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Nelson BC, Eiras DP, Gomez-Simmonds A, Loo AS, Satlin MJ, Jenkins SG, Whittier S, Calfee DP, Furuya EY, Kubin CJ. Clinical outcomes associated with polymyxin B dose in patients with bloodstream infections due to carbapenem-resistant Gram-negative rods. Antimicrob Agents Chemother 2015; 59:7000-6. [PMID: 26324272 PMCID: PMC4604419 DOI: 10.1128/aac.00844-15] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/26/2015] [Indexed: 11/20/2022] Open
Abstract
There is significant variation in the use of polymyxin B (PMB), and optimal dosing has not been defined. The purpose of this retrospective study was to evaluate the relationship between PMB dose and clinical outcomes. We included patients with bloodstream infections (BSIs) due to carbapenem-resistant Gram-negative rods who received ≥48 h of intravenous PMB. The objective was to evaluate the association between PMB dose and 30-day mortality, clinical cure at day 7, and development of acute kidney injury (AKI). A total of 151 BSIs were included. The overall 30-day mortality was 37.8% (54 of 151), and the median PMB dosage was 1.3 mg/kg (of total body weight)/day. Receipt of PMB dosages of <1.3 mg/kg/day was significantly associated with 30-day mortality (46.5% versus 26.3%; P = 0.02), and this association persisted in multivariable analysis (odds ratio [OR] = 1.58; 95% confidence interval [CI] = 1.05 to 1.81; P = 0.04). Eighty-two percent of patients who received PMB dosages of <1.3 mg/kg/day had baseline renal impairment. Clinical cure at day 7 was not significantly different between dosing groups. AKI was more common in patients receiving PMB dosages of ≥250 mg/day (66.7% versus 32.0%; P = 0.03), and this association persisted in multivariable analysis (OR = 4.32; 95% CI = 1.15 to 16.25; P = 0.03). PMB dosages of <1.3 mg/kg/day were administered primarily to patients with renal impairment, and this dosing was independently associated with 30-day mortality. However, dosages of ≥250 mg/day were independently associated with AKI. These data support the use of PMB without dose reduction in the setting of renal impairment.
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Affiliation(s)
- Brian C Nelson
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Daniel P Eiras
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Angela Gomez-Simmonds
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Angela S Loo
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Michael J Satlin
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Stephen G Jenkins
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Susan Whittier
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - David P Calfee
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - E Yoko Furuya
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Christine J Kubin
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
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Abstract
INTRODUCTION The emergence of multidrug-resistant gram-negative bacteria has led to the increasing use of polymyxins. Nephrotoxicity and, to a lesser degree, neurotoxicity occur often during systemic polymyxin therapy. Scientific evidence regarding safety associated with polymyxins remains limited. AREAS COVERED Case reports/case series, observational studies and clinical trials assessing safety and toxicity of polymyxins were critically reviewed. EXPERT OPINION Polymyxins are drugs with a narrow therapeutic range. Nephrotoxicity is associated with both host factors and polymyxin exposure, and recent studies suggest that the relative risk of nephrotoxicity is similar for colistin and polymyxin B. Studies that have examined the safety of polymyxins have several limitations. Considering the available evidence, toxicities that may develop while on polymyxin therapy most often are mild to moderate in magnitude and reversible in nature. Strategies to minimize toxicity associated with polymyxins have evolved and include avoidance of toxic medications, careful dosing, use of critical care, therapeutic drug monitoring and development of polymyxin derivatives. However, given that polymyxin use has re-emerged in an era of increased antimicrobial resistance, the presence of other treatment modalities may be limited. Therefore, clinicians must consider overall risk to benefit ratio of continuing versus stopping polymyxin treatment and optimize minimization strategies to reduce polymyxin-induced toxicities.
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Affiliation(s)
- Theodoros Kelesidis
- a 1 University of California, David Geffen School of Medicine, Division of Infectious Diseases, Department of Medicine , Los Angeles, CA 90095, USA
| | - Matthew E Falagas
- b 2 Alfa Institute of Biomedical Sciences (AIBS) , 9 Neapoleos Street, 151 23 Marousi, Athens, Greece +30 69 46 11 00 00 ; +30 21 06 83 96 05 ;
- c 3 Tufts University School of Medicine, Department of Medicine , Boston, MA, USA
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Nation RL, Li J, Cars O, Couet W, Dudley MN, Kaye KS, Mouton JW, Paterson DL, Tam VH, Theuretzbacher U, Tsuji BT, Turnidge JD. Framework for optimisation of the clinical use of colistin and polymyxin B: the Prato polymyxin consensus. THE LANCET. INFECTIOUS DISEASES 2015; 15:225-34. [DOI: 10.1016/s1473-3099(14)70850-3] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Justo JA, Bosso JA. Adverse Reactions Associated with Systemic Polymyxin Therapy. Pharmacotherapy 2014; 35:28-33. [DOI: 10.1002/phar.1493] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences; South Carolina College of Pharmacy; Columbia and Charleston South Carolina
| | - John A. Bosso
- Department of Clinical Pharmacy and Outcomes Sciences; South Carolina College of Pharmacy; Columbia and Charleston South Carolina
- Division of Infectious Diseases; Department of Medicine; Medical University of South Carolina College of Medicine; Charleston South Carolina
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Nation RL, Velkov T, Li J. Colistin and polymyxin B: peas in a pod, or chalk and cheese? Clin Infect Dis 2014; 59:88-94. [PMID: 24700659 DOI: 10.1093/cid/ciu213] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Colistin and polymyxin B have indistinguishable microbiological activity in vitro, but they differ in the form administered parenterally to patients. Polymyxin B is administered directly as the active antibiotic, whereas colistin is administered as the inactive prodrug, colistin methanesulfonate (CMS). CMS must be converted to colistin in vivo, but this occurs slowly and incompletely. Here we summarize the key differences between parenteral CMS/colistin and polymyxin B, and highlight the clinical implications. We put forth the view that overall polymyxin B has superior clinical pharmacological properties compared with CMS/colistin. We propose that in countries such as the United States where parenteral products of both colistin and polymyxin B are available, prospective studies should be conducted to formally examine their relative efficacy and safety in various types of infections and patients. In the meantime, where clinicians have access to both polymyxins, they should carefully consider the relative merits of each in a given circumstance.
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Affiliation(s)
- Roger L Nation
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Tony Velkov
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jian Li
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
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Tuon FF, Rigatto MH, Lopes CK, Kamei LK, Rocha JL, Zavascki AP. Risk factors for acute kidney injury in patients treated with polymyxin B or colistin methanesulfonate sodium. Int J Antimicrob Agents 2014; 43:349-52. [DOI: 10.1016/j.ijantimicag.2013.12.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 12/01/2013] [Indexed: 01/29/2023]
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In vitro assessment and multicenter cohort study of comparative nephrotoxicity rates associated with colistimethate versus polymyxin B therapy. Antimicrob Agents Chemother 2014; 58:2740-6. [PMID: 24566187 DOI: 10.1128/aac.02476-13] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Despite concerns of nephrotoxicity, polymyxin antibiotics often remain the only susceptible agents for multidrug-resistant (MDR) Gram-negative bacteria. Colistin has been more commonly used clinically due to a perceived safety benefit. We compared the nephrotoxicity of colistin to polymyxin B. The in vitro cytotoxicity of colistin was compared to polymyxin B in two mammalian renal cell lines. To validate the clinical relevance of the findings, we evaluated adult patients with normal renal function who received a minimum of 72 h of polymyxin therapy in a multicenter study. The primary outcome was the prevalence of nephrotoxicity, as defined by the RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria. Colistin exhibited an in vitro cytotoxicity profile similar to polymyxin B. A total of 225 patients (121 receiving colistimethate, 104 receiving polymyxin B) were evaluated. Independent risk factors for colistimethate-associated nephrotoxicity included age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.00 to 1.07; P = 0.03), duration of therapy (OR 1.08; 95% CI, 1.02 to 1.15; P = 0.02), and daily dose by ideal body weight (OR 1.40; 95% CI, 1.05 to 1.88; P = 0.02). In contrast, cystic fibrosis was found to be a protective factor in patients who received colistimethate (OR, 0.03; 95% CI, 0.001 to 0.79; P = 0.04). In a matched analysis based on the risk factors identified (n = 76), the prevalence of nephrotoxicity was higher with colistimethate than with polymyxin B (55.3% versus 21.1%; P = 0.004). Polymyxin B was not found to be more nephrotoxic than colistin and may be the preferred polymyxin for MDR infections. A prospective study comparing the two polymyxins directly is warranted.
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Risk factors for treatment failure of polymyxin B monotherapy for carbapenem-resistant Klebsiella pneumoniae infections. Antimicrob Agents Chemother 2013; 57:5394-7. [PMID: 23959321 DOI: 10.1128/aac.00510-13] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Polymyxins are reserved for salvage therapy of infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP). Though synergy has been demonstrated for the combination of polymyxins with carbapenems or tigecycline, in vitro synergy tests are nonstandardized, and the clinical effect of synergy remains unclear. This study describes outcomes for patients with CRKP infections who were treated with polymyxin B monotherapy. We retrospectively reviewed the medical records of patients with CRKP infections who received polymyxin B monotherapy from 2007 to 2011. Clinical, microbiology, and antimicrobial treatment data were collected. Risk factors for treatment failure were identified by logistic regression. Forty patients were included in the analysis. Twenty-nine of 40 (73%) patients achieved clinical cure as defined by clinician-documented improvement in signs and symptoms of infections, and 17/32 (53%) patients with follow-up culture data achieved microbiological cure. End-of-treatment mortality was 10%, and 30-day mortality was 28%. In a multivariate analysis, baseline renal insufficiency was associated with a 6.0-fold increase in clinical failure after adjusting for septic shock (odds ratio [OR] = 6.0; 95% confidence interval [CI] = 1.22 to 29.59). Breakthrough infections with organisms intrinsically resistant to polymyxins occurred in 3 patients during the treatment. Eighteen of 40 (45%) patients developed a new CRKP infection a median of 23 days after initial polymyxin B treatment, and 3 of these 18 infections were polymyxin resistant. The clinical cure rate achieved in this retrospective study was 73% of patients with CRKP infections treated with polymyxin B monotherapy. Baseline renal insufficiency was a risk factor for treatment failure after adjusting for septic shock. Breakthrough infections with organisms intrinsically resistant to polymyxin B and development of resistance to polymyxin B in subsequent CRKP isolates are of concern.
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59
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Akajagbor DS, Wilson SL, Shere-Wolfe KD, Dakum P, Charurat ME, Gilliam BL. Higher incidence of acute kidney injury with intravenous colistimethate sodium compared with polymyxin B in critically ill patients at a tertiary care medical center. Clin Infect Dis 2013; 57:1300-3. [PMID: 23840000 DOI: 10.1093/cid/cit453] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nephrotoxicity was assessed in 173 critically ill patients receiving intravenous colistin or polymyxin B; it occurred in 60.4% and 41.8%, respectively. Further investigation is necessary to elucidate the reason for the difference in nephrotoxicity observed between the groups and to assess the impact of severity of illness and dosing/administration.
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Affiliation(s)
- Darowan S Akajagbor
- Department of Pharmacy Practice, D'Youville College School of Pharmacy, Buffalo
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60
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Gaspar MC, Couet W, Olivier JC, Pais AACC, Sousa JJS. Pseudomonas aeruginosa infection in cystic fibrosis lung disease and new perspectives of treatment: a review. Eur J Clin Microbiol Infect Dis 2013; 32:1231-52. [DOI: 10.1007/s10096-013-1876-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/01/2013] [Indexed: 12/20/2022]
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David SA. Antimicrobial peptides for gram-negative sepsis: a case for the polymyxins. Front Immunol 2012; 3:252. [PMID: 22912638 PMCID: PMC3419356 DOI: 10.3389/fimmu.2012.00252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 07/30/2012] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sunil A David
- Department of Medicinal Chemistry, University of Kansas Lawrence, KS, USA
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62
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Quale J, Shah N, Kelly P, Babu E, Backer M, Rosas-Garcia G, Salamera J, George A, Bratu S, Landman D. Activity of Polymyxin B and the Novel Polymyxin Analogue CB-182,804 Against Contemporary Gram-Negative Pathogens in New York City. Microb Drug Resist 2012; 18:132-6. [DOI: 10.1089/mdr.2011.0163] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- John Quale
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Neha Shah
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Paul Kelly
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Elizabeth Babu
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Martin Backer
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | | | - Julius Salamera
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Avrille George
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Simona Bratu
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - David Landman
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
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Kubin CJ, Ellman TM, Phadke V, Haynes LJ, Calfee DP, Yin MT. Incidence and predictors of acute kidney injury associated with intravenous polymyxin B therapy. J Infect 2012; 65:80-7. [PMID: 22326553 DOI: 10.1016/j.jinf.2012.01.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/19/2012] [Accepted: 01/27/2012] [Indexed: 10/14/2022]
Abstract
BACKGROUND Increases in multidrug-resistance among gram-negative organisms have necessitated the use of polymyxins. To date, the incidence of acute kidney injury (AKI) associated with polymyxin B has not been evaluated using RIFLE criteria. METHODS Adult patients who received polymyxin B were retrospectively evaluated to determine the incidence of AKI during polymyxin B therapy using RIFLE criteria. Predictors of AKI were identified by comparing characteristics of patients with and without AKI. RESULTS A total of 73 patients were included. The incidence of AKI was 60%. Ten (14%) patients discontinued therapy due to nephrotoxicity. Median duration of polymyxin B was 11 days with a median cumulative dose of 18 mg/kg. Concomitant nephrotoxins were received in 69 (95%). Patients with AKI had a higher median cumulative dose (1578 mg vs. 800 mg; p = 0.02), a higher body mass index (BMI) (27.2 vs. 24.5 kg/m(2); p = 0.03), and were more likely to receive vancomycin (82% vs. 55%; p = 0.03) compared to those without AKI. After controlling for polymyxin B duration, independent predictors of AKI were higher BMI and concomitant vancomycin. CONCLUSIONS The incidence of AKI during polymyxin B therapy was 60%. Further studies are needed to define dosing parameters that maximize efficacy and minimize nephrotoxicity.
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Affiliation(s)
- Christine J Kubin
- Department of Pharmacy, New York-Presbyterian Hospital, 630 W. 168th Street, New York, NY 10032, USA.
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Abstract
With more antibiotic resistance and emerging pathogens in cystic fibrosis (CF) patients, the need for new strategies in the lifelong treatment of pulmonary infection has increased. Most of the focus is on chronic infection with Pseudomonas aeruginosa, which is still thought to be the main pathogen leading to advanced CF lung disease. Other bacterial species are also recognized in the pathogenesis of CF lung disease, even though their definitive role is not well established yet. Clearly, expansion of treatment options is urgently needed. This article focuses on recent developments in the field of new antimicrobial strategies for CF. It is clear that studies on new classes of antibiotics or antimicrobial-like drugs are scarce, and that most studies involve new (inhalation) formulations, new routes of delivery, or analogs of existing classes of antibiotics. Studies of new antibiotic-like drugs are, in most cases, in preclinical phases of development and only a few of these agents may reach the market. Importantly, new inhaled antibiotics, e.g. aztreonam, levofloxacin, and fosfomycin, and new, more efficient delivery systems such as dry powder inhalation and liposomes for current antibiotics are in the clinical phase of development. These developments will be of great importance in improving effective treatment and reducing the treatment burden for CF patients in the near future.
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Affiliation(s)
- Mireille van Westreenen
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands.
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Vaara M. Polymyxins and their novel derivatives. Curr Opin Microbiol 2010; 13:574-81. [PMID: 20869908 DOI: 10.1016/j.mib.2010.09.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 08/31/2010] [Accepted: 09/02/2010] [Indexed: 11/18/2022]
Abstract
The emerging very multiresistant Gram-negative bacteria cause remarkable therapeutic challenges. There are no novel classes of agents in clinical development for the treatment of Gram-negative infections. Polymyxins (polymyxin B and colistin) were abandoned in the seventies but are now back in the therapy as the last resort. Their nephrotoxicity may complicate the therapy or even necessitate its discontinuation. Less toxic polymyxin derivatives would be highly welcome. Novel derivatives lack in strategic positions two of the five cationic charges of polymyxins, differ from polymyxins in their renal handling and affinity to kidney brush-border membrane, and are in preclinical studies. Less characterized other recent derivatives, also reviewed here, have increased the collective knowledge on the structure-function relationships in polymyxins. Acquired resistance to polymyxins has been encountered. However, the resistance mechanism compromises the function of the bacterial outer membrane as a permeability barrier to other noxious agents.
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Affiliation(s)
- Martti Vaara
- Northern Antibiotics Ltd., Eskolantie 1, POB 72, FI-00720 Helsinki, Finland; Division of Clinical Microbiology, Helsinki University Hospital, Haartmaninkatu 3, POB 30, FI-00029 HUSLAB, Helsinki, Finland.
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Elias LS, Konzen D, Krebs JM, Zavascki AP. The impact of polymyxin B dosage on in-hospital mortality of patients treated with this antibiotic. J Antimicrob Chemother 2010; 65:2231-7. [PMID: 20685752 DOI: 10.1093/jac/dkq285] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To assess the impact of dosage on in-hospital mortality of patients receiving intravenous polymyxin B. METHODS A retrospective cohort study was performed from January 2003 to December 2009. Patients ≥ 18 years receiving intravenous polymyxin B for ≥ 72 h were analysed. Clinical covariates were assessed and data were retrieved from medical records. Subgroup analyses were performed in patients with microbiologically confirmed infections and in patients with bacteraemia. Renal toxicity was also assessed. Logistic regression models (LRMs) were performed for the entire cohort and subgroups. RESULTS A total of 276 patients were included. The overall in-hospital mortality was 60.5% (167 of 276). The final LRM showed that severe sepsis or septic shock [adjusted odds ratio (aOR) 4.07; 95% confidence interval (CI) 2.22-7.46], presence of mechanical ventilation (aOR 3.14; 95% CI 1.73-5.71), Charlson co-morbidity score (aOR 1.25; 95% CI 1.09-1.44) and age (aOR 1.02; 95% CI 1.01-1.04) were independently associated with increased in-hospital mortality, while ≥ 200 mg/day polymyxin B was associated with lower risk for this outcome (aOR 0.43; 95% CI 0.23-0.79). The effect of ≥ 200 mg/day polymyxin B on in-hospital mortality was higher in both subgroups (microbiologically documented infections and bacteraemia). Patients receiving ≥ 200 mg/day of polymyxin B had significantly higher risk of severe renal impairment. CONCLUSION A dosage of ≥ 200 mg/day polymyxin B was associated with lower in-hospital mortality. The benefit of these higher doses outweighed the risk of severe renal dysfunction during therapy. Large prospective studies including pharmacokinetic/pharmacodynamic analysis are still required to define the best dosage regimens of polymyxin B.
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Affiliation(s)
- Laura S Elias
- Infection Control Service, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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