Review
Immunomodulatory effects of quinolones

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Summary

We review data on the in-vitro, ex-vivo, in-vivo, and clinical effects of fluoroquinolones on the synthesis of cytokines and their mechanisms of immunomodulation. In general, most fluoroquinolone derivatives superinduce in-vitro interleukin 2 synthesis but inhibit synthesis of interleukin 1 and tumour necrosis factor (TNF); α furthermore, they enhance significantly the synthesis of colony-stimulating factors (CSF). Fluoroquinolones affect in-vivo cellular and humoral immunity by attenuating cytokine responses. Interleukins 10 and 12 have an important role in the functional differentiation of immunocompetent cells and trigger the initiation of the acquired immune response. In addition, certain fluoroquinolones were seen to enhance haematopoiesis by increasing the concentrations of CSF in the lung as well as in the bone marrow and shaft. Those fluoroquinolones exerting significant effects on haematopoiesis were those with a cyclopropyl moiety at position N1 of their quinolone core structure. Mechanisms that could explain the various immunomodulatory effects of fluoroquinolones include: (1) an effect on intracellular cyclic adenosine-3,5-monophosphate and phosphodiesterases; (2) an effect on transcription factors such as nuclear factor (NF) κB, activator protein 1, NF-interleukin-6 and nuclear factor of activated T cells; and (3) a triggering effect on the eukaryotic equivalent of bacterial SOS response with its ensuing intracellular events. Further studies are required, especially in the clinical setting to exploit fully the potential of the immunomodulatory effect of fluoroquinolones during, for example, immunosuppression, chronic airway inflammatory diseases, and sinusitis.

Section snippets

Quinolones and prokaryotic or eukaryotic topoisomerases

When the first fluoroquinolones—eg, norfloxacin, ofloxacin, and ciprofloxacin—were about to be launched onto the market, one of the main issues was to exclude any mutagenic or genotoxic potential. Since fluoroquinolones inhibit bacterial DNA gyrase and topoisomerase IV,23, 52, 53 the mammalian topoisomerase type II enzymes could in principle also be inhibited by fluoroquinolones. The selectivity of fluoroquinolones for bacterial topoisomerases is up to 1000-fold that of mammalian counterparts.54

In vitro experiments

Results summarised in table 1 complete the synopsis of data provided by Riesbeck20 and Labro.18 Since the publication of these comprehensive reviews summarising published data up to the years 2000/2001, only a few publications have described the in-vitro effects of recently launched fluoroquinolones on cytokine synthesis by lipopolysaccharide-stimulated human monocytes; ciprofloxacin serves as a reference, despite the high drug concentrations originally studied.

Ciprofloxacin decreased cytokine

Ex vivo studies

Based on the findings described above 44, 47, 73 the in-vivo effect of orally administered ciprofloxacin (25 mg/kg) on the capacity of PBMC from healthy human volunteers to produce interleukin 1α, interleukin 1β, interleukin 6, and TNFα ex vivo in response to endotoxin stimulation was established.46

Eight patients received ciprofloxacin (25 mg/kg) orally twice a day for 7 days corresponding to usual treatment. Peripheral blood was collected the day before the treatment (DO), 2 hours after the

Intra-abdominal infections

Assessment of the effects of ciprofloxacin and rufloxacin in an intra-abdominal infection model represents one of the first attempts to establish whether fluoroquinolones in vivo alter the T-cell response and cytokine production.61 These two fluoroquinolones were studied because they are inactive against Bacteroides fragilis in vitro, so that their in-vivo efficacy is most probably because immunomodulatory effects.78

The elimination of B fragilis from 66·6–63·5% of treated animals coincided with

Mechanisms of immunomodulatory activity

The first findings on potential immunomodulating activity of fluoroquinolones were published in the late 1980s.27, 44, 124, 125 Whereas the mechanism of antibacterial activity of fluoroquinolones and their effects on topoisomerase II in prokaryotic and eukaryotic cells have been broadly investigated in vitro and in vivo,126 the basic mechanisms underlying their immunomodulatory activity have not been elucidated in a comprehensive and satisfying manner. The sequence of events after penetration

Conclusion

Progress has been made in elucidating some of the specific mechanisms underlying the immunomodulatory effects of quinolones. The kinetics of cytokine and chemokine production, the elucidation of early gene transcription by analysis of cytokines mRNAs, as well as the activation or inhibition of certain key transcription factors within mammalian cells by quinolones have all contributed to a better understanding of their unique effects. Nevertheless, the exact sequence of events following

Search strategy and selection criteria

Many articles quoted in this review originate from the authors' files; others were chosen from searches on Pubmed on the combination of the words “fluoroquinolones”, “quinolones”, or specific quinolone names with each of the following terms: “immunity”, “immune modulation”, “immunomodulation”, “immune system”, “immunology”, “immunoglobulines”, “immune suppression”, “immune compromised hosts”, “nuclear factors”, “signal transduction”, “gene transcription”, “NFkB”, “IkB”, “IKK”, “MAPK”,

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