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Sturaro MC, Damaceno NDS, Faccin ID, Silva ON, de Aquino TM, Freire NML, Alcântara MGDS, Monteiro KLC, Rossato L, de Souza GHDA, Simionatto S. Synergistic antimicrobial combination of third-generation cephalosporins and polymyxin B against carbapenem-polymyxin-resistant Klebsiella pneumoniae: an in vitro and in vivo analysis. Antimicrob Agents Chemother 2024; 68:e0093024. [PMID: 39254296 PMCID: PMC11459926 DOI: 10.1128/aac.00930-24] [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: 06/21/2024] [Accepted: 08/19/2024] [Indexed: 09/11/2024] Open
Abstract
Antibiotic combination therapy is a promising approach to address the urgent need for novel treatment options for infections caused by carbapenem-polymyxin-resistant Klebsiella pneumoniae (CPR-Kp). The present study aimed to investigate the synergistic potential of four cephalosporins in combination with polymyxin B (PMB). A checkerboard assay was performed to evaluate the synergistic effects of cephalexin (CLX), cefixime, cefotaxime (CTX), and cefmenoxime (CMX) in combination with PMB. Subsequently, experiments evaluating the use of CTX or CMX in combination with PMB (CTX-PMB or CMX-PMB, respectively), including growth curve and SynergyFinder analysis, antibiofilm activity assays, cell membrane integrity assays, and scanning electron microscopy, were performed. Safety assessments were also conducted, including hemolysis and toxicity evaluations, using Caenorhabditis elegans. Furthermore, an in vivo model in C. elegans was adopted to assess the treatment efficacy against CPR-Kp infections. CTX-PMB and CMX-PMB exhibited low fractional inhibitory concentration indexes ranging from 0.19 to 0.50 and from 0.25 to 1.5, respectively, and zero interaction potency scores of 37.484 and 15.076, respectively. The two combinations significantly reduced growth and biofilm formation in CPR-Kp. Neither CTX-PMB nor CMX-PMB compromised bacterial cell integrity. Safety assessments revealed a low hemolysis percentage and high survival rates in the C. elegans toxicity evaluations. The in vivo model revealed that the CTX-PMB and CMX-PMB treatments improved the survival rates of C. elegans. The synergistic effects of the CTX-PMB and CMX-PMB combinations, both in vitro and in vivo, indicate that these antibiotic pairings could represent effective therapeutic options for infections caused by CPR-Kp.
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Affiliation(s)
- Mariana Carvalho Sturaro
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Brazil
| | | | - Izadora Dillis Faccin
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Brazil
| | | | - Thiago Mendonça de Aquino
- Laboratório de Síntese e Pesquisa em Química Medicinal, Instituto de Química e Biotecnologia, Universidade Federal de Alagoas, Maceió, Brazil
| | - Nathalia Monteiro Lins Freire
- Laboratório de Síntese e Pesquisa em Química Medicinal, Instituto de Química e Biotecnologia, Universidade Federal de Alagoas, Maceió, Brazil
| | - Marcone Gomes dos Santos Alcântara
- Laboratório de Síntese e Pesquisa em Química Medicinal, Instituto de Química e Biotecnologia, Universidade Federal de Alagoas, Maceió, Brazil
| | - Kadja Luana Chagas Monteiro
- Laboratório de Síntese e Pesquisa em Química Medicinal, Instituto de Química e Biotecnologia, Universidade Federal de Alagoas, Maceió, Brazil
| | - Luana Rossato
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Brazil
| | | | - Simone Simionatto
- Laboratório de Pesquisa em Ciências da Saúde, Universidade Federal da Grande Dourados, Dourados, Brazil
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Zhao Y, Zhang T, Liang Y, Xie X, Pan H, Cao M, Wang S, Wu D, Wang J, Wang C, Hu W. Combination of aloe emodin, emodin, and rhein from Aloe with EDTA sensitizes the resistant Acinetobacter baumannii to polymyxins. Front Cell Infect Microbiol 2024; 14:1467607. [PMID: 39346899 PMCID: PMC11428196 DOI: 10.3389/fcimb.2024.1467607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024] Open
Abstract
Background The continuous emergence and spread of polymyxin-resistant Acinetobacter baumannii pose a significant global health challenge, necessitating the development of novel therapeutic strategies. Aloe, with its long-standing history of medicinal use, has recently been the subject of substantial research for its efficacy against pathogenic infections. Methods This study investigates the potential application of anthraquinone components in aloe against polymyxin-resistant A. baumannii by liquid chromatography-mass spectrometry, in vitro activity assessment, and construction of animal infection models. Results The findings demonstrate that aloe emodin, emodin, rhein, and their mixtures in equal mass ratios (EAR) exhibit strain-specific antibacterial activities against polymyxin-resistant A. baumannii. Co-administration of EAR with EDTA synergistically and universally enhanced the antibacterial activity and bactericidal efficacy of polymyxins against polymyxin-resistant A. baumannii, while also reducing the frequency of polymyxin-resistant mutations in polymyxinssensitive A. baumannii. Following toxicity assessment on human hepatic and renal cell lines, the combination therapy was applied to skin wounds in mice infected with polymyxin-resistant A. baumannii. Compared to monotherapy, the combination therapy significantly accelerated wound healing and reduced bacterial burden. Conclusions The combination of EAR and EDTA with polymyxins offers a novel therapeutic approach for managing skin infections caused by polymyxinresistant A. baumannii.
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Affiliation(s)
- Yue Zhao
- College of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tingting Zhang
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Yinping Liang
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Xiaoqing Xie
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Hongwei Pan
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Meng Cao
- Research and Development Center, Shandong Aobo Biotechnology Co., Ltd, Liaocheng, Shandong, China
| | - Shuhua Wang
- Research and Development Center, Shandong Aobo Biotechnology Co., Ltd, Liaocheng, Shandong, China
| | - Dalei Wu
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Jing Wang
- College of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chuandong Wang
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
| | - Wei Hu
- State Key Laboratory of Microbial Technology, Microbial Technology Institute, Shandong University, Qingdao, China
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Li L, Huang X, Liu J, Li C, Lin Z, Ren R, Zhang Y, Ding H, Chen J, Mao Y. Efficacy and Safety Factors Related to Plasma Concentration-Optimized Polymyxin B Therapy in Treating Carbapenem-Resistant Gram-Negative Bacterial Infections in China. Infect Drug Resist 2024; 17:3057-3071. [PMID: 39050834 PMCID: PMC11268568 DOI: 10.2147/idr.s468890] [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: 05/16/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
Background Polymyxin B (PMB)-based combination therapies are used to treat severe carbapenem-resistant gram-negative bacterial (CR-GNB) infections. This observational study investigated the relationship between clinical factors, including PMB concentration, and clinical efficacy and safety. Patients and Methods Polymyxin B regimens were optimized through therapeutic drug monitoring (TDM) and area under the concentration-time curve (AUC). In all, 382 samples were tested from 130 patients. Logistic regression was used to analyze the relationships between variables with clinical efficacy and 30-day mortality factors were analyzed by Cox regression. The sensitivity and specificity of Cmin and AUC for the occurrence of acute kidney injury (AKI) were determined by ROC curve analysis. Results The clinical effectiveness of PMB was 65.4%. Multivariate logistic regression analysis revealed that lung infection, continuous renal replacement therapy, and C-reactive protein were independent factors significantly associated with efficacy. AKI occurred in 14.6% of the patients during treatment; age > 73 years (OR: 3.63; 95% CI: 1.035-12.727; P = 0.044), Cmin greater than 2.3 µg/mL (OR: 7.37; 95% CI: 1.571-34.580; P = 0.011), combined vancomycin (OR: 9.47; 95% CI: 1.732-51.731; P = 0.009), and combined piperacillin-tazobactam (OR: 21.87; 95% CI: 3.139-152.324; P = 0.002) were independent risk factors. The identified PMB cut-offs for predicting AKI were Cmin = 2.3 µg/mL and AUC = 82.0 mg h/L. Conclusion Polymyxin B-based combination regimens are effective in treating CR-GNB infections, particularly bloodstream infections, but have shown unsatisfactory for lung infections. Cmin ≥ 2.3 µg /mL and AUC ≥ 82.0 mg h/L may increase PMB-associated AKI incidence. PMB dose should be adjusted based on TDM to ensure efficacy.
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Affiliation(s)
- Lixia Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jingxian Liu
- Department of Clinical Laboratory, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Chao Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Zhiyan Lin
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Rongrong Ren
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yan Zhang
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Haoshu Ding
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yanfei Mao
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
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Rafailidis P, Panagopoulos P, Koutserimpas C, Samonis G. Current Therapeutic Approaches for Multidrug-Resistant and Extensively Drug-Resistant Acinetobacter baumannii Infections. Antibiotics (Basel) 2024; 13:261. [PMID: 38534696 DOI: 10.3390/antibiotics13030261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/28/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
The treatment of Acinetobacter baumannii infections remains a challenge for physicians worldwide in the 21st century. The bacterium possesses a multitude of mechanisms to escape the human immune system. The consequences of A. baumannii infections on morbidity and mortality, as well on financial resources, remain dire. Furthermore, A. baumannii superinfections have also occurred during the COVID-19 pandemic. While prevention is important, the antibiotic armamentarium remains the most essential factor for the treatment of these infections. The main problem is the notorious resistance profile (including resistance to carbapenems and colistin) that this bacterium exhibits. While newer beta lactam/beta-lactamase inhibitors have entered clinical practice, with excellent results against various infections due to Enterobacteriaceae, their contribution against A. baumannii infections is almost absent. Hence, we have to resort to at least one of the following, sulbactam, polymyxins E or B, tigecycline or aminoglycosides, against multidrug-resistant (MDR) and extensively drug-resistant (XDR) A. baumannii infections. Furthermore, the notable addition of cefiderocol in the fight against A. baumannii infections represents a useful addition. We present herein the existing information from the last decade regarding therapeutic advances against MDR/XDR A. baumannii infections.
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Affiliation(s)
- Petros Rafailidis
- Second University Department of Internal Medicine, University General Hospital of Alexandroupolis, 681 00 Alexandroupolis, Greece
| | - Periklis Panagopoulos
- Second University Department of Internal Medicine, University General Hospital of Alexandroupolis, 681 00 Alexandroupolis, Greece
| | - Christos Koutserimpas
- Department of Orthopaedics and Traumatology, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - George Samonis
- Department of Oncology, Metropolitan Hospital, 185 47 Athens, Greece
- Department of Medicine, University of Crete, 715 00 Heraklion, Greece
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Bezerra CLPAM, Dos Santos EL, Oliveira MS, Dias MBS, Levin AS, Freire MP, Boszczowski I, Salomão MC. Crude Mortality Associated With the Empirical Use of Polymyxins in Septic Patients in a Setting of High Prevalence of Carbapenem-Resistant Gram-negative Bacteria: Retrospective Analysis of a Cohort. Clin Infect Dis 2023; 77:S62-S69. [PMID: 37406048 DOI: 10.1093/cid/ciad272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Our aim in this retrospective cohort study was to assess the impact on mortality of the empirical use of polymyxin as therapy for carbapenem-resistant gram-negative bacteria (CR-GNB) in septic patients. The study was performed at a tertiary academic hospital in Brazil, from January 2018 to January 2020, the pre-coronavirus disease 2019 period. METHODS We included 203 patients with suspected sepsis. The first doses of antibiotics were prescribed from a "sepsis antibiotic kit", which contained a selection of drugs, including polymyxin, with no preapproval policy. We developed a logistic regression model to assess risk factors associated with 14-day crude mortality. Propensity score for polymyxin was used to control biases. RESULTS Seventy (34%) of 203 patients had infections with at least 1 multidrug-resistant organism isolated from any clinical culture. Polymyxins in monotherapy or in combination therapy were prescribed to 140 of the 203 (69%) patients. The overall 14-day mortality rate was 30%. The 14-day crude mortality was associated with age (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 1.01-1.05; P = .01), SOFA (sepsis-related organ failure assessment) score value (aOR, 1.2; 95% CI, 1.09-1.32; P < .001), CR-GNB infection (aOR, 3.94; 95% CI, 1.53-10.14; P = .005), and time between suspected sepsis and antibiotic administration (aOR, 0.73; 95% CI, .65-.83; P < .001). The empirical use of polymyxins was not associated with decreased crude mortality (aOR, 0.71; 95% CI, .29-1.71; P = .44). CONCLUSIONS Empirical use of polymyxin for septic patients in a setting with high CR-GNB prevalence was not associated with decreased crude mortality.
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Affiliation(s)
- Camila L P A M Bezerra
- Department of Infectious Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Eusébio L Dos Santos
- Department of Infectious Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Maura S Oliveira
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Maria Beatriz S Dias
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maristela P Freire
- Department of Infectious Diseases, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Icaro Boszczowski
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Matias C Salomão
- Infection Control Department, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
- Department of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Next-Generation Polymyxin Class of Antibiotics: A Ray of Hope Illuminating a Dark Road. Antibiotics (Basel) 2022; 11:antibiotics11121711. [PMID: 36551367 PMCID: PMC9774142 DOI: 10.3390/antibiotics11121711] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Although new-generation antimicrobials, in particular β-lactam/β-lactamase inhibitors, have largely replaced polymyxins in carbapenem-resistant Gram-negative bacterial infections, polymyxins are still needed for carbapanem-resistant Acinetobacter baumannii infections and in settings where novel agents are not readily available. Despite their potent in vitro activity, the clinical utility of polymyxins is significantly limited by their pharmacokinetic properties and nephrotoxicity risk. There is significant interest, therefore, in developing next-generation polymyxins with activity against colistin-resistant strains and lower toxicity than existing polymyxins. In this review, we aim to present the antibacterial activity mechanisms, in vitro and in vivo efficacy data, and toxicity profiles of new-generation polymyxins, including SPR206, MRX-8, and QPX9003, as well as the general characteristics of old polymyxins. Considering the emergence of colistin-resistant strains particularly in endemic regions, the restoration of the antimicrobial activity of polymyxins via PBT2 is also described in this review.
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Qu J, Qi TT, Qu Q, Long WM, Chen Y, Luo Y, Wang Y. Polymyxin B-Based Regimens for Patients Infected with Carbapenem-Resistant Gram-Negative Bacteria: Clinical and Microbiological Efficacy, Mortality, and Safety. Infect Drug Resist 2022; 15:1205-1218. [PMID: 35345474 PMCID: PMC8957303 DOI: 10.2147/idr.s357746] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background The increasing prevalence of carbapenem-resistant Gram-negative bacteria (CR-GNB) represents a global healthcare crisis. This study explored the efficacy and safety of Polymyxin B (PMB)-based regimens and factors influencing their effectiveness. Methods Patients with CR-GNB infections treated with PMB for more than three days were enrolled in this retrospective study from 1st June 2018 to 30th April 2020. Data were collected on patient characteristics, bacterial culture, and drug-sensitivity test results; anti-infection treatment regimens, particularly details of PMB use; and adverse drug reactions. Clinical and microbiological efficacy, mortality, and safety of PMB-based regimens in CR-GNB infected patients were evaluated. Univariate analysis and multivariate logistic regression analyses were used to assess factors influencing efficacy and mortality. Results A total of 373 CR-GNB strains were cultured from 268 patients. About 41.04% of patients used PMB loading dose of 1.01 (0.84–1.69) mg/kg. Maintenance dose was 0.85 (0.82–1.00) mg/kg q12h. The clinical efficacy rate was 36.57% (98/268), the total bacterial clearance rate of PMB was 39.42%, and the all-cause mortality rate was 33.96%. The adverse drug reaction rate was 19.58%, among which the incidence of renal toxicity was highest (8.21%). Multivariate logistic regression analysis showed that clinical efficacy, bacterial clearance rate, and all-cause mortality were associated with patient-related facts, including mechanical ventilation use, underlying diseases (such as respiratory disease), the type and site of CR-GNB infection, and PMB administration timing and loading dose. Conclusion PMB is a relatively safe and effective antibiotic drug for treatment of critically ill patients with CR-GNB infection; however, PMB use should be subject to guidelines recommendations for early administration, loading administration, and adequate administration, which could help to improve the clinical efficacy, microbiological efficacy, and mortality.
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Affiliation(s)
- Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
| | - Ting-Ting Qi
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410078, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, People’s Republic of China
| | - Wen-Ming Long
- Department of Pharmacy, Jingzhou District, Second People’s Hospital of Huaihua City, Huaihua, 418400, People’s Republic of China
| | - Ying Chen
- Department of Pharmacy, Wuhan University, Renmin Hospital, Wuhan, 430060, People’s Republic of China
| | - Yue Luo
- Department of Pharmacy, The People’s Hospital of Liuyang, Liuyang, 410300, People’s Republic of China
| | - Ying Wang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, People’s Republic of China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
- Correspondence: Ying Wang, Department of Pharmacy, The Second Xiangya Hospital, Central South University, Institute of Clinical Pharmacy, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, People’s Republic of China, Tel +86-15173198700, Fax +86-731-85292072, Email
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The Role of Colistin in the Era of New β-Lactam/β-Lactamase Inhibitor Combinations. Antibiotics (Basel) 2022; 11:antibiotics11020277. [PMID: 35203879 PMCID: PMC8868358 DOI: 10.3390/antibiotics11020277] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
With the current crisis related to the emergence of carbapenem-resistant Gram-negative bacteria (CR-GNB), classical treatment approaches with so-called “old-fashion antibiotics” are generally unsatisfactory. Newly approved β-lactam/β-lactamase inhibitors (BLBLIs) should be considered as the first-line treatment options for carbapenem-resistant Enterobacterales (CRE) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) infections. However, colistin can be prescribed for uncomplicated lower urinary tract infections caused by CR-GNB by relying on its pharmacokinetic and pharmacodynamic properties. Similarly, colistin can still be regarded as an alternative therapy for infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) until new and effective agents are approved. Using colistin in combination regimens (i.e., including at least two in vitro active agents) can be considered in CRAB infections, and CRE infections with high risk of mortality. In conclusion, new BLBLIs have largely replaced colistin for the treatment of CR-GNB infections. Nevertheless, colistin may be needed for the treatment of CRAB infections and in the setting where the new BLBLIs are currently unavailable. In addition, with the advent of rapid diagnostic methods and novel antimicrobials, the application of personalized medicine has gained significant importance in the treatment of CRE infections.
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Bianchini ML, Jeffres MN, Campbell JD. Cost-Effectiveness Analysis of New Beta-Lactam Beta-Lactamase Inhibitor Antibiotics Versus Colistin for the Treatment of Carbapenem-Resistant Infections. Hosp Pharm 2022; 57:93-100. [PMID: 35521000 PMCID: PMC9065533 DOI: 10.1177/0018578720985436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction: Carbapenem-resistant organisms (CROs) present a serious public health problem. Limited treatment options has led to increased use of colistin and polymyxin. Since 2014, the US Food and Drug Administration approved 4 new beta-lactam beta-lactamase inhibitor (BLBLI) combination antibiotics with activity against CROs. These new antibiotics have been shown to be more effective and less toxic than colistin and polymyxin but are considerably more expensive. This study evaluated the cost-effectiveness of the new BLBLIs versus colistin-based therapy for the treatment of CROs. Methods: A decision-tree microsimulation model was used to evaluate the cost effectiveness of the new BLBLIs versus colistin-based therapy for the treatment of CROs. Treatment groups differed in risk of mortality and risk of an acute kidney injury (AKI). The relative risk of mortality was determined by creating a meta-analysis comparing new BLBLIs to colistin. Cost inputs included medication costs and the cost to treat an AKI. The primary outcomes include quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). Model inputs included: clinical outcomes and adverse events (30-day mortality and AKI); cost of treatment and adverse drug events; and health utilities. A 3% discount was applied for outcomes. A lifetime horizon was used from the perspective of the US healthcare system with a willingness-to-pay (WTP) threshold of $100 000. A sensitivity analysis was done to incorporate uncertainty. Results: The meta-analysis found the treatment with a new BLBLI was associated with a 50% decrease in the relative risk of 30-day mortality compared to colistin (RR 0.47, 95% CI 0.25-0.88). Treatment with a new BLBLI cost $16 200 and produced 11.5 QALYs, on average. The average colistin based regimen cost $3500 and produced 8.3 QALYs. The new BLBLIs were determined to be cost-effective with an ICER of $3900 per QALY gained. Treatment with a BLBLI remained cost-effective under all uncertainty scenarios tested. Conclusion: New BLBLIs are cost-effective compared to colistin for the treatment of CROs and are associated with improved mortality and fewer AKI events. The use of colistin should be reserved for cases where new BLBLIs are not available or there is documented resistance to these new antibiotics.
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Affiliation(s)
- Monica L. Bianchini
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Monica L. Bianchini, University of Colorado Anschutz Medical Campus, 12850 E Montview Blvd, Mail stop C238, Aurora, CO 80045-0508, USA.
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Zhang X, Qi S, Duan X, Han B, Zhang S, Liu S, Wang H, Zhang H, Sun T. Clinical outcomes and safety of polymyxin B in the treatment of carbapenem-resistant Gram-negative bacterial infections: a real-world multicenter study. J Transl Med 2021; 19:431. [PMID: 34656132 PMCID: PMC8520283 DOI: 10.1186/s12967-021-03111-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 10/07/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND High morbidity and mortality due to carbapenem-resistant Gram-negative bacilli (CR-GNB) has led to the resurgence of polymyxin B (PMB) use in the last decade. The aim of our multicenter, real-world study was to evaluate the effectiveness and safety of PMB in the treatment of CR-GNB infections. METHODS The real-world study included patients treated with intravenous PMB for at least 7 days during the period of October 2018 through June 2019. Associations between these clinical features and 28-day mortality or all-cause hospital mortality were explored through univariate analyses and multivariable logistic regression. RESULTS The study included 100 patients. Many patients presented with combined chronic conditions, septic shock, mechanical ventilation, and the presence of Klebsiella pneumoniae. The mean duration of PMB therapy was 11 days (range 7-38 days). Temperature (38 °C vs 37.1 °C), white blood cells (14.13 × 109/l vs 9.28 × 109/l), C-reactive protein (103.55 ug/l vs 47.60 ug/l), procalcitonin (3.89 ng/ml vs 1.70 ng/ml) and APACHE II levels (17.75 ± 7.69 vs 15.98 ± 7.95) were significantly decreased after PMB treatment. The bacteria eradication rate was 77.65%. The overall mortality at discharge was 15%, and 28-day mortality was 40%. Major adverse reactions occurred in 16 patients. Nephrotoxicity was observed in 7 patients (7%). CONCLUSIONS Our results provide positive clinical and safety outcomes for PMB in the treatment of CR-GNB. Timely and appropriate use of PMB may be particularly useful in treating patients with sepsis in CR-GNB infections.
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Affiliation(s)
- Xiaojuan Zhang
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Shaoyan Qi
- Department of ICU, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaoguang Duan
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Bing Han
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Shuguang Zhang
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Shaohua Liu
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Haixu Wang
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China
| | - Haibo Zhang
- Interdepartmental Division of Critical Care Medicine, Departments of Anesthesia and Physiology, University of Toronto, Room 619, LKSKI, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Tongwen Sun
- Department of General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, Henan, China.
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11
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Maynard M, Drusano GL, Vicchiarelli M, Liu W, Myrick J, Nole J, Duncanson B, Brown D, Louie A. Polymyxin B Pharmacodynamics in the Hollow-Fiber Infection Model: What You See May Not Be What You Get. Antimicrob Agents Chemother 2021; 65:e0185320. [PMID: 34097487 PMCID: PMC8284464 DOI: 10.1128/aac.01853-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Dose range studies for polymyxin B (PMB) regimens of 0.75 to 12 mg/kg given every 12 h (q12h) were evaluated for bacterial killing and resistance prevention against an AmpC-overexpressing Pseudomonas aeruginosa and a blaKPC-3-harboring Klebsiella pneumoniae in 10-day in vitro hollow-fiber models. An exposure-response was observed. But all regimens failed due to regrowth. Lower-dose regimens amplified isolates that expressed transient, lower-level adaptive resistance to PMB (MICs ≤ 4 mg/liter). Higher PMB dosages amplified isolates that expressed this resistance mechanism, a higher-MIC "moderately stable" adaptive resistance, and a higher-MIC stable resistance to PMB. Failure of the highest dose regimens was solely due to subpopulations that expressed the two higher-level resistances. Total and bioactive PMB concentrations in broth declined below targeted PK profiles within hours of treatment initiation and prior to bacterial regrowth. With treatment failure, the total PMB measured in bacteria was substantially higher than in broth. But the bioactive PMB in broth and bacteria were low to nondetectable. Together, these findings suggest a sequence of events for treatment failure of the clinical regimen. First, PMB concentrations in broth are diluted as PMB binds to bacteria, resulting in total and bioactive PMB in broth that is lower than targeted. Bacterial regrowth and treatment failure follow, with emergence of subpopulations that express transient lower-level adaptive resistance to PMB and possibly higher-level adaptive and stable resistances. Higher-dose PMB regimens can prevent the emergence of transient lower-level adaptive resistance, but they do not prevent treatment failure due to isolates that express higher-level resistance mechanisms.
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Affiliation(s)
- Michael Maynard
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - G. L. Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Michael Vicchiarelli
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Weiguo Liu
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Jenny Myrick
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Jocelyn Nole
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Brandon Duncanson
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - David Brown
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Arnold Louie
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
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12
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Lu Q, Li GH, Qu Q, Zhu HH, Luo Y, Yan H, Yuan HY, Qu J. Clinical Efficacy of Polymyxin B in Patients Infected with Carbapenem-Resistant Organisms. Infect Drug Resist 2021; 14:1979-1988. [PMID: 34093026 PMCID: PMC8168961 DOI: 10.2147/idr.s312708] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Carbapenem-resistant organisms (CROs) pose great challenges for clinical treatment. Polymyxin B (PMB) is one of the “last resort” choices of CRO infections. We explored the possible factors affecting PMB efficacy. Patients and Methods This retrospective study involved CRO-infected patients treated with PMB for ≥72 h. The endpoint indicator was clinical efficacy. We compared the characteristics (demographics, pathogenic bacteria, PMB treatment) between patients who had “clinical success” (CS) and “clinical failure” (CF). Results A total of 191 patients were enrolled: 110 in the CS group and 81 in the CF group. The total cumulative dose for the CS group was higher than the CF group [1100 (700–1443.75) vs 800 (500–1112.5) mg; P = 0.001]. Treatment duration in the CS group was longer than the CF group [11 (8–14) vs 8 (6–11) days; P < 0.000]. Multivariate logistic regression analysis showed mechanical ventilation, vasoactive agents, multiple-site infection, and total cumulative dose to be independently associated with clinical efficacy. Cox survival analysis for 30-day mortality also showed that the use of vasoactive agents and the total cumulative dose of PMB could influence survival time and mortality rate independently. Conclusion PMB had good efficacy and a low prevalence of adverse reactions. The total cumulative dose, duration of PMB treatment, mechanical ventilation, vasoactive agents, and multiple-site infection were factors associated with the clinical efficacy of PMB.
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Affiliation(s)
- Qiong Lu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Guo-Hua Li
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Hai-Hong Zhu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Yue Luo
- Department of Pharmacy, the People's Hospital of LIUYANG, Liuyang, People's Republic of China
| | - Han Yan
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Hai-Yan Yuan
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Jian Qu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
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13
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Heinonen T, Hargraves S, Georgieva M, Widmann C, Jacquier N. The antimicrobial peptide TAT-RasGAP 317-326 inhibits the formation and expansion of bacterial biofilms in vitro. J Glob Antimicrob Resist 2021; 25:227-231. [PMID: 33852935 DOI: 10.1016/j.jgar.2021.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Biofilms are structured aggregates of bacteria embedded in a self-produced matrix that develop in diverse ecological niches. Pathogenic bacteria can form biofilms on surfaces and in tissues, causing nosocomial and chronic infections that are difficult to treat. While antibiotics are largely inefficient in limiting biofilm formation and expansion, antimicrobial peptides (AMPs) are emerging as alternative antibiofilm treatments. In this study, we explore the effect of the newly described AMP TAT-RasGAP317-326 on Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus biofilms. METHODS Efficiency of TAT-RasGAP317-326 on biofilms was tested in vitro. Both viability of bacteria contained in the biofilm as well as biomass of the biofilm were quantified using resazurin and crystal violet staining, respectively. The antibiofilm effect of TAT-RasGAP317-326 was compared with a selection of classical antibiotics and AMPs. RESULTS We observe that TAT-RasGAP317-326 inhibits biofilm formation at concentrations equivalent or two times greater than the minimum inhibitory concentration (MIC) of planktonic bacteria. Moreover, TAT-RasGAP317-326 limits the expansion of A. baumannii and P. aeruginosa established biofilms at twice the concentration inhibiting biofilm formation. CONCLUSION These results underscore the potential use of TAT-RasGAP317-326 against biofilms and encourage further studies in the development of AMPs to treat biofilm-related infections.
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Affiliation(s)
- Tytti Heinonen
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 48, 1011 Lausanne, Switzerland
| | - Simone Hargraves
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 48, 1011 Lausanne, Switzerland
| | - Maria Georgieva
- Department of Biomedical Sciences, University of Lausanne, Rue du Bugnon 7, 1005 Lausanne, Switzerland
| | - Christian Widmann
- Department of Biomedical Sciences, University of Lausanne, Rue du Bugnon 7, 1005 Lausanne, Switzerland
| | - Nicolas Jacquier
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 48, 1011 Lausanne, Switzerland.
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14
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Wagenlehner F, Lucenteforte E, Pea F, Soriano A, Tavoschi L, Steele VR, Henriksen AS, Longshaw C, Manissero D, Pecini R, Pogue JM. Systematic review on estimated rates of nephrotoxicity and neurotoxicity in patients treated with polymyxins. Clin Microbiol Infect 2021; 27:S1198-743X(20)30764-3. [PMID: 33359542 DOI: 10.1016/j.cmi.2020.12.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/03/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Nephrotoxicity and neurotoxicity are commonly associated with polymyxin treatment; however, the emergence of multidrug-resistant Gram-negative bacteria with limited therapeutic options has resulted in increased use of polymyxins. OBJECTIVES To determine the rates of nephrotoxicity and neurotoxicity during polymyxin treatment and whether any factors influence these. DATA SOURCES Medline, Embase and Cochrane Library databases were searched on 2 January 2020. STUDY ELIGIBILITY CRITERIA Studies reporting nephrotoxicity and/or neurotoxicity rates in patients with infections treated with polymyxins were included. Reviews, meta-analyses and reports not in English were excluded. PARTICIPANTS Patients hospitalized with infections treated with systemic or inhaled polymyxins were included. For comparative analyses, patients treated with non-polymyxin-based regimens were also included. METHODS Meta-analyses were performed using a random-effects model; subgroup meta-analyses were conducted where data permitted using a mixed-effects model. RESULTS In total, 237 reports of randomized controlled trials, cohort and case-control studies were eligible for inclusion; most were single-arm observational studies. Nephrotoxic events in 35,569 patients receiving polymyxins were analysed. Overall nephrotoxicity rate was 0.282 (95% confidence interval (CI) 0.259-0.307). When excluding studies where >50% of patients received inhaled-only polymyxin treatment or nephrotoxicity assessment was by methods other than internationally recognized criteria (RIFLE, KDIGO or AKIN), the nephrotoxicity rate was 0.391 (95% CI 0.364-0.419). The odds of nephrotoxicity were greater with polymyxin therapies compared to non-polymyxin-based regimens (odds ratio 2.23 (95% CI 1.58-3.15); p < 0.001). Meta-analyses showed a significant effect of polymyxin type, dose, patient age, number of concomitant nephrotoxins and use of diuretics, glycopeptides or vasopressors on the rate of nephrotoxicity. Polymyxin therapies were not associated with a significantly different rate of neurotoxicity than non-polymyxin-based regimens (p 0.051). The overall rate of neurotoxicity during polymyxin therapy was 0.030 (95% CI 0.020-0.043). CONCLUSIONS Polymyxins are associated with a higher risk of nephrotoxicity than non-polymyxin-based regimens.
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Affiliation(s)
- Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Giessen, Germany
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Pea
- Department of Medicine, University of Udine and Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUIUD, Udine, Italy
| | - Alex Soriano
- Infectious Diseases Department, Hospital Clínic of Barcelona, University of Barcelona IDIBAPS, Barcelona, Spain
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | | | | | - Davide Manissero
- University College of London, Institute for Global Health, London, UK
| | | | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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15
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Xing H, Cheng C, Zhang Y, Cai Y, Wang X, Deng D, Xu L, Xu M, Chen J. Successful Treatment With Intrathecal and Intravenous Polymyxin B-Based Combination Against MDR Acinetobacter baumannii Meningitis in Pediatric Patient: A Case Report. Front Pediatr 2021; 9:564991. [PMID: 34386463 PMCID: PMC8353103 DOI: 10.3389/fped.2021.564991] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 06/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Nosocomial meningitis with multidrug-resistant (MDR) or extensively drug-resistant (XDR) Acinetobacter baumannii is a life-threatening complication in neurosurgery. Treatment of these infections is challenging because of poor penetration of the available antibiotics into the cerebrospinal fluid (CSF). Intrathecal (ITH) or intraventricular (IVT) administration of antibiotics is increasingly used as the last treatment option against MDR/XDR Gram-negative bacteria meningitis not responding to intravenous (IV) regimens. However, pertinent data in pediatric patients is scarce. Case Presentation: A 14-year-old male patient developed meningitis from an MDR strain of A. baumannii following endoscopic endonasal resection of craniopharyngioma. Despite a combination therapy involving IV tigecycline, we observed clinical and bacteriologic failure. The patient was then successfully treated with an ITH and IV polymyxin B-based combination. Quantification of tigecycline and polymyxin B in CSF was performed with two-dimensional high-performance liquid chromatography (2D-HPLC) and HDLC coupled with tandem mass spectrometry (HPLC-MS/MS), respectively. Adverse drug reactions (neurotoxicity and skin hyperpigmentation), probably induced by polymyxin B, were acceptable and reversible. Conclusions: The case illustrates ITH and IV Polymyxin B-based combination is an optimal therapeutic option against MDR A. baumannii meningitis in this pediatric patient. In the future, real-time PK/PD data obtained from patients during ITH/IVT polymyxin B therapy should be required to optimize polymyxin use with maximal efficacy and minimal adverse effects.
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Affiliation(s)
- Haiyan Xing
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Caiyi Cheng
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Yihua Zhang
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yongqing Cai
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Xianfeng Wang
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Dongmei Deng
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
| | - Lunshan Xu
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Minhui Xu
- Department of Neurosurgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Jianhong Chen
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
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16
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Is it time to move away from polymyxins?: evidence and alternatives. Eur J Clin Microbiol Infect Dis 2020; 40:461-475. [PMID: 33009595 DOI: 10.1007/s10096-020-04053-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/25/2020] [Indexed: 12/17/2022]
Abstract
Increasing burden of carbapenem resistance and resultant difficult-to-treat infections are of particular concern due to the lack of effective and safe treatment options. More recently, several new agents with activity against certain multidrug-resistant (MDR) and extensive drug-resistant (XDR) Gram-negative pathogens have been approved for clinical use. These include ceftazidime-avibactam, meropenem-vaborbactam, imipenem-cilastatin-relebactam, plazomicin, and cefiderocol. For the management of MBL infections, clinically used triple combination comprising ceftazidime-avibactam and aztreonam is hindered due to non-availability of antimicrobial susceptibility testing methods and lack of information on potential drug-drug interaction leading to PK changes impacting its safety and efficacy. Moreover, in several countries including Indian subcontinent and developing countries, these new agents are yet to be made available. Under these circumstances, polymyxins are the only last resort for the treatment of carbapenem-resistant infections. With the recent evidence of suboptimal PK/PD particularly in lung environment, limited efficacy and increased nephrotoxicity associated with polymyxin use, the Clinical and Laboratory Standards Institute (CLSI) has revised both colistin and polymyxin B breakpoints. Thus, polymyxins 'intermediate' breakpoint for Enterobacterales, P. aeruginosa, and Acinetobacter spp. are now set at ≤ 2 mg/L, implying limited clinical efficacy even for isolates with the MIC value 2 mg/L. This change has questioned the dependency on polymyxins in treating XDR infections. In this context, recently approved cefiderocol and phase 3 stage combination drug cefepime-zidebactam assume greater significance due to their potential to act as polymyxin-supplanting therapies.
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17
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Bento Talizin T, Dantas de Maio Carrilho CM, Magalhães Carvalho Grion C, Tibery Queiroz Cardoso L, Toshiyuki Tanita M, Boll KM, Moro Kauss IA, Festti J, Ribeiro Lopes C, Alves da Silva LM, Patruceli de Azevedo I, Paes K, Medeiros EA. Polymyxin for treatment of ventilator-associated pneumonia in a setting of high carbapenem resistance. PLoS One 2020; 15:e0237880. [PMID: 32813749 PMCID: PMC7437913 DOI: 10.1371/journal.pone.0237880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022] Open
Abstract
Objectives To analyse the use of polymyxins for the treatment of ventilator-associated pneumonia (VAP) at a teaching hospital where carbapenem-resistant gram-negative bacteria are endemic. Patients and methods This was a historical cohort study of patients receiving polymyxins to treat VAP in ICUs at a public university hospital in southern Brazil between January 1, 2017 and January 31, 2018. Results During the study period, 179 cases of VAP were treated with polymyxins. Of the 179 patients, 158 (88.3%) were classified as having chronic critical illness. Death occurred in 145 cases (81.0%). Multivariate analysis showed that the factors independently associated with mortality were the presence of comorbidities (P<0.001) and the SOFA score of the day of polymyxin prescription (P<0.001). Being a burn patient was a protective factor for mortality (P<0.001). Analysis of the 14-day survival probability showed that mortality was higher among the patients who had sepsis or septic shock at the time of polymyxin prescription (P = 0.028 and P<0.001, respectively). Acinetobacter baumannii was identified as the etiological agent of VAP in 121 cases (67.6%). In our cohort, polymyxin consumption and the incidence density of VAP were quite high. Conclusions In our study, comprised primarily of chronically critically ill patients, there was a high prevalence of VAP caused by multidrug-resistant bacteria, consistent with healthcare-associated infections in low- and middle-income countries. Presence of comorbidities and the SOFA score at the time of polymyxin prescription were predictors of mortality in this cohort. Despite aggressive antimicrobial treatment, mortality was high, stressing the need for antibiotic stewardship.
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Affiliation(s)
- Thalita Bento Talizin
- Comissão de Epidemiologia Hospitalar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
- Medical School, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
- * E-mail:
| | | | | | | | - Marcos Toshiyuki Tanita
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Karine Maria Boll
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Ivanil Aparecida Moro Kauss
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Josiane Festti
- Hospital Universitário da Universidade Estadual de Londrina, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | | | | | | | - Késia Paes
- Medical School, Universidade Estadual de Londrina, Londrina, Paraná, Brazil
| | - Eduardo Alexandrino Medeiros
- Comissão de Epidemiologia Hospitalar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
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