Polymyxins: pharmacology, pharmacokinetics, pharmacodynamics, and clinical applications

Identification of impurities in polymyxin B and colistin bulk sample using liquid chromatography coupled to mass spectrometry

The European Pharmacopoeia (Ph. Eur.) describes liquid chromatography-ultraviolet (LC-UV) methods using C(18) stationary phases for the analysis of polymyxin B and colistin. Several unknown impurities were detected in commercial samples of those polypeptide complexes. However, the Ph. Eur. does not specify any related substances for polymyxin B and colistin. Since both methods use non-volatile buffers, the mobile phases were incompatible with mass spectrometry (MS). For the identification of related substances in bulk samples by LC/MS, volatile mobile phase systems were developed. However, the LC/MS methods (with volatile additives) showed inferior chromatographic separation compared to the LC-UV method (with non-volatile additives). Moreover, previously identified impurities by LC/MS could not be assigned in LC-UV methods as the separation in both systems was different. In this study, known impurities were traced in the LC-UV methods and new impurities present in polymyxin B and colistin bulk samples were characterized. To achieve this, each peak from the non-volatile system was collected separately and reinjected into an LC system with a volatile mobile phase coupled to MS. This way, collected impurity peaks were rechromatographed on a reversed phase column in order to separate the analyte from the buffer salts. Using this method, out of 39 peaks, five novel related substances were characterized in a polymyxin B bulk sample. Fourteen impurities, which were already reported in the literature were traced as good as possible in the LC-UV method. In the case of colistin, a total of 36 peaks were investigated, among which four new compounds. Additionally, 30 known impurities were traced in the LC-UV method.

Safety and efficacy of polymyxin B in multidrug resistant Gram-negative severe sepsis and septic shock

BACKGROUND AND AIMS

The emergence of multidrug resistant strains of Gram-negative bacteria, especially the lactose nonfermenters like Pseudomonas and Acinetobacter, in the intensive care units have prompted renewed worldwide interest in the polymyxins. However, perceived nephrotoxicity has been a major vexation limiting their early and regular use in severe sepsis. This study was conducted to assess the safety and efficacy of polymyxin B in patients with severe sepsis and septic shock.

MATERIALS AND METHODS

Forty-five patients with sepsis admitted in our medical-surgical intensive care units were identified from pharmacy records to have received polymyxin B. We retrospectively reviewed the clinical and microbiologic outcomes as well as occurrence of renal failure temporally related to the use of intravenous polymyxin B.

RESULTS

polymyxin B was used in severe sepsis and septic shock with the isolated organism being resistant to other available antimicrobials or clinical deterioration despite carbapenem use. Overall mortality was 52% and among patients who received at least eight days of intravenous polymyxin B, 67% patients with initial septic shock and 62% with severe sepsis survived. The target multidrug resistant organism was cleared in 88% of subjects evaluated by repeat microbiologic testing. Acute renal failure developed in only two patients (4%).

CONCLUSIONS

Polymyxin B has acceptable effectiveness against nosocomial multidrug resistant Gram-negative sepsis. The associated nephrotoxicity has been found to be significantly lower than previously reported even in patients with background renal impairment and established risk factors of renal failure.

Current use for old antibacterial agents: polymyxins, rifamycins, and aminoglycosides

This article reviews three classes of antibacterial agents that are uncommonly used in bacterial infections and therefore can be thought of as special-use agents. The polymyxins are reserved for gram-negative bacilli that are resistant to virtually all other classes of drugs. Rifampin is used therapeutically, occasionally as a companion drug in treatment of refractory gram-positive coccal infections, especially those involving foreign bodies. Rifaximin is a new rifamycin that is a strict enteric antibiotic approved for treatment of traveler's diarrhea and is showing promise as a possible agent for refractory Clostridium difficile infections. The aminoglycosides are used mainly as companion drugs for the treatment of resistant gram-negative bacillary infections and for gram-positive coccal endocarditis.

Toxicity and gut associated lymphoid tissue translocation of polymyxin B orally administered by alginate/chitosan microparticles in rats

Fluorescent calcium alginate/chitosan microparticles, prepared using a spray-drying technique followed by crosslinking reactions with calcium ions and chitosan, were assayed in-vivo for polymyxin B (PMB) oral toxicity, uptake by Peyer's patches and PMB oral absorption. A single PMB dose (300 mg kg−1), loaded in microparticles or dissolved in water, was administered to rats by oral gavage under fasted and fed conditions. By monitoring incidence of mortality, animal behaviour, clinical signs and abnormality in several organs, PMB in water solution was found lethal at a dose lower than the LD50 (790 mg kg−1) in the fasted state and toxic for the gastrointestinal tract in the fed state. However, no signs of acute toxicity at the level of the gastrointestinal tract were observed when animals were administered PMB loaded in microparticles under fasted and fed conditions. A lower PMB dose (125 mg kg−1), loaded in microparticles or dissolved in water, was given to rats in a fed state to determine PMB levels in Peyer's patches, urine and serum as well as to detect the loaded microparticles inside Peyer's patches for three days after dosing. Abnormalities were observed at gut level only when PMB was dosed in a water solution. Detectable antibiotic levels in Peyer's patches and urine as well as more constant PMB serum concentrations were provided by dosing PMB loaded in microparticles. Therefore, the use of alginate/chitosan microparticles to target the lymphatic system could improve safety when administering PMB orally.

Evaluation of the anti-endotoxin effects of polymyxin B in a feline model of endotoxemia

Directed, effective therapies for feline sepsis are needed to reduce the high morbidity and mortality associated with this disease. We investigated the anti-endotoxin effects of polymyxin B (PMB) in a blinded, placebo controlled fashion, both ex vivo in a feline whole blood culture system and in vivo, using a low-dose endotoxin infusion in cats. Serial measures of systemic inflammation, and hemodynamic stability, were compared between groups. Ex vivo, PMB significantly decreased lipopolysaccharide-induced tumor necrosis factor (TNF) production from whole blood. PMB (1mg/kg over 30min) demonstrated anti-endotoxin effects in vivo, including decreased peak plasma TNF activity (P<0.001) and increased white blood cell count (P=0.019), with no adverse effects. Given the apparent safety and anti-endotoxin effects of PMB in this endotoxemia model, a carefully designed, randomized, blinded, placebo controlled clinical trial evaluating the use of PMB in naturally occurring Gram-negative feline sepsis should be considered.

Subinhibitory concentrations of the cationic antimicrobial peptide colistin induce the pseudomonas quinolone signal in Pseudomonas aeruginosa

Colistin is an important cationic antimicrobial peptide (CAMP) in the fight against Pseudomonas aeruginosa infection in cystic fibrosis (CF) lungs. The effects of subinhibitory concentrations of colistin on gene expression in P. aeruginosa were investigated by transcriptome and functional genomic approaches. Analysis revealed altered expression of 30 genes representing a variety of pathways associated with virulence and bacterial colonization in chronic infection. These included response to osmotic stress, motility, and biofilm formation, as well as genes associated with LPS modification and quorum sensing (QS). Most striking was the upregulation of Pseudomonas quinolone signal (PQS) biosynthesis genes, including pqsH, pqsB and pqsE, and the phenazine biosynthesis operon. Induction of this central component of the QS network following exposure to subinhibitory concentrations of colistin may represent a switch to a more robust population, with increased fitness in the competitive environment of the CF lung.

Contribution of each amino acid residue in polymyxin B(3) to antimicrobial and lipopolysaccharide binding activity

This study on the structure-activity relationship of polymyxin B, a cyclic peptide antibiotic, used sixteen synthetic polymyxin B(3) analogs including alanine scanning analogs to elucidate the contribution of the side chains to antimicrobial activity and lipopolysaccharide (LPS) binding. Of these analogs, [Ala(5)]-polymyxin B(3) showed greatly reduced antimicrobial activity against Escherichia coli (E. coli), Salmonella Typhimurium (S. Typhimurium) and Pseudomonas aeruginosa (P. aeruginosa) with MIC values of 4-16 nmol/ml, suggesting that the Dab (alpha,gamma-diaminobutyric acid) residue at position 5 is the most important residue contributing to bactericidal activity. The antibacterial contribution of Dab when located within the lactam ring (positions 5, 8 and 9) was greater than when located outside the ring (positions 1 and 3). [D-Ala(6)]-, [L-Phe(6)]-, [Ala(7)]-, and [Gly(7)]-polymyxin B(3) analogs retained potent antimicrobial activity, indicating that neither the reduction of hydrophobic character of the D-Phe(6)-Leu(7) region nor the D-configuration at position 6 is indispensable for antimicrobial activity. LPS binding studies showed that decreased hydrophobicity of the lactam ring had little effect, but the N(gamma)-amino function of the Dab residues at position 1, 3, 5, 8 and 9 greatly affected LPS binding, with the contribution of Dab(5) being the most significant.

Identification of a polymyxin synthetase gene cluster of Paenibacillus polymyxa and heterologous expression of the gene in Bacillus subtilis

Polymyxin, a long-known peptide antibiotic, has recently been reintroduced in clinical practice because it is sometimes the only available antibiotic for the treatment of multidrug-resistant gram-negative pathogenic bacteria. Lack of information on the biosynthetic genes of polymyxin, however, has limited the study of structure-function relationships and the development of improved polymyxins. During whole genome sequencing of Paenibacillus polymyxa E681, a plant growth-promoting rhizobacterium, we identified a gene cluster encoding polymyxin synthetase. Here, we report the complete sequence of the gene cluster and its function in polymyxin biosynthesis. The gene cluster spanning the 40.6-kb region consists of five open reading frames, designated pmxA, pmxB, pmxC, pmxD, and pmxE. The pmxC and pmxD genes are similar to genes that encode transport proteins, while pmxA, pmxB, and pmxE encode polymyxin synthetases. The insertional disruption of pmxE led to a loss of the ability to produce polymyxin. Introduction of the pmx gene cluster into the amyE locus of the Bacillus subtilis chromosome resulted in the production of polymyxin in the presence of extracellularly added L-2,4-diaminobutyric acid. Taken together, our findings demonstrate that the pmx gene cluster is responsible for polymyxin biosynthesis.

Neurotoxicity in patients treated with intravenous polymyxin B: Two case reports

PURPOSE

Two cases of reversible neurotoxicity associated with the administration of intravenous polymyxin B are described.

SUMMARY

In the first case, a 60-year-old, obese, white woman with a medical history of recurring urinary tract infections, nephrolithiasis, and chronic renal insufficiency was admitted for parenteral antibiotics for dysuria and hematuria despite outpatient management with oral antibiotics. Her urinalysis revealed pyuria and large blood content. The corresponding urine culture contained >or=100,000 colony-forming units/mL of multidrug-resistant (MDR) Klebsiella pneumoniae. The patient was treated with polymyxin B at 20,000 units/kg i.v. as a loading dose and then 10,000 units/kg i.v. daily based on her renal function. The patient experienced oral paresthesia that resolved upon discontinuation of the infusion with no further complications. In the second case, a 57-year-old white man with hypertension and ascending cholangitis was admitted. He required percutaneous drainage of an infected pancreatic cyst and received polymyxin B at 25,000 units/kg i.v. as a loading dose and then 15,000 units/kg i.v. daily in addition to imipenem-cilastatin based on the sensitivities of two organisms (Escherichia coli and MDR K. pneumoniae) isolated from the abdominal drainage. For his pancreatic abscess, the patient received a prolonged course of polymyxin B, which was well tolerated for the first four weeks. On day 30 of the polymyxin B, the patient reported oral and lower extremity paresthesias. The symptoms resolved upon discontinuation of the polymyxin B.

CONCLUSION

Two patients developed symptoms of neurotoxicity after receiving intravenous polymyxin B for the treatment of MDR gram-negative infections.

Polymyxins: A Review of the Current Status Including Recent Developments

Introduction: Polymyxins have become the drug of choice for treatment of multidrug-resistant gram-negative bacilli infections in Singapore, simply because these pathogens are only susceptible to either aminoglycosides and polymyxins, or polymyxins only. Furthermore, there is no new antibiotic in the pipeline that targets these difficult-to-treat infections. Materials and Methods: All published literatures (up to end of February 2008) regarding polymyxins are included for review. Results: This review serves to give a summary of polymyxins from the current available literature, highlighting relevant clinical studies and information that help to guide informed prescription of polymyxins, should the need arise. Conclusions: However, there are substantial information gaps that needed to be filled urgently, to preserve the clinical utility of this very last line of antibiotic. Key words: Acinetobacter baumannii, Colistin, Multidrug resistance, Polymyxin B, Pseudomonas aeruginosa

Development and validation of a reversed-phase high-performance liquid chromatography assay for polymyxin B in human plasma

OBJECTIVES

The purpose of this study was to develop a specific, sensitive, accurate and reproducible high-performance liquid chromatographic (HPLC) method to measure polymyxin B in human plasma.

METHODS

Derivatization of polymyxin B with fluorescent 9-fluorenylmethyl chloroformate (FMOC-Cl) was performed in the same solid-phase extraction C18 cartridge used for the sample pre-treatment. Reversed-phase HPLC was employed with fluorometric detection. The summed peak areas of polymyxin B1 and B2 derivatives were used for quantification. Stability of polymyxin B FMOC derivatives was examined at room temperature for 6 days. Specificity was investigated against seven potentially co-administered antibiotics. Accuracy and reproducibility of the HPLC assay were determined by inter- and intra-day validation.

RESULTS

The derivatives of polymyxin B2 and B1 were well resolved and had retention times of 4.75 and 5.55 min, respectively. Good linearity (r(2) > 0.99) was obtained between 0.125 and 4.00 mg/L polymyxin B in human plasma with good accuracy and reproducibility at the limit of quantification (0.125 mg/L). Intra- and inter-day validation demonstrated good accuracy and reproducibility for quality control samples with nominal concentrations of 0.30 and 3.00 mg/L. FMOC derivatives of polymyxin B were stable for at least 3 days at room temperature. None of the possibly co-administered antibiotics tested interfered with the chromatographic analysis of the polymyxin B FMOC derivatives.

CONCLUSIONS

A rapid, specific, sensitive, accurate and reproducible HPLC method has been developed and validated to measure polymyxin B in human plasma. The method is suitable for clinical pharmacokinetic studies.

Antimicrobial therapy for Stenotrophomonas maltophilia infections

Stenotrophomonas maltophilia has emerged as an important nosocomial pathogen capable of causing respiratory, bloodstream, and urinary infections. The treatment of nosocomial infections by S. maltophilia is difficult, as this pathogen shows high levels of intrinsic or acquired resistance to different antimicrobial agents, drastically reducing the antibiotic options available for treatment. Intrinsic resistance may be due to reduced outer membrane permeability or to the multidrug efflux pumps. However, specific mechanisms of resistance such as aminoglycoside-modifying enzymes or the heterogeneous production of metallo-beta-lactamase have contributed to the multidrug-resistant phenotype displayed by this pathogen. Moreover, the lack of standardized susceptibility tests and their interpretative criteria hinder the choice of an adequate antibiotic treatment. Recommendations for the treatment of infections by S. maltophilia are based on in vitro studies, certain nonrandomized clinical trials, and anecdotal experience. Trimethoprim-sulfamethoxazole remains the drug of choice, although in vitro studies indicate that ticarcillin-clavulanic acid, minocycline, some of the new fluoroquinolones, and tigecycline may be useful agents. This review describes the main resistance mechanisms, the in vitro susceptibility profile, and treatment options for S. maltophilia infections.

Polymyxin antibiotics for gram-negative infections

PURPOSE

The role of polymyxin antibiotics in the treatment of multidrug-resistant gram-negative infections is reviewed.

SUMMARY

Antimicrobial resistance is an increasing problem across hospitals worldwide, especially in intensive care settings, where nosocomial infections are 5-10 times more likely to occur than on the general wards. The polymyxins, a group of basic polypeptide antibiotics, were first isolated from Bacillus species in the late 1940s and appear to have a surface detergent effect, making them active against most gram-negative organisms. Early clinical reports suggested a high rate of toxicity associated with the polymyxins, specifically nephrotoxicity (20%) and neurotoxicity (7%); thus the polymyxins had largely fallen out of favor. However, recent studies have suggested that the toxicities associated with the polymyxins may be less severe and less frequent than earlier reports. The emergence of multidrug-resistant gram-negative organisms has led to a reemergence in the use of this antibiotic class. Various clinical trials that evaluated the polymyxins for the treatment of multidrug-resistant gram-negative organisms found that these antibiotics have acceptable effectiveness and may be used if necessary.

CONCLUSION

The polymyxins have become a last resort for the treatment of infections caused by multidrug-resistant gram-negative organisms. Recent studies have suggested that the frequency of polymyxin-associated nephrotoxicity and neurotoxicity may not be as high as was once thought. The polymyxins seem to be effective in treating various infections caused by multidrug-resistant gram-negative organisms but should not be used as first-line therapy until more is known about this class of antibiotics.

Intraventricular or intrathecal use of polymyxins in patients with Gram-negative meningitis: a systematic review of the available evidence

Several reports have described the use of polymyxins by the intraventricular or intrathecal route for multidrug-resistant Gram-negative meningitis. We reviewed the available clinical evidence regarding intraventricular/intrathecal administration of polymyxins in patients with meningitis, focusing on effectiveness and safety. Relevant studies were identified from PubMed (January 1950 to April 2006) as well as from the references of relevant articles. We identified 31 case reports/series that matched our inclusion criteria. Sixty-four episodes of Gram-negative meningitis (34 in adults) were reviewed. Monotherapy with polymyxins via the intraventricular or intrathecal route was used in 11 episodes and combination of systemic and local polymyxins was used in 25 episodes. In the remaining episodes, various combinations of local polymyxins with systemic and/or local antibiotics were administered. Cure was achieved in 51/64 episodes (80%); in 26/30 episodes (87%) due to Pseudomonas aeruginosa and in 10/11 episodes (91%) due to Acinetobacter spp. Toxicity related to local administration of polymyxins was noted in 17/60 (28%) patients. The most common toxicity was meningeal irritation (12 cases). Discontinuation of treatment was necessary in four episodes and dose reduction in four episodes; irreversible toxicity was not reported. The limited available evidence suggests that therapy with intraventricular/intrathecal polymyxins alone or in combination with systemic antimicrobial agents is effective against Gram-negative meningitis. Toxicity is not uncommon but it is dose-dependent and reversible. Further studies are needed to evaluate the criteria for initiation of local central nervous system treatment with polymyxins, the optimal dosages and the role of adjuvant systemic or local therapy.

New uses for older antibiotics: nitrofurantoin, amikacin, colistin, polymyxin B, doxycycline, and minocycline revisited

Nitrofurantoin, amikacin, colistin, polymyxin B, doxycycline, and minocycline are antibiotics with proven effectiveness against selected pathogens. These antibiotics have not developed resistance over time. As "low-resistance potential antibiotics" that are effective against an increasing number of infections due to resistant gram-positive or gram-negative pathogens, these antimicrobials remain an important part of the antibiotic armamentarium. They will be used increasingly in the future, as highly resistant organisms continue to be important clinically and therapeutic options remain limited.

Quinolones sensitize gram-negative bacteria to antimicrobial peptides

The treatment of infections caused by bacteria resistant to the vast majority of antibiotics is a challenge worldwide. Antimicrobial peptides (APs) make up the front line of defense in those areas exposed to microorganisms, and there is intensive research to explore their use as new antibacterial agents. On the other hand, it is known that subinhibitory concentrations of antibiotics affect the expression of numerous bacterial traits. In this work we evaluated whether treatment of bacteria with subinhibitory concentrations of quinolones may alter the sensitivity to APs. A 1-h treatment of Klebsiella pneumoniae with 0.25 x the MIC of ciprofloxacin rendered bacteria more sensitive to polymyxins B and E, human neutrophil defensin 1, and beta-defensin 1. Levofloxacin and nalidixic acid at 0.25 x the MICs also increased the sensitivity of K. pneumoniae to polymyxin B, whereas gentamicin and ceftazidime at 0.25 x the MICs did not have such an effect. Ciprofloxacin also increased the sensitivities of K. pneumoniae ciprofloxacin-resistant strains to polymyxin B. Two other pathogens, Pseudomonas aeruginosa and Haemophilus influenzae, also became more sensitive to polymyxins B and E after treatment with 0.25 x the MIC of ciprofloxacin. Incubation with ciprofloxacin did not alter the expression of the K. pneumoniae loci involved in resistance to APs. A 1-N-phenyl-naphthylamine assay showed that ciprofloxacin and levofloxacin increased the permeabilities of the K. pneumoniae and P. aeruginosa outer membranes, while divalent cations antagonized this action. Finally, we demonstrated that ciprofloxacin and levofloxacin increased the binding of APs to the outer membrane by using dansylated polymyxin B.

Applying antimicrobial pharmacodynamics to resistant gram-negative pathogens

PURPOSE

Guided antibiotic adjustment for the treatment of multidrug-resistant, gram-negative pathogens is explored.

SUMMARY

Multidrug-resistant pathogens are being isolated with increasing frequency, while the production of novel agents to circumvent resistance has slowed to a near halt. Hence, antimicrobial adjustment based on drug pharmacokinetic and pharmacodynamic properties has moved to the forefront of treatment. Pharmacodynamic principles for major classes of antimicrobials are reviewed, and the use of susceptibility reports to optimize pharmacodynamics to treat gram-negative infections is described. The need for the application of antimicrobial pharmacodynamics continues to grow as resistance to the agents becomes more common. Susceptibility reports, including antibiograms, and their limitations are briefly discussed. The resistance profiles of the beta-lactams (including carbapenems), aminoglycosides, fluoroquinolones, tetracyclines and glycylcyclines, and the polymyxins are reviewed, and the pharmacodynamic optimization of these profiles is explored.

CONCLUSION

Various mechanisms account for resistance of bacteria to antibiotics. The appropriate use of pharmacokinetics and pharmacodynamics can guide antibiotic therapy and enhance the likelihood of success.

Global assessment of the antimicrobial activity of polymyxin B against 54 731 clinical isolates of Gram-negative bacilli: report from the SENTRY antimicrobial surveillance programme (2001-2004)

In total, 54 731 Gram-negative bacilli isolated worldwide between 2001 and 2004 from diverse sites of infection were tested for susceptibility to polymyxin B by the broth reference microdilution method, with interpretation of results according to CLSI (formerly NCCLS) guidelines. Polymyxin B showed excellent potency and spectrum against 8705 Pseudomonas aeruginosa and 2621 Acinetobacter spp. isolates (MIC50, < or = 1 mg/L and MIC90, 2 mg/L for both pathogens). Polymyxin B resistance rates were slightly higher for carbapenem-resistant P. aeruginosa (2.7%) and Acinetobacter spp. (2.8%), or multidrug-resistant (MDR) P. aeruginosa (3.3%) and Acinetobacter spp. (3.2%), when compared with the entire group (1.3% for P. aeruginosa and 2.1% for Acinetobacter spp.). Among P. aeruginosa, polymyxin B resistance rates varied from 2.9% in the Asia-Pacific region to only 1.1% in Europe, Latin America and North America, while polymyxin B resistance rates ranged from 2.7% in Europe to 1.7% in North America and Latin America among Acinetobacter spp. Polymyxin B also demonstrated excellent activity (MIC90, < or = 1 mg/L; > 98% susceptible) against Citrobacter spp., Escherichia coli and Klebsiella spp., but activity was more variable against Enterobacter spp. (MIC50, < or = 1 mg/L; 83.3% susceptible) and Stenotrophomonas maltophilia (MIC50, < or = 1 mg/L; 72.4% susceptible), and was very limited (MIC50, > 8 mg/L) against Burkholderia cepacia (11.8% susceptible), Serratia spp. (5.4% susceptible), indole-positive Proteus spp. (1.3% susceptible) and Proteus mirabilis (0.7% susceptible).

Pharmacodynamics of polymyxin B against Pseudomonas aeruginosa

Despite limited data, polymyxin B (PB) is increasingly used clinically as the last therapeutic option for multidrug-resistant (MDR) gram-negative bacterial infections. We examined the in vitro pharmacodynamics of PB against four strains of Pseudomonas aeruginosa. Clonal relatedness of the strains was assessed by random amplification of polymorphic DNA. Time-kill studies over 24 h were performed with approximately 10(5) and 10(7) CFU/ml of bacteria, using PB at 0, 0.25, 0.5, 1, 2, 4, 8, and 16x MIC. Dose fractionation studies were performed using an in vitro hollow-fiber infection model (HFIM) against a wild-type and a MDR strain. Approximately 10(5) CFU/ml of bacteria were exposed to placebo and three regimens (every 8 h [q8 h], q12 h, and q24h) simulating the steady-state unbound PB pharmacokinetics resulting from a daily dose of 2.5 mg/kg of body weight and 20 mg/kg (8 times the clinical dose). Samples were obtained over 4 days to quantify PB concentrations, total bacterial population, and subpopulation with reduced PB susceptibility (>3x MIC). The bactericidal activity of PB was concentration dependent, but killing was significantly reduced with a high inoculum. In HFIM studies, a significant reduction in bacterial load was seen at 4 h in all active regimens, but selective amplification of the resistant subpopulation(s) was apparent at 24 h with the clinical dose (both strains). Regrowth was eventually observed in all dosing regimens with the MDR strain, but its occurrence was prevented in the wild-type strain by using 8 times the clinical dose (regardless of dosing intervals). Our results suggested that the bactericidal activity of PB was concentration dependent and appeared to be related to the ratio of the area under the concentration-time curve to the MIC.

Current use for old antibacterial agents: polymyxins, rifampin, and aminoglycosides

This article discusses three classes of antibacterial agents that are uncommonly used in bacterial infections (other than mycobacterial infections) and can be thought of as special-use agents. These are the polymyxins, rifampin, and the aminoglycosides.