Sulfonamide Allergies

Impact of sulfonamide allergy label on clinical outcomes of acute cystitis: a retrospective matched cohort study

BACKGROUND

Cystitis is a common infection in an otherwise healthy individual. Sulfonamide antibiotics are first-line treatment options. Sulfonamide allergy label (SAL) is the second most common antibiotic allergy label in electronic health records, yet its impact on clinical outcomes in patients with cystitis is not well-characterised.

AIMS

The aim of this study is to characterise the impact of SAL on clinical outcomes of acute cystitis.

METHODS

In this retrospective matched cohort study utilising the TriNetX US Collaborative Network (Cambridge, MA, USA), adult patients with cystitis were categorised based on their SAL status. The 28-day risks of acute pyelonephritis and Clostridium difficile infection and the risk of recurrent or relapsed cystitis (defined as cystitis 15-28 days post-indexed cystitis) were contrasted. Antibiotic prescription practices within 14 days of the index cystitis were also compared.

RESULTS

When comparing 19 767 patients with cystitis and SAL to an equal number of matched controls, more patients with SAL had acute pyelonephritis (RR 1.27; 95% CI 1.08-1.48; P = 0.003; corrected P = 0.027) within 28 days of index. More patients with SAL developed recurrent/relapsed cystitis 15-28 days post-indexed cystitis (RR 1.19; 95% CI 1.08-1.31; P = 0.001; corrected P = 0.009) as compared to controls. SAL altered antibiotic prescription practices with under-utilisation of trimethoprim and sulfamethoxazole and increased utilisation of alternative antibiotics, including fluoroquinolones and nitrofurantoin, which was associated with an increased risk of Clostridium difficile infection.

CONCLUSIONS

SAL alters antibiotic prescription practices and is associated with a slightly increased risk of poor outcomes in adult patients with cystitis.

Trophic transfer of sulfonamide antibiotics in aquatic food chains: A comprehensive review with a focus on environmental health risks

Antibiotics, which have been identified as emerged pollutants, are creating an increase in environmental concerns, with sulfonamide antibiotics (SAs) being among the most commonly discovered antibiotics. Due to their widespread usage and inadequate sewage treatment, SAs are frequently released into the aquatic environment. The introduction of SAs into aquatic environments can kill or inhibit the growth or metabolic activity of microorganisms, thereby affecting biological communities and ecological functions and disrupting the equilibrium of aquatic ecosystems. The transmission of SAs to human beings can occur through trophic transfer of food chains, particularly when humans consume aquatic food. This study examines the trophic transfer of SAs along the aquatic food chain, provides a summarize of the spatial distribution of SAs in aquatic environments, and evaluates the environmental risks associated with it. The prevalence of SAs was predominantly noted in the aqueous phase, with relatively lower concentrations detected in sediments, solidifying their status as one of the most widespread antibiotics among aquatic organisms. SAs, characterized by their high biomagnification capacity and strong bioaccumulative properties in invertebrates, emerge as the antibiotic type with the greatest ecological risks. The ecological risk posed by sulfonamide antibiotics to aquatic organisms is more pronounced than the health risk to humans, suggesting that the adverse effects on aquatic life warrant greater attention. Additionally, this study offers practical recommendations to address the limitations of previous research, emphasizing the importance of regulating exposure and establishing a robust health risk prediction system as effective measures for antibiotic control.

Cefiderocol for the Treatment of Nosocomial Bloodstream Infections Caused by Stenotrophomonas maltophilia: A Case Series and Literature Review

INTRODUCTION

The treatment of Stenotrophomonas maltophilia bloodstream infections (BSI) remains challenging due to the organism's intrinsic multidrug resistance and the potential side effects of commonly used first-line antibiotics.

METHODS

Here, we describe four cases of S. maltophilia BSI treated with cefiderocol (≥ 72 h) in different Italian hospitals. Additionally, we conducted a PubMed search to identify other studies reporting cases of S. maltophilia BSI managed with cefiderocol.

RESULTS

We reviewed a total of 8 cases of S. maltophilia BSI [median age 52.5 years (Q1-Q3 27.5-61.0), 50% males] treated with cefiderocol, including ours. BSI sources were mainly central venous catheters (62.5%) and the lower respiratory tract (25.0%). Cefiderocol was used as first-line therapy in 87.5% of patients (7/8), with a median treatment duration of 14 days (IQR 6.2-16.0). Combination therapy was administered in 62.5% of cases. Infection source control was required in 75.0% and achieved in 40.0%. Clinical success was observed in 62.5% of patients, with microbiological eradication in 87.5%. In-hospital mortality occurred in 37.5% of cases, with one death directly attributable to S. maltophilia. No significant differences were observed in terms of outcomes between cefiderocol monotherapy and combination therapy.

CONCLUSIONS

Based on our findings and a review of the literature, cefiderocol-based regimens show promise as an effective treatment option for S. maltophilia BSI, warranting further investigation in larger studies.

α-Galactose Syndrome Cases within the Prisma Health System, South Carolina

OBJECTIVES

Humans can develop a vector-associated allergy to galactose-α-1,3-galactose (α-gal) a polysaccharide found in mammalian meats and by-products, resulting in α-gal syndrome (AGS). Amblyomma americanum tick bites have been implicated in AGS development in the United States, but the AGS clinical burden in South Carolina is not well understood. Because A. americanum is the predominant tick species in the state and large AGS cohorts exist in neighboring states, the potential for AGS clinical cases in South Carolina exists. Increased understanding of high-incidence geographical clusters is critical for clinical and public education given the potential for severe anaphylaxis.

METHODS

We conducted a 5-year retrospective chart abstraction of AGS patient cases serologically confirmed within the state's largest healthcare system to characterize this condition in South Carolina's Upstate and Midlands regions.

RESULTS

From October 2017 to February 2023, 50 patients were serologically diagnosed as having AGS within the Prisma Health system. Cohort demographics were mostly older, White males, and Black patients were significantly underrepresented in the AGS caseload (P = 0.0004). Immunosuppressing comorbidities and cooccurring allergies were common.

CONCLUSIONS

This article presents the first clinical AGS case series in South Carolina, warranting further clinical and public education and a need for continued clinical research on this emerging tick-associated condition.

Prescribing carbonic anhydrase inhibitors to patients with "sulfa" antibiotics allergy: do we dare?

OBJECTIVE

To evaluate if provider characteristics affect attitude toward carbonic anhydrase inhibitors (CAI) prescription for patients with history of sulfonamide antibiotic (SA) hypersensitivity.

METHODS

A survey querying providers' attitudes toward CAI prescription in hypothetical patients with prior SA hypersensitivity was distributed to four ophthalmology and optometry organizations. Logistic regression was used to assess the relationship between avoiding CAI and profession, specialty, organizational affiliation, and years in practice.

RESULTS

Of 250 respondents, 27% and 52% would avoid topical and oral CAI, respectively, in patients with prior SA rash and/or urticaria. >90% would avoid oral CAI in patients with prior severe SA hypersensitivity. Respondents with >10 years in practice were more likely to avoid oral CAI in patients with prior SA rash and/or urticaria than those with ≤10 (OR 2.27, p = 0.002). Respondents affiliated with non-glaucoma organizations were more likely to avoid oral CAI in patients with prior SA rash and/or urticaria than those affiliated with glaucoma organizations (p = 0.03). Providers without glaucoma training were more likely to avoid topical CAI in patients with prior SA rash and/or urticaria (p = 0.004) and anaphylaxis (p = 0.01) than glaucoma-trained providers.

CONCLUSIONS

Despite no supporting evidence, a significant number of respondents would avoid CAI in patients with prior SA hypersensitivity. Respondents without glaucoma training, no affiliation with a glaucoma organization, and >10 years in practice are more likely to avoid CAI in patients with type I SA hypersensitivity. Providers should be informed of the low cross-reactivity risk between CAI and SA so more patients may benefit from these drugs.

Anaphylaxis to Oral Trimethoprim-Sulfamethoxazole in a Child: A Case Report

Trimethoprim-sulfamethoxazole (TMP-SMX) is a non-β-lactam antibiotic commonly used in pediatrics to treat infections and as a prophylactic medication. Hypersensitivity to TMP-SMX is generally non-immediate, and immediate allergic reactions, including anaphylaxis, are rare. This case report details a six-year-old girl who experienced anaphylaxis to TMP-SMX. Her skin prick test with TMP-SMX was negative, but she developed anaphylaxis in a drug provocation test (DPT). An additional basophil activation test (BAT) for the TMP-SMX combination tablet was evaluated and was confirmed positive. This case underscores the need for alternative diagnostic methods like BAT, which pose a lower risk than DPT. The findings suggest that BAT could offer a safer diagnostic approach, though more studies are required to validate its use for TMP-SMX allergy diagnosis.

Probenecid as a pharmacotherapy for alcohol use disorder: A randomized placebo-controlled alcohol interaction trial

BACKGROUND

This study shows the first evidence for pannexin 1 channels as a new target to develop medications for alcohol use disorder (AUD). Due to its history of long-term safe clinical use and preclinical evidence of reducing excessive alcohol intake in rodents, probenecid has clinical potential for AUD.

METHODS

We conducted a Phase I/IIa randomized, double-blind, placebo-controlled, crossover trial investigating the safety, tolerability, and efficacy of an oral dose of probenecid (2 g) when administered with alcohol (0.08 g/dL) in individuals who regularly consume alcohol to the 0.08 g/dL level (N = 35) and in individuals with mild to severe AUD. Alcohol pharmacokinetics and subjective responses were evaluated to assess potential interactions between probenecid and alcohol. Alcohol craving, inflammatory biomarkers, cognitive assessments, and hemodynamics were assessed as additional alcohol research domains. All outcomes were assessed both in the ascending and descending limb of alcohol intoxication using Generalized Estimating Equation.

RESULTS

Probenecid did not exert any significant effect on alcohol pharmacokinetics and did not affect alcohol stimulation or sedation. Probenecid, compared to placebo, significantly decreased alcohol craving during the alcohol ascending limb. Inflammatory biomarkers, cognitive performance following alcohol ingestion, and hemodynamics were likewise not affected by probenecid administration. Analysis of sex as a biological variable revealed no differences of probenecid compared to placebo.

CONCLUSIONS

Taken together, our data support the potential of probenecid for treatment of AUD and suggest that pannexin 1 channels represent a novel emerging therapeutic target for the development of new pharmacotherapies for treating AUD.

An isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS)-based candidate reference measurement procedure for the quantification of zonisamide in human serum and plasma

OBJECTIVES

To describe and validate an isotope dilution-liquid chromatograph-tandem mass spectrometry (ID-LC-MS/MS) based reference measurement procedure (RMP) for zonisamide to accurately measure serum and plasma concentrations.

METHODS

Quantitative nuclear magnetic resonance (qNMR) spectroscopy was employed to determine the absolute content of the reference material used in order to establish traceability to SI units. Separation of zonisamide from known or unknown interferences was performed on a C8 column. For sample preparation a protocol based on protein precipitation in combination with a high dilution step was established. Assay validation and determination of measurement uncertainty were performed based on guidelines from the Clinical and Laboratory Standards Institute, the International Conference on Harmonization, and the Guide to the expression of uncertainty in measurement.

RESULTS

The RMP was proven to be highly selective and specific with no evidence of a matrix effect, allowing for quantification of zonisamide within the range of 1.50-60.0 μg/mL. Intermediate precision was <1.4 % and repeatability CV ranged from 0.7 to 1.2 % over all concentration levels. The relative mean bias ranged from 0.0 to 0.8 % for native serum levels and from 0.2 to 2.0 % for Li-heparin plasma levels. The measurement uncertainties for single measurements and target value assignment ranged from 1.1 to 1.4 % and 0.8-1.0 %, respectively.

CONCLUSIONS

We present a novel LC-MS/MS-based candidate RMP for zonisamide in human serum and plasma which provides a traceable and reliable platform for the standardization of routine assays and evaluation of clinically relevant samples.

Unveiling sultam in drug discovery: spotlight on the underexplored scaffold

Decades ago, the application of cyclic sulfonamide (sultam) and its derivatives primarily focused on their antibacterial properties. However, recent years have seen a shift in research attention towards exploring their potential as anticancer, anti-inflammatory, antidiabetic, and antiviral agents. Despite this broadening scope, only a few sultam drugs have made it to the commercial market, as much of the research on sultams remains in the discovery phase. This class of compounds holds significant promise and remains pertinent in pharmaceutical research. Due to sultam's relevance and growing importance in drug discovery, this review paper aims to consolidate and examine the biological activities of sultam derivatives ranging from 4 to 8-membered ring structures.

Impact of Sulfonamide Allergy Label on Clinical Outcomes in Patients with Pneumocystis jirovecii Pneumonia

INTRODUCTION

The presence of antibiotic allergy labels can have harmful impacts on clinical outcomes, particularly among immunosuppressed patients, in whom there have been associations with increased complications, readmission rates, and mortality. We explore the effects of a sulfonamide allergy label (SAL) on clinical outcomes in adult patients with Pneumocystis jirovecii pneumonia (PJP).

METHODS

In this retrospective matched cohort study, we utilized TriNetX, a multicenter national database, to match 535 adult patients with PJP and SAL to an equal number of controls. We identified cases indexed between 01/01/2010 and 01/01/2023 utilizing ICD-10 codes for PJP and allergy status to sulfonamides and through detection of P. jirovecii antigen with immunofluorescence or PCR. Propensity score matching was performed in a 1:1 fashion for demographics and comorbidities, and our analysis included clinical outcomes that occurred within 30 days after the occurrence of the index event.

RESULTS

While hospitalization risk tended to be lower among patients with SAL as compared to controls (RR: 0.90; 95% CI 0.81-1.01), there were no major differences in the risk of respiratory failure (RR: 0.94; 95% CI 0.84-1.05), prednisone use (RR: 1; 95% CI 0.91-1.10), intensive level of care requirement (RR: 0.85; 95% CI 0.69-1.06), intubation (RR: 0.85; 95% CI 0.61-1.19), or mortality (RR: 0.98; 95% CI 0.68-1.42). The presence of SAL did however impact antibiotic prescription patterns, with an underutilization of trimethoprim (RR: 0.50; 95% CI 0.43-0.59) and sulfamethoxazole (RR, 0.47; 95% CI 0.40-0.56) and overuse of alternative agents by patients with SAL as compared to controls. Yet, there was no difference in the occurrence of adverse outcomes such as hepatotoxicity (RR: 1.09; 95% CI 0.49-2.45) or acute kidney injury (RR: 0.94; 95% CI 0.78-1.14) between patients with SAL and controls.

CONCLUSIONS

The presence of SAL alters antibiotic prescription patterns among adults with Pneumocystis infection but has no clinically significant impact on outcomes.

Analysis of Allergy and Hypersensitivity Reactions to COVID-19 Vaccines According to the EudraVigilance Database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic presented a new challenge in modern medicine: the development of vaccines was followed by massive population vaccinations. A few reports on post-vaccination allergic reactions have made patients and medical personnel uneasy as to COVID-19 vaccines' allergic potential. Most of the studies in this area to date have been small, and some that were based on global databases skipped most of the allergic diseases and concentrated only on anaphylaxis. We aimed to analyze the incidence of serious allergic reactions based on the EudraVigilance (EV) database, regardless of the reported symptoms and allergy mechanism.

METHODS

The total number of administrated vaccine doses was extracted on 5 October 2023 from Vaccine Tracker and included all administrations since vaccinations began in the European Economic Area (EEA). Data on serious allergic reactions to COVID-19 vaccines were extracted from the EudraVigilance database with the same time point. The code names of 147 allergic symptoms or diseases were used.

RESULTS

The frequency of serious allergic reactions per 100,000 administered vaccine doses was 1.53 for Comirnaty, 2.16 for Spikevax, 88.6 for Vaxzevria, 2.11 for Janssen, 7.9 for Novavax, 13.3 for VidPrevtyn Beta, and 3.1 for Valneva. The most prevalent reported reactions were edema (0.46) and anaphylaxis (0.40). Only 6% of these reactions were delayed hypersensitivity-oriented.

CONCLUSIONS

The overall frequency of potential serious allergic reactions to COVID-19 is very rare. Therefore, COVID-19 vaccines seem to be safe for human use. The lowest frequency of allergic reaction was observed for Comirnaty and the highest for Vaxzevria.

How to Define and Manage Low-Risk Drug Allergy Labels

Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.

A Comprehensive Review of Sulfonamide Hypersensitivity: Implications for Clinical Practice

Sulfonamides, which are drugs commonly prescribed in hospital and outpatient settings, have historically been associated with a high incidence of hypersensitivity reactions. It is believed that there is an increased risk of cross-reactions with other drugs that contain this functional group in their structure. However, it has not been conclusively established that the sulfonamide group is the sole cause of hypersensitivity reactions, as non-antibiotic sulfonamides do not share the same accessory groups with antibiotic sulfonamides. Therefore, cross-reactivity between different types of sulfonamides and sulfonamide-type antibiotics is not clearly demonstrated, and allergic reactions may involve other mechanisms. Misinformation about this topic can lead to inappropriate use of alternative antibiotics with lower efficacy or higher adverse effects, contributing to antibiotic resistance. It is crucial to individualize and monitor patients with a history of allergies to sulfonamide-type antibiotics when introducing a new drug containing sulfa and manage any adverse reactions promptly. Desensitization protocols may be a viable option for patients who specifically benefit from these antibiotics, particularly those who are immunosuppressed. This article provides a descriptive bibliographic review to update information on sulfa allergy, its prevalence, management, and recommendations to prevent such reactions and optimize pharmacotherapy, without underusing these drugs.

ROCK Inhibitors in Corneal Diseases and Glaucoma-A Comprehensive Review of These Emerging Drugs

Rho kinase (ROCK) inhibitors have gained significant attention as emerging novel treatment options in the field of ophthalmology in recent years. The evidence supporting their efficacy in glaucoma and corneal pathology includes both in vitro and clinical studies. Among the available options, ripasudil and netarsudil have emerged as the leading ROCK inhibitors, and some countries have approved these therapeutic options as treatments for glaucoma. Various dosing regimens have been studied, including monotherapy and combination therapy, especially for patients with secondary glaucoma who are already on multiple medications. Another rising application of ROCK inhibitors includes their use as an adjunct in surgical procedures such as Descemetorhexis Without Endothelial Keratoplasty (DWEK), Descemet Stripping Only (DSO) to accelerate visual recovery, glaucoma surgeries to reduce scarring process and allow better intraocular pressure (IOP) control, or after complicated anterior segment surgery to treat corneal oedema. This article provides a comprehensive overview of the existing literature in the field, offering recommendations for prescribing ROCK inhibitors and also discussing patient selection, drug efficacy, and possible adverse effects.

Management and Mitigation of Vibriosis in Aquaculture: Nanoparticles as Promising Alternatives

Vibriosis is one of the most common diseases in marine aquaculture, caused by bacteria belonging to the genus Vibrio, that has been affecting many species of economically significant aquatic organisms around the world. The prevention of vibriosis in aquaculture is difficult, and the various treatments for vibriosis have their limitations. Therefore, there is an imperative need to find new alternatives. This review is based on the studies on vibriosis, specifically on the various treatments and their limitations, as well as the application of nanoparticles in aquaculture. One of the promising nanoparticles is graphene oxide (GO), which has been used in various applications, particularly in biological applications such as biosensors, drug delivery, and potential treatment for infectious diseases. GO has been shown to have anti-bacterial properties against both Gram-positive and Gram-negative bacteria, but no research has been published that emphasizes its impact on Vibrio spp. The review aims to explore the potential use of GO for treatment against vibriosis.

[Drug allergy: Fundamental aspects in diagnosis and treatment.]

BACKGROUND

Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms.

OBJECTIVES

To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis.

METHODS

A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups.

RESULTS

This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events.

CONCLUSION

ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.

Antibiotics and Bacterial Resistance-A Short Story of an Endless Arms Race

Despite the undisputed development of medicine, antibiotics still serve as first-choice drugs for patients with infectious disorders. The widespread use of antibiotics results from a wide spectrum of their actions encompassing mechanisms responsible for: the inhibition of bacterial cell wall biosynthesis, the disruption of cell membrane integrity, the suppression of nucleic acids and/or proteins synthesis, as well as disturbances of metabolic processes. However, the widespread availability of antibiotics, accompanied by their overprescription, acts as a double-edged sword, since the overuse and/or misuse of antibiotics leads to a growing number of multidrug-resistant microbes. This, in turn, has recently emerged as a global public health challenge facing both clinicians and their patients. In addition to intrinsic resistance, bacteria can acquire resistance to particular antimicrobial agents through the transfer of genetic material conferring resistance. Amongst the most common bacterial resistance strategies are: drug target site changes, increased cell wall permeability to antibiotics, antibiotic inactivation, and efflux pumps. A better understanding of the interplay between the mechanisms of antibiotic actions and bacterial defense strategies against particular antimicrobial agents is crucial for developing new drugs or drug combinations. Herein, we provide a brief overview of the current nanomedicine-based strategies that aim to improve the efficacy of antibiotics.

Incidence of Allergic Drug Eruption due to Cotrimoxazole in HIV-Positive Individuals with CD4 ≤200 Cells/ul

Allergic drug eruptions (ADE) remain a challenge in people living with HIV (PLWH), requiring more studies to guide clinical approaches. While cotrimoxazole is widely used as prophylaxis in PLWH, relationship between client characteristics toward the occurrence of cotrimoxazole ADEs is still poorly understood.A retrospective cohort study followed PLWH initiated with antiretroviral therapy (ART) in St. Carolus Hospital between January 2009 to December 2021. ADE occurrence due to cotrimoxazole were tested for significance using Pearson's Chi-square and Fisher's Exact Test (significant outcome measured as p < 0.05) against CD4 levels at very low (0-100 cells/ul) and low (101-200 cells/ul) groups, comorbidities, and retention status.Cotrimoxazole-related ADEs occurred in 258 (14%) of 1789 subjects with CD4 levels ≤200 cells/ul. Comorbidities of Hepatitis B, Hepatitis C, and M. tuberculosis infections were found in 11, 4, and 95 subjects respectively. 151 (59%) of ADE group had very low CD4 levels (p value > 0.05). No significant difference was found in ADE incidence between age groups, genders, CD4 levels, comorbidities, and ART retention.Cotrimoxazole-induced ADE is unrelated to CD4 levels, and ART retention was not affected. ADE severity ranges from mild to serious manifestations, and close monitoring is crucial to ensure ADEs are treated ART are well-maintained.

Soluble chitosan derivative treats wound infections and promotes wound healing in a novel MRSA-infected porcine partial-thickness burn wound model

Burns are physically debilitating and potentially fatal injuries. The most common etiology of burn wound infections in the US is methicillin-resistant Staphylococcus aureus (MRSA), which is particularly recalcitrant when biofilms form. The current standard of care, silver sulfadiazine (SSD) is effective in reducing bacterial load, but less effective in improving burn wound healing. New treatments that can manage infection while simultaneously improving healing would provide a benefit in the treatment of burns. Porcine models are frequently used as a model for human wound healing but can be expensive due to the need to separate wounds to avoid cross contamination. The porcine model developed in this study offers the capability to study multiple partial thickness burn wound (PTBW) sites on a single animal with minimal crosstalk to study wound healing, infection, and inflammation. The current study evaluates a wound rinse and a wound gel formulated with a non-toxic, polycationic chitosan derivative that is hypothesized to manage infection while also promoting healing, providing a potential alternate to SSD. Studies in vitro and in this PTBW porcine model compare treatment with the chitosan derivative formulations to SSD. The wound rinse and wound gel are observed to disrupt mature MRSA biofilms in vitro and reduce the MRSA load in vivo when compared to that of the standard of care. In vivo data further show increased re-epithelialization and faster healing in burns treated with wound rinse/gel as compared to SSD. Taken together, the data demonstrate the potential of the wound rinse/gel to significantly enhance healing, promote re-epithelialization, and reduce bacterial burden in infected PTBW using an economical porcine model.

Feasibility of trimethoprim/sulfamethoxazole desensitization therapy in hematological diseases

The effectiveness and safety of trimethoprim/sulfamethoxazole (TMP/SMX) desensitization therapy is insufficiently evaluated in hematological diseases. From 2002 to 2019, we retrospectively analyzed 112 patients with hematological diseases who underwent desensitization therapy after TMP/SMX prophylaxis withdrawal due to adverse events. They orally started TMP/SMX at 0.4 mg/2 mg, which was then increased daily to 80 mg/400 mg for 5 or 9 days. Eighty-eight patients (79%) had complete desensitization, and the major reason for failure was rash seen in 21 cases (19%). The cause of desensitization and reasons for failure matched in 22 cases (92%). Pneumocystis pneumonia was not observed throughout the study. In the failure group, the number of eosinophils and alanine aminotransferase (ALT) levels were significantly increased after desensitization. In particular in the failure group, the slight increase in eosinophils was seen through the beginning to halfway during desensitization (36/μL (0-900/μL) and 48/μL (0-2560/μL), respectively, p = 0.025). These data show that TMP/SMX desensitization therapy is effective and safe in hematological diseases. The recurrence of adverse events could help predict desensitization success.

Antibiotic Prescribing Patterns and Guideline Concordance for Uncomplicated Urinary Tract Infections Among Adult Women in the US Military Health System

IMPORTANCE

Urinary tract infections (UTIs) are one of the most commonly diagnosed infections, and prior studies have reported discordance in antibiotic treatment with the Infectious Diseases Society of America (IDSA) guidelines.

OBJECTIVE

To assess IDSA guideline concordance rates for women with uncomplicated UTIs treated with antibiotics, and compare concordance rates between different specialty field.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cross-sectional study of health care claims data from the US Military Health System Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries. Participants were adult women between the ages of 18 to 50 years with uncomplicated UTIs from October 1, 2017, to September 30, 2019. Data extraction and analysis were performed in 2022. Patients with diagnosis of UTI in the preceding 6 months, current pregnancy, history of pyelonephritis, history of diabetes, history of organ transplant, history of human immunodeficiency virus, immunosuppression, renal insufficiency, urinary tract abnormalities, or history of urologic procedures were excluded.

EXPOSURES

Antibiotic treatment for uncomplicated UTIs. Only antibiotics received within 1 day after the diagnosis were analyzed. The IDSA recommends the following antibiotics as first-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, pivmecillinam.

MAIN OUTCOMES AND MEASURES

The IDSA guideline concordance rates were calculated as the number of patients receiving first-line antibiotic therapy divided by the total number of cases for uncomplicated UTIs.

RESULTS

A total of 46 793 adult women (67.3% [31 475 of 46 793] aged 18-34 years; 38.2% [31 475 of 46 793] of White race) were diagnosed with uncomplicated UTIs with 91.0% receiving guideline-concordant antibiotic treatment. In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Compared with direct military care, private sector care had lower concordance rates (aOR, 0.63; 95% CI, 0.62-0.64).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of antibiotic treatments for uncomplicated UTIs in a universally insured population, the IDSA guideline-concordance rate was high at 91.0% with higher rates in direct military care compared with private sector care. There were higher rates in general medical specialties, surgery, and emergency medicine and lower rates in urology and obstetrics and gynecology. These results further enhance the literature on current antibiotic prescribing practices for uncomplicated UTIs in adult women.

Clinical Manifestations and Genetic Influences in Sulfonamide-Induced Hypersensitivity

Drug hypersensitivity is an inflammatory or immune reaction induced by drugs. It can be fatal if not appropriately treated and cause the risk of long-term complications. Sulfonamides are classified as antimicrobial drugs with a broad spectrum effective for gram-positive and gram-negative bacteria. This antibacterial agent works by competitively inhibiting folic acid synthesis, which prevents the growth and proliferation of microorganisms. In its use as antibiotics, sulfonamides can also cause adverse reactions in specific individuals. It has been widely reported that sulfonamide antimicrobials cause hypersensitivity reactions mediated by IgE or T cells. This review identifies symptoms or signs that can appear, as well as genes associated with sulfonamide hypersensitivity reactions, as sulfonamide may cause hypersensitivity in the form of uveitis, skin rash, Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), parotitis, angioedema, drug reaction with eosinophilia and systemic symptoms (DRESS), and pruritus. In addition, several genes were found to be associated with sulfonamide hypersensitivity, including HLA-A29, HLA-B12, HLA-DR7, HLA-B44, and HLA A*11:01.

Characterization of Stenotrophomonas maltophilia phage AXL1 as a member of the genus Pamexvirus encoding resistance to trimethoprim-sulfamethoxazole

Stenotrophomonas maltophilia is a ubiquitous environmental bacterium capable of causing disease in humans. Antibiotics are largely ineffective against this pathogen due to numerous chromosomally encoded antibiotic resistance mechanisms. An alternative treatment option is phage therapy, the use of bacteriophages to selectively kill target bacteria that are causing infection. To this aim, we isolated the Siphoviridae bacteriophage AXL1 (vB_SmaS-AXL_1) from soil and herein describe its characterization. Host range analysis on a panel of 30 clinical S. maltophilia strains reveals a moderate tropism that includes cross-species infection of Xanthomonas, with AXL1 using the type IV pilus as its host surface receptor for infection. Complete genome sequencing and analysis revealed a 63,962 bp genome encoding 83 putative proteins. Comparative genomics place AXL1 in the genus Pamexvirus, along with seven other phages that infect one of Stenotrophomonas, Pseudomonas or Xanthomonas species. Functional genomic analyses identified an AXL1-encoded dihydrofolate reductase enzyme that provides additional resistance to the antibiotic combination trimethoprim-sulfamethoxazole, the current recommended treatment option for S. maltophilia infections. This research characterizes the sixth type IV pilus-binding phage of S. maltophilia and is an example of phage-encoded antibiotic resistance.

Uracil as a Zn-Binding Bioisostere of the Allergic Benzenesulfonamide in the Design of Quinoline-Uracil Hybrids as Anticancer Carbonic Anhydrase Inhibitors

A series of quinoline-uracil hybrids (10a-l) has been rationalized and synthesized. The inhibitory activity against hCA isoforms I, II, IX, and XII was explored. Compounds 10a-l demonstrated powerful inhibitory activity against all tested hCA isoforms. Compound 10h displayed the best selectivity profile with good activity. Compound 10d displayed the best activity profile with minimal selectivity. Compound 10l emerged as the best congener considering both activity (IC50 = 140 and 190 nM for hCA IX and hCA XII, respectively) and selectivity (S.I. = 13.20 and 9.75 for II/IX, and II/XII, respectively). The most active hybrids were assayed for antiproliferative and pro-apoptotic activities against MCF-7 and A549. In silico studies, molecular docking, physicochemical parameters, and ADMET analysis were performed to explain the acquired CA inhibitory action of all hybrids. A study of the structure-activity relationship revealed that bulky substituents at uracil N-1 were unfavored for activity while substituted quinoline and thiouracil were effective for selectivity.

Trimethoprim-sulfamethoxazole induced eosinophilic pneumonia: A case report

We report herein a case of trimethoprim-sulfamethoxazole (TMP-SMX) induced eosinophilic pneumonia in a 27-year-old woman with radiological features of bilateral nonsegmental airspace consolidation resembling cryptogenic organizing pneumonia at the peripheral lung fields. Organizing pneumonia with eosinophil infiltration in the lung specimens and marked eosinophilia in the peripheral blood and bronchoalveolar lavage fluid were observed. Discontinuation of TMP-SMX improved eosinophilia and radiological abnormality, which confirmed the association between the use of TMP-SMX and onset of eosinophilic pneumonia. Although TMP-SMX induced eosinophilic pneumonia is not common, clinician should be aware that drug-induced eosinophilic pneumonia could happen during the course of TMP-SMX administration.

VG, Kadri SS. Trimethoprim-Sulfamethoxazole versus Levofloxacin for Stenotrophomonas maltophilia Infections: A Retrospective Comparative Effectiveness Study of Electronic Health Records from 154 U.S. Hospitals

Background

Trimethoprim-sulfamethoxazole (TMP-SMX) is considered first-line therapy for Stenotrophomonas maltophilia infections based on observational data from small studies. Levofloxacin has emerged as a popular alternative due to tolerability concerns related to TMP-SMX. Data comparing levofloxacin to TMP-SMX as targeted therapy are lacking.

Methods

Adult inpatient encounters January 2005 through December 2017 with growth of S maltophilia in blood and/or lower respiratory cultures were identified in the Cerner Healthfacts database. Patients included received targeted therapy with either levofloxacin or TMP-SMX. Overlap weighting was used followed by downstream weighted regression. The primary outcome was adjusted odds ratio (aOR) for in-hospital mortality or discharge to hospice. The secondary outcome was number of days from index S maltophilia culture to hospital discharge.

Results

Among 1581 patients with S maltophilia infections, levofloxacin (n = 823) displayed statistically similar mortality risk (aOR, 0.76 [95% confidence interval {CI}, .58–1.01]; P = .06) compared to TMP-SMX (n = 758). Levofloxacin (vs TMP-SMX) use was associated with a lower aOR of death in patients with lower respiratory tract infection (n = 1452) (aOR, 0.73 [95% CI, .54–.98]; P = .03) and if initiated empirically (n = 89) (aOR, 0.16 [95% CI, .03–.95]; P = .04). The levofloxacin cohort had fewer hospital days between index culture collection and discharge (weighted median [interquartile range], 7 [4–13] vs 9 [6–16] days; P < .0001).

Conclusions

Based on observational evidence, levofloxacin is a reasonable alternative to TMP-SMX for the treatment of bloodstream and lower respiratory tract infections caused by S maltophilia.

Current prescribing practices and guideline concordance for the treatment of uncomplicated urinary tract infections in women

BACKGROUND

Uncomplicated urinary tract infections are one of the most common bacterial infections in the United States. Clinical practice guidelines from the Infectious Diseases Society of America recommend nitrofurantoin, trimethoprim-sulfamethoxazole, and Fosfomycin as first-line antibiotic treatments and discourage the use of fluoroquinolone antibiotic agents. US Food and Drug Administration released several black box warnings about fluoroquinolones over the past decade owing to antibiotic resistance and a high burden of adverse events. Historically, uncomplicated urinary tract infections have high rates of guideline-discordant treatment with past studies noting substantial use of fluoroquinolones, directly contradicting clinical practice guidelines.

OBJECTIVE

This study aimed to assess the current concordance of physician prescribing practices with Infectious Diseases Society of America guidelines for the treatment of uncomplicated urinary tract infections in women and identify patient and physician predictors of guideline concordance.

STUDY DESIGN

A retrospective observational secondary analysis was conducted using a series of cross-sectional data extracted from the IQVIA (Plymouth Meeting, Pennsylvania) National Disease and Therapeutic Index from 2015 to 2019. An estimated 44.9 million women with uncomplicated urinary tract infections at the age of 18 to 75 years were treated as outpatients. This population was selected to lack relevant comorbidities or urological abnormalities so that it matched the Infectious Diseases Society of America guidelines. The proportion of prescriptions for each antibiotic drug class were reported with 95% confidence intervals and compared with the Infectious Diseases Society of America guidelines. Patient and physician characteristics were included in a multivariate logistic regression model to identify independent predictors of antibiotic selection and thereby guideline concordance.

RESULTS

Of the visits that resulted in antibiotic treatment, the overall concordance rate was 58.4% (26.2 million visits of 44.9 million visits) and increased from 48.2% (3.9 million visits of 8.1 million visits) in 2015 to 64.6% (6.3 million visits of 9.8 million visits) in 2019. The most commonly prescribed antibiotic agents were fluoroquinolones (36.4%, 16.3 million visits of 44.9 million visits), nitrofurantoin (31.8%, 14.3 million visits of 44.9 million visits), and trimethoprim-sulfamethoxazole (26.3%, 11.8 million visits of 44.9 million visits). From 2015 to 2019, fluoroquinolone use decreased whereas nitrofurantoin and beta-lactam use increased. Based on the logistic regression, patients aged 18 to 29 years (odds ratio, 1.60; 95% confidence interval, 1.36-1.88; P<.001) and 30 to 44 years (odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P=.020) had a statistically significantly higher likelihood of receiving guideline-concordant treatment than patients aged 45 to 75 years (reference group). Obstetricians-gynecologists (odds ratio, 3.56; 95% confidence interval, 2.91-4.37; P<.001) and urologists (odds ratio, 3.51; 95% confidence interval, 2.45-5.13; P<.001) had a statistically significantly higher likelihood of concordant treatment than all other specialties combined (reference group).

CONCLUSION

Guideline discordance continues in the treatment of uncomplicated urinary tract infections with the overuse of fluoroquinolones and the underuse of first-line antibiotic agents. Although improving, continued misuse of antibiotic agents may contribute to the growing rates of antibiotic resistance. Actions such as educating physicians about antibiotic resistance and clinical practice guidelines and providing feedback on prescription habits are needed to increase guideline concordance and therefore reduce the use of fluoroquinolones, especially for physicians in family and internal medicine.

Benzofuran sulfonates and small self-lipid antigens activate type II NKT cells via CD1d

Natural killer T (NKT) cells detect lipids presented by CD1d. Most studies focus on type I NKT cells that express semi-invariant αβ T cell receptors (TCR) and recognize α-galactosylceramides. However, CD1d also presents structurally distinct lipids to NKT cells expressing diverse TCRs (type II NKT cells), but our knowledge of the antigens for type II NKT cells is limited. An early study identified a nonlipidic NKT cell agonist, phenyl pentamethyldihydrobenzofuransulfonate (PPBF), which is notable for its similarity to common sulfa drugs, but its mechanism of NKT cell activation remained unknown. Here, we demonstrate that a range of pentamethylbenzofuransulfonates (PBFs), including PPBF, activate polyclonal type II NKT cells from human donors. Whereas these sulfa drug-like molecules might have acted pharmacologically on cells, here we demonstrate direct contact between TCRs and PBF-treated CD1d complexes. Further, PBF-treated CD1d tetramers identified type II NKT cell populations expressing αβTCRs and γδTCRs, including those with variable and joining region gene usage (TRAV12-1-TRAJ6) that was conserved across donors. By trapping a CD1d-type II NKT TCR complex for direct mass-spectrometric analysis, we detected molecules that allow the binding of CD1d to TCRs, finding that both selected PBF family members and short-chain sphingomyelin lipids are present in these complexes. Furthermore, the combination of PPBF and short-chain sphingomyelin enhances CD1d tetramer staining of PPBF-reactive T cell lines over either molecule alone. This study demonstrates that nonlipidic small molecules, which resemble sulfa drugs implicated in systemic hypersensitivity and drug allergy reactions, are targeted by a polyclonal population of type II NKT cells in a CD1d-restricted manner.

[Acute angle-closure glaucoma and effusion syndrome after phacoemulsification]

A 72-year-old female patient developed bilateral secondary iridocorneal angle-closure glaucoma with uveal effusion syndrome after uncomplicated cataract surgery. The postoperative intake of acetazolamide was identified as causative for the development of the effusion syndrome. Taking a sulfonamide-free systemic and local intraocular pressure lowering and anti-inflammatory treatment into account, a rapid improvement of the ocular manifestation was achieved. The case illustrates a rare but clinically severe adverse effect of acetazolamide and outlines efficient treatment options.

A review of bismuth-based photocatalysts for antibiotic degradation: Insight into the photocatalytic degradation performance, pathways and relevant mechanisms

The intensive production and utilization of antibiotics worldwide has inevitably led to releases of very large amounts of these medicines into the environment, and numerous strategies have recently been developed to eliminate antibiotic pollution. Therefore, bismuth-based photocatalysts have attracted much attention due to their high adsorption of visible light and low production cost. This review summarizes the performance, degradation pathways and relevant mechanisms of typical antibiotics during bismuth-based photocatalytic degradation. First, the band gap and redox ability of the bismuth-based catalysts and modified materials (such as morphology, structure mediation, heterojunction construction and element doping) were compared and evaluated. Second, the performance and potential mechanisms of bismuth oxides, bismuth sulfides, bismuth oxyhalides and bismuth-based metal oxides for antibiotic removal were investigated. Third, we analysed the effect of co-existing interfering substances in a real water matrix on the photocatalytic ability, as well as the coupling processes for degradation enhancement. In the last section, current difficulties and future perspectives on photocatalytic degradation for antibiotic elimination by bismuth-based catalysts are summarized. Generally, modified bismuth-based compounds showed better performance than single-component photocatalysts during photocatalytic degradation for most antibiotics, in which h⁺ played a predominant role among all the related reactive oxygen species. Moreover, the crystal structures and morphologies of bismuth-based catalysts seriously affected their practical efficiencies.

The Potential of Phage Therapy against the Emerging Opportunistic Pathogen Stenotrophomonas maltophilia

The isolation and characterization of bacteriophages for the treatment of infections caused by the multidrug resistant pathogen Stenotrophomonas maltophilia is imperative as nosocomial and community-acquired infections are rapidly increasing in prevalence. This increase is largely due to the numerous virulence factors and antimicrobial resistance genes encoded by this bacterium. Research on S. maltophilia phages to date has focused on the isolation and in vitro characterization of novel phages, often including genomic characterization, from the environment or by induction from bacterial strains. This review summarizes the clinical significance, virulence factors, and antimicrobial resistance mechanisms of S. maltophilia, as well as all phages isolated and characterized to date and strategies for their use. We further address the limited in vivo phage therapy studies conducted against this bacterium and discuss the future research needed to spearhead phages as an alternative treatment option against multidrug resistant S. maltophilia.

Acute lung toxicity by nitrofurantoin

Nitrofurantoin is a synthetic derivative of imidazolinedione, used to treat uncomplicated urinary tract infections. It acts by inhibiting bacterial DNA, RNA and cell wall protein synthesis. It is used prophylactically as a urinary anti-infective agent against most gram-positive organism and for long-term suppression of infections. Nitrofurantoin-associated pulmonary injuries occur in 1% of patients, presenting with dyspnoea and dry cough, and it can mimic interstitial lung disease. We present a case of an 81-year-old woman with shortness of breath and cough 3 days after initiation of nitrofurantoin. CT of the chest revealed bilateral pleural effusion and extensive pulmonary interstitial prominence, suggesting pulmonary fibrosis. According to the Naranjo Adverse Drug Reaction Probability Scale score of 6, it was determined that nitrofurantoin was the probable cause, and immediate cessation of the medication showed a marked clinical improvement and resolution after 10 days.

Sulfonamide drugs: structure, antibacterial property, toxicity, and biophysical interactions

Sulfonamide (or sulphonamide) functional group chemistry (SN) forms the basis of several groups of drug. In vivo sulfonamides exhibit a range of pharmacological activities, such as anti-carbonic anhydrase and anti-t dihydropteroate synthetase allowing them to play a role in treating a diverse range of disease states such as diuresis, hypoglycemia, thyroiditis, inflammation, and glaucoma. Sulfamethazine (SMZ) is a commonly used sulphonamide drug in veterinary medicine that acts as an antibacterial compound to treat livestock diseases such as gastrointestinal and respiratory tract infections. Sulfadiazine (SDZ) is another frequently employed sulphonamide drug that is used in combination with the anti-malarial drug pyrimethamine to treat toxoplasmosis in warm-blooded animals. This study explores the research findings and the work behaviours of SN (SMZ and SDZ) drugs. The areas covered include SN drug structure, SN drug antibacterial activity, SN drug toxicity, and SN environmental toxicity.

CPX-351 (Vyxeos®) can cause severe rash in acute myeloid leukemia-A case report

CPX-351, a promising new agent for patients with treatment-related and secondary acute myeloid leukemia can lead to a severe whole-body rash. Although severe side effects are rare, treatment should be carefully monitored at specialized centers.

Investigating the biodegradation of sulfadiazine in soil using Enterobacter cloacae T2 immobilized on bagasse

The application of the antibiotic sulfadiazine (SD) in veterinary medicine has created serious environmental issues due to its high mobility and non-degradability. A novel immobilized cell system has been developed and showed significant SD biodegradation potential in soil.