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Gibson JE, Nandanwar N, Neely MN. Time-dependent pharmacodynamics of amikacin on Mycobacterium abscessus growth and resistance emergence. Microbiol Spectr 2024; 12:e0322223. [PMID: 38236037 PMCID: PMC10846206 DOI: 10.1128/spectrum.03222-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/19/2024] Open
Abstract
Mycobacterium abscessus pulmonary disease is increasing in prevalence globally, particularly for individuals with cystic fibrosis. These infections are challenging to treat due to a high rate of resistance. Amikacin is critical to treatment, but the development of toxicity, amikacin resistance, and treatment failure are significant challenges. Amikacin has been characterized previously as peak-dependent and extended-interval dosing is commonly used. In our hollow fiber infection model of M. abscessus, amikacin exhibited time-dependent rather than the expected peak-dependent pharmacodynamics. Humanized amikacin exposures with more frequent, short-interval dosing (continuous infusion or every 12 hours) yielded improved microbiological response compared to extended-interval dosing (every 24 hours or 1-3 times per week). Short-interval dosing inhibited growth with a mean (SD) maximum Δlog10 colony forming units of -4.06 (0.52), significantly more than extended-interval dosing (P = 0.0013) every 24 hours, -2.40 (0.58), or 1-3 times per week, -2.39 (0.38). Growth recovery, an indicator of resistance emergence, occurred at 6.56 (0.70) days with short-interval dosing but was significantly earlier with extended-interval dosing (P = 0.0032) every 24 hours, 3.88 (0.85) days, and 1-3 times per week, 3.27 (1.72) days. Microbiological response correlated best with the pharmacodynamic index of %T > minimum inhibitory concentration (MIC), with an EC80 for growth inhibition of ~40%T > MIC. We used a previously published population model of amikacin to determine the probability of achieving 40%T > MIC and show that current dosing strategies are far below this target, which may partially explain why treatment failure remains so high for these infections. These data support a cautious approach to infrequent amikacin dosing for the treatment of M. abscessus.IMPORTANCEPulmonary disease caused by Mycobacterium abscessus complex (MABSC) is increasing worldwide, particularly in patients with cystic fibrosis. MABSC is challenging to treat due to high levels of antibiotic resistance. Treatment requires 2-4 antibiotics over more than 12 months and has a significant risk of toxicity but still fails to eradicate infection in over 50% of patients with cystic fibrosis. Antibiotic dosing strategies have been largely informed by common bacteria such as Pseudomonas aeruginosa. The "pharmacodynamic" effects of amikacin, a backbone of MABSC treatment, were thought to be related to maximum "peak" drug concentration, leading to daily or three times weekly dosing. However, we found that amikacin MABSC kill and growth recovery, an indicator of antibiotic resistance, are dependent on how long amikacin concentrations are above the minimum inhibitory concentration, not how high the peak concentration is. Therefore, we recommend a re-evaluation of amikacin dosing to determine if increased frequency can improve efficacy.
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Affiliation(s)
- Joy E. Gibson
- Division of Infectious Diseases and the Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Nishant Nandanwar
- Division of Infectious Diseases and the Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Michael N. Neely
- Division of Infectious Diseases and the Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Schlegtendal A, Rettberg S, Maier C, Brinkmann F, Koerner-Rettberg C. Necessity of Tobramycin trough Levels in Once Daily Iv-Treatment in Patients with Cystic Fibrosis. KLINISCHE PADIATRIE 2024; 236:116-122. [PMID: 38286409 DOI: 10.1055/a-2244-6903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Once daily intravenous (iv) treatment with tobramycin for Pseudomonas aeruginosa infection in patients with cystic fibrosis (pwCF) is frequently monitored by measuring tobramycin trough levels (TLs). Although the necessity of these TLs is recently questioned in pwCF without renal impairment, no study has evaluated this so far. The aim of this observational study was to evaluate the frequency of increased tobramycin TLs in pwCF treated with a once daily tobramycin dosing protocol. METHODS Patient records of all consecutive once daily iv tobramycin courses in 35 pwCF between 07/2009 and 07/2019 were analyzed for tobramycin level, renal function, co-medication and comorbidity. RESULTS Eight elevated TLs (2.9% of 278 courses) were recorded in four patients, two with normal renal function. One of these resolved without adjustment of tobramycin dosages suggesting a test timing or laboratory error. In the other patient the elevated tobramycin level decreased after tobramycin dosage adjustment. Six of the elevated levels occurred in two patients with chronic renal failure. In 15 other patients with reduced glomerular filtration rate (GFR) (36 courses) but normal range creatinine no case of elevated tobramycin trough levels was detected. Neither cumulative tobramycin dosages nor concomitant diabetes or nutritional status were risk factors for elevated TLs. CONCLUSION Our data show that elevated tobramycin TLs are rare but cannot be excluded, so determination of tobramycin TLs is still recommended for safety.
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Affiliation(s)
- Anne Schlegtendal
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Sophia Rettberg
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Christoph Maier
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
| | - Folke Brinkmann
- Department of pediatrics, Ruhr-Universität Bochum Medizinische Fakultät, Bochum, Germany
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McLeod C, Smyth AR, Messer M, Schultz A, Wood J, Norman R, Blyth CC, Webb S, Elliott Z, Van Devanter D, Stephenson AL, Tong A, Snelling TL. Protocol for establishing a core outcome set for evaluation in studies of pulmonary exacerbations in people with cystic fibrosis. BMJ Open 2022; 12:e056528. [PMID: 36153014 PMCID: PMC9511571 DOI: 10.1136/bmjopen-2021-056528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pulmonary exacerbations are associated with increased morbidity and mortality in people with cystic fibrosis (CF). There is no consensus about which outcomes should be evaluated in studies of pulmonary exacerbations or how these outcomes should be measured. Outcomes of importance to people with lived experience of the disease are frequently omitted or inconsistently reported in studies, which limits the value of such studies for informing practice and policy. To better standardise outcome reporting and measurement, we aim to develop a core outcome set for studies of pulmonary exacerbations in people with CF (COS-PEX) and consensus recommendations for measurement of core outcomes. METHODS AND ANALYSIS Preliminary work for development of COS-PEX has been reported, including (1) systematic reviews of outcomes and methods for measurement reported in existing studies of pulmonary exacerbations; (2) workshops with people affected by CF within Australia; and (3) a Bayesian knowledge expert elicitation workshop with health professionals to ascertain outcomes of importance. Here we describe a protocol for the additional stages required for COS-PEX development and consensus methods for measurement of core outcomes. These include (1) an international two-round online Delphi survey and (2) consensus workshops to review and endorse the proposed COS-PEX and to agree with methods for measurement. ETHICS AND DISSEMINATION National mutual ethics scheme approval has been provided by the Child and Adolescent Health Service Human Research Ethics Committee (RGS 4926). Results will be disseminated via consumer and research networks and peer-reviewed publications. This study is registered with the Core Outcome Measures in Effectiveness Trials database.
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Affiliation(s)
- Charlie McLeod
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Alan Robert Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Mitch Messer
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Andre Schultz
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jamie Wood
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard Norman
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Christopher C Blyth
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Infectious Diseases Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Steve Webb
- Intensive Care Unit, St John of God Health Care, West Perth, Western Australia, Australia
- School of Population Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe Elliott
- Consumer representative, University of Nottingham, Nottingham, UK
| | | | - Anne L Stephenson
- Department of Respirology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Allison Tong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Thomas L Snelling
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Ringshausen FC, Hellmuth T, Dittrich AM. [Evidence-based treatment of cystic fibrosis]. Internist (Berl) 2020; 61:1212-1229. [PMID: 33201261 DOI: 10.1007/s00108-020-00896-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mucoviscidosis (cystic fibrosis [CF]) is the most common autosomal recessive inherited multisystem disease with fatal outcome. It is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, which lead to a dysfunctional chloride channel and a defective CFTR protein. As a consequence, retention of insufficiently hydrated mucus affects multiple essential organs, mainly the lungs and airways, pancreas, liver, biliary tract and intestines. This leads to inflammation and infection, fibrosis and progressive tissue destruction. Respiratory failure is the major cause of mortality; however, in the no more than 30 years since the molecular characterization of the basic CFTR defect causing CF, tremendous success has been made with respect to the long-term prognosis of people with CF. This improvement in the prognosis was achieved by the cooperative spirit and networking of the very active and international CF research community and by establishing a multidisciplinary clinical CF team that implements the existing evidence in various aspects of standardized care together with the CF patient. This narrative review article presents the evidence in selected aspects of CF treatment, with special consideration of the most recent development of highly effective CFTR modulator treatment. This treatment will soon become available for more than 90% of the global CF patients and transform the pathophysiology as well as the course of disease towards a treatable chronic condition in internal medicine.
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Affiliation(s)
- F C Ringshausen
- Klinik für Pneumologie, OE 6870, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - T Hellmuth
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - A-M Dittrich
- Klinik für Pädiatrische Pneumologie, Allergologie und Neonatologie, Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
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