50 previously untreated patients with cavitary pulmonary tuberculosis. Treatment consisted of isoniazid, rifampicin and pyrazinamide for three months, followed by isoniazid and rifampicin. After eight weeks of treatment, negative smears and cultures were obtained in 46 and 84% of the patients, respectively. In 76% of patients, cultural conversion preceded smear conversion, and in 24% of the patients, cultural conversion occurred up to 6 weeks after smear conversion. Thus, the time course of smear conversion provides reliable information on the loss of infectivity in patients with pulmonary tuberculosis receiving chemotherapy.

Adolescent↗

[Indirect sensitivity testing of pyrazinamide].

Susceptibility tests of M. tuberculosis for pyrazinamide are to perform by indirect methods only. Differences in susceptibility of different methods are only low. We prefer the NSA-method, because it is to use like other drugs. Only M. tuberculosis is susceptible for PZA, not M. bovis, BCG and also not atypical mycobacteria.

Microbial Sensitivity Tests↗

[Absorption and urinary elimination of pyrazinamid administered alone or in combination with isoniazid and rifampicin].

The aim of this work to study the PZA absorption in man its urinary excretion. The PZA was administered alone and in association with INH or/and Rifampicin. The PZA dosage in blood and urine and pyrazinoic acid in urine were performed in a sample of 80 patients divided into 4 groups. PZA dosage was also performed in blood from mice in the same experimental conditions. Our results showed that in man, the titres in serum gave higher peaks when PZA was given alone. Titres were significantly lower when PZA was associated with the two other drugs. The comparative study of PZA seral rates in men and women in one side and mice in the other, showed that the seral concentration was proportional to the body weight. Urinary excretion of Pyrazinamide and pyrazinoic acid showed a relation between the seral concentration and the urinary concentration. However, there was no correlation between the maximum seral concentration and urinary excretion of pyrazinoic acid.

Adult↗

[Comparative characterization of the hepatotoxicity of isoniazid, rifampicin and pyrazinamide].

In experiments of rats it was established that administration of isoniazid and rifampicin in equimolecular doses (50 and 250 mg/kg) for 14 days increased the activities of alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase in the serum, enhanced lipid peroxidation in hepatocytic membranes, caused significant disturbances of bile excretion. Pyrazinamide administered in an equimolecular dose (45 mg/kg) moderately suppresses bile excretion and exerts no effect on the activity of the liver enzymes in the serum and the level of lipid peroxidation.

Alanine Transaminase↗

Susceptibility testing of Mycobacterium tuberculosis to pyrazinamide.

One hundred and sixty clinical isolates of Mycobacterium tuberculois were tested for their sensitivity to pyrazinamide (PZA) using the conventional proportion method (Middlebrook 7H10 agar) and the results compared to the pyrazinamidase (PZase) activity of the strains. The correlation between strains susceptible to PZA and the production of PZase was 99%. None of the isolates were exclusively resistant to PZA. At present the rate of initial PZA resistance in Kanton Zurich is 0.6%.

Amidohydrolases↗

Interaction between allopurinol and pyrazinamide.

Pyrazinamide (PZA) is increasingly used with isoniazid and rifampicin, in short-course antituberculous chemotherapy in service programme conditions. Complicating arthralgias occur due to hyperuricaemia induced by the inhibition of renal tubular secretion of uric acid by pyrazinoic acid, the main PZA metabolite. Allopurinol (Al), a hypouricaemic agent, provides no substantial clinical improvement. Pharmacokinetics of PZA and its metabolites were studied in six healthy volunteers, in a cross-over design, after a single oral dose of PZA alone and, in a second trial, after the same dose together with Al. Plasma and urinary concentrations were measured by high pressure liquid chromatography with a column of cation exchange resin. Analysis of the pharmacokinetic parameters showed that Al induced marked changes in levels of PZA metabolites and accumulation of pyrazinoic acid. Despite decreasing uric acid synthesis, allopurinol increased plasma concentrations of pyrazinoic acid, which is directly responsible for the inhibition of renal urate secretion. Other drugs, which do not involve xanthine oxidase inhibition, should be used in the treatment of this side effect of chemotherapy.

Adult↗

[Microdetermination of pyrazinamide and its metabolites (pyrazinoic acid, 5-hydroxypyrazinoic acid, 5-hydroxypyrazinamide and pyrazinuric acid) in plasma and urine with liquid chromatography].

The method reported here for determining pyrazinamide and its metabolites (2-pyrazinoic acid, 5-hydroxypyrazinamide, 5-hydroxypyrazinoic acid and pyrazinuric acid) consists of diluting urine or acid deproteinisation of serum followed by chromatography on a cation-exchange column. The column length and the detection system (ultraviolet or fluorimetry) allow for a very good separation of the different compounds; the sensitivity of the method makes it suitable for pharmacokinetic studies.

Chromatography, High Pressure Liquid↗