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Pammi M, Haque KN. Pentoxifylline for treatment of sepsis and necrotising enterocolitis in neonates. Cochrane Database Syst Rev 2023; 6:CD004205. [PMID: 37338074 PMCID: PMC10282162 DOI: 10.1002/14651858.cd004205.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Mortality and morbidity due to neonatal sepsis and necrotising enterocolitis (NEC) remain high despite the use of potent antimicrobial agents. Agents that modulate inflammation may improve outcomes. Pentoxifylline (PTX), a phosphodiesterase inhibitor, is one such agent. This is an update of a review first published in 2003 and updated in 2011 and 2015. OBJECTIVES To assess the effectiveness and safety of intravenous PTX as an adjunct to antibiotic therapy on mortality and morbidity in neonates with suspected or confirmed sepsis and neonates with NEC. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registries in July 2022. We also searched the reference lists of identified clinical trials and handsearched conference abstracts. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs assessing the efficacy of PTX with antibiotics (any dose or duration) for treatment of suspected or confirmed sepsis or NEC in neonates. We included three comparisons: (1) PTX with antibiotics compared to placebo or no intervention with antibiotics; (2) PTX with antibiotics compared to PTX with antibiotics and adjunct treatments such as immunoglobulin M-enriched intravenous immunoglobulin (IgM-enriched IVIG); (3) PTX with antibiotics compared to adjunct treatments such as IgM-enriched IVIG with antibiotics. DATA COLLECTION AND ANALYSIS We reported typical risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) for continuous outcomes derived from a fixed-effect model of meta-analysis. We calculated the number needed to treat for an additional beneficial outcome (NNTB) if there was a statistically significant reduction in RD. MAIN RESULTS We identified no new studies for this update. We included six RCTs (416 neonates). All of the included studies examined neonates with sepsis; we identified no studies on neonates with NEC. Four of the six trials had high risk of bias for at least one risk of bias domain. Comparison 1: PTX with antibiotics compared to placebo with antibiotics, or antibiotics alone, in neonates with sepsis may reduce all-cause mortality during hospital stay (typical RR 0.57, 95% CI 0.35 to 0.93; typical RD -0.08, 95% CI -0.14 to -0.01; NNTB 13, 95% CI 7 to 100; 6 studies, 416 participants, low-certainty evidence) and may decrease length of hospital stay (LOS) (MD -7.74, 95% CI -11.72 to -3.76; 2 studies, 157 participants, low-certainty evidence). The evidence is very uncertain that PTX with antibiotics compared to placebo or no intervention results in any change in chronic lung disease (CLD) (RR 1.50, 95% CI 0.45 to 5.05; 1 study, 120 participants, very low-certainty evidence), severe intraventricular haemorrhage (sIVH) (RR 0.75, 95% CI 0.28 to 2.03; 1 study, 120 participants, very low-certainty evidence), periventricular leukomalacia (PVL) (RR 0.50, 95% CI 0.10 to 2.63; 1 study, 120 participants, very low-certainty evidence), NEC (RR 0.56, 95% CI 0.29 to 1.06; 6 studies, 405 participants, very low-certainty evidence), or retinopathy of prematurity (ROP) (RR 0.40, 95% CI 0.08 to 1.98; 1 study, 120 participants, very low-certainty evidence) in neonates with sepsis. Comparison 2: the evidence is very uncertain that PTX with antibiotics compared to PTX with antibiotics and IgM-enriched IVIG has any effect on mortality (RR 0.71, 95% CI 0.24 to 2.10; 102 participants, 1 study, very low-certainty evidence) or development of NEC in neonates with sepsis (RR 1.33, 95% CI 0.31 to 5.66; 1 study, 102 participants, very low-certainty evidence). The outcomes of CLD, sIVH, PVL, LOS, and ROP were not reported. Comparison 3: the evidence is very uncertain that PTX with antibiotics compared to IgM-enriched IVIG with antibiotics has any effect on mortality (RR 1.25, 95% CI 0.36 to 4.39; 102 participants, 1 study, very low-certainty evidence) or development of NEC (RR 1.33, 95% CI 0.31 to 5.66; 102 participants, 1 study, very low-certainty evidence) in neonates with sepsis. The outcomes of CLD, sIVH, PVL, LOS, and ROP were not reported. All of the included studies evaluated adverse effects due to PTX, but none were reported in the intervention group in any of the comparisons. AUTHORS' CONCLUSIONS Low-certainty evidence suggests that adjunct PTX therapy in neonatal sepsis may decrease mortality and length of hospital stay without any adverse effects. The evidence is very uncertain if PTX with antibiotics compared to PTX with antibiotics and IgM-enriched IVIG, or PTX with antibiotics compared to IgM-enriched IVIG with antibiotics, has any effect on mortality or development of NEC. We encourage researchers to undertake well-designed multicentre trials to confirm or refute the effectiveness and safety of pentoxifylline in reducing mortality and morbidity in neonates with sepsis or NEC.
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Affiliation(s)
- Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Khalid N Haque
- (Formerly) Division of Neonatology, Department of Child Health, Queen Mary's Hospital for Children, Wrythe Lane, Carshalton, UK
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Kallem VR, Pullattayil AK, Kaushal M. Adjuvant therapy in neonatal sepsis to prevent mortality - A systematic review and network meta-analysis. J Neonatal Perinatal Med 2022; 15:699-719. [PMID: 36189501 DOI: 10.3233/npm-221025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite appropriate antibiotic therapy, the risk of mortality in neonatal sepsis still remains high. We conducted a systematic review to comprehensively evaluate different adjuvant therapies in neonatal sepsis in a network meta-analysis. METHODS We included randomized controlled trials (RCTs) and quasi-RCTs that evaluated adjuvant therapies in neonatal sepsis. Neonates of all gestational and postnatal ages, who were diagnosed with sepsis based on blood culture or sepsis screen were included. We searched MEDLINE, CENTRAL, EMBASE and CINAHL until 12th April 2021 and reference lists. Data extraction and risk of bias assessment were performed in duplicate. A network meta-analysis with bayesian random-effects model was used for data synthesis. Certainty of evidence (CoE) was assessed using GRADE. RESULTS We included 45 studies involving 6,566 neonates. Moderate CoE showed IVIG [Relative Risk (RR); 95% Credible Interval (CrI): 1.00; (0.67-1.53)] as an adjunctive therapy probably does not reduce all-cause mortality before discharge, compared to standard care. Melatonin [0.12 (0-0.08)] and granulocyte transfusion [0.39 (0.19-0.76)] may reduce mortality before discharge, but CoE is very low. The evidence is also very uncertain regarding other adjunctive therapies to reduce mortality before discharge. Pentoxifylline may decrease the duration of hospital stay [Mean difference; 95% CrI: -7.48 days (-14.50-0.37)], but CoE is very low. CONCLUSION Given the biological plausibility for possible efficacy of these adjuvant therapies and that the CoE from the available trials is very low to low except for IVIG, we need large adequately powered RCTs to evaluate these therapies in sepsis in neonates.
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Affiliation(s)
- T Abiramalatha
- Associate Professor of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - V V Ramaswamy
- Consultant Neonatologist, Ankura Hospital for Women and Children, Hyderabad, India
| | - T Bandyopadhyay
- Departmentof Neonatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - S H Somanath
- Department of Neonatology, All India Institute of Medical Sciences, Mangalagiri, India
| | - N B Shaik
- Consultant Neonatologist, Ankura Hospital for Women and Children, Hyderabad, India
| | - V R Kallem
- Consultant Neonatologist, Paramitha Children's Hospital, Hyderabad, India
| | - A K Pullattayil
- Health Sciences Librarian, Queen's University, Kingston, Canada
| | - M Kaushal
- Consultant Neonatologist and Head of Department, Emirates Specialty Hospital, DHCC, U.A.E
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Broekhuizen M, de Vries R, Smits MAW, Dik WA, Schoenmakers S, Koch BCP, Merkus D, Reiss IKM, Danser AHJ, Simons SHP, Hitzerd E. Pentoxifylline as a therapeutic option for pre-eclampsia: a study on its placental effects. Br J Pharmacol 2022; 179:5074-5088. [PMID: 35861684 PMCID: PMC9804511 DOI: 10.1111/bph.15931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Recently pentoxifylline, a non-selective phosphodiesterase inhibitor and adenosine receptor antagonist, has attracted much interest for the treatment of the increased vascular resistance and endothelial dysfunction in pre-eclampsia. We therefore investigated the placental transfer, vascular effects and anti-inflammatory actions of pentoxifylline in healthy and pre-eclamptic human placentas. EXPERIMENTAL APPROACH The placental transfer and metabolism of pentoxifylline were studied using ex vivo placenta perfusion experiments. In wire myography experiments with chorionic plate arteries, pentoxifyllines vasodilator properties were investigated, focusing on the cGMP and cAMP pathways and adenosine receptors. Its effects on inflammatory factors were also studied in placental explants. KEY RESULTS Pentoxifylline transferred from the maternal to foetal circulation, reaching identical concentrations. The placenta metabolized pentoxifylline into its active metabolite lisofylline (M1), which was released into both circulations. In healthy placentas, pentoxifylline potentiated cAMP- and cGMP-induced vasodilation, as well as causing vasodilation by adenosine A1 antagonism and via NO synthase and PKG. Pentoxifylline also reduced inflammatory factors secretion. In pre-eclamptic placentas, we observed that its vasodilator capacity was preserved, however not via NO-PKG but likely through adenosine signalling. Pentoxifylline neither potentiated vasodilation through cAMP and cGMP, nor suppressed the release of inflammatory factors from these placentas. CONCLUSION AND IMPLICATIONS Pentoxifylline is transferred across and metabolized by the placenta. Its beneficial effects on the NO pathway and inflammation are not retained in pre-eclampsia, limiting its application in this disease, although it could be useful for other placenta-related disorders. Future studies might focus on selective A1 receptor antagonists as a new treatment for pre-eclampsia.
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Affiliation(s)
- Michelle Broekhuizen
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Experimental Cardiology, Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Rene de Vries
- Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Marja A. W. Smits
- Laboratory Medical Immunology, Department of ImmunologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Willem A. Dik
- Laboratory Medical Immunology, Department of ImmunologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and GynaecologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Birgit C. P. Koch
- Department of PharmacyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands
| | - A. H. Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Sinno H. P. Simons
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Emilie Hitzerd
- Division of Neonatology, Department of PaediatricsErasmus MC University Medical CenterRotterdamThe Netherlands,Division of Pharmacology and Vascular Medicine, Department of Internal MedicineErasmus MC University Medical CenterRotterdamThe Netherlands
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Gan MY, Lee WL, Yap BJ, Seethor STT, Greenberg RG, Pek JH, Tan B, Hornik CPV, Lee JH, Chong SL. Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:890767. [PMID: 35722477 PMCID: PMC9204066 DOI: 10.3389/fped.2022.890767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors. Methods We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs. Results The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time. Conclusion Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions. Systematic Review Registration [www.crd.york.ac.uk/prospero], identifier [CRD42020164321].
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Affiliation(s)
- Ming Ying Gan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Li Lee
- Duke-NUS Medical School, Singapore, Singapore
| | - Bei Jun Yap
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Rachel G Greenberg
- Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jen Heng Pek
- Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Bobby Tan
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Christoph Paul Vincent Hornik
- Division of Critical Care Medicine, Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Henry CJ, Semova G, Barnes E, Cotter I, Devers T, Rafaee A, Slavescu A, Cathain NO, McCollum D, Roche E, Mockler D, Allen J, Meehan J, Klingenberg C, Latour JM, van den Hoogen A, Strunk T, Giannoni E, Schlapbach LJ, Degtyareva M, Plötz FB, de Boode WP, Naver L, Wynn JL, Küster H, Janota J, Keij FM, Reiss IKM, Bliss JM, Polin R, Koenig JM, Turner MA, Gale C, Molloy EJ; Infection, Inflammation, Immunology and Immunisation (I4) section of the European Society for Paediatric Research (ESPR). Neonatal sepsis: a systematic review of core outcomes from randomised clinical trials. Pediatr Res 2022; 91:735-42. [PMID: 34997225 DOI: 10.1038/s41390-021-01883-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/23/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The lack of a consensus definition of neonatal sepsis and a core outcome set (COS) proves a substantial impediment to research that influences policy and practice relevant to key stakeholders, patients and parents. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In the included studies, the described outcomes were extracted in accordance with the provisions of the Core Outcome Measures in Effectiveness Trials (COMET) handbook and registered. RESULTS Among 884 abstracts identified, 90 randomised controlled trials (RCTs) were included in this review. Only 30 manuscripts explicitly stated the primary and/or secondary outcomes. A total of 88 distinct outcomes were recorded across all 90 studies included. These were then assigned to seven different domains in line with the taxonomy for classification proposed by the COMET initiative. The most frequently reported outcome was survival with 74% (n = 67) of the studies reporting an outcome within this domain. CONCLUSIONS This systematic review constitutes one of the initial phases in the protocol for developing a COS in neonatal sepsis. The paucity of standardised outcome reporting in neonatal sepsis hinders comparison and synthesis of data. The final phase will involve a Delphi Survey to generate a COS in neonatal sepsis by consensus recommendation. IMPACT This systematic review identified a wide variation of outcomes reported among published RCTs on the management of neonatal sepsis. The paucity of standardised outcome reporting hinders comparison and synthesis of data and future meta-analyses with conclusive recommendations on the management of neonatal sepsis are unlikely. The final phase will involve a Delphi Survey to determine a COS by consensus recommendation with input from all relevant stakeholders.
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Kurul S, Taal HR, Flint RB, Mazela J, Reiss IKM, Allegaert K, Simons SHP. Protocol: Pentoxifylline optimal dose finding trial in preterm neonates with suspected late onset sepsis (PTX-trial). BMC Pediatr 2021; 21:517. [PMID: 34794420 PMCID: PMC8603542 DOI: 10.1186/s12887-021-02975-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late onset sepsis is a leading cause of death and morbidity in preterm infants. Despite optimal antibiotic treatment, sepsis related mortality and morbidity is still high. Pentoxifylline (PTX) is a methylxanthine with promising immunomodulatory properties, which can be used as an additional therapy next to antibiotics in preterm infants. PTX is increasingly used off-label in neonatal intensive care units, however up till now no dose finding study has been done for PTX in this specific population. The aim of this study (PTX-trial) is to determine the optimal dose of PTX in preterm infants (gestational age < 30 weeks) with (suspected) late onset sepsis. Dose finding in this particular population is unique, since for most drugs used in neonates the optimal dosage has not been investigated in phase II dose-seeking studies. METHODS The PTX-trial is a prospective open label sequential dose-optimization study with an adapted continual reassessment method. An up-and-down dose-response design will be used, with dose step-up and step-down titration after every 3 patients. The PTX starting dosage will be 30 mg/kg/day in 6 hours as described in most previous neonatal studies. Efficacy is defined by means of biochemical and clinical parameters. Toxicity in these vulnerable patients is unwarranted. The optimal dose is defined as the ED75 (i.e., clinically and chemically effective dose for 75% of patients) in preterm neonates with late onset sepsis. We plan to include 30 neonates to determine the optimal dose using this study design. Subsequently, the optimal dose will be validated in 10 additional preterm neonates. In parallel, pharmacokinetics of PTX and its metabolites will be described as well as longitudinal evaluation of metabolomics and proteomics. DISCUSSION The study has been approved by the Regional Medical Ethics Board of Erasmus Medical Center University Rotterdam (MEC 2019-0477) and registered at Clinicaltrials.gov (NCT04152980). Results of the main trial and each of the secondary endpoints will be submitted for publications in peer-reviewed journals. TRIAL REGISTRATION Clinicaltrials.gov, NCT04152980 , Registered November 6th, 2019.
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Affiliation(s)
- Serife Kurul
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - H Rob Taal
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Robert B Flint
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Mazela
- Department of Neonatology, Poznan University of Medical Sciences, Poznań, Poland
| | - Irwin K M Reiss
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands
| | - Karel Allegaert
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Sinno H P Simons
- Department of Pediatrics, Division Neonatology, Research Neonatology (Sk-4246), Erasmus Medical Center, PO Box 2060, Rotterdam, 300 CB, The Netherlands.
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Bayraktar S, Tanyeri-Bayraktar B. Pentoxifylline in the treatment of neonatal vasospasm and thromboembolism: An observational case series study. J Clin Pharm Ther 2021; 47:455-461. [PMID: 34726284 DOI: 10.1111/jcpt.13565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Newborns, particularly preterm babies, are prone to vascular vasospasm and thromboembolism. Differences in the haemostatic system, small vessel diameter and presence of any serious diseases are predisposing causes of thromboembolic disease in newborns. The lack of randomized controlled studies on the management of vasospasm and thromboembolism exacerbates the problem. We present a case series of the successful and safe use of PTX for the treatment of vasospasm and thrombosis in neonates. METHODS The study was conducted in the Bezmialem Vakif University Hospital Neonatal Intensive Care Unit (NICU). A retrospective chart review was performed on consecutive patients treated for vascular spasm and thrombosis. Nine patients diagnosed with vasospasm or thrombosis were enrolled in the study. RESULTS Five patients had arterial injuries. Six patients were premature, and five patients were diagnosed with thrombosis by using Doppler ultrasonography (US). The drug was diluted with 5% dextrose and administered intravenously at a dose of 5 mg/kg/h over six hours, ranging from 1 to 5 days. No drug-related side effects were observed. All babies recovered, and no amputation was performed. WHAT IS NEW AND CONCLUSION PTX may be an alternative treatment for vascular vasospasm and thromboembolism with fewer side effects than anticoagulant and thrombolytic agents in neonates. Starting PTX in the early stages of vascular insult may prevent the development of vasospasm and thromboembolism and thus limb ischaemia.
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Affiliation(s)
- Süleyman Bayraktar
- Department of Pediatric Intensive Care, Haseki Research and Training Hospital, Istanbul, Turkey
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Senarathna SMDKG, Strunk T, Petrovski M, Batty KT. Stability of Pentoxifylline Injection: Application to Neonatal/Pediatric Care Setting. J Pharm Sci 2021; 110:3862-3865. [PMID: 34481836 DOI: 10.1016/j.xphs.2021.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
Pentoxifylline (PTX) is administered as 6- or 12-hour intravenous infusions in the treatment of sepsis or necrotizing enterocolitis in neonates; however, there is a paucity of formal stability data for PTX in the end-use solution. We investigated PTX stability in the simulated clinical conditions of neonatal intensive care, where PTX injection is diluted to 5 mg/mL and administered via syringe pump. A stability-indicating high performance liquid chromatography (HPLC) assay was established for PTX. The clinical simulation stability study comprised PTX 5 mg/mL in 20 mL syringes and was conducted at three temperatures, all protected from light: refrigerator (4°C); room temperature (22°C) and incubator/humidicrib (35°C). PTX stability also was evaluated at room temperature and exposed to light. Samples were drawn at pre-determined times over a 10 day period and stored frozen (-80°C) until assayed by HPLC. A single exponential equation was fitted to the concentration-time data to determine PTX stability. Forced degradation studies confirmed that PTX was stable at elevated temperature (up to 45°C), exposed to light and under acidic stress for up to 10 days, but subject to degradation under alkali and oxidative stress. PTX injection 5 mg/mL in 0.9% w/v sodium chloride or 5% w/v glucose was found to be stable when protected from light at 22°C and 35°C, and exposed to light at 22°C for at least 7 days. These data provide clinically relevant evidence that PTX injection is stable in the end-use, ICU/incubator clinical conditions for at least 24 hours.
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Affiliation(s)
| | - Tobias Strunk
- Medical School, University of Western Australia, Crawley, WA, Australia; Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia.
| | - Michael Petrovski
- Pharmacy Department, King Edward Memorial Hospital, Women and Newborn Health Service, WA, Australia.
| | - Kevin T Batty
- Curtin Medical School, Curtin University, Bentley, WA, Australia; Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia.
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Erbaş İM, Çetinkaya M, Yıldız Ekinci D, Yılmaz Semerci S. The possible effect of pentoxifylline on development and severity of retinopathy of prematurity. Cutan Ocul Toxicol 2021; 40:359-364. [PMID: 34429007 DOI: 10.1080/15569527.2021.1973024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIM Retinopathy of prematurity (ROP) is the major ocular problem of preterm infants that occurs with abnormal proliferation of immature retinal vessels. Although pentoxifylline (PTX) was reported to inhibit vasculogenesis and neovascularization in experimental studies, there is no clinical data about the effects of PTX treatment on the development and severity of ROP. This clinical study aimed to investigate the possible effects of PTX on the development of ROP. MATERIALS AND METHODS A single-centre retrospective study was conducted including preterm infants who were hospitalised in the neonatal intensive care unit between 2015-2017 years. Infants were divided into two groups in terms of PTX administration for adjuvant therapy, as PTX and non-PTX groups. RESULTS A total of 211 infants were included in the study [gestational age 29 (27-31) weeks, birth weight 1140 (960-1340) g]. From these, 97 infants (46%) were given PTX treatment. The two groups were similar in terms of demographic data and baseline clinical characteristics. Any stage of ROP was detected in 47.4% of infants in the PTX group, which was significantly higher than those in the non-PTX group (27.2%) (p = 0.002). The incidence of advanced-stage ROP in the PTX group (10.3%) was also higher than in the non-PTX group (2.6%) (p = 0.021). Repeated usage of PTX was not found to be related to the development of ROP (p = 0.059). The time of PTX administration was similar between the ROP and no-ROP groups (median; one vs one week, p = 0.825). Surfactant therapy, duration of hospital stay, and PTX treatment were found as significant risk factors for ROP in the logistic regression analysis. CONCLUSIONS In contrast to the experimental studies and also promising results of PTX treatment in some neonatal morbidities, it may be associated with increased incidence and stage of ROP.
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Affiliation(s)
- İbrahim Mert Erbaş
- Department of Pediatrics, Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - Merih Çetinkaya
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - Dilbade Yıldız Ekinci
- Department of Ophthalmology, Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
| | - Seda Yılmaz Semerci
- Department of Neonatology, Kanuni Sultan Suleyman Training and Research Hospital, İstanbul, Turkey
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Chavarría AP, Vázquez RRV, Cherit JGD, Bello HH, Suastegui HC, Moreno-Castañeda L, Alanís Estrada G, Hernández F, González-Marcos O, Saucedo-Orozco H, Manzano-Pech L, Márquez-Velasco R, Guarner-Lans V, Pérez-Torres I, Soto ME. Antioxidants and pentoxifylline as coadjuvant measures to standard therapy to improve prognosis of patients with pneumonia by COVID-19. Comput Struct Biotechnol J 2021; 19:1379-1390. [PMID: 33680348 PMCID: PMC7910139 DOI: 10.1016/j.csbj.2021.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 01/08/2023] Open
Abstract
The type 2 coronavirus causes severe acute respiratory syndrome (SARS-CoV-2) and produces pneumonia with pulmonary alveolar collapse. In some cases it also causes sepsis and septic shock. There is no specific treatment for coronavirus disease 2019 (COVID-19). Vitamin C (Vit C), Vitamin E (Vit E), N-acetylcysteine (NAC) and Melatonin (MT) increase the intracellular content of GSH, kidnap free radicals and protect DNA, proteins in the cytosol and lipids in cell membranes. Pentoxifylline (Px) has anti-inflammatory activities. Here we evaluate the effect of Vit C, Vit E, NAC, and MT plus Px in COVID-19 patients with moderate and severe pneumonia. 110 patients of either sex were included. They were divided into five groups with 22 patients each. Group 1 received Vit C + Px, group 2 Vit E + Px, group 3 NAC + Px, group 4 MT + Px, and group 5 only Px. Oxidative stress (OS) markers such as lipid peroxidation (LPO) levels, total antioxidant capacity (TAC) and nitrites (NO2 -) were evaluated in plasma. The antioxidant therapy improved the survival scores including the Sequential Organ Failure Assessment (SOFA), the Acute Physiology and chronic Health Evaluation II (Apache II), the Simplified Acute Physiology Score II (SAPS II), the Critical Illness Risk Score, Launched during COVID-19 crisis (COVIDGRAM) and the Glasgow Coma Scale (GCS). We found that LPO (p≤0.04) and inflammation markers such as interleukin-6 (IL-6, p≤ 0.01), C reactive protein (CRP, p ≤ 0.01) and procalcitonin (PCT, p ≤ 0.05) were elevated. TAC (p ≤ 0.03) and NO2 - (p ≤ 0.04) found themselves diminished in diminished in COVID-19 patients upon admission to the hospital. The different antioxidants reversed this alteration at the end of the treatment. The treatment with antioxidant supplements such as Vit C, E, NAC, and MT plus Px could decelerate the aggressive and lethal development of COVID-19. Antioxidant therapy can be effective in this pandemia since it improves the survival scores including SOFA, Apache II, SAPS II, COVIDGRAM, GCS by lowering the LPO, IL-6, CRP, PCT and increasing systemic TAC and NO2 -.
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Affiliation(s)
- Adrián Palacios Chavarría
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
- Critical Care in American British Cowdray (ABC) Medical Center, I.A.P. ABC I.A.P. ABC Sur 136 No. 116 Col. Las Américas, México City 01120 , Mexico
| | - Rafael Ricardo Valdez Vázquez
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - José Guillermo Domínguez Cherit
- Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” Vasco de Quiroga 15, Sección XVI, Tlalpan, México City 14000, Mexico
- Tecnológico de Monterrey EMCS, Mexico
| | - Héctor Herrera Bello
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Humberto Castillejos Suastegui
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Lidia Moreno-Castañeda
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Gabriela Alanís Estrada
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Fabián Hernández
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Omar González-Marcos
- Critical Care Unit of the Temporal COVID-19 Unit, Citibanamex Center Av. del Conscripto 311, Lomas de Sotelo, Hipódromo de las Américas, Miguel Hidalgo, 11200 Ciudad de México, CDMX, Mexico
| | - Huitzilihuitl Saucedo-Orozco
- Cardioneumology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico
- Cardioneumology Department, Centro Médico Nacional La Raza Instituto Mexicano del Seguro Social Seris y Zaachila, Col. La Raza Azcapotzalco, 02990 Ciudad de México, CDMX, Mexico
| | - Linaloe Manzano-Pech
- Department of Cardiovascular Biomedicine, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Ricardo Márquez-Velasco
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Verónica Guarner-Lans
- Department of Physiology, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080 Mexico
| | - Israel Pérez-Torres
- Department of Cardiovascular Biomedicine, Instituto Nacional de Cardiología Ignacio Chávez. Badiano 1, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Maria Elena Soto
- Department of Immunology , Instituto Nacional de Cardiología Ignacio Chávez. Juan Badiano 1 , Sección XVI , Tlalpan , México City 14080 , Mexico
- American British Cowdray (ABC) Medical Center , I.A.P. ABC I.A.P. ABC Sur 136 No. 116 Col. Las Américas , México City 01120 , Mexico
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Mokra D, Mokry J. Phosphodiesterase Inhibitors in Acute Lung Injury: What Are the Perspectives? Int J Mol Sci 2021; 22:1929. [PMID: 33669167 PMCID: PMC7919656 DOI: 10.3390/ijms22041929] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/12/2021] [Accepted: 02/14/2021] [Indexed: 12/14/2022] Open
Abstract
Despite progress in understanding the pathophysiology of acute lung damage, currently approved treatment possibilities are limited to lung-protective ventilation, prone positioning, and supportive interventions. Various pharmacological approaches have also been tested, with neuromuscular blockers and corticosteroids considered as the most promising. However, inhibitors of phosphodiesterases (PDEs) also exert a broad spectrum of favorable effects potentially beneficial in acute lung damage. This article reviews pharmacological action and therapeutical potential of nonselective and selective PDE inhibitors and summarizes the results from available studies focused on the use of PDE inhibitors in animal models and clinical studies, including their adverse effects. The data suggest that xanthines as representatives of nonselective PDE inhibitors may reduce acute lung damage, and decrease mortality and length of hospital stay. Various (selective) PDE3, PDE4, and PDE5 inhibitors have also demonstrated stabilization of the pulmonary epithelial-endothelial barrier and reduction the sepsis- and inflammation-increased microvascular permeability, and suppression of the production of inflammatory mediators, which finally resulted in improved oxygenation and ventilatory parameters. However, the current lack of sufficient clinical evidence limits their recommendation for a broader use. A separate chapter focuses on involvement of cyclic adenosine monophosphate (cAMP) and PDE-related changes in its metabolism in association with coronavirus disease 2019 (COVID-19). The chapter illuminates perspectives of the use of PDE inhibitors as an add-on treatment based on actual experimental and clinical trials with preliminary data suggesting their potential benefit.
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Affiliation(s)
- Daniela Mokra
- Department of Physiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia
| | - Juraj Mokry
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia;
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Schüller SS, Kempf K, Unterasinger L, Strunk T, Berger A. Intravenous pentoxifylline is well tolerated in critically ill preterm infants with sepsis or necrotizing enterocolitis. Eur J Pediatr 2020; 179:1325-1330. [PMID: 32179980 DOI: 10.1007/s00431-020-03612-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
Abstract
Pentoxifylline (PTX) is a candidate adjuvant medication for the treatment of sepsis and necrotizing enterocolitis in preterm infants. There is only limited data on safety and compatibility with other commonly used intravenous medications. This retrospective single-center study of 198 preterm infants (September 2012-September 2018) was performed at a level IV neonatal intensive care unit. Electronic data of all preterm infants who received pentoxifylline for sepsis or necrotizing were extracted from routine databases. We analyzed a total of 1081 PTX treatment days from 217 treatment episodes in 198 preterm infants (mean gestational age 27 weeks; mean birth weight 1060 g). At a mean daily dose of 28 mg/kg, no clinically relevant side effects were observed. PTX therapy was not associated with clinically significant changes of blood biochemistry and hematology parameters. Concomitant infusion of PTX with other common NICU medications was well tolerated, and there was no evidence of incompatibility.Conclusion: Intravenous PTX is compatible with standard NICU drugs and well tolerated in critically ill preterm infants. What is Know: •Currently, there are no evidence-based adjuvant medications available that target the harmful inflammatory host response in neonatal sepsis or necrotizing enterocolitis. •Pentoxifylline (PTX) is a candidate adjuvant medication for the treatment of sepsis and necrotizing enterocolitis in preterm infants; however, safety data are rare and PTX is currently used off-label. What is New: •Here we report on our experience in the pragmatic routine use of PTX as adjuvant therapy in 198 preterm infants with sepsis or NEC. •Concomitant infusion of PTX with other common NICU medications was well tolerated, and there was no evidence of incompatibility. No clinically relevant side effects were observed.
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Affiliation(s)
- Simone S Schüller
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria. .,Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia. .,Neonatal Directorate, King Edward Memorial Hospital, 374 Bagot Rd, Subiaco, WA, 6008, Australia.
| | - Kristina Kempf
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Lukas Unterasinger
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Tobias Strunk
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia.,Neonatal Directorate, King Edward Memorial Hospital, 374 Bagot Rd, Subiaco, WA, 6008, Australia
| | - Angelika Berger
- Department of Paediatrics, Division of Neonatology, Pediatric Intensive Care Medicine and Neuropaediatrics, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
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Soto ME, Guarner-Lans V, Soria-Castro E, Manzano Pech L, Pérez-Torres I. Is Antioxidant Therapy a Useful Complementary Measure for Covid-19 Treatment? An Algorithm for Its Application. ACTA ACUST UNITED AC 2020; 56:E386. [PMID: 32752010 DOI: 10.3390/medicina56080386] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes the corona virus disease-19 which is accompanied by severe pneumonia, pulmonary alveolar collapses and which stops oxygen exchange. Viral transmissibility and pathogenesis depend on recognition by a receptor in the host, protease cleavage of the host membrane and fusion. SARS-CoV-2 binds to the angiotensin converting enzyme 2 receptor. Here, we discuss the general characteristics of the virus, its mechanism of action and the way in which the mechanism correlates with the comorbidities that increase the death rate. We also discuss the currently proposed therapeutic measures and propose the use of antioxidant drugs to help patients infected with the SARS-CoV-2. Oxidizing agents come from phagocytic leukocytes such as neutrophils, monocytes, macrophages and eosinophils that invade tissue. Free radicals promote cytotoxicity thus injuring cells. They also trigger the mechanism of inflammation by mediating the activation of NFkB and inducing the transcription of cytokine production genes. Release of cytokines enhances the inflammatory response. Oxidative stress is elevated during critical illnesses and contributes to organ failure. In corona virus disease-19 there is an intense inflammatory response known as a cytokine storm that could be mediated by oxidative stress. Although antioxidant therapy has not been tested in corona virus disease-19, the consequences of antioxidant therapy in sepsis, acute respiratory distress syndrome and acute lung injury are known. It improves oxygenation rates, glutathione levels and strengthens the immune response. It reduces mechanical ventilation time, the length of stay in the intensive care unit, multiple organ dysfunctions and the length of stay in the hospital and mortality rates in acute lung injury/acute respiratory distress syndrome and could thus help patients with corona virus disease-19.
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Elgendy HA, Ibrahim HM, Hasan BEE, Elkawe ASA. Effect of Pentoxifylline on Organ Dysfunction and Mortality in Severe Sepsis. TOATJ 2020. [DOI: 10.2174/2589645802014010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background:
Sepsis and infection are among the leading causes of death world-wide. The annual burden of sepsis in high-income countries is rising with a mortality rate of 40% and 90% of the worldwide deaths from pneumonia, meningitis or other infections occur in less developed countries. This study was performed to evaluate the therapeutic efficacy of pentoxifylline as an adjuvant therapy in septic patients and its effect on multiple organ dysfunction and mortality in septic patients.
Methods:
This randomized, double-blinded prospective study was conducted from October 2017 to November 2018, which included a total sample size of 52 cases of septic patients. Organ dysfunction was used as a primary outcome with proposed large effect size ((0.8) and alfa =0.05 and power=0.80, so, 26 cases were needed in each group). Secondary outcomes were inflammatory markers C-Reactive Protein (CRP) and pro-calcitonin, duration of hospital stay, need for hemodialysis, need for vasopressor & inotropes, need for mechanical ventilation and 28 days survival.
Results:
Fifty-two patients with sepsis were divided in 1: 1 ratio to receive pentoxifylline or not. The average age of the included patients was almost 53 years, chest disorders were the main cause of sepsis in both groups. There were no statistically significant differences between both groups in terms of Sequential Organ Failure Assessment (SOFA) score, lactate level, CRP level and pro-calcitonin level. As regards secondary outcomes, there were no statistically significant differences between study’s groups in terms of length of hospital stay (p =0.707), need for hemodialysis (p =0.541), need for vasopressor & inotropes (p =0.249), need for mechanical ventilation (p =0.703), and 28 days survival (p =0.5).
Conclusion:
We concluded that pentoxifylline as an adjuvant therapy in septic patients had no significant influence on multiple organ dysfunction and mortality.
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Conti MG, Angelidou A, Diray-Arce J, Smolen KK, Lasky-Su J, De Curtis M, Levy O. Immunometabolic approaches to prevent, detect, and treat neonatal sepsis. Pediatr Res 2020; 87:399-405. [PMID: 31689710 DOI: 10.1038/s41390-019-0647-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/03/2019] [Accepted: 10/23/2019] [Indexed: 12/12/2022]
Abstract
The first days of postnatal life are energetically demanding as metabolic functions change dramatically to accommodate drastic environmental and physiologic transitions after birth. It is increasingly appreciated that metabolic pathways are not only crucial for nutrition but also play important roles in regulating inflammation and the host response to infection. Neonatal susceptibility to infection is increased due to a functionally distinct immune response characterized by high reliance on innate immune mechanisms. Interactions between metabolism and the immune response are increasingly recognized, as changes in metabolic pathways drive innate immune cell function and activation and consequently host response to pathogens. Moreover, metabolites, such as acetyl-coenzyme A (acetyl-CoA) and succinate have immunoregulatory properties and serve as cofactors for enzymes involved in epigenetic reprogramming or "training" of innate immune cells after an initial infectious exposure. Highly sensitive metabolomic approaches allow us to define alterations in metabolic signatures as they change during ontogeny and as perturbed by immunization or infection, thereby linking metabolic pathways to immune cell effector functions. Characterizing the ontogeny of immunometabolism will offer new opportunities to prevent, diagnose, and treat neonatal sepsis.
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Mert MK, Özlü F, Yapıcıoğlu Yıldızdaş H, Satar M. Preterm bebeklerin nozokomiyal sepsisinde pentoksifilin tedavisi. Cukurova Medical Journal 2019. [DOI: 10.17826/cumj.605903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Abstract
Introduction: Neonatal sepsis (NS) is a very severe condition that causes significant morbidity and mortality.Areas covered: To overcome the limits of antibiotic therapy and improve NS outcomes, measures chosen among those theoretically able to improve host defenses or positively interfere with deleterious immune responses could be suggested. This paper discusses the mechanisms of action of these measures, whether their efficacy in prophylaxis justifies use in NS therapy and their impact.Expert opinion: NS remains a relevant problem despite the availability of antibiotics effective against the most common agents and the introduction of effective preventive measures such as group B Streptococcus prenatal screening and intrapartum antibiotic prophylaxis. This explains why attempts to introduce new prophylactic and therapeutic measures have been made. Unfortunately, none of the measures suggested and tested to date can be considered a definitive advance. It is highly likely that in the future, new measures will be proposed according to the increase in the knowledge of the characteristics of immune system function in preterm infants and the methods to modulate unproper immune responses.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Nicola Principi
- Professor Emeritus of Pediatrics, Università degli Studi di Milano, Milan, Italy
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Tian J, Shen P, Pan K, Zhou Q. Efficacy of pentoxifylline treatment for neonatal sepsis: a meta-analysis of randomized controlled studies. Ital J Pediatr 2019; 45:108. [PMID: 31439016 PMCID: PMC6704640 DOI: 10.1186/s13052-019-0697-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Pentoxifylline may be an important approach to treat neonatal sepsis. However, its use has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of pentoxifylline treatment for neonatal sepsis. Methods PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials (RCTs) assessing the influence of pentoxifylline treatment on neonatal sepsis are included. Two investigators independently have searched articles, extracted data, and assessed the quality of included studies. This meta-analysis is performed using the random-effect model. Results Seven RCTs involving 439 patients are included in the meta-analysis. Compared with control intervention for neonatal sepsis, pentoxifylline treatment is associated with reduced hospital stay (Std. MD = -0.61; 95% CI = -0.93 to − 0.29; P = 0.0002) and metabolic acidosis (RR = 0.38; 95% CI = 0.22 to 0.66; P = 0.0006), but has no remarkable impact on mortality (RR = 0.59; 95% CI = 0.30 to 1.16; P = 0.13), serum TNF-α (Std. MD = -0.38; 95% CI = -1.29 to 0.52; P = 0.41), serum CRP (Std. MD = -0.25; 95% CI = -0.92 to 0.42; P = 0.47), plasma IL-6 (Std. MD = -0.13; 95% CI = -0.41 to 0.15; P = 0.37), disseminated intravascular coagulopathy (RR = 0.55; 95% CI = 0.25 to 1.21; P = 0.14), and oliguria/anuria (RR = 0.77; 95% CI = 0.28 to 2.16; P = 0.62). In addition, pentoxifylline treatment can significantly reduce mortality (RR = 0.50; 95% CI = 0.29 to 0.88; P = 0.02) after excluding the study conducted by Akdag during the sensivity analysis. Conclusions Pentoxifylline treatment may be associated with reduced mortality and hospital stay in neonatal sepsis.
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Affiliation(s)
- Jun Tian
- Department of pediatrics, The First people's Hospital of Xiaosha, Hangzhou, China
| | - Peifang Shen
- Department of pediatrics, The First people's Hospital of Xiaosha, Hangzhou, China
| | - Kaiyu Pan
- Department of pediatrics, The First people's Hospital of Xiaosha, Hangzhou, China
| | - Qiong Zhou
- Department of pediatrics, Children's Hospital of Hangzhou, No 318 Chaowang Road, Hangzhou, 310005, Zhejiang Province, People's Republic of China.
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Abstract
Introduction:Pentoxifylline may be an important approach to treat neonatal sepsis. However, its use has not been well established. We conduct a systematic review and meta-analysis to evaluate the efficacy of pentoxifylline treatment for neonatal sepsis.Methods:PubMed, Embase, and the Cochrane Central Register of Controlled Trials are searched. Randomized controlled trials assessing the influence of pentoxifylline treatment on neonatal sepsis are included. Two investigators independently have searched articles, extracted data, and assessed the quality of included studies. This meta-analysis is performed using the random-effect model.Results:Seven randomized controlled trials involving 439 patients are included in the meta-analysis. Compared with control intervention for neonatal sepsis, pentoxifylline treatment is associated with reduced hospital stay (standard mean differences = −0.61; 95% confidence interval = −0.93 to −0.29; p = 0.0002) and metabolic acidosis (risk ratio = 0.38; 95% confidence interval = 0.22 to 0.66; p = 0.0006), but has no remarkable impact on mortality (risk ratio = 0.59; 95% confidence interval = 0.30 to 1.16; p = 0.13), serum tumor necrosis factor-α (standard mean differences = −0.38; 95% confidence interval = −1.29 to 0.52; p = 0.41), serum C-reactive protein (standard mean differences = −0.25; 95% confidence interval = −0.92 to 0.42; p = 0.47), plasma interleukin-6 (standard mean differences = −0.13; 95% confidence interval = −0.41 to 0.15; p = 0.37), disseminated intravascular coagulopathy (risk ratio = 0.55; 95% confidence interval = 0.25 to 1.21; p = 0.14), and oliguria/anuria (risk ratio = 0.77; 95% confidence interval = 0.28 to 2.16; p = 0.62).Conclusion:Pentoxifylline treatment may be associated with reduced mortality and hospital stay in neonatal sepsis with caution.
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Affiliation(s)
- Peiyun Peng
- Department of Cardiology, The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunfeng Xia
- Department of Nephrology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Salman S, Hibbert J, Page-Sharp M, Manning L, Simmer K, Doherty DA, Patole S, Batty KT, Strunk T. Effects of maturation and size on population pharmacokinetics of pentoxifylline and its metabolites in very preterm infants with suspected late-onset sepsis or necrotizing enterocolitis: a pilot study incorporating clinical outcomes. Br J Clin Pharmacol 2018; 85:147-159. [PMID: 30281170 DOI: 10.1111/bcp.13775] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/08/2018] [Accepted: 09/09/2018] [Indexed: 01/10/2023] Open
Abstract
AIMS Infection-induced inflammation is associated with adverse long-term outcomes in preterm infants. Pentoxifylline (PTX) is a candidate for adjunct immunomodulatory therapy in preterm infants with late-onset sepsis (LOS) and necrotizing enterocolitis (NEC), but pharmacokinetic data in this population are extremely limited. This study aims to characterize the pharmacokinetic properties of intravenous PTX and its metabolites in preterm infants. METHOD An open label pilot clinical study of intravenous PTX as an adjunct therapy in preterm infants (gestation <32 weeks) with suspected LOS or NEC was undertaken. PTX was infused for 12 h for two days (60 mg kg-1 per 12 h), and in infants with confirmed diagnosis of LOS or NEC, for 6 h for another 4 days (30 mg kg-1 per 6 h). Plasma concentrations of PTX and its principal metabolites from collected blood samples were measured using a validated LCMS assay. NONMEM was used to analyse the data using population pharmacokinetic modelling. RESULTS The preterm infants (n = 26) had a median (range) gestation of 24.8 weeks (23.3-30.4) and birthweight of 689 g (370-1285). PTX was well tolerated and without treatment-limiting adverse effects. Changes in size (weight) and maturation were successfully modelled for PTX and metabolites. After allometric scaling, clearance increased with postmenstrual age, increasing by approximately 30% per week for PTX and M1 (lisofylline) and simulations of current dosing demonstrated a six-fold difference in exposure between 24 and 35 weeks postmenstrual age. CONCLUSIONS The developed model can be used to explore dosing strategies based on size and maturation for preterm infants.
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MESH Headings
- Administration, Intravenous
- Body Weight/physiology
- Drug Therapy, Combination/methods
- Enterocolitis, Necrotizing/blood
- Enterocolitis, Necrotizing/drug therapy
- Female
- Humans
- Infant
- Infant, Extremely Premature/blood
- Infant, Extremely Premature/physiology
- Infant, Newborn
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Infant, Very Low Birth Weight/blood
- Infant, Very Low Birth Weight/physiology
- Male
- Metabolic Clearance Rate/physiology
- Models, Biological
- Pentoxifylline/administration & dosage
- Pentoxifylline/pharmacokinetics
- Phosphodiesterase Inhibitors/administration & dosage
- Phosphodiesterase Inhibitors/pharmacokinetics
- Pilot Projects
- Sepsis/blood
- Sepsis/drug therapy
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Sam Salman
- Medical School, University of Western Australia, Crawley, WA, Australia
| | - Julie Hibbert
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia
| | - Laurens Manning
- Medical School, University of Western Australia, Crawley, WA, Australia
| | - Karen Simmer
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Dorota A Doherty
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia
| | - Sanjay Patole
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Kevin T Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia
| | - Tobias Strunk
- Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Crawley, WA, Australia
- Neonatal Directorate, King Edward Memorial Hospital, Subiaco, WA, Australia
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21
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Poggi C, Dani C. Sepsis and Oxidative Stress in the Newborn: From Pathogenesis to Novel Therapeutic Targets. Oxid Med Cell Longev 2018; 2018:9390140. [PMID: 30174784 DOI: 10.1155/2018/9390140] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 12/15/2022]
Abstract
Sepsis is at present one of the leading causes of morbidity and mortality in the neonatal population. Together with inflammation, oxidative stress is involved in detrimental pathways activated during neonatal sepsis, eventually leading to organ dysfunction and death. The redox cascade during sepsis is mainly initiated by IL-6 and IL-8 stimulation in newborns and includes multiple noxious processes, as direct cell damage induced by reactive oxygen species, activation of gene expression leading to amplification of inflammation and oxidative stress, and impairment of mitochondrial function. Once proinflammatory and prooxidant pathways are established as stimulated by causing pathogens, self-maintaining unfavorable redox cycles ensue, leading to oxidative stress-related cellular damage, independently from the activating pathogens themselves. Despite antioxidant systems are induced during neonatal sepsis, as an adaptive response to an increased oxidative burden, a condition of redox imbalance favoring oxidative pathways occurs, resulting in increased markers of oxidative stress damage. Therefore, antioxidant treatment would exert beneficial effects during neonatal sepsis, potentially interrupting prooxidant pathways and preventing the maintenance of detrimental redox cycles that cannot be directly affected by antibiotic treatment. Among others, antioxidant agents investigated in clinical settings as adjunct treatment for neonatal sepsis include melatonin and pentoxifylline, both showing promising results, while novel antioxidant molecules, as edaravone and endothelin receptor antagonists, are at present under investigation in animal models. Finally, mitochondria-targeted antioxidant treatments could represent an interesting line of research in the treatment of neonatal sepsis.
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22
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Schüller SS, Kramer BW, Villamor E, Spittler A, Berger A, Levy O. Immunomodulation to Prevent or Treat Neonatal Sepsis: Past, Present, and Future. Front Pediatr 2018; 6:199. [PMID: 30073156 PMCID: PMC6060673 DOI: 10.3389/fped.2018.00199] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/25/2018] [Indexed: 12/12/2022] Open
Abstract
Despite continued advances in neonatal medicine, sepsis remains a leading cause of death worldwide in neonatal intensive care units. The clinical presentation of sepsis in neonates varies markedly from that in older children and adults, and distinct acute inflammatory responses results in age-specific inflammatory and protective immune response to infection. This review first provides an overview of the neonatal immune system, then covers current mainstream, and experimental preventive and adjuvant therapies in neonatal sepsis. We also discuss how the distinct physiology of the perinatal period shapes early life immune responses and review strategies to reduce neonatal sepsis-related morbidity and mortality. A summary of studies that characterize immune ontogeny and neonatal sepsis is presented, followed by discussion of clinical trials assessing interventions such as breast milk, lactoferrin, probiotics, and pentoxifylline. Finally, we critically appraise future treatment options such as stem cell therapy, other antimicrobial protein and peptides, and targeting of pattern recognition receptors in an effort to prevent and/or treat sepsis in this highly vulnerable neonatal population.
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Affiliation(s)
- Simone S. Schüller
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, Netherlands
| | - Andreas Spittler
- Department of Surgery, Research Labs & Core Facility Flow Cytometry, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ofer Levy
- Precision Vaccines Program, Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Broad Institute of MIT and Harvard, Boston, MA, United States
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23
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Speer EM, Dowling DJ, Xu J, Ozog LS, Mathew JA, Chander A, Yin D, Levy O. Pentoxifylline, dexamethasone and azithromycin demonstrate distinct age-dependent and synergistic inhibition of TLR- and inflammasome-mediated cytokine production in human newborn and adult blood in vitro. PLoS One 2018; 13:e0196352. [PMID: 29715306 PMCID: PMC5929513 DOI: 10.1371/journal.pone.0196352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/11/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Neonatal inflammation, mediated in part through Toll-like receptor (TLR) and inflammasome signaling, contributes to adverse outcomes including organ injury. Pentoxifylline (PTX), a phosphodiesterase inhibitor which potently suppresses cytokine production in newborn cord blood, is a candidate neonatal anti-inflammatory agent. We hypothesized that combinations of PTX with other anti-inflammatory agents, the steroid dexamethasone (DEX) or the macrolide azithromycin (AZI), may exert broader, more profound and/or synergistic anti-inflammatory activity towards neonatal TLR- and inflammasome-mediated cytokine production. Methods Whole newborn and adult blood was treated with PTX (50–200 μM), DEX (10−10–10−7 M), or AZI (2.5–20 μM), alone or combined, and cultured with lipopolysaccharide (LPS) (TLR4 agonist), R848 (TLR7/8 agonist) or LPS/adenosine triphosphate (ATP) (inflammasome induction). Supernatant and intracellular cytokines, signaling molecules and mRNA were measured by multiplex assay, flow cytometry and real-time PCR. Drug interactions were assessed based on Loewe's additivity. Results PTX, DEX and AZI inhibited TLR- and/or inflammasome-mediated cytokine production in newborn and adult blood, whether added before, simultaneously or after TLR stimulation. PTX preferentially inhibited pro-inflammatory cytokines especially TNF. DEX inhibited IL-10 in newborn, and TNF, IL-1β, IL-6 and interferon-α in newborn and adult blood. AZI inhibited R848-induced TNF, IL-1β, IL-6 and IL-10, and LPS-induced IL-1β and IL-10. (PTX+DEX) synergistically decreased LPS- and LPS/ATP-induced TNF, IL-1β, and IL-6, and R848-induced IL-1β and interferon-α, while (PTX+AZI) synergistically decreased induction of TNF, IL-1β, and IL-6. Synergistic inhibition of TNF production by (PTX+DEX) was especially pronounced in newborn vs. adult blood and was accompanied by reduction of TNF mRNA and enhancement of IL10 mRNA. Conclusions Age, agent, and specific drug-drug combinations exert distinct anti-inflammatory effects towards TLR- and/or inflammasome-mediated cytokine production in human newborn blood in vitro. Synergistic combinations of PTX, DEX and AZI may offer benefit for prevention and/or treatment of neonatal inflammatory conditions while potentially limiting drug exposure and toxicity.
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Affiliation(s)
- Esther M. Speer
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
- * E-mail:
| | - David J. Dowling
- Department of Medicine, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jianjin Xu
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York, United States of America
| | - Lukasz S. Ozog
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Jaime A. Mathew
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Avinash Chander
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Donglei Yin
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York, United States of America
| | - Ofer Levy
- Department of Medicine, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Precision Vaccine Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
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24
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Sass L, Karlowicz MG. Healthcare-Associated Infections in the Neonate. Principles and Practice of Pediatric Infectious Diseases 2018. [PMCID: PMC7152335 DOI: 10.1016/b978-0-323-40181-4.00094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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25
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İpek MS, Aktar F, Okur N, Celik M, Ozbek E. Colistin use in critically ill neonates: A case-control study. Pediatr Neonatol 2017; 58:490-496. [PMID: 28501490 DOI: 10.1016/j.pedneo.2016.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/27/2016] [Accepted: 10/06/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the safety and efficacy of colistin use in critically ill neonates. METHODS This was a case-control study that included newborn infants with proven or suspected nosocomial infections between January 2012 and October 2015, at two centers in Diyarbakir, Turkey. The clinical and laboratory characteristics and outcomes of patients who received colistin therapy were reviewed and compared to patients who were treated with antimicrobial agents other than colistin during the same period. RESULTS Forty-seven cases who received intravenous colistin (colistin group) and 59 control patients (control group) were included. There were no significant differences between the groups regarding outcomes and nephrotoxicity, including acute renal failure. Colistin therapy was associated with significantly reduced serum magnesium (1.38 ± 0.39 mg/dL vs. 1.96 ± 0.39 mg/dL, p < 0.001) and hypokalemia (46.8% vs. 25.4%, p = 0.026). The patients who received colistin also had longer hospital stays (43 (32-70) days vs. 39 (28-55) days, p = 0.047), a higher rate of previous carbapenem exposure (40.4% vs. 11.9%, p = 0.001), and a higher age at the onset of infection (13 (10-21) days vs. 11 (9-15) days, p = 0.03). CONCLUSION This study showed that colistin was both effective and safe for treating neonatal infections caused by multidrug-resistant gram-negative bacteria. However, intravenous colistin use was significantly associated with hypomagnesemia and hypokalemia.
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Affiliation(s)
- Mehmet Sah İpek
- Division of Neonatology, Department of Pediatrics, Memorial Dicle Hospital, Diyarbakir, Turkey.
| | - Fesih Aktar
- Department of Pediatrics, Dicle University Faculty of Medicine, Diyarbakir, Turkey.
| | - Nilufer Okur
- Department of Pediatrics, Maternity and Children's Hospital, Diyarbakir, Turkey.
| | - Muhittin Celik
- Division of Neonatology, Department of Pediatrics, Diyarbakir Children's Hospital, Diyarbakir, Turkey.
| | - Erdal Ozbek
- Department of Microbiology, Maternity and Children's Hospital, Diyarbakir, Turkey.
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Page-Sharp M, Strunk T, Salman S, Hibbert J, Patole SK, Manning L, Batty KT. Simultaneous determination of pentoxifylline, metabolites M1 (lisofylline), M4 and M5, and caffeine in plasma and dried blood spots for pharmacokinetic studies in preterm infants and neonates. J Pharm Biomed Anal 2017; 146:302-313. [PMID: 28903089 DOI: 10.1016/j.jpba.2017.08.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 08/17/2017] [Accepted: 08/19/2017] [Indexed: 11/18/2022]
Abstract
Advances in bioanalytical methods are facilitating micro-volume and dried blood spot (DBS) analysis of drugs in biological matrices for pharmacokinetic studies in children and neonates. We sought to develop a UPLC-MS/MS assay for simultaneous measurement of caffeine, pentoxifylline (PTX) and three metabolites of PTX in both plasma and DBS. Caffeine, PTX, the metabolites M1 (lisofylline), M4 and M5, and the internal standards (caffeine-d9 and PTX-d6) were separated using a Waters Aquity T3 UPLC C18 column and gradient mobile phase (water-methanol-formic acid). Retention times for caffeine, M5, M4, PTX and M1 were 1.6, 1.7, 1.9, 2.0 and 2.1min, respectively, with a run time of 5min. The precision (≤10%) and accuracy (≤15%) across the concentration range 0.1-50mg/L for caffeine, PTX and the three metabolites in plasma and DBS were within accepted limits, as were the limits of quantification (100μg/L for caffeine and 10μg/L for PTX, M1, M4 and M5). Caffeine, PTX and the metabolites were stable in DBS for >34days at room and refrigerated temperatures. Plasma and DBS samples were obtained from 24 preterm infants recruited into a clinical pharmacokinetic study of PTX. Paired analysis indicated that DBS concentrations were 9% lower than concurrent plasma concentrations for caffeine, 7% lower for PTX (consistent with the blood:plasma ratio) and 13% lower for M1 (lisofylline). The validated UPLC-MS/MS method is suitable for micro-volume plasma and DBS analysis of caffeine, PTX and its metabolites for pharmacokinetic studies in paediatric patients.
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Affiliation(s)
- Madhu Page-Sharp
- School of Pharmacy, Curtin University, Bentley, Western Australia, Australia
| | - Tobias Strunk
- King Edward Memorial Hospital for Women & UWA Centre for Neonatal Research and Education, University of Western Australia, Subiaco, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Sam Salman
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Julie Hibbert
- King Edward Memorial Hospital for Women & UWA Centre for Neonatal Research and Education, University of Western Australia, Subiaco, Western Australia, Australia
| | - Sanjay K Patole
- King Edward Memorial Hospital for Women & UWA Centre for Neonatal Research and Education, University of Western Australia, Subiaco, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia; Harry Perkins Research Institute, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Kevin T Batty
- School of Pharmacy, Curtin University, Bentley, Western Australia, Australia.
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Schüller SS, Wisgrill L, Herndl E, Spittler A, Förster-Waldl E, Sadeghi K, Kramer BW, Berger A. Pentoxifylline modulates LPS-induced hyperinflammation in monocytes of preterm infants in vitro. Pediatr Res 2017; 82:215-25. [PMID: 28288151 DOI: 10.1038/pr.2017.41] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 02/08/2017] [Indexed: 12/11/2022]
Abstract
BackgroundPentoxifylline (PTX), a methylxanthine derivate with immunomodulating properties, has been used as adjunctive treatment in severe neonatal sepsis. The aim of the study was to investigate the anti-inflammatory effects of PTX on Lipopolysaccharides (LPS)-stimulated monocytes of preterm neonates in vitro compared with monocytes of term infants and adult controls.MethodsWhole cord blood samples and control adult blood samples were incubated with LPS and PTX. The expression of surface markers, phagocytosis, cytokine secretion, and Toll-like receptor (TLR)4 signaling of monocytes were assessed by flow cytometry. Changes of TLR4-messenger RNA (mRNA) levels were confirmed by reverse-transcriptase PCR.ResultsThe expression of CD14, CD11b, CD64, CD71, and CD80 was downregulated by PTX in a dose-dependent manner; the greatest effect was observed on CD14 and CD11b in preterm infants. PTX markedly downregulated LPS-induced tumor necrosis factor-α, interleukin (IL)-1β, and IL-6 levels in all age groups. Early IL-10 production was significantly downregulated by PTX in term and preterm neonates, while remaining unchanged in adults. Moreover, PTX downregulated TLR4 expression of monocytes on cellular and mRNA level, decreased signaling, and suppressed phagocytosis.ConclusionPTX downregulated TLR4 expression and signaling, thereby leading to strong anti-inflammatory properties in monocytes. Age-dependent differences were identified for CD14 and CD11b expression and IL-10 production.
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Speer EM, Dowling DJ, Ozog LS, Xu J, Yang J, Kennady G, Levy O. Pentoxifylline inhibits TLR- and inflammasome-mediated in vitro inflammatory cytokine production in human blood with greater efficacy and potency in newborns. Pediatr Res 2017; 81:806-816. [PMID: 28072760 DOI: 10.1038/pr.2017.6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/19/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Toll-like receptor (TLR)-mediated inflammation may contribute to neonatal sepsis, for which pentoxifylline (PTX), a phosphodiesterase inhibitor that raises intracellular cAMP, is a candidate adjunctive therapy. We characterized the anti-inflammatory effects of PTX toward TLR-mediated production of inflammatory (tumor necrosis factor (TNF) and interleukin (IL)-1β) and proresolution (IL-6 and IL-10) cytokines in human newborn and adult blood. METHODS Newborn cord and adult blood were treated with PTX (50-400 µmol/l) before, during or after stimulation with LPS (TLR4 agonist), R848 (TLR7/8 agonist) or LPS/ATP (inflammasome activation). Cytokines were measured by multiplex assay (supernatants), intracellular cytokines and signaling molecules by flow cytometry, and mRNA by quantitative real-time PCR. RESULTS Whether added 2 h pre-, simultaneously to, or 2 h post-TLR stimulation, PTX inhibited TLR-mediated cytokine production in a concentration-dependent manner, with greater efficacy and potency in newborn blood, decreasing intracellular TNF and IL-1β with relative preservation of IL-10 and IL-6. PTX decreased TLR-mediated TNF mRNA while increasing IL-10 mRNA. Neonatal plasma factors contributed to the anti-inflammatory effects of PTX in newborn blood that were independent of soluble TNF receptor concentrations, p38 MAPK phosphorylation and IĸB degradation. CONCLUSION PTX is a potent and efficacious inhibitor of TLR-mediated inflammatory cytokines in newborn cord blood and a promising neonatal anti-inflammatory agent.
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Affiliation(s)
- Esther M Speer
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, New York
| | - David J Dowling
- Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Lukasz S Ozog
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jianjin Xu
- Department of Applied Mathematics and Statistics, Stony Brook University School of Medicine, Stony Brook, New York
| | - Jie Yang
- Family, Population, and Preventive Medicine Department, Stony Brook University School of Medicine, Stony Brook, New York
| | - Geetika Kennady
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, New York
| | - Ofer Levy
- Department of Medicine, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Precision Vaccines Program, Boston Children's Hospital, Boston, Massachusetts
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Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a serious multifactorial gastrointestinal disease which is often discovered in premature infants. Various additives have been used to prevent NEC; yet, their relative efficacy and safety remain disputed. This study aims to compare the efficacy and safety of 5 food additives, namely, probiotics, probiotics + fructo-oligosaccharides, pentoxifylline, arginine, and lactoferrin in preventing NEC in neonates. METHODS Embase, PubMed, and Cochrane Library had been searched for all eligible randomized control trials. Odds ratios (ORs) were estimated for dichotomous data and mean differences with 95% credible intervals (CrIs) were estimated for continuous data. Surface under the cumulative ranking curve was used to rank efficacy and safety of the prevention methods on each endpoint. RESULTS A total of 27 eligible studies with 4649 preterm infants were included in this network meta-analysis (NMA), and the efficacy and safety of 5 food additives were evaluated. Probiotic and arginine exhibited better preventive efficacy compared with placebo (OR = 0.50, 95% CrIs: 0.32-0.73; OR = 0.30, 95% CrIs: 0.12-0.73, respectively). Only probiotic achieved a considerable decrease in the risk of mortality compared to placebo (OR = 0.68, 95% CrIs: 0.46-0.98). NEC patients with lactoferrin appeared to have lower incidence of sepsis than those of placebo (OR = 0.13, 95% CrIs: 0.03-0.61) or probiotic (OR = 0.18, 95% CrIs: 0.03-0.83). CONCLUSION Based on this NMA, probiotics had the potential to be the most preferable additive, since it exhibited a significant superiority for NEC and mortality as well as a relatively balanced performance in safety.
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Affiliation(s)
- Wentao Yu
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Wu Sui
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Linsong Mu
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Wenying Yi
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Haijuan Li
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Liqin Wei
- Department of General Surgery and Pediatric Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Medical College
| | - Weihong Yin
- Department of Ultrasound, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
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30
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Ling R, Greenough A. Advances in emerging treatment options to prevent bronchopulmonary dysplasia. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1281736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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