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Kunz Coyne AJ, Stamper K, El Ghali A, Kebriaei R, Biswas B, Wilson M, Deschenes MV, Tran TT, Arias CA, Rybak MJ. Phage-Antibiotic Cocktail Rescues Daptomycin and Phage Susceptibility against Daptomycin-Nonsusceptible Enterococcus faecium in a Simulated Endocardial Vegetation Ex Vivo Model. Microbiol Spectr 2023; 11:e0034023. [PMID: 37338375 PMCID: PMC10433949 DOI: 10.1128/spectrum.00340-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 06/21/2023] Open
Abstract
Enterococcus faecium is a difficult-to-treat pathogen with emerging resistance to most clinically available antibiotics. Daptomycin (DAP) is the standard of care, but even high DAP doses (12 mg/kg body weight/day) failed to eradicate some vancomycin-resistant strains. Combination DAP-ceftaroline (CPT) may increase β-lactam affinity for target penicillin binding proteins (PBP); however, in a simulated endocardial vegetation (SEV) pharmacokinetic/pharmacodynamic (PK/PD) model, DAP-CPT did not achieve therapeutic efficacy against a DAP-nonsusceptible (DNS) vancomycin-resistant E. faecium (VRE) isolate. Phage-antibiotic combinations (PAC) have been proposed for resistant high-inoculum infections. We aimed to identify PAC with maximum bactericidal activity and prevention/reversal of phage and antibiotic resistance in an SEV PK/PD model against DNS isolate R497. Phage-antibiotic synergy (PAS) was evaluated with modified checkerboard MIC and 24-h time-kill analyses (TKA). Human-simulated antibiotic doses of DAP and CPT with phages NV-497 and NV-503-01 were then evaluated in 96-h SEV PK/PD models against R497. Synergistic and bactericidal activity was identified with the PAC of DAP-CPT combined with phage cocktail NV-497-NV-503-01, demonstrating a significant reduction in viability down to 3-log10 CFU/g (-Δ, 5.77-log10 CFU/g; P < 0.001). This combination also demonstrated isolate resensitization to DAP. Evaluation of phage resistance post-SEV demonstrated prevention of phage resistance for PACs containing DAP-CPT. Our results provide novel data highlighting bactericidal and synergistic activity of PAC against a DNS E. faecium isolate in a high-inoculum ex vivo SEV PK/PD model with subsequent DAP resensitization and prevention of phage resistance. IMPORTANCE Our study supports the additional benefit of standard-of-care antibiotics combined with a phage cocktail compared to antibiotic alone against a daptomycin-nonsusceptible (DNS) E. faecium isolate in a high-inoculum simulated endocardial vegetation ex vivo PK/PD model. E. faecium is a leading cause of hospital-acquired infections and is associated with significant morbidity and mortality. Daptomycin is considered the first-line therapy for vancomycin-resistant E. faecium (VRE), but the highest published doses have failed to eradicate some VRE isolates. The addition of a β-lactam to daptomycin may result in synergistic activity, but previous in vitro data demonstrate that daptomycin plus ceftaroline failed to eradicate a VRE isolate. Phage therapy as an adjunct to antibiotic therapy has been proposed as a salvage therapy for high-inoculum infections; however, pragmatic clinical comparison trials for endocarditis are lacking and difficult to design, reinforcing the timeliness of such analysis.
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Affiliation(s)
- Ashlan J. Kunz Coyne
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Kyle Stamper
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Amer El Ghali
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Razieh Kebriaei
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | | | - Melanie Wilson
- Naval Medical Research Center–Frederick, Maryland, USA
- Leidos, Reston, Virginia, USA
| | - Michael V. Deschenes
- Naval Medical Research Center–Frederick, Maryland, USA
- Leidos, Reston, Virginia, USA
| | - Truc T. Tran
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Cesar A. Arias
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas, USA
- Center for Infectious Diseases, Houston Methodist Research Institute, Houston, Texas, USA
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
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Rox K. Influence of tramadol on bacterial burden in the standard neutropenic thigh infection model. Sci Rep 2022; 12:19606. [PMID: 36380116 PMCID: PMC9666522 DOI: 10.1038/s41598-022-24111-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
The neutropenic thigh infection model is one of the standard models in pharmacokinetic/ pharmacodynamic (PK/PD) characterization of novel antibacterials which are urgently needed due to the rise of antimicrobial resistance. The model enables to investigate PK/PD parameters crucial for translation of animal results towards humans. However, the neutropenic thigh infection model can result in moderate to severe discomfort of the animals, especially when high inocula are used. Tramadol has been proven to reduce pain effectively. This study investigates if tramadol influences the bacterial burden in the primary organ, the thighs, and organs affected by secondary seeding. Therefore, several strains of the ESKAPE pathogens, namely S. aureus, P. aeruginosa, K. pneumoniae, E. coli, A. baumannii and E. faecalis were examined. It was shown that tramadol did not influence the bacterial burden neither in thighs nor in organs affected by secondary seeding for the strains of E. faecalis, S. aureus, P. aeruginosa, K. pneumoniae and E.coli tested here, whereas secondary seeding seemed to be affected by tramadol for the tested strain of A. baumannii. Consequently, it was demonstrated that tramadol is an option to reduce discomfort in the untreated group for the strains of five out of the six tested ESKAPE pathogens and, thereby, contributes to the refinement of one of the standard PK/PD models.
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Affiliation(s)
- K. Rox
- grid.7490.a0000 0001 2238 295XDepartment of Chemical Biology, Helmholtz Centre for Infection Research (HZI), Inhoffenstraße 7, 38124 Braunschweig, Germany ,grid.452463.2German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, 38124 Braunschweig, Germany
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Chuang YC, Lin HY, Wang JT, Yang JL, Lin CY, Huang SH, Chen YC, Chang SC. Daptomycin area under the curve to minimum inhibitory concentration ratio by broth microdilution for predicting the outcome of vancomycin-resistant Enterococcus bloodstream infection. Biomed Pharmacother 2022; 155:113710. [PMID: 36156368 DOI: 10.1016/j.biopha.2022.113710] [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: 08/04/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES Different methods are used to determine the minimum inhibitory concentration (MIC) for daptomycin. The threshold is unknown for the free drug area under the concentration-time curve to MIC ratio (fAUC/MIC) of daptomycin using broth microdilution (BMD) to predict outcome of vancomycin-resistant enterococcus (VRE) bacteremia. The MIC testing method which is best for predicting the outcome remains unclear. METHODS This is a retrospective cohort study. The inclusion criterion was VRE bacteremia treated with ≥ 8 mg/kg of daptomycin. As we aimed to compare different daptomycin MIC testing methods for predicting the clinical outcome of VRE bacteremia, the inclusion criteria included the availability of MIC values for BMD, Etest, and automated antimicrobial susceptibility testing (AST). The primary end point was 28-day mortality. The fAUC/MIC was dichotomized using classification and regression tree analysis for predicting survival. RESULTS A total of 393 patients were included; 215 survived and 178 died. In the multivariable logistic model for predicting mortality, the dichotomized fAUC/MICs for Etest and AST were 0.508 and 0.065 times as probable, respectively, as that for BMD to minimize information loss. An fAUC/MIC > 75.07 for BMD significantly predicted lower mortality (adjusted odds ratio, 0.53, 95% confidence interval, 0.30-0.95; P = 0.03) after adjusting for underlying disease and bacteremia severity. Using Monte Carlo simulation, none of the doses had a probability of target attainment of ≥ 50% with an MIC of ≥ 2 mg/L. CONCLUSION The dichotomized threshold for fAUC/MIC for BMD was the best predictor of mortality. An fAUC/MIC > 75.07 for BMD independently predicted better survival.
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Affiliation(s)
- Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Hsin-Yi Lin
- Department of Economics, National Chengchi University, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Ling Yang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ying Lin
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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4
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Daptomycin Physiology-Based Pharmacokinetic Modeling to Predict Drug Exposure and Pharmacodynamics in Skin and Bone Tissues. Clin Pharmacokinet 2022; 61:1443-1456. [PMID: 35972685 DOI: 10.1007/s40262-022-01168-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Daptomycin has been recommended in the treatment of bone and joint infection. Previous work showed that the approved dosage of daptomycin may be insufficient to achieve optimal exposure in patients with bone and joint infection. However, those studies assumed that bone exposure was similar to steady-state daptomycin-free plasma concentrations. We sought to establish a physiologically based pharmacokinetic (PBPK) model of daptomycin to describe the dynamics of daptomycin disposition in bone and skin tissue. METHODS A PBPK model of daptomycin was built using PK-Sim®. Daptomycin concentrations in plasma and bone were obtained from three previously published studies. Physicochemical drug characteristics, mass balance, anthropometrics, and experimental data were used to build and refine the PBPK model. Internal validation of the PBPK model was performed using the usual diagnostic plots. The final PBPK model was then used to run simulations with doses of 6, 8, 10, and 12 mg/kg/24 h. Pharmacokinetic profiles were simulated in 1000 subjects and the probabilities of target attainment for the area under the concentration-time curve over the bacterial minimum inhibitory concentration were computed in blood, skin, and bone compartments. RESULTS The final model showed a good fit of all datasets with an absolute average fold error between 0.5 and 2 for all pharmacokinetic quantities in blood, skin and bone tissues. Results of dosing simulations showed that doses ≥10 mg/kg should be used in the case of bacteremia caused by Staphylococcus aureus with a minimum inhibitory concentration >0.5 mg/L or Enterococcus faecalis with a minimum inhibitory concentration >1 mg/L, while doses ≥12 mg/kg should be used in the case of bone and joint infection or complicated skin infection. When considering a lower minimum inhibitory concentration, doses of 6-8 mg/kg would likely achieve a sufficient success rate. However, in the case of infections caused by E. faecalis with a minimum inhibitory concentration >2 mg/L, a higher dosage and combination therapy would be necessary to maximize efficacy. CONCLUSIONS We developed the first daptomycin PBPK/pharmacodynamic model for bone and joint infection, which confirmed that a higher daptomycin dosage is needed to optimize exposure in bone tissue. However, such higher dosages raise safety concerns. In this setting, therapeutic drug monitoring and model-informed precision dosing appear necessary to ensure the right exposure on an individual basis.
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5
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1432-1435. [DOI: 10.1093/jac/dkac042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
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Interplay between ESKAPE Pathogens and Immunity in Skin Infections: An Overview of the Major Determinants of Virulence and Antibiotic Resistance. Pathogens 2021; 10:pathogens10020148. [PMID: 33540588 PMCID: PMC7912840 DOI: 10.3390/pathogens10020148] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The skin is the largest organ in the human body, acting as a physical and immunological barrier against pathogenic microorganisms. The cutaneous lesions constitute a gateway for microbial contamination that can lead to chronic wounds and other invasive infections. Chronic wounds are considered as serious public health problems due the related social, psychological and economic consequences. The group of bacteria known as ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter sp.) are among the most prevalent bacteria in cutaneous infections. These pathogens have a high level of incidence in hospital environments and several strains present phenotypes of multidrug resistance. In this review, we discuss some important aspects of skin immunology and the involvement of ESKAPE in wound infections. First, we introduce some fundamental aspects of skin physiology and immunology related to cutaneous infections. Following this, the major virulence factors involved in colonization and tissue damage are highlighted, as well as the most frequently detected antimicrobial resistance genes. ESKAPE pathogens express several virulence determinants that overcome the skin's physical and immunological barriers, enabling them to cause severe wound infections. The high ability these bacteria to acquire resistance is alarming, particularly in the hospital settings where immunocompromised individuals are exposed to these pathogens. Knowledge about the virulence and resistance markers of these species is important in order to develop new strategies to detect and treat their associated infections.
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Satlin MJ, Nicolau DP, Humphries RM, Kuti JL, Campeau SA, Lewis Ii JS, Weinstein MP, Jorgensen JH. Development of Daptomycin Susceptibility Breakpoints for Enterococcus faecium and Revision of the Breakpoints for Other Enterococcal Species by the Clinical and Laboratory Standards Institute. Clin Infect Dis 2021; 70:1240-1246. [PMID: 31504338 DOI: 10.1093/cid/ciz845] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022] Open
Abstract
Daptomycin is one of the few treatment options for infections caused by enterococci that are resistant to ampicillin and vancomycin, such as vancomycin-resistant Enterococcus faecium. The emergence and clinical significance of daptomycin-resistant enterococci and evolving microbiologic, pharmacokinetic-pharmacodynamic, and clinical data indicated that the pre-2019 Clinical and Laboratory Standards Institute (CLSI) susceptible-only breakpoint of ≤4 μg/mL for daptomycin and enterococci was no longer appropriate. After analyzing data that are outlined in this article, the CLSI Subcommittee on Antimicrobial Susceptibility Testing established new breakpoints for daptomycin and enterococci. For E. faecium, a susceptible dose-dependent (SDD) breakpoint of ≤4 μg/mL was established based on an increased dosage of 8-12 mg/kg/day (≥8 μg/mL-resistant). CLSI suggests infectious diseases consultation to guide daptomycin use for the SDD category. For Enterococcus faecalis and other enterococcal species, revised breakpoints of ≤2 μg/mL-susceptible, 4 μg/mL-intermediate, and ≥8 μg/mL-resistant were established based on a standard dosage of 6 mg/kg/day.
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Affiliation(s)
- Michael J Satlin
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Connecticut
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Connecticut
| | | | - James S Lewis Ii
- Department of Pharmacy, Oregon Health and Science University, Portland
| | - Melvin P Weinstein
- Departments of Medicine and Pathology and Laboratory Medicine Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - James H Jorgensen
- Department of Pathology, University of Texas Health Sciences Center at San Antonio
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8
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Avery LM, Kuti JL, Weisser M, Egli A, Rybak MJ, Zasowski EJ, Arias CA, Contreras GA, Chong PP, Aitken SL, DiPippo AJ, Wang JT, Britt NS, Nicolau DP. Pharmacodynamic Analysis of Daptomycin-treated Enterococcal Bacteremia: It Is Time to Change the Breakpoint. Clin Infect Dis 2020; 68:1650-1657. [PMID: 30188976 DOI: 10.1093/cid/ciy749] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/28/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Currently, there is debate over whether the daptomycin susceptibility breakpoint for enterococci (ie, minimum inhibitory concentration [MIC] ≤4 mg/L) is appropriate. In bacteremia, observational data support prescription of high doses (>8 mg/kg). However, pharmacodynamic targets associated with positive patient outcomes are undefined. METHODS Data were pooled from observational studies that assessed outcomes in daptomycin-treated enterococcal bacteremia. Patients who received an additional antienterococcal antibiotic and/or a β-lactam antibiotic at any time during treatment were excluded. Daptomycin exposures were calculated using a published population pharmacokinetic model. The free drug area under the concentration-time curve to MIC ratio (fAUC/MIC) threshold predictive of survival at 30 days was identified by classification and regression tree analysis and confirmed with multivariable logistic regression. Monte Carlo simulations determined the probability of target attainment (PTA) at clinically relevant MICs. RESULTS Of 114 patients who received daptomycin monotherapy, 67 (58.8%) were alive at 30 days. A fAUC/MIC >27.43 was associated with survival in low-acuity (n = 77) patients (68.9 vs 37.5%, P = .006), which remained significant after adjusting for infection source and immunosuppression (P = .026). The PTA for a 6-mg/kg/day (every 24 hours) dose was 1.5%-5.5% when the MIC was 4 mg/L (ie, daptomycin-susceptible) and 91.0%-97.9% when the MIC was 1 mg/L. CONCLUSIONS For enterococcal bacteremia, a daptomycin fAUC/MIC >27.43 was associated with 30-day survival among low-acuity patients. As pharmacodynamics for the approved dose are optimized only when MIC ≤1 mg/L, these data continue to stress the importance of reevaluation of the susceptibility breakpoint.
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Affiliation(s)
- Lindsay M Avery
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Maja Weisser
- Division of Infectious Diseases and Hospital Epidemiology
| | - Adrian Egli
- Division of Clinical Microbiology, University Hospital Basel.,Applied Microbiology Research, University of Basel, Switzerland
| | - Michael J Rybak
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan
| | - Evan J Zasowski
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan.,Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston.,Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston.,Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Colombia
| | - German A Contreras
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston
| | - Pearlie P Chong
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
| | - Samuel L Aitken
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Adam J DiPippo
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Nicholas S Britt
- Research Department, Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth.,Department of Pharmacy Practice, University of Kansas School of Pharmacy
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Connecticut
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Turnidge J, Kahlmeter G, Cantón R, MacGowan A, Giske CG. Daptomycin in the treatment of enterococcal bloodstream infections and endocarditis: a EUCAST position paper. Clin Microbiol Infect 2020; 26:1039-1043. [PMID: 32353412 DOI: 10.1016/j.cmi.2020.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 12/20/2022]
Abstract
SCOPE This position paper describes the view adopted by EUCAST on the role of daptomycin in the treatment of serious infections caused by Enterococcus species. BACKGROUND High-dose daptomycin is considered effective in the treatment of enterococcal bloodstream infection (BSI) and endocarditis, although published clinical experience with the latter condition is limited. METHODS EUCAST reviewed the available published data on pharmacokinetics-pharmacodynamics (PK-PD), resistance selection, clinical efficacy and safety for the use of 10-12 mg/kg/day of daptomycin for these conditions, noting that the doses licensed by the European Medicines Agency are only 4-6 mg/kg/day, and only for infections caused by Staphylococcus aureus. FINDINGS AND RECOMMENDATIONS The PK-PD evidence shows that, even with doses of 10-12 mg/kg/day, it is not possible to treat infections caused by isolates at the upper end of the wild-type distributions of Enterococcus faecalis (with MICs of 4 mg/L) and E. faecium (with MICs of 4 or 8 mg/L). For this reason, and because there are ongoing issues with the reliability of laboratory testing, EUCAST lists daptomycin breakpoints for Enterococcus species as "IE"-insufficient evidence. EUCAST advises increased vigilance in the use of high-dose of daptomycin to treat enterococcal BSI and endocarditis. Additional PK-PD studies and prospective efficacy and safety studies of serious Enterococcal infections treated with high-dose daptomycin may permit the setting of breakpoints in the future.
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Affiliation(s)
- J Turnidge
- Adelaide Medical School and School of Biological Sciences, University of Adelaide, Adelaide, Australia.
| | - G Kahlmeter
- Clinical Microbiology, Central Hospital, Växjö, Sweden
| | - R Cantón
- Servicio de Microbiología. Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - A MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Infection Sciences, Severn Pathology Partnership, Southmead Hospital, Bristol, UK
| | - C G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet and Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
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Assessment of Tedizolid In Vitro Activity and Resistance Mechanisms against a Collection of Enterococcus spp. Causing Invasive Infections, Including Isolates Requiring an Optimized Dosing Strategy for Daptomycin from U.S. and European Medical Centers, 2016 to 2018. Antimicrob Agents Chemother 2020; 64:AAC.00175-20. [PMID: 32015026 DOI: 10.1128/aac.00175-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/14/2022] Open
Abstract
High-level aminoglycoside resistance was noted in 30.0% of Enterococcus faecalis and 25.2% of Enterococcus faecium isolates. Only 3.3% and 2.1% of E. faecalis isolates had elevated daptomycin MIC (≥2 mg/liter) and vancomycin resistance, respectively. In contrast, 37.4% to 40.3% of E. faecium isolates exhibited these phenotypes. Tedizolid inhibited 98.9% to 100.0% of enterococci causing serious invasive infections, including resistant subsets. Oxazolidinone resistance was mainly driven by G2576T; however, optrA and poxtA genes were also detected, including poxtA in the United States and Turkey.
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11
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Synergistic Activity of Exebacase (CF-301) in Addition to Daptomycin against Staphylococcus aureus in a Neutropenic Murine Thigh Infection Model. Antimicrob Agents Chemother 2020; 64:AAC.02176-19. [PMID: 31818816 DOI: 10.1128/aac.02176-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/02/2019] [Indexed: 01/09/2023] Open
Abstract
We evaluated the efficacy of escalating doses of exebacase administered with subtherapeutic daptomycin exposures against 8 Staphylococcus aureus isolates in a neutropenic murine thigh infection model. Daptomycin alone resulted in mean growth of 0.39 ± 1.19 log10 CFU/thigh. When administered with daptomycin, exebacase resulted in a mean log10 CFU/thigh reduction of -1.03 ± 0.72 (range, -0.77 ± 0.98 to -1.20 ± 0.59) across evaluated doses (15 to 90 mg/kg), indicative of potential in vivo synergy.
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12
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One Size Fits All? Application of Susceptible-Dose-Dependent Breakpoints to Pediatric Patients and Laboratory Reporting. J Clin Microbiol 2019; 58:JCM.01446-19. [PMID: 31666359 DOI: 10.1128/jcm.01446-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The Clinical and Laboratory Standards Institute antimicrobial and antifungal standards define a susceptible-dose-dependent (SDD) category for certain organisms and drug combinations. Reporting MICs within the SDD category suggests that treatment success is likely with increased drug exposure. These breakpoints are based on pharmacokinetic, pharmacodynamic, and clinical outcome data from adults and not pediatric patients. This commentary aims to discuss the implications of reporting SDD interpretations for pediatric patients and recommends laboratory reporting comments.
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13
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Menezes BK, Alves IA, Staudt KJ, Beltrame BM, Venz L, Michelin L, Araujo BV, Tasso L. Time-kill curves of daptomycin and Monte Carlo simulation for the treatment of bacteraemia caused by Enterococcus faecium. Braz J Microbiol 2019; 51:169-176. [PMID: 31845296 DOI: 10.1007/s42770-019-00200-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 11/22/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate the effect of daptomycin against vancomycin-resistant Enterococcus faecium bacteraemia using computer modelling. METHODS Data obtained in vitro from time-kill curves were evaluated by PK/PD modelling and Monte Carlo simulations to determine the logarithmic reduction in the number of colony-forming units (CFU)/mL over 18 days of daptomycin treatment at 6, 8, and 10 mg/kg doses every 24 or 48 h and with variations in creatinine clearance (CLCR) of 15-29, 30-49, and 50-100 mL/min/1.73 m2. Monte Carlo simulations were performed to evaluate the probability of target attainment (PTA) for an area under the unbound drug concentration-time curve/minimum inhibitory concentration (fAUC/MIC) > 36 at the same doses and CLCR. RESULTS Static time-kill model was employed to investigate the antibacterial efficacy of constant daptomycin concentrations. The time-kill curve analysis was performed using mathematical modelling based on a Hill coefficient factor. There was an expressive reduction (> 2 Log CFU/mL) over 18 days of daptomycin treatment in 75th percentile of individuals with CLCR of 15-100 mL/min/1.73 m2) with daptomycin 6-10 mg/kg/day, except for daptomycin every 48 h. Using fAUC/MIC > 36, PTA was > 90% at MICs ≤ 2 μg/mL. CONCLUSIONS Higher daptomycin doses were associated with higher mortality in time-kill curves. The simulations indicated that independent of the CLCR the therapeutic responses of VRE occur with doses of daptomycin ≥ 6 mg/kg/day and daptomycin every 48 h is insufficient to treat enterococcal bacteraemia.
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Affiliation(s)
| | - Izabel Almeida Alves
- Pharmaceutical Sciences Graduate Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Keli Jaqueline Staudt
- Medical Sciences Graduate Program, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Letícia Venz
- College of Pharmacy, University of Caxias do Sul, Caxias do Sul, Brazil
| | | | | | - Leandro Tasso
- Health Sciences Graduate Program, University of Caxias do Sul, Caxias do Sul, Brazil.
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Santimaleeworagun W, Changpradub D, Thunyaharn S, Hemapanpairoa J. Optimizing the Dosing Regimens of Daptomycin Based on the Susceptible Dose-Dependent Breakpoint against Vancomycin-Resistant Enterococci Infection. Antibiotics (Basel) 2019; 8:antibiotics8040245. [PMID: 31795437 PMCID: PMC6963552 DOI: 10.3390/antibiotics8040245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 11/16/2022] Open
Abstract
Daptomycin, a lipopeptide antibiotic, is one of the therapeutic options used for the treatment of vancomycin-resistant enterococci (VRE). Recently, the Clinical and Laboratory Standards Institute (CLSI) M100 30th edition has removed the susceptibility (S) breakpoint for Enterococcus faecium and replaced it with a susceptible dose-dependent (SDD) breakpoint of ≤4 μg/mL, with a suggested dosage of 8–12 mg/kg/day. Herein, we aimed to determine the minimum inhibitory concentration (MIC) values of daptomycin against clinical VRE isolates and to study the appropriate daptomycin dosing regimens among critically ill patients based on the new susceptibility CLSI breakpoint. The MIC determination of daptomycin was performed using E-test strips among clinical VRE strains isolated from patients at the Phramongkutklao Hospital. We used Monte Carlo simulation to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR) of the ratio of the free area under the curve to MIC (fAUC0–24/MIC) > 27.4 and fAUC0–24/MIC > 20 for survival and microbiological response, respectively, at the first day and steady state. Further, we determined that the simulated daptomycin dosing regimen met the minimum concentration (Cmin) requirements for safety of being below 24.3 mg/L. All of the 48 VRE isolates were E. faecium strains, and the percentiles at the 50th and 90th MIC of daptomycin were 1 and 1.5 μg/mL, respectively. At MIC ≤ 2 μg/mL, a daptomycin dosage of 12 mg/kg/day achieved the PTA target of survival and microbiological response at the first 24 h time point and steady state. For a MIC of 4 μg/mL, none of the dosage regimens achieved the PTA target. For CFR, a dosage of 8–12 mg/kg/day could achieve the 90% CFR target at the first day and steady state. All dosing regimens had a low probability of Cmin being greater than 24.3 mg/L. In conclusion, the MIC of VRE against daptomycin is quite low, and loading and maintenance doses with 8 mg/kg/day were determined to be optimal and safe.
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Affiliation(s)
- Wichai Santimaleeworagun
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakorn Pathom 73000, Thailand
- Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group (PIRBIG), Nakorn Pathom 73000, Thailand
| | - Dhitiwat Changpradub
- Division of Infectious Disease, Department of Medicine, Phramongkutklao Hospital, Bangkok 10400, Thailand
| | - Sudaluck Thunyaharn
- Faculty of Medical Technology, Nakhonratchasima College, Nakhon Ratchasima 30000, Thailand
| | - Jatapat Hemapanpairoa
- Department of Pharmacy Practice and Pharmaceutical Care, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi 20131, Thailand
- Correspondence: ; Tel.: +66-3839-040-1
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15
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Abstract
In 2019, the Clinical and Laboratory Standards Institute revised the daptomycin breakpoints for Enterococcus spp. twice in rapid succession. Analyses leading to these revisions included review of testing issues, murine and human in vivo pharmacodynamics, safety of off-label doses, and treatment outcomes. The data review brought up a dilemma that is encountered with increasing frequency: a breakpoint supported by pharmacokinetic/pharmacodynamic modeling that bisected the wild-type Enterococcus faecium MIC distribution. In such instances, not only does the probability of pharmacokinetic/pharmacodynamic targets need to be taken into account but also the probability that the laboratory can generate an accurate MIC that is reproducible within one interpretive category.
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16
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Understanding and Addressing CLSI Breakpoint Revisions: a Primer for Clinical Laboratories. J Clin Microbiol 2019; 57:JCM.00203-19. [PMID: 30971460 DOI: 10.1128/jcm.00203-19] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The Clinical and Laboratory Standards Institute (CLSI) has revised several breakpoints since 2010 for bacteria that grow aerobically. In 2019, these revisions include changes to the ciprofloxacin and levofloxacin breakpoints for the Enterobacteriaceae and Pseudomonas aeruginosa, daptomycin breakpoints for Enterococcus spp., and ceftaroline breakpoints for Staphylococcus aureus Implementation of the revisions is a challenge for all laboratories, as not all systems have FDA clearance for the revised (current) breakpoints, compounded by the need for laboratories to perform validation studies and to make updates to laboratory information system/electronic medical record builds in the setting of limited information technology infrastructure. This minireview describes the breakpoint revisions in the M100 supplement since 2010 and strategies for the laboratory on how to best adopt these in clinical testing.
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17
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Avery LM, Kuti JL, Weisser M, Egli A, Rybak MJ, Zasowski EJ, Arias CA, Contreras GA, Chong PP, Aitken SL, DiPippo AJ, Wang JT, Britt NS, Nicolau DP. Pharmacodynamic Analysis of Daptomycin-treated Enterococcal Bacteremia: It Is Time to Change the Breakpoint. Clin Infect Dis 2019. [PMID: 30188976 DOI: 10.1093/cid/ciy749.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Currently, there is debate over whether the daptomycin susceptibility breakpoint for enterococci (ie, minimum inhibitory concentration [MIC] ≤4 mg/L) is appropriate. In bacteremia, observational data support prescription of high doses (>8 mg/kg). However, pharmacodynamic targets associated with positive patient outcomes are undefined. METHODS Data were pooled from observational studies that assessed outcomes in daptomycin-treated enterococcal bacteremia. Patients who received an additional antienterococcal antibiotic and/or a β-lactam antibiotic at any time during treatment were excluded. Daptomycin exposures were calculated using a published population pharmacokinetic model. The free drug area under the concentration-time curve to MIC ratio (fAUC/MIC) threshold predictive of survival at 30 days was identified by classification and regression tree analysis and confirmed with multivariable logistic regression. Monte Carlo simulations determined the probability of target attainment (PTA) at clinically relevant MICs. RESULTS Of 114 patients who received daptomycin monotherapy, 67 (58.8%) were alive at 30 days. A fAUC/MIC >27.43 was associated with survival in low-acuity (n = 77) patients (68.9 vs 37.5%, P = .006), which remained significant after adjusting for infection source and immunosuppression (P = .026). The PTA for a 6-mg/kg/day (every 24 hours) dose was 1.5%-5.5% when the MIC was 4 mg/L (ie, daptomycin-susceptible) and 91.0%-97.9% when the MIC was 1 mg/L. CONCLUSIONS For enterococcal bacteremia, a daptomycin fAUC/MIC >27.43 was associated with 30-day survival among low-acuity patients. As pharmacodynamics for the approved dose are optimized only when MIC ≤1 mg/L, these data continue to stress the importance of reevaluation of the susceptibility breakpoint.
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Affiliation(s)
- Lindsay M Avery
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut
| | - Maja Weisser
- Division of Infectious Diseases and Hospital Epidemiology
| | - Adrian Egli
- Division of Clinical Microbiology, University Hospital Basel.,Applied Microbiology Research, University of Basel, Switzerland
| | - Michael J Rybak
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan
| | - Evan J Zasowski
- Anti-infective Research Laboratory, College of Pharmacy, School of Medicine, Division of Infectious Diseases, Wayne State University, Detroit, Michigan.,Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston.,Center for Infectious Diseases, University of Texas Health Science Center, School of Public Health, Houston.,Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Colombia
| | - German A Contreras
- Center for Antimicrobial Resistance and Microbial Genomics and Division of Infectious Diseases, University of Texas Health Science Center, McGovern Medical School at Houston
| | - Pearlie P Chong
- Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
| | - Samuel L Aitken
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Adam J DiPippo
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Nicholas S Britt
- Research Department, Dwight D. Eisenhower Veterans Affairs Medical Center, Leavenworth.,Department of Pharmacy Practice, University of Kansas School of Pharmacy
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Connecticut.,Division of Infectious Diseases, Hartford Hospital, Connecticut
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