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Comprehensive assay for pyrazinamide, rifampicin and isoniazid with its hydrazine metabolites in human plasma by column liquid chromatography.

A comprehensive assay for determination of pyrazinamide (PZA), rifampicin (RIF), isoniazid (INH) and hydrazine metabolites is described. The method involves organic solvent extraction of PZA and RIF, followed by derivatization of INH, monoacetylhydrazine (mHYD) and hydrazine (HYD) with salicylaldehyde and extraction with diethyl ether. Acetylisoniazid (acINH) and diacetylhydrazine (dHYD) were hydrolyzed to INH and mHYD, respectively, and processed as above. Using a gradient solvent programmer, PZA and RIF were analyzed on a C8 (5 microns) column at 248 nm, while INH and metabolites were analyzed on a C18 (5 microns) ODS2 column at 280 nm.

Chromatography, High Pressure Liquid↗

Rapid radiometric method for pyrazinamide susceptibility testing of Mycobacterium tuberculosis.

Pyrazinamide (PZA) is one of the most important drugs in modern chemotherapy of tuberculosis. Since PZA is active only at an acid pH, testing the susceptibility of Mycobacterium tuberculosis to PZA is difficult and timeconsuming. Therefore, we evaluated the BACTEC system for rapid testing of PZA susceptibility at pH 6. A total of 91 M. tuberculosis strains and 2 different strains of M. bovis BCG were screened for susceptibility to PZA. Each strain was tested in special 7H12 broth supplemented with polyoxyethylene stearate containing 25, 50 and 100 micrograms PZA/ml. Strains resistant to 100 micrograms/ml were retested against 25-100 micrograms/ml and at an extended range of PZA concentrations from 200-6,400 micrograms/ml. The MIC was determined with all strains within 4-20 (mean 7) days. Of the 77 susceptible strains, based on the pyrazinamidase test, MIC were less than or equal to 25 micrograms/ml for 34 strains, 50 for 38 and 100 for 2 strains. Three pyrazinamidase-positive strains had still higher MIC, 1 at 800 and 2 at 3,200 micrograms/ml. PZA-resistant strains had MIC of 800 or greater. Monoresistance to PZA has not been detected to date. The clear bimodal distribution of MIC in this method could enable the routine clinical microbiology laboratory to perform PZA susceptibility testing as easily as the 4 drugs now tested in the BACTEC system.

Evaluation Studies as Topic↗

4-, 5- and 6-month regimens containing isoniazid, rifampicin, pyrazinamide and streptomycin for treatment of pulmonary tuberculosis under program conditions in Hong Kong.

SETTING: Ten full time urban government chest clinics in Hong Kong. OBJECTIVE: To assess the effectiveness of 4-, 5- and 6-month fully supervised thrice-weekly regimens containing 4 months of isoniazid, rifampicin, pyrazinamide and streptomycin followed by nil, 1 or 2 months of isoniazid and rifampicin for the treatment of smear-negative culture-negative, smear-negative culture-positive and smear-positive pulmonary tuberculosis. DESIGN: Retrospective study of the 3 antituberculosis treatment regimens given under program conditions during a 6-month period in 1983. RESULTS: Of the 1616 patients assessed, 953 (59%) completed their treatment strictly as planned, 443 (27%) had their treatment prolonged, 107 (7%) had their treatment modified and 113 (7%) defaulted or did not complete their treatment as planned. There were 2 treatment failures at the end of chemotherapy. At 60 months of follow-up, 67 patients died, 2 from the sequelae of tuberculosis. Of 1287 patients assessable up to 60 months, a total of 47 (3.7%) patients relapsed and were eventually treated successfully. 11 (20%) relapses occurred among the 55 patients who had defaulted and did not complete treatment as planned. CONCLUSION: The effectiveness of the 3 treatment regimens depended very much on the patient's adherence to treatment. The necessity of prolongation of treatment is not known and requires further assessment.

Adolescent↗

Determination of pyrazinamide and its main metabolites in rat urine by high-performance liquid chromatography.

A new high-performance liquid chromatograhic procedure for simultaneous determination of pyrazinamide (PZA) and its three metabolites 5-hydroxypyrazinamide (5-OH-PZA), pyrazinoic acid (PA), and 5-hydroxypyrazinoic acid (5-OH-PA), in rat urine was developed. 5-OH-PZA and 5-OH-PA standards were obtained by enzymatic synthesis (xanthine oxidase) and checked by HPLC and GC-MS. Chromatographic separation was achieved in 0.01 M KH2PO4 (pH 5.2), circulating at 0.9 ml/min, on a C18 silica column, at 22 degrees C. The limits of detection were 300 microg/l for PZA, 125 microg/l for PA, 90 microg/l for 5-OH-PZA and 70 microg/l for 5-OH-PA. Good linearity (r2>0.99) was observed within the calibration ranges studied: 0.375-7.50 mg/l for PZA, 0.416-3.33 mg/l for PA, 0.830-6.64 mg/l for 5-OH-PZA and 2.83-22.6 mg/l for 5-OHPA. Accuracy was always lower than +/- 10.8%. Precision was in the range 0.33-5.7%. The method will constitute a useful tool for studies on the influence of drug interactions in tuberculosis treatment.

Animals↗

Quantification of pyrazinamide and its metabolites in plasma by ionic-pair high-performance liquid chromatography. Implications for the separation mechanism.

Pyrazinamide, the amide of pyrazinoic acid, is one of the basic therapeutic agents currently used in combination for chemotherapy of tuberculosis. A reversed-phase high-performance liquid chromatography method based on ionic pair chromatography, was developed after solid-phase extraction of the analytes from plasma with prior addition of internal standard. The main metabolites, pyrazinoic acid, 5-hydroxypyrazinoic acid and 5-hydroxypyrazinamide, were included as well as uric acid and other purine derivatives to allow detailed study of the pharmacokinetics of the drug, especially in patients with impaired kidney function. Some interesting features of the chromatographic system giving some insight in the retention mechanism and of the solid-phase extraction are discussed in detail.

Administration, Oral↗

Simultaneous determination of rifampicin, isoniazid and pyrazinamide in tablet preparations by multivariate spectrophotometric calibration.

The use of multivariate spectrophotometric calibration is presented for the simultaneous determination of the active components of tablets used in the treatment of pulmonary tuberculosis. The resolution of ternary mixtures of rifampicin, isoniazid and pyrazinamide has been accomplished by using partial least squares (PLS-1) regression analysis. Although the components show an important degree of spectral overlap, they have been simultaneously determined with high accuracy and precision, rapidly and with no need of nonaqueous solvents for dissolving the samples. No interference has been observed from the tablet excipients. A comparison is presented with the related multivariate method of classical least squares (CLS) analysis, which is shown to yield less reliable results due to the severe spectral overlap among the studied compounds. This is highlighted in the case of isoniazid, due to the small absorbances measured for this component.

Antitubercular Agents↗

Combined effect of pyrazinamide and ofloxacin within the human macrophage.

SETTING: Recent reports of outbreaks of multidrug resistant tuberculosis have raised questions as to the most appropriate therapeutic response for those exposed to such organisms. A recent Centers for Disease Control National Action Plan suggests the combination of pyrazinamide (PZA) and a quinolone as a potential preventive therapy regimen. OBJECTIVE: Prior studies in the ex-vivo human macrophage model have shown PZA to have only a bacteriostatic effect and, in addition, to diminish the bactericidal effect of rifampin. This study was designed to quantify the intramacrophage antimycobacterial effect of PZA when combined with a quinolone (ofloxacin). DESIGN: Forty micrograms/ml of PZA was combined with varying concentrations of ofloxacin and administered to human macrophages infected with virulent tubercle bacilli; drug sequencing was also studied. RESULTS: A clinically achievable level of PZA enhances the antimycobacterial effect of low, non-bactericidal levels of ofloxacin and does not impede the bactericidal effect of a higher clinically effective level of ofloxacin. Unlike the combination of PZA and rifampin, these interactive effects are not affected by the sequence of drug administration. CONCLUSIONS: Findings support the use of these agents as a potentially effective preventive therapy combination for individuals exposed to multidrug resistant tuberculous organisms.

Animals↗

Mutation in pncA is a major mechanism of pyrazinamide resistance in Mycobacterium tuberculosis.

OBJECTIVE: To characterize the correlation of the mutations in the pncA gene encoding pyrazinamidase (PZase) of Mycobacterium tuberculosis to a loss of PZase activity and development of pyrazinamide (PZA) resistance. DESIGN: The association of PZase activity, minimum inhibitory concentrations (MICs), and mutations in the pncA gene of M. tuberculosis isolated in mostly Asian countries was investigated. RESULTS: One hundred thirty-five out of 168 isolates were PZase positive, and 33 were negative. The MICs of PZA at pH 6.0 were over 400 micrograms/ml for all 33 PZase-negative isolates, while those of PZase-positive isolates were equal to or less than 200 micrograms/ml. Among 33 PZase-negative isolates sequenced, 32 (97%) had mutations within the pncA gene. A mutation was seen in various regions throughout the pncA gene. It was surprising that all three strains of in vitro selected PZA resistant mutants were PZase-positive and showed no change in the pncA gene. These results indicate that additional mechanisms may be involved in PZA resistance. No mutations were observed in all of 135 PZase-positive M. tuberculosis isolates tested, indicating that mutations in the pncA gene could be involved in the loss of PZase activity. CONCLUSIONS: Sequencing analysis of the pncA gene should provide rapid diagnosis of PZA resistant clinical isolates of M. tuberculosis.

Amidohydrolases↗

Evaluating current methods for determination of the susceptibility of mycobacteria to pyrazinamide, conventional, radiometric Bactec and two methods of pyrazinamidase testing.

The authors compared conventional and Bactec determinations of pyrazinamide susceptibility with pyrazinamidase activity determined using either standard Dubos Oleic agar or Middlebrooks 7H9 agar. Of the 26 Mycobacterium tuberculosis tested, Bactec found 16 strains susceptible and 10 resistant, conventional methods found six susceptible and 20 resistant. Dubos identified 13 and Middlebrooks 10 strains as producing pyrazinamidase (susceptible). Of the 11 strains susceptible in Bactec and resistant by conventional methods, eight produced pyrazinamidase. All mycobacteria other than tuberculosis (6) and Mycobacterium bovis (2) were resistant by all methods. Bactec results gave a better correlation with pyrazinamidase results than conventional tests.

Amidohydrolases↗

Probenecid, sulfinpyrazone and pyrazinamide do not inhibit urinary excretion of the beta 2-adrenoceptor agonist clenbuterol in cattle.

The objective of this study was to develop an analytical approach to determine whether the illegal application of clenbuterol in cattle as an anabolic agent can be concealed by co-treatment with substances that affect urinary excretion. Female veal calves were dosed orally with 0.8 microgram clenbuterol per kg of body weight twice daily for 28 days, as licensed for the therapeutic use which is registered in most European countries. On the eighth day of clenbuterol treatment each calf was additionally dosed orally either with probenecid, sulfinpyrazone or pyrazinamide at three different doses that were increased in weekly intervals. During the treatment blood and urine samples were obtained and analysed for clenbuterol by enzyme immunoassay and by high performance liquid chromatography/ enzyme immunoassay to determine whether these drugs or their metabolites interfered with the immunological detection of clenbuterol. Clenbuterol could be in plasma (approximately 200 pg ml-1) and urine (1-40 ng ml-1) 5 h after the initial intake and throughout the whole treatment. None of the drugs reduced urinary excretion of clenbuterol to concentrations below the limit of detection. There was no prevention of clenbuterol detection in urine samples from calves that were co-treated with the drugs tested in this study. Our results demonstrate the uselessness of applying these drugs in order to conceal the illegal use of clenbuterol in meat production.

Administration, Oral↗

Correlation of pncA sequence with pyrazinamide resistance level in BACTEC for 21 mycobacterium tuberculosis clinical isolates.

Mutations in the pncA gene, encoding pyrazinamidase, are considered the major mechanism of pyrazinamide (PZA) resistance in Mycobacterium tuberculosis, but resistant strains containing the wild-type gene have been described. The correlation of pncA sequence with PZA resistance level was examined for 21 M. tuberculosis clinical isolates. Susceptibility patterns were determined for 100, 300, and 900 microg/ml concentrations of the drug in BACTEC. Insertions and deletions and a substitution in the putative promoter region led to high-level resistance, whereas substitutions within the open reading frame seemed to confer variable levels of resistance. Variable resistance levels and PZase activities were also observed among isolates lacking pncA mutations. The high-level resistance (900 microg/ml) in pncA wild-type isolates highlights the clinical significance of these isolates. These data also suggest that there may still be more than one alternative mechanism leading to PZA resistance in M. tuberculosis isolates.

Amidohydrolases↗

Pyrazinamide and pyrazinoic acid activity against tubercle bacilli in cultured human macrophages and in the BACTEC system.

Pyrazinamide (PZA) has become an essential component of current 6-month regimens for therapy of tuberculosis. Susceptible strains of tubercle bacilli convert PZA to pyrazinoic acid (POA) through pyrazinamidase (PZase), which resistant strains and Mycobacterium bovis bacille Calmette-Guérin lack. PZA susceptibility results obtained in cultured human macrophages were compared with those in the broth BACTEC system with 7H12 medium at pH 6.0 for strains known to be PZase-positive or -negative. Although added POA was unable to inhibit tubercle bacilli in cultured macrophages, it was able to inhibit them at very high concentrations in the BACTEC broth. Intracellularly formed POA would not be able to escape from the macrophage, and therefore would accumulate sufficiently to lower pH to toxic levels for tubercle bacilli. The results suggest that the cultured macrophages contribute actively or passively to the effectiveness of PZA, such as through the proposed mechanism of low pH generated by PZase in the phagolysosomes.

Amidohydrolases↗

Stability of isoniazid, rifampin and pyrazinamide in suspensions used for the treatment of tuberculosis in children.

The stability of monosuspensions, cosuspensions and multisuspensions of isoniazid (INH), pyrazinamide (PZA) and rifampin (RIF) has been evaluated by high pressure liquid chromatography over a period of 28 days both with and without the addition of vitamin C (20 micrograms/ml) and at ambient temperatures of 4 degrees C, 24 degrees C and 40 degrees C. At the end of 28 days greater than 90% of initial concentrations of INH, PZA and RIF in monosuspensions remained unchanged irrespective of ambient temperature as was the case with INH and PZA in cosuspension. The addition of RIF to either INH or PZA in cosuspension or together in multisuspension led to a marked fall in the concentration of one or more of the agents, an effect that was accentuated by the addition of vitamin C. In the case of a multisuspension of INH + RIF + PZA with vitamin C added, 41.7% (4 degrees C), 24.1% (24 degrees C) and 20.3% (40 degrees C) of initial INH concentrations and 1.9% (4 degrees C), 1.3% (24 degrees C) and 0.0% (40 degrees C) of initial RIF concentrations remained detectable after 28 days. The addition of vitamin C to monosuspensions of INH and PZA led to a marked decline in the amount of drug detectable and only in the case of RIF was greater than 90% of initial concentrations of the drug detectable after 28 days. The dispensing of cosuspensions or multisuspensions of antituberculosis agents containing RIF is inadvisable as is the addition of vitamin C in any form.

Ascorbic Acid↗

Mechanisms of pyrazinamide resistance in mycobacteria: importance of lack of uptake in addition to lack of pyrazinamidase activity.

Mycobacteria are known to acquire resistance to the antituberculous drug pyrazinamide (PZA) through mutations in the gene encoding pyrazinamidase (PZase), an enzyme that converts PZA into pyrazinoic acid, the presumed active form of PZA against bacteria. Additional mechanisms of resistance to the drug are known to exist but have not been fully investigated. Among these is the non-uptake of the pro-drug, a possibility investigated in the present study. The uptake mechanism of PZA, a requisite step for the activation of the pro-drug, was studied in Mycobacterium tuberculosis. The incorporation of [14C]PZA by the bacilli was followed in both neutral and acidic environments since PZA activity is known to be optimal at acidic pH. By using a protonophore (carbonyl cyanide m-chlorophenylhydrazone; CCCP), valinomycin, arsenate and low temperature, it was shown that an ATP-dependent transport system is involved in the uptake of PZA. Whilst the structurally analogous compound nicotinamide inhibited the transport system of PZA, other structurally related compounds such as pyrazinoic acid, isoniazid and cytosine did not. Acidic conditions were also without effect. Based on diffusion experiments in liposomes, it was found that PZA diffuses rapidly through membrane bilayers, faster than glycerol, whilst the presence of OmpATb, the porin-like protein of M. tuberculosis, in proteoliposomes slightly increased the diffusion of the drug. This finding may explain why the cell wall mycolate hydrophobic layer does not represent the limiting step in the diffusion of PZA, as judged from comparative experiments using a M. tuberculosis strain and its isogenic mutant elaborating 40% less covalently linked mycolates. PZase activity, and PZA uptake and susceptibility in different mycobacterial species were compared. M. tuberculosis, a naturally PZA-susceptible species, was the only species that exhibited both PZase activity and PZA uptake; no such correlation was observed with the four naturally resistant species examined. Mycobacterium smegmatis possessed a functional PZase but did not take up PZA; the reverse was true for the PZase-negative strain of Mycobacterium avium used, with PZA uptake comparable to that of M. tuberculosis. Mycobacterium bovis BCG and Mycobacterium kansasii exhibited neither a PZase activity nor PZA uptake. These data clearly demonstrate that one of the mechanisms of resistance to PZA resides in the failure of strains to take up the drug, indicating that susceptibility to PZA in mycobacteria requires both the presence of a functional PZase and a PZA transport system. No correlation was observed between the occurrence and cellular location of PZase and of nicotinamidase in the strains examined, suggesting that one or both amides can be hydrolysed by other mycobacterial amidases.

Amidohydrolases↗

The penetration of dapsone, rifampicin, isoniazid and pyrazinamide into peripheral nerves.

1 Dapsone, rifampicin, isoniazid and pyrazinamide were shown to penetrate readily into the sciatic nerves of the dog and sheep. 2 These findings suggest that the continued persistence of viable drug-sensitive leprosy bacilli in the peripheral nerves of patients treated for long periods with either dapsone or rifampicin is not due to inadequate intraneural drug penetration.

Animals↗

Comparison of growth and susceptibility testing of pyrazinamide in different Bactec media using strains of the M. tuberculosis complex.

The aim of this study was to evaluate and compare growth and susceptibility testing of pyrazinamide (pza) in different Bactec media using 85 strains of the M. tuberculosis complex. Fifty-four were clinical isolates of M. tuberculosis, of which 34 strains were selected as they failed to grow in primary pza susceptibility testing. Fourteen were strains of M. bovis, 10 were different strains of M. bovis BCG, five were strains of M. africanum, and two were strains of M. microti. The following Bactec media were evaluated: (1) Bactec PZA test medium, (2) acidified Bactec 12B medium with pH reduced to 5.6, (3) acidified 12B medium supplemented with fresh egg yolk, (4) acidified 12B medium supplemented with a commercial egg yolk enrichment. Demonstration of pyrazinamidase activity was included for comparison. All strains of M. tuberculosis, M. microti and M. africanum were inhibited by pza at 100 micrograms/ml, and all strains of M. bovis and M. bovis BCG were found to be resistant to pza at 100 micrograms/ml. Bactec PZA test medium supported growth for all 85 strains tested. The two egg yolk-supplemented media supported growth in all strains except one strain of M. microti, and acidified but otherwise unsupplemented Bactec 12B medium supported growth in 64 strains (75%). A pza sensitivity test result could be obtained within one week in > 79% of strains. An overall correlation of 89% between susceptibility to pza and demonstration of pyrazinamidase activity was demonstrated.

Amidohydrolases↗

Use of pyrazinamidase activity on Mycobacterium tuberculosis as a rapid method for determination of pyrazinamide susceptibility.

Pyrazinamidase activity in clinical isolates of Mycobacterium tuberculosis has been previously found to correlate with susceptibility to the antituberculosis drug pyrazinamide. The Wayne method for determining pyrazinamidase activity, a technique also utilized as an aid in identification of mycobacteria, and thin-layer chromatography method were found to be useful screening methods for susceptibility testing, since resistant strains are pyrazinamidase negative. These simple methods overcome the difficulty in growing M. tuberculosis at pH 5.5, as is required in the conventional method of susceptibility testing.

Amidohydrolases↗

Determination of pyrazinamide MICs for Mycobacterium tuberculosis at different pHs by the radiometric method.

The MICs of pyrazinamide (PZA) were determined for Mycobacterium tuberculosis cultivated under different pH conditions in 7H12 liquid medium. Mycobacterial growth was monitored by the radiometric method (BACTEC system; Johnston Laboratories, Inc., Towson, Md.). We observed a predictable eightfold difference between the MICs determined at pH 5.5 and those determined at pH 5.95. The highest MICs for 21 susceptible strains were 50.0 micrograms/ml at pH 5.5 and 400 micrograms/ml at pH 5.95. This eightfold difference enabled us to predict MICs at pH 5.5 from the values observed at pH 5.95. The use of 7H12 broth at pH 5.95 simplified the radiometric PZA susceptibility test by avoiding the addition of acid solutions in the course of cultivation, which was required when the test was performed at pH 5.5. An additional benefit of using pH 5.95 instead of pH 5.5 was that all tested strains grew at pH 5.95, while some of them, especially PZA-resistant strains, did not grow at pH 5.5.

Cell Survival↗