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Ubals M, Nadal-Baron P, Arando M, Rivero Á, Mendoza A, Descalzo Jorro V, Ouchi D, Pérez-Mañá C, Álvarez M, Alemany A, Hoyos-Mallecot Y, Nunley E, Lieberman NAP, Greninger AL, Galván-Casas C, Suñer C, G-Beiras C, Paredes R, Rodríguez-Gascón A, Canut A, García-Patos V, Farré M, Marks M, Giacani L, Vall-Mayans M, Mitjà O. Oral linezolid compared with benzathine penicillin G for treatment of early syphilis in adults (Trep-AB Study) in Spain: a prospective, open-label, non-inferiority, randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:404-416. [PMID: 38211601 PMCID: PMC10954560 DOI: 10.1016/s1473-3099(23)00683-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Management of syphilis, a sexually transmitted infection (STI) with increasing incidence, is challenged by drug shortages, scarcity of randomised trial data, an absence of non-penicillin alternatives for pregnant women with penicillin allergy (other than desensitisation), extended parenteral administration for neurosyphilis and congenital syphilis, and macrolide resistance. Linezolid was shown to be active against Treponema pallidum, the causative agent of syphilis, in vitro and in the rabbit model. We aimed to assess the efficacy of linezolid for treating early syphilis in adults compared with the standard of care benzathine penicillin G (BPG). METHODS We did a multicentre, open-label, non-inferiority, randomised controlled trial to assess the efficacy of linezolid for treating early syphilis compared with BPG. We recruited participants with serological or molecular confirmation of syphilis (either primary, secondary, or early latent) at one STI unit in a public hospital and two STI community clinics in Catalonia (Spain). Participants were randomly allocated in a 1:1 ratio using a computer-generated block randomisation list with six participants per block, to receive either oral linezolid (600 mg once per day for 5 days) or intramuscular BPG (single dose of 2·4 million international units) and were assessed for signs and symptoms (once per week until week 6 and at week 12, week 24, and week 48) and reagin titres of non-treponemal antibodies (week 12, week 24, and week 48). The primary endpoint was treatment response, assessed using a composite endpoint that included clinical response, serological response, and absence of relapse. Clinical response was assessed at 2 weeks for primary syphilis and at 6 weeks for secondary syphilis following treatment initiation. Serological cure was defined as a four-fold decline in rapid plasma reagin titre or seroreversion at any of the 12-week, 24-week, or 48-week timepoints. The absence of relapse was defined as the presence of different molecular sequence types of T pallidum in recurrent syphilis. Non-inferiority was shown if the lower limit of the two-sided 95% CI for the difference in rates of treatment response was higher than -10%. The primary analysis was done in the per-protocol population. The trial is registered at ClinicalTrials.gov (NCT05069974) and was stopped for futility after interim analysis. FINDINGS Between Oct 20, 2021, and Sept 15, 2022, 62 patients were assessed for eligibility, and 59 were randomly assigned to linezolid (n=29) or BPG (n=30). In the per-protocol population, after 48 weeks' follow-up, 19 (70%) of 27 participants (95% CI 49·8 to 86·2) in the linezolid group had responded to treatment and 28 (100%) of 28 participants (87·7 to 100·0) in the BPG group (treatment difference -29·6, 95% CI -50·5 to -8·8), which did not meet the non-inferiority criterion. The number of drug-related adverse events (all mild or moderate) was similar in both treatment groups (five [17%] of 29, 95% CI 5·8 to 35·8 in the linezolid group vs five [17%] of 30, 5·6 to 34·7, in the BPG group). No serious adverse events were reported during follow-up. INTERPRETATION The efficacy of linezolid at a daily dose of 600 mg for 5 days did not meet the non-inferiority criteria compared with BPG and, as a result, this treatment regimen should not be used to treat patients with early syphilis. FUNDING European Research Council and Fondo de Investigaciones Sanitarias.
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Affiliation(s)
- Maria Ubals
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Facultat de Medicina, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Dermatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Patricia Nadal-Baron
- Facultat de Medicina, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maider Arando
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ángel Rivero
- Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Barcelona Checkpoint, Projecte dels NOMS, Hispanosida, Barcelona
| | - Adrià Mendoza
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Vicent Descalzo Jorro
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Dan Ouchi
- Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Clara Pérez-Mañá
- Clinical Pharmacology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marlene Álvarez
- Pharmacy Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Andrea Alemany
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Ethan Nunley
- Department of Laboratory Medicine and Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Nicole A P Lieberman
- Department of Laboratory Medicine and Pathology, University of Washington Medical Center, Seattle, WA, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington Medical Center, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Cristina Galván-Casas
- Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Hospital Universitario de Mostoles, Madrid, Spain
| | - Clara Suñer
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Camila G-Beiras
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Roger Paredes
- Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Infectious Diseases, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; IrsiCaixa AIDS Research Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain; Center for Global Health and Diseases, Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alicia Rodríguez-Gascón
- Pharmacokinetic, Nanotechnology, and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy Group, Vitoria-Gasteiz, Spain
| | - Andrés Canut
- Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy Group, Vitoria-Gasteiz, Spain; Microbiology Service, Araba University Hospital, Osakidetza Basque Health Service, Vitoria-Gasteiz, Spain
| | | | - Magí Farré
- Clinical Pharmacology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Michael Marks
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK; Hospital for Tropical Diseases, London, UK; Division of Infection and Immunity, University College London, London, UK
| | - Lorenzo Giacani
- Department of Medicine, Division of Allergy and Infectious Diseases and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Martí Vall-Mayans
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Oriol Mitjà
- Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Fundació Lluita Contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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Landersdorfer CB, Nation RL. Limitations of Antibiotic MIC-Based PK-PD Metrics: Looking Back to Move Forward. Front Pharmacol 2021; 12:770518. [PMID: 34776982 PMCID: PMC8585766 DOI: 10.3389/fphar.2021.770518] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/14/2021] [Indexed: 12/28/2022] Open
Abstract
Within a few years after the first successful clinical use of penicillin, investigations were conducted in animal infection models to explore a range of factors that were considered likely to influence the antibacterial response to the drug. Those studies identified that the response was influenced by not only the total daily dose but also the interval between individual doses across the day, and whether penicillin was administered in an intermittent or continuous manner. Later, as more antibiotics were discovered and developed, antimicrobial pharmacologists began to measure antibiotic concentrations in biological fluids. This enabled the linking of antibacterial response at a single time point in an animal or in vitro infection model with one of three summary pharmacokinetic (PK) measures of in vivo exposure to the antibiotic. The summary PK exposure measures were normalised to the minimum inhibitory concentration (MIC), an in vitro measure of the pharmacodynamic (PD) potency of the drug. The three PK-PD indices (ratio of maximum concentration to MIC, ratio of area under the concentration-time curve to MIC, time concentration is above MIC) have been used extensively since the 1980s. While these MIC-based summary PK-PD metrics have undoubtedly facilitated the development of new antibiotics and the clinical application of both new and old antibiotics, it is increasingly recognised that they have a number of substantial limitations. In this article we use a historical perspective to review the origins of the three traditional PK-PD indices before exploring in detail their limitations and the implications arising from those limitations. Finally, in the interests of improving antibiotic development and dosing in patients, we consider a model-based approach of linking the full time-course of antibiotic concentrations with that of the antibacterial response. Such an approach enables incorporation of other factors that can influence treatment outcome in patients and has the potential to drive model-informed precision dosing of antibiotics into the future.
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Affiliation(s)
- Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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Seña AC, Zhang XH, Li T, Zheng HP, Yang B, Yang LG, Salazar JC, Cohen MS, Moody MA, Radolf JD, Tucker JD. A systematic review of syphilis serological treatment outcomes in HIV-infected and HIV-uninfected persons: rethinking the significance of serological non-responsiveness and the serofast state after therapy. BMC Infect Dis 2015; 15:479. [PMID: 26511465 PMCID: PMC4625448 DOI: 10.1186/s12879-015-1209-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/12/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Syphilis remains a global public health threat and can lead to severe complications. In addition to resolution of clinical manifestations, a reduction in nontreponemal antibody titers after treatment is regarded as "proof of cure." However, some patients manifest < 4-fold decline ("serological non-response") or persistently positive nontreponemal titers despite an appropriate decline ("serofast") that may represent treatment failure, reinfection, or a benign immune response. To delineate these treatment phenomena, we conducted a systematic review of the literature regarding serological outcomes and associated factors among HIV-infected and -uninfected subjects. METHODS Six databases (PubMed, Embase, CINAHL, Web of Science, Scopus, and BIOSIS) were searched with no date restrictions. Relevant articles that evaluated serological treatment responses and correlates of serological cure (≥ four-fold decline in nontreponemal titers) were included. RESULTS We identified 1693 reports in the literature, of which 20 studies met selection criteria. The median proportion of patients who had serological non-response was 12.1% overall (interquartile range, 4.9-25.6), but varied depending on the time points after therapy. The serofast proportion could only be estimated from 2 studies, which ranged from 35.2-44.4%. Serological cure was primarily associated with younger age, higher baseline nontreponemal titers, and earlier syphilis stage. The relationship between serological cure and HIV status was inconsistent; among HIV-infected patients, CD4 count and HIV viral load was not associated with serological cure. CONCLUSIONS Serological non-response and the serofast state are common syphilis treatment outcomes, highlighting the importance of determining the immunological and clinical significance of persistent nontreponemal antibody titers after therapy.
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Affiliation(s)
- Arlene C Seña
- Department of Medicine, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Xiao-Hui Zhang
- Sexually Transmitted Diseases Department, Guangdong Provincial Dermatology Hospital, Guangzhou, China.
| | - Trudy Li
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - He-Ping Zheng
- Sexually Transmitted Diseases Department, Guangdong Provincial Dermatology Hospital, Guangzhou, China.
| | - Bin Yang
- Sexually Transmitted Diseases Department, Guangdong Provincial Dermatology Hospital, Guangzhou, China.
| | - Li-Gang Yang
- Sexually Transmitted Diseases Department, Guangdong Provincial Dermatology Hospital, Guangzhou, China.
| | - Juan C Salazar
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Connecticut and Connecticut Children's Medical Center, Farmington, Connecticut, USA.
| | - Myron S Cohen
- Department of Medicine, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - M Anthony Moody
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA.
- Duke Human Vaccine Institute, Duke University, Durham, North Carolina, USA.
| | - Justin D Radolf
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Connecticut and Connecticut Children's Medical Center, Farmington, Connecticut, USA.
- Department of Medicine, UConn Health, Farmington, Connecticut, USA.
| | - Joseph D Tucker
- Department of Medicine, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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EAGLE H, MUSSELMAN AD. The rate of bactericidal action of penicillin in vitro as a function of its concentration, and its paradoxically reduced activity at high concentrations against certain organisms. ACTA ACUST UNITED AC 2008; 88:99-131. [PMID: 18871882 PMCID: PMC2135799 DOI: 10.1084/jem.88.1.99] [Citation(s) in RCA: 217] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
1. The concentrations of penicillin G which (a) reduced the net rate of multiplication, (b) exerted a net bactericidal effect, and (c) killed the organisms at a maximal rate, have been defined for a total of 41 strains of α- and β-hemolytic streptococci, Staphylococcus aureus and Staphylococcus albus, Diplococcus pneumoniae, and the Reiter treponoma. 2. The concentration which killed the organisms at a maximal rate was 2 to 20 times the minimal effective level ("sensitivity" as ordinarily defined). With some organisms, even a 32,000-fold increase beyond this maximally effective level did not further increase the rate of its bactericidal effect. However, with approximately half the strains here studied (all 4 strains of group B β-hemolytic streptococci, 4 of 5 group C strains, 5 of 7 strains of Streptococcus fecalis, 2 of 4 other α-hemolytic streptococci, and 4 of 9 strains of staphylococci), when the concentration of penicillin was increased beyond that optimal level, the rate at which the organisms died was paradoxically reduced rather than increased, so that the maximal effect was obtained only within a relatively narrow optimal zone. 3. There were marked differences between bacterial species, and occasionally between different strains of the same species, not only with respect to the effective concentrations of penicillin, but also with respect to the maximal rate at which they could be killed by the drug in any concentration. Although there was a rough correlation between these two factors, there were many exceptions; individual strains affected only by high concentrations of penicillin might nevertheless be killed rapidly, while strains sensitive to minute concentrations might be killed only slowly. 4. Within the same bacterial suspension, individual organisms varied only to a minor degree with respect to the effective concentrations of penicillin. They varied strikingly, however, in their resistance to penicillin as measured by the times required to kill varying proportions of the cells.
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