Risk Factors for Nephrotoxicity in Methicillin-Resistant Staphylococcus aureus Bacteraemia: A Post Hoc Analysis of the CAMERA2 Trial

Safe and effective use of vancomycin

Vancomycin is an important antimicrobial for prophylactic, empirical and directed therapy of Gram-positive organisms. Therapeutic drug monitoring is recommended for all patients expected to receive vancomycin for more than 48 hours to optimise drug exposure. Monitoring the area under the concentration-time curve over a 24-hour period (AUC24) for vancomycin is preferred over monitoring trough plasma concentrations. An AUC24 of 400 to 600 mg.hr/L is recommended for infections other than central nervous system infections. Vancomycin may cause nephrotoxicity, ototoxicity, cutaneous reactions, hypersensitivity and haematological toxicity. Reducing the incidence of vancomycin-induced nephrotoxicity involves recognising and modifying risk factors where possible.

Polygonum tinctorium extract suppresses the virulence of methicillin-resistant Staphylococcus aureus by disrupting its extracellular vesicles

ETHNOPHARMACOLOGICAL RELEVANCE

Methicillin-resistant S. aureus (MRSA) is a significant global health concern, causing both hospital- and community-acquired infections. The extracellular vesicles released by S. aureus (SaEVs) contain essential factors related to the bacterial survival and pathogenicity. Polygonum tinctorium is traditionally used as a natural dye (indigo) and for treating various infectious diseases caused by microorganisms. However, the effect of P. tinctorium extract (Indigo Ex) and its mechanism on SaEVs is unknown.

AIM OF THE STUDY

We investigated the effect and mechanism of Indigo Ex on SaEVs, which could be used in controlling S. aureus, especially MRSA infection.

MATERIALS AND METHODS

Indigo Ex was prepared from pesticide-free P. tinctorium, which was dried, powdered, and extracted with d-limonene. SaEVs were isolated and purified from MRSA culture supernatant by step-gradient ultracentrifugation. The effect of Indigo Ex on SaEVs morphology was observed by both transmission and scanning electron microscopy after incubating the Indigo Ex and SaEVs under shaking conditions. The cytotoxicity of Indigo Ex was performed using mouse macrophage cell line, RAW 264.7. In addition, the ability of Indigo Ex-treated SaEVs to stimulate the immune response and cytotoxicity in RAW 264.7 cells were evaluated by ELISA and WST-1 assay, respectively.

RESULTS

SaEV particles were disrupted when treated with undiluted Indigo Ex in a time-dependent manner. For the cytotoxicity of Indigo Ex on RAW 264.7 cells, over 50% of the cell viability decreased when diluted Indigo Ex 1000-fold and no cytotoxic effect was observed at a 25,000-fold dilution of Indigo Ex. Interestingly, the Indigo Ex-treated SaEVs showed less cytotoxic effect than SaEVs alone. Similarly, SaEVs treated with Indigo Ex reduced stimulation of pro-inflammatory cytokines (TNF-α and IL-6) and anti-inflammatory cytokine (IL-10) in RAW 264.7 cells compared to untreated SaEVs. Our results indicate that Indigo Ex disrupted SaEV particles, resulting in reduced virulence and stimulation of immune response.

CONCLUSIONS

This study reveals that the low concentration of Indigo Ex can suppresses the virulence of SaEVs without causing cytotoxicity to the host cells. Therefore, Indigo Ex may have the potential to be used to control S. aureus infection.

Understanding vancomycin nephrotoxicity augmented by β-lactams: a synthesis of endosymbiosis, proximal renal tubule mitochondrial metabolism, and β-lactam chemistry

The recent understanding that hydrophobic β-lactams have greater affinity for organic anion transporter-3 (OAT-3) of the proximal renal tubule could provide valuable insights for anticipating β-lactams that may exacerbate vancomycin-induced nephrotoxicity. Vancomycin alone provides oxidative stress on the highly metabolic proximal tubular cells. Hydrophobic β-lactams (eg, piperacillin and anti-staphylococcal β-lactams) could have greater OAT-3 mediated uptake into proximal tubular cells than hydrophilic β-lactams (eg, most cephalosporins and carbapenems), thereby causing greater mitochondrial stress on these susceptible cells. It remains to be seen whether concomitant drugs that inhibit OAT-3 mediated cellular uptake of β-lactams into proximal tubular cells or provide antioxidant effects might mitigate β-lactam augmented vancomycin nephrotoxicity. Furthermore, the serum creatinine rise seen with vancomycin and hydrophobic β-lactams might represent competition for creatinine-secreting transporters (of which OAT-3 is one), thus, indicating creatinine retention rather than renal injury. In the meantime, clinicians are advised to utilise less nephrotoxic combinations in both empirical and directed antibiotic selection settings until further research is conducted.

Flucloxacillin worsens while imipenem-cilastatin protects against vancomycin-induced kidney injury in a translational rat model

BACKGROUND AND PURPOSE

Vancomycin is one of the most common clinical antibiotics, yet acute kidney injury is a major limiting factor. Common combinations of antibiotics with vancomycin have been reported to worsen and improve vancomycin-induced kidney injury. We aimed to study the impact of flucloxacillin and imipenem-cilastatin on kidney injury when combined with vancomycin in our translational rat model.

EXPERIMENTAL APPROACH

Male Sprague-Dawley rats received allometrically scaled (1) vancomycin, (2) flucloxacillin, (3) vancomycin + flucloxacillin, (4) vancomycin + imipenem-cilastatin or (5) saline for 4 days. Kidney injury was evaluated via drug accumulation and urinary biomarkers including urinary output, kidney injury molecule-1 (KIM-1), clusterin and osteopontin. Relationships between vancomycin accumulation in the kidney and urinary kidney injury biomarkers were explored.

KEY RESULTS

Urinary output increased every study day for vancomycin + flucloxacillin, but after the first dose only in the vancomycin group. In the vancomycin + flucloxacillin group, urinary KIM-1 increased on all days compared with vancomycin. In the vancomycin + imipenem-cilastatin group, urinary KIM-1 was decreased on Days 1 and 2 compared with vancomycin. Similar trends were observed for clusterin. More vancomycin accumulated in the kidney with vancomycin + flucloxacillin compared with vancomycin and vancomycin + imipenem-cilastatin. The accumulation of vancomycin in the kidney tissue correlated with increasing urinary KIM-1.

CONCLUSIONS AND IMPLICATIONS

Vancomycin + flucloxacillin caused more kidney injury compared with vancomycin alone and vancomycin + imipenem-cilastatin in a translational rat model. The combination of vancomycin + imipenem-cilastatin was nephroprotective.

Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study

BACKGROUND

The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L.

AIM

To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions.

METHOD

A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data.

RESULTS

Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L.

CONCLUSION

Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.

Optimal drug therapy for Staphylococcus aureus bacteraemia in adults

PURPOSE OF REVIEW

Staphylococcus aureus is a significant human pathogen, causing a variety of infections, from skin and soft tissue infections to endocarditis, bone and joint infections and deep tissue abscesses. Mortality from S. aureus bacteraemia remains high, without major therapeutic advances in recent decades.

RECENT FINDINGS

In recent years, optimized dosing of antibiotics is increasingly being recognized as a cornerstone of management for severe infections including S. aureus bacteraemia. This comprehensive review details the pharmacokinetics/pharmacodynamics (PK/PD) targets for commonly used antistaphylococcal antibiotics and the doses predicted to achieve them in clinical practice. Recent advances in dosing of teicoplanin and use of cefazolin in CNS infections and findings from combination therapy studies are discussed. Drug exposure relationships related to toxicity are also detailed.

SUMMARY

This review details the different PK/PD targets for drugs used to treat S. aureus bacteraemia and how to apply them in various scenarios. The drug doses that achieve them, and the risks of toxicity are also provided.