The Veterinary Journal 200 (2014) 122–126

Contents lists available at ScienceDirect

The Veterinary Journal

journal homepage: www.elsevier.com/locate/tvjl

Azithromycin pharmacokinetics in the serum and its distribution to the

skin in healthy dogs and dogs with pyoderma
Gila Zur a, Stefan Soback b, Yfat Weiss a, Elad Perry a, Eran Lavy a, Malka Britzi b,⇑
a
Veterinary Teaching Hospital, The Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, PO Box 12, Rehovot 76100, Israel
b
National Residue Control Laboratory, Kimron Veterinary Institute, Veterinary Services, Ministry of Agriculture, 50250 Beit Dagan, Israel

a r t i c l e i n f o a b s t r a c t

Article history: Serum and skin tissue azithromycin (AZM) concentrations were analysed in healthy and pyoderma
Accepted 31 December 2013 affected dogs to determine AZM pharmacokinetics and to establish the effect of disease on AZM skin dis-
position. AZM was administered orally to two groups of healthy dogs: (1) at 7.02 mg/kg (n = 7) and (2) at
11.2 mg/kg (n = 9). A crossover design was used on five of them. Seven dogs with pyoderma were treated
Keywords: with AZM at 10.7 mg/kg. The two groups of healthy dogs received AZM once daily over three consecutive
Azithromycin days and dogs with pyoderma received the same treatment repeated twice with an interval of 1 week.
Pharmacokinetics
AZM concentrations were determined by liquid chromatography–tandem mass spectrometry.
Canine
Serum
AZM was rapidly absorbed and slowly excreted. In healthy dogs, maximum serum concentrations
Skin appeared 2 h after administration and were (mean ± standard deviation) 0.60 ± 0.25 lg/mL and
Pyoderma 1.03 ± 0.43 lg/mL, and the half-lives were 49.9 ± 5.10 and 51.9 ± 6.69 h for doses of 7.02 and 11.2 mg/kg,
respectively. Clearance (CL0–24/F) was similar in both dosing groups (1.24 ± 0.24 and 1.29 ± 0.24 L/h/kg)
and the respective mean residence time (MRT0–24) was 11.1 ± 0.8 and 8.4 ± 2.2 h. The skin concentration
in healthy dogs was 3.5–6.5 and 5.0–12.0 times higher than the corresponding serum concentration after
the two doses and increased after the cessation of AZM administration. The ratio increased significantly
in inflamed tissue (9.5–26.2).
Ó 2014 Elsevier Ltd. All rights reserved.

Introduction although it has been found to be effective in therapy of skin and

Azithromycin (AZM) is the first semi-synthetic macrolide deriv-
ative classified as an azalide (Girard et al., 1987). AZM differs from
erythromycin (ERY) in the methyl-substituted nitrogen at position
9a in the lactone ring creating a 15-membered macrolide (Mutak,
2007), which improves the potency against Gram-negative bacte-
ria (Retsema et al., 1987; Dunkin et al., 1988). Furthermore, AZM
is more stable than ERY in an acidic environment (Fiese and Stef-
fen, 1990), improving AZM bioavailability. AZM free base suspen-
sion bioavailability in dogs was 97% whereas ERY was 52%
(Shepard and Falkner, 1990). Bioavailability in other species was
lower: 57% in cats (Hunter et al., 1995), 46% in rats (Shepard and
Falkner, 1990) and 37% in human beings (Foulds et al., 1990).
AZM tissue concentrations in various organs of mice, rats, ger-
bils, dogs and humans were significantly above the minimum inhi-
bition concentration (MIC) of the relevant pathogens, while AZM
serum concentrations were below the MIC (Girard et al., 1987;
Foulds et al., 1990; Retsema et al., 1990; Foulds and Johnson,
1993). AZM skin concentrations have not been investigated,
subcutaneous infections, including those caused by Staphylococcus
spp. (Daniel, 1991; Mallory, 1991; Amaya-Tapia et al., 1993; Rodri-
guez-Solares et al., 1993; Noli and Boothe, 1999).
Staphylococcus pseudintermedius is the primary pathogen in ca-
nine pyoderma, followed by other coagulase negative Staphylococ-
cus spp., coagulase positive Staphylococcus spp., Streptococcus spp.,
Escherichia coli, Pseudomonas spp. and Proteus spp. (Miller et al.,
2012). Treatment of canine pyoderma involves long term oral
administration of antibiotics relying strongly on dog owner-depen-
dent administration compliance (Stegemann et al., 2007). Once
daily administration of AZM is potentially beneficial in achieving
owner compliance (Norrby, 1991; Noli and Boothe, 1999). The
aim of the present study was to determine the pharmacokinetics
(PK) of AZM in healthy dogs and to investigate AZM distribution
to normal and pyoderma affected skin.
Materials and methods
Experimental design

Two groups of healthy dogs and one group of pyoderma affected dogs received
⇑ Corresponding author. Tel.: +972 3 9681714. AZM tablets (Zeto 250 mg, Unipharm) according to the dosing regimen described
E-mail address: malkab@moag.gov.il (M. Britzi). below. Plasma and skin biopsies were collected according to the design below

1090-0233/$ - see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.tvjl.2013.12.022
 G. Zur et al. / The Veterinary Journal 200 (2014) 122–126 123

and in Table 1. The AZM concentrations in plasma and skin were analysed using a healthy dogs (Table 1). Sample collection coinciding with drug administration
liquid chromatography–tandem mass spectrometry (LC/MS/MS) method and AZM was performed immediately before AZM administration. The sample preparation
PK were determined for each group of dogs. was identical to that described above.

Ethical approval Azithromycin analysis

The experiments and the suggested protocols were approved by the Ethics
Committee of Faculty of the Agricultural, Food and Environmental Quality Sciences
of the Hebrew University of Jerusalem for Clinical Trials of the Koret School of Vet-
erinary Medicine (KSVM-VTH/6_2006). All owners signed an informed consent
form.
Study animals
Eleven mixed breed, healthy dogs, 9 months to 3 years of age and weighing
22.7 ± 11.7 kg (mean ± standard deviation; range 8.0–40.5 kg) were included in
the study. All dogs were healthy based on physical examination, complete blood
count (CBC) and serum chemistry panel results prior to the study. The target
AZM doses were 5 mg/kg (seven dogs) and 10 mg/kg (nine dogs), resulting in exact
doses of 7.02 ± 0.50 mg/kg and 11.2 ± 1.66 mg/kg; five dogs received both doses
(crossover), with a period of 2.5 weeks in between the treatments.
Seven dogs with clinical pyoderma, 9 months to 12 years of age and weighing
33.0 ± 6.47 kg (range 22–40 kg), admitted to the Dermatology Department of the Vet-
erinary Teaching Hospital, Koret School of Veterinary Medicine, were enrolled in the
study. Three dogs were male, one female and three were castrated males. There were
two mixed breed dogs, two Golden Retrievers and one each of Great Dane, Boxer and
Staffordshire bull terrier. Prior to inclusion in the study, all dogs exhibited clinical
superficial pyoderma due to various causes (atopic dermatitis, flea allergy, short
coated breed dermatitis) without apparent accompanying systemic disease based
on physical examination, CBC and serum chemistry panel results. One dog had epi-
lepsy that was medically controlled (phenobarbital and potassium bromide). Pyo-
derma was diagnosed according to clinical signs (Miller et al., 2012). Samples of
skin tissue were examined histologically for the presence of bacteria and neutrophil
infiltration. All seven dogs received AZM at 10.7 mg/kg actual dose once daily for
three consecutive days. This protocol was repeated twice with weekly intervals.
Blood and tissue samples
The timeline of blood and skin sample collection relative to drug administration
is shown in Table 1. Blood was collected from a peripheral vein (cephalic, saphe-
nous or metatarsal veins), allowed to clot and centrifuged at 2000 g for 5 min.
The serum samples were stored at 80 °C until analysis.
For the determination of AZM concentrations in skin, biopsies were performed
in the trunk area of the dogs using an aseptic technique, including clipping the hair
and applying a topical analgesic ointment containing 5% lidocaine (Emla, AstraZen-
eca) with a 6–8 mm diameter punch biopsy device followed by 2–0 nylon sutures.
The sutures were inspected daily and removed after 10 days. Biopsies were taken
according to the protocol described in Table 1 and stored at 80 °C until analysis.
Blood and skin tissue sample collection, as well as the drug administration pro-
tocol, from dogs with pyoderma was slightly different from that used for the
Serum samples were prepared by the addition of 0.5 mL acetonitrile (J.T. Baker)
to 0.2 mL serum. The tube was mix-vortexed, centrifuged at 16,000 g for 10 min;
100 lL of the supernatant solution were diluted with 100 lL 0.01 M ammonium
formate, pH 3.5 (Sigma–Aldrich). The resulting mixture was used for injection to
the LC/MS/MS instrument. AZM (Sigma–Aldrich) standard solution was prepared
in methanol at 1 mg/mL and working standards (0.01–100 lg/mL) were kept at
30 °C. Standard curves for serum analysis were prepared by fortifying drug free
dog serum with AZM to produce a concentration range from 0.0025 to 5 lg/mL.
AZM concentrations were determined using an LC/MS/MS method comprising a
Hewlett–Packard H-P 1100 (Agilent Technologies) high performance liquid chroma-
tography (HPLC) system (binary pump, degasser, thermostat column compartment
and autosampler) combined with a tandem mass spectrometer (MS/MS) ABI 3200
QTrap (ABSciex). Liquid chromatography separation was performed on a C18
Hypersil Gold column (3 lm, 100 mm  2.1 mm; Thermo Electron Corporation).
The mobile phase consisted of 0.01 M ammonium formate at pH 3.5 and acetoni-
trile. A linear gradient of acetonitrile concentration from 5% to 70% within 1 min
was applied at a flow rate of 0.45 mL/min. The column compartment was main-
tained at 30 °C and the injection volume was 5 lL. Turbo ion electrospray (ESI/
MS/MS) in positive ion mode was operated at a temperature of 500 °C. Multiple
reaction monitoring (MRM) was applied. AZM was detected by identifying the pre-
cursor ion 734 m/z and the product ion 576 m/z. The lower limit of quantification (LLOQ)
and the higher limit of quantification (HLOQ) were 0.005 lg/mL and 5 lg/mL,
respectively. The calibration curve was linear within the range 0.005–5 lg/mL
(coefficient of correlation 0.9972). Recovery was 86–93%. The per cent coefficient
of variation (%CV) within and between days was 8–14%.
For preparation of skin samples, each biopsy sample was weighed and acetoni-
trile (10:1 V/W) was added. The samples were placed overnight in a shaker bath at
37 °C. The tube was centrifuged at 3000 g for 10 min. The acetonitrile layer was col-
lected, evaporated to dryness and the residue was re-dissolved in 0.01 M ammo-
nium formate (pH 3.5):methanol (1:1 V/V). The volume was proportional to
biopsy weight (2:1 V/W). The solution was then used for injection to the LC/MS/
MS as described above. Standard curves for skin analysis were prepared by fortify-
ing blank dog skin with AZM. The LLOQ and the HLOQ were 0.005 lg/g and 5 lg/g,
respectively. The calibration curve was linear within the range 0.005–5 lg/g (coef-
ficient of correlation 0.9972). Recovery was 65–71% and the %CV within and be-
tween days was 12–19%. Samples for which the AZM concentration exceeded the
HLOQ were diluted and re-analysed.
Pharmacokinetic analysis
The PK parameters of AZM were determined by use of the non-compartmental
approach based on the statistical moment theory (Yamaoka et al., 1978) using a
computer programme (Yamaoka, 1986). The linear terminal slope kz after the third
daily administration was calculated by linear, least squares regression analysis,

Table 1
Timeline of administration of azithromycin to healthy dogs and pyoderma affected dogs.

Time (h) Healthy dogs Healthy dogs Dogs with pyoderma

5 mg/kg 10 mg/kg 10 mg/kg
Drug administration Serum Skin Drug administration Serum Skin Drug administration Serum Skin
0 x x x x x x x x x
2 – x – – x – – x –
4 – x – – x – – – –
6 – x – – x – – – –
10 – x – – x – – – –
16 – x – – x – – – –
24 x x x x x x x x x
48 x x – x x – x x x
60 – x – – – – – – –
72 – x x – x x – – –
96 – x – – x – – – –
120 – x – – x – – – –
144 – x – – x – – – –
168 – x x – x x x x x
192 – – – – – – x – –
216 – – – – – – x – –
336 – – – – – – x – –
360 – – – – – – x – –
384 – – – – – – x – –
504 – – – – – – – x x

Serum and tissue sample collection times are indicated with ‘x’ and no sample with ‘–’.
124 G. Zur et al. / The Veterinary Journal 200 (2014) 122–126

using the logarithm of plasma concentration vs. time-points. The area under the
concentration vs. time curve (AUC(0–24h)) was calculated by the trapezoidal method
from the time of first AZM administration to 24 h after administration (Gibaldi and
Perrier, 1982). The total body clearance after extra-vascular administration was ex-
pressed as CL(0–24h)/F, where F is the bioavailability. The maximum drug plasma
concentration (Cmax) and the time of occurrence (tmax) were determined directly
from the serum drug concentration vs. time curve.

Statistical analysis

In the study using healthy dogs, a one sample t test was used to determine sta-
tistical significance between skin concentrations of AZM and the MIC of 1 lg/mL,
the suggested MIC break point for most Gram-positive bacteria (Retsema et al.,
1987; Pereira et al., 2009). Fisher’s exact test was used to determine significant dif-
ferences between the results of the two dosages. In the study using dogs with pyo-
derma, the Wilcoxon signed Rank test was performed to compare AZM
concentrations between serum and skin. Comparison of the AZM skin concentration
between healthy and pyoderma dogs, was carried out using Mann–Whitney test. All
tests were two-tailed and P values <0.05 were considered to be significant. Statisti-
cal analyses were carried out using the SPSS statistical software (PASW statistics Fig. 1. Serum concentrations (± standard deviation) of azithromycin (AZM) after
version 18). initial oral administration of AZM at 7.02 mg/kg and 11.2 mg/kg to healthy
laboratory dogs (Serum-H).

Results

No adverse drug effects were observed during the study and the
biopsy wounds healed uneventfully. The PK parameters that were
determined for the healthy dogs are shown in Table 2. The actual
doses were significantly greater than the target doses of 5 and
10 lg/g (P < 0.0001 and P = 0.039, respectively). Hence, the true
individual dose was used in all PK calculations.
AZM serum concentration vs. time curves during the first 24 h
obtained after administration of AZM to healthy dogs are shown
in Fig. 1. AZM serum concentrations throughout the study are
shown in Fig. 2. Skin concentrations are shown in Fig. 3. AZM con-
centrations in serum and skin samples collected at 504 h only from
pyoderma dogs were 0.53 ± 0.31 and 13.07 ± 4.67 lg/g, respec-
tively (Fig. 4). In healthy dogs only the AZM concentrations after
the higher dose reached the suggested MIC of 1 lg/mL serum con-
centration (P = 0.019, one sample t test MIC value vs. measured Fig. 2. Serum concentrations (± standard deviation) of azithromycin (AZM) after
concentrations). The ratio between skin tissue and serum concen- oral administration of AZM at 7.02 mg/kg and 11.2 mg/kg to healthy dogs (Serum-
H) and dogs affected by pyoderma (Serum-P) at 10.7 mg/kg once daily during three
tration is presented in Fig. 4. Both serum and skin AZM concentra-
consecutive days in a 7 day period (repeated three times in the Serum-P group.
tions were higher (P = 0.04 and P = 0.0031) in dogs with pyoderma
than in healthy dogs. The ratio was significantly higher in dogs
with pyoderma than healthy dogs (P = 0.005).

Discussion

The absorption of AZM was rapid and Cmax values in healthy

dogs occurred 2 h after drug administration. These values may
slightly underestimate the Cmax, since tmax was determined to be
0.33–2.25 h in various species in previous studies (Girard et al.,
1987; Shepard and Falkner, 1990; Hunter et al., 1995). The slightly

Table 2
The average (± standard deviation, SD) of azithromycin (AZM) pharmacokinetic
parameters and SD in clinically healthy dogs after single oral dose administration of
AZM at 7.02 or 11.2 mg/kg (the target doses were 5 or 10 mg/kg).

7.02 mg/kg 11.2 mg/kg Fig. 3. Skin concentrations (± standard deviation) of azithromycin (AZM) in
Mean ± SD Range Mean ± SD Range biopsies obtained during the total duration of the study after oral administration
of AZM at 7.02 mg/kg and 11.2 mg/kg to healthy laboratory dogs (Skin-H) and dogs
Cmax (lg/mL) 0.60 ± 0.25 0.25–0.86 1.03 ± 0.43 2.10–0.67 affected by pyoderma (Skin-P) at 10.7 mg/kg once daily during three consecutive
AUC0–24h (lg/mL h) 6.08 ± 1.97 4.34–9.25 8.78 ± 1.36 6.08–10.4 days in a 7 day period.
MRT0–24h (h) 11.1 ± 0.8 10.2–12.8 8.40 ± 2.2 5.20–11.3
CL(0–24h)/F (L/h/kg) 1.24 ± 0.24 0.81–1.80 1.29 ± 0.24 1.02–1.79
t1/2 (h) 49.9 ± 5.10 43.3–57.8 51.9 ± 6.69 43.3–63.0
shorter MRT after the higher dose indicates faster absorption
Cmax, maximum serum AZM concentration (after first dose); AUC(0–24), area under
the AZM concentration vs. time curve; MRT(0–24h), mean residence time during the
compared to the lower dose assuming the same MRT value after
24 h from AZM administration; CL(0–24h)/F, total body clearance during the 24 h intravenous administration for both doses in the mean absorption
after AZM administration divided by bioavailability; t1/2, terminal half-life deter- time (MAT) calculation (Rowland and Tozer, 2011). There was a
mined after three consecutive once daily AZM administrations. linear relationship in Cmax values after both doses, consistent with
 G. Zur et al. / The Veterinary Journal 200 (2014) 122–126
Fig. 4. Skin tissue:serum concentration ratios of azithromycin (AZM) during the
total duration of the study after oral administration of AZM at 7.02 mg/kg and
11.2 mg/kg to healthy laboratory dogs (Skin-H) and pyoderma affected dogs (Skin-
P) at 10.7 mg/kg once daily during three consecutive days in a 7 day period
(repeated twice in the Serum-P group). The difference in the ratio between healthy
dogs (Skin-H 11.2 mg/kg) and dogs with pyoderma (Skin-P 10.7 mg/kg) at 24 and
168 h after drug administration was significant (P < 0.01).
previous studies (Girard et al., 1987; Shepard and Falkner, 1990;
Breitschwerdt et al., 1999). Cmax was similar to that found in cats
(Hunter et al., 1995), and slightly lower than reported previously
in dogs (Girard et al., 1987). All previous experiments used purified
drug compared to the commercial formulation used here. Hence,
Cmax may have been affected by the absorption rate in which the
AZM release from the tablet matrix may be incomplete or delayed.
In healthy dogs, t1/2 was 46 h and 49 h for the 7.02 and 11.2 mg/kg
doses. While the accurate determination of half-life using the present
study protocol may be compromised (determined after the third
dose compared to a single dose experiment), it was much longer
than the previously reported times of 3.5 h (Shepard and Falkner,
1990) or 21 h (Girard et al., 1987) in dogs, but only slightly longer
than the times reported in other species, e.g. 10–40 h in humans
(Lalak and Morris, 1993), 35 h in cats (Hunter et al., 1995) and 32 h
in rats (Shepard and Falkner, 1990). The t1/2 of AZM in foals was 16
and 18.3 h after IV and oral administration, respectively (Davis
et al., 2002).
According to Fig. 1, the induction phase indicated multi-com-
partment model disposition. This is consistent with the drug being
rapidly and extensively distributed. A long terminal phase exhibit-
ing linear decline was observed after the last administration. An
earlier study showed rapid absorption and a polyphasic decline
of plasma concentrations (Wildfeuer et al., 1993). Terminal half-
lives were similar in serum and in most tissues in rats and dogs
respectively; in dogs the t1/2 was 90 h after five doses of 30 mg/kg
(Shepard and Falkner, 1990).
AZM is dibasic compared to the monobasic 14-member ring
structure macrolides. The pKa value of AZM describing the two
nitrogen groups undergoing dissociation is 8.85 (8.8 and 8.9) and
almost equal to the pKa 8.6–8.9 of erythromycin (Goldman et al.,
1990). At physiological pH, both antimicrobial agents are proton-
ated and <4% will be in their neutral, non-ionised form. Macrolides
tend to accumulate in tissues due to higher level of ionisation com-
pared to serum (pH gradient). Skin tissue pH increases as a result of
an infection (Matousek and Campbell, 2002). Subsequently, skin
AZM concentration should decrease due to the reversed pH gradi-
ent with potential therapeutic consequences in treatment of der-
mal infections. Tissue concentrations up to 100 fold greater than
125
serum concentrations in dogs have been reported (Shepard and
Falkner, 1990).
The ratio, in declining order, in spleen, liver, kidney, lung, lymph
nodes and tonsils, ranged from 10 to over 100 after single or multi-
ple dose administrations in dogs and rats (Shepard and Falkner,
1990). Our results indicated low skin tissue to serum concentration
ratio in intact skin, but this ratio was increased up to 25-fold in the
pyoderma group (Fig. 4). This cannot be explained based on Hen-
derson–Hasselbalch equations as the pH gradient is to the opposite
direction. Leucocytes contain high concentrations of AZM, which
persists longer than in plasma (Gladue et al., 1989; Foulds et al.,
1990; Gladue and Snider, 1990; McDonald and Pruul, 1991; Pant-
eix et al., 1993; Wildfeuer et al., 1993; Bosnar et al., 2005; Liu
et al., 2007). Hence, the theoretical explanation for increased
AZM concentrations in the skin of dogs with pyoderma could be ac-
tive drug transport by leucocytes.
The 10 mg/kg AZM target dose during three consecutive days
appeared to be sufficient to maintain higher >1 lg/g skin concen-
trations for the following 4 days, in compliance with the suggested
MIC break point for most of the Gram-positive bacteria (Retsema
et al., 1987; Pereira et al., 2009). The AZM skin concentration after
168 h was 0.9 ± 0.37 lg/g at 5 mg/kg dose. Hence, 10 mg/kg AZM
appears the preferable option for clinical trials. AZM protein bind-
ing in the serum is very low (Girard et al., 1990). However, in hu-
mans it is concentration dependent (50% at 0.02 lg/mL and 12% at
0.5 lg/mL; Foulds et al., 1990). Protein binding has not been deter-
mined in dogs, but at the plasma concentrations measured in this
study (>0.1 lg/mL) it is likely to have a minor effect on azithromy-
cin disposition.
The large concentration difference between the serum and skin
observed in our study indicated that most of the AZM in skin is
either ionised or bound to tissue. The apparent volume of distribu-
tion at steady state (Vss) can only be determined after IV adminis-
tration (Soback and Britzi, 2011). Hence, despite the high
bioavailability (97%) of AZM in dogs (Shepard and Falkner, 1990),
Vss values were not calculated. Vss values in humans were 13.1
and 30.8 L/kg after single bolus dose and steady state IV infusion,
respectively (Chiu et al., 2002). Such a large apparent Vss indicates
that the amount of AZT in the body is almost totally outside the
vascular bed (Rowland and Tozer, 2011). Serum AZT concentra-
tions in healthy dogs were only initially positively correlated to
the dose (Figs. 1 and 2), which was consistent with the findings
in human beings (Blandizzi et al., 2002).
The ratio between skin and serum concentrations increased
with time after administration. The therapeutic applicability of
an antibiotic in treatment of an organ specific bacterial infection
is often related to the drug concentration at the infection site
(Drusano, 2005). PK data providing relevant drug tissue concentra-
tions are seldom available. Hence, extrapolations from plasma/ser-
um drug concentration data are frequently used for therapeutic
predictions. A multitude of PK/pharmacodynamic (PD) scores have
been developed for various classes of antimicrobial agents, such as
the ratio AUC/MIC (Craig, 1998; Thomas et al., 1998). Similar PK/PD
scores can be derived from Cmax/MIC or T > MIC, where T describes
the time that the drug concentration exceeds the MIC (Craig, 1998).
Both AUC/MIC and T > MIC have been indicated as meaningful for
AZM (Nightingale, 1997).
While protein binding and ionisation of the drug in serum/plas-
ma are likely to change little in disease, especially in chronic infec-
tions, the tissue changes may be greater. That will have a
significant effect on the drug concentration at the infection site.
The results of the present study enable these scores to be calcu-
lated and provide concentrations of AZM in the skin of healthy
dogs and dogs with pyoderma.
126 G. Zur et al. / The Veterinary Journal 200 (2014) 122–126
Conclusions
AZM pharmacokinetics in dogs were characterised by a long
half-life and slow clearance. Skin tissue concentrations were signif-
icantly higher than serum concentrations and the ratio increased
further in the inflamed skin. Henderson–Hasselbalch equations
relating to the plasma and skin pH and the effect on AZM dissoci-
ation in those matrixes cannot explain the increased AZM skin con-
centrations in the inflamed skin. The increased skin concentration
in pyoderma may be advantageous therapeutically. The experi-
mental in vivo data obtained in this study is valuable in planning
future clinical trials and in establishing an ad hoc dose regimen.
A once daily 10 mg/kg dose during three consecutive days weekly
may be suitable for treatment of pyoderma in dogs.
Conflict of interest statement
None of the authors of this paper has a financial or personal
relationship with other people or organisations that could inappro-
priately influence or bias the content of the paper.
Acknowledgements
The authors thank Mrs. Tali Bdolah-Abram for performing the
statistical analysis. This work was supported in part by Applied
Grants of Yissum, The Hebrew University of Jerusalem, Israel.
References
Amaya-Tapia, G., Aguirre-Avalos, G., Andrade-Villanueva, J., Peredo-Gonzalez, G.,
Morfin-Otero, R., Esparza-Ahumada, S., Rodriguez-Noriega, E., 1993. Once-daily
azithromycin in the treatment of adult skin and skin-structure infections.
Journal of Antimicrobial Chemotherapy 31, 129–135.
Blandizzi, C., Malizia, T., Batoni, G., Ghelardi, E., Baschiera, F., Bruschini, P., Senesi, S.,
Campa, M., Del Tacca, M., 2002. Distribution of azithromycin in plasma and
tonsil tissue after repeated oral administration of 10 or 20 milligrams per
kilogram in pediatric patients. Antimicrobial Agents and Chemotherapy 46,
1594–1596.
Bosnar, M., Kelneric, Z., Munic, V., Erakovic, V., Parnham, M.J., 2005. Cellular uptake
and efflux of azithromycin, erythromycin, clarithromycin, telithromycin, and
cethromycin. Antimicrobial Agents and Chemotherapy 49, 2372–2377.
Breitschwerdt, E.B., Papich, M.G., Hegarty, B.C., Gilger, B., Hancock, S.I., Davidson,
M.G., 1999. Efficacy of doxycycline, azithromycin, or trovafloxacin for treatment
of experimental Rocky Mountain spotted fever in dogs. Antimicrobial Agents
and Chemotherapy 43, 813–821.
Chiu, L.M., Menhinick, A.M., Johnson, P.W., Amsden, G.W., 2002. Pharmacokinetics
of intravenous azithromycin and ceftriaxone when administered alone and
concurrently to healthy volunteers. Journal of Antimicrobial Chemotherapy 50,
1075–1079.
Craig, W.A., 1998. Pharmacokinetic/pharmacodynamic parameters: Rationale for
antibacterial dosing of mice and men. Clinical Infectious Diseases 26, 1–10.
Daniel, R., 1991. Azithromycin, erythromycin and cloxacillin in the treatment of
infections of skin and associated soft tissues. European Azithromycin Study
Group. Journal of International Medical Research 19, 433–445.
Davis, J.L., Gardner, S.Y., Jones, S.L., Schwabenton, B.A., Papich, M.G., 2002.
Pharmacokinetics of azithromycin in foals after i.v. and oral dose and
disposition into phagocytes. Journal of Veterinary Pharmacology and
Therapeutics 25, 99–104.
Drusano, G.L., 2005. Infection site concentrations: Their therapeutic importance and
the macrolide and macrolide-like class of antibiotics. Pharmacotherapy 25,
150S–158S.
Dunkin, K.T., Jones, S., Howard, A.J., 1988. The in-vitro activity of CP-62,993 against
Haemophilus influenzae, Branhamella catarrhalis, staphylococci and streptococci.
Journal of Antimicrobial Chemotherapy 21, 405–411.
Fiese, E.F., Steffen, S.H., 1990. Comparison of the acid stability of azithromycin and
erythromycin A. Journal of Antimicrobial Chemotherapy 25, 39–47.
Foulds, G., Johnson, R.B., 1993. Selection of dose regimens of azithromycin. Journal
of Antimicrobial Chemotherapy 31, 39–50.
Foulds, G., Shepard, R.M., Johnson, R.B., 1990. The pharmacokinetics of azithromycin
in human serum and tissues. Journal of Antimicrobial Chemotherapy 25, 73–82.
Gibaldi, M., Perrier, D., 1982. Pharmacokinetics. Marcel Dekker, New York, USA, 504
pp.
Girard, A.E., Girard, D., English, A.R., Gootz, T.D., Cimochowski, C.R., Faiella, J.A.,
Haskell, S.L., Retsema, J.A., 1987. Pharmacokinetic and in vivo studies with
azithromycin (CP-62,993), a new macrolide with an extended half-life and
excellent tissue distribution. Antimicrobial Agents and Chemotherapy 31,
1948–1954.
Girard, A.E., Girard, D., Retsema, J.A., 1990. Correlation of the extravascular
pharmacokinetics of azithromycin with in-vivo efficacy in models of localized
infection. Journal of Antimicrobial Chemotherapy 25 (Suppl. A), 61–71.
Gladue, R.P., Bright, G.M., Isaacson, R.E., Newborg, M.F., 1989. In vitro and in vivo
uptake of azithromycin (CP-62,993) by phagocytic cells: Possible mechanism of
delivery and release at sites of infection. Antimicrobial Agents and
Chemotherapy 33, 277–282.
Gladue, R.P., Snider, M.E., 1990. Intracellular accumulation of azithromycin by
cultured human fibroblasts. Antimicrobial Agents and Chemotherapy 34, 1056–
1060.
Goldman, R.C., Fesik, S.W., Doran, C.C., 1990. Role of protonated and neutral forms of
macrolides in binding to ribosomes from Gram-positive and Gram-negative
bacteria. Antimicrobial Agents and Chemotherapy 34, 426–431.
Hunter, R., Lynch, M.J., Ericson, J.F., Millas, W.J., Fletcher, A.M., Ryan, N.I., Olson, J.A.,
1995. Pharmacokinetics, oral bioavailability and tissue distribution of
azithromycin in cats. Journal of Veterinary Pharmacology and Therapeutics
18, 38–46.
Lalak, N.J., Morris, D.L., 1993. Azithromycin clinical pharmacokinetics. Clinical
Pharmacokinetics 25, 370–374.
Liu, P., Allaudeen, H., Chandra, R., Phillips, K., Jungnik, A., Breen, J.D., Sharma, A.,
2007. Comparative pharmacokinetics of azithromycin in serum and white blood
cells of healthy subjects receiving a single-dose extended-release regimen
versus a 3-day immediate-release regimen. Antimicrobial Agents and
Chemotherapy 51, 103–107.
Mallory, S.B., 1991. Azithromycin compared with cephalexin in the treatment of
skin and skin structure infections. American Journal of Medicine 91, 36S–39S.
Matousek, J.L., Campbell, K.L., 2002. A comparative review of cutaneous pH.
Veterinary Dermatology 13, 293–300.
McDonald, P.J., Pruul, H., 1991. Phagocyte uptake and transport of azithromycin.
European Journal of Clinical Microbiology and Infectious Diseases 10, 828–833.
Miller Jr., W.H., Griffin, C.E., Campbell, K.A., 2012. Dermatologic therapy. In: Muller
and Kirk’s Small Animal Dermatology, Seventh Ed. W.B. Saunders, Philadelphia,
Pennsylvania, USA, pp. 108–183.
Mutak, S., 2007. Azalides from azithromycin to new azalide derivatives. Journal of
Antibiotics 60, 85–122.
Nightingale, C.H., 1997. Pharmacokinetics and pharmacodynamics of newer
macrolides. Pediatrics Infectious Disease Journal 16, 438–443.
Noli, C., Boothe, D., 1999. Macrolides and lincosamides. Veterinary Dermatology 10,
217–223.
Norrby, S.R., 1991. Azithromycin: An antibiotic with unusual properties. European
Journal of Clinical Microbiology and Infectious Diseases 10, 805–806.
Panteix, G., Guillaumond, B., Harf, R., Desbos, A., Sapin, V., Leclercq, M., Perrin-
Fayolle, M., 1993. In-vitro concentration of azithromycin in human phagocytic
cells. Journal of Antimicrobial Chemotherapy 31, 1–4.
Pereira, I., Soares, L.C., Coelho, S.M.O., Pribul, B.R., Souza, M.M.S., 2009. Susceptibility
to azithromycin of bacteria isolated from infectious processes in dogs and cats.
Brazilian Journal of Veterinary Research and Animal Science 29, 153–156.
Retsema, J., Girard, A., Schelkly, W., Manousos, M., Anderson, M., Bright, G., Borovoy,
R., Brennan, L., Mason, R., 1987. Spectrum and mode of action of azithromycin
(CP-62,993), a new 15-membered-ring macrolide with improved potency
against Gram-negative organisms. Antimicrobial Agents and Chemotherapy
31, 1939–1947.
Retsema, J.A., Girard, A.E., Girard, D., Milisen, W.B., 1990. Relationship of high tissue
concentrations of azithromycin to bactericidal activity and efficacy in vivo.
Journal of Antimicrobial Chemotherapy 25, 83–89.
Rodriguez-Solares, A., Perez-Gutierrez, F., Prosperi, J., Milgram, E., Martin, A., 1993.
A comparative study of the efficacy, safety and tolerance of azithromycin,
dicloxacillin and flucloxacillin in the treatment of children with acute skin and
skin-structure infections. Journal of Antimicrobial Chemotherapy 31, 103–
109.
Rowland, M., Tozer, T.N., 2011. Clinical Pharmacokinetics and Pharmacodynamics:
Concepts and Applications, Fourth Ed. Lippincott Williams and Wilkins,
Philadelphia, Pennsylvania, USA, 864 pp.
Shepard, R.M., Falkner, F.C., 1990. Pharmacokinetics of azithromycin in rats and
dogs. Journal of Antimicrobial Chemotherapy 25, 49–60.
Soback, S., Britzi, M., 2011. Absorption-dependent apparent volume of distribution
at steady state (V(ss)/F) in pharmacokinetic data analysis. Journal of Veterinary
Pharmacology and Therapeutics 34, 512–514.
Stegemann, M.R., Coati, N., Passmore, C.A., Sherington, J., 2007. Clinical efficacy and
safety of cefovecin in treatment of canine pyoderma and wound infections.
Journal of Small Animal Practice 48, 378–386.
Thomas, J.K., Forrest, A., Bhavnani, S.M., Hyatt, J.M., Cheng, A., Ballow, C.H.,
Schentag, J.J., 1998. Pharmacodynamic evaluation of factors associated with the
development of bacterial resistance in acutely ill patients during therapy.
Antimicrobial Agents and Chemotherapy 42, 521–527.
Wildfeuer, A., Laufen, H., Leitold, M., Zimmermann, T., 1993. Comparison of the
pharmacokinetics of three-day and five-day regimens of azithromycin in
plasma and urine. Journal of Antimicrobial Chemotherapy 31, 51–56.
Yamaoka, K., Nakagawa, T., Uno, T., 1978. Statistical moments in pharmacokinetics.
Journal of Pharmacokinetics and Biopharmaceutics 6, 547–558.
Yamaoka, K., 1986. Methods for Pharmacokinetic Analysis for Personal Computer,
Second Ed. Nanko-Do, Tokyo, Japan, pp. 145–174.