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Fernández-Rubio B, Herrera-Hidalgo L, de Alarcón A, Luque-Márquez R, López-Cortés LE, Luque S, Gutiérrez-Urbón JM, Fernández-Polo A, Gutiérrez-Valencia A, Gil-Navarro MV. Stability Studies of Antipseudomonal Beta Lactam Agents for Outpatient Therapy. Pharmaceutics 2023; 15:2705. [PMID: 38140046 PMCID: PMC10747133 DOI: 10.3390/pharmaceutics15122705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) is a useful treatment strategy against Pseudomonas aeruginosa and other multidrug-resistant bacteria. However, it is hindered by the lack of stability data for the administration of antibiotics under OPAT conditions. Our objective was to investigate the stability of nine antipseudomonal and broad-spectrum beta lactam antibiotics (aztreonam, cefepime, cefiderocol, ceftazidime, ceftazidime/avibactam, ceftolozane/tazobactam, meropenem, meropenem/vaborbactam, and piperacillin/tazobactam) to allow the spread of OPAT programs. All the antibiotics were diluted in 500 mL 0.9% sodium chloride and stored at 4, 25, 32, and 37 °C for 72 h in two different devices (infusion bags and elastomeric pumps). The solutions were considered stable if the color, clearness, and pH remained unchanged and if the percentage of intact drug was ≥90%. All the antimicrobials remained stable 72 h under refrigerated conditions and at least 30 h at 25 °C. At 32 °C, all the antibiotics except for meropenem and meropenem/vaborbactam remained stable for 24 h or more. At 37 °C, only aztreonam, piperacillin/tazobactam, cefepime, cefiderocol, and ceftolozane/tazobactam were stable for at least 24 h. The stability results were the same in the two devices tested. All the antibiotics studied are actual alternatives for the treatment of antipseudomonal or multidrug-resistant infections in OPAT programs, although the temperature of the devices is crucial to ensure antibiotic stability.
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Affiliation(s)
- Beatriz Fernández-Rubio
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Arístides de Alarcón
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Rafael Luque-Márquez
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Luis E. López-Cortés
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena/Department of Medicine, School of Medicine, University of Sevilla/Biomedicine Institute of Sevilla (IBiS)/CSIC, 41009 Seville, Spain
| | - Sònia Luque
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), 08003 Barcelona, Spain
| | - José María Gutiérrez-Urbón
- Unidad de Gestión Clínica de Farmacia, Complexo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain;
| | - Aurora Fernández-Polo
- Unidad de Gestión Clínica de Farmacia, Hospital Universitari Vall d’Hebron, Institut de Recerca Vall d’Hebron, 08035 Barcelona, Spain;
| | - Alicia Gutiérrez-Valencia
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
| | - María V. Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
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Venuti F, Trunfio M, Martson AG, Lipani F, Audagnotto S, Di Perri G, Calcagno A. Extended and Continuous Infusion of Novel Protected β-Lactam Antibiotics: A Narrative Review. Drugs 2023:10.1007/s40265-023-01893-6. [PMID: 37314633 DOI: 10.1007/s40265-023-01893-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
Consolidated data from pharmacokinetic and pharmacodynamic studies support the administration of β-lactam antibiotics in prolonged infusion (i.e., extended or continuous) to optimize therapeutic efficacy by increasing the probability of attaining maximal bactericidal activity. This is the longest possible time during which the free drug concentrations are approximately four-fold the minimum inhibitory concentration between dosing intervals. In the context of antimicrobial stewardship strategies, achieving aggressive pharmacokinetic and pharmacodynamic targets is an important tool in the management of multi-drug resistant (MDR) bacterial infections and in the attainment of mutant preventing concentrations. However, prolonged infusion remains an unexploited resource. Novel β-lactam/β-lactamase inhibitor (βL/βLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-cilastatin-relebactam) have been released in recent years to face the emerging challenge of MDR Gram-negative bacteria. Pre-clinical and real-life evidence has confirmed the promising role of prolonged infusion of these molecules in specific settings and clinical populations. In this narrative review we have summarized available pharmacological and clinical data, future perspectives, and current limitations of prolonged infusion of the novel protected β-lactams, their application in hospital settings and in the context of outpatient parenteral antimicrobial therapy.
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Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy.
| | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Anne-Grete Martson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Filippo Lipani
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
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Quinn AM, Bottery MJ, Thompson H, Friman VP. Resistance evolution can disrupt antibiotic exposure protection through competitive exclusion of the protective species. THE ISME JOURNAL 2022; 16:2433-2447. [PMID: 35859161 PMCID: PMC9477885 DOI: 10.1038/s41396-022-01285-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 12/05/2022]
Abstract
Antibiotic degrading bacteria can reduce the efficacy of drug treatments by providing antibiotic exposure protection to pathogens. While this has been demonstrated at the ecological timescale, it is unclear how exposure protection might alter and be affected by pathogen antibiotic resistance evolution. Here, we utilised a two-species model cystic fibrosis (CF) community where we evolved the bacterial pathogen Pseudomonas aeruginosa in a range of imipenem concentrations in the absence or presence of Stenotrophomonas maltophilia, which can detoxify the environment by hydrolysing β-lactam antibiotics. We found that P. aeruginosa quickly evolved resistance to imipenem via parallel loss of function mutations in the oprD porin gene. While the level of resistance did not differ between mono- and co-culture treatments, the presence of S. maltophilia increased the rate of imipenem resistance evolution in the four μg/ml imipenem concentration. Unexpectedly, imipenem resistance evolution coincided with the extinction of S. maltophilia due to increased production of pyocyanin, which was cytotoxic to S. maltophilia. Together, our results show that pathogen resistance evolution can disrupt antibiotic exposure protection due to competitive exclusion of the protective species. Such eco-evolutionary feedbacks may help explain changes in the relative abundance of bacterial species within CF communities despite intrinsic resistance to anti-pseudomonal drugs.
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Loeuille G, D’Huart E, Vigneron J, Nisse YE, Beiler B, Polo C, Ayari G, Sacrez M, Demoré B, Charmillon A. Stability Studies of 16 Antibiotics for Continuous Infusion in Intensive Care Units and for Performing Outpatient Parenteral Antimicrobial Therapy. Antibiotics (Basel) 2022; 11:antibiotics11040458. [PMID: 35453211 PMCID: PMC9030478 DOI: 10.3390/antibiotics11040458] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/16/2022] Open
Abstract
The use of continuous infusion to improve the therapeutic efficacy of time-dependent antibiotics has been demonstrated. There is still a lack of data to safely perform these continuous infusions. The objectives in this study were to evaluate the stability by using stability-indicating methods (High-Performance Liquid Chromatography) of 16 antibiotics in concentrated solutions, especially for administration in intensive care units and solutions in elastomeric diffusers at 37 °C for outpatient parenteral antimicrobial therapy. The solutions were considered stable if the percentage of the drug was ≥90%, and the colour and clearness remained unchanged. In syringes, the stability data vary from 4 to 8 h (h) for meropenem in Dextrose 5% (D5W) and Normal Saline (NS), respectively, 6 h for cefotaxime, 12 h for cefoxitin, and 24 h for aztreonam, cefazolin, cefepime, cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam in NS and D5W, and in water for injection for cloxacillin. A stability period of 48 h has been validated for vancomycin (D5W), aztreonam, and piperacillin/tazobactam. Cefoxitin, cefazolin, cefepime, cefotaxime, cloxacillin, and piperacillin are unstable for diffuser administration. In diffusers, stability times vary from 6 h for cefiderocol, 8 h for ceftazidime, 12 h for ceftazidime/avibactam and ceftolozane/tazobactam (NS), 24 h for temocillin (NS) and piperacillin/tazobactam (D5W), up to 48 h for aztreonam and vancomycin. Solutions stored at 37 °C are less stable and allow the administration of seven antibiotics using diffusers.
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Affiliation(s)
- Guillaume Loeuille
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Elise D’Huart
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
- Infostab, Non-Profit Association, 54180 Heillecourt, France
- Correspondence: e.d’; Tel.: +33-383154410
| | - Jean Vigneron
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
- Infostab, Non-Profit Association, 54180 Heillecourt, France
| | - Yann-Eric Nisse
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Benoit Beiler
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Caroline Polo
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Gillian Ayari
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Matthieu Sacrez
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
| | - Béatrice Demoré
- Pharmacy Department, University Hospital, 54511 Vandoeuvre-lès-Nancy, France; (G.L.); (J.V.); (Y.-E.N.); (B.B.); (C.P.); (G.A.); (M.S.); (B.D.)
- Infostab, Non-Profit Association, 54180 Heillecourt, France
- EA 4360 APEMAC, Lorraine University, 54000 Nancy, France
| | - Alexandre Charmillon
- Infectious Diseases Department in Charge of Mobile Infectiology Team University Hospital, 54511 Vandoeuvre-lès-Nancy, France;
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Jadhav RA, Ahirrao VK, Pathan AR, Patil KR, Rane VP, Yeole RD. An Efficient HPLC–MS Method for Impurity Profile of Ertapenem. Chromatographia 2020. [DOI: 10.1007/s10337-020-03928-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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