Liposomal amikacin: improved treatment of Mycobacterium avium complex infection in the beige mouse model

The role of amikacin in the treatment of nontuberculous mycobacterial disease

Introduction: Guidelines recommend the use of amikacin in the treatment of nontuberculous mycobacterial (NTM) disease. The authors have evaluated the evidence for the position of amikacin in NTM disease treatment.Areas covered: The authors performed a literature search for original research on amikacin in NTM disease, including its mechanism of action, emergence of resistance, pre-clinical and clinical investigations.Expert opinion: Amikacin shows moderate in vitro activity against the clinically most relevant NTM species (M. avium complex and M. abscessus). It is synergistic with ethambutol, clofazimine, and macrolides and these combinations are effective in animal models. Liposomal encapsulation increases amikacin efficacy. Clinically, the recommended dose of 15 mg/kg intravenous amikacin does not lead to PK/PD target attainment in all patients and a positive impact on long-term treatment outcomes remains unproven in both M. avium complex and M. abscessus disease. Adding the amikacin liposome inhalation suspension did prove to be effective in short and long term in patients not responding to recommended treatment for M. avium complex pulmonary disease. Its optimal use in M. avium complex and M. abscessus pulmonary disease warrants further evaluation.

Amikacin liposome inhalation suspension as a treatment for patients with refractory mycobacterium avium complex lung infection

Introduction: Amikacin liposome inhalation suspension (ALIS) contains amikacin sulfate, an aminoglycoside antibacterial drug. It has been approved in the US as a combined antibiotic treatment for refractory MAC lung disease patients. ALIS, as an inhaled antibiotic, can deliver amikacin to the infected site effectively and reduce systemic toxicity.Areas covered: This article gives a summated review of the pharmacodynamics, pharmacokinetics, therapeutic efficacy, post-marketing surveillance, and regulatory affairs of ALIS as an add-on therapy for MAC lung disease in adults by analyzing data from preclinical studies, clinical trials and original studies. We systematically searched Medline/PubMed through October 2020.Expert opinion: Studies demonstrate that ALIS as an add-on treatment significantly improve the rate of sputum culture conversion in MAC lung disease patients compare to guideline-recommended therapy only. The ALIS treatment showed a similar risk of serious adverse events and a low chance of renal adverse events. However, ALIS was associated with more respiratory adverse events than guideline-recommended therapy only. There was not sufficient data to conclude that ALIS treatment can improve clinical outcomes; however, with the significant improvement in the microbiology outcome in MAC lung disease patients, ALIS showed its potential use as an adjunct treatment for treating MAC lung disease.

Pharmacologically Aware Phage Therapy: Pharmacodynamic and Pharmacokinetic Obstacles to Phage Antibacterial Action in Animal and Human Bodies

The use of viruses infecting bacteria (bacteriophages or phages) to treat bacterial infections has been ongoing clinically for approximately 100 years. Despite that long history, the growing international crisis of resistance to standard antibiotics, abundant anecdotal evidence of efficacy, and one successful modern clinical trial of efficacy, this phage therapy is not yet a mainstream approach in medicine. One explanation for why phage therapy has not been subject to more widespread implementation is that phage therapy research, both preclinical and clinical, can be insufficiently pharmacologically aware. Consequently, here we consider the pharmacological obstacles to phage therapy effectiveness, with phages in phage therapy explicitly being considered to serve as drug equivalents. The study of pharmacology has traditionally been differentiated into pharmacokinetic and pharmacodynamic aspects. We therefore separately consider the difficulties that phages as virions can have in traveling through body compartments toward reaching their target bacteria (pharmacokinetics) and the difficulties that phages can have in exerting antibacterial activity once they have reached those bacteria (pharmacodynamics). The latter difficulties, at least in part, are functions of phage host range and bacterial resistance to phages. Given the apparently low toxicity of phages and the minimal side effects of phage therapy as practiced, phage therapy should be successful so long as phages can reach the targeted bacteria in sufficiently high numbers, adsorb, and then kill those bacteria. Greater awareness of what obstacles to this success generally or specifically can exist, as documented in this review, should aid in the further development of phage therapy toward wider use.

Amikacin Liposome Inhalation Suspension (ALIS) Penetrates Non-tuberculous Mycobacterial Biofilms and Enhances Amikacin Uptake Into Macrophages

Non-tuberculous mycobacteria (NTM) cause pulmonary infections in patients with structural lung damage, impaired immunity, or other risk factors. Delivering antibiotics to the sites of these infections is a major hurdle of therapy because pulmonary NTM infections can persist in biofilms or as intracellular infections within macrophages. Inhaled treatments can improve antibiotic delivery into the lungs, but efficient nebulization delivery, distribution throughout the lungs, and penetration into biofilms and macrophages are considerable challenges for this approach. Therefore, we developed amikacin liposome inhalation suspension (ALIS) to overcome these challenges. Nebulization of ALIS has been shown to provide particles within the respirable size range that distribute to both central and peripheral lung compartments in humans. The in vitro and in vivo efficacy of ALIS against NTM has been demonstrated previously. The key mechanistic questions are whether ALIS penetrates NTM biofilms and enhances amikacin uptake into macrophages. We found that ALIS effectively penetrated throughout NTM biofilms and concentration-dependently reduced the number of viable mycobacteria. Additionally, we found that ALIS improved amikacin uptake by ∼4-fold into cultured macrophages compared with free amikacin. In rats, inhaled ALIS increased amikacin concentrations in pulmonary macrophages by 5- to 8-fold at 2, 6, and 24 h post-dose and retained more amikacin at 24 h in airways and lung tissue relative to inhaled free amikacin. Compared to intravenous free amikacin, a standard-of-care therapy for refractory and severe NTM lung disease, ALIS increased the mean area under the concentration-time curve in lung tissue, airways, and macrophages by 42-, 69-, and 274-fold. These data demonstrate that ALIS effectively penetrates NTM biofilms, enhances amikacin uptake into macrophages, both in vitro and in vivo, and retains amikacin within airways and lung tissue. An ongoing Phase III trial, adding ALIS to guideline based therapy, met its primary endpoint of culture conversion by month 6. ALIS represents a promising new treatment approach for patients with refractory NTM lung disease.

Nanomaterials in the Prevention, Diagnosis, and Treatment of Mycobacterium Tuberculosis Infections

Despite the tremendous advancements that have been made in biomedical research, Mycobacterium tuberculosis (TB) still remains one of the top 10 causes of death worldwide, outpacing the Human Immunodeficiency Virus as a leading cause of death from an infectious disease. In the light of such significant disease burden, tremendous efforts have been made worldwide to stem this burgeoning spread of disease. The use of nanomaterials in TB management has increased in the past decade, particularly in the areas of early TB detection, prevention, and treatment. Nanomaterials have been proven to be efficacious in the rapid and accurate detection of TB pathogens. Novel nanocarriers have also shown tremendous promise in improving drug delivery, potentially enhancing drug concentrations in target organs while at the same time, reducing treatment frequency. In addition, the engineering of antigen nanocarriers represents an exciting front in TB research, potentially paving the way for the successful development of a new class of effective TB vaccines. This article discusses epidemiology and pathogenesis of TB infections, current TB therapeutics, advanced nanomaterials for anti-TB drug delivery, and TB vaccines. In addition, challenges and future perspectives in developing safe and effective nanomaterials in TB diagnosis and therapy are also presented.

Lipid-based nanovesicles for nanomedicine

Multifunctional lipid-based nanovesicles (L-NVs) prepared by molecular self-assembly of membrane components together with (bio)-active molecules, by means of compressed CO₂-media or other non-conventional methods lead to highly homogeneous, tailor-made nanovesicles that are used for advanced nanomedicine. Confocal microscopy image of siRNA transfection using L-NVs, reprinted with permission from de Jonge,et al.,Gene Therapy, 2006,13, 400–411.

In-vitro and in-vivo evaluation of ciprofloxacin liposomes for pulmonary administration

OBJECTIVE

The aim of this study was to investigate the ciprofloxacin liposome of high encapsulation efficiency with optimal physical properties for pulmonary administration and to test its in-vivo potential in rats.

METHODS

Ciprofloxacin-loaded liposome was prepared by gradient of ammonium sulfate method. The particle size and morphology were determined using a NANOPHOX particle size analyzer and a transmission electron microscope, respectively. Encapsulation efficiency was calculated by UV spectrophotometry. Ciprofloxacin liposome released in vitro was performed using simulated lung fluid. In-vivo studies, pharmacokinetics and pulmonary distribution, HPLC method was established to determine the concentration of ciprofloxacin in rat plasma and lung tissue. The pulmonary pathological section was used to observe the change of pulmonary pathology.

RESULTS

The optimized ciprofloxacin liposome, which had a high encapsulation efficiency of 93.96%, and an average particle size of 349.6 nm with a span of 0.42, showed sustained in-vitro release. The optimized ciprofloxacin liposome was further examined in the in-vivo study in rats. The concentration of ciprofloxacin in lung and blood was simultaneously determined in each rat. The ratio of the AUClung value between ciprofloxacin liposome and ciprofloxacin solution was 288.33, whereas the relative bioavailability was 72.42%, and the drug targeting efficiency of ciprofloxacin liposome and ciprofloxacin solution by intratracheal administration were 799.71 and 2.01, respectively.

CONCLUSION

Ciprofloxacin liposome for pulmonary administration offered an attractive alternative that was able to deliver high concentrations of antibiotic directly to the chosen target site while minimizing the local irritation.

Nanotechnology and pulmonary delivery to overcome resistance in infectious diseases

Used since ancient times especially for the local treatment of pulmonary diseases, lungs and airways are a versatile target route for the administration of both local and systemic drugs. Despite the existence of different platforms and devices for the pulmonary administration of drugs, only a few formulations are marketed, partly due to physiological and technological limitations.

Respiratory infections represent a significant burden to health systems worldwide mainly due to intrahospital infections that more easily affect immune-compromised patients. Moreover, tuberculosis (TB) is an endemic infectious disease in many developing nations and it has resurged in the developed world associated with the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic.

Currently, medicine faces the specter of antibiotic resistance. Besides the development of new anti-infectious drugs, the development of innovative and more efficient delivery systems for drugs that went off patent appears as a promising strategy pursued by the pharmaceutical industry to improve the therapeutic outcomes and to prolong the utilities of their intellectual property portfolio. In this context, nanotechnology-based drug delivery systems (nano-DDS) emerged as a promising approach to circumvent the limitations of conventional formulations and to treat drug resistance, opening the hypothesis for new developments in this area.

Long-Circulating Sterically Stabilized Liposomes in the Treatment of Infections

The administration of antimicrobial agents encapsulated in long-circulating sterically stabilized liposomes results in a considerable enhancement of therapeutic efficacy compared with the agents in the free form. After liposomal encapsulation, the pharmacokinetics of the antimicrobial agents is significantly changed. An increase in circulation time and reduction in toxic side effects of the agents are observed. In contrast to other types of long-circulating liposomes, an important characteristic of these sterically stabilized liposomes is that their prolonged blood circulation time is, to a high degree, independent of liposome characteristics such as liposome particle size, charge and lipid composition (rigidity) of the bilayer, and lipid dose. This provides the opportunity to manipulate antibiotic release from these liposomes at the site of infection, which is important in view of the differences in pharmacodynamics of different antibiotics and can be done without compromising blood circulation time and degree of target localization of these liposomes. Depending on the liposome characteristics and the agent encapsulated, antibiotic delivery to the infected site is achieved, or the liposomes act as a micro-reservoir function for the antibiotic. In experimental models of localized or disseminated bacterial and fungal infections, the sterically stabilized liposomes have successfully been used to improve antibiotic treatment using representative agents of various classes of antibacterial agents such as the beta-lactams, the aminoglycosides, and the quinolones or the antifungal agent amphotericin B. Extensive biodistribution studies have been performed. Critical factors that contribute to liposome target localization in infected tissue have been elucidated. Liposome-related factors that were investigated were poly(ethylene glycol) density, particle size, bilayer fluidity, negative surface charge, and circulation kinetics. Host-related factors focused on the components of the inflammatory response.

Liposome-encapsulated antibiotics

Encapsulation of certain antibiotics in liposomes can enhance their effect against microorganisms invading cultured cells and in animal models. We describe the incorporation of amikacin, streptomycin, ciprofloxacin, sparfloxacin, and clarithromycin in a variety of liposomes. We delineate the methods used for the evaluation of their efficacy against Mycobacterium avium-intracellulare complex (MAC) infections in macrophages and in the beige mouse model of MAC disease. We also describe the efficacy of pH-sensitive liposomes incorporating sparfloxacin or azithromycin. We summarize studies with other antibiotics, including rifampicin, rifabutin, ethambutol, isoniazid, clofazimine, and enrofloxacin, and their use against MAC, as well as other infection models, including Mycobacterium tuberculosis.

Interdigitation–Fusion Liposomes

IF-liposomes are formed by a unique process that involves fusing small liposomes into interdigitated lipid sheets, using either ethanol or hydrostatic pressure. The interdigitation-fusion method requires liposome formulations with lipids that form the L beta I phase. Preparing ethanol-induced IF-liposomes is simple and quick. IF-liposomes are particularly well suited for biomembrane research experiments that require large unilamellar liposomes and for liposome drug delivery applications that require a high drug-to-lipid ratio.

Long-circulating sterically stabilized liposomes as carriers of agents for treatment of infection or for imaging infectious foci

Liposomes are considered as potential carriers for biologically active compounds. One evident drawback of 'classical' liposomes is their fast elimination by cells of the mononuclear phagocyte system (MPS), primarily by liver and spleen. An important breakthrough in this respect is the development of long-circulating liposomes among which liposomes coated with polyethyleneglycol (PEG), the so-called 'sterically stabilized' liposomes (SSL). An important characteristic of SSL is that their prolonged blood residence time and infectious target localization is relatively independent of the lipid dose, particle size or lipid composition of the bilayer. SSL are applied as carriers of antimicrobial agents to achieve infectious target localization, to reduce side effects, or to serve as a micro-reservoir in the circulation. In addition, radiolabelled SSL are used to image infectious and inflammatory foci.

Liposomes: applications in medicine

Liposomes are spherical lipid bilayers from 50 nm to 1000 nm in diameter that serve as convenient delivery vehicles for biologically active compounds. The field of liposome research has expanded considerably over the last 30 years. It is now possible to engineer a wide range of liposomes varying in size, phospholipid composition and surface characteristics to suit the specific application for which they are intended. This paper gives an overview of the main advances in liposome research from a point of view of their applications in medicine. Aqueous contrast enhancing agents entrapped in liposomal carriers can be targeted to the liver and spleen and distinctions can be made between normal and tumorous tissue using computed tomography. Topical application of liposomes has great potential in dermatology. Liposomes have been used to deliver anticancer agents in order to reduce the toxic effects of the drugs when given alone or to increase the circulation time and effectiveness of the drugs. From the original concept of encapsulating hemoglobin in an inert shell, liposome-encapsulated hemoglobin (LEH) has evolved into a fluid proven to carry oxygen, capable of surviving for reasonable periods in the circulation and amenable to large-scale production. Liposomes may be used to target specific cells by attaching amino acid fragments such as antibodies or proteins or appropriate fragments that target specific receptor sites. Liposomal DNA delivery vectors and further enhancements in the forms of LPDI and LPDII are some of the safest and potentially most versatile transfer vectors used to date. DNA vaccination and improved efficiency of gene therapy are just a few of the upcoming applications of liposomes.

Improved efficacy of ciprofloxacin administered in polyethylene glycol-coated liposomes for treatment of Klebsiella pneumoniae pneumonia in rats

Animal and clinical data show that high ratios of the area under the concentration-time curve and the peak concentration in blood to the MIC of fluoroquinolones for a given pathogen are associated with a favorable outcome. The present study investigated whether improvement of the therapeutic potential of ciprofloxacin could be achieved by encapsulation in polyethylene glycol (PEG)-coated long-circulating sustained-release liposomes. In a rat model of unilateral Klebsiella pneumoniae pneumonia (MIC = 0.1 microg/ml), antibiotic was administered at 12- or 24-h intervals at twofold-increasing doses. A treatment period of 3 days was started 24 h after inoculation of the left lung, when the bacterial count had increased 1,000-fold and some rats had positive blood cultures. The infection was fatal within 5 days in untreated rats. Administration of ciprofloxacin in the liposomal form resulted in delayed ciprofloxacin clearance and increased and prolonged ciprofloxacin concentrations in blood and tissues. The ED(50) (dosage that results in 50% survival) of liposomal ciprofloxacin was 3.3 mg/kg of body weight/day given once daily, and that of free ciprofloxacin was 18.9 mg/kg/day once daily or 5.1 mg/kg/day twice daily. The ED(90) of liposomal ciprofloxacin was 15.0 mg/kg/day once daily compared with 36.0 mg/kg/day twice daily for free ciprofloxacin; 90% survival could not be achieved with free ciprofloxacin given once daily. In summary, the therapeutic efficacy of liposomal ciprofloxacin was superior to that of ciprofloxacin in the free form. PEG-coated liposomal ciprofloxacin was well tolerated in relatively high doses, permitting once daily administration with relatively low ciprofloxacin clearance and without compromising therapeutic efficacy.

Therapeutic efficacy of liposomal rifabutin in a Mycobacterium avium model of infection

Liposomal formulations of rifabutin were developed, and the effects of some parameters on the incorporation efficiency were studied. The antimycobacterial activity of rifabutin incorporated into liposomes prepared with phosphatidylcholine and phosphatidylserine (molar ratio, 7:3) was evaluated in a murine model of infection with a virulent Mycobacterium avium strain (strain P1581) and was compared with that of free rifabutin. The influences of the size of the liposomal rifabutin formulation, the administered doses, and the treatment schedules on the evolution of infection were studied. Two types of treatment schedules were assayed: therapeutic and prophylactic. The therapeutic treatment started 2 weeks after infection, while the prophylactic treatment began 1 day before the experimental infection with mycobacteria. Incorporation of rifabutin in liposomes resulted in a significant enhancement of activity against M. avium infection compared to that of rifabutin in the free form in both schedules. These results demonstrate that liposomal formulations of antibiotics such as rifabutin may be effective for the treatment or prophylaxis of infectious diseases.

Targeted delivery of antibiotics using liposomes and nanoparticles: research and applications

This review examines current technologies for increasing the bioavailability of antibiotics by means of liposomes or nanoparticles. The main focus is on liposomes. These carriers were preferentially developed because their composition is compatible with biological constituents. Biodegradable polymers in the form of colloidal particles have also been used and show promise for future applications in antimicrobial chemotherapy. The in vivo behaviour of both types of carriers and consequently their therapeutic potential, are determined by their route of administration. Conventional carrier strategies permit the mononuclear phagocyte system to be targeted by intravenous injection of antibiotics. Stealthy strategies avoid major uptake by these cells and extend the systemic presence of these carriers. The purpose of this review is to provide background information in antibiotic targeting gathered from papers published over the last twenty years. It seems clear that such drug carriers (liposomes, nanoparticles) allow increased drug concentration at infected sites but reduce drug toxicity.

Efficacy of microencapsulated rifampin in Mycobacterium tuberculosis-infected mice

Rifampin is a first-line drug useful in the treatment of tuberculosis. By using biocompatible polymeric excipients of lactide and glycolide copolymers, two microsphere formulations were developed for targeted and sustained delivery of rifampin, with minimal dosing. A small-microsphere formulation, with demonstrated ability to inhibit intracellularly replicating Mycobacterium tuberculosis H37Rv, was tested along with a large-microsphere formulation in an infected mouse model. Results revealed that by using a single treatment of the large-microsphere formulation, it was possible to achieve a significant reduction in M. tuberculosis H37Rv CFUs in the lungs of mice by 26 days postinfection. A combination of small (given as two injections on day 0 and day 7) and large (given as one injection at day 0) rifampin-loaded microsphere formulations resulted in significant reductions in CFUs in the lungs by 26 days, achieving a 1.23 log10 reduction in CFUs. By comparison, oral treatment with 5, 10, or 20 mg of rifampin/kg of body weight, administered every day, resulted in a reduction of 0.42, 1.7, or 1.8 log10 units, respectively. Thus the microsphere formulations, administered in one or two doses, were able to achieve results in mice similar to those obtained with a daily drug regimen within the range of the highest clinically tolerated dosage in humans. These results demonstrate that microsphere formulations of antimycobacterial drugs such as rifampin can be used for therapy of tuberculosis with minimal dosing.

Use of microsphere technology for targeted delivery of rifampin to Mycobacterium tuberculosis-infected macrophages

Microsphere technology was used to develop formulations of rifampin for targeted delivery to host macrophages. These formulations were prepared by using biocompatible polymeric excipients of lactide and glycolide copolymers. Release characteristics were examined in vitro and also in two monocytic cell lines, the murine J774 and the human Mono Mac 6 cell lines. Bioassay assessment of cell culture supernatants from monocyte cell lines showed release of bioactive rifampin during a 7-day experimental period. Treatment of Mycobacterium tuberculosis H37Rv-infected monocyte cell lines with rifampin-loaded microspheres resulted in a significant decrease in numbers of CFU at 7 days following initial infection, even though only 8% of the microsphere-loaded rifampin was released. The levels of rifampin released from microsphere formulations within monocytes were more effective at reducing M. tuberculosis intracellular growth than equivalent doses of rifampin given as a free drug. These results demonstrate that rifampin-loaded microspheres can be formulated for effective sustained and targeted delivery to host macrophages.