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Leegwater E, Baidjoe L, Wilms EB, Visser LG, Touw DJ, de Winter BCM, de Boer MGJ, van Paassen J, van den Berg CHSB, van Prehn J, van Gelder T, Moes DJAR. Population Pharmacokinetics of Trimethoprim/Sulfamethoxazole: Dosage Optimization for Patients with Renal Insufficiency or Receiving Continuous Renal Replacement Therapy. Clin Pharmacol Ther 2024. [PMID: 39148353 DOI: 10.1002/cpt.3421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/23/2024] [Indexed: 08/17/2024]
Abstract
The goal of the study was to describe the population pharmacokinetics of trimethoprim, sulfamethoxazole, and N-acetyl sulfamethoxazole in hospitalized patients. Furthermore, this study used the model to optimize dosing regimens of cotrimoxazole for Pneumocystis jirovecii pneumonia and in patients with renal insufficiency or with continuous renal replacement therapy (CRRT). This was a retrospective multicenter observational cohort study based on therapeutic drug monitoring (TDM) data from hospitalized patients treated with cotrimoxazole. We developed two population pharmacokinetic (POPPK) models: a model of trimethoprim and an integrated model with both sulfamethoxazole and N-acetyl sulfamethoxazole concentrations. Monte Carlo simulations were performed to determine the optimal dosing regimen. A total of 348 measurements from 168 patients were available. The estimated glomerular filtration rate (eGFR) and CRRT were included as covariates on the clearance of all three compounds. Cotrimoxazole TID 1,920 mg and b.i.d. 2,400 mg led to sufficient exposure for infections with P. jirovecii in patients without renal insufficiency. To reach equivalent exposure, a dose reduction of 33.3% is needed in patients with an eGFR of 10 mL/minute/1.73 m2 and of 16.7% for an eGFR of 30 mL/minute/1.73 m2. N-acetyl sulfamethoxazole accumulates in patients with a reduced eGFR. CRRT increased the clearance of sulfamethoxazole, but not trimethoprim or N-acetyl sulfamethoxazole, compared with the median clearance in the population. Doubling the sulfamethoxazole dose is needed for patients on CRRT to reach equivalent exposure.
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Affiliation(s)
- Emiel Leegwater
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands
- Apotheek Haagse Ziekenhuizen, The Hague, The Netherlands
- Department of Infectious Diseases, Leiden University Center for Infectious Diseases (LU-CID) Leiden University Medical Center, Leiden, The Netherlands
| | - Lauren Baidjoe
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik B Wilms
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands
- Apotheek Haagse Ziekenhuizen, The Hague, The Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Center for Infectious Diseases (LU-CID) Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Center for Infectious Diseases (LU-CID) Leiden University Medical Center, Leiden, The Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joffrey van Prehn
- Department of Medical Microbiology, Leiden University Center for Infectious Diseases (LU-CID) Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk Jan A R Moes
- Department Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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Palillo MB, Carrasco SE, Mishkin N, Palillo JA, Lynch DB, Lawton S, Aydin M, Mourino A, Lipman NS, Ricart Arbona RJ. Assessment of Antimicrobial Therapy in Eradicating Chlamydia muridarum in Research Mice: Immune Status and its Impact on Outcomes. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.28.600682. [PMID: 38979332 PMCID: PMC11230361 DOI: 10.1101/2024.06.28.600682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Chlamydia muridarum (Cm) is a moderately prevalent, gram-negative, intracellular bacterium that affects laboratory mice, causing subclinical to severe disease, depending on the host's immune status. The effectiveness of various antibiotic regimens aimed at eradicating Cm in both immunodeficient and immunocompetent laboratory mice was evaluated. NSG mice were cohoused with Cm-shedding BALB/cJ mice for 14 days to simulate natural exposure. Four groups of 8 infected NSG mice were treated for 7 days with either 0.08% sulfamethoxazole and 0.016% trimethoprim (TMS) in water, 0.0625% doxycycline in feed, 0.124%/0.025% TMS in feed, or 0.12% amoxicillin in feed. A control group was provided standard water and feed. The impact of treatment on gastrointestinal microbiota (GM) was performed using next-generation shotgun sequencing on the last day of treatment. TMS and Amoxicillin had negligible effects on GM, while doxycycline had the largest effect. All antibiotic treated NSG mice exhibited clinical disease, including dehydration, hunched posture, >20% weight loss, and dyspnea, leading to euthanasia 21-40 days post-treatment (32.6 ± 4.2 days; mean ± SD). Untreated controls were euthanized 14-33 days post-exposure (23.75 ± 5.9 days). All mice were fecal PCR positive for Cm at euthanasia. Histological evaluation revealed multifocal histiocytic and neutrophilic bronchointerstitial pneumonia and/or bronchiolitis featuring prominent intralesional chlamydial inclusion bodies in all mice. Subsequently, groups of 8 C57BL/6J, BALB/cJ, NOD.SCID, and NSG mice infected with Cm were treated with 0.124%/0.025% TMS in feed for 7 (BALB/cJ and C57BL/6J) or 21 days (NSG and NOD.SCID). All immunocompetent and NOD.SCID mice were negative for Cm by PCR 14 days post-treatment, remained clinically normal and had no evidence of Cm infection at necropsy, all NSG mice remained Cm positive and were euthanized. While these findings highlight the difficulties in eradicating Cm from highly immunodeficient mice, eradication of Cm from immunocompetent or moderately immunocompromised mice with antibiotics is feasible.
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Martinez MN, Miller RA, Martín-Jiménez T, Sharkey MJ. Application of pharmacokinetic/pharmacodynamic concepts to the development of treatment regimens for sporadic canine urinary tract infections: Challenges and paths forward. J Vet Pharmacol Ther 2022; 45:415-425. [PMID: 35906854 DOI: 10.1111/jvp.13088] [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: 03/20/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
Antimicrobial efficacy can be predicted based on infection site exposure to the antimicrobial agent relative to the in vitro susceptibility of the pathogen to that agent. When infections occur in soft tissues (e.g., muscle, blood, and ligaments), exposure at the infection site is generally assumed to reflect an equilibrium between the unbound concentrations in plasma and that in the interstitial fluids. In contrast, for sporadic urinary tract infections (UTIs) in dogs and uncomplicated UTIs in humans, the primary site of infection is the bladder wall. Infection develops when bacteria invade the host bladder urothelium (specifically, the umbrella cells that form the urine-contacting layer of the stratified uroepithelium) within which these bacteria can avoid exposure to host defenses and antimicrobial agents. Traditionally, pathogen susceptibility has been estimated using standardized in vitro tests that measure the minimal concentration that will inhibit pathogen growth (MIC). When using exposure-response relationships during drug development to explore dose optimization, these relationships can either be based upon an assessment of a correlation between clinical outcome, drug exposure at the infection site, and pathogen MIC, or upon benchmark exposure-response relationships (i.e., pharmacokinetic/pharmacodynamic indices) typically used for the various drug classes. When using the latter approach, it is essential that the unbound concentrations at the infection site be considered relative to the MIC within the biological matrix to which the pathogen will be exposed. For soft tissue infections, this typically is the unbound plasma concentrations versus MICs determined in standardized media such as cation-adjusted Mueller Hinton broth, which is how many indices were originally established. However, for UTIs, it is the unbound drug concentrations within the urine versus the MICs in the actual urine biophase that needs to be considered. The importance of these relationships and how they are influenced by drug resistance, resilience, and inoculum are discussed in this review using fluoroquinolones and beta-lactams as examples.
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Affiliation(s)
- Marilyn N Martinez
- Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Ron A Miller
- Division of Human Food Safety, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Tomás Martín-Jiménez
- Division of Scientific Support, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Michele J Sharkey
- Division of Companion Animal Drugs, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
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Asai N, Motojima S, Ohkuni Y, Matsunuma R, Nakashita T, Kaneko N, Mikamo H. Pathophysiological mechanism of non-HIV Pneumocystis jirovecii pneumonia. Respir Investig 2022; 60:522-530. [PMID: 35501264 DOI: 10.1016/j.resinv.2022.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/18/2022] [Accepted: 04/03/2022] [Indexed: 06/14/2023]
Abstract
While Pneumocystis jirovecii pneumonia (PCP) can occur in immunocompromised patients with HIV infection, the prognosis of non-HIV PCP is still poor, showing a high mortality rate of 30%-75%. The pathophysiological mechanism of non-HIV PCP is quite different from that of HIV-PCP. Aging, underlying disease, dysbiotic gut microbiome, and Th1 predominance, leads to macrophagic polarization shifting from M2 to M1. These cause dysregulation in the host immunity against P. jirovecii, resulting in severe lung injury and a high mortality rate among non-HIV PCP patients. This review describes poor prognostic factors, an issue of predictive values used for general pneumonia practice, and new aspects, including the dysbiosis of the gut microbiome and macrophagic polarization in the treatment of non-HIV PCP.
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Affiliation(s)
- Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan; Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Shinji Motojima
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Yoshihiro Ohkuni
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryo Matsunuma
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Tamao Nakashita
- Department of Rheumatology & Allergy, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Norihiro Kaneko
- Department of Pulmonology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Nagakute, Aichi, Japan.
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Ekstrand C, Nostell K, Gehring R, Bondesson U, Bröjer J. The disposition of trimethoprim and sulfadiazine in neonatal foals after intravenous administration. Vet Med Sci 2022; 8:1065-1071. [PMID: 35152563 PMCID: PMC9122441 DOI: 10.1002/vms3.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Septicaemia in the neonatal foal is caused by both Gram positive and Gram negative bacteria. The life‐threatening nature of this condition requires treatment to be initiated with broad spectrum antimicrobial drugs pending antimicrobial susceptibility testing. Potentiated sulphonamides, for example, trimethoprim combined with sulfadiazine, could be clinically relevant options but their pharmacokinetics in the neonatal foal are unknown. Objectives To describe the plasma disposition of trimethoprim and sulfadiazine in neonatal foals and to relate the results to patterns in the minimum inhibitory concentration (MIC) for Escherichia coli, a recognized pathogen in neonatal foal sepsis. Method A total of five doses of trimethoprim (2.5 mg/kg) and sulfadiazine (12.5 mg/kg) were administered intravenously every 12 h to eight neonatal foals that were 3 days old at inclusion. A non‐linear mixed effects model was fitted to the trimethoprim and sulfadiazine experimental data. The 24 h area under the free plasma trimethoprim and sulfadiazine concentration‐time curves (fAUC) and the pharmacokinetic/pharmacodynamik (PK/PD)‐index fAUC/MIC was calculated to evaluate the potential clinical benefits of the administered dose. Results For trimethoprim, the typical values were 1.99 L/kg, 0.33 L/h·kg and 4.2 h for the apparent volume of distribution, clearance and terminal half‐life, respectively. The 24 h fAUC for trimethoprim was 11.3 μg·h/ml (7.2–15.2) and the fAUC/MIC ratio for E. coli was 23 (16.4–29.2) (population mean (range)). For sulfadiazine, the typical values were 0.61 L/kg, 0.09 L/h·kg and 5.3 h for the apparent volume of distribution, clearance and terminal half‐life, respectively. The 24 h fAUC for sulfadiazine was 246.8 μg·h/ml (175.6–335.4). Conclusion For trimethoprim, the plasma exposure is insufficient in some foals to successfully treat bacterial infections with an MIC‐value of 0.5 μg/ml using the studied dosing regimen.
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Affiliation(s)
- Carl Ekstrand
- Department of Biomedical Sciences and Veterinary Public Health Division of Pharmacology and Toxicology Swedish University of Agricultural Sciences Uppsala Sweden
| | - Katarina Nostell
- Department of Clinical Sciences Swedish University of Agricultural Sciences Uppsala Sweden
| | - Ronette Gehring
- Department of Biomedical Sciences and Veterinary Public Health Division of Pharmacology and Toxicology Swedish University of Agricultural Sciences Uppsala Sweden
- Department of Population Health Sciences Division of Veterinary and Comparative Pharmacology Utrecht University Utrecht The Netherlands
| | - Ulf Bondesson
- Department of Chemistry Environment and Feed Hygiene National Veterinary Institute (SVA) Uppsala Sweden
| | - Johan Bröjer
- Department of Clinical Sciences Swedish University of Agricultural Sciences Uppsala Sweden
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