Quinolone-induced arthropathy is probably caused by a lack of functionally available magnesium in immature joint cartilage. We used an in vitro assay to study the effects of fluoroquinolones on cartilage formation in mouse limb buds from 12-day-old mouse embryos in regular and in magnesium-deficient medium. Omission of magnesium from the medium had no adverse effect on the outcome of the culture: limb buds grew and differentiated well in regular and in magnesium-deficient Bigger's medium. Lack of calcium, however, severely impaired the development of the explants; this result was even more enhanced when both minerals (magnesium and calcium) were omitted. Electron microscopy revealed cell necrosis and deposition of electron-dense material in the vicinity of chondrocytes from limb buds after 6 days in a magnesium-free medium. A series of seven fluoroquinolones was tested at 30, 60, and 100 mg/l medium. At a concentration of 30 mg/l sparfloxacin only had a slight effect on limb development. At concentrations of 60 and 100 mg/l sparfloxacin, temafloxacin and ciprofloxacin impaired limb development in vitro concentration-dependently. The effects were enhanced in a magnesium-deficient medium (concentration of magnesium <10 micromol/l). Fleroxacin, lomefloxacin and ofloxacin impaired limb development only slightly; no significant differences were recognizable between the outcome in regular and in magnesium-deficient medium. Pefloxacin did not show any effect on limb development in both media. Using electron microscopy, very similar alterations as described above for the limbs cultured in magnesium-deficient medium were observed with ofloxacin at a concentration of 30 mg/l, which had no effect on the growth of the explants when evaluated macroscopically. The affinity of six fluoroquinolones to magnesium was determined by the use of a fluorescence assay. The affinity to magnesium correlated with the activity of the drugs in the limb bud assay. We conclude that fluoroquinolones have no effect on murine limb development in vitro at concentrations that are achieved under therapeutic conditions (peak concentrations approx. 1-5 mg/l in plasma). Effects at higher concentrations (60 and 100 mg/l) are slightly enhanced (factor 2) if the magnesium concentration in the medium is low. Macroscopically, limbs develop regularly in a magnesium-free medium, but ultrastructurally typical alterations are exhibited (e.g. cell necrosis and pericellular deposition of electron-dense material).

Background Fever and hypothermia have been observed in septic patients. Their influence on prognosis is subject to ongoing debates. Methods We did a secondary analysis of a large clinical dataset from a quality improvement trial. A binary logistic regression model was calculated to assess the association of the thermal response with outcome and a multinomial regression model to assess factors associated with fever or hypothermia. Results With 6542 analyzable cases we observed a bimodal temperature response characterized by fever or hypothermia, normothermia was rare. Hypothermia and high fever were both associated with higher lactate values. Hypothermia was associated with higher mortality, but this association was reduced after adjustment for other risk factors. Age, community-acquired sepsis, lower BMI and lower outside temperatures were associated with hypothermia while bacteremia and higher procalcitonin values were associated with high fever. Conclusions Septic patients show either a hypothermic or a fever response. Whether hypothermia is a maladaptive response, as indicated by the higher mortality in hypothermic patients, or an adaptive response in patients with limited metabolic reserves under colder environmental conditions, remains an open question. Trial registration The original trial whose dataset was analyzed was registered at ClinicalTrials.gov (NCT01187134) on August 23, 2010, the first patient was included on July 1, 2011.

Background Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain. Methods We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing. Results Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1–3 h, or 1 h versus 3–6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04). Conclusions Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov (NCT01187134). Registered 23 August 2010, NCT01187134

The effects of selected quinolones (levofloxacin, lomefloxacin, temafloxacin and grepafloxacin) on growth and differentiation of murine limb buds were studied in vitro. Ciprofloxacin and ofloxacin served as controls. We used limb buds from 12-day-old mouse embryos that were grown for 6 days in a serum-free, standard or magnesium-deficient medium. Besides evaluation under a dissecting microscope, we used electron microscopy to characterize the effects in detail. The following results are noteworthy. (1) Comparing the effects of standard and magnesium-deficient medium after 3 and 6 days in culture, we found ultrastructural changes after 6 days only. (2) Direct comparison of ofloxacin (racemate) and levofloxacin (L-enantiomer) showed that they had a similar, rather low, potential for affecting cartilage development. (3) The effects of temafloxacin and ciprofloxacin were more pronounced in magnesium-deficient medium, but those of the other drugs were not. (4) Grepafloxacin was the most active quinolone in this assay. It impaired growth and differentiation of limb buds at 30 mg/l; at higher concentrations the explants did not grow. With lower concentrations of 10 mg grepafloxacin/l, no effects were detectable under a dissecting microscope but characteristic changes were seen by electron microscopy. We observed electron-dense aggregates on and within chondrocytes, detachment of the cell membrane from the matrix with matrix-free pericellular areas around chondrocytes, and swelling of cell organelles such as mitochondria and rough endoplasmic reticulum. (5) The affinity of grepafloxacin for divalent cations (Mg2+, Ca2+) was studied by measuring the fluorescence of grepafloxacin solution at various concentrations of Mg2+ and Ca2+. Grepafloxacin showed a relatively high affinity for Ca2+ in the fluorescence assay, which was more pronounced than the affinities of six other fluoroquinolones tested before.

Fluoroquinolones are known for their ability to form chelate complexes with magnesium. Cartilage lesions observed in juvenile animals after quinolone treatment very probably are a consequence of the lack of functionally available magnesium. In cartilage, which contains high amounts of negatively charged proteoglycans, a Donnan distribution can be expected leading to an inhomogeneous distribution of ions (such as magnesium), which may support the toxic effects of magnesium deficiency or quinolone treatment of cartilage. We performed in vitro experiments using dialysis tubes to simulate the unequal distribution of proteoglycans in cartilage and measured the distribution of magnesium, calcium and ofloxacin. We found that the concentration of free magnesium is significantly reduced with the chondroitin sulphate-free solution due to a Donnan effect. For example, using a 3% chondroitin sulphate solution (outside the tubing) dialysed against a chondroitin sulphate-free solution (inside the tubing) the magnesium concentration decreased by 24% from 0.55 +/- 0.02 to 0.42 +/- 0.04 mmol/l inside the tubing during 48 h observation (P < 0.01). Under physiological conditions this unequal distribution of magnesium probably will be much more pronounced because chondroitin sulphate concentrations in cartilage are higher; nevertheless, magnesium concentration is sufficient for regular function of the tissue. During the sensitive phase of quinolone toxicity, magnesium in juvenile cartilage is lower than at other time points during postnatal development. Moreover, additional complexation by quinolones may further reduce the concentration of functionally available magnesium below the critical level.