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Gao P, Odem-Davis K. Assessing noninferiority: Evaluating efficacy of a new treatment without complete data. Pharm Stat 2019; 18:546-554. [PMID: 30977258 DOI: 10.1002/pst.1946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 01/15/2019] [Accepted: 03/05/2019] [Indexed: 11/12/2022]
Abstract
The FDA released the final guidance on noninferiority trials in November 2016. In noninferiority trials, validity of the assessment of the efficacy of the test treatment depends on the control treatment's efficacy. Therefore, it is critically important that there be a reliable estimate of the control treatment effect-which is generally obtained from historical trials, and often assumed to hold in the current setting (the assay constancy assumption). Validating the constancy assumption requires clinical data, which are typically lacking. The guidance acknowledges that "lack of constancy can occur for many reasons." We clarify the objectives of noninferiority trials. We conclude that correction for bias, rather than assay constancy, is critical to conducting valid noninferiority trials. We propose that assay constancy not be assumed and discounting or thresholds be used to address concern about loss of historical efficacy. Examples are provided for illustration.
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Affiliation(s)
- Ping Gao
- Brightech International, Somerset, New Jersey
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2
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Comparison of vancomycin and linezolid in patients with peripheral vascular disease and/or diabetes in an observational European study of complicated skin and soft-tissue infections due to methicillin-resistant Staphylococcus aureus. Clin Microbiol Infect 2015. [DOI: 10.1016/j.cmi.2015.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Dryden M, Baguneid M, Eckmann C, Corman S, Stephens J, Solem C, Li J, Charbonneau C, Baillon-Plot N, Haider S. Pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: focus on skin and soft-tissue infections. Clin Microbiol Infect 2015. [PMID: 26198368 DOI: 10.1016/j.cmi.2015.03.024] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus affects 284 million adults worldwide and is increasing in prevalence. Accelerated atherosclerosis in patients with diabetes mellitus contributes an increased risk of developing cardiovascular diseases including peripheral vascular disease (PVD). Immune dysfunction, diabetic neuropathy and poor circulation in patients with diabetes mellitus, especially those with PVD, place these patients at high risk for many types of typical and atypical infections. Complicated skin and soft-tissue infections (cSSTIs) are of particular concern because skin breakdown in patients with advanced diabetes mellitus and PVD provides a portal of entry for bacteria. Patients with diabetes mellitus are more likely to be hospitalized with cSSTIs and to experience related complications than patients without diabetes mellitus. Patients with PVD requiring lower extremity bypass are also at high risk of surgical site and graft infections. Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent causative pathogen in cSSTIs, and may be a significant contributor to surgical site infections, especially in patients who are colonized with MRSA on hospital admission. Patients with cSSTIs and diabetes mellitus or PVD experience lower clinical success rates than patients without these comorbidities, and may also have a longer length of hospital stay and higher risk of adverse drug events. Clinicians should be vigilant in recognizing the potential for infection with multi-drug-resistant organisms, especially MRSA, in these populations and initiating therapy with appropriate antibiotics.
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Affiliation(s)
- M Dryden
- Hampshire Hospitals NHS Foundation Trust, Coitbury House Friarsgate, Winchester, UK
| | - M Baguneid
- Department of Vascular Surgery, University Hospital of South Manchester NHS, Manchester, UK
| | - C Eckmann
- Klinikum Peine, Academic Hospital of Medical University Hannover, Peine, Germany
| | - S Corman
- Pharmerit International, Bethesda, MD, USA
| | - J Stephens
- Pharmerit International, Bethesda, MD, USA.
| | - C Solem
- Pharmerit International, Bethesda, MD, USA
| | - J Li
- Pfizer Inc., San Diego, CA, USA
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Vazquez-Guillamet C, Kollef MH. Treatment of Gram-positive infections in critically ill patients. BMC Infect Dis 2014; 14:92. [PMID: 25431211 PMCID: PMC4289239 DOI: 10.1186/1471-2334-14-92] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 02/03/2014] [Indexed: 01/08/2023] Open
Abstract
Gram-positive bacteria to include methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), and enterococci, to include vancomycin-resistant enterococci (VRE), display a remarkable array of resistance and virulence factors, which have contributed to their prominent role in infections of the critically ill. Over the last three decades infections with these pathogens has increased as has their overall resistance to available antimicrobial agents. This has led to the development of a number of new antibiotics for the treatment of Gram-positive bacteria. At present, it is important that clinicians recognize the changing resistance patterns and epidemiology of Gram-positive bacteria as these factors may impact patient outcomes. The increasing range of these pathogens, such as the emergence of community-associated MRSA clones, emphasizes that all specialties of physicians treating infections should have a good understanding of the infections caused by Gram-positive bacteria in their area of practice. When initiating empiric antibiotics, it is of vital importance that this therapy be timely and appropriate, as delays in treatment are associated with adverse outcomes. Although vancomycin has traditionally been considered a first-line therapy for serious MRSA infections, multiple concerns with this agent have opened the door for alternative agents demonstrating efficacy in this role. Similarly, the expansion of VRE as a pathogen in the ICU setting has required the development of agents targeting this important pathogen.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St, Louis, Missouri.
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Abstract
PURPOSE OF REVIEW Despite concerns regarding efficacy and tolerability, vancomycin continues to be the standard treatment for skin and soft tissue infections (SSTIs) when β-lactam antimicrobials cannot be used. This review sought to establish the role of both old and new alternatives to vancomycin. Methods for achieving optimization of vancomycin therapy are also explored. RECENT FINDINGS Several meta-analyses have demonstrated poorer clinical outcomes when the vancomycin minimum inhibitory concentration approaches the breakpoint of 2 μg/ml. Higher doses should be utilized to optimize pharmacokinetics and pharmacodynamics when higher volumes of distribution occur (e.g. sepsis). Newer agents with established noninferiority to vancomycin include the oxazolidinones linezolid and tedizolid, the lipopeptide daptomycin, the anti-meticillin-resistant Staphylococcus aureus cephalosporin ceftaroline and the glycylcycline tigecycline. Linezolid is thus far the only agent that has been shown to be associated with better clinical and microbiological cure rates. Ceftaroline and tigecycline are broad-spectrum agents best reserved for polymicrobial infections (e.g. diabetic foot infections). SUMMARY When vancomycin is used for the treatment of SSTIs, maximizing the dose should be performed to improve efficacy. Cost is often the main limiting factor with regard to the newer agents, but their suitability for outpatient antimicrobial therapy may counteract this.
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Edwards B, Andini R, Esposito S, Grossi P, Lew D, Mazzei T, Novelli A, Soriano A, Gould IM. Treatment options for methicillin-resistant Staphylococcus aureus (MRSA) infection: Where are we now? J Glob Antimicrob Resist 2014; 2:133-140. [PMID: 27873719 DOI: 10.1016/j.jgar.2014.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 03/28/2014] [Accepted: 03/31/2014] [Indexed: 01/05/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) infection continues to be a substantial global problem with significant associated morbidity and mortality. This review summarises the discussions that took place at the 4th MRSA Consensus Conference in relation to the current treatment options for serious MRSA infections and how to optimise whichever therapy is embarked upon. It highlights the many challenges faced by both the laboratory and clinicians in the diagnosis and treatment of MRSA infections.
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Affiliation(s)
- B Edwards
- Medical Microbiology Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Dalkeith Road, Edinburgh EH16 4SA, UK.
| | - R Andini
- Second University of Naples, UOC Transplant and Infectious Disease Medicine, AORN Monaldi, Naples, Italy
| | - S Esposito
- Department of Medicine, University of Salerno, Salerno, Italy
| | - P Grossi
- Department of Surgical and Morphological Studies, University of Unisubria, Varese, Italy
| | - D Lew
- Chief Infectious Diseases Division, Chief Department of Specialties of Internal Medicine, Geneva University Hospital, Geneva, Switzerland
| | - T Mazzei
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Firenze, Firenze, Italy
| | - A Novelli
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Firenze, Firenze, Italy
| | - A Soriano
- Department of Infectious Diseases, IDIBAPS, Hospital Clinic of Barcelona, Spain
| | - I M Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, UK
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Bassetti M, Baguneid M, Bouza E, Dryden M, Nathwani D, Wilcox M. European perspective and update on the management of complicated skin and soft tissue infections due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid. Clin Microbiol Infect 2014; 20 Suppl 4:3-18. [DOI: 10.1111/1469-0691.12463] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Puzniak LA, Capitano B, Biswas P, Lodise TP. Impact of patient characteristics and infection type on clinical outcomes of patients who received linezolid or vancomycin for complicated skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus: a pooled data analysis. Diagn Microbiol Infect Dis 2014; 78:295-301. [DOI: 10.1016/j.diagmicrobio.2013.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 10/17/2013] [Accepted: 11/04/2013] [Indexed: 01/22/2023]
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Anstead GM, Cadena J, Javeri H. Treatment of infections due to resistant Staphylococcus aureus. Methods Mol Biol 2014; 1085:259-309. [PMID: 24085702 DOI: 10.1007/978-1-62703-664-1_16] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This chapter reviews data on the treatment of infections caused by drug-resistant Staphylococcus aureus, particularly methicillin-resistant S. aureus (MRSA). This review covers findings reported in the English language medical literature up to January of 2013. Despite the emergence of resistant and multidrug-resistant S. aureus, we have seven effective drugs in clinical use for which little resistance has been observed: vancomycin, quinupristin-dalfopristin, linezolid, tigecycline, telavancin, ceftaroline, and daptomycin. However, vancomycin is less effective for infections with MRSA isolates that have a higher MIC within the susceptible range. Linezolid is probably the drug of choice for the treatment of complicated MRSA skin and soft tissue infections (SSTIs); whether it is drug of choice in pneumonia remains debatable. Daptomycin has shown to be non-inferior to either vancomycin or β-lactams in the treatment of staphylococcal SSTIs, bacteremia, and right-sided endocarditis. Tigecycline was also non-inferior to comparator drugs in the treatment of SSTIs, but there is controversy about whether it is less effective than other therapeutic options in the treatment of more serious infections. Telavancin has been shown to be non-inferior to vancomycin in the treatment of SSTIs and pneumonia, but has greater nephrotoxicity. Ceftaroline is a broad-spectrum cephalosporin with activity against MRSA; it is non-inferior to vancomycin in the treatment of SSTIs. Clindamycin, trimethoprim-sulfamethoxazole, doxycycline, rifampin, moxifloxacin, and minocycline are oral anti-staphylococcal agents that may have utility in the treatment of SSTIs and osteomyelitis, but the clinical data for their efficacy is limited. There are also several drugs with broad-spectrum activity against Gm-positive organisms that have reached the phase II and III stages of clinical testing that will hopefully be approved for clinical use in the upcoming years: oritavancin, dalbavancin, omadacycline, tedizolid, delafloxacin, and JNJ-Q2. Thus, there are currently many effective drugs to treat resistant S. aureus infections and many promising agents in the pipeline. Nevertheless, S. aureus remains a formidable adversary, and despite our deep bullpen of potential therapies, there are still frequent treatment failures and unfortunate clinical outcomes. The following discussion summarizes the clinical challenges presented by MRSA, the clinical experience with our current anti-MRSA antibiotics, and the gaps in our knowledge on how to use these agents to most effectively combat MRSA infections.
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Affiliation(s)
- Gregory M Anstead
- Medicine Service, South Texas Veterans Health Care System, San Antonio, TX, USA
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Fu J, Ye X, Chen C, Chen S. The efficacy and safety of linezolid and glycopeptides in the treatment of Staphylococcus aureus infections. PLoS One 2013; 8:e58240. [PMID: 23484002 PMCID: PMC3590119 DOI: 10.1371/journal.pone.0058240] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 02/01/2013] [Indexed: 01/22/2023] Open
Abstract
To assess the effectiveness and safety of linezolid in comparison with glycopeptides (vancomycin and teicoplanin) for the treatment of Staphylococcus aureus infections, we conducted a meta-analysis of relevant randomized controlled trials. A thorough search of Pubmed and other databases was performed. Thirteen trials on 3863 clinically assessed patients were included. Linezolid was slightly more effective than glycopeptides in the intent-to-treat population (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01–1.10), was more effective in clinically assessed patients (OR 95% CI: 1.38, 1.17–1.64) and in all microbiologically assessed patients (OR 95% CI: 1.38, 1.15–1.65). Linezolid was associated with better treatment in skin and soft-tissue infections (SSTIs) patients (OR 95% CI: 1.61, 1.22–2.12), but not in bacteraemia (OR 95% CI: 1.24, 0.78–1.97) or pneumonia (OR 95% CI: 1.25, 0.97–1.60) patients. No difference of mortality between linezolid and glycopeptides was seen in the pooled trials (OR 95% CI: 0.98, 0.83–1.15). While linezolid was associated with more haematological (OR 95% CI: 2.23, 1.07–4.65) and gastrointestinal events (OR 95% CI: 2.34, 1.53–3.59), a significantly fewer events of skin adverse effects (OR 95% CI: 0.27, 0.16–0.46) and nephrotoxicity (OR 95% CI: 0.45, 0.28–0.72) were recorded in linezolid. Based on the analysis of the pooled data of randomized control trials, linezolid should be a better choice for treatment of patients with S. aureus infections, especially in SSTIs patients than glycopeptides. However, when physicians choose to use linezolid, risk of haematological and gastrointestinal events should be taken into account according to the characteristics of the specific patient populations.
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Affiliation(s)
- Jinjian Fu
- Department of Epidemiology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Key Laboratory of Molecular Epidemiology, Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
- Department of Laboratory Medicine, Liuzhou Municipal Maternity and Child Healthcare Hospital, Liuzhou, Guangxi, China
| | - Xiaohua Ye
- Department of Epidemiology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Key Laboratory of Molecular Epidemiology, Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Cha Chen
- Department of Laboratory Medicine, Guangzhou High Education Mega Centre Hospital, Branch of Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong, China
| | - Sidong Chen
- Guangdong Key Laboratory of Molecular Epidemiology, Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
- * E-mail:
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Watkins RR, Lemonovich TL, File TM. An evidence-based review of linezolid for the treatment of methicillin-resistant Staphylococcus aureus (MRSA): place in therapy. CORE EVIDENCE 2012; 7:131-43. [PMID: 23271985 PMCID: PMC3526863 DOI: 10.2147/ce.s33430] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA), including community-associated and hospital-associated strains, is a major cause of human morbidity and mortality. Treatment options have become limited due to the emergence of MRSA strains with decreased sensitivity to vancomycin, which has long been the first-line therapy for serious infections. This has prompted the search for novel antibiotics that are efficacious against MRSA. Linezolid, an oxazolidinone class of antibiotic, was approved by the Food and Drug Administration in 2000 for treatment of MRSA infections. Since then, there have been a multitude of clinical trials and research studies evaluating the effectiveness of linezolid against serious infections, including pneumonia (both community- and hospital-acquired), skin and soft-tissue infections such as diabetic foot ulcers, endocarditis, osteomyelitis, prosthetic devices, and others. The primary aim of this review is to provide an up-to-date evaluation of the clinical evidence for using linezolid to treat MRSA infections, with a focus on recently published studies, including those on nosocomial pneumonia. Other objectives are to analyze the cost-effectiveness of linezolid compared to other agents, and to review the pharmokinetics and pharmacodynamics of linezolid, emphasizing the most current concepts.
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Affiliation(s)
- Richard R Watkins
- Division of Infectious Diseases, Akron General Medical Center, Akron, OH, USA
| | - Tracy L Lemonovich
- Division of Infectious Diseases and HIV Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Thomas M File
- Division of Infectious Diseases, Summa Health System, Akron, OH, USA
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