Overview of Antibiotic-Induced Nephrotoxicity

Antimicrobial data set and occurrence of acute kidney injury in patients admitted to a hospital in Western Pará, Brazil

In hospital units, the evaluation and pharmaceutical follow-up of medical prescriptions is an important source for pharmaceutical care and pharmaceutical clinical services. One common problem that has high hospital incidence rates is the occurrence of acute kidney injury (AKI). Pharmacovigilance among other activities is implemented in hospitals for the purpose of receiving and monitoring reports of adverse effects related to medications administered to patients. The survey evaluated the incidence of acute kidney injury in patients hospitalized and exposed to antimicrobials in a public hospital in the state of Pará, Brazil. A prospective and observational cohort was carried out, whose outcome of interest is the occurrence of AKI in patients admitted to the hospital between October 2018 and January 2019. The data were recorded and stored in a database, then descriptive analysis was performed in the GraphPad Prism 6.0 program. Quantitative variables were expressed as standard deviation (SD) of the mean and the number of cases as a percentage. We collected data from 70 patients who were admitted to the hospital and needed to use any of the antimicrobials selected in the observation period during hospital treatment. The survey results showed that mostly male (64.29%; n = 45). Age ranged from 19 to 96 years, with a mean of 52.49 years (SD = 20.31). The patients included were mostly from the oncology clinic (34.29%; n = 24) those that had had surgery (27.14%; n = 19). Most critically ill patients admitted to the adult ICU (26.47 %; n = 9) developed AKI. Regarding the number of medications used by patients, there was a variation from 5 to 17, with a mean of 10.26 (SD = 2.90) medications prescribed per patient. In the data regarding the antimicrobials, most patients took ceftriaxone (n = 29), cefepime (n = 27) and piperacillin/tazobactam (n = 23). In terms of the number of antimicrobials prescribed per patient, 60% (n = 42) of patients took only one, 30% (n = 21) took two and 10% (n = 7) took three or more antimicrobials for treatment of infections. The plasma concentrations of vancomycin ranged from 3.0 µg/mL to 22.5 µg/mL. Of the 10 samples collected, 10.0% (n = 1) were above the therapeutic range established by the literature (between 10 to 20 µg/mL), 30.0% (n = 3) were within the reference values and 60.0% (n = 6) of the patients had values below the reference values. Patients who developed AKI (60.0%; n = 6) during vancomycin use had concentration values between 3 µg/mL and 15.9 µg/mL, most of whom had values below the recommended therapeutic range. Of these patients with AKI, 83.33% (n = 5) used more than one nephrotoxic antimicrobial during hospital treatment. The concentrations of patients who were not diagnosed with AKI (40.0%; n = 4) ranged from 3.0 µg/mL to 22.5 µg/mL.

Novel bifunctional antibacterial peptides mediated by a covalent conjugation strategy combat priority multidrug-resistant gram-negative pathogens through dual targets

The escalating antibiotic resistance presents formidable challenges in the treatment of Gram-negative bacterial infections. Clinically, these bacteria have also acquired resistance to polymyxin, the last resort of defense. Novel antibiotics with a single mode of action are susceptible to rapid resistance development, and sometimes asynchronous pharmacokinetics also hinders the effectiveness of combined administration strategies in vivo. Here, we developed a class of novel bifunctional antibacterial peptides by covalently conjugating a series of modified PbgA-derived peptides with colistin analog (PE-2C-C8-DH) via a small-molecule linker (KCM02). These bifunctional peptides show remarkable synergistic antibacterial efficacy, where "1 + 1 > 2", against various priority multidrug-resistant Gram-negative bacteria, involving polymyxin-resistant strains. By optimizing the structure-activity relationship, two compounds (BP-28 and BP-37) with distinct activity preferences were obtained, which possess rapid bactericidal efficacy and a significantly lower risk of resistance compared to single-mode-of-action antibacterial agents, without hemolytic toxicity and cytotoxicity. Identification of antibacterial targets revealed that they can damage Gram-negative bacterial membrane by targeting LPS and BamA. Our study offers a referable approach for the development of novel antimicrobial agents.

A screening question to assess risk of using antibiotics without a prescription: a diagnostic study

OBJECTIVES

Non-prescription antibiotic use (using antibiotics without medical advice) is potentially unsafe and promotes antimicrobial resistance. We studied predictors of prior non-prescription use and whether screening for prior non-prescription antibiotic use predicted intention of future non-prescription antibiotic use.

METHODS

The survey was performed from January 2020 - June 2021 in six public primary care clinics and two private emergency departments. Prior non-prescription users were respondents who reported taking oral antibiotics for symptoms without contacting a clinician. Intended use was defined by answering yes to the question, "would you use antibiotics without contacting a doctor/nurse/dentist/clinic." We examined predictors for prior non-prescription use. We also calculated the sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of (a) any prior non-prescription antibiotic use and (b) prior use in the past 12 months - for future intended non-prescription use.

RESULTS

Of 564 survey respondents, 246 (43.6%) reported non-prescription use; 91 (37.0%) of these respondents, 16.1% overall, reported doing so in the past 12 months. Approximately 63% of non-prescription antibiotic use was in those with a previous prescription of the same antibiotic for similar symptoms/illnesses. The screening characteristics of non-prescription use in the past 12 months to identify intention to use of antibiotics without a prescription in the future were: sensitivity 75.9% (95% CI: 65.3-84.6), specificity 91.4% (95% CI: 87.8-94.2), Bayes' PPV 74.5% (95% CI: 66.7-80.9), and Bayes' NPV 93.7% (95% CI: 90.5-96.1).

CONCLUSIONS

This study proposed a method to screen for future use of non-prescription antibiotics, which may have implications on antimicrobial stewardship efforts in primary care settings.

Effects of Broad-Spectrum Antimicrobials on Patients with Community-Acquired Pneumonia with Low Risk for Drug-Resistant Pathogens: Historical Cohort Study in Japan

INTRODUCTION

Broad-spectrum antimicrobials are commonly administered for community-acquired pneumonia (CAP); however, unnecessary administration may cause adverse events and poor outcomes. This study aimed to understand the impact of broad-spectrum anti-pseudomonal β-lactam use on clinical outcomes and healthcare resource utilization (HCRU) in inpatients with CAP and a low risk of drug-resistant pathogens (DRPs).

METHODS

This historical cohort study reviewed Japan's hospital claims database (January to December of 2018) and included inpatients aged ≥ 20 years who received intravenous antimicrobial therapy for CAP. Those with high DRP risk were excluded. According to the initial antimicrobial regimen, patients were divided into broad-spectrum (anti-pseudomonal β-lactam therapy) and narrow-spectrum (non-anti-pseudomonal β-lactam therapy) groups. This study evaluated 30-day hospital mortality as a primary outcome using inverse probability of treatment weighting (IPTW) to adjust for differences between both groups and HCRU as an exploratory analysis.

RESULTS

A total of 15,617 patients were analyzed (2627 in the broad-spectrum group and 12,990 in the narrow-spectrum group). In the broad-spectrum group, the 30-day mortality rate was 10.6%, which was higher than that in the narrow-spectrum group (5.3%). Furthermore, it was associated with an increased 30-day mortality compared with the narrow-spectrum group after IPTW (adjusted odds ratio, 1.77; 95% confidence interval, 1.52-2.06; p < 0.001). The mean inpatient cost was USD 6139 and USD 5184 for the broad- and narrow-spectrum groups, respectively.

CONCLUSIONS

The initial use of anti-pseudomonal β-lactams for CAP with low DRP risk is associated with poor outcomes, including death and high HCRU. Thus, initial antimicrobials should be judiciously selected for CAP management.

Natural polymer based drug-loaded hydrogel platform for comprehensive care of acute spinal cord injury

Traumatic spinal cord injury typically occurs at significant depths and triggers rapid and severe physiological responses. It is commonly accompanied by oxidative stress disorders, lipid peroxidation, accumulation of toxic aldehydes, and edema among other symptoms. The management of this condition requires intricate surgical procedures and vigilance against postoperative complications. Slow wound healing is a major clinical challenge. In this study, we developed an injectable hydrogel-based smart drug delivery platform (OPDL gel) for the treatment of cord injuries and integrated postoperative wound care. The hydrogel encapsulates the glucocorticoid dexamethasone (Dex) through a borate ester bond and can respond to degradation caused by reactive oxygen species (ROS) and pH changes in the microenvironment of spinal cord injuries. The OPDL gel was injected into the lesion with a degradation period of 60 h, enabling a controlled and intelligent release of Dex. Additionally, poly-ε-lysine macromolecules within the gel can absorb toxic aldehydes present in the microenvironment via Schiff base reactions, thereby mitigating secondary progression of spinal cord injury. When locally applied to spinal cord injuries, the gel demonstrated good biocompatibility and had a protective effect on damaged neural structures. In addition, OPDL gel also exhibited excellent bactericidal properties, achieving a 100 % kill rate against microorganisms within 80 min and providing wound healing care comparable to a commercial product, Tegaderm™. Therefore, this multifunctional hydrogel drug-loading platform represents a novel approach for integrated treatment strategies in the clinical setting to address spinal cord injuries.

Frequency of Acute Kidney Injury After the Initiation of Vitamin D Receptor Activators: A Multicenter Retrospective Observational Study

BACKGROUND AND OBJECTIVES

Vitamin D receptor activators (VDRAs) are widely used in patients with osteoporosis; however, the frequency of acute kidney injury (AKI) due to VDRAs is unclear. This study aimed to investigate whether the incidence of AKI after VDRA initiation differed among patients with different renal functions.

METHODS

The medical records of Japanese patients who were newly prescribed with VDRAs for osteoporosis at the Fujita Health University Hospital or Kyoto University Hospital between April 2012 and March 2022 were retrospectively reviewed in this study. The RIFLE (Risk, Injury, Failure, Loss of function, End-stage kidney disease) criteria were used to assess the incidence of AKI within 7 days after initiation of VDRA therapy. Additionally, the AKI algorithm was used to assess the incidence of AKI from 8 to 365 days after initiation of VDRA therapy.

RESULTS

The incidence of AKI, as defined by the RIFLE criteria, was significantly higher in patients with normal renal function or end-stage renal failure than in those with mild renal decline (p < 0.05); the incidence of AKI, defined using the AKI algorithm, showed a similar trend. We found that the lack of serum calcium level monitoring before the initiation of VDRAs might be a risk factor for AKI defined by the RIFLE criteria (odds ratio = 2.004, p = 0.096).

CONCLUSIONS

The incidence of AKI after the initiation of VDRA therapy was high, even if renal function was normal. Thus, our results suggest that monitoring serum calcium levels before the initiation of VDRA therapy is necessary, regardless of renal function.

Incidence of Acute Kidney Injury (AKI) in Critically Ill Patients Receiving Concomitant Vancomycin with Piperacillin-Tazobactam or Cefepime; a Systemic Review and Meta-analysis

Background: Nephrotoxicity remains a significant concern in the management of critically ill patients receiving antibiotic therapy. The combination of Vancomycin and Piperacillin-Tazobactam (VPT) is frequently employed to combat multidrug-resistant infections. However, emerging evidence suggests a potential increase in the risk of acute kidney injury (AKI) associated with this combination. This study aims to systematically review and analyze the nephrotoxic risk of the VPT combination in comparison to Vancomycin with Cefepime (VC) combination therapy. Methodology: We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed in databases including PubMed and Google Scholar for studies published until 2024. Studies that reported AKI incidence in patients treated with VPT, or VC were included. The data were analyzed using random-effects models to estimate pooled incidence rates of AKI. Subgroup analyses were performed based on patient demographics and baseline renal function. Results: A total of six studies involving 23 794 patients were included in the analysis. The pooled incidence of AKI in the VPT group was found to be 29.9% (95% CI: 25.3%-38.4%), significantly higher than that of the VC (22.7%) (P < .05). A comparative analysis demonstrated a significantly higher risk of AKI in patients on VPT compared to VC (1.503; 95% CI: 1.221-1.849 P < .001). Conclusion: The findings of this study underscore a significant increase in the risk of AKI associated with the Vancomycin and Piperacillin-Tazobactam combination in critically ill patients. Clinicians should exercise caution when prescribing this combination, particularly for patients with pre-existing renal dysfunction.

A mechanistic neural network model predicts both potency and toxicity of antimicrobial combination therapies

Antimicrobial resistance poses a major global threat due to the diminishing efficacy of current treatments and limited new therapies. Combination therapy with existing drugs offers a promising solution, yet current empirical methods often lead to suboptimal efficacy and inadvertent toxicity. The high cost of experimentally testing numerous combinations underscores the need for data-driven methods to streamline treatment design. We introduce CALMA, an approach that predicts the potency and toxicity of multi-drug combinations in Escherichia coli and Mycobacterium tuberculosis. CALMA identified synergistic antimicrobial combinations involving vancomycin and isoniazid that were antagonistic for toxicity, which were validated using in vitro cell viability assays in human cell lines and through mining of patient health records that showed reduced side effects in patients taking combinations identified by CALMA. By combining mechanistic modelling with deep learning, CALMA improves the interpretability of neural networks, identifies key pathways influencing drug interactions, and prioritizes combinations with enhanced potency and reduced toxicity.

Acute kidney injury and energy metabolism

Acute kidney injury (AKI) predominantly affects hospitalized patients, particularly those in intensive care units, and has emerged as a significant global public health concern. Several factors, including severe cardiovascular disease, surgery-induced renal ischemia, nephrotoxic drugs, and sepsis, contribute to the development of AKI. Despite the implementation of various clinical strategies to prevent or treat AKI, its morbidity and mortality remain high, and there are no clinically effective therapeutic agents available. The limitations of traditional renal function markers (such as urine output, serum creatinine, and urea nitrogen levels), including their delayed response and insensitivity, underscore the urgent need for novel early biomarkers to facilitate the timely diagnosis of AKI. The proximal tubular epithelial cells in the kidney play a central role in both the onset and progression of AKI. These cells are highly metabolically active and have a substantial energy demand, primarily relying on fatty acid oxidation to meet their energy needs. Acylcarnitines are crucial in transporting fatty acids from the cytoplasm into the mitochondrial matrix for β-oxidation, which generates energy essential for maintaining cellular function and viability. This review aims to summarize the current understanding of AKI, including its triggers, classification, underlying mechanisms, and potential biomarkers. Special emphasis is placed on the role of fatty acid and carnitine metabolism in AKI, with the goal of providing a theoretical foundation for future investigations into AKI mechanisms and the identification of early diagnostic biomarkers.

Effects of Zofenopril and Thymoquinone in Cyclophosphamide-Induced Urotoxicity and Nephrotoxicity in Rats; The Value of Their Anti-Inflammatory and Antioxidant Properties

Objective

The study aimed to investigate whether zofenopril (ZOF), thymoquinone (TQ), or their co-administration effectively ameliorates urotoxicity and nephrotoxicity following cyclophosphamide (CPH) treatment.

Methods

A total of 48 Wister Albino female rats were divided into six groups each of eight rats; negative control (NC), positive control (PC), mesna (MS), ZOF, TQ, and ZOF+TQ groups. Normal saline, mesna, ZOF-15mg/kg, TQ-80mg/kg, and their combination were given orally for 19 days to the groups NC, MS, ZOF, TQ, and ZOF+TQ respectively. On the 17th day, a single dose of CPH 200 mg/kg was given intraperitoneally for all the groups except the NC group. Urine was collected over 24 hours before animal scarification for urinalysis. After scarification, blood, and kidney tissue were obtained for assessment of conventional kidney function parameters, novel kidney injury biomarkers, pro-inflammatory cytokines, oxidative status, complete blood count (CBC), and histopathological examination.

Results

CPH disturbed the urinary excretion of urea, creatinine, and protein, and significantly elevated novel biomarkers for kidney injury including cystatin-C (Cys-C) (p=0.019) and markedly kidney injury molecule-1 (KIM-1) (p=0.27), the semiquantitative measurement of hematuria revealed significant elevation of hematuria score (p=0.0002), urine pus and protein (p=0.0005). Additionally, CBC-derived inflammatory biomarkers including neutrophil-lymphocyte ratio (NLR) (p=0.001), neutrophil-monocyte ratio (NMR) (p=0.0004), pro-inflammatory cytokine interleukin (IL)-6 (p=0.016) and tumor necrosis factor (TNF)-α (p<=0.007), total antioxidant capacity (TAC) (p<0.0001) were significantly increased. Evidence of obvious histopathological structural alteration was noticed in kidney tissue and bladder urothelium in CPH-treated animals. ZOF, TQ, and their co-treatment significantly prevented these deleterious effects associated with CPH treatment.

Conclusion

This study demonstrated that ZOF and TQ provided uroprotective and nephroprotective effects against CPH-induced nephrotoxicity by reducing kidney injury biomarkers, and CBC-derived inflammatory markers, restoring antioxidant capacity, and improving histopathological outcomes. The suggested mechanism involves the anti-inflammatory and antioxidant activity of TQ and the sulfhydryl-angiotensin converting enzyme inhibitor ZOF.

Post-market safety profile of cefiderocol: a real-world pharmacovigilance exploratory analysis based on U.S. FDA adverse event reporting system (FAERS)

BACKGROUND

Cefiderocol is a new drug class, which is approved to treat Gram-negative bacteria infection. Its approval for marketing has provided clinicians with additional options for treating antimicrobial resistant gram-negative infections. The aim of our study was to assess the safety profiles of cefiderocol in real-world through data mining of the United States Food and Drug Administration Adverse Event Reporting System (FAERS).

METHODS

We included adverse event (AE) reports regarding cefiderocol submitted to the FAERS from 2019 quarter 4 (2019Q4) to 2024 quarter 3 (2024Q3). Disproportionality analyses, including reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN) and Multi-item Gamma Poisson Shrinker (MGPS) techniques were performed to identify the signals of disproportionate reporting of AEs in patients receiving cefiderocol. A signal of disproportionate reporting was detected if the lower limit of the 95% confidence interval (CI) of ROR > 1, the PRR was ≥ 2(while the Chi-Square of PRR was ≥ 4), the lower limit of 95% CI of the information component (IC025) was > 0, the lower limit of 95% CI of the Empirical Bayes Geometric Mean (EBGM05) was > 2 and at least 3 AEs were reported.

RESULTS

A total of 29 significant preferred terms (PTs) were identified among the 592 cefiderocol-associated adverse events (AEs) reports collected from the FAERS database. Cefiderocol-induced adverse events involved 24 System Organ Class (SOC). 29 positive signals of disproportionate reporting are also presented, such as Pathogen resistance (n = 16, ROR 189.35, PRR 184.26, IC 7.52, EBGM 183.89), Systemic candida (n = 3, ROR 138.79, PRR 138.19, IC7.11, EBGM 137.88), Drug resistance (n = 30, ROR 131.96, PRR 125.33, IC6.97, EBGM 125.16), and Drug effect less than expected (n = 6, ROR 68.42, PRR 67.74, IC6.08, EBGM 67.69). The most frequently observed were Death, Drug resistance and Treatment failure.

CONCLUSIONS

Our findings offer significant evidence regarding the safety profile of cefiderocol in real-world settings. This information may assist clinicians and pharmacists in enhancing their vigilance and improving the overall safety of cefiderocol in clinical practice.

Clopidogrel protects against gentamicin-induced nephrotoxicity through targeting oxidative stress, apoptosis, and coagulation pathways

Gentamicin (Genta)-induced nephrotoxicity poses a significant clinical challenge due to its detrimental effects on kidney function. Clopidogrel (Clop), an antiplatelet drug known for its ability to prevent blood clots by inhibiting platelet aggregation, also has potential effects on oxidative stress and cell death. This study investigates Clop's protective role against Genta-induced nephrotoxicity, emphasizing the importance of the coagulation cascade. The 32 adult male albino rats were randomly assigned to four groups of eight (n = 8). The first group received only the vehicle. Genta was injected intraperitoneally at 100 mg/kg/day for 8 days in the second group. Groups 3 and 4 received oral Clop at 10 and 20 mg/kg/day for 1 week before Genta delivery and throughout the experiment. Renal tissue showed renal function tests, oxidative stress, pro-inflammatory cytokines, apoptotic markers, coagulation profile, and fibrin expression. Clop improved Genta-induced kidney function and histopathology. Clop substantially reduced pro-inflammatory cytokines, oxidative stress indicators, pro-apoptotic proteins, and fibrin protein. Clop also significantly boosted renal tissue anti-inflammatory and anti-apoptotic protein expression. Genta-induced nephrotoxicity involves oxidative stress, apoptosis, and coagulation system activation, according to studies. This study underscores that Genta-induced nephrotoxicity is associated with oxidative stress, apoptosis, and activation of the coagulation system. Clop's protective effects on nephrons are attributed to its anticoagulant, antioxidant, anti-inflammatory, and anti-apoptotic properties, presenting it as a promising therapeutic strategy against Genta-induced kidney damage.

Methyl Donor Ameliorates CCl4-Induced Nephrotoxicity by Inhibiting Oxidative Stress, Inflammation, and Fibrosis Through the Attenuation of Kidney Injury Molecule 1 and Neutrophil Gelatinase-Associated Lipocalin Expression

Carbon tetrachloride (CCl4), a volatile organic compound, is harmful to multi-organs, including the liver, lungs, muscles, and kidneys. Methyl donors, such as methionine, choline, betaine, and folic acid, are vital to one-carbon metabolism and have great potential to alleviate oxidative stress and inflammation, thus mitigating disease onset. Hence, the current study aims to examine the therapeutic effect of methyl donors against CCl4-induced nephrotoxicity. Nephrotoxicity was developed in male Sprague Dawley rats using CCl4 at a dose of 1 mL/kg (4-week model induction) twice a week via the intraperitoneal route. Thereafter, methyl donor treatments through oral gavage were given for the next 6 weeks with a continuation of CCl4 administration. Biochemical, oxidative stress parameters, histopathological, and qRT-PCR analyses were done at the completion of the 10-week. Biochemical analyses revealed that CCl4 induces nephrotoxicity, as evidenced by increased urea and creatinine levels and decreased albumin levels. These detrimental effects were significantly ameliorated by methyl donor treatment. Moreover, CCl4 decreased the antioxidant enzyme activity (superoxide dismutase; SOD and catalase; CAT) while increasing oxidative stress markers (malondialdehyde; MDA and nitrite). Methyl donor treatment effectively mitigated these oxidative changes. Histopathological analysis demonstrated the nephroprotective effect of methyl donors against CCl4-induced nephrotoxicity, showing reduced tissue damage and protection of renal architecture. At the molecular level, methyl donor treatment alleviated the CCl4-induced increase in kidney injury biomarkers (Kidney injury molecule 1; KIM-1 and Neutrophil gelatinase-associated lipocalin; NGAL), as well as inflammatory (IL-6 and TNF-α) and fibrosis-related genes (Acta-2 and TGF-β). In conclusion, our findings suggest that methyl donors possess anti-inflammatory and anti-fibrotic properties. They protect against CCl4-induced oxidative damage to renal cells, likely due to their reactive oxygen species scavenging capabilities and their ability to restore key early renal injury biomarkers (KIM-1 and NGAL). Methyl donors hold great promise as a cutting-edge therapy approach for preventing CCl4-induced nephrotoxicity.

Influence of Ageing on the Pharmacodynamics and Pharmacokinetics of Chronically Administered Medicines in Geriatric Patients: A Review

As people age, the efficiency of various regulatory processes that ensure proper communication between cells and organs tends to decline. This deterioration can lead to difficulties in maintaining homeostasis during physiological stress. This includes but is not limited to cognitive impairments, functional difficulties, and issues related to caregivers which contribute significantly to medication errors and non-adherence. These factors can lead to higher morbidity, extended hospital stays, reduced quality of life, and even mortality. The decrease in homeostatic capacity varies among individuals, contributing to the greater variability observed in geriatric populations. Significant pharmacokinetic and pharmacodynamic alterations accompany ageing. Pharmacokinetic changes include decreased renal and hepatic clearance and an increased volume of distribution for lipid-soluble drugs, which prolong their elimination half-life. Pharmacodynamic changes typically involve increased sensitivity to various drug classes, such as anticoagulants, antidiabetic and psychotropic medications. This review examines the primary age-related physiological changes in geriatrics and their impact on the pharmacokinetics and pharmacodynamics of medications.

Severe Acute Kidney Injury with Necrotizing Glomerulonephritis After Piperacillin/Tazobactam Therapy in a Patient with Peritonitis: A Case Report and Literature Review

Piperacillin/tazobactam (PT), a widely utilized broad-spectrum antibiotic, has been associated with acute kidney injury (AKI). Although the precise mechanism remains uncertain, and most cases of PT-associated AKI are mild, this report describes a rare and severe complication of PT, which manifested as severe AKI with necrotizing glomerulonephritis requiring hemodialysis. A 42-year-old man was transferred to the nephrology clinic due to progressive deterioration of kidney function. Prior to the transfer, the patient had been diagnosed with appendicitis complicated by peritonitis and received intravenous PT for 8 days. Baseline kidney function was normal, but serum creatinine subsequently increased to 7.2 mg/dL. Hemodialysis was initiated to address metabolic acidosis and edema. Kidney biopsy revealed severe acute tubular injury and necrotizing glomerulonephritis. Steroid therapy was initiated based on the biopsy findings, and serum creatinine returned to normal levels after 4 weeks of treatment. This case demonstrates that severe AKI with necrotizing glomerulonephritis can occur after PT use. Prompt kidney biopsy and the timely initiation of immunosuppressive therapy are essential for a favorable outcome.

Strategic Synthesis of Sulfinamides as Versatile S(IV) Intermediates

Sulfinamides constitute adaptable S(IV) intermediates with a sulfur stereocenter, having emerging interest in divergent synthesis of high-valent S(VI) functional bioisosteres. Recent years have witnessed the strategic development of mild and selective synthetic routes for highly functionalized sulfinamides, employing stable organometallic reagents, carbon-centered radical precursors, and other abundant coupling partners merged with various sulfur reagents in the arena of metal, photoredox, and organocatalysis. Furthermore, asymmetric metal and organocatalysis have enabled the stereoselective synthesis of enantioenriched sulfinamides. In this Perspective, we present the recent (2021 to present) advancement of various synthetic methods toward sulfinamides.

A multi-valent polymyxin-based fluorescent probe for the detection of Gram-negative infections

A multi-branched fluorogenic probe for the rapid and specific detection of Gram-negative bacteria is reported. Three Gram-negative-targeting azido-modified polymyxins were clicked onto a trivalent scaffold functionalised with the environmental green-emitting fluorophore 7-nitrobenz-2-oxa-1,3-diazole. The probe allowed wash-free detection of target bacteria with increased sensitivity and lower limits of detection compared to monovalent probes.

A Comprehensive 10-Year Nationwide Pharmacovigilance Surveillance on Antibacterial Agents in Korea: Data Mining for Signal Detection of Trends and Seriousness of Adverse Events

A comprehensive pharmacovigilance surveillance on antibacterials is lacking. This study aims to investigate safety signals of antibacterial-related adverse drug events (ADEs) with seriousness and to identify predictors of serious ADEs. This study investigated 52,503 antibacterial-induced ADEs reported to the Korea Adverse Event Reporting System Database from January 2013 to December 2022. Disproportionality analysis was conducted, and the effect sizes were estimated by reporting odds ratios (ROR), proportional reporting ratio (PRR), and information component (IC). Multivariate logistic regression was performed to investigate the predictors of serious ADEs by estimating the odds ratio (OR). Serious events were more likely to be cardiovascular disorders (ROR 6.77, PRR 6.6, IC 2.37), urinary system disorders (ROR 5.56, PRR 5.22, IC 2.12), and platelet, bleeding, and clotting disorders (ROR 5.41, PRR 5.17, IC 2.06). The predictors may include age (OR 1.05), the number of concomitant medications (OR 1.44), concomitant proton pump inhibitors (OR 1.46) and non-steroidal anti-inflammatory drugs (OR 1.38) use, and specific antibacterial classes, while multiple antibacterial therapy was associated with lower serious ADE risks. The sensitivity analysis also suggests the male sex (OR 1.18) as a potential predictor of serious ADEs. However, further studies are imperative to determine the causality of antibacterial-induced ADEs in critically ill patients.

An Integrated Approach for Representing Knowledge on the Potential of Drugs to Cause Acute Kidney Injury

INTRODUCTION AND OBJECTIVE

The recent rise in acute kidney injury (AKI) incidence, with approximately 30% attributed to potentially preventable adverse drug events (ADEs), poses challenges in evaluating drug-induced AKI due to polypharmacy and other risk factors. This study seeks to consolidate knowledge on the drugs with AKI potential from four distinct sources: (i) bio(medical) peer-reviewed journals; (ii) spontaneous reporting systems (SRS); (iii) drug information databases (DIDs); and (iv) NephroTox website. By harnessing the potential of these underutilised sources, our objective is to bridge gaps and enhance the understanding of drug-induced AKI.

METHODS

By searching Medline, studies with lists of drugs with AKI potential established through consensus amongst medical experts were selected. A final list of 63 drugs was generated aggregating the original studies. For these 63 drugs, the AKI reporting odds ratios (RORs) using three SRS databases, the average frequency of ADEs from four different DIDs and the number of published studies identified via NephroTox was reported.

RESULTS

Drugs belonging to the antivirals, antibacterials, and non-steroidal anti-inflammatory pharmacological classes exhibit substantial consensus on AKI potential, which was also reflected in strong ROR signals, frequent to very frequent AKI-related ADEs and a high number of published studies reporting adverse kidney events as identified via NephroTox. Renin-angiotensin aldosterone system inhibitors and diuretics also display comparable signal strengths, but this can be attributed to expected haemodynamic changes. More variability is noted for proton-pump inhibitors.

CONCLUSIONS

By integrating four disjointed sources of knowledge, we have created a novel, comprehensive resource on drugs with AKI potential, contributing to kidney safety improvement efforts.

Association between age and onset of daptomycin-induced adverse events using the U.S. food and drug administration adverse event reporting system

BACKGROUND

Daptomycin is a lipopeptide antibiotic with a broad spectrum of activity against gram-positive bacteria. Although information on daptomycin-induced adverse events can be found in clinical trials, data regarding the impact of age on these events are insufficient. Therefore, we evaluated whether age affects the occurrence of daptomycin-induced adverse events using adverse drug event reports in post-marketing stages provided by the U.S. Food and Drug Administration (FDA).

METHODS

A total dataset of 7307 reports of patients treated with daptomycin in the FDA's Adverse Event Reporting System were analyzed. The patients were divided into seven age groups: 0-28 days, >28 days-23 months, 2-11 years, 12-17 years, 18-64 years, 65-80 years, and >80 years. A disproportionality analysis was conducted to calculate the reporting odds ratio, with a 95 % confidence interval. The univariate regression analysis was conducted using the percentage of each adverse event and age groups.

RESULTS

Compared with the number of reports aged 18-64 years, there were significantly increased reports of eosinophilic pneumonia in patients aged 65-80 years and >80 years, anaphylactic reaction and pseudomembranous colitis in patients aged 12-17 years, and acute renal failure in patients aged 65-80 years. The regression coefficient for the reporting proportion of eosinophilic pneumonia was significantly positive.

CONCLUSIONS

Our findings revealed age-related trends in daptomycin-induced adverse events, supporting the idea that implementing age-dependent follow-up and supportive care helps in the continuation of daptomycin therapy.

The Challenge of Treating Infections Caused by Metallo-β-Lactamase-Producing Gram-Negative Bacteria: A Narrative Review

Gram-negative multidrug-resistant (MDR) bacteria, including Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa, pose a significant challenge in clinical practice. Infections caused by metallo-β-lactamase (MBL)-producing Gram-negative organisms, in particular, require careful consideration due to their complexity and varied prevalence, given that the microbiological diagnosis of these pathogens is intricate and compounded by challenges in assessing the efficacy of anti-MBL antimicrobials. We discuss both established and new approaches in the treatment of MBL-producing Gram-negative infections, focusing on 3 strategies: colistin; the recently approved combination of aztreonam with avibactam (or with ceftazidime/avibactam); and cefiderocol. Despite its significant activity against various Gram-negative pathogens, the efficacy of colistin is limited by resistance mechanisms, while nephrotoxicity and acute renal injury call for careful dosing and monitoring in clinical practice. Aztreonam combined with avibactam (or with avibactam/ceftazidime if aztreonam plus avibactam is not available) exhibits potent activity against MBL-producing Gram-negative pathogens. Cefiderocol in monotherapy is effective against a wide range of multidrug-resistant organisms, including MBL producers, and favorable clinical outcomes have been observed in various clinical trials and case series. After examining scientific evidence in the management of infections caused by MBL-producing Gram-negative bacteria, we have developed a comprehensive clinical algorithm to guide therapeutic decision making. We recommend reserving colistin as a last-resort option for MDR Gram-negative infections. Cefiderocol and aztreonam/avibactam represent favorable options against MBL-producing pathogens. In the case of P. aeruginosa with MBL-producing enzymes and with difficult-to-treat resistance, cefiderocol is the preferred option. Further research is needed to optimize treatment strategies and minimize resistance.

Model-informed precision dosing: State of the art and future perspectives

Model-informed precision dosing (MIPD) stands as a significant development in personalized medicine to tailor drug dosing to individual patient characteristics. MIPD moves beyond traditional therapeutic drug monitoring (TDM) by integrating mathematical predictions of dosing and considering patient-specific factors (patient characteristics, drug measurements) as well as different sources of variability. For this purpose, rigorous model qualification is required for the application of MIPD in patients. This review delves into new methods in model selection and validation, also highlighting the role of machine learning in improving MIPD, the utilization of biosensors for real-time monitoring, as well as the potential of models integrating biomarkers for efficacy or toxicity for precision dosing. The clinical evidence of TDM and MIPD is discussed for various medical fields including infection medicine, oncology, transplant medicine, and inflammatory bowel diseases, thereby underscoring the role of pharmacokinetics/pharmacodynamics and specific biomarkers. Further research, particularly randomized clinical trials, is warranted to corroborate the value of MIPD in enhancing patient outcomes and advancing personalized medicine.

ID Consultant: Laboratory Monitoring During Long-Term Use of Oral Antimicrobials in Pediatric Patients

Oral antimicrobials remain the mainstay of long-term treatment for many infections. Meanwhile, the use of oral agents is becoming commonplace for the treatment of several pediatric infections once managed exclusively with parenteral therapies. Unfortunately, antimicrobials are associated with several laboratory toxicities, particularly when high doses or combination therapies are used, but there is a paucity of data on optimal laboratory monitoring strategies. In this ID Consultant article, we offer a summary of the 3 most common laboratory-based toxicities seen with long-term use of oral antimicrobials-drug-induced kidney injury, liver injury, and hematological toxicities-and we provide our recommended approach to monitoring.

Transition from acute kidney injury to chronic kidney disease: mechanisms, models, and biomarkers

Acute kidney injury (AKI) and chronic kidney disease (CKD) are increasingly recognized as interconnected conditions with overlapping pathophysiological mechanisms. This review examines the transition from AKI to CKD, focusing on the molecular mechanisms, animal models, and biomarkers essential for understanding and managing this progression. AKI often progresses to CKD due to maladaptive repair processes, persistent inflammation, and fibrosis, with both conditions sharing common pathways involving cell death, inflammation, and extracellular matrix (ECM) deposition. Current animal models, including ischemia-reperfusion injury (IRI) and nephrotoxic damage, help elucidate these mechanisms but have limitations in replicating the complexity of human disease. Emerging biomarkers such as kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and soluble tumor necrosis factor receptors (TNFRs) show promise in early detection and monitoring of disease progression. This review highlights the need for improved animal models and biomarker validation to better mimic human disease and enhance clinical translation. Advancing our understanding of the AKI-to-CKD transition through targeted therapies and refined research approaches holds the potential to significantly improve patient outcomes.

External Evaluation of Population Pharmacokinetic Models of Piperacillin in Preterm and Term Patients from Neonatal Intensive Care

BACKGROUND AND OBJECTIVES

Piperacillin/tazobactam is extensively used off-label to treat late-onset neonatal sepsis, but safety and pharmacokinetic data in this population are limited. Additionally, the organic immaturity of the newborns contributes to a high piperacillin pharmacokinetic variability. This affects the clinical efficacy of the antibiotic treatment and increases the probability of developing drug resistance. This study aimed to evaluate the predictive performance of reported piperacillin population pharmacokinetic models for their application in a model-informed precision dosing strategy in preterm and term Mexican neonatal intensive care patients.

METHODS

Published population pharmacokinetic models for piperacillin which included neonates in their study population were identified. From the reference models, structured models, population pharmacokinetic parameters, and interindividual and residual variability data were extracted to be replicated in pharmacokinetic software (NONMEM® version 7.4). For the clinical study, a sampling schedule was designed, and 2-3 blood samples of 250 µL were taken from neonates who met the inclusion criteria. Piperacillin plasma concentrations were determined by liquid chromatography/tandem mass spectrometry. The clinical treatment data were collected, and piperacillin plasma concentrations were estimated using reference pharmacokinetic models for an a priori or Bayesian approach. Statistical methods were used in terms of bias and precision to evaluate the differences between observed and estimated neonatal piperacillin plasma concentrations with the different approaches and to identify the pharmacokinetic model that best fits the neonatal data.

RESULTS

A total of 70 plasma samples were collected from 25 neonatal patients, of which 15 were preterm neonates. The overall median value (range) postnatal age, gestational age, body weight, and serum creatinine at the sampling collecting day were 12 (3-26) days, 34.2 (26-41.1) weeks, 1.78 (0.08-3.90) Kg, 0.47 (0.20-0.90) mg/dL, respectively. Three population pharmacokinetic models for piperacillin in infants up to 2 months were identified, and their predictive performance in neonatal data was evaluated. No pharmacokinetic model was suitable for our population using an a priori approach. The model published by Cohen-Wolkowiez et al. in 2014 with a Bayesian approach showed the best performance of the pharmacokinetic models evaluated in our neonatal data. The procedure requires two blood samples (predose and postdose), and, when applied, it predicted 66.6% of the observations with a relative median absolute predicted error of less than 30%.

CONCLUSIONS

The population pharmacokinetic model developed by Cohen-Wolkowiez et al. in 2014 demonstrated superior performance in predicting the plasma concentration of piperacillin in preterm and term Mexican neonatal intensive care patients. The Bayesian approach, including two different piperacillin plasma concentrations, was clinically acceptable regarding bias and precision. Its application for model-informed precision dosing can be an option to optimize the piperacillin dosage in our population.

Murepavadin Enhances the Killing Efficacy of Ciprofloxacin against Pseudomonas aeruginosa by Inhibiting Drug Efflux

Pseudomonas aeruginosa is a multidrug-resistant Gram-negative pathogen and one of the leading causes of ventilator-associated pneumonia and infections in patients with chronic obstructive pulmonary disease and cystic fibrosis. Murepavadin is a peptidomimetic that specifically targets outer-membrane lipopolysaccharide transport protein LptD of P. aeruginosa. In this study, we find that murepavadin enhances the bactericidal efficacy of ciprofloxacin. We further demonstrate that murepavadin increases intracellular accumulation of ciprofloxacin by suppressing drug efflux. In addition, the murepavadin-ciprofloxacin combination exhibits a synergistic bactericidal effect in an acute murine pneumonia model. In conclusion, our results identify an effective drug combination for the treatment of P. aeruginosa infections.

A universal optical aptasensor for antibiotics determination based on a new high-efficiency Förster resonance energy transfer pair

A novel "turn-on" aptasensor for kanamycin (Kana) detection based on a new Förster resonance energy transfer (FRET) pair is reported. A new organic small molecule was employed as a high-efficiency quencher for fluorophore. Based on specific interactions between ssDNA and the quencher, an ingenious and amplified strategy was designed. In the absence of the target, the fluorescence of the fluorophore labeled at the end of the aptamer was quenched. After the binding of the aptamer to the target, the fluorescence was recovered and amplified. The proposed aptasensor showed high specificity, selectivity, and stability in complicated systems. With the P3-based strategy, the limit of detection for Kana is estimated to be 10 nM, which is much lower than the maximum allowable concentration in milk. The recoveries of spiked Kana in milk were in the range 99.8 ~ 105.3% (n = 3). Fortunately, this novel method can be easily extended to other antibiotics such as tobramycin by simply replacing the aptamer, showing great potential as a universal platform for selective, sensitive, and rapid detection of hazardous analytes in food samples.

Impaired kidney function: supporting the safe use of medicines for patients

Due to the increasing incidence of acute kidney injury (AKI) and chronic kidney disease (CKD), nurses in most healthcare settings are likely to care for patients with some degree of impaired kidney function. Impaired kidney function can adversely affect the way the body excretes, absorbs, distributes and metabolises medicines (pharmacokinetics), potentially resulting in a wide range of drug-related complications. This article provides an overview of the effects of impaired kidney function on pharmacokinetics and the importance of accurate drug dose adjustments for patients with related conditions. It also discusses various aspects of medicines use in patients with AKI, the pharmacological management of patients with CKD and the use of immunosuppressive therapy in patients who have had a kidney transplant. The authors consider the role of the nurse in ensuring safe medicines use for patients with impaired kidney function throughout the article.

Serum Amyloid A3 Promoter-Luciferase Reporter Mice Are Useful for Early Drug-Induced Nephrotoxicity Detection

Early detection of drug-induced kidney injury is essential for drug development. In this study, multiple low-dose aristolochic acid (AA) and cisplatin (Cis) injections increased renal mRNA levels of inflammation, fibrosis, and renal tubule injury markers. We applied a serum amyloid A3 (Saa3) promoter-driven luciferase reporter (Saa3 promoter-luc mice) to these two tubulointerstitial nephritis models and performed in vivo bioluminescence imaging to monitor early renal pathologies. The bioluminescent signals from renal tissues with AA or CIS injections were stronger than those from normal kidney tissues obtained from normal mice. To verify whether the visualized bioluminescence signal was specifically generated by the injured kidney, we performed in vivo bioluminescence analysis after opening the stomachs of Saa3 promoter-luc mice, and the Saa3-mediated bioluminescent signal was specifically detected in the injured kidney. This study showed that Saa3 promoter activity is a potent non-invasive indicator for the early detection of drug-induced nephrotoxicity.

Tetracycline and sulfadiazine toxicity in human liver cells Huh-7

As typical antibiotics, tetracycline (TC) and sulfadiazine (SDZ) enter the human body through the food chain. Therefore, it is necessary to understand their individual and combined toxicity. In this study, the effects of TC, SDZ, and their mixture on cell viability, cell membrane damage, liver cell damage, and oxidative damage were evaluated in in vitro assays with human liver cells Huh-7. The results showed cytotoxicity of TC, SDZ, and their mixture, which induced oxidative stress and caused membrane and cell damage. The effect of antibiotics on Huh-7 cells increased with increasing concentration, except for lactate dehydrogenase (LDH) activity that commonly showed a threshold concentration response and cell viability, which commonly showed a biphasic trend, suggesting the possibility of hormetic responses where proper doses are included. The toxicity of TC was commonly higher than that of SDZ when applied at the same concentration. These findings shed light on the individual and joint effects of these major antibiotics on liver cells, providing a scientific basis for the evaluation of antibiotic toxicity and associated risks.