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Enoxacin

A Reappraisal of its Clinical Efficacy in the Treatment of Genitourinary Tract Infections

  • Drug Evaluation
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Abstract

Synopsis

Enoxacin is a 6-fluoronaphthyridinone antibacterial agent with good in vitro activity against Neisseria gonorrhoeae and most Gram-negative urinary tract pathogens. It is less active in vitro against Acinetobacter spp., Pseudomonas aeruginosa, and most Gram-positive bacteria, than against Gram-negative organisms.

Enoxacin is rapidly absorbed, with a high oral bioavailability (87 to 91%). Of the absorbed dose, 44 to 56% is excreted unchanged in the urine, with peak urinary concentrations (>500 mg/L within 4 hours) remaining high (>100 mg/L) for up to 24 hours, sufficient to inhibit most urinary tract pathogens.

Single (400mg) and multiple oral dose regimens (100 to 600mg twice or 3 times daily for 5 to 14 days) of enoxacin are as effective for the treatment of patients with complicated or uncomplicated urinary tract infections as other antibacterial agents such as amoxicillin, cefuroxime axetil, cotrimoxazole (trimethoprim-sulfamethoxazole) or trimethoprim. Noncomparative data suggest that enoxacin is also an effective agent for the treatment of prostatitis. Single 400mg oral doses of enoxacin produce >95% bacteriological cure rates in gonococcal infections, comparable to those produced by single intramuscular doses of ceftriaxone 250mg. Perioperative doses of oral enoxacin 200mg provide effective prophylaxis against postoperative bacteriuria after transurethral resection of the prostate.

Concomitant administration of enoxacin with a number of commonly used therapeutic agents (e.g. antacids, methylxanthines, warfarin) affects thepharmacokinetic properties of either enoxacin or the coadministered agents.

Enoxacin is reasonably well tolerated, with the incidence of adverse experiences ranging from 0 to 24%. Adverse events are mainly gastrointestinal, neuro-logical or dermatological and resolve with minimal intervention.

Overall, although enoxacin exhibits a number of clinical characteristics that are similar to those of other agents for the treatment of genitourinary tract infections, the advantages offered by this agent generally do not outweigh those of alternative fluoroquinolone agents. Thus, it is likely to prove to be yet another addition to the list of agents available for the management of these infections.

Antibacterial Activity

Enoxacin is a 6-fluoronaphthyridinone antibacterial agent with good in vitro activity against Neisseria gonorrhoeae and most Gram-negative urinary tract pathogens but less activity (in vitro) against Acinetobacter spp., Pseudomonas aeruginosa, and most Gram-positive bacteria. Although it is not a potent in vitro inhibitor of multiresistant Pseudomonas spp., it is effective against rifampicin (rifampin)-resistant coagulase-negative staphylococci and all tested Gram-negative strains resistant to β-lactam agents and aminoglycosides. Overall, the in vitro activity of enoxacin is 2- to 4-fold less than that of ciprofloxacin but more or less similar to that of ofloxacin and norfloxacin.

Enoxacin has a rapid bactericidal action, which produces a > 100-fold reduction in viable bacterial cell count within 2 hours of inoculation of a concentration of >2 times the minimum inhibitory concentration (MIC), without bacterial re-growth at 24 hours. The time to onset of bactericidal activity is similar to that of ciprofloxacin.

Enoxacin exerts a post-antibiotic effect similar to that of ciprofloxacin against Escherichia coli. At minimum inhibitory concentrations, enoxacin inhibited adhesion to uroepithelial cells in >95% of strains of E. coli.

Resistant mutants develop spontaneously at rates ranging from <10 & s-7 for E. coli and P. aeruginosa to <10s-10 for Enterobacter aerogenes on exposure to enoxacin concentrations of 4 times the MIC value. Cross-resistance between enoxacin and other fluoroquinolone agents has been reported in a number of Gram-negative and Gram-positive organisms.

Changes in normal human intestinal flora as a result of enoxacin treatment are generally minimal and tend to return to baseline levels 2 weeks post-therapy.

Pharmacokinetic Properties

Following a single oral dose of enoxacin 400mg, peak plasma concentrations (Cmax) of 2.0 to 4.4 mg/L are reached within 0.9 to 1.4 hours (tmax). Steady-state plasma concentrations of enoxacin are observed within 3 days of beginning treatment with 400mg twice daily for 14 days. The area under the plasma concentration-time curve from time zero to infinity (AUC∞) value ranges from 14.3 to 17.6 mg/L • h after a single oral dose of enoxacin 400mg. The oral bioavailability of enoxacin is 87 to 91% and is independent of the dose given. Decreases in gastric acidity (i.e. pH > 5) significantly reduces the AUC∞ and Cmax values of enoxacin.

Enoxacin is distributed widely throughout the body, with a dose-independent apparent volume of distribution >2 L/kg after single oral doses of 200 to 1000 mg. It is 18 to 67% protein-bound. Enoxacin is well distributed into renal and prostatic tissue; the concentrations achieved in these tissues tend to exceed the MICs for most urinary pathogens.

The terminal elimination half-life (t1/2β) of a single oral dose of enoxacin 400mg ranges from 4.3 to 5.6 hours. After a single oral dose of enoxacin 400mg, 44 to 56% of the absorbed dose is excreted unchanged in the urine within 48 hours. Peak urinary concentrations of enoxacin (>500 mg/L) are observed within 4 hours of a single oral dose of 400mg and remain high (>100 mg/L) for up to 24 hours.

Renal clearance of enoxacin is lower and values of Cmax and AUC∞ are higher in the elderly (>65 years) than in young adults. Impaired renal function results in cumulation of enoxacin, with a corresponding increase in t1/2β and decrease in the urinary excretion of unchanged drug. The elimination of enoxacin is little affected by haemodialysis.

Therapeutic Efficacy

Comparative and noncomparative studies show that multiple-dose regimens of enoxacin ranging from 100 to 600mg given 3 times daily for 7 days produce >70% bacteriological eradication in patients with uncomplicated urinary tract infections (UTIs). The eradication rate is similar to that observed with multiple-dose regimens of pipemidic acid, norfloxacin or sparfloxacin. Single oral doses of enoxacin 400mg are as effective as single oral doses of amoxicillin 3g or trimethoprim 600mg, whereas enoxacin 200mg twice daily for 3 days is as effective as multipledose regimens of cotrimoxazole (trimethoprim-sulfamethoxazole) or cefuroxime axetil.

In complicated UTIs, enoxacin doses ranging from 200mg (twice or 3 times daily for 5 to 14 days) to 400mg (twice daily for 7 to 14 days) produce >70% bacteriological eradication, similar to that seen with multiple-dose regimens of cotrimoxazole, norfloxacin or sparfloxacin, but significantly higher than that seen with pipemidic acid. Enoxacin 400 to 600mg (twice or 3 times daily for 7 to 56 days) is also effective for treatment of prostatitis (≥75% overall cure rate) according to noncomparative studies.

Single oral doses of enoxacin 200, 400 or 600mg have been shown to be effective (bacteriological cure rates generally >90%) for the treatment of uncomplicated urethral or endocervical gonococcal infections. Data from comparative studies indicate that a single dose of enoxacin 400mg is as effective as a single intramuscular dose of ceftriaxone 250mg, producing bacteriological cure rates of ≥95% at 6 to 10 days post-treatment. Enoxacin is effective against strains of N. gonorrhoeae that are penicillin- or tetracycline-resistant.

Perioperative doses of oral enoxacin 200mg provide effective prophylaxis against postoperative bacteriuria after transurethral resection of the prostate.

Tolerability

As with most other fluoroquinolone antibacterial agents, enoxacin is reasonably well tolerated, with the incidence of adverse experiences ranging from 6 to 24% during treatment for UTIs and 0 to 10% during treatment for gonococcal infections. Adverse events were mainly gastrointestinal (nausea and/or vomiting, diarrhoea, abdominal discomfort), neurological (headache, dizziness, insomnia) or dermatological (pruritus, maculo-papular rash). Most of these events were mild and resolved with minimal intervention. Clinically significant haematological, biochemical or urinary abnormalities have been rarely reported.

Dosage and Administration

For the treatment of uncomplicated UTIs, the recommended dose of enoxacin is 200mg twice daily for 7 days; for complicated UTIs it is 400mg twice daily for 14 days. A 400mg single dose is the recommended treatment for uncomplicated urethral or cervical gonorrhoea. Enoxacin should be taken orally at least 1 hour before or at least 2 hours after a meal.

Enoxacin dosage adjustment (in parallel with the degree of reduced creatinine clearance) is recommended in patients with known or suspected impaired renal function. Some preliminary data suggest that dosage adjustment may be necessary for patients with advanced cirrhosis requiring diuretics.

Coadministration of enoxacin with bismuth subsalicylate, caffeine, sucralfate, antacid agents, H2-histamine antagonists or nonsteroidal anti-inflammatory agents should be avoided. Serum concentrations of theophylline, warfarin or cyclosporin should be monitored, and dosage adjustments made as appropriate, when these agents are coadministered with enoxacin.

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    Sanjay S. Patel & Caroline M. Spencer

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Various sections of the manuscript reviewed by: R.N. Jones, Department of Pathology, Medical Microbiology Division and the Anti-Infectives Research Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; B.M. Lomaestro, Department of Pharmacy, Albany Medical Center, Albany, New York, USA; K. Nakata, Department of Urology, School of Medicine, Kobe University, Kobe, Japan; D.E. Nix, Center for Clinical Pharmacy Research, State University of New York at Buffalo School of Pharmacy, Buffalo, New York, USA; S.R. Norrby, Department of Infectious Diseases, Lund University Hospital, University of Lund, Lund, Sweden.

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Patel, S.S., Spencer, C.M. Enoxacin. Drugs 51, 137–160 (1996). https://doi.org/10.2165/00003495-199651010-00009

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