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Meschiari M, Faltoni M, Kaleci S, Tassoni G, Orlando G, Franceschini E, Burastero G, Bedini A, Serio L, Biagioni E, Melegari G, Venturelli C, Sarti M, Bertellini E, Girardis M, Mussini C. Intravenous fosfomycin in combination regimens as a treatment option for difficult-to-treat infections due to multi-drug-resistant Gram-negative organisms: A real-life experience. Int J Antimicrob Agents 2024; 63:107134. [PMID: 38453094 DOI: 10.1016/j.ijantimicag.2024.107134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 03/09/2024]
Abstract
AIM To investigate the efficacy of intravenous (IV) fosfomycin as combination therapy for treatment of difficult-to-treat (DTT) acute and subacute infections with multi-drug-resistant (MDR) Gram-negative bacteria (GNB), and risk factors associated with 90-day mortality. METHODS A retrospective, observational, monocentric study enrolled patients treated with IV fosfomycin in combination regimens (≥72 h) for proven DTT-MDR-GNB infection. Multi-variate regression analysis identified independent risk factors for 90-day mortality. A propensity score for receiving fosfomycin was performed to control for confounding factors. RESULTS In total, 70 patients were included in this study: 54.3% had carbapenem-resistant isolates, 31.4% had ceftazidime/avibactam-resistant isolates and 28.6% had ceftolozane/tazobactam-resistant isolates. The main pathogens were Pseudomonas aeruginosa (57.1%) and Klebsiella pneumoniae (22.9%). The most prevalent infections were nosocomial pneumonia (42.9%), osteomyelitis (17.1%) and intra-abdominal infections. All-cause 30- and 90-day mortality were 15.7% and 31.4%, respectively (18.9% and 50% considering acute DTT-MDR-GNB infections alone). Relapse at 30 days occurred in 22.9% of cases (29% with emergence of fosfomycin resistance). Mortality at 90 days was independently associated with septic shock and ceftolozane/tazobactam resistance. The relationship between resistance to ceftolozane/tazobactam and 90-day mortality was confirmed to be significant after adjustment by propensity score analysis (hazard ratio 5.84, 95% confidence interval 1.65-20.68; P=0.006). CONCLUSIONS Fosfomycin seems to be a promising salvage, combination treatment in DTT-MDR-GNB infections. Resistance to ceftolozane/tazobactam seems to be independently associated with treatment failure. Randomized clinical trials focusing on pathogen and infection sites are needed urgently to demonstrate the superiority of fosfomycin in combination with other agents for the resolution of DTT-MDR-GNB infections.
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Affiliation(s)
- Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.
| | - Matteo Faltoni
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Shaniko Kaleci
- Clinical and Experimental Medicine Department of Surgical, Medical , Dental and Morphological Sciences With Interest in Transplant Oncology and Regenerative Medicine University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Tassoni
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Gabriella Orlando
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Erica Franceschini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Giulia Burastero
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Andrea Bedini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Lucia Serio
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Emanuela Biagioni
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Gabriele Melegari
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Claudia Venturelli
- Clinical Microbiology Laboratory, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Mario Sarti
- Clinical Microbiology Laboratory, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Elisabetta Bertellini
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Massimo Girardis
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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Tang PC, Sánchez-Hevia DL, Westhoff S, Fatsis-Kavalopoulos N, Andersson DI. Within-species variability of antibiotic interactions in Gram-negative bacteria. mBio 2024; 15:e0019624. [PMID: 38391196 PMCID: PMC10936430 DOI: 10.1128/mbio.00196-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
Treatments with antibiotic combinations are becoming increasingly important even though the supposed clinical benefits of combinations are, in many cases, unclear. Here, we systematically examined how several clinically used antibiotics interact and affect the antimicrobial efficacy against five especially problematic Gram-negative pathogens. A total of 232 bacterial isolates were tested against different pairwise antibiotic combinations spanning five classes, and the ability of all combinations in inhibiting growth was quantified. Descriptive statistics, principal component analysis (PCA), and Spearman's rank correlation matrix were used to determine the correlations between the different combinations on interaction outcome. Several important conclusions can be drawn from the 696 examined interactions. Firstly, within a species, the interactions are in general conserved but can be isolate-specific for a given antibiotic combination and can range from antagonistic to synergistic. Secondly, additive and antagonistic interactions are the most common observed across species and antibiotics, with 87.1% of isolate-antibiotic combinations being additive, 11.6% antagonistic, and only 0.3% showing synergy. These findings suggest that to achieve the highest precision and efficacy of combination therapy, not only isolate-specific interaction profiling ought to be routinely performed, in particular to avoid using drug combinations that show antagonistic interaction and an expected associated reduction in efficacy, but also discovering rare and potentially valuable synergistic interactions.IMPORTANCEAntibiotic combinations are often used to treat bacterial infections, which aim to increase treatment efficacy and reduce resistance evolution. Typically, it is assumed that one specific antibiotic combination has the same effect on different isolates of the same species, i.e., the interaction is conserved. Here, we tested this idea by examining how several clinically used antibiotics interact and affect the antimicrobial efficacy against several bacterial pathogens. Our results show that, even though within a species the interactions are often conserved, there are also isolate-specific differences for a given antibiotic combination that can range from antagonistic to synergistic. These findings suggest that isolate-specific interaction profiling ought to be performed in clinical microbiology routine to avoid using antagonistic drug combinations that might reduce treatment efficacy.
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Affiliation(s)
- Po-Cheng Tang
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Dione L. Sánchez-Hevia
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | - Sanne Westhoff
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
| | | | - Dan I. Andersson
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
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Önal U, Tüzemen NÜ, Kaya PK, İşçimen R, Girgin NK, Özakın C, Kahveci FŞ, Akalın H. Evaluation of the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230727. [PMID: 37820167 PMCID: PMC10561911 DOI: 10.1590/1806-9282.20230727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/03/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the combination treatments with intravenous fosfomycin for carbapenem-resistant Klebsiella pneumoniae infections in a tertiary-care center. METHODS Between December 24, 2018 and November 21, 2022, adult patients diagnosed with bloodstream infection or ventilator-associated pneumonia due to culture-confirmed carbapenem-resistant Klebsiella pneumoniae in the anesthesiology and reanimation intensive care units were investigated retrospectively. RESULTS There were a total of 62 patients fulfilling the study inclusion criteria. No significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations. Hypokalemia (OR:5.651, 95%CI 1.019-31.330, p=0.048) was found to be a significant risk factor for 14-day mortality, whereas SOFA score at the time of diagnosis (OR:1.497, 95%CI 1.103-2.032, p=0.010) and CVVHF treatment (OR:6.409, 95%CI 1.395-29.433, p=0.017) were associated with 30-day mortality in multivariate analysis. CONCLUSION In our study, high mortality rates were found in patients with bloodstream infection or ventilator-associated pneumonia due to carbapenem-resistant Klebsiella pneumoniae, and no significant difference was recorded in 14- and 30-day mortality among different types of combination regimens such as fosfomycin plus one or two antibiotic combinations.
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Affiliation(s)
- Uğur Önal
- Uludag University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology – Bursa, Turkey
| | - Nazmiye Ülkü Tüzemen
- Uludag University, Faculty of Medicine, Department of Microbiology – Bursa, Turkey
| | - Pınar Küçükdemirci Kaya
- Uludag University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Bursa, Turkey
| | - Remzi İşçimen
- Uludag University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Bursa, Turkey
| | - Nermin Kelebek Girgin
- Uludag University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Bursa, Turkey
| | - Cüneyt Özakın
- Uludag University, Faculty of Medicine, Department of Microbiology – Bursa, Turkey
| | - Ferda Şöhret Kahveci
- Uludag University, Faculty of Medicine, Department of Anesthesiology and Reanimation – Bursa, Turkey
| | - Halis Akalın
- Uludag University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology – Bursa, Turkey
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Assessment of the Susceptibility of Clinical Gram-Negative and Gram-Positive Bacterial Strains to Fosfomycin and Significance of This Antibiotic in Infection Treatment. Pathogens 2022; 11:pathogens11121441. [PMID: 36558775 PMCID: PMC9786176 DOI: 10.3390/pathogens11121441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Multidrug resistance of bacteria has prompted intensive development work on new medicines, but also the search for effective options among the oldest antibiotics. Although intravenous fosfomycin (IVFOS) seems to be an interesting proposal, the recommended agar dilution method for susceptibility determination poses a major problem in routine diagnostic testing. As a consequence, there is a lack of comprehensive data on the frequency of isolation of susceptible or resistant strains. This fact triggered the disposition of EUCAST concerning the revision of IVFOS breakpoints (BPs), including withdrawal of BPs for Enterobacterales (excluding E. coli) and coagulase-negative staphylococci. Therefore, the aim of this study was to assess the activity of fosfomycin against numerous clinical strains using recommended methods. Materials and methods: A total of 997 bacterial strains were tested from the following genera: Enterobacterales, Pseudomonas spp., Staphylococcus spp., Acinetobacter spp., and Enterococcus spp., for which there are currently no BPs. The strains were isolated from various clinical materials from patients hospitalized in five hospitals. During the investigation, the recommended agar dilution method was used. Susceptibility to other antibiotics and resistance mechanisms were determined using an automatic method (Phoenix) the disk diffusion method, and E-tests. MIC values of fosfomycin were estimated for all strains and for susceptible and multidrug-resistant (MDR) strains individually. Results: Except for Acinetobacter and Enterococcus, 83% of the strains were susceptible to IVFOS, including the largest percentage of S. aureus and E. coli. Klebsiella spp. turned out to be the least susceptible strains (66%). The highest proportion of susceptibility to fosfomycin was found among strains that were sensitive to other antibiotics (80.9%), and the lowest was found among Gram-negative carbapenemase-producing bacteria (55.6%) and ESBL+ bacteria (61.6%). The MIC evaluation revealed the lowest MIC50 and MIC90 values for S. aureus (0.5 mg/L and 1 mg/L, respectively) and E. coli (4 mg/L and 32 mg/L, respectively). The highest values of MIC50 were found for Acinetobacter spp. (256 mg/L), while the highest values of MIC90 were found for Acinetobacter spp. and Klebsiella spp. (256 mg/L and 512 mg/L, respectively). Conclusions: IVFOS appears to be suitable for the treatment of many infections, including the empirical treatment of polymicrobial infections and those caused by MDR strains, since the sensitivity of the studied strains to this antibiotic in different groups ranged from 66% to as much as 99%. Sensitivity to fosfomycin was also demonstrated by 60% of carbapenem-resistant strains; therefore, IVFOS is one of the few therapeutic options that can be effective against the most resistant Gram-negative rods. In light of the general consultation posted by EUCAST, obtaining data such as IVFOS MIC value distributions may be vital for the decision of implementing fosfomycin into breakpoint tables.
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Cojutti PG, Fornaro G, Gatti M, Rinaldi M, Gaibani P, Giannella M, Pea F, Viale P. Successful Treatment of Bacteremia and Ventilator-Associated Pneumonia Caused by KPC/OXA-48-like Klebsiella pneumoniae Co-Producer with a Continuous Infusion of High-Dose Meropenem Plus Fosfomycin Guided by Real-Time Therapeutic Drug Monitoring. Infect Dis Rep 2022; 14:88-92. [PMID: 35200438 PMCID: PMC8872245 DOI: 10.3390/idr14010010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 12/04/2022] Open
Abstract
Bacteremia and ventilator-associated pneumonia due to a pan-resistant Klebsiella pneumoniae strain co-producing KPC and OXA-48 carbapenemases was successfully treated in a COVID-19 critically ill patient with a combination therapy of a high-dose continuous infusion of meropenem (up to 3 g every 6 h, daily) plus fosfomycin (up to 24 g/daily) that was guided by real-time therapeutic drug monitoring. Clinical pharmacological advice was helpful in maximizing, over time, the pharmacodynamic target attainment of both antibiotics.
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Affiliation(s)
- Pier Giorgio Cojutti
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (P.G.C.); (M.G.)
| | - Giacomo Fornaro
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Milo Gatti
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (P.G.C.); (M.G.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Paolo Gaibani
- Division of Microbiology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy;
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Federico Pea
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy; (P.G.C.); (M.G.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
- Correspondence: ; Tel.: +39-051-214-3627
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (G.F.); (M.R.); (M.G.); (P.V.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
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Goh KKK, Toh WGH, Hee DKH, Ting EZW, Chua NGS, Zulkifli FIB, Sin LJ, Tan TT, Kwa ALH, Lim TP. Quantification of Fosfomycin in Combination with Nine Antibiotics in Human Plasma and Cation-Adjusted Mueller-Hinton II Broth via LCMS. Antibiotics (Basel) 2022; 11:antibiotics11010054. [PMID: 35052932 PMCID: PMC8772704 DOI: 10.3390/antibiotics11010054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 02/05/2023] Open
Abstract
Fosfomycin-based combination therapy has emerged as an attractive option in our armamentarium due to its synergistic activity against carbapenem-resistant Gram-negative bacteria (CRGNB). The ability to simultaneously measure fosfomycin and other antibiotic drug levels will support in vitro and clinical investigations to develop rational antibiotic combination dosing regimens against CRGNB infections. We developed an analytical assay to measure fosfomycin with nine important antibiotics in human plasma and cation-adjusted Mueller–Hinton II broth (CAMHB). We employed a liquid-chromatography tandem mass spectrometry method and validated the method based on accuracy, precision, matrix effect, limit-of-detection, limit-of-quantification, specificity, carryover, and short-term and long-term stability on U.S. Food & Drug Administration (FDA) guidelines. Assay feasibility was assessed in a pilot clinical study in four patients on antibiotic combination therapy. Simultaneous quantification of fosfomycin, levofloxacin, meropenem, doripenem, aztreonam, piperacillin/tazobactam, ceftolozane/tazobactam, ceftazidime/avibactam, cefepime, and tigecycline in plasma and CAMHB were achieved within 4.5 min. Precision, accuracy, specificity, and carryover were within FDA guidelines. Fosfomycin combined with any of the nine antibiotics were stable in plasma and CAMHB up to 4 weeks at −80 °C. The assay identified and quantified the respective antibiotics administered in the four subjects. Our assay can be a valuable tool for in vitro and clinical applications.
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Affiliation(s)
- Kelvin Kau-Kiat Goh
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
- SingHealth Duke-NUS Pathology Academic Clinical Programme, 8 College Road, Singapore 169857, Singapore
| | - Wilson Ghim-Hon Toh
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
| | - Daryl Kim-Hor Hee
- Shimadzu (Asia Pacific) Pte Ltd., 79 Science Park Dr, #02-01/08 Cintech IV, Singapore 118264, Singapore; (E.Z.-W.T.); (D.K.-H.H.)
| | - Edwin Zhi-Wei Ting
- Shimadzu (Asia Pacific) Pte Ltd., 79 Science Park Dr, #02-01/08 Cintech IV, Singapore 118264, Singapore; (E.Z.-W.T.); (D.K.-H.H.)
| | - Nathalie Grace Sy Chua
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
| | - Farah Iffah Binte Zulkifli
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
| | - Li-Jiao Sin
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
| | - Thuan-Tong Tan
- SingHealth Duke-NUS Medicine Academic Clinical Programme, 8 College Road, Singapore 169857, Singapore;
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
- SingHealth Duke-NUS Medicine Academic Clinical Programme, 8 College Road, Singapore 169857, Singapore;
- Emerging Infectious Diseases Program, Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore
- Correspondence: (A.L.-H.K.); (T.-P.L.); Tel.: +65-6321-3401 (A.L.-H.K.); +65-6326-6959 (T.-P.L.)
| | - Tze-Peng Lim
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (K.K.-K.G.); (W.G.-H.T.); (N.G.S.C.); (F.I.B.Z.); (L.-J.S.)
- SingHealth Duke-NUS Pathology Academic Clinical Programme, 8 College Road, Singapore 169857, Singapore
- SingHealth Duke-NUS Medicine Academic Clinical Programme, 8 College Road, Singapore 169857, Singapore;
- Correspondence: (A.L.-H.K.); (T.-P.L.); Tel.: +65-6321-3401 (A.L.-H.K.); +65-6326-6959 (T.-P.L.)
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Gatti M, Viaggi B, Rossolini GM, Pea F, Viale P. An evidence-based multidisciplinary approach focused at creating algorithms for targeted therapy of infection-related ventilator associated complications (IVACs) caused by Enterobacterales in critically ill adult patients. Expert Rev Anti Infect Ther 2021; 20:331-352. [PMID: 34488527 DOI: 10.1080/14787210.2021.1976145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Prompt implementation of appropriate targeted antibiotic therapy representsa valuable approach in improving clinical and ecological outcome in critically septic patients. Thismultidisciplinary opinion article aims to develop evidence-based algorithms for targeted antibiotictherapy of infection-related ventilator associated complications (IVACs) caused by Enterobacterales,which are among the most common pathogens associated with these conditions. AREAS COVERED A multidisciplinary team of four experts had several rounds of assessment for developingalgorithms devoted to targeted antimicrobial therapy of IVACs caused by Enterobacterales.A literature search was performed on PubMed-MEDLINE (until March 2021) to provide evidence forsupporting therapeutic choices. Quality and strength of evidence was established according toa hierarchical scale of the study design. Six different algorithms with associated recommendations concerning therapeutic choice and dosing optimization were suggested according to the susceptibilitypattern of Enterobacterales: multi-susceptible, extended-spectrum beta-lactamase (ESBL)-producing,AmpC beta-lactamase-producing, Klebsiella pneumoniae carbapenemase (KPC)-producing, OXA-48-producing, and metallo-beta-lactamase (MBL)-producing Enterobacterales. EXPERT OPINION The implementation of algorithms focused on prompt revision of antibiotic regimensguided by results of conventional and rapid diagnostic methodologies, appropriate place in therapy ofnovel beta-lactams, implementation of strategies for sparing the broadest-spectrum antibiotics, and PK/PD optimization of antibiotic dosing regimens is strongly suggested.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Ssd Clinical Pharmacology, Irccs Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi, University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Ssd Clinical Pharmacology, Irccs Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Infectious Diseases Unit, Irccs Azienda Ospedaliero Universitaria Di Bologna, Bologna, Italy
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Rodríguez-Santiago J, Cornejo-Juárez P, Silva-Sánchez J, Garza-Ramos U. Polymyxin resistance in Enterobacterales: overview and epidemiology in the Americas. Int J Antimicrob Agents 2021; 58:106426. [PMID: 34419579 DOI: 10.1016/j.ijantimicag.2021.106426] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/07/2021] [Accepted: 08/15/2021] [Indexed: 12/30/2022]
Abstract
The worldwide spread of carbapenem- and polymyxin-resistant Enterobacterales represents an urgent public-health threat. However, for most countries in the Americas, the available data are limited, although Latin America has been suggested as a silent spreading reservoir for isolates carrying plasmid-mediated polymyxin resistance mechanisms. This work provides an overall update on polymyxin and polymyxin resistance and focuses on uses, availability and susceptibility testing. Moreover, a comprehensive review of the current polymyxin resistance epidemiology in the Americas is provided. We found that reports in the English and Spanish literature show widespread carbapenemase-producing and colistin-resistant Klebsiella pneumoniae in the Americas determined by the clonal expansion of the pandemic clone ST258 and mgrB-mediated colistin resistance. In addition, widespread IncI2 and IncX4 plasmids carrying mcr-1 in Escherichia coli come mainly from human sources; however, plasmid-mediated colistin resistance in the Americas is underreported in the veterinary sector. These findings demonstrate the urgent need for the implementation of polymyxin resistance surveillance in Enterobacterales as well as appropriate regulatory measures for antimicrobial use in veterinary medicine.
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Affiliation(s)
- J Rodríguez-Santiago
- Instituto Nacional de Salud Pública (INSP), Centro de Investigación sobre Enfermedades Infecciosas (CISEI), Laboratorio de Resistencia Bacteriana, Cuernavaca, Morelos, México; Programa de Doctorado en Ciencias Biomédicas, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - P Cornejo-Juárez
- Departamento de Infectología, Instituto Nacional de Cancerología (INCan), Ciudad de México, México
| | - J Silva-Sánchez
- Instituto Nacional de Salud Pública (INSP), Centro de Investigación sobre Enfermedades Infecciosas (CISEI), Laboratorio de Resistencia Bacteriana, Cuernavaca, Morelos, México
| | - U Garza-Ramos
- Instituto Nacional de Salud Pública (INSP), Centro de Investigación sobre Enfermedades Infecciosas (CISEI), Laboratorio de Resistencia Bacteriana, Cuernavaca, Morelos, México.
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9
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Karakonstantis S, Kritsotakis EI, Gikas A. Pandrug-resistant Gram-negative bacteria: a systematic review of current epidemiology, prognosis and treatment options. J Antimicrob Chemother 2021; 75:271-282. [PMID: 31586417 DOI: 10.1093/jac/dkz401] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The literature on the epidemiology, mortality and treatment of pandrug-resistant (PDR) Gram-negative bacteria (GNB) is scarce, scattered and controversial. OBJECTIVES To consolidate the relevant literature and identify treatment options for PDR GNB infections. METHODS A systematic search in MEDLINE, Scopus and clinical trial registries was conducted. Studies reporting PDR clinical isolates were eligible for review if susceptibility testing for all major antimicrobials had been performed. Characteristics and findings of retrieved studies were qualitatively synthesized. RESULTS Of 81 studies reviewed, 47 (58%) were published in the last 5 years. The reports reflected a worldwide dissemination of PDR GNB in 25 countries in 5 continents. Of 526 PDR isolates reported, Pseudomonas aeruginosa (n=175), Acinetobacter baumannii (n=172) and Klebsiella pneumoniae (n=125) were most common. PDR GNB were typically isolated in ICUs, but several studies demonstrated wider outbreak potential, including dissemination to long-term care facilities and international spread. All-cause mortality was high (range 20%-71%), but appeared to be substantially reduced in studies reporting treatment regimens active in vitro. No controlled trial has been performed to date, but several case reports and series noted successful use of various regimens, predominantly synergistic combinations, and in selected patients increased exposure regimens and newer antibiotics. CONCLUSIONS PDR GNB are increasingly being reported worldwide and are associated with high mortality. Several treatment regimens have been successfully used, of which synergistic combinations appear to be most promising and often the only available option. More pharmacokinetic/pharmacodynamic and outcome studies are needed to guide the use of synergistic combinations.
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Affiliation(s)
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, School of Medicine, University of Crete, Heraklion, Crete, Greece.,Department of Epidemiology and Medical Statistics, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Achilleas Gikas
- Department of Internal Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
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10
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Vrancianu CO, Dobre EG, Gheorghe I, Barbu I, Cristian RE, Chifiriuc MC. Present and Future Perspectives on Therapeutic Options for Carbapenemase-Producing Enterobacterales Infections. Microorganisms 2021; 9:730. [PMID: 33807464 PMCID: PMC8065494 DOI: 10.3390/microorganisms9040730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 12/26/2022] Open
Abstract
Carbapenem-resistant Enterobacterales (CRE) are included in the list of the most threatening antibiotic resistance microorganisms, being responsible for often insurmountable therapeutic issues, especially in hospitalized patients and immunocompromised individuals and patients in intensive care units. The enzymatic resistance to carbapenems is encoded by different β-lactamases belonging to A, B or D Ambler class. Besides compromising the activity of last-resort antibiotics, CRE have spread from the clinical to the environmental sectors, in all geographic regions. The purpose of this review is to present present and future perspectives on CRE-associated infections treatment.
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Affiliation(s)
- Corneliu Ovidiu Vrancianu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Elena Georgiana Dobre
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
| | - Irina Gheorghe
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Ilda Barbu
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
| | - Roxana Elena Cristian
- Department of Biochemistry and Molecular Biology, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania;
| | - Mariana Carmen Chifiriuc
- Microbiology Immunology Department, Faculty of Biology, University of Bucharest, 050095 Bucharest, Romania; (C.O.V.); (E.G.D.); (I.B.); (M.C.C.)
- The Research Institute of the University of Bucharest, 050095 Bucharest, Romania
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11
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Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
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Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
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12
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Treatment options for K. pneumoniae, P. aeruginosa and A. baumannii co-resistant to carbapenems, aminoglycosides, polymyxins and tigecycline: an approach based on the mechanisms of resistance to carbapenems. Infection 2020; 48:835-851. [PMID: 32875545 PMCID: PMC7461763 DOI: 10.1007/s15010-020-01520-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
The management of carbapenem-resistant infections is often based on polymyxins, tigecycline, aminoglycosides and their combinations. However, in a recent systematic review, we found that Gram-negative bacteria (GNB) co-resistant to carbapanems, aminoglycosides, polymyxins and tigecycline (CAPT-resistant) are increasingly being reported worldwide. Clinical data to guide the treatment of CAPT-resistant GNB are scarce and based exclusively on few case reports and small case series, but seem to indicate that appropriate (in vitro active) antimicrobial regimens, including newer antibiotics and synergistic combinations, may be associated with lower mortality. In this review, we consolidate the available literature to inform clinicians dealing with CAPT-resistant GNB about treatment options by considering the mechanisms of resistance to carbapenems. In combination with rapid diagnostic methods that allow fast detection of carbapenemase production, the approach proposed in this review may guide a timely and targeted treatment of patients with infections by CAPT-resistant GNB. Specifically, we focus on the three most problematic species, namely Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii. Several treatment options are currently available for CAPT-resistant K. pneumonia. Newer β-lactam-β-lactamase combinations, including the combination of ceftazidime/avibactam with aztreonam against metallo-β-lactamase-producing isolates, appear to be more effective compared to combinations of older agents. Options for P. aeruginosa (especially metallo-β-lactamase-producing strains) and A. baumannii remain limited. Synergistic combination of older agents (e.g., polymyxin- or fosfomycin-based synergistic combinations) may represent a last resort option, but their use against CAPT-resistant GNB requires further study.
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13
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Antonello RM, Principe L, Maraolo AE, Viaggi V, Pol R, Fabbiani M, Montagnani F, Lovecchio A, Luzzati R, Di Bella S. Fosfomycin as Partner Drug for Systemic Infection Management. A Systematic Review of Its Synergistic Properties from In Vitro and In Vivo Studies. Antibiotics (Basel) 2020; 9:antibiotics9080500. [PMID: 32785114 PMCID: PMC7460049 DOI: 10.3390/antibiotics9080500] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022] Open
Abstract
Fosfomycin is being increasingly prescribed for multidrug-resistant bacterial infections. In patients with systemic involvement, intravenous fosfomycin is usually administered as a partner drug, as part of an antibiotic regimen. Hence, the knowledge of fosfomycin pharmacodynamic interactions (synergistic, additive, indifferent and antagonistic effect) is fundamental for a proper clinical management of severe bacterial infections. We performed a systematic review to point out fosfomycin’s synergistic properties, when administered with other antibiotics, in order to help clinicians to maximize drug efficacy optimizing its use in clinical practice. Interactions were more frequently additive or indifferent (65.4%). Synergism accounted for 33.7% of total interactions, while antagonism occurred sporadically (0.9%). Clinically significant synergistic interactions were mostly distributed in combination with penicillins (51%), carbapenems (43%), chloramphenicol (39%) and cephalosporins (33%) in Enterobactaerales; with linezolid (74%), tetracyclines (72%) and daptomycin (56%) in Staphylococcus aureus; with chloramphenicol (53%), aminoglycosides (43%) and cephalosporins (36%) against Pseudomonas aeruginosa; with daptomycin (97%) in Enterococcus spp. and with sulbactam (75%) and penicillins (60%) and in Acinetobacter spp. fosfomycin-based antibiotic associations benefit from increase in the bactericidal effect and prevention of antimicrobial resistances. Taken together, the presence of synergistic interactions and the nearly total absence of antagonisms, make fosfomycin a good partner drug in clinical practice.
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Affiliation(s)
- Roberta Maria Antonello
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy; (R.M.A.); (A.L.); (R.L.)
| | | | - Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, AORN dei Colli, 80131 Naples, Italy;
| | | | - Riccardo Pol
- Department of Infectious Diseases, Udine University, 33100 Udine, Italy;
| | - Massimiliano Fabbiani
- Department of Medical Sciences, Tropical and Infectious Diseases Unit, University Hospital of Siena, 53100 Siena, Italy; (M.F.); (F.M.)
| | - Francesca Montagnani
- Department of Medical Sciences, Tropical and Infectious Diseases Unit, University Hospital of Siena, 53100 Siena, Italy; (M.F.); (F.M.)
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy
| | - Antonio Lovecchio
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy; (R.M.A.); (A.L.); (R.L.)
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy; (R.M.A.); (A.L.); (R.L.)
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy; (R.M.A.); (A.L.); (R.L.)
- Correspondence:
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14
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Abstract
PURPOSE OF REVIEW In the last decade, an increasing interest in using fosfomycin for the treatment of multidrug-resistant gram-negative (MDR-GNB) infections have been registered, especially when none or only a few other active alternatives remained available. RECENT FINDINGS Fosfomycin may remain active against a considerable proportion of MDR-GNB. In observational studies, a possible curative effect of oral fosfomycin monotherapy has been described for uncomplicated urinary tract infections (UTI) and bacterial prostatitis caused by MDR-GNB, whereas intravenous fosfomycin has been mostly used in combination with other agents for various type of severe MDR-GNB infections. The ZEUS randomized controlled trial (RCT) has started to provide high-level evidence about the possible use of fosfomycin for complicated UTI caused by extended-spectrum β-lactamase-producing GNB, but no results of large RCT are currently available to firmly guide the use of fosfomycin for carbapenem-resistant GNB. SUMMARY Fosfomycin is an important therapeutic option for MDR-GNB infections. Further pharmacokinetic/pharmacodynamic and clinical research is needed to optimize its use.
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15
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Papp-Wallace KM, Zeiser ET, Becka SA, Park S, Wilson BM, Winkler ML, D'Souza R, Singh I, Sutton G, Fouts DE, Chen L, Kreiswirth BN, Ellis-Grosse EJ, Drusano GL, Perlin DS, Bonomo RA. Ceftazidime-Avibactam in Combination With Fosfomycin: A Novel Therapeutic Strategy Against Multidrug-Resistant Pseudomonas aeruginosa. J Infect Dis 2020; 220:666-676. [PMID: 31099835 DOI: 10.1093/infdis/jiz149] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/12/2019] [Indexed: 02/06/2023] Open
Abstract
Previously, by targeting penicillin-binding protein 3, Pseudomonas-derived cephalosporinase (PDC), and MurA with ceftazidime-avibactam-fosfomycin, antimicrobial susceptibility was restored among multidrug-resistant (MDR) Pseudomonas aeruginosa. Herein, ceftazidime-avibactam-fosfomycin combination therapy against MDR P. aeruginosa clinical isolate CL232 was further evaluated. Checkerboard susceptibility analysis revealed synergy between ceftazidime-avibactam and fosfomycin. Accordingly, the resistance elements present and expressed in P. aeruginosa were analyzed using whole-genome sequencing and transcriptome profiling. Mutations in genes that are known to contribute to β-lactam resistance were identified. Moreover, expression of blaPDC, the mexAB-oprM efflux pump, and murA were upregulated. When fosfomycin was administered alone, the frequency of mutations conferring resistance was high; however, coadministration of fosfomycin with ceftazidime-avibactam yielded a lower frequency of resistance mutations. In a murine infection model using a high bacterial burden, ceftazidime-avibactam-fosfomycin significantly reduced the P. aeruginosa colony-forming units (CFUs), by approximately 2 and 5 logs, compared with stasis and in the vehicle-treated control, respectively. Administration of ceftazidime-avibactam and fosfomycin separately significantly increased CFUs, by approximately 3 logs and 1 log, respectively, compared with the number at stasis, and only reduced CFUs by approximately 1 log and 2 logs, respectively, compared with the number in the vehicle-treated control. Thus, the combination of ceftazidime-avibactam-fosfomycin was superior to either drug alone. By employing a "mechanism-based approach" to combination chemotherapy, we show that ceftazidime-avibactam-fosfomycin has the potential to offer infected patients with high bacterial burdens a therapeutic hope against infection with MDR P. aeruginosa that lack metallo-β-lactamases.
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Affiliation(s)
- Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Biochemistry, Case Western Reserve University (CWRU), Cleveland, Ohio.,Center for Proteomics and Bioinformatics, Case Western Reserve University (CWRU), Cleveland, Ohio
| | - Elise T Zeiser
- Research Service, Louis Stokes Cleveland VA Medical Center
| | - Scott A Becka
- Research Service, Louis Stokes Cleveland VA Medical Center
| | - Steven Park
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Brigid M Wilson
- Research Service, Louis Stokes Cleveland VA Medical Center.,Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio
| | | | | | | | | | | | - Liang Chen
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Barry N Kreiswirth
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | | | - George L Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando
| | - David S Perlin
- Hackensack Meridian Health Center for Discovery and Innovation, Nutley, New Jersey
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland VA Medical Center.,Medical Service, Louis Stokes Cleveland VA Medical Center.,Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center.,Department of Medicine, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Biochemistry, Case Western Reserve University (CWRU), Cleveland, Ohio.,Center for Proteomics and Bioinformatics, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Molecular Biology and Microbiology, Case Western Reserve University (CWRU), Cleveland, Ohio.,Department of Pharmacology, Case Western Reserve University (CWRU), Cleveland, Ohio.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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16
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Gaudereto JJ, Neto LVP, Leite GC, Espinoza EPS, Martins RCR, Villas Boa Prado G, Rossi F, Guimarães T, Levin AS, Costa SF. Comparison of methods for the detection of in vitro synergy in multidrug-resistant gram-negative bacteria. BMC Microbiol 2020; 20:97. [PMID: 32299353 PMCID: PMC7161189 DOI: 10.1186/s12866-020-01756-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/20/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The use of combined antibiotic therapy has become an option for infections caused by multidrug-resistant (MDR) bacteria. The time-kill (TK) assay is considered the gold standard method for the evaluation of in vitro synergy, but it is a time-consuming and expensive method. The purpose of this study was to evaluate two methods for testing in vitro antimicrobial combinations: the disk diffusion method through disk approximation (DA) and the agar gradient diffusion method via the MIC:MIC ratio. The TK assay was included as the gold standard. MDR Gram-negative clinical isolates (n = 62; 28 Pseudomonas aeruginosa, 20 Acinetobacter baumannii, and 14 Serratia marcescens) were submitted to TK, DA, and MIC:MIC ratio synergy methods. RESULTS Overall, the agreement between the DA and TK assays ranged from 20 to 93%. The isolates of A. baumannii showed variable results of synergism according to TK, and the calculated agreement was statistically significant in this species against fosfomycin with meropenem including colistin-resistant isolates. The MIC:MIC ratiometric agreed from 35 to 71% with TK assays. The kappa test showed good agreement for the combination of colistin with amikacin (K = 0.58; P = 0.04) among the colistin-resistant A. baumannii isolates. CONCLUSIONS The DA and MIC:MIC ratiometric methods are easier to perform and might be a more viable tool for clinical microbiology laboratories.
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Affiliation(s)
- Juliana Januario Gaudereto
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Lauro Vieira Perdigão Neto
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Gleice Cristina Leite
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Evelyn Patricia Sanchez Espinoza
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Roberta Cristina Ruedas Martins
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Gladys Villas Boa Prado
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Flavia Rossi
- Divisão de Laboratório Central - Serviço de Microbiologia Clínica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Thais Guimarães
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Anna Sara Levin
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil
| | - Silvia Figueiredo Costa
- Laboratório de Investigação Médica 49 - LIM-49, Instituto de Medicina Tropical, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Avenida Doutor Enéas de Carvalho Aguiar, 470, São Paulo, SP, 05403-000, Brazil.
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17
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Bakthavatchalam YD, Shankar A, Muthuirulandi Sethuvel DP, Asokan K, Kanthan K, Veeraraghavan B. Synergistic activity of fosfomycin-meropenem and fosfomycin-colistin against carbapenem resistant Klebsiella pneumoniae: an in vitro evidence. Future Sci OA 2020; 6:FSO461. [PMID: 32257374 PMCID: PMC7117555 DOI: 10.2144/fsoa-2019-0074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aim: To evaluate the antibacterial activity of fosfomycin–meropenem and fosfomycin–colistin combinations against carbapenem-resistant Klebsiella pneumoniae (CR-Kp). Methods: A total of 50 CR-Kp isolates recovered from blood cultures were included in this study. All the CR-Kp isolates were screened for the presence of carbapenem resistant genes blaIMP. blaVIM. blaNDM. blaOXA-48 like, blaKPC. blaGES.#x00A0;and blaSPM. Combination testing of fosfomycin–meropenem and fosfomycin–colistin were performed using time-kill assay. Results: Fosfomycin–meropenem combination showed synergy in 20% of the tested CR-Kp isolates. While, fosfomycin–colistin exhibited synergy against 16% of the isolates. A total of 68% (n = 34) of CR-Kp isolates were characterised as OXA-48-like producers and 22% (n = 11) as NDM producers. Synergistic activity of these combinations was observed against OXA-48, NDM and NDM + OXA-48 co-producers. Conclusion: Considerable synergistic antibacterial activity of fosfomycin–meropenem and fosfomycin–colistin was not observed against CR-Kp isolates. Therefore, these combinations may not be promising for infections associated with CR-Kp. Carbapenem-resistant Klebsiella pneumoniae (CR-Kp) infections are difficult to treat and are associated with a high mortality rate. This study aimed to evaluate the synergistic activity of fosfomycin–meropenem and fosfomycin–colistin combinations against CR-Kp. Synergistic activity of these combinations was observed against OXA-48, NDM and NDM + OXA-48 co-producers. However, synergism was not found to be significant. Therefore, these combinations may not be promising for infections associated with CR-Kp.
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Affiliation(s)
| | - Abirami Shankar
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
| | | | - Kalaiarasi Asokan
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
| | - Kalaiarasi Kanthan
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore 632004, India
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18
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Carbapenem-Resistant Gram-Negative Bacterial Infections in Children. Antimicrob Agents Chemother 2020; 64:AAC.02183-19. [PMID: 31844014 DOI: 10.1128/aac.02183-19] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Carbapenem-resistant organisms (CRO) are a major global public health threat. Enterobacterales hydrolyze almost all β-lactams through carbapenemase production. Infections caused by CRO are challenging to treat due to the limited number of antimicrobial options. This leads to significant morbidity and mortality. Over the last few years, several new antibiotics effective against CRO have been approved. Some of them (e.g., plazomicin or imipenem-cilastatin-relebactam) are currently approved for use only by adults; others (e.g., ceftazidime-avibactam) have recently been approved for use by children. Recommendations for antibiotic therapy of CRO infections in pediatric patients are based on evidence mainly from adult studies. The availability of pediatric pharmacokinetic and safety data is the cornerstone to broaden the use of proposed agents in adults to the pediatric population. This article provides a comprehensive review of the current knowledge regarding infections caused by CRO with a focus on children, which includes epidemiology, risk factors, outcomes, and antimicrobial therapy management, with particular attention being given to new antibiotics.
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19
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Boszczowski I, Salomão MC, Moura ML, Freire MP, Guimarães T, Cury AP, Rossi F, Rizek CF, Martins RCR, Costa SF. Multidrug-resistant Klebsiella pneumoniae: genetic diversity, mechanisms of resistance to polymyxins and clinical outcomes in a tertiary teaching hospital in Brazil. Rev Inst Med Trop Sao Paulo 2019; 61:e29. [PMID: 31241658 PMCID: PMC6592011 DOI: 10.1590/s1678-9946201961029] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 01/10/2019] [Indexed: 11/22/2022] Open
Abstract
Increased resistance to polymyxin in Klebsiella pneumoniae
(ColRKP) has been observed. Molecular epidemiology, as well as the clinical
impact of these difficult to treat pathogens need to be better characterized. We
present the clinical outcomes of 28 patients infected by ColRKP in a tertiary
hospital. Isolates with MIC >2 by Vitek 2 were confirmed by the microdilution
broth test. Polymerase chain reaction (PCR) was performed for
blaKPC, blaNDM, blaOXA-48 and blamcr-1 genes in the isolates, and Whole Genome Sequencing (WGS) was
performed in six isolates. Seventeen (61%) patients were female and the mean age
was 50 years old. In-hospital and 30-day mortality were 64% (18/28) and 53%
(15/28), respectively. Central line-associated bloodstream infection in addition
to bacteremia episodes due to other sources were the most frequent (61%). Mean
APACHE and Charlson comorbidity index were 16 and 5, respectively. Twenty
patients (71%) received at least one active drug and ten (35%) received two
drugs: tigecycline 46% (13/28); amikacin 21% (6/28) and fosfomycin 3% (1 case).
Twenty-six out of 28 tested cases were positive for blaKPC. Eight different clusters were identified. Four STs were detected
(ST11, ST23, ST340, and ST437). Mutations on pmrA,
arnB, udg, and yciM genes
were present in all six isolates submitted to WGS; lpxMand
mgrB mutations were also detected in all but one isolate.
In conclusion, we observed resistance to polymyxin in severely ill patients
mostly from intensive care units and/or immunosuppressed patients with high
mortality rates in whom a diversity of ColRKP clusters was identified and might
indicate selective pressure.
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Affiliation(s)
- Icaro Boszczowski
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Subcomissão de Controle de Infecção Hospitalar, São Paulo, São Paulo, Brazil
| | - Matias Chiarastelli Salomão
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Subcomissão de Controle de Infecção Hospitalar, São Paulo, São Paulo, Brazil
| | - Maria Luísa Moura
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Subcomissão de Controle de Infecção Hospitalar, São Paulo, São Paulo, Brazil
| | - Maristela Pinheiro Freire
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Subcomissão de Controle de Infecção Hospitalar, São Paulo, São Paulo, Brazil
| | - Thais Guimarães
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Subcomissão de Controle de Infecção Hospitalar, São Paulo, São Paulo, Brazil
| | - Ana Paula Cury
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Laboratório Clínico, São Paulo, São Paulo, Brazil
| | - Flávia Rossi
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Laboratório Clínico, São Paulo, São Paulo, Brazil
| | - Camila Fonseca Rizek
- Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica (LIM) 54, São Paulo, São Paulo, Brazil
| | - Roberta Cristina Ruedas Martins
- Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica (LIM) 54, São Paulo, São Paulo, Brazil
| | - Silvia Figueiredo Costa
- Universidade de São Paulo, Instituto de Medicina Tropical de São Paulo, Laboratório de Investigação Médica (LIM) 54, São Paulo, São Paulo, Brazil.,Universidade de São Paulo, Faculdade de Medicina, Departamento de Moléstias Infecciosas e Parasitárias, São Paulo, São Paulo, Brazil
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20
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Karaiskos I, Lagou S, Pontikis K, Rapti V, Poulakou G. The "Old" and the "New" Antibiotics for MDR Gram-Negative Pathogens: For Whom, When, and How. Front Public Health 2019; 7:151. [PMID: 31245348 PMCID: PMC6581067 DOI: 10.3389/fpubh.2019.00151] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022] Open
Abstract
The recent expansion of multidrug resistant and pan-drug-resistant pathogens poses significant challenges in the treatment of healthcare associated infections. An important advancement, is a handful of recently launched new antibiotics targeting some of the current most problematic Gram-negative pathogens, namely carbapenem-producing Enterobacteriaceae (CRE) and carbapenem-resistant P. aeruginosa (CRPA). Less options are available against carbapenem-resistant Acinetobacter baumannii (CRAB) and strains producing metallo-beta lactamases (MBL). Ceftazidime-avibactam signaled a turning point in the treatment of KPC and partly OXA- type carbapenemases, whereas meropenem-vaborbactam was added as a potent combination against KPC-producers. Ceftolozane-tazobactam could be seen as an ideal beta-lactam backbone for the treatment of CRPA. Plazomicin, an aminoglycoside with better pharmacokinetics and less toxicity compared to other class members, will cover important proportions of multi-drug resistant pathogens. Eravacycline holds promise in the treatment of infections by CRAB, with a broad spectrum of activity similar to tigecycline, and improved pharmacokinetics. Novel drugs and combinations are not to be considered "panacea" for the ongoing crisis in the therapy of XDR Gram-negative bacteria and colistin will continue to be considered as a fundamental companion drug for the treatment of carbapenem-resistant Enterobacteriaceae (particularly in areas where MBL predominate), for the treatment of CRPA (in many cases being the only in vitro active drug) as well as CRAB. Aminoglycosides are still important companion antibiotics. Finally, fosfomycin as part of combination treatment for CRE infections and P. aeruginosa, deserves a greater attention. Optimal conditions for monotherapy and the "when and how" of combination treatments integrating the novel agents will be discussed.
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Affiliation(s)
- Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Styliani Lagou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Rapti
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Medicine, School of Medicine, Sotiria General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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