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Ehrmann S, Barbier F, Li J. Aerosolized Antibiotic Therapy in Mechanically Ventilated Patients. Am J Respir Crit Care Med 2024; 210:730-736. [PMID: 38984938 DOI: 10.1164/rccm.202402-0437cp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/03/2024] [Indexed: 07/11/2024] Open
Abstract
Delivering antibiotics directly to the respiratory tract through inhalation to address lung infections has garnered clinical and scientific interest for decades, given the potential favorable pharmacokinetic profile of this administration route. Among critically ill patients, the burden of healthcare-associated pulmonary infections particularly drove continued interest in delivering inhaled antibiotics to intubated patients. We present a concise overview of the existing rationale and evidence and provide guidance for implementing inhaled antibiotics among ventilated critically ill patients, emphasizing insights from recent literature.
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Affiliation(s)
- Stephan Ehrmann
- Médecine Intensive Réanimation, Centre d'Investigation Clinique de Tours, Institut national de la santé et de la recherche médicale 1415, CRICS-TriggerSEP French Clinical Research Infrastructure Network, Centre Hospitalier Régional Universitaire de Tours, Tours, France
- Centre d'étude des pathologies respiratoires, Institut national de la santé et de la recherche médicale U1100, Tours, France
| | - François Barbier
- Centre d'étude des pathologies respiratoires, Institut national de la santé et de la recherche médicale U1100, Tours, France
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Orléans, Orleans, France; and
| | - Jie Li
- Division of Respiratory Care, Department of Cardiopulmonary Sciences, Rush University, Chicago, Illinois
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2
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Shi R, Fu Y, Gan Y, Wu D, Zhou S, Huang M. Use of polymyxin B with different administration methods in the critically ill patients with ventilation associated pneumonia: a single-center experience. Front Pharmacol 2023; 14:1222044. [PMID: 37719858 PMCID: PMC10502420 DOI: 10.3389/fphar.2023.1222044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Background: Whether nebulized polymyxin B should be used as an adjunctive therapy or substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia (VAP) remains controversial. This study's aim is to evaluate the efficacy and safety of different administration ways of polymyxin B in the treatment of ventilator-associated pneumonia caused by extensively drug-resistant Gram-negative bacteria(XDR-GNB). Methods: This retrospective cohort study enrolled ventilator-associated pneumonia patients caused by XDR-GNB treated with polymyxin B in the intensive care unit. Patients were categorized by the administration methods as intravenous (IV) group, inhaled (IH) group, and the intravenous combined with inhaled (IV + IH) group. Microbiological outcome and clinical outcome were compared in each group. The side effects were also explored. Results: A total of 111 patients were enrolled and there was no difference in demographic and clinical characteristics among the three groups. In terms of efficacy, clinical cure or improvement was achieved in 21 patients (55.3%) in the intravenous group, 19 patients (50%) in the IH group, and 20 patients (57.1%) in IV + IH group (p = 0.815). All three groups showed high success rates in microbiological eradication, as 29 patients with negative cultures after medication in inhaled group. Among all the patients who had negative bacterial cultures after polymyxin B, the inhaled group had significantly shorter clearance time than the intravenous group (p = 0.002), but with no significant difference in 28-day mortality. Compared with intravenous group, a trend towards a lower risk of acute kidney injury was observed in inhaled group (p = 0.025). Conclusion: From the perspective of minimal systemic renal toxicity, nebulized polymyxin B as a substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia caused by XDR-GNB is feasible.
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Affiliation(s)
- Rupeng Shi
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanyuan Fu
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yujing Gan
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Danying Wu
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Suming Zhou
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Huang
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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3
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Li J, Liu K, Lyu S, Jing G, Dai B, Dhand R, Lin HL, Pelosi P, Berlinski A, Rello J, Torres A, Luyt CE, Michotte JB, Lu Q, Reychler G, Vecellio L, de Andrade AD, Rouby JJ, Fink JB, Ehrmann S. Aerosol therapy in adult critically ill patients: a consensus statement regarding aerosol administration strategies during various modes of respiratory support. Ann Intensive Care 2023; 13:63. [PMID: 37436585 DOI: 10.1186/s13613-023-01147-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Clinical practice of aerosol delivery in conjunction with respiratory support devices for critically ill adult patients remains a topic of controversy due to the complexity of the clinical scenarios and limited clinical evidence. OBJECTIVES To reach a consensus for guiding the clinical practice of aerosol delivery in patients receiving respiratory support (invasive and noninvasive) and identifying areas for future research. METHODS A modified Delphi method was adopted to achieve a consensus on technical aspects of aerosol delivery for adult critically ill patients receiving various forms of respiratory support, including mechanical ventilation, noninvasive ventilation, and high-flow nasal cannula. A thorough search and review of the literature were conducted, and 17 international participants with considerable research involvement and publications on aerosol therapy, comprised a multi-professional panel that evaluated the evidence, reviewed, revised, and voted on recommendations to establish this consensus. RESULTS We present a comprehensive document with 20 statements, reviewing the evidence, efficacy, and safety of delivering inhaled agents to adults needing respiratory support, and providing guidance for healthcare workers. Most recommendations were based on in-vitro or experimental studies (low-level evidence), emphasizing the need for randomized clinical trials. The panel reached a consensus after 3 rounds anonymous questionnaires and 2 online meetings. CONCLUSIONS We offer a multinational expert consensus that provides guidance on the optimal aerosol delivery techniques for patients receiving respiratory support in various real-world clinical scenarios.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA.
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan Lyu
- Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Guoqiang Jing
- Department of Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Bing Dai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Paolo Pelosi
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Ariel Berlinski
- Pulmonary and Sleep Medicine Division, Department of Pediatrics, University of Arkansas for Medical Sciences, and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Clinical Research in the ICU, Anaesthesia Department, CHU Nimes, Université de Nimes-Montpellier, Nimes, France
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, University of Barcelona, IDIBAPS CIBERES, Icrea, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, and INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Jean-Bernard Michotte
- School of Health Sciences (HESAV), HES-SO University of Applied Sciences and Arts of Western Switzerland, Lausanne, Switzerland
| | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, and Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang University School of Medicine, Hangzhou, China
| | - Gregory Reychler
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL and Dermatologie, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Jean-Jacques Rouby
- Research Department DMU DREAM and Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Sorbonne University of Paris, Paris, France
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, 600 S Paulina St, Suite 765, Chicago, IL, 60612, USA
- Chief Science Officer, Aerogen Pharma Corp, San Mateo, CA, USA
| | - Stephan Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, and INSERM, Centre d'étude des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
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4
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Kyriakoudi A, Pontikis K, Valsami G, Avgeropoulou S, Neroutsos E, Christodoulou E, Moraitou E, Markantonis SL, Dokoumetzidis A, Rello J, Koutsoukou A. Pharmacokinetic Characteristics of Nebulized Colistimethate Sodium Using Two Different Types of Nebulizers in Critically Ill Patients with Ventilator-Associated Respiratory Infections. Antibiotics (Basel) 2022; 11:1528. [PMID: 36358184 PMCID: PMC9686516 DOI: 10.3390/antibiotics11111528] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 05/25/2024] Open
Abstract
Background: Rising antimicrobial resistance has led to a revived interest in inhaled colistin treatment in the critically ill patient with ventilator-associated respiratory infection (VARI). Nebulization via vibrating mesh nebulizers (VMNs) is considered the current standard-of-care, yet the use of generic jet nebulizers (JNs) is more widespread. Few data exist on the intrapulmonary pharmacokinetics of colistin when administered through VMNs, while there is a complete paucity regarding the use of JNs. Methods: In this study, 18 VARI patients who received 2 million international units of inhaled colistimethate sodium (CMS) through a VMN were pharmacokinetically compared with six VARI patients who received the same drug dose through a JN, in the absence of systemic CMS administration. Results: Surprisingly, VMN and JN led to comparable formed colistin exposures in the epithelial lining fluid (ELF) (median (IQR) AUC0-24: 86.2 (46.0-185.9) mg/L∙h with VMN and 91.5 (78.1-110.3) mg/L∙h with JN). The maximum ELF concentration was 10.4 (4.7-22.6) mg/L and 7.4 (6.2-10.3) mg/L, respectively. Conclusions: Based on our results, JN might be considered a viable alternative to the theoretically superior VMN. Therapeutic drug monitoring in the ELF can be advised due to the observed low exposure, high variability, and appreciable systemic absorption.
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Affiliation(s)
- Anna Kyriakoudi
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Georgia Valsami
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Stavrina Avgeropoulou
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Efthymios Neroutsos
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Eirini Christodoulou
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Eleni Moraitou
- Microbiology Department, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Sophia L. Markantonis
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Aristides Dokoumetzidis
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Jordi Rello
- Clinical Research in Pneumonia (CRIPS), Vall d’Hebron Institute of Research, 08035 Barcelona, Spain
- Clinical Research, CHU Nîmes, 30900 Nîmes, France
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
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5
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Rouby JJ, Zhu Y, Torres A, Rello J, Monsel A. Aerosolized polymyxins for ventilator-associated pneumonia caused by extensive drug resistant Gram-negative bacteria: class, dose and manner should remain the trifecta. Ann Intensive Care 2022; 12:97. [PMID: 36251177 PMCID: PMC9576828 DOI: 10.1186/s13613-022-01068-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023] Open
Affiliation(s)
- Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance-Publique Hôpitaux de Paris, Sorbonne University of Paris, Paris, France.
| | - Yinggang Zhu
- Department of Pulmonary and Critical Care Medicine, Hua-Dong Hospital, Fudan University, Shanghai, China
| | - Antoni Torres
- Department of Pneumology, SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Jordi Rello
- Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Clinical Research & Innovation in Pneumonia & Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance-Publique Hôpitaux de Paris, Sorbonne University of Paris, Paris, France.,Unité mixte de recherche (UMR)-S 959, Immunology-Immunopathology-Immunotherapy (I3), Institut National de La Santé et de La Recherche Médicale (INSERM), Paris, France.,Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
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6
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Giacobbe DR, Roberts JA, Abdul-Aziz MH, de Montmollin E, Timsit JF, Bassetti M. Treatment of ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacteria with novel agents: a contemporary, multidisciplinary ESGCIP perspective. Expert Rev Anti Infect Ther 2022; 20:963-979. [PMID: 35385681 DOI: 10.1080/14787210.2022.2063838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION : In the past 15 years, treatment of VAP caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) has represented an intricate challenge for clinicians. AREAS COVERED In this perspective article, we discuss the available clinical data about novel agents for the treatment of CR-GNB VAP, together with general PK/PD principles for the treatment of VAP, in the attempt to provide some suggestions for optimizing antimicrobial therapy of CR-GNB VAP in the daily clinical practice. EXPERT OPINION Recently, novel BL and BL/BLI combinations have become available that have shown potent in vitro activity against CR-GNB and have attracted much interest as novel, less toxic, and possibly more efficacious options for the treatment of CR-GNB VAP compared with previous standard of care. Besides randomized controlled trials, a good solution to enrich our knowledge on how to use these novel agents at best in the near future, while at the same time remaining adherent to current evidence-based guidelines, is to improve our collaboration to conduct larger multinational observational studies to collect sufficiently large populations treated in real life with those novel agents for which guidelines currently do not provide a recommendation (in favor or against) for certain causative organisms.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
| | - Jason A Roberts
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
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7
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Treatment of Severe Infections Due to Metallo-Betalactamases Enterobacterales in Critically Ill Patients. Antibiotics (Basel) 2022; 11:antibiotics11020144. [PMID: 35203747 PMCID: PMC8868391 DOI: 10.3390/antibiotics11020144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 02/06/2023] Open
Abstract
Metallo-beta-lactamases-producing (MBL) Enterobacterales is a growing problem worldwide. The optimization of antibiotic therapy is challenging. The pivotal available therapeutic options are either the combination of ceftazidime/avibactam and aztreonam or cefiderocol. Colistin, fosfomycin, tetracyclines and aminoglycosides are also frequently effective in vitro, but are associated with less bactericidal activity or more toxicity. Prior to the availability of antibiotic susceptibility testing, severe infections should be treated with a combination therapy. A careful optimization of the pharmacokinetic/pharmacodynamic properties of antimicrobials is instrumental in severe infections. The rules of antibiotic therapy are also reported and discussed. To conclude, treatment of severe MBL infections in critically ill patients is difficult. It should be individualized with a close collaboration of intensivists with microbiologists, pharmacists and infection control practitioners.
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Boisson M, Bouglé A, Sole-Lleonart C, Dhanani J, Arvaniti K, Rello J, Rouby JJ, Mimoz O. Nebulized Antibiotics for Healthcare- and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:255-270. [PMID: 35042259 DOI: 10.1055/s-0041-1740340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Global emergence of multidrug-resistant and extensive drug-resistant gram-negative bacteria has increased the risk of treatment failure, especially for healthcare- or ventilator-associated pneumonia (HAP/VAP). Nebulization of antibiotics, by providing high intrapulmonary antibiotic concentrations, represents a promising approach to optimize the treatment of HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria, while limiting systemic antibiotic exposure. Aminoglycosides and colistin methanesulfonate are the most common nebulized antibiotics. Although optimal nebulized drug dosing regimen is not clearly established, high antibiotic doses should be administered using vibrating-mesh nebulizer with optimized ventilator settings to ensure safe and effective intrapulmonary concentrations. When used preventively, nebulized antibiotics reduced the incidence of VAP without any effect on mortality. This approach is not yet recommended and large randomized controlled trials should be conducted to confirm its benefit and explore the impact on antibiotic selection pressure. Compared with high-dose intravenous administration, high-dose nebulized colistin methanesulfonate seems to be more effective and safer in the treatment of ventilator-associated tracheobronchitis and VAP caused by multidrug resistant and extensive-drug resistant gram-negative bacteria. Adjunctive nebulized aminoglycosides could increase the clinical cure rate and bacteriological eradication in patients suffering from HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria. As nebulized aminoglycosides broadly diffuse in the systemic circulation of patients with extensive bronchopneumonia, monitoring of plasma trough concentrations is recommended during the period of nebulization. Large randomized controlled trials comparing high dose of nebulized colistin methanesulfonate to high dose of intravenous colistin methanesulfonate or to intravenous new β-lactams in HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria are urgently needed.
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Affiliation(s)
- Matthieu Boisson
- INSERM U1070, Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,Service de Prévention et de Contrôle de l'Infection, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Adrien Bouglé
- Medicine Sorbonne University, Anaesthesiology and Critical Care, Cardiology Institute, Paris, France.,Department of Anaesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Candela Sole-Lleonart
- Intensive Care Unit, Consorci Hospitalari de Vic (CHV), The University of Vic - Central University of Catalonia (UVic-UCC), Vic, Barcelona, Spain
| | - Jayesh Dhanani
- Department of Intensive care medicine, Centre for Clinical Research, The University of Queensland, The Royal Brisbane and Women's Hospital Herston, Brisbane, Australia
| | - Kostoula Arvaniti
- Intensive Care Unit Department, Papageorgiou Hospital of Thessaloniki, Thessaloniki, Greece
| | - Jordi Rello
- Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Clinical Research and Innovation in Pneumonia and Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
| | - Jean-Jacques Rouby
- Department of Anaesthesiology and Critical Care, Medicine Sorbonne University, Multidisciplinary Intensive Care Unit, La Pitié Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Olivier Mimoz
- INSERM U1070 Université de Poitiers, UFR de Médecine Pharmacie and Service des Urgences Adultes & SAMU 86, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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9
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Cusack R, Garduno A, Elkholy K, Martín-Loeches I. Novel investigational treatments for ventilator-associated pneumonia and critically ill patients in the intensive care unit. Expert Opin Investig Drugs 2022; 31:173-192. [PMID: 35040388 DOI: 10.1080/13543784.2022.2030312] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is common; its prevalence has been highlighted by the Covid-19 pandemic. Even young patients can suffer severe nosocomial infection and prolonged mechanical ventilation. Multidrug-resistant bacteria can spread alarmingly fast around the globe and new antimicrobials are struggling to keep pace; hence physicians must stay abreast of new developments in the treatment of nosocomial pneumonia and VAP. AREAS COVERED This narrative review examines novel antimicrobial investigational drugs and their implementation in the ICU setting for VAP. The paper highlights novel approaches such as monoclonal antibody treatments for P. aeruginosa and S. aureus, and phage antibiotic synthesis. The paper also examines mechanisms of resistance in gram-negative bacteria, virulence factors and inhaled antibiotics and questions what may be on the horizon in terms of emerging treatment strategies. EXPERT OPINION The post-antibiotic era is rapidly approaching and the need for personalised medicine, point-of-care microbial sensitivity testing and development of biomarkers for severe infections is clear. Results from emerging and new antibiotics are encouraging, but infection control measures and de-escalation protocols must be employed to prolong their usefulness in critical illness.
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Affiliation(s)
- Rachael Cusack
- Department of Clinical Medicine, Trinity College Dublin.,Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland)
| | - Alexis Garduno
- Department of Clinical Medicine, Trinity College Dublin.,Intensive Care Translational Research, Trinity College Dublin
| | - Khalid Elkholy
- Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland)
| | - Ignacio Martín-Loeches
- Department of Clinical Medicine, Trinity College Dublin.,Department of Intensive Care Medicine, St. James's Hospital, Dublin, (Ireland).,Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, (Ireland)
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10
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Camps-Cortés M, Galdón-Crestermayer L, Solé-Lleonart C. Nursing points of interest when nebulizing antibiotics in ventilated patients. Intensive Crit Care Nurs 2021; 69:103168. [PMID: 34893398 DOI: 10.1016/j.iccn.2021.103168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Candela Solé-Lleonart
- Intensive Care Unit, Consorci Hospitalari de Vic (CHV), Vic, Spain; University of Vic - Central University of Catalonia (UVic-UCC), Vic, Spain.
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11
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Rello J, Schrenzel J, Tejo AM. New insights into pneumonia in patients on prolonged mechanical ventilation: need for a new paradigm addressing dysbiosis. ACTA ACUST UNITED AC 2021; 47:e20210198. [PMID: 34190866 PMCID: PMC8332723 DOI: 10.36416/1806-3756/e20210198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jordi Rello
- . Clinical Research/Epidemiology in Pneumonia & Sepsis-CRIPS-Vall d'Hebron Institut de Recerca-VHIR-Barcelona, España.,. Centro de Investigación Biomedica En Red de Enfermedades Respiratorias - CIBERES - Instituto de Salud Carlos III, Madrid, España.,. Centre Hospitalier Universitaire, Nîmes, France
| | - Jacques Schrenzel
- . Laboratoire de Bactériologie et Laboratoire de Recherche en Génomique, Service des Maladies Infectieuses et Service de Médecine de Laboratoire, Hôpitaux Universitaires Genève, Genève, Suisse
| | - Alexandre M Tejo
- . Divisão de Doenças Infecciosas, Departamento de Medicina Interna, Universidade Estadual de Londrina, Londrina (PR) Brasil
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12
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Tang R, Luo R, Wu B, Wang F, Song H, Chen X. Effectiveness and safety of adjunctive inhaled antibiotics for ventilator-associated pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2021; 65:133-139. [PMID: 34144265 DOI: 10.1016/j.jcrc.2021.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The efficacy and safety of adjunctive inhaled antibiotic therapy for ventilator-associated pneumonia (VAP) was systematically reviewed based on updated studies. METHODS We searched four databases and four clinical trial registration platforms to identify relevant studies published prior to May 19, 2020. Randomized controlled trials (RCTs) assessing adjunctive antibiotic inhalation treatment for VAP patients were eligible for this review. Two reviewers independently screened the articles and extracted the data. Information on inhaled therapy and clinical outcomes was collected. Study quality was assessed with the Cochrane risk of bias tool. The meta-analysis was conducted with Review Manager and R software. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines were used to evaluate the quality of evidence for each pooled outcome. RESULTS Eleven RCTs and 1210 patients were included in this analysis after the application of the inclusion and exclusion criteria. Compared with the use of intravenous injection alone, the use of adjunctive inhaled antibiotic therapy improved the rates of clinical cure (relative risk (RR) 1.13, 95% CI [1.02,1.26]) and microbiological eradication (RR 1.45, 95% CI [1.19,1.76]) in VAP patients. However, despite these improvements, mortality was not reduced (RR 1.00, 95% CI [0.82,1.21]). Adjunctive antibiotics delivered through the respiratory tract were not associated with a higher risk of renal impairment but were associated with an increased risk of bronchospasm (RR 2.74, 95% CI [1.31,5.73] during treatment. CONCLUSIONS Adjunctive inhaled antibiotics improved the clinical outcomes in VAP patients, but the increased rates clinical cure and microbiological eradication were not associated with reduced mortality. The use of nebulized antibiotics is not supported by the currently available evidence as a routine therapeutic strategy for VAP. PROSPERO REGISTRATION NUMBER CRD42020186970.
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Affiliation(s)
- Rui Tang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China.
| | - Rui Luo
- Department of Pain Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fusheng Wang
- Department of Critical Care, The Sixth Affiliated Hospital of Kunming Medical University, Kunming Medical University, Yuxi, China
| | - Haoxin Song
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiujuan Chen
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Qin JP, Huang HB, Zhou H, Zhu Y, Xu Y, Du B. Amikacin nebulization for the adjunctive therapy of gram-negative pneumonia in mechanically ventilated patients: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2021; 11:6969. [PMID: 33772055 PMCID: PMC7997905 DOI: 10.1038/s41598-021-86342-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/08/2021] [Indexed: 12/29/2022] Open
Abstract
Treatment of ventilated patients with gram-negative pneumonia (GNP) is often unsuccessful. We aimed to assess the efficacy and safety of nebulized amikacin (NA) as adjunctive therapy to systemic antibiotics in this patient population. PubMed, Embase, China national knowledge infrastructure, Wanfang, and the Cochrane database were searched for randomized controlled trials (RCTs) investigating the effect of NA as adjunctive therapy in ventilated adult patients with GNP. Heterogeneity was explored using subgroup analysis and sensitivity analysis. The Grading of recommendations assessment, development, and evaluation approach was used to assess the certainty of the evidence. Thirteen RCTs with 1733 adults were included. The pooled results showed NA had better microbiologic eradication (RR = 1.51, 95% CI 1.35 to 1.69, P < 0.0001) and improved clinical response (RR = 1.23; 95% CI 1.13 to 1.34; P < 0.0001) when compared with control. Meanwhile, overall mortality, pneumonia associated mortality, duration of mechanical ventilation, length of stay in ICU and change of clinical pneumonia infection scores were similar between NA and control groups. Additionally, NA did not add significant nephrotoxicity while could cause more bronchospasm. The use of NA adjunctive to systemic antibiotics therapy showed better benefits in ventilated patients with GNP. More well-designed RCTs are still needed to confirm our results.
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Affiliation(s)
- Jun-Ping Qin
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China.
| | - Hua Zhou
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Yuan Zhu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, China
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14
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Zhang C, Mi J, Wang X, Lv S, Zhang Z, Nie Z, Luo X, Gan R, Zou Y, Chen X, Fan L, Chen Y, Zhao H, Liao G. Knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation: a nationwide cross-sectional study. J Clin Nurs 2021; 30:3429-3438. [PMID: 33440027 DOI: 10.1111/jocn.15639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 11/14/2020] [Accepted: 12/31/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aerosol therapy is a routine operation for intensive care unit (ICU) nurses; however, evidence of the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation is insufficient in China. OBJECTIVE This study aimed to determine the knowledge and current practices of ICU nurses regarding aerosol therapy for patients with invasive mechanical ventilation in China. SETTING A total of 433 hospitals in 92 cities (including 31 capital cities) in 31 provinces in China participated in the study. METHODS A questionnaire was used to investigate the knowledge and current practices of ICU nurses regarding aerosol therapy for patients treated with invasive mechanical ventilation, including 42 questions covering five aspects: sociodemographic information, aerosolization devices, atomised drugs, atomisation operation, and atomisation-related knowledge. Descriptive analyses of the distribution of the sample are reported as percentages and medians. Univariate and multivariate analysis was used to detect the factors of the interviewee's atomisation knowledge and practices scores. A STROBE checklist was used to guide the reporting of the research. RESULTS Of the 1,995 questionnaires that were returned, 1,978 were analysed. Bronchodilators and glucocorticoids were the most frequently administered drugs. Seventy-four percent of the total respondents reported placing a filter on the expiratory limb during aerosol therapy, and 47% of these reported that the filter was changed once a day. Only 13% of the respondents reported always turning the heating humidifier off during aerosol therapy, and 48% never did. Knowledge about the optimal droplet size or atomisation yield was poor. Work experience in the ICU and frequency of atomisation training were the independent influencing factors for atomisation knowledge and practice scores (F=279.653, P<0.001; F=120.556, P<0.001, respectively). CONCLUSIONS The knowledge of ICU nurses about the optimal implementation of aerosol therapy is poor, and the current scientific knowledge about optimal implementation seemed to be applied infrequently. Atomisation-related training should be strengthened, especially for nurses with junior titles and with less work experience. RELEVANCE TO CLINICAL PRACTICE Improving the level of ICU nurses' atomization practice ability is helpful to ensure patient safety. In clinical work, atomization expert consensus can be used to carry out relevant training and standardize atomization operation.
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Affiliation(s)
- Chuanlin Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Jie Mi
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xueqin Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Shunqiao Lv
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Zeju Zhang
- School of Nursing, Chongqing Medical and Pharmaceutical College, Chongqing, PR China
| | - Zhi Nie
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xinyi Luo
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Ruiying Gan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yujun Zou
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Xiaoya Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Lu Fan
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Yu Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Huanhuan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
| | - Guoyu Liao
- Department of Medical Records, The First Affiliated Hospital of Chongqing Medical University, Chongqing, PR China
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15
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Macesic N, Nelson B, Mcconville TH, Giddins MJ, Green DA, Stump S, Gomez-Simmonds A, Annavajhala MK, Uhlemann AC. Emergence of Polymyxin Resistance in Clinical Klebsiella pneumoniae Through Diverse Genetic Adaptations: A Genomic, Retrospective Cohort Study. Clin Infect Dis 2021; 70:2084-2091. [PMID: 31513705 DOI: 10.1093/cid/ciz623] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/17/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Polymyxins are antimicrobials of last resort for the treatment of carbapenem-resistant Enterobacteriaceae, but resistance in 5% to >40% isolates has been reported. We conducted a genomic survey of clinical polymyxin-resistant (PR) Klebsiella pneumoniae to determine the molecular mechanisms of PR and the role of polymyxin exposure versus transmission in PR emergence. METHODS We included 88 patients with PR K. pneumoniae from 2011-2018 and collected demographic, antimicrobial exposure, and infection data. Whole-genome sequencing was performed on 388 isolates, including 164 PR isolates. Variant calling and insertion sequence detection were performed, focusing on key genes associated with PR (mgrB, crrAB, phoPQ, and pmrAB). We conducted phylogenetic analyses of key K. pneumoniae multi-locus sequence types (ST258, ST17, ST307, and ST392). RESULTS Polymyxin exposure was documented in 53/88 (60%) patients prior to PR detection. Through an analysis of key PR genes, we detected 129 individual variants and 72 unique variant combinations in PR isolates. This included multiple, distinct changes in 36% of patients with serial PR isolates. Insertion sequence disruption was limited to mgrB (P < .001). Polymyxin minimum inhibitory concentrations showed stepwise increases with the number of PR genes affected (P < .001). When clusters containing PR isolates in ≥2 patients were analyzed, 10/14 had multiple genetic events leading to PR. CONCLUSIONS Molecular mechanisms leading to PR in clinical K. pneumoniae isolates are remarkably heterogenous, even within clusters or individual patients. Polymyxin exposure with de novo PR emergence led to PR in the majority of patients, rather than transmission. Optimizing polymyxin use should be a key strategy in stopping the spread of PR.
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Affiliation(s)
- Nenad Macesic
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York.,Central Clinical School, Monash University, Melbourne, Australia
| | - Brian Nelson
- Department of Pharmacy, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York City, New York
| | - Thomas H Mcconville
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York
| | - Marla J Giddins
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York.,Microbiome & Pathogen Genomics Core, , New York City, New York
| | - Daniel A Green
- Clinical Microbiology Laboratory, Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York City, New York
| | - Stephania Stump
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York.,Microbiome & Pathogen Genomics Core, , New York City, New York
| | - Angela Gomez-Simmonds
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York
| | - Medini K Annavajhala
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York.,Microbiome & Pathogen Genomics Core, , New York City, New York
| | - Anne-Catrin Uhlemann
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York City, New York.,Microbiome & Pathogen Genomics Core, , New York City, New York
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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17
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Abstract
PURPOSE OF REVIEW To describe recent data about Acinetobacter baumannii pneumonia epidemiology and the therapeutic options including adjunctive nebulized therapy. RECENT FINDINGS A. baumannii is a major cause of nosocomial pneumonia in certain geographic areas affecting mainly debilitated patients, with prolonged hospitalization and broad-spectrum antimicrobials. Inappropriate empirical treatment has clearly been associated with increased mortality in A. baumannii pneumonia. Carbapenems may not be considered the treatment of choice in areas with high rates of carbapenem-resistant A. baumannii. Nowadays, polymyxins are the antimicrobials with the greatest level of in-vitro activity. Colistin is the antimicrobial most widely used although polymyxin B is associated with less renal toxicity. It is clear that lung concentrations of polymyxins are suboptimal in a substantial proportion of patients. This issue has justified the use of combination therapy or adjunctive nebulized antibiotics. Current evidence does not allow us to recommend combination therapy for A. baumannii pneumonia. Regarding nebulized antibiotics, it seems reasonable to use in patients who are nonresponsive to systemic antibiotics or A. baumannii isolates with colistin minimum inhibitory concentrations close to the susceptibility breakpoints. Cefiderocol, a novel cephalosporin active against A. baumannii, may represent an attractive therapeutic option if ongoing clinical trials confirm preliminary results. SUMMARY The optimal treatment for multidrug-resistant A. baumannii pneumonia has not been established. New therapeutic options are urgently needed. Well designed, randomized controlled trials must been conducted to comprehensively evaluate the effectiveness and safety of nebulized antibiotics for the treatment of A. baumannii pneumonia.
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Dimopoulos G, Akova M, Rello J, Poulakou G. Understanding resistance in Pseudomonas. Intensive Care Med 2020; 46:350-352. [PMID: 31960069 PMCID: PMC7224039 DOI: 10.1007/s00134-019-05905-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/19/2019] [Indexed: 12/26/2022]
Affiliation(s)
- George Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, National and Kapodistrian University of Athens, 1 Rimini str. Haidari, 12462 Athens, Greece
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Jordi Rello
- Ciberes, Instituto Salud Carlos III & Vall D’Hebron Research Institute (VHIR), Barcelona, Spain
- Scientific Collaborator, Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Garyphalia Poulakou
- 3rd Department of Internal Medicine, SOTIRIA Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Update in antibiotic therapy in intensive care unit: report from the 2019 Nîmes International Symposium. Anaesth Crit Care Pain Med 2019; 38:647-656. [DOI: 10.1016/j.accpm.2019.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/14/2022]
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20
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Shi Y, Huang Y, Zhang TT, Cao B, Wang H, Zhuo C, Ye F, Su X, Fan H, Xu JF, Zhang J, Lai GX, She DY, Zhang XY, He B, He LX, Liu YN, Qu JM. Chinese guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition). J Thorac Dis 2019; 11:2581-2616. [PMID: 31372297 PMCID: PMC6626807 DOI: 10.21037/jtd.2019.06.09] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Shi
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Hui Wang
- Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Fu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Guo-Xiang Lai
- Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China
| | - Dan-Yang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Yan Zhang
- Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Guillon A, Darrouzain F, Heuzé-Vourc'h N, Petitcollin A, Barc C, Vecellio L, Cormier B, Lanotte P, Sarradin P, Dequin PF, Paintaud G, Ehrmann S. Intra-tracheal amikacin spray delivery in healthy mechanically ventilated piglets. Pulm Pharmacol Ther 2019; 57:101807. [PMID: 31102741 DOI: 10.1016/j.pupt.2019.101807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 04/12/2019] [Accepted: 05/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nebulization during mechanical ventilation is impeded by large extra-pulmonary drug deposition and long administration durations which currently limit implementation of inhaled antibiotic therapy. Direct intra-tracheal delivery using a sprayer represents an appealing alternative investigated in small animal models, but large animal data are lacking. METHODS Amikacin was administered through intravenous infusion (20 mg/kg), nebulization (60 mg/kg) and direct intra-tracheal spray (30 mg/kg) to 10 intubated piglets, in a randomized cross-over design. Amikacin concentrations were measured in the serum and pulmonary parenchyma. Anatomic deposition was investigated using immuno-histochemistry. RESULTS Spray delivery resulted in higher amikacin outputs than nebulization and infusion. Pulmonary inhaled delivery techniques yielded much higher lung concentrations and much lower serum concentrations than intravenous infusion. However, unlike nebulization and infusion, intra-tracheal spray delivery was associated with more than 100- and 1000-fold variability in lung concentrations between and within animals. Amikacin specific immuno-histochemistry showed consistent bronchial and alveolar drug deposition with all modalities. CONCLUSION Nebulization remains the most reliable and simple technique to deliver inhaled amikacin uniformly to the lung during mechanical ventilation. Further development of tracheal sprays is required to take advantage of potential benefits related to high drug output and low extra-pulmonary deposition in large animals.
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Affiliation(s)
- Antoine Guillon
- CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-Triggersep, Tours, France; Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR), UMR 1100, Tours, France
| | | | - Nathalie Heuzé-Vourc'h
- Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR), UMR 1100, Tours, France
| | | | - Céline Barc
- INRA Val de Loire, Plateforme d'infectiologie expérimentale, UE 1277, Nouzilly, France
| | - Laurent Vecellio
- Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR), UMR 1100, Tours, France
| | | | - Philippe Lanotte
- CHRU de Tours, Bactériologie-Virologie, Tours, France; ISP, INRA, Université de Tours, UMR1282, F-37380, Nouzilly, France
| | - Pierre Sarradin
- INRA Val de Loire, Plateforme d'infectiologie expérimentale, UE 1277, Nouzilly, France
| | - Pierre-François Dequin
- CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-Triggersep, Tours, France; Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR), UMR 1100, Tours, France
| | | | - Stephan Ehrmann
- CHRU de Tours, Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-Triggersep, Tours, France; Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR), UMR 1100, Tours, France.
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22
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Zhang Z, Xu P, Fang Q, Ma P, Lin H, Fink JB, Liang Z, Chen R, Ge H. Practice pattern of aerosol therapy among patients undergoing mechanical ventilation in mainland China: A web-based survey involving 447 hospitals. PLoS One 2019; 14:e0221577. [PMID: 31465523 PMCID: PMC6715194 DOI: 10.1371/journal.pone.0221577] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Aerosol therapies are widely used for mechanically ventilated patients. However, the practice pattern of aerosol therapy in mainland China remains unknown. This study aimed to determine the current practice of aerosol therapy in mainland China. METHODS A web-based survey was conducted by the China Union of Respiratory Care (CURC) from August 2018 to January 2019. The survey was disseminated via Email or WeChat to members of CURC. A questionnaire comprising 16 questions related to hospital information and 12 questions related to the practice of aerosol therapy. Latent class analysis was employed to identify the distinct classes of aerosol therapy practice. MAIN RESULTS A total of 693 valid questionnaires were returned by respiratory care practitioners from 447 hospitals. Most of the practitioners used aerosol therapy for both invasive mechanical ventilation (90.8%) and non-invasive mechanical ventilation (91.3%). Practitioners from tertiary care centers were more likely to use aerosol therapy compared with those from non-tertiary care centers (91.9% vs. 85.4%, respectively; p = 0.035). The most commonly used drugs for aerosol therapy were bronchodilators (64.8%) followed by mucolytic agents (44.2%), topical corticosteroids (43.4%) and antibiotics (16.5%). The ultrasonic nebulizer (48.3%) was the most commonly used followed by the jet nebulizer (39.2%), the metered dose inhaler (15.4%) and the vibrating mesh nebulizer (14.6%). Six latent classes were identified via latent class analysis. Class 1 was characterized by the aggressive use of aerosol therapy without a standard protocol, while class 3 was characterized by the absence of aerosol therapy. CONCLUSIONS Substantial heterogeneity among institutions with regard to the use of aerosol therapy was noted. The implementation of aerosol therapy during mechanical ventilation was inconsistent in light of recent practice guidelines. Additional efforts by the CURC to improve the implementation of aerosol therapy in mainland China are warranted.
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Affiliation(s)
- Zhongheng Zhang
- Department of emergency medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peifeng Xu
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Fang
- Department of critical care medicine, First hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Penglin Ma
- Department of Critical Care Medicine, Eighth Medical Center of PLA General Hospital, Beijing, China
| | - Huiling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan City, Taiwan
| | - Jim B. Fink
- Aerogen Pharma Corp., San Mateo, California, United States of America
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Medical Center, Sichuan University, China
| | - Rongchang Chen
- Guangzhou Institute of Respiratory Diseases, Guangzhou, China
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- * E-mail:
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23
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Biopharmaceutical Characterization of Nebulized Antimicrobial Agents in Rats: 6. Aminoglycosides. Antimicrob Agents Chemother 2018; 62:AAC.01261-18. [PMID: 30082284 DOI: 10.1128/aac.01261-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/28/2018] [Indexed: 11/20/2022] Open
Abstract
Amikacin and gentamicin pharmacokinetic behaviors after nebulization were determined by comparing plasma and pulmonary epithelial lining fluid (ELF) concentrations in rats after intratracheal and intravenous administrations. ELF areas under concentration-time curve were 874 and 162 times higher after nebulization than after intravenous administration for amikacin and gentamicin, respectively. Even if both molecules appear to be good candidates for nebulization, these results demonstrate a much higher targeting advantage of nebulization for amikacin than for gentamicin.
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24
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Rello J, Domingo C. Precision medicine and aerosolization in mechanically ventilated adults. J Thorac Dis 2018; 10:S3111-S3114. [PMID: 30370091 DOI: 10.21037/jtd.2018.07.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jordi Rello
- CIBERES, Instituto Salud Carlos III & Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Christian Domingo
- Servei de Pneumologia, Corporació Sanitària Parc Tauli, Sabadell, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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25
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Poulakou G, Matthaiou DK, Nicolau DP, Siakallis G, Dimopoulos G. Inhaled Antimicrobials for Ventilator-Associated Pneumonia: Practical Aspects. Drugs 2018; 77:1399-1412. [PMID: 28741229 DOI: 10.1007/s40265-017-0787-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Positive experience with inhaled antibiotics in pulmonary infections of patients with cystic fibrosis has paved the way for their utilization in mechanically ventilated, critically ill patients with lower respiratory tract infections. A successful antibiotic delivery depends upon the size of the generated particle and the elimination of drug impaction in the large airways and the ventilator circuit. Generated droplet size is mainly affected by the type of the nebulizer employed. Currently, jet, ultrasonic, and vibrating mesh nebulizers are marketed; the latter can deliver optimal antibiotic particle size. Promising novel drug-device combinations are able to release drug concentrations of 25- to 300-fold the minimum inhibitory concentration of the targeted pathogens into the pulmonary alveoli. The most important practical steps of nebulization include pre-assessment and preparation of the patient (suctioning, sedation, possible bronchodilation, adjustment of necessary ventilator settings); adherence to the procedure (drug preparation, avoidance of unnecessary tubing connections, interruption of heated humidification, removal of heat-moisture exchanger); inspection of the procedure (check for residual in drug chamber, change of expiratory filter, return sedation, and ventilator settings to previous status); and surveillance of the patient for adverse events (close monitoring of the patient and particularly of peak airway pressure and bronchoconstriction). Practical aspects of nebulization are very important to ensure optimal drug delivery and safe procedure for the patient. Therefore, the development of an operational checklist is a priority for every department adopting this modality.
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Affiliation(s)
- Garyphallia Poulakou
- Fourth Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, 1 Rimini St, 12462, Athens, Greece.
| | - Dimitrios K Matthaiou
- Department of Critical Care, University Hospital Attikon, Faculty of Medicine, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Georgios Siakallis
- Fourth Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, 1 Rimini St, 12462, Athens, Greece
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Faculty of Medicine, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece
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26
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Alves J, Alp E, Koulenti D, Zhang Z, Ehrmann S, Blot S, Bassetti M, Conway-Morris A, Reina R, Teran E, Sole-Lleonart C, Ruiz-Rodríguez M, Rello J. Nebulization of antimicrobial agents in mechanically ventilated adults in 2017: an international cross-sectional survey. Eur J Clin Microbiol Infect Dis 2018; 37:785-794. [PMID: 29318460 DOI: 10.1007/s10096-017-3175-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/21/2017] [Indexed: 02/07/2023]
Abstract
2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Despoina Koulenti
- BTCCRC, UQCCR, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- 2nd Critical Care Department, Attikon Univesrity Hospital, Athens, Greece
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CHRU de Tours and CRICS-TriggerSEP Network, Tours, France
- Centre d'étude des pathologies respiratoires, INSERM U1100, Aérosolthérapie et biomédicaments à visée respiratoire, Faculté de médecine de Tours, Université François Rabelais, Tours, France
| | - Stijn Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, Ghent, Belgium
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Andrew Conway-Morris
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rosa Reina
- Terapia Intensiva, Hospital Interzonal de Agudos "General San Martín", La Plata, Argentina
| | - Enrique Teran
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
| | - Candela Sole-Lleonart
- Centre Hospitalier Universitaire Vaudoise, Geneve, Switzerland
- Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Maria Ruiz-Rodríguez
- Department of Clinical Research & Innovation in Pneumonia and Sepsis, Vall d'Hebron Institut of Research, Barcelona, Spain
| | - Jordi Rello
- Critical Care Department, Vall d'Hebron Institut of Research, Barcelona, Spain.
- Centro de Investigacion Biomedica en Red (CIBERES), Ps Vall d'Hebron 119, AMI- 14a Planta, 08035, Barcelona, Spain.
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27
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de Pablo E, Fernández-García R, Ballesteros MP, Torrado JJ, Serrano DR. Nebulised antibiotherapy: conventional versus nanotechnology-based approaches, is targeting at a nano scale a difficult subject? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:448. [PMID: 29264365 DOI: 10.21037/atm.2017.09.17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nebulised antibiotics offer great advantages over intravenously administered antibiotics and other conventional antibiotic formulations. However, their use is not widely standardized in the current clinical practice. This is the consequence of large variability in the performance of nebulisers, patient compliance and a deficiency of robust preclinical and clinical data. Nebulised antibiotherapy may play a significant role in future pulmonary drug delivery treatments as it offers the potential to achieve both a high local drug concentration and a lower systemic toxicity. In this review, the physicochemical parameters required for optimal deposition to the lung in addition to the main characteristics of currently available formulations and nebuliser types are discussed. Particular attention will be focused on emerging nanotechnology based approaches which are revolutionizing inhaled therapies used to treat both infections and lung cancer. Promising carriers such as Trojan-Horse microparticles, liposomes, polymeric and lipid nanoparticulate systems have been investigated and proposed as viable options. In order to achieve site-specific targeting and to optimize the PK/PD balance critical nanoscale design parameters such as particle size, morphology, composition, rigidity and surface chemistry architecture must be controlled. Development of novel excipients to manufacture these nanomedicines and assessment of their toxicity is also a keystone and will be discussed in this review.
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Affiliation(s)
- Esther de Pablo
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Madrid, Spain
| | - Raquel Fernández-García
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Madrid, Spain
| | - María Paloma Ballesteros
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Madrid, Spain.,Instituto Universitario de Farmacia Industrial (IUFI), Facultad de Farmacia, Universidad Complutense de Madrid, Avenida Complutense, Madrid, Spain
| | - Juan José Torrado
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Madrid, Spain.,Instituto Universitario de Farmacia Industrial (IUFI), Facultad de Farmacia, Universidad Complutense de Madrid, Avenida Complutense, Madrid, Spain
| | - Dolores R Serrano
- Departamento de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramón y Cajal s/n, Madrid, Spain.,Instituto Universitario de Farmacia Industrial (IUFI), Facultad de Farmacia, Universidad Complutense de Madrid, Avenida Complutense, Madrid, Spain
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28
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Nebulized antibiotics in mechanically ventilated patients: a challenge for translational research from technology to clinical care. Ann Intensive Care 2017; 7:78. [PMID: 28766281 PMCID: PMC5539056 DOI: 10.1186/s13613-017-0301-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/17/2017] [Indexed: 01/20/2023] Open
Abstract
Nebulized antibiotic therapy directly targets airways and lung parenchyma resulting in high local concentrations and potentially lower systemic toxicities. Experimental and clinical studies have provided evidence for elevated lung concentrations and rapid bacterial killing following the administration of nebulized antibiotics during mechanical ventilation. Delivery of high concentrations of antibiotics to infected lung regions is the key to achieving efficient nebulized antibiotic therapy. However, current non-standardized clinical practice, the difficulties with implementing optimal nebulization techniques and the lack of robust clinical data have limited its widespread adoption. The present review summarizes the techniques and clinical constraints for optimal delivery of nebulized antibiotics to lung parenchyma during invasive mechanical ventilation. Pulmonary pharmacokinetics and pharmacodynamics of nebulized antibiotic therapy to treat ventilator-associated pneumonia are discussed and put into perspective. Experimental and clinical pharmacokinetics and pharmacodynamics support the use of nebulized antibiotics. However, its clinical benefits compared to intravenous therapy remain to be proved. Future investigations should focus on continuous improvement of nebulization practices and techniques. Before expanding its clinical use, careful design of large phase III randomized trials implementing adequate therapeutic strategies in targeted populations is required to demonstrate the clinical effectiveness of nebulized antibiotics in terms of patient outcomes and reduction in the emergence of antibiotic resistance.
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29
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Nebulization of Antiinfective Agents in Invasively Mechanically Ventilated Adults: A Systematic Review and Meta-analysis. Anesthesiology 2017; 126:890-908. [PMID: 28248714 DOI: 10.1097/aln.0000000000001570] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nebulization of antiinfective agents is a common but unstandardized practice in critically ill patients. METHODS A systematic review of 1,435 studies was performed in adults receiving invasive mechanical ventilation. Two different administration strategies (adjunctive and substitute) were considered clinically relevant. Inclusion was restricted to studies using jet, ultrasonic, and vibrating-mesh nebulizers. Studies involving children, colonized-but-not-infected adults, and cystic fibrosis patients were excluded. RESULTS Five of the 11 studies included had a small sample size (fewer than 50 patients), and only 6 were randomized. Diversity of case-mix, dosage, and devices are sources of bias. Only a few patients had severe hypoxemia. Aminoglycosides and colistin were the most common antibiotics, being safe regarding nephrotoxicity and neurotoxicity, but increased respiratory complications in 9% (95% CI, 0.01 to 0.18; I = 52%), particularly when administered to hypoxemic patients. For tracheobronchitis, a significant decrease in emergence of resistance was evidenced (risk ratio, 0.18; 95% CI, 0.05 to 0.64; I = 0%). Similar findings were observed in pneumonia by susceptible pathogens, without improvement in mortality or ventilation duration. In pneumonia caused by resistant pathogens, higher clinical resolution (odds ratio, 1.96; 95% CI, 1.30 to 2.96; I = 0%) was evidenced. These findings were not consistently evidenced in the assessment of efficacy against pneumonia caused by susceptible pathogens. CONCLUSIONS Performance of randomized trials evaluating the impact of nebulized antibiotics with more homogeneous populations, standardized drug delivery, predetermined clinical efficacy, and safety outcomes is urgently required. Infections by resistant pathogens might potentially have higher benefit from nebulized antiinfective agents. Nebulization, without concomitant systemic administration of the drug, may reduce nephrotoxicity but may also be associated with higher risk of respiratory complications.
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30
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Rello J, Solé-Lleonart C, Rouby JJ, Chastre J, Blot S, Poulakou G, Luyt CE, Riera J, Palmer LB, Pereira JM, Felton T, Dhanani J, Bassetti M, Welte T, Roberts JA. Use of nebulized antimicrobials for the treatment of respiratory infections in invasively mechanically ventilated adults: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect 2017; 23:629-639. [PMID: 28412382 DOI: 10.1016/j.cmi.2017.04.011] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
Abstract
With an established role in cystic fibrosis and bronchiectasis, nebulized antibiotics are increasingly being used to treat respiratory infections in critically ill invasively mechanically ventilated adult patients. Although there is limited evidence describing their efficacy and safety, in an era when there is a need for new strategies to enhance antibiotic effectiveness because of a shortage of new agents and increases in antibiotic resistance, the potential of nebulization of antibiotics to optimize therapy is considered of high interest, particularly in patients infected with multidrug-resistant pathogens. This Position Paper of the European Society of Clinical Microbiology and Infectious Diseases provides recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology regarding the use of nebulized antibiotics in invasively mechanically ventilated adults, based on a systematic review and meta-analysis of the existing literature (last search July 2016). Overall, the panel recommends avoiding the use of nebulized antibiotics in clinical practice, due to a weak level of evidence of their efficacy and the high potential for underestimated risks of adverse events (particularly, respiratory complications). Higher-quality evidence is urgently needed to inform clinical practice. Priorities of future research are detailed in the second part of the Position Paper as guidance for researchers in this field. In particular, the panel identified an urgent need for randomized clinical trials of nebulized antibiotic therapy as part of a substitution approach to treatment of pneumonia due to multidrug-resistant pathogens.
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Affiliation(s)
- J Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients, Barcelona, Spain.
| | - C Solé-Lleonart
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - J-J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie of Paris 6, Paris, France
| | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie of Paris, Paris, France
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, Ghent, Belgium
| | - G Poulakou
- 4th Department of Internal Medicine, Athens University School of Medicine, Attikon University General Hospital, Athens, Greece
| | - C-E Luyt
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie of Paris 6, Paris, France
| | - J Riera
- Clinical Research & Innovation in Pneumonia and Sepsis, Vall d'Hebron Institute of Research, CIBERES, Barcelona, Spain
| | - L B Palmer
- Pulmonary, Critical Care and Sleep Division, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - J M Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - T Felton
- Acute Intensive Care Unit, University Hospital of South Manchester, Manchester, United Kingdom
| | - J Dhanani
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Butterfield Street, Herston, Brisbane, Australia
| | - M Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - T Welte
- German Centre for Lung Research (DZL), Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Butterfield Street, Herston, Brisbane, Australia
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31
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Kollef MH, Micek ST. Recommendations for aerosolized antibiotics in ventilator-associated pneumonia and ventilator-associated tracheobronchitis: too little and too late? Clin Microbiol Infect 2017; 23:593-595. [PMID: 28400338 DOI: 10.1016/j.cmi.2017.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/01/2017] [Indexed: 10/19/2022]
Affiliation(s)
- M H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA.
| | - S T Micek
- St Louis College of Pharmacy, St Louis, MO, USA
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32
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Rello J, Rouby JJ, Sole-Lleonart C, Chastre J, Blot S, Luyt CE, Riera J, Vos MC, Monsel A, Dhanani J, Roberts JA. Key considerations on nebulization of antimicrobial agents to mechanically ventilated patients. Clin Microbiol Infect 2017; 23:640-646. [PMID: 28347790 DOI: 10.1016/j.cmi.2017.03.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 11/30/2022]
Abstract
Nebulized antibiotics have an established role in patients with cystic fibrosis or bronchiectasis. Their potential benefit to treat respiratory infections in mechanically ventilated patients is receiving increasing interest. In this consensus statement of the European Society of Clinical Microbiology and Infectious Diseases, the body of evidence of the therapeutic utility of aerosolized antibiotics in mechanically ventilated patients was reviewed and resulted in the following recommendations: Vibrating-mesh nebulizers should be preferred to jet or ultrasonic nebulizers. To decrease turbulence and limit circuit and tracheobronchial deposition, we recommend: (a) the use of specifically designed respiratory circuits avoiding sharp angles and characterized by smooth inner surfaces, (b) the use of specific ventilator settings during nebulization including use of a volume controlled mode using constant inspiratory flow, tidal volume 8 mL/kg, respiratory frequency 12 to 15 bpm, inspiratory:expiratory ratio 50%, inspiratory pause 20% and positive end-expiratory pressure 5 to 10 cm H2O and (c) the administration of a short-acting sedative agent if coordination between the patient and the ventilator is not obtained, to avoid patient's flow triggering and episodes of peak decelerating inspiratory flow. A filter should be inserted on the expiratory limb to protect the ventilator flow device and changed between each nebulization to avoid expiratory flow obstruction. A heat and moisture exchanger and/or conventional heated humidifier should be stopped during the nebulization period to avoid a massive loss of aerosolized particles through trapping and condensation. If these technical requirements are not followed, there is a high risk of treatment failure and adverse events in mechanically ventilated patients receiving nebulized antibiotics for pneumonia.
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Affiliation(s)
- J Rello
- European Study Group for Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain.
| | - J J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | | | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, European Study Group for Infections in Critically Ill Patients (ESGCIP), Ghent, Belgium
| | - C E Luyt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Riera
- Critical Care Department, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Institut of Research, Barcelona, Spain
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, European Study Group of Nosocomial Infections (ESGNI), Rotterdam, The Netherlands
| | - A Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Dhanani
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
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33
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Kim YK, Lee JH, Lee HK, Chung BC, Yu SJ, Lee HY, Park JH, Kim S, Kim HK, Kiem S, Jang HJ. Efficacy of nebulized colistin-based therapy without concurrent intravenous colistin for ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii. J Thorac Dis 2017; 9:555-567. [PMID: 28449463 PMCID: PMC5394082 DOI: 10.21037/jtd.2017.02.61] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although there have been studies regarding the role of nebulized colistin as adjunctive therapy of ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB), a paucity of information on the efficacy of nebulized colistin as monotherapy is available. METHODS We retrospectively reviewed 219 patients with VAP caused by CRAB treated with either intravenous (n=93) or nebulized colistin (n=126), from March 2010 to November 2015. Factors related to clinical failure was assessed using propensity-score-matched analysis. RESULTS Of 219 patients, 39 patients from each group (n=78) were matched after covariate adjustment using propensity score. There were no significant differences in baseline characteristics as well as the rates of clinical failure between the propensity-score-matched groups [Odds ratio (OR), 0.48; 95% confidence interval (CI), 0.19-1.19; P=0.11], while a significantly lower rate of acute kidney injury (AKI) during colistin therapy (18% vs. 49%, P=0.004) was observed in nebulized colistin group. In addition, multivariable analysis revealed that nebulized colistin did not significantly alter the rate of clinical failure [adjusted odds ratio (aOR), 0.36; 95% CI, 0.12-1.09; P=0.070]. Instead, medical intensive care unit (ICU) admission (aOR, 7.14; 95% CI, 1.60-32.00; P=0.010), and septic shock (aOR, 3.93; 95% CI, 1.27-12.17; P=0.018) were independent risk factors for clinical failure. CONCLUSIONS Our findings suggest that nebulized colistin-based therapy, even without concurrent administration of intravenous colistin, may be an effective and safe treatment option for VAP caused by CRAB.
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Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jae Ha Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun-Kyung Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byung Cheol Chung
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Seung Jung Yu
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ho-Young Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jin-Han Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sunyoung Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyeon-Kuk Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sungmin Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hang-Jea Jang
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Khomami NTS, Heshmatpour F. Magnetically recoverable nano-zirconium(IV) complex: enhancement of antibacterial activity. RESEARCH ON CHEMICAL INTERMEDIATES 2017. [DOI: 10.1007/s11164-016-2651-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Poulakou G, Siakallis G, Tsiodras S, Arfaras-Melainis A, Dimopoulos G. Nebulized antibiotics in mechanically ventilated patients: roadmap and challenges. Expert Rev Anti Infect Ther 2017; 15:211-229. [DOI: 10.1080/14787210.2017.1268052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Poulakou
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Siakallis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - S Tsiodras
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - A Arfaras-Melainis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Zhang X, Guo F, Shao H, Zheng X. Clinical translation of polymyxin-based combination therapy: Facts, challenges and future opportunities. J Infect 2016; 74:118-130. [PMID: 27998750 DOI: 10.1016/j.jinf.2016.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/18/2016] [Accepted: 11/27/2016] [Indexed: 10/20/2022]
Abstract
The emergence and spread of multidrug resistant Gram-negative bacteria has led to a resurgence in the clinical use of polymyxin antibiotics. However, the prevalence of polymyxin resistance is on the rise at an alarming rate, motivating the idea of combination therapy to sustain the revival of these "old" antibiotics. Although ample evidence in favor of combination therapy has emerged, it seems impracticable and confusing to find a promising combination from the diverse reports or gain adequate information on the efficacy and safety profile. With a stagnating discovery pipeline of novel antimicrobials, there is a clear need to fill the knowledge gaps in translating these basic research data to beneficial clinical practice. In this review, we examined the factors and ambiguities that stand as major hurdles in bringing polymyxin combination therapy to bedside care, highlighting the importance and urgency of incorporating translational research insights into areas of difficulty. We also discussed future research priorities that are essential to gather the necessary evidence and insights for promoting the best possible use of polymyxins in combination therapy.
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Affiliation(s)
- Xueli Zhang
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Hua Shao
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China.
| | - Xiao Zheng
- State Key Laboratory of Natural Medicines, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.
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Kollef MH. COUNTERPOINT: Should Inhaled Antibiotic Therapy Be Used Routinely for the Treatment of Bacterial Lower Respiratory Tract Infections in the ICU Setting? No. Chest 2016; 151:740-743. [PMID: 27916619 DOI: 10.1016/j.chest.2016.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/18/2022] Open
Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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Bassetti M, Carnelutti A, Peghin M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther 2016; 15:55-65. [PMID: 27766913 DOI: 10.1080/14787210.2017.1251840] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The isolation of multi-drug-resistant gram-negative (MDRGN) pathogens has progressively increased worldwide and has been associated with important delays in the prescription of an adequate antibiotic treatment, resulting in increased mortality rates. Patient's stratification for MDRGN infections to optimize the prescription of an adequate empiric antimicrobial regimen is crucial. Areas covered: This article covers MDRGN epidemiology, with a specific focus on risk factors for harbouring infections sustained by extended-spectrum-Beta-lactamase (ESBL), carbapenem resistant Enterobacteriacae (CRE), MDR Pseudomonas aeruginosa and MDR Acinetobacter baumanii. Moreover, we will propose an algorithm for the choice of empiric treatment when a MDRGN infection is suspected. Expert commentary: Although in clinical practice, a patient's stratification represents a challenge, whenever a MDRGN pathogen is suspected broad-spectrum, combination empiric treatment should be promptly started, looking for a balance between the prescription of an adequate empiric treatment and the risk of resistance selection.
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Affiliation(s)
- Matteo Bassetti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Alessia Carnelutti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Maddalena Peghin
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
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Rello J, Bunsow E. What is the Research Agenda in Ventilator-associated Pneumonia? Int J Infect Dis 2016; 51:110-112. [PMID: 27664931 DOI: 10.1016/j.ijid.2016.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jordi Rello
- CIBERES & Universitat Autonoma de Barcelona, Spain.
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Dhanani J, Fraser JF, Chan HK, Rello J, Cohen J, Roberts JA. Fundamentals of aerosol therapy in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:269. [PMID: 27716346 PMCID: PMC5054555 DOI: 10.1186/s13054-016-1448-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Drug dosing in critically ill patients is challenging due to the altered drug pharmacokinetics–pharmacodynamics associated with systemic therapies. For many drug therapies, there is potential to use the respiratory system as an alternative route for drug delivery. Aerosol drug delivery can provide many advantages over conventional therapy. Given that respiratory diseases are the commonest causes of critical illness, use of aerosol therapy to provide high local drug concentrations with minimal systemic side effects makes this route an attractive option. To date, limited evidence has restricted its wider application. The efficacy of aerosol drug therapy depends on drug-related factors (particle size, molecular weight), device factors, patient-related factors (airway anatomy, inhalation patterns) and mechanical ventilation-related factors (humidification, airway). This review identifies the relevant factors which require attention for optimization of aerosol drug delivery that can achieve better drug concentrations at the target sites and potentially improve clinical outcomes.
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Affiliation(s)
- Jayesh Dhanani
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.
| | - John F Fraser
- Department of Intensive Care Medicine, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, The University of Queensland, Brisbane, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Jordi Rello
- Critical Care Department, Hospital Vall d'Hebron, Barcelona, Spain.,CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jeremy Cohen
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, 4029, QLD, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Australia
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Die schwere Pneumonie auf der Intensivstation. Med Klin Intensivmed Notfmed 2016; 111:279-89. [DOI: 10.1007/s00063-016-0165-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 04/04/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
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