1
|
Smith NM, Boissonneault KR, Holden PN, Kaur JN, Klem JF, Cha R, Sutton MD, Tsuji BT. PBP-3 Directed Therapy in VIM-producing Pseudomonas aeruginosa Creates Bacterial Transformers, Persisters in Disguise. Int J Antimicrob Agents 2024; 64:107260. [PMID: 38945177 DOI: 10.1016/j.ijantimicag.2024.107260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 05/03/2024] [Accepted: 06/16/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES The proliferation of metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa represents a significant public health threat. P. aeruginosa undergoes significant phenotypic changes that drastically impair antibiotic efficacy. The objectives of this study were (1) to quantify the time-course of killing of VIM-2-producing P. aeruginosa in response to aztreonam-based therapies (including avibactam for coverage of AmpC), and (2) to document the capacity of P. aeruginosa to undergo morphological transformations that facilitate persistence. METHODS A well-characterised, clinical VIM-2-producing P. aeruginosa was studied in the hollow fibre infection model (HFIM) over 9 days (7 days of active antibiotic therapy, 2 days of treatment withdrawal) at a 107.5 CFU/mL starting inoculum. HFIM treatment arms included: growth control, aztreonam, ceftazidime/avibactam, aztreonam/ceftazidime/avibactam, polymyxin B, and aztreonam/ceftazidime/avibactam/polymyxin B. In addition, real-time imaging studies were conducted under static conditions to determine the time course of the reversion of persister cells. RESULTS There was a pronounced discrepancy between OD620 and bacterial counts obtained from plating methods (hereafter referred to as 'OD-count discrepancy'). For aztreonam monotherapy, observed counts were 0 CFU/mL by 120 h. Despite this, there was a significant OD-count discrepancy compared with the pre-treatment 0 h. Between therapy withdrawal at 168 h and 216 h, all arms with suppressed counts had regrown to the system-carrying capacity. Real-time imaging of the P. aeruginosa filaments after drug removal showed rapid reversion from a long, filamentous phenotype to many individual rods within 2 h. CONCLUSION Managing MBL-producing P. aeruginosa requires a multifaceted approach, focused on maximising killing and minimising proliferation of resistant and persistent subpopulations, which will involve eliminating drug-induced phenotypic transformers.
Collapse
Affiliation(s)
- Nicholas M Smith
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
| | - Katie Rose Boissonneault
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Patricia N Holden
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jan Naseer Kaur
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jack F Klem
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Raymond Cha
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Mark D Sutton
- Department of Biochemistry, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Brian T Tsuji
- Division of Clinical and Translational Therapeutics, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA.
| |
Collapse
|
2
|
Das S, Riccobene T, Carrothers TJ, Wright JG, MacPherson M, Cristinacce A, McFadyen L, Xie R, Luckey A, Raber S. Dose selection for aztreonam-avibactam, including adjustments for renal impairment, for Phase IIa and Phase III evaluation. Eur J Clin Pharmacol 2024; 80:529-543. [PMID: 38252170 PMCID: PMC10937790 DOI: 10.1007/s00228-023-03609-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
PURPOSE A series of iterative population pharmacokinetic (PK) modeling and probability of target attainment (PTA) analyses based on emerging data supported dose selection for aztreonam-avibactam, an investigational combination antibiotic for serious Gram-negative bacterial infections. METHODS Two iterations of PK models built from avibactam data in infected patients and aztreonam data in healthy subjects with "patient-like" assumptions were used in joint PTA analyses (primary target: aztreonam 60% fT > 8 mg/L, avibactam 50% fT > 2.5 mg/L) exploring patient variability, infusion durations, and adjustments for moderate (estimated creatinine clearance [CrCL] > 30 to ≤ 50 mL/min) and severe renal impairment (> 15 to ≤ 30 mL/min). Achievement of > 90% joint PTA and the impact of differential renal clearance were considerations in dose selection. RESULTS Iteration 1 simulations for Phase I/IIa dose selection/modification demonstrated that 3-h and continuous infusions provide comparable PTA; avibactam dose drives joint PTA within clinically relevant exposure targets; and loading doses support more rapid joint target attainment. An aztreonam/avibactam 500/137 mg 30-min loading dose and 1500/410 mg 3-h maintenance infusions q6h were selected for further evaluation. Iteration 2 simulations using expanded PK models supported an alteration to the regimen (500/167 mg loading; 1500/500 mg q6h maintenance 3-h infusions for CrCL > 50 mL/min) and selection of doses for renal impairment for Phase IIa/III clinical studies. CONCLUSION A loading dose plus 3-h maintenance infusions of aztreonam-avibactam in a 3:1 fixed ratio q6h optimizes joint PTA. These analyses supported dose selection for the aztreonam-avibactam Phase III clinical program. CLINICAL TRIAL REGISTRATION NCT01689207; NCT02655419; NCT03329092; NCT03580044.
Collapse
Affiliation(s)
- Shampa Das
- AstraZeneca, Alderley Park, Macclesfield, UK
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | | | | | - Merran MacPherson
- Wright Dose Ltd, Altrincham, Cheshire, UK
- UCB, Braine-l'Alleude, Wallonia, Belgium
| | | | | | | | - Alison Luckey
- , Pfizer, New York, NY, USA
- Present Address: GARDP (Global Antibiotics Research & Development Partnership), Geneva, Switzerland
| | - Susan Raber
- Global Product Development, Pfizer Inc, 10555 Science Center Dr, San Diego, CA, 92121, USA.
| |
Collapse
|
3
|
Smith NM, Nguyen TD, Lodise TP, Chen L, Kaur JN, Klem JF, Boissonneault KR, Holden PN, Roach DR, Tsuji BT. Machine Learning-Led Optimization of Combination Therapy: Confronting the Public Health Threat of Extensively Drug Resistant Gram-Negative Bacteria. Clin Pharmacol Ther 2024; 115:896-905. [PMID: 38062797 DOI: 10.1002/cpt.3134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023]
Abstract
Developing optimized regimens for combination antibiotic therapy is challenging and often performed empirically over many clinical studies. Novel implementation of a hybrid machine-learning pharmacokinetic/pharmacodynamic/toxicodynamic (ML-PK/PD/TD) approach optimizes combination therapy using human PK/TD data along with in vitro PD data. This study utilized human population PK (PopPK) of aztreonam, ceftazidime/avibactam, and polymyxin B along with in vitro PDs from the Hollow Fiber Infection Model (HFIM) to derive optimal multi-drug regimens de novo through implementation of a genetic algorithm (GA). The mechanism-based PD model was constructed based on 7-day HFIM experiments across 4 clinical, extensively drug resistant Klebsiella pneumoniae isolates. GA-led optimization was performed using 13 different fitness functions to compare the effects of different efficacy (60%, 70%, 80%, or 90% of simulated subjects achieving bacterial counts of 102 CFU/mL) and toxicity (66% of simulated subjects having a target polymyxin B area under the concentration-time curve [AUC] of 100 mg·h/L and aztreonam AUC of 1,332 mg·h/L) on the optimized regimen. All regimens, except those most heavily weighted for toxicity prevention, were able to achieve the target efficacy threshold (102 CFU/mL). Overall, GA-based regimen optimization using preclinical data from animal-sparing in vitro studies and human PopPK produced clinically relevant dosage regimens similar to those developed empirically over many years for all three antibiotics. Taken together, these data provide significant insight into new therapeutic approaches incorporating ML to regimen design and treatment of resistant bacterial infections.
Collapse
Affiliation(s)
- Nicholas M Smith
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas D Nguyen
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Troy, New York, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack-Meridian Health, Nutley, New Jersey, USA
| | - Jan Naseer Kaur
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - John F Klem
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Patricia N Holden
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Brian T Tsuji
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
4
|
Yang Y, Jiang L, Zhu HR, Sun WX, Mao JY, Miao JW, Wang YC, He SM, Wang DD, Chen X. Remedial Dosing Recommendations for Sirolimus Delayed or Missed Dosages Caused by Poor Medication Compliance in Pediatric Tuberous Sclerosis Complex Patients. Curr Pharm Des 2024; 30:877-886. [PMID: 38454763 DOI: 10.2174/0113816128299479240213151714] [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: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Delayed or missed dosages caused by poor medication compliance significantly affected the treatment of diseases in children. AIMS The present study aimed to investigate the influence of delayed or missed dosages on sirolimus pharmacokinetics (PK) in pediatric tuberous sclerosis complex (TSC) patients and to recommend remedial dosages for nonadherent patients. METHODS A published sirolimus population PK model in pediatric TSC patients was used to assess the influence of different nonadherence scenarios and recommend optimally remedial dosages based on Monte Carlo simulation. Thirteen nonadherent scenarios were simulated in this study, including delayed 2h, 4 h, 6 h, 8 h, 10 h, 12 h, 14 h, 16 h, 18 h, 20 h, 22 h, 23.5 h, and missed one dosage. Remedial dosing strategies contained 10-200% of scheduled dosages. The optimal remedial dosage was that with the maximum probability of returning the individual therapeutic range. RESULTS For delayed or missed sirolimus dosages in pediatric TSC patients, when the delayed time was 0-8 h, 8-10 h, 10-18 h, 18-22.7 h, 22.7-24 h, 70%, 60%, 40%, 30%, 20% scheduled dosages were recommended to take immediately. When one dosage was missed, 120% of scheduled dosages were recommended at the next dose. CONCLUSION It was the first time to recommend remedial dosages for delayed or missed sirolimus therapy caused by poor medication compliance in pediatric TSC patients based on Monte Carlo simulation. Meanwhile, the present study provided a potential solution for delayed or missed dosages in clinical practice.
Collapse
Affiliation(s)
- Yang Yang
- Department of Pharmacy, The Affiliated Changzhou Children's Hospital of Nantong University, Changzhou, Jiangsu 213003, China
| | - Lei Jiang
- Department of Pharmacy, Taixing People's Hospital, Taixing, Jiangsu 225400, China
| | - Hai-Rong Zhu
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Wen-Xin Sun
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Jing-Yu Mao
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Jing-Wen Miao
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Yi-Chen Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Su-Mei He
- Department of Pharmacy, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, Jiangsu 215153, China
| | - Dong-Dong Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Xiao Chen
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| |
Collapse
|
5
|
Goutelle S, Jullien V, Bru JP, Cattoir V, Gauzit R, Lesprit P, Lina G, Schramm F, Canoui E, Lepeule R. Defining standard and high dosages for β-lactam agents administered by intermittent, prolonged or continuous infusion: a PK/PD simulation study. J Antimicrob Chemother 2023; 78:2762-2769. [PMID: 37796958 DOI: 10.1093/jac/dkad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND The new definitions of antimicrobial susceptibility categories proposed by EUCAST in 2020 require the definition of standard and high dosages of antibiotic. For injectable β-lactams, standard and high dosages have been proposed for short-infusion regimens only. OBJECTIVES To evaluate dosages for β-lactams administered by prolonged infusion (PI) and continuous infusion (CI). METHODS Monte Carlo simulations were performed for seven injectable β-lactams: aztreonam, cefepime, cefotaxime, cefoxitin, ceftazidime, piperacillin and temocillin. Various dosage regimens based on short infusion, PI or CI were simulated in virtual patients. Pharmacokinetic (PK) profiles and PTAs were obtained based on reference population PK models, as well as PK/pharmacodynamic targets and MIC breakpoints proposed by EUCAST. Alternative dosage regimens associated with PTA values similar to those of recommended dosages up to the breakpoints were considered acceptable. RESULTS Adequate PTAs were confirmed for most EUCAST short-infusion dosage regimens. A total of 9 standard and 14 high dosages based on PI (3 to 4 h) or CI were identified as alternatives. For cefepime and aztreonam, only PI and CI regimens could achieve acceptable PTAs for infections caused by Pseudomonas spp.: 2 g q8h as PI of 4 h or 6 g/24 h CI for cefepime; 2 g q6h as PI of 3 h or 6 g/24 h CI for aztreonam. CONCLUSIONS These alternative standard and high dosage regimens are expected to provide antibiotic exposure compatible with new EUCAST definitions of susceptibility categories and associated MIC breakpoints. However, further clinical evaluation is necessary.
Collapse
Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon, Lyon, France
| | - Vincent Jullien
- Unité Fonctionnelle de Pharmacologie, AP-HP, Groupe Hospitalier Paris Seine Saint-Denis, Bondy, F-93140, France
- Département de Pharmacologie, Université Sorbonne Paris Nord, Bobigny, F-93000, France
| | - Jean-Pierre Bru
- Service des Maladies Infectieuses, Centre Hospitalier Annecy Genevois, Pringy Cedex 74374, France
| | - Vincent Cattoir
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, F-35033, France
| | - Rémy Gauzit
- Infectiologie Transversale, CHU Cochin, AP-HP, Paris, 75014, France
| | - Philippe Lesprit
- Service des Maladies Infectieuses, CHU Grenoble Alpes, La Tronche, F-38700, France
| | - Gérard Lina
- Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon and Equipe Pathogénie des Staphylocoques, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS, UMR 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Frédéric Schramm
- Laboratory of Bacteriology, FMTS-CHRU Strasbourg, University of Strasbourg, Strasbourg, F67000, France
| | - Etienne Canoui
- Equipe mobile d'infectiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris Centre-Cochin, Paris, F75014, France
| | - Raphael Lepeule
- Unité Transversale de Traitement des Infections, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, F-94010, France
| |
Collapse
|
6
|
Pharmacokinetic/Pharmacodynamic Evaluation of Aztreonam/Amoxicillin/Clavulanate Combination against New Delhi Metallo-β-Lactamase and Serine-β-Lactamase Co-Producing Escherichia coli and Klebsiella pneumoniae. Pharmaceutics 2023; 15:pharmaceutics15010251. [PMID: 36678879 PMCID: PMC9865866 DOI: 10.3390/pharmaceutics15010251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/04/2023] [Accepted: 01/08/2023] [Indexed: 01/12/2023] Open
Abstract
This study aimed to examine specific niches and usage for the aztreonam/amoxicillin/clavulanate combination and to use population pharmacokinetic simulations of clinical dosing regimens to predict the impact of this combination on restricting mutant selection. The in vitro susceptibility of 19 New-Delhi metallo-β-lactamase (NDM)-producing clinical isolates to amoxicillin/clavulanate and aztreonam alone and in co-administration was determined based on the minimum inhibitory concentration (MIC) and mutant prevention concentration (MPC). The fractions of a 24-h duration that the free drug concentration was within the mutant selection window (fTMSW) and above the MPC (fT>MPC) in both plasma and epithelial lining fluid were determined from simulations of 10,000 subject profiles based on regimens by renal function categories. This combination reduced the MIC of aztreonam and amoxicillin/clavulanate to values below their clinical breakpoint in 7/9 K. pneumoniae and 8/9 E. coli, depending on the β-lactamase genes detected in the isolate. In the majority of the tested isolates, the combination resulted in fT>MPC > 90% and fTMSW < 10% for both aztreonam and amoxicillin/clavulanate. Clinical dosing regimens of aztreonam and amoxicillin/clavulanate were sufficient to provide mutant restriction coverage for MPC and MIC ≤ 4 mg/L. This combination has limited coverage against NDM- and extended-spectrum β-lactamase co-producing E. coli and K. pneumoniae and is not effective against isolates carrying plasmid-mediated AmpC and KPC-2. This study offers a potential scope and limitations as to where the aztreonam/amoxicillin/clavulanate combination may succeed or fail.
Collapse
|
7
|
Lodise TP, O’Donnell JN, Balevic S, Liu X, Gu K, George J, Raja S, Guptill JT, Zaharoff S, Schwager N, Fowler VG, Wall A, Wiegand K, Chambers HF. Pharmacokinetics of Ceftazidime-Avibactam in Combination with Aztreonam (COMBINE) in a Phase 1, Open-Label Study of Healthy Adults. Antimicrob Agents Chemother 2022; 66:e0093622. [PMID: 36394326 PMCID: PMC9764983 DOI: 10.1128/aac.00936-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022] Open
Abstract
Scant pharmacokinetic (PK) data are available on ceftazidime-avibactam (CZA) and aztreonam (ATM) in combination, and it is unknown if CZA-ATM exacerbates alanine aminotransferase (ALT)/aspartate aminotransferase (AST) elevations relative to ATM alone. This phase 1 study sought to describe the PK of CZA-ATM and assess the associations between ATM exposures and ALT/AST elevations. Subjects (n = 48) were assigned to one of six cohorts (intermittent infusion [II] CZA, continuous infusion [CI] CZA, II ATM, CI ATM [8 g/daily], II CZA with II ATM [6 g/daily], and II CZA with II ATM [8 g/daily]), and study product(s) were administered for 7 days. A total of 19 subjects (40%) had ALT/AST elevations, and most (89%) occurred in the ATM/CZA-ATM cohorts. Two subjects in the CI ATM cohort experienced severe ALT/AST elevations, which halted the study. All subjects with ALT/AST elevations were asymptomatic with no other signs of liver injury, and all ALT/AST elevations resolved without sequalae after cessation of dosing. In the population PK (PopPK) analyses, CZA-ATM administration reduced total ATM clearance by 16%, had a negligible effect on total ceftazidime clearance, and was not a covariate in the avibactam PopPK model. In the exposure-response analyses, coadministration of CZA-ATM was not found to augment ALT/AST elevations. Modest associations were observed between ATM exposure (maximum concentration of drug in serum [Cmax] and area under the concentration-time curve [AUC]) and ALT/AST elevations in the analysis of subjects in the II ATM/CZA-ATM cohorts. The findings suggest that administration of CZA-ATM reduces ATM clearance but does not exacerbate AST/ALT elevations relative to ATM alone. The results also indicate that CI ATM should be used with caution.
Collapse
Affiliation(s)
- Thomas P. Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | | | - Stephen Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xing Liu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenan Gu
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Jomy George
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Shruti Raja
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey T. Guptill
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Smitha Zaharoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nyssa Schwager
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vance G. Fowler
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Henry F. Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
| | - Antibacterial Resistance Leadership Group
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Office of Regulatory Affairs (ORA), Division of Microbiology and Infectious Diseases (DMID), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
- Duke Early Phase Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
- The Emmes Company, Rockville, Maryland, USA
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, California, USA
| |
Collapse
|
8
|
Mechanistic Insights to Combating NDM- and CTX-M-Coproducing Klebsiella pneumoniae by Targeting Cell Wall Synthesis and Outer Membrane Integrity. Antimicrob Agents Chemother 2022; 66:e0052722. [PMID: 35924913 PMCID: PMC9487485 DOI: 10.1128/aac.00527-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Metallo-β-lactamase (MBL)-producing Gram-negative bacteria cause infections associated with high rates of morbidity and mortality. Currently, a leading regimen to treat infections caused by MBL-producing bacteria is aztreonam combined with ceftazidime-avibactam. The purpose of the present study was to evaluate and rationally optimize the combination of aztreonam and ceftazidime-avibactam with and without polymyxin B against a clinical Klebsiella pneumoniae isolate producing NDM-1 and CTX-M by use of the hollow fiber infection model (HFIM). A novel de-escalation approach to polymyxin B dosing was also explored, whereby a standard 0-h loading dose was followed by maintenance doses that were 50% of the typical clinical regimen. In the HFIM, the addition of polymyxin B to aztreonam plus ceftazidime-avibactam significantly improved bacterial killing, leading to eradication, including for the novel de-escalation dosing strategy. Serial samples from the growth control and monotherapies were explored in a Galleria mellonella virulence model to assess virulence changes. Weibull regression showed that low-level ceftazidime resistance and treatment with monotherapy resulted in increased G. mellonella mortality (P < 0.05). A neutropenic rabbit pneumonia model demonstrated that aztreonam plus ceftazidime-avibactam with or without polymyxin B resulted in similar bacterial killing, and these combination therapies were statistically significantly better than monotherapies (P < 0.05). However, only the polymyxin B-containing combination therapy produced a statistically significant decrease in lung weights (P < 0.05), indicating a decreased inflammatory process. Altogether, adding polymyxin B to the combination of aztreonam plus ceftazidime-avibactam for NDM- and CTX-M-producing K. pneumoniae improved bacterial killing effects, reduced lung inflammation, suppressed resistance amplification, and limited virulence changes.
Collapse
|
9
|
O'Donnell JN, Putra V, Belfiore GM, Maring BL, Young K, Lodise TP. In vitro activity of imipenem/relebactam plus aztreonam against metallo-β-lactamase producing, OprD-deficient Pseudomonas aeruginosa with varying levels of Pseudomonas-derived cephalosporinase production. Int J Antimicrob Agents 2022; 59:106595. [PMID: 35483625 DOI: 10.1016/j.ijantimicag.2022.106595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 03/07/2022] [Accepted: 04/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited treatment options exist for metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa infections. Imipenem/relebactam plus aztreonam may be an option. METHODS Ten OprD(-) P. aeruginosa isolates (3 parent strains; 7 MBL-producers) were evaluated using checkerboard methodology and Fractional Inhibitory Concentration Index (FICI). Isolates exhibiting synergy in checkerboard studies (FICI ≤0.5) were evaluated using 24-hour static concentration time-kill. Bacteria in late log-phase growth were diluted to 1 × 106 cfu/mL and incubated at 37°C for 24 hours. Samples were drawn at 0, 2, 4, 6 and 24 hours. Physiologic fCmax, fCss,avg and fCmin of imipenem (26.7, 5.6, 0.5 mg/L), relebactam (13.1, 4, 0.8 mg/L) and aztreonam (62, 29, 8 mg/L) were used. Synergy in time-kill studies was defined as >2 log10 cfu/mL reduction compared to the most active individual agent. RESULTS Synergy was observed in five isolates in checkerboard studies, including three of seven MBL-producing isolates. Isolates which were OprD(-) and harboured inducible Pseudomonas-derived cephalosporinases (PDCs) did not show synergy as defined by FICI, however aztreonam MICs were significantly reduced with the combination. In time-kill studies, ATM alone was as active as combination regimens for MBL-producing isolates with deleted or inducible PDC production. For strains exhibiting constitutive PDC production, I/R plus ATM was synergistic at fCss,avg concentrations but exhibited similar activity to ATM at fCmin and fCmax concentrations. CONCLUSIONS Imipenem/relebactam plus aztreonam appears to exhibit synergy for some MBL-producing P. aeruginosa at physiologic concentrations. Further study of the effect of dynamic concentrations is needed to understand fully the utility of this combination.
Collapse
Affiliation(s)
- J Nicholas O'Donnell
- Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA.
| | - Vibert Putra
- Graduate Research Assistant, Department of Basic and Clinical Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Gina M Belfiore
- PharmD Candidate, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Brittney L Maring
- Research Assistant, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Katherine Young
- Senior Principal Scientist, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Thomas P Lodise
- Professor of Pharmacy Practice, Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| |
Collapse
|
10
|
Feng K, Jia N, Zhu P, Sy S, Liu Y, Dong D, Zhu S, Zhang J, Liu Y, Martins FS, Gong H, Lv Z, Yu M, Sy SKB, Zhu Y. Aztreonam/avibactam effect on pharmacodynamic indices for mutant selection of Escherichia coli and Klebsiella pneumoniae harbouring serine- and New Delhi metallo-β-lactamases. J Antimicrob Chemother 2021; 76:2875-2883. [PMID: 34383928 DOI: 10.1093/jac/dkab292] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/17/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Ceftazidime/avibactam is not active against MBL-producing bacteria. Combining ceftazidime/avibactam or avibactam with aztreonam can counter the resistance of MBL-producing Enterobacterales. The aim of this study was to evaluate whether the addition of avibactam could reduce or close the mutant selection window (MSW) of aztreonam in Escherichia coli and Klebsiella pneumoniae harbouring MBLs; MSW is a pharmacodynamic (PD) parameter for the selection of emergent resistant mutants. METHODS In vitro susceptibility of 19 clinical isolates to ceftazidime/avibactam, aztreonam alone, and in co-administration (aztreonam/ceftazidime/avibactam and aztreonam/avibactam) was determined, as well as the mutant prevention concentration (MPC). The fraction of time within 24 h that the free drug concentration was within the MSW (fTMSW) and the fraction of time that the free drug concentration was above the MPC (fT>MPC) in both plasma and epithelial lining fluid (ELF) were determined from simulations of 10 000 profiles. The joint PTA was used to derive a joint cumulative fraction of response (CFR). RESULTS All isolates were resistant to ceftazidime/avibactam or aztreonam. Combining aztreonam and avibactam or ceftazidime/avibactam resulted in synergistic bactericidal activities against all isolates. Synergism was primarily due to the aztreonam/avibactam combination. For aztreonam/avibactam dosing regimens evaluated in clinical trials, fT>MPC values were >90% and >80%, whereas fTMSW measures were <10% and <20% in plasma and ELF, respectively. The CFR was 100% for aztreonam/avibactam against the collection of clinical isolates. CONCLUSIONS Effective antimicrobial combination optimized the PD parameters measuring selection for emergent mutants by increasing fT>MPC and reducing fTMSW.
Collapse
Affiliation(s)
- Kun Feng
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Nan Jia
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Peijuan Zhu
- Department of Pharmacology, University of Pennsylvania, Philadelphia, PA, USA
| | - Serubbabel Sy
- Department of Chemical Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Yanfei Liu
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Dandan Dong
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Shixing Zhu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Jiayuan Zhang
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Yuwei Liu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | | | - Hugh Gong
- Department of Statistics, Valparaiso University, Valparaiso, IN, USA
| | - Zhihua Lv
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China.,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao 266003, PR China
| | - Mingming Yu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China.,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao 266003, PR China
| | - Sherwin K B Sy
- Department of Statistics, State University of Maringá, Maringá, Paraná, Brazil
| | - Yuanqi Zhu
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| |
Collapse
|
11
|
Falcone M, Menichetti F, Cattaneo D, Tiseo G, Baldelli S, Galfo V, Leonildi A, Tagliaferri E, Di Paolo A, Pai MP. Pragmatic options for dose optimization of ceftazidime/avibactam with aztreonam in complex patients. J Antimicrob Chemother 2021; 76:1025-1031. [PMID: 33378458 DOI: 10.1093/jac/dkaa549] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Avibactam is a β-lactamase inhibitor that is combined with aztreonam against Enterobacterales co-expressing serine- and metallo-β-lactamases (MBL). Optimal dosing of aztreonam with avibactam is not well-defined in critically ill patients and contingent on ceftazidime/avibactam product labelling. OBJECTIVES To identify a pragmatic dosing strategy for aztreonam with avibactam to maximize the probability of target attainment (PTA). METHODS We conducted a prospective observational pharmacokinetic study. Five blood samples were collected around the fourth dose of aztreonam or ceftazidime/avibactam and assayed for all three drugs. Population pharmacokinetic (PK) analysis coupled with Monte Carlo simulations were used to create a dosing nomogram for aztreonam and ceftazidime/avibactam based on drug-specific pharmacodynamic (PD) targets. RESULTS A total of 41 participants (59% male) median age of 75 years (IQR 63-79 years) were enrolled. They were critically ill (46%) with multiple comorbidities and complications including burns (20%). Population PK analysis identified higher volume of distribution and lower clearance (CL) compared with typical value expectations for aztreonam and ceftazidime/avibactam. Estimated glomerular filtration (eGFR) rate using the CKD-EPI equation predicted CL for all three drugs. The need for high doses of aztreonam and ceftazidime/avibactam above those in the existing product labels are not predicted by this analysis with the exception of ceftazidime/avibactam for patients with eGFR of 6-15 mL/min, in whom suboptimal PTA of ≤71% is predicted. CONCLUSIONS Pragmatic and lower daily-dose options are predicted for aztreonam and ceftazidime/avibactam when the eGFR is <90 mL/min. These options should be tested prospectively.
Collapse
Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Valentina Galfo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Leonildi
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy.,Microbiology Unit, Azienda Ospedaliera Universitaria Pisana., Pisa, Italy
| | - Enrico Tagliaferri
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Antonello Di Paolo
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
12
|
Lodise TP, Smith NM, O'Donnell N, Eakin AE, Holden PN, Boissonneault KR, Zhou J, Tao X, Bulitta JB, Fowler VG, Chambers HF, Bonomo RA, Tsuji BT. Determining the optimal dosing of a novel combination regimen of ceftazidime/avibactam with aztreonam against NDM-1-producing Enterobacteriaceae using a hollow-fibre infection model. J Antimicrob Chemother 2021; 75:2622-2632. [PMID: 32464664 DOI: 10.1093/jac/dkaa197] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND MBL-producing strains of Enterobacteriaceae are a major public health concern. We sought to define optimal combination regimens of ceftazidime/avibactam with aztreonam in a hollow-fibre infection model (HFIM) of MBL-producing strains of Escherichia coli and Klebsiella pneumoniae. METHODS E. coli ARLG-1013 (blaNDM-1, blaCTX-M, blaCMY, blaTEM) and K. pneumoniae ARLG-1002 (blaNDM-1, blaCTXM-15, blaDHA, blaSHV, blaTEM) were studied in the HFIM using simulated human dosing regimens of ceftazidime/avibactam and aztreonam. Experiments were designed to evaluate the effect of staggered versus simultaneous administration, infusion duration and aztreonam daily dose (6 g/day versus 8 g/day) on bacterial killing and resistance suppression. Prospective validation experiments for the most active combination regimens were performed in triplicate to ensure reproducibility. RESULTS Staggered administration of the combination (ceftazidime/avibactam followed by aztreonam) was found to be inferior to simultaneous administration. Longer infusion durations (2 h and continuous infusion) also resulted in enhanced bacterial killing relative to 30 min infusions. The rate of killing was more pronounced with 8 g/day versus 6 g/day aztreonam combination regimens for both tested strains. In the prospective validation experiments, ceftazidime/avibactam with aztreonam dosed every 8 and 6 h, respectively (ceftazidime/avibactam 2/0.5 g every 8 h + aztreonam 2 g every 6 h), or ceftazidime/avibactam with aztreonam as continuous infusions resulted in maximal bacterial killing and resistance suppression over 7 days. CONCLUSIONS Simultaneous administration of aztreonam 8 g/day given as a continuous or 2 h infusion with ceftazidime/avibactam resulted in complete bacterial eradication and resistance suppression. Further study of this combination is needed with additional MBL-producing Gram-negative pathogens. The safety of this double β-lactam strategy also warrants further study in Phase 1 clinical trials.
Collapse
Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Nicolas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | - Nick O'Donnell
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Ann E Eakin
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | | | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Xun Tao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Henry F Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, CA, USA
| | - Robert A Bonomo
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| |
Collapse
|
13
|
Zhou D, Li J, Bui K, Learoyd M, Berges A, Milenkova T, Al-Huniti N, Tomkinson H, Xu H. Bridging Olaparib Capsule and Tablet Formulations Using Population Pharmacokinetic Meta-analysis in Oncology Patients. Clin Pharmacokinet 2020; 58:615-625. [PMID: 30357650 DOI: 10.1007/s40262-018-0714-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Olaparib is a first-in-class potent oral poly(ADP-ribose) polymerase inhibitor. OBJECTIVES The aims of this analysis were to establish an integrated population pharmacokinetic (PK) model of olaparib in patients with solid tumors and to bridge the PK of olaparib between capsule and tablet formulations. METHODS The population PK model was developed using plasma concentration data from 659 patients in 11 phase I, II, and III studies of olaparib tablets/capsules monotherapy. Relative bioavailability between the tablet and capsule formulations was estimated and the relative exposure between olaparib tablet and capsule therapeutic doses was further assessed. RESULTS The concentration-time profile was described using a two-compartment model with sequential zero- and first-order absorption and first-order elimination for both capsules and tablets with different absorption parameters. Multiple-dose clearance compared with single-dose clearance was reduced by approximately 15% (auto-inhibition). Disease severity had an impact on olaparib clearance, and tablet strength had an impact on Ka. The olaparib geometric mean area under the curve (AUC) and maximal concentration (Cmax) following a single 300 mg tablet were 42.1 μg h/mL and 5.8 μg/mL, respectively, and the steady-state geometric mean AUC and Cmax following a 300 mg tablet twice daily were 49.0 μg h/mL and 7.7 μg/mL, respectively. The relative exposure (AUC) of the 300 mg tablet formulation is 13% higher than the 400 mg capsule formulation. CONCLUSION This analysis bridged the olaparib capsule and tablet formulation PK and provided key assessment to support the approval of the olaparib tablet formulation in patients with ovarian cancer, regardless of their BRCA mutation status.
Collapse
Affiliation(s)
- Diansong Zhou
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, 35 Gatehouse Drive, Boston, MA, 02451, USA
| | - Jianguo Li
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, 35 Gatehouse Drive, Boston, MA, 02451, USA
| | - Khanh Bui
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, 35 Gatehouse Drive, Boston, MA, 02451, USA
| | - Maria Learoyd
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, UK
| | - Alienor Berges
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, UK
| | | | - Nidal Al-Huniti
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, 35 Gatehouse Drive, Boston, MA, 02451, USA
| | - Helen Tomkinson
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, UK
| | - Hongmei Xu
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, 35 Gatehouse Drive, Boston, MA, 02451, USA.
| |
Collapse
|
14
|
Antibiotics and chronic kidney disease: Dose adjustment update for infectious disease clinical practice. Med Mal Infect 2019; 50:323-331. [PMID: 31326299 DOI: 10.1016/j.medmal.2019.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/10/2018] [Accepted: 06/24/2019] [Indexed: 12/16/2022]
Abstract
Antibiotic prescription in chronic kidney disease patients poses a twofold problem. The appropriate use of antibacterial agents is essential to ensure efficacy and to prevent the emergence of resistance, and dosages should be adapted to the renal function to prevent adverse effects. SiteGPR is a French website for health professionals to help with prescriptions to chronic kidney disease patients. A working group of infectious disease specialists and nephrology pharmacists reviewed the indications, dosing regimens, administration modalities, and dose adjustments of antibiotics marketed in France for patients with renal failure. Data available on the SiteGPR website and detailed in the present article aims to provide an evidence-based update of infectious disease recommendations to health professionals managing patients with chronic kidney disease.
Collapse
|
15
|
Simplified Aztreonam Dosing in Patients with End-Stage Renal Disease: Results of a Monte Carlo Simulation. Antimicrob Agents Chemother 2018; 62:AAC.01066-18. [PMID: 30150467 DOI: 10.1128/aac.01066-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/19/2018] [Indexed: 11/20/2022] Open
Abstract
The manufacturer-recommended aztreonam dosing for patients with creatinine clearance values of <10 ml/min/1.73 m2 is complex. It is not known whether simpler posthemodialysis dosing administered once daily or thrice weekly can reliably achieve pharmacodynamic goals. We found that 1 or 2 g administered once daily after hemodialysis had >90% probability of target attainment up to MICs of 4 or 8 mg/liter, respectively. Thrice-weekly dosing should generally be avoided, except in nonsevere infections with MICs of ≤0.5 mg/liter.
Collapse
|
16
|
Tong X, Zhou D, Savage A, Mullen JA, Li Y, Taylor W, Li J, Al-Huniti N, Xu H. Population Pharmacokinetic Modeling With Enterohepatic Circulation for AZD3241 in Healthy Subjects and Patients With Multiple System Atrophy. J Clin Pharmacol 2018; 58:1452-1460. [PMID: 29873817 DOI: 10.1002/jcph.1134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/14/2018] [Indexed: 12/11/2022]
Abstract
AZD3241 is a potent and selective myeloperoxidase inhibitor potentially for the treatment of a number of neurodegenerative disorders, including multiple system atrophy (MSA). The objectives of this work were to develop a population pharmacokinetic (PopPK) model for AZD3241 and to investigate the correlation between AZD3241 exposure and myeloperoxidase inhibition. The PopPK model was developed using AZD3241 data from one phase 1 study in healthy subjects and one phase 2 study in patients with MSA. A one-compartment model incorporating a gallbladder compartment for enterohepatic circulation, sequential zero-first order absorption, and first-order elimination adequately described the AZD3241 concentration profiles. The apparent clearance and central volume of distribution were 63.1 L/h (interindividual variability: 34.8%) and 121.9 L (interindividual variability: 44.0%), respectively. The enterohepatic circulation model reasonably captured the second peak of AZD3241, and high-fat food increased the absorption rate by 69%. A linear regression model was applied to describe the relationship between AZD3241 exposure and percentage change from baseline in myeloperoxidase-specific activity. The developed PopPK model was consistent with known pharmacokinetic characteristics of AZD3241. This model can be used to estimate AZD3241 exposure in patients with MSA and could be applied to future pharmacokinetic-pharmacodynamic analyses of AZD3241 in clinical development.
Collapse
Affiliation(s)
- Xiao Tong
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Diansong Zhou
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Alicia Savage
- Neuroscience, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Jamie A Mullen
- Neuroscience, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Yan Li
- Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Wendy Taylor
- Personalized Healthcare & Biomarkers, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden
| | - Jianguo Li
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Nidal Al-Huniti
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| | - Hongmei Xu
- Quantitative Clinical Pharmacology, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Boston, MA, USA
| |
Collapse
|
17
|
Ribera A, Soldevila L, Rigo-Bonnin R, Tubau F, Padullés A, Gómez-Junyent J, Ariza J, Murillo O. Beta-lactams in continuous infusion for Gram-negative bacilli osteoarticular infections: an easy method for clinical use. Infection 2018; 46:239-244. [PMID: 29363049 DOI: 10.1007/s15010-018-1116-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/16/2018] [Indexed: 12/16/2022]
Abstract
Continuous infusion (CI) of beta-lactams could optimize their pharmacokinetic/pharmacodynamic indices, especially in difficult-to-treat infections. PURPOSE To validate an easy-to-use method to guide beta-lactams dosage in CI (formula). METHODS A retrospective analysis was conducted of a prospectively collected cohort (n = 24 patients) with osteoarticular infections caused by Gram-negative bacilli (GNB) managed with beta-lactams in CI. Beta-lactams dose was calculated using a described formula (daily dose = 24 h × beta-lactam clearance × target "steady-state" concentration) to achieve concentrations above the MIC. We correlated the predicted concentration (Cpred = daily dose/24 h × beta-lactam clearance) with the patient's observed concentration (Cobs) measured by UPLC-MS/MS (Spearman's coefficient). RESULTS The most frequent microorganism treated was P. aeruginosa (21 cases; 9 MDR). Beta-lactams in CI were ceftazidime (n = 14), aztreonam (7), and piperacillin/tazobactam (3), mainly used in combination (12 with colistin, 5 with ciprofloxacin) and administered without notable side effects. The plasma Cobs was higher overall than Cpred; the Spearman correlation between both concentrations was rho = 0.6 (IC 95%: 0.2-0.8) for all beta-lactams, and rho = 0.8 (IC 95%: 0.4-1) for those treated with ceftazidime. CONCLUSIONS The formula may be useful in clinical practice for planning the initial dosage of beta-lactams in CI, while we await a systematic therapeutic drug monitoring. The use of beta-lactams in CI was safe.
Collapse
Affiliation(s)
- Alba Ribera
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Laura Soldevila
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Raul Rigo-Bonnin
- Clinical Laboratory Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Fe Tubau
- Microbiology Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain.,Ciber de Enfermedades Respiratorias ISCIII, Madrid, Spain
| | - Ariadna Padullés
- Pharmacy Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Gómez-Junyent
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Javier Ariza
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Oscar Murillo
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain.
| |
Collapse
|