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Huang Y, Yu S, Ahmed MU, Zhou QT. Liposomal Formulation Reduces Transport and Cell Uptake of Colistin in Human Lung Epithelial Calu-3 Cell and 3D Human Lung Primary Tissue Models. AAPS PharmSciTech 2024; 25:40. [PMID: 38366100 DOI: 10.1208/s12249-024-02753-6] [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: 10/19/2023] [Accepted: 01/23/2024] [Indexed: 02/18/2024] Open
Abstract
Respiratory tract infections caused by multi-drug-resistant (MDR) bacteria have been a severe risk to human health. Colistin is often used to treat the MDR Gram-negative bacterial infections as a last-line therapy. Inhaled colistin can achieve a high concentration in the lung but none of aerosolized colistin products has been approved in the USA. Liposome has been reported as an advantageous formulation strategy for antibiotics due to its controlled release profile and biocompatibility. We have developed colistin liposomal formulations in our previous study. In the present study, the cellular uptake and transport of colistin in colistin liposomes were examined in two human lung epithelium in vitro models, Calu-3 monolayer and EpiAirway 3D tissue models. In both models, cellular uptake (p < 0.05) and cellular transport (p < 0.01) of colistin were significantly reduced by the colistin liposome compared to the colistin solution. Our findings indicate that inhaled colistin liposomes could be a promising treatment for extracellular bacterial lung infections caused by MDR Pseudomonas aeruginosa (P. aeruginosa).
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Affiliation(s)
- Yijing Huang
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Shihui Yu
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, 510006, People's Republic of China
| | - Maizbha Uddin Ahmed
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA.
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Talwar D, Prajapat D, Talwar S, Talwar D. Retrospective Observational Study to Assess Safety and Tolerability of Nebulized Colistin for the Treatment of Patients With Pneumonia in Real-World Settings in Respiratory ICU. Cureus 2024; 16:e54652. [PMID: 38524091 PMCID: PMC10959766 DOI: 10.7759/cureus.54652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/26/2024] Open
Abstract
INTRODUCTION Colistin is used to treat hospital-acquired pneumonia and ventilator-associated pneumonia. However, direct drug deposition at the site of infection may improve its efficacy and reduce systemic exposure. The aim of this study was to assess the safety and tolerability of nebulized colistin among Indian patients diagnosed with pneumonia caused by multidrug-resistant gram-negative bacilli in real-world settings. METHODOLOGY We retrospectively reviewed the medical records of patients treated with nebulized colistin for pneumonia. We assessed the adverse events and relevant abnormal laboratory findings of nebulized colistin therapy. RESULTS All enrolled patients (N=30, males: 22, females: 8; average age: 71.06 years) were treated for 13.36 days. Almost 80% of patients had a history of shortness of breath, which was a major symptom when they were admitted to the hospital. The patients were administered nebulized colistin for an average of six days (8 hours per day). The most common dosing schedule was 1 million international units (MIU)/8 hours. No serious adverse event was observed, and only one patient died while on the treatment but the death was not related to colistin treatment. The average sequential organ failure assessment score for all patients was 6.5. CONCLUSION Our study demonstrated the efficient clinical utility and well-tolerated safety profile of nebulized colistin in the treatment of patients with pneumonia. Neurotoxicity and nephrotoxicity were not reported. Since a significant percentage of patients were with chronic respiratory diseases, our study further indicates the safety and effectiveness of nebulized colistin in chronic obstructive pulmonary disease (COPD) patients too.
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Affiliation(s)
- Deepak Talwar
- Pulmonary, Sleep, and Critical Care Medicine, Metro Centre for Respiratory Diseases, Noida, IND
| | - Deepak Prajapat
- Pulmonary and Critical Care Medicine, Metro Centre for Respiratory Diseases, Noida, IND
| | - Surbhi Talwar
- Nephrology, University Hospitals Coventry and Warwickshire (UHCW), Coventry, GBR
| | - Dhruv Talwar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
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Shi R, Fu Y, Gan Y, Wu D, Zhou S, Huang M. Use of polymyxin B with different administration methods in the critically ill patients with ventilation associated pneumonia: a single-center experience. Front Pharmacol 2023; 14:1222044. [PMID: 37719858 PMCID: PMC10502420 DOI: 10.3389/fphar.2023.1222044] [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: 05/16/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Background: Whether nebulized polymyxin B should be used as an adjunctive therapy or substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia (VAP) remains controversial. This study's aim is to evaluate the efficacy and safety of different administration ways of polymyxin B in the treatment of ventilator-associated pneumonia caused by extensively drug-resistant Gram-negative bacteria(XDR-GNB). Methods: This retrospective cohort study enrolled ventilator-associated pneumonia patients caused by XDR-GNB treated with polymyxin B in the intensive care unit. Patients were categorized by the administration methods as intravenous (IV) group, inhaled (IH) group, and the intravenous combined with inhaled (IV + IH) group. Microbiological outcome and clinical outcome were compared in each group. The side effects were also explored. Results: A total of 111 patients were enrolled and there was no difference in demographic and clinical characteristics among the three groups. In terms of efficacy, clinical cure or improvement was achieved in 21 patients (55.3%) in the intravenous group, 19 patients (50%) in the IH group, and 20 patients (57.1%) in IV + IH group (p = 0.815). All three groups showed high success rates in microbiological eradication, as 29 patients with negative cultures after medication in inhaled group. Among all the patients who had negative bacterial cultures after polymyxin B, the inhaled group had significantly shorter clearance time than the intravenous group (p = 0.002), but with no significant difference in 28-day mortality. Compared with intravenous group, a trend towards a lower risk of acute kidney injury was observed in inhaled group (p = 0.025). Conclusion: From the perspective of minimal systemic renal toxicity, nebulized polymyxin B as a substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia caused by XDR-GNB is feasible.
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Affiliation(s)
- Rupeng Shi
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanyuan Fu
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yujing Gan
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Danying Wu
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Suming Zhou
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Huang
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Rodvold KA, Bader J, Bruss JB, Hamed K. Pharmacokinetics of SPR206 in Plasma, Pulmonary Epithelial Lining Fluid, and Alveolar Macrophages following Intravenous Administration to Healthy Adult Subjects. Antimicrob Agents Chemother 2023; 67:e0042623. [PMID: 37338378 PMCID: PMC10353446 DOI: 10.1128/aac.00426-23] [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: 03/29/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023] Open
Abstract
SPR206 is a next-generation polymyxin being developed for the treatment of multidrug-resistant (MDR) Gram-negative infections. This Phase 1 bronchoalveolar lavage (BAL) study was conducted to evaluate SPR206's safety and pharmacokinetics in plasma, pulmonary epithelial lining fluid (ELF), and alveolar macrophages (AM) in healthy volunteers. Subjects received a 100 mg intravenous (IV) dose of SPR206 infused over 1 h every 8 h for 3 consecutive doses. Each subject underwent 1 bronchoscopy with BAL at 2, 3, 4, 6, or 8 h after the start of the third IV infusion. SPR206 concentrations in plasma, BAL, and cell pellet were measured with a validated LC-MS/MS assay. Thirty-four subjects completed the study and 30 completed bronchoscopies. Mean SPR206 peak concentrations (Cmax) in plasma, ELF, and AM were 4395.0, 735.5, and 860.6 ng/mL, respectively. Mean area under the concentration-time curve (AUC0-8) for SPR206 in plasma, ELF, and AM was 20120.7, 4859.8, and 6026.4 ng*h/mL, respectively. The mean ELF to unbound plasma concentration ratio was 0.264, and mean AM to unbound plasma concentration ratio was 0.328. Mean SPR206 concentrations in ELF achieved lung exposures above the MIC for target Gram-negative pathogens for the entire 8-h dosing interval. Overall, SPR206 was well tolerated; 22 subjects (64.7%) reported at least 1 treatment-emergent adverse event (TEAE). Of the 40 reported TEAEs, 34 (85.0%) were reported as mild in severity. The most frequent TEAEs were oral paresthesia (10 subjects [29.4%]) and nausea (2 subjects [5.9%]). This study demonstrates pulmonary penetration of SPR206 and supports further development of SPR206 for the treatment of patients with serious infections caused by MDR Gram-negative pathogens.
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Affiliation(s)
| | - Justin Bader
- Spero Therapeutics, Inc., Cambridge, Massachusetts, USA
| | - Jon B. Bruss
- Spero Therapeutics, Inc., Cambridge, Massachusetts, USA
| | - Kamal Hamed
- Spero Therapeutics, Inc., Cambridge, Massachusetts, USA
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Karaiskos I, Gkoufa A, Polyzou E, Schinas G, Athanassa Z, Akinosoglou K. High-Dose Nebulized Colistin Methanesulfonate and the Role in Hospital-Acquired Pneumonia Caused by Gram-Negative Bacteria with Difficult-to-Treat Resistance: A Review. Microorganisms 2023; 11:1459. [PMID: 37374959 DOI: 10.3390/microorganisms11061459] [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: 04/26/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
Hospital-acquired pneumonia, including ventilator-associated pneumonia (VAP) due to difficult-to-treat-resistant (DTR) Gram-negative bacteria, contributes significantly to morbidity and mortality in ICUs. In the era of COVID-19, the incidences of secondary nosocomial pneumonia and the demand for invasive mechanical ventilation have increased dramatically with extremely high attributable mortality. Treatment options for DTR pathogens are limited. Therefore, an increased interest in high-dose nebulized colistin methanesulfonate (CMS), defined as a nebulized dose above 6 million IU (MIU), has come into sight. Herein, the authors present the available modern knowledge regarding high-dose nebulized CMS and current information on pharmacokinetics, clinical studies, and toxicity issues. A brief report on types of nebulizers is also analyzed. High-dose nebulized CMS was administrated as an adjunctive and substitutive strategy. High-dose nebulized CMS up to 15 MIU was attributed with a clinical outcome of 63%. High-dose nebulized CMS administration offers advantages in terms of efficacy against DTR Gram-negative bacteria, a favorable safety profile, and improved pharmacokinetics in the treatment of VAP. However, due to the heterogeneity of studies and small sample population, the apparent benefit in clinical outcomes must be proven in large-scale trials to lead to the optimal use of high-dose nebulized CMS.
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Affiliation(s)
- Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4, Erythrou Stavrou Str. & Kifisias, 15123 Athens, Greece
| | - Aikaterini Gkoufa
- Infectious Diseases and COVID-19 Unit, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Elena Polyzou
- School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| | | | - Zoe Athanassa
- Intensive Care Unit, Sismanoglio General Hospital, 15126 Athens, Greece
| | - Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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How to Use Nebulized Antibiotics in Severe Respiratory Infections. Antibiotics (Basel) 2023; 12:antibiotics12020267. [PMID: 36830177 PMCID: PMC9952454 DOI: 10.3390/antibiotics12020267] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Difficult-to-treat pulmonary infections caused by multidrug-resistant (MDR) pathogens are of great concern because their incidence continues to increase worldwide and they are associated with high morbidity and mortality. Nebulized antibiotics are increasingly being used in this context. The advantages of the administration of a nebulized antibiotic in respiratory tract infections due to MDR include the potential to deliver higher drug concentrations to the site of infection, thus minimizing the systemic adverse effects observed with the use of parenteral or oral antibiotic agents. However, there is an inconsistency between the large amount of experimental evidence supporting the administration of nebulized antibiotics and the paucity of clinical studies confirming the efficacy and safety of these drugs. In this narrative review, we describe the current evidence on the use of nebulized antibiotics for the treatment of severe respiratory infections.
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Feng JY, Huang JR, Lee CC, Tseng YH, Pan SW, Chen YM, Yang KY. Role of nebulized colistin as a substitutive strategy against nosocomial pneumonia caused by CR-GNB in intensive care units: a retrospective cohort study. Ann Intensive Care 2023; 13:1. [PMID: 36609725 PMCID: PMC9825688 DOI: 10.1186/s13613-022-01088-4] [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: 08/06/2022] [Accepted: 11/26/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Adverse reactions, especially nephrotoxicity, are great concerns of intravenous colistin treatment. The role of substitutive nebulized colistin in treating nosocomial pneumonia caused by carbapenem-resistant Gram-negative bacterial (CR-GNB) in critically ill patients remains unknown. METHODS This retrospective study enrolled patients with nosocomial pneumonia caused by colistin-susceptible CRGNB in the intensive care unit (ICU) without intravenous colistin treatment. Patients were categorized based on whether substitutive nebulized colistin was used alongside other intravenous antibiotics. Clinical responses and mortality rates were compared between the two groups in the original and propensity score (PS)-matched cohorts. This study aimed to investigate the clinical effectiveness of substitutive nebulized colistin in treatment outcomes of nosocomial pneumonia caused by CR-GNB. The impact of dosing strategy of nebulized colistin was also explored. RESULTS In total, 343 and 214 patients with and without substitutive nebulized colistin, respectively, were enrolled for analysis. In the PS-matched cohort, clinical failure rates on day 7 (22.6 vs. 42.6%, p = 0.001), day 14 (27.0 vs. 42.6%, p = 0.013), and day 28 (27.8 vs. 41.7%, p = 0.027) were significantly lower in patients with nebulized colistin. In multivariate analysis, nebulized colistin was an independent factor associated with lower day 14 clinical failure (Original cohort: adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.30-0.67; PS-matched cohort: aOR 0.48, 95% CI 0.27-0.87). There were no differences in clinical failure rate and mortality rate between patients receiving high (> 6 MIU/day) and low (≤ 6 MIU/day) dose nebulized colistin in the PS-matched cohort. CONCLUSIONS In ICU-admitted patients with nosocomial pneumonia caused by colistin-susceptible CRGNB, substitutive nebulized colistin was associated with better clinical outcomes.
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Affiliation(s)
- Jia-Yih Feng
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jhong-Ru Huang
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan
| | - Chang-Ching Lee
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan
| | - Yen-Han Tseng
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Wei Pan
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuh-Min Chen
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan ,grid.260539.b0000 0001 2059 7017School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuang-Yao Yang
- grid.278247.c0000 0004 0604 5314Department of Chest Medicine, Taipei Veterans General Hospital, #201, Sec. 2, Shih-Pai Road, Taipei, 11217 Taiwan ,grid.260539.b0000 0001 2059 7017Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Kyriakoudi A, Pontikis K, Valsami G, Avgeropoulou S, Neroutsos E, Christodoulou E, Moraitou E, Markantonis SL, Dokoumetzidis A, Rello J, Koutsoukou A. Pharmacokinetic Characteristics of Nebulized Colistimethate Sodium Using Two Different Types of Nebulizers in Critically Ill Patients with Ventilator-Associated Respiratory Infections. Antibiotics (Basel) 2022; 11:1528. [PMID: 36358184 PMCID: PMC9686516 DOI: 10.3390/antibiotics11111528] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 05/25/2024] Open
Abstract
Background: Rising antimicrobial resistance has led to a revived interest in inhaled colistin treatment in the critically ill patient with ventilator-associated respiratory infection (VARI). Nebulization via vibrating mesh nebulizers (VMNs) is considered the current standard-of-care, yet the use of generic jet nebulizers (JNs) is more widespread. Few data exist on the intrapulmonary pharmacokinetics of colistin when administered through VMNs, while there is a complete paucity regarding the use of JNs. Methods: In this study, 18 VARI patients who received 2 million international units of inhaled colistimethate sodium (CMS) through a VMN were pharmacokinetically compared with six VARI patients who received the same drug dose through a JN, in the absence of systemic CMS administration. Results: Surprisingly, VMN and JN led to comparable formed colistin exposures in the epithelial lining fluid (ELF) (median (IQR) AUC0-24: 86.2 (46.0-185.9) mg/L∙h with VMN and 91.5 (78.1-110.3) mg/L∙h with JN). The maximum ELF concentration was 10.4 (4.7-22.6) mg/L and 7.4 (6.2-10.3) mg/L, respectively. Conclusions: Based on our results, JN might be considered a viable alternative to the theoretically superior VMN. Therapeutic drug monitoring in the ELF can be advised due to the observed low exposure, high variability, and appreciable systemic absorption.
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Affiliation(s)
- Anna Kyriakoudi
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Georgia Valsami
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Stavrina Avgeropoulou
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Efthymios Neroutsos
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Eirini Christodoulou
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Eleni Moraitou
- Microbiology Department, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
| | - Sophia L. Markantonis
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Aristides Dokoumetzidis
- Department of Pharmacy, School of Health Sciences, National & Kapodistrian University of Athens, 15784 Athens, Greece
| | - Jordi Rello
- Clinical Research in Pneumonia (CRIPS), Vall d’Hebron Institute of Research, 08035 Barcelona, Spain
- Clinical Research, CHU Nîmes, 30900 Nîmes, France
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonology, Medical School, National & Kapodistrian University of Athens, General Hospital for the Diseases of the Chest “I Sotiria”, 11527 Athens, Greece
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Rouby JJ, Zhu Y, Torres A, Rello J, Monsel A. Aerosolized polymyxins for ventilator-associated pneumonia caused by extensive drug resistant Gram-negative bacteria: class, dose and manner should remain the trifecta. Ann Intensive Care 2022; 12:97. [PMID: 36251177 PMCID: PMC9576828 DOI: 10.1186/s13613-022-01068-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023] Open
Affiliation(s)
- Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance-Publique Hôpitaux de Paris, Sorbonne University of Paris, Paris, France.
| | - Yinggang Zhu
- Department of Pulmonary and Critical Care Medicine, Hua-Dong Hospital, Fudan University, Shanghai, China
| | - Antoni Torres
- Department of Pneumology, SGR 911- Ciber de Enfermedades Respiratorias (Ciberes), Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Jordi Rello
- Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Clinical Research & Innovation in Pneumonia & Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance-Publique Hôpitaux de Paris, Sorbonne University of Paris, Paris, France.,Unité mixte de recherche (UMR)-S 959, Immunology-Immunopathology-Immunotherapy (I3), Institut National de La Santé et de La Recherche Médicale (INSERM), Paris, France.,Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
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10
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [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: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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11
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Secondary Prophylaxis With Inhaled Colistin to Prevent Recurrence of Pseudomonas aeruginosa and Extended-spectrum β-lactamase-producing Enterobacterales Pneumonia in ICU After Lung Transplantation: A Before-and-after Retrospective Cohort Analysis. Transplantation 2022; 106:2232-2240. [PMID: 35675449 DOI: 10.1097/tp.0000000000004187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early pneumonia is an independent risk factor for 1-y mortality after lung transplantation (LTx). Pseudomonas aeruginosa is the most common isolate in early pneumonia and is also associated with an increased risk of chronic lung allograft dysfunction. The aim of our study was to evaluate the efficacy of secondary prophylaxis with inhaled colistin (IC) in preventing the recurrence of P aeruginosa or extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) pneumonia in the postoperative period in the intensive care unit after LTx. METHODS We conducted a before-and-after retrospective cohort study by including all patients who underwent LTx between January 2015 and December 2020 in our center. Secondary prophylaxis with IC was instituted in January 2018 (observation period from January 2015 to December 2017, intervention period from January 2018 to December 2020). RESULTS A total of 271 lung transplants were included (125 in the observation period and 146 in the intervention period). The patients were predominately male (64.2%) with a median age of 57 y and received double LTx (67.9%) for chronic obstructive pulmonary disease/emphysema (36.2%) or interstitial lung disease (48.3%). The proportion of patients who experienced at least 1 recurrence of P aeruginosa or ESBL-PE pneumonia was significantly lower in the intervention period than in the observation period (0.7% versus 7.2%, P = 0.007). CONCLUSIONS Our study suggests a potential benefit of secondary prophylaxis with IC to prevent the recurrence of P aeruginosa or ESBL-PE pneumonia in the intensive care unit after LTx.
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12
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Boisson M, Bouglé A, Sole-Lleonart C, Dhanani J, Arvaniti K, Rello J, Rouby JJ, Mimoz O. Nebulized Antibiotics for Healthcare- and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:255-270. [PMID: 35042259 DOI: 10.1055/s-0041-1740340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Global emergence of multidrug-resistant and extensive drug-resistant gram-negative bacteria has increased the risk of treatment failure, especially for healthcare- or ventilator-associated pneumonia (HAP/VAP). Nebulization of antibiotics, by providing high intrapulmonary antibiotic concentrations, represents a promising approach to optimize the treatment of HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria, while limiting systemic antibiotic exposure. Aminoglycosides and colistin methanesulfonate are the most common nebulized antibiotics. Although optimal nebulized drug dosing regimen is not clearly established, high antibiotic doses should be administered using vibrating-mesh nebulizer with optimized ventilator settings to ensure safe and effective intrapulmonary concentrations. When used preventively, nebulized antibiotics reduced the incidence of VAP without any effect on mortality. This approach is not yet recommended and large randomized controlled trials should be conducted to confirm its benefit and explore the impact on antibiotic selection pressure. Compared with high-dose intravenous administration, high-dose nebulized colistin methanesulfonate seems to be more effective and safer in the treatment of ventilator-associated tracheobronchitis and VAP caused by multidrug resistant and extensive-drug resistant gram-negative bacteria. Adjunctive nebulized aminoglycosides could increase the clinical cure rate and bacteriological eradication in patients suffering from HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria. As nebulized aminoglycosides broadly diffuse in the systemic circulation of patients with extensive bronchopneumonia, monitoring of plasma trough concentrations is recommended during the period of nebulization. Large randomized controlled trials comparing high dose of nebulized colistin methanesulfonate to high dose of intravenous colistin methanesulfonate or to intravenous new β-lactams in HAP/VAP due to multidrug-resistant and extensive drug-resistant gram-negative bacteria are urgently needed.
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Affiliation(s)
- Matthieu Boisson
- INSERM U1070, Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,Service de Prévention et de Contrôle de l'Infection, Hôpitaux Universitaires de Genève, Genève, Suisse
| | - Adrien Bouglé
- Medicine Sorbonne University, Anaesthesiology and Critical Care, Cardiology Institute, Paris, France.,Department of Anaesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Candela Sole-Lleonart
- Intensive Care Unit, Consorci Hospitalari de Vic (CHV), The University of Vic - Central University of Catalonia (UVic-UCC), Vic, Barcelona, Spain
| | - Jayesh Dhanani
- Department of Intensive care medicine, Centre for Clinical Research, The University of Queensland, The Royal Brisbane and Women's Hospital Herston, Brisbane, Australia
| | - Kostoula Arvaniti
- Intensive Care Unit Department, Papageorgiou Hospital of Thessaloniki, Thessaloniki, Greece
| | - Jordi Rello
- Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Clinical Research and Innovation in Pneumonia and Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain.,Clinical Research, CHU Nîmes, Université Montpellier-Nîmes, Nîmes, France
| | - Jean-Jacques Rouby
- Department of Anaesthesiology and Critical Care, Medicine Sorbonne University, Multidisciplinary Intensive Care Unit, La Pitié Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Olivier Mimoz
- INSERM U1070 Université de Poitiers, UFR de Médecine Pharmacie and Service des Urgences Adultes & SAMU 86, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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13
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Zachar O. Nanomedicine formulations for respiratory infections by inhalation delivery: Covid-19 and beyond. Med Hypotheses 2022; 159:110753. [PMID: 35002023 PMCID: PMC8721932 DOI: 10.1016/j.mehy.2021.110753] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/02/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022]
Abstract
For respiratory infections treatment and prevention, we analyze for the first time the possibility of providing a broad range medication based on metallic nanoparticles colloids (NpC) delivery by controlled aerosol inhalation. (i) Based on in-vitro data combined with aerosol deposition characteristics in the respiratory system, we calculate the required effective formulations, dosages and delivery parameters for an aerosol inhalation treatment. The goal is to achieve an effective NpC inhibitory concentration (IC) in the target airway surface liquid (ASL); (ii) We evaluate the clinical safety of such dosages, drawing on information from animal testing data and regulatory limits in the USA for such nanoparticles aerosol inhalation safety. Our analysis indicates a wide range of potentially safe and effective dosages that can be clinically explored, targeting the upper respiratory and bronchial tree system. Similar dosages can also provide antibacterial effectiveness for prophylactic treatment in hospital intensive care units to lower the risk of ventilator-associated pneumonia (VAP). Our calculations are phenomenological, independent of mechanisms. Nevertheless, we highlight a mechanism of action by which any suitably designed NpC, with nanoparticles sized 2–10 nm and having a large negative zeta-potential, preferentially bind to viruses with predominantly positively-charged spike proteins. These will be ineffective against viruses with predominantly negatively-charged spike proteins. Accordingly, the popular silver metal base for NpC serves just as a construction ingredient, and other metal or metal-oxides which can serve to construct the noted nanoparticle properties would be similarly effective. We suggest that inhalation delivery of the proposed antiviral formulations could be applied as a first-line intervention while respiratory infections are primarily localized to the upper respiratory system and bronchial tree.
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Affiliation(s)
- Oron Zachar
- Yamor Technologies Ltd., 23 Mahane Yosef, Tel Aviv 6515325, Israel
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14
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Wang Y, Chang RYK, Britton WJ, Chan HK. Advances in the development of antimicrobial peptides and proteins for inhaled therapy. Adv Drug Deliv Rev 2022; 180:114066. [PMID: 34813794 DOI: 10.1016/j.addr.2021.114066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022]
Abstract
Antimicrobial peptides and proteins (APPs) are becoming increasingly important in targeting multidrug-resistant (MDR) bacteria. APPs is a rapidly emerging area with novel molecules being produced and further optimised to enhance antimicrobial efficacy, while overcoming issues associated with biologics such as potential toxicity and low bioavailability resulting from short half-life. Inhalation delivery of these agents can be an effective treatment of respiratory infections owing to the high local drug concentration in the lungs with lower exposure to systemic circulation hence reducing systemic toxicity. This review describes the recent studies on inhaled APPs, including in vitro and in vivo antimicrobial activities, toxicity assessments, and formulation strategies whenever available. The review also includes studies on combination of APPs with other antimicrobial agents to achieve enhanced synergistic antimicrobial effect. Since different APPs have different biological and chemical stabilities, a targeted formulation strategy should be considered for developing stable and inhalable antimicrobial peptides and proteins. These strategies include the use of sodium chloride to reduce electrostatic interaction between APP and extracellular DNA in sputum, the use of D-enantiomers or dendrimers to minimise protease-mediated degradation and or the use of prodrugs to reduce toxicity. Although great effort has been put towards optimising the biological functions of APPs, studies assessing biological stability in inhalable aerosols are scarce, particularly for novel molecules. As such, formulation and manufacture of inhalable liquid and powder formulations of APPs are underexplored, yet they are crucial areas of research for clinical translation.
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15
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Jung YJ, Kim EJ, Choi YH. Aerosolized antibiotics in the treatment of hospital-acquired pneumonia/ventilator-associated pneumonia. Korean J Intern Med 2022; 37:1-12. [PMID: 34666432 PMCID: PMC8747925 DOI: 10.3904/kjim.2021.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/22/2021] [Indexed: 01/02/2023] Open
Abstract
Aerosolized antibiotics are being increasingly used to treat respiratory infections, especially those caused by drug-resistant pathogens. Their use in the treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in critically ill patients is especially significant. They are also used as an efficient alternative to overcome the issues caused by systemic administration of antibiotics, including the occurrence of drug-resistant strains, drug toxicity, and insufficient drug concentration at the target site. However, the rationale for the use of aerosolized antibiotics is limited owing to their insufficient efficacy and the potential for underestimated risks of developing side effects. Despite the lack of availability of high-quality evidence, the use of aerosolized antibiotics is considered as an attractive alternative treatment approach, especially in patients with multidrug-resistant pathogens. In this review, we have discussed the effectiveness and side effects of aerosolized antibiotics as well as the latest advancements in this field and usage in the Republic of Korea.
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Affiliation(s)
- Yun Jung Jung
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Eun Jin Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon,
Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon,
Korea
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16
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Sato M, Honda A, Maki H, Toyama K, Yamaguchi R, Ikeda M, Moriya K, Kurokawa M. Successful treatment of pneumonia caused by multidrug-resistant Pseudomonas aeruginosa after allogeneic hematopoietic stem cell transplantation with colistin and amikacin inhalation therapy. J Infect Chemother 2021; 28:91-94. [PMID: 34518095 DOI: 10.1016/j.jiac.2021.08.023] [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: 07/07/2021] [Revised: 08/23/2021] [Accepted: 08/29/2021] [Indexed: 11/27/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative bacillus that often causes severe infections during immunosuppression in patients with hematologic malignancies. P. aeruginosa can easily acquire drug resistance, and often develops into multidrug-resistant P. aeruginosa (MDRP). Although many antibiotics are used in combination to treat MDRP infections, colistin and amikacin are less likely to be transferred to the lungs, and inhalation therapy may be used. Herein, we report a Case of pneumonia caused by MDRP after allogeneic hematopoietic stem cell transplantation (HSCT) treated with inhaled colistin and amikacin. This 61-year-old female patient was diagnosed with myelodysplastic syndromes and underwent allogeneic HSCT from an 8/8 HLA-matched unrelated donor after reduced-intensity conditioning. On the day of the stem cell infusion, the patient's sputum culture was found to be positive for MDRP. The patient subsequently developed bacteremia, pneumonia, and lung abscess caused by MDRP, and we administered multidrug antibiotic therapy including colistin and amikacin inhalation therapy. The patient's blood cultures were subsequently turned negative, and the lung abscess disappeared. To our knowledge, this is the first case of MDRP pneumonia after HSCT in which colistin and amikacin inhalation therapy was effective.
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Affiliation(s)
- Michiaki Sato
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Honda
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Maki
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Toyama
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryo Yamaguchi
- Department of Pharmacy, The University of Tokyo Hospital, Japan
| | - Mahoko Ikeda
- Department of Infection Control and Prevention, Faculty of Medicine, The University of Tokyo, Japan
| | - Kyoji Moriya
- Department of Infection Control and Prevention, Faculty of Medicine, The University of Tokyo, Japan
| | - Mineo Kurokawa
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Tokyo, Japan.
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17
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Nebulized antibiotics for ventilator-associated pneumonia: methodological framework for future multicenter randomized controlled trials. Curr Opin Infect Dis 2021; 34:156-168. [PMID: 33605620 DOI: 10.1097/qco.0000000000000720] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Although experimental evidence supports the use of nebulized antibiotics in ventilator-associated pneumonia (VAP), two recent multicenter randomized controlled trials (RCTs) have failed to demonstrate any benefit in VAP caused by Gram-negative bacteria (GNB). This review examines the methodological requirements concerning future RCTs. RECENT FINDINGS High doses of nebulized antibiotics are required to reach the infected lung parenchyma. Breath-synchronized nebulizers do not allow delivery of high doses. Mesh nebulizers perform better than jet nebulizers. Epithelial lining fluid concentrations do not reflect interstitial lung concentrations in patients receiving nebulized antibiotics. Specific ventilator settings for optimizing lung deposition require sedation to avoid patient's asynchrony with the ventilator. SUMMARY Future RCTs should compare a 3-5 day nebulization of amikacin or colistimethate sodium (CMS) to a 7-day intravenous administration of a new cephalosporine/ß-lactamase inhibitor. Inclusion criteria should be a VAP or ventilator-associated tracheobronchitis caused by documented extensive-drug or pandrug resistant GNB. If the GNB remains susceptible to aminoglycosides, nebulized amikacin should be administered at a dose of 40 mg/kg/day. If resistant to aminoglycosides, nebulized CMS should be administered at a dose of 15 millions international units (IU)/day. In VAP caused by pandrug-resistant GNB, 15 millions IU/day nebulized CMS (substitution therapy) should be compared with a 9 millions IU/day intravenous CMS.
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18
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Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
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Aerosolized plus intravenous colistin vs intravenous colistin alone for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria: A retrospective cohort study. Int J Infect Dis 2021; 108:406-412. [PMID: 34111542 DOI: 10.1016/j.ijid.2021.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To compare the effectiveness and safety of aerosolized (AER) plus intravenous (IV) colistin with IV colistin alone in patients with nosocomial pneumonia (NP) due to multidrug-resistant (MDR) Gram-negative bacteria. METHODS This was a retrospective cohort study of adults with NP who received IV colistin alone or in combination with AER colistin. The primary endpoint was clinical cure at end of therapy. Secondary endpoints included microbiological eradication, in-hospital mortality and nephrotoxicity. RESULTS In total, 135 patients were included in this study: 65 patients received AER plus IV colistin and 70 patients received IV colistin alone. Baseline characteristics were similar between the two groups. Clinical cure was achieved in 42 (65%) patients who received AER plus IV colistin and 26 (37%) patients who received IV colistin alone (P = 0.01). Among a total of 88 patients who were microbiologically evaluable, 27 (42%) patients who received AER plus IV colistin and 12 (17%) patients who received IV colistin alone attained favourable microbiological outcomes (P = 0.022). In-hospital mortality (43% vs 59%, P = 0.072) was higher in patients who received IV colistin alone, but the difference was not significant. Renal injury occurred in 31% of patients who received AER plus IV colistin and in 41% of patients who received IV colistin alone (P = 0.198). CONCLUSION AER colistin can be considered as salvage therapy as an adjunct to IV administration for the treatment of patients with NP due to MDR Gram-negative pathogens.
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20
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Nebulized Colistin in Ventilator-Associated Pneumonia and Tracheobronchitis: Historical Background, Pharmacokinetics and Perspectives. Microorganisms 2021; 9:microorganisms9061154. [PMID: 34072189 PMCID: PMC8227626 DOI: 10.3390/microorganisms9061154] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
Clinical evidence suggests that nebulized colistimethate sodium (CMS) has benefits for treating lower respiratory tract infections caused by multidrug-resistant Gram-negative bacteria (GNB). Colistin is positively charged, while CMS is negatively charged, and both have a high molecular mass and are hydrophilic. These physico-chemical characteristics impair crossing of the alveolo-capillary membrane but enable the disruption of the bacterial wall of GNB and the aggregation of the circulating lipopolysaccharide. Intravenous CMS is rapidly cleared by glomerular filtration and tubular excretion, and 20-25% is spontaneously hydrolyzed to colistin. Urine colistin is substantially reabsorbed by tubular cells and eliminated by biliary excretion. Colistin is a concentration-dependent antibiotic with post-antibiotic and inoculum effects. As CMS conversion to colistin is slower than its renal clearance, intravenous administration can lead to low plasma and lung colistin concentrations that risk treatment failure. Following nebulization of high doses, colistin (200,000 international units/24h) lung tissue concentrations are > five times minimum inhibitory concentration (MIC) of GNB in regions with multiple foci of bronchopneumonia and in the range of MIC breakpoints in regions with confluent pneumonia. Future research should include: (1) experimental studies using lung microdialysis to assess the PK/PD in the interstitial fluid of the lung following nebulization of high doses of colistin; (2) superiority multicenter randomized controlled trials comparing nebulized and intravenous CMS in patients with pandrug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis; (3) non-inferiority multicenter randomized controlled trials comparing nebulized CMS to intravenous new cephalosporines/ß-lactamase inhibitors in patients with extensive drug-resistant GNB ventilator-associated pneumonia and ventilator-associated tracheobronchitis.
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21
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Almangour TA, Garcia E, Zhou Q, Forrest A, Kaye KS, Li J, Velkov T, Rao GG. Polymyxins for the treatment of lower respiratory tract infections: lessons learned from the integration of clinical pharmacokinetic studies and clinical outcomes. Int J Antimicrob Agents 2021; 57:106328. [PMID: 33785362 DOI: 10.1016/j.ijantimicag.2021.106328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/18/2021] [Accepted: 03/20/2021] [Indexed: 11/26/2022]
Abstract
The global rise in nosocomial pneumonia caused by multidrug-resistant (MDR) Gram-negative pathogens and the increasingly limited antibiotic treatment options are growing threats to modern medicine. As a result, older antibiotics such as polymyxins are being used as last-resort drugs for MDR nosocomial pneumonia. Polymyxins are bactericidal against most aerobic Gram-negative bacilli. High-dose intravenous (IV) adminsitration of polymyxins, however, results in subtherapeutic concentrations at the site of infection making treatment challenging. Alternative forms of polymyxin delivery have been considered in order to better achieve the necessary concentrations at the site of infection. Several studies have evaluated the effectiveness of aerosolised polymyxins in patients with nosocomial pneumonia caused by MDR Gram-negative pathogens such as Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae. Here we evaluated the pharmacokinetic data supporting the use of inhaled polymyxins in nosocomial pneumonia and provide insight into the limitations and challenges that future studies should address. We have also reviewed the literature published between 2006 and 2020 on the use of aerosolised polymyxins for the treatment of nosocomial pneumonia, including ventilator-associated pneumonia, in patients without cystic fibrosis to evaluate their safety and efficacy as monotherapy or as an adjunct to IV antimicrobials. This review highlights the need for well-designed multicentre studies with standardised methodologies to further evaluate the effectiveness of inhaled polymyxins and to provide reliable pharmacokinetic/pharmacodynamic data in order to redefine appropriate dosing strategies.
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Affiliation(s)
- Thamer A Almangour
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA; Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Estefany Garcia
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Qi Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | - Alan Forrest
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Tony Velkov
- Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gauri G Rao
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.
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22
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Nwabor OF, Terbtothakun P, Voravuthikunchai SP, Chusri S. Evaluation of the Synergistic Antibacterial Effects of Fosfomycin in Combination with Selected Antibiotics against Carbapenem-Resistant Acinetobacter baumannii. Pharmaceuticals (Basel) 2021; 14:185. [PMID: 33668905 PMCID: PMC7996625 DOI: 10.3390/ph14030185] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 12/22/2022] Open
Abstract
The spread of multi-drug resistant (MDR) pathogens and the lagging pace in the development of novel chemotherapeutic agents warrant the use of combination therapy as a reliable, cost-effective interim option. In this study, the synergistic effects of fosfomycin in combination with other antibiotics were assessed. Of the 193 isolates, 90.6% were non-susceptible to fosfomycin, with minimum inhibitory concentrations (MICs) of ≥128 µg/mL. Antibacterial evaluation of fosfomycin-resistant isolates indicated multi-drug resistance to various antibiotic classes. Combinations of fosfomycin with 12 commonly used antibiotics synergistically inhibited most fosfomycin-resistant isolates. The fractional inhibitory concentration index indicated that combining fosfomycin with either aminoglycosides, glycylcyclines, fluoroquinolones, or colistin resulted in 2- to 16-fold reduction in the MIC of fosfomycin. Time-kill kinetics further confirmed the synergistic bactericidal effects of fosfomycin in combination with either amikacin, gentamicin, tobramycin, minocycline, tigecycline, or colistin, with more than 99.9% reduction in bacterial cells. Fosfomycin-based combination therapy might serve as an alternative option for the treatment of MDR A. baumannii. Further steps including in vivo efficacy and toxicity in experimental models of infection are required prior to clinical applications.
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Affiliation(s)
- Ozioma F. Nwabor
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand; (O.F.N.); (P.T.)
- Division of Biological Science, Faculty of Science and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand;
| | - Pawarisa Terbtothakun
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand; (O.F.N.); (P.T.)
- Division of Biological Science, Faculty of Science and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand;
| | - Supayang P. Voravuthikunchai
- Division of Biological Science, Faculty of Science and Natural Product Research Center of Excellence, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand;
| | - Sarunyou Chusri
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand; (O.F.N.); (P.T.)
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23
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Speck PG, Warner MS, Bihari S, Bersten AD, Mitchell JG, Tucci J, Gordon DL. Potential for bacteriophage therapy for Staphylococcus aureus pneumonia with influenza A coinfection. Future Microbiol 2021; 16:135-142. [PMID: 33538181 DOI: 10.2217/fmb-2020-0163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The ability of influenza A virus to evolve, coupled with increasing antimicrobial resistance, could trigger an influenza pandemic with great morbidity and mortality. Much of the 1918 influenza pandemic mortality was likely due to bacterial coinfection, including Staphylococcus aureus pneumonia. S. aureus resists many antibiotics. The lack of new antibiotics suggests alternative antimicrobials, such as bacteriophages, are needed. Potential delivery routes for bacteriophage therapy (BT) include inhalation and intravenous injection. BT has recently been used successfully in compassionate access pulmonary infection cases. Phage lysins, enzymes that hydrolyze bacterial cell walls and which are bactericidal, are efficacious in animal pneumonia models. Clinical trials will be needed to determine whether BT can ameliorate disease in influenza and S. aureus coinfection.
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Affiliation(s)
- Peter G Speck
- Flinders University of South Australia, College of Science and Engineering, Bedford Park, SA, 5042, Australia
| | - Morgyn S Warner
- The Queen Elizabeth Hospital, Infectious Diseases Unit, Woodville, SA, 5011, Australia.,Microbiology & Infectious Diseases Directorate, SA Pathology, Adelaide, SA, 5000, Australia.,University of Adelaide, Faculty of Health & Medical Sciences, Adelaide, SA, 5006, Australia
| | - Shailesh Bihari
- Flinders Medical Centre, Intensive & Critical Care Unit, Bedford Park, SA, 5042, Australia.,Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia
| | - Andrew D Bersten
- Flinders Medical Centre, Intensive & Critical Care Unit, Bedford Park, SA, 5042, Australia.,Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia
| | - James G Mitchell
- Flinders University of South Australia, College of Science and Engineering, Bedford Park, SA, 5042, Australia
| | - Joseph Tucci
- Department of Pharmacy & Biomedical Science, LaTrobe University, La Trobe Institute for Molecular Science, Bendigo, Victoria, 3552, Australia
| | - David L Gordon
- Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia.,Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, SA, 5042, Australia
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24
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Feng JY, Peng CK, Sheu CC, Lin YC, Chan MC, Wang SH, Chen CM, Shen YC, Zheng ZR, Lin YT, Yang KY. Efficacy of adjunctive nebulized colistin in critically ill patients with nosocomial carbapenem-resistant Gram-negative bacterial pneumonia: a multi-centre observational study. Clin Microbiol Infect 2021; 27:1465-1473. [PMID: 33540113 DOI: 10.1016/j.cmi.2021.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To investigate the association between adjunctive nebulized colistin and treatment outcomes in critically ill patients with nosocomial carbapenem-resistant Gram-negative bacterial (CR-GNB) pneumonia. METHODS This retrospective, multi-centre, cohort study included individuals admitted to the intensive care unit with nosocomial pneumonia caused by colistin-susceptible CR-GNB. Enrolled patients were divided into groups with/without nebulized colistin as adjunct to at least one effective intravenous antibiotic. Propensity score matching was performed in the original cohort (model 1) and a time-window bias-adjusted cohort (model 2). The association between adjunctive nebulized colistin and treatment outcomes was analysed. RESULTS In total, 181 and 326 patients treated with and without nebulized colistin, respectively, were enrolled for analysis. The day 14 clinical failure rate and mortality rate were 41.4% (75/181) versus 46% (150/326), and 14.9% (27/181) versus 21.8% (71/326), respectively. In the propensity score-matching analysis, patients with nebulized colistin had lower day 14 clinical failure rates (model 1: 41% (68/166) versus 54.2% (90/166), p 0.016; model 2: 35.3% (41/116) versus 56.9% (66/116), p 0.001). On multivariate analysis, nebulized colistin was an independent factor associated with fewer day 14 clinical failures (model 1: adjusted odds ratio (aOR) 0.59, 95% CI 0.37-0.92; model 2: aOR 0.37, 95% CI 0.21-0.65). Nebulized colistin was not associated independently with a lower 14-day mortality rate in the time-dependent analysis in both models 1 and 2. CONCLUSIONS Adjunctive nebulized colistin was associated with lower day 14 clinical failure rate, but not lower 14-day mortality rate, in critically ill patients with nosocomial pneumonia caused by colistin-susceptible CR-GNB.
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Affiliation(s)
- Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chao Lin
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; College of Science, Tunghai University, Taichung, Taiwan
| | - Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defence Medical Centre, Taipei, Taiwan
| | - Chia-Min Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Cheng Shen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Zhe-Rong Zheng
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Tsung Lin
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Cancer Progression Research Center, National Yang-Ming University, Taipei, Taiwan.
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25
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Li Y, Xie M, Zhou J, Lin H, Xiao T, Wu L, Ding H, Fang B. Increased Antimicrobial Activity of Colistin in Combination With Gamithromycin Against Pasteurella multocida in a Neutropenic Murine Lung Infection Model. Front Microbiol 2020; 11:511356. [PMID: 33072002 PMCID: PMC7536268 DOI: 10.3389/fmicb.2020.511356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/21/2020] [Indexed: 01/09/2023] Open
Abstract
We investigate the antimicrobial activity of combined colistin and gamithromycin against nine Pasteurella multocida strains by testing in vitro susceptibility. Two high-colistin minimal inhibitory concentration (MIC) isolates (D18 and T5) and one low-colistin MIC isolate (WJ11) were used in time-kill tests and therapeutic effect experiments using a neutropenic murine pneumonia model over 24 h. Pharmacokinetics (PK) in plasma was calculated along with pharmacodynamics (PD) to determine the PK/PD index. Synergy between colistin and gamithromycin was observed using high-colistin MIC isolates, equating to a 128- or 256-fold and 4- or 8-fold reduction in colistin and gamithromycin concentration, respectively. Interestingly, no synergistic effect of the combination on low-colistin MIC isolates was observed. However, regardless of the MIC difference among isolates, each drug tended to reach the same concentration in all isolates subjected to combined treatments, which was verified by the time-kill tests presenting similar rates and extent of killing for isolates D18, T5, and WJ11. The AUC(0–24 h)/MIC index was used to evaluate the relationship between PK and PD, and the correlation was >0.89. The relevant gamithromycin doses for combined therapy were determined, and the value decreased from 6- to 35-fold compared with monotherapy. Combined colistin and gamithromycin therapy provides a more potent therapeutic regimen than monotherapy against P. multocida strains.
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Affiliation(s)
- Yanqin Li
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Mengjuan Xie
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Junwen Zhou
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Hao Lin
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Tianan Xiao
- Guangdong Center for Agricultural Products Quality and Safety, Guangzhou, China
| | - Liqin Wu
- Guangdong Center for Agricultural Products Quality and Safety, Guangzhou, China
| | - Huanzhong Ding
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Binghu Fang
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
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26
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Nebulization of Vancomycin Provides Higher Lung Tissue Concentrations than Intravenous Administration in Ventilated Female Piglets with Healthy Lungs. Anesthesiology 2020; 132:1516-1527. [PMID: 32053565 DOI: 10.1097/aln.0000000000003171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intravenous vancomycin is used to treat ventilator-associated pneumonia caused by methicillin-resistant Staphylococcus aureus, but achieves high rates of failure. Vancomycin nebulization may be efficient to provide high vancomycin lung tissue concentrations. The aim of this study was to compare lung tissue and serum concentrations of vancomycin administered intravenously and by aerosol in mechanically ventilated and anesthetized healthy piglets. METHODS Twelve female piglets received a single intravenous dose of vancomycin (15 mg/kg) and were killed 1 (n = 6) or 12 h (n = 6) after the end of administration. Twelve piglets received a single nebulized dose of vancomycin (37.5 mg/kg) and were killed 1 (n = 6) or 12 h (n = 6) after the end of the aerosol administration. In each group, vancomycin lung tissue concentrations were assessed on postmortem lung specimens using high-performance liquid chromatography. Blood samples were collected for serum vancomycin concentration measurement 30 min and 1, 2, 4, 6, 8, and 12 h after the end of vancomycin administration. Pharmacokinetics was analyzed by nonlinear mixed effect modeling. RESULTS One hour after vancomycin administration, lung tissue concentrations in the aerosol group were 13 times the concentrations in the intravenous group (median and interquartile range: 161 [71, 301] μg/g versus 12 [4, 42] μg/g; P < 0.0001). Twelve hours after vancomycin administration, lung tissue concentrations in the aerosol group were 63 (23, 119) μg/g and 0 (0, 19) μg/g in the intravenous group (P < 0.0001). A two-compartment weight-scaled allometric model with first-order absorption and elimination best fit serum pharmacokinetics after both routes of administration. Area under the time-concentration curve from 0 to 12 h was lower in the aerosol group in comparison to the intravenous group (56 [8, 70] mg · h · l vs. 121 [103, 149] mg · h · l, P = 0.002). Using a population model, vancomycin bioavailability was 13% (95% CI, 6 to 69; coefficient of variation = 85%) and absorption rate was slow (absorption half life = 0.3 h). CONCLUSIONS Administration of vancomycin by nebulization resulted in higher lung tissue concentrations than the intravenous route.
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27
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Inhaled colistin for the treatment of nosocomial pneumonia due to multidrug-resistant Gram-negative bacteria: A real-life experience in tertiary care hospitals in Saudi Arabia. Saudi Pharm J 2020; 28:1009-1013. [PMID: 32792845 PMCID: PMC7414068 DOI: 10.1016/j.jsps.2020.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023] Open
Abstract
Background Nosocomial pneumonia (NP) due to multidrug-resistant (MDR) Gram-negative pathogens, has continued to rise over the last several decades. Parenteral administration of colistin results in poor alveolar penetration and subtherapeutic concentration; therefore, direct drug deposition at site of infection may improve the effectiveness while minimizing the systemic exposure. The aim of this study is to describe the safety and effectiveness of inhaled colistin for the treatment of NP caused by MDR Gram-negative pathogens. Method Patients who received inhaled colistin from May 2015 to May 2019 at 2 different tertiary care hospitals in Riyadh, Saudi Arabia were identified from pharmacy databases and their charts were retrospectively reviewed. Results 86 patients were enrolled in this study. The mean age was 56 ± 20 years. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) was 17 ± 5. The responsible pathogens for NP were Pseudomonas aeruginosa (60%) Acinetobacter baumannii (28%), and Klebsiella pneumoniae (9%). Most patients (76/86) received concomitant intravenous antibiotics. Mean colistin total daily dose was 6 ± 3 million international units divided into 2-3 doses. Mean inhaled colistin duration of therapy was 11 ± 6 days. Favorable clinical outcome was achieved in 51 (59%) patients while favorable microbiological outcome occurred in 29 (34%) patients. Death due to all causes was noted in 39 (45%) cases. Renal injury occurred in 19 (22%) patients, all received concomitant intravenous colistin. Conclusion Inhaled colistin can be considered as salvage therapy as adjunct to intravenous administration for treatment of patients with NP due to MDR Gram-negative pathogens.
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Wu DW, Wang SW, Chang YF, Tsai JH. Effective pharmacotherapy for lung abscess in a patient with alcoholism. Respir Med Case Rep 2020; 30:101061. [PMID: 32373455 PMCID: PMC7193124 DOI: 10.1016/j.rmcr.2020.101061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Da-Wei Wu
- Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, 807, Kaohsiung, Taiwan
| | - Song-Wei Wang
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ya-Fan Chang
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jui-Hsiu Tsai
- Department of Psychiatry, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan.,Environmental and Occupation Medicine, (Taiwan) National Health Research Institute and Kaohsiung Medical University, Kaohsiung, Taiwan
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29
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Desoubeaux G, Lemaignen A, Ehrmann S. Reply to the reply to Scientific rationale for inhaled caspofungin to treat Pneumocystis pneumonia: A therapeutic innovation likely relevant to investigate in a near future …. Int J Infect Dis 2020; 95:469-470. [PMID: 32276043 DOI: 10.1016/j.ijid.2020.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Guillaume Desoubeaux
- Université de Tours, INSERM U1100, Centre d'étude des pathologies respiratoires, Tours, France.
| | - Adrien Lemaignen
- CHRU de Tours, Médecine interne & Maladies infectieuses, Tours, France
| | - Stephan Ehrmann
- Université de Tours, INSERM U1100, Centre d'étude des pathologies respiratoires, Tours, France; CHRU de Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, Tours, France
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Grabein B, Ebenhoch M, Kühnen E, Thalhammer F. Calculated parenteral initial treatment of bacterial infections: Infections with multi-resistant Gram-negative rods - ESBL producers, carbapenemase-producing Enterobacteriaceae, carbapenem-resistant Acinetobacter baumannii. GMS INFECTIOUS DISEASES 2020; 8:Doc04. [PMID: 32373429 PMCID: PMC7186793 DOI: 10.3205/id000048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This is the sixteenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Infections due to multiresistant Gram-negative rods are challenging. In this chapter recommendations for targeted therapy for infections caused by ESBL-producing Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii are given, based on the limited available evidence.
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Affiliation(s)
- Béatrice Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Munich, Germany
| | - Michael Ebenhoch
- Stabsstelle Hygiene, Klinische Infektiologie und Mikrobiologie, BG-Unfallklinik Murnau, Germany
| | - Ernst Kühnen
- Mikrobiologie & Hygiene, MVZ Synlab Trier, Germany
| | - Florian Thalhammer
- Klinische Abteilung für Infektiologie und Tropenmedizin, Medizinische Universität Wien, Vienna, Austria
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31
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Rouby JJ, Sole-Lleonart C, Rello J. Ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria: understanding nebulization of aminoglycosides and colistin. Intensive Care Med 2020; 46:766-770. [PMID: 31915838 PMCID: PMC7223812 DOI: 10.1007/s00134-019-05890-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/01/2019] [Indexed: 01/01/2023]
Affiliation(s)
- J J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Medicine Sorbonne University, Paris, France.
| | - C Sole-Lleonart
- Critical Care Department, Centre Hospitalo-Universtaire Vaudois, Lausanne, Switzerland
- Unitat Cures Intensives, Hospital Universitari de Vic, Barcelona, Spain
| | - J Rello
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain
- Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
- Anesthesiology Department, CHU Nîmes, Université Nîmes-Montepellier, Nîmes, France
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32
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Lung Pharmacokinetics of Tobramycin by Intravenous and Nebulized Dosing in a Mechanically Ventilated Healthy Ovine Model. Anesthesiology 2019; 131:344-355. [PMID: 31107274 DOI: 10.1097/aln.0000000000002752] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Nebulized antibiotics may be used to treat ventilator-associated pneumonia. In previous pharmacokinetic studies, lung interstitial space fluid concentrations have never been reported. The aim of the study was to compare intravenous and nebulized tobramycin concentrations in the lung interstitial space fluid, epithelial lining fluid, and plasma in mechanically ventilated sheep with healthy lungs. METHODS Ten anesthetized and mechanically ventilated healthy ewes underwent surgical insertion of microdialysis catheters in upper and lower lobes of both lungs and the jugular vein. Five ewes were given intravenous tobramycin 400 mg, and five were given nebulized tobramycin 400 mg. Microdialysis samples were collected every 20 min for 8 h. Bronchoalveolar lavage was performed at 1 and 6 h. RESULTS The peak lung interstitial space fluid concentrations were lower with intravenous tobramycin 20.2 mg/l (interquartile range, 12 mg/l, 26.2 mg/l) versus the nebulized route 48.3 mg/l (interquartile range, 8.7 mg/l, 513 mg/l), P = 0.002. For nebulized tobramycin, the median epithelial lining fluid concentrations were higher than the interstitial space fluid concentrations at 1 h (1,637; interquartile range, 650, 1,781, vs. 16 mg/l, interquartile range, 7, 86, P < 0.001) and 6 h (48, interquartile range, 17, 93, vs. 4 mg/l, interquartile range, 2, 9, P < 0.001). For intravenous tobramycin, the median epithelial lining fluid concentrations were lower than the interstitial space fluid concentrations at 1 h (0.19, interquartile range, 0.11, 0.31, vs. 18.5 mg/l, interquartile range, 9.8, 23.4, P < 0.001) and 6 h (0.34, interquartile range, 0.2, 0.48, vs. 3.2 mg/l, interquartile range, 0.9, 4.4, P < 0.001). CONCLUSIONS Compared with intravenous tobramycin, nebulized tobramycin achieved higher lung interstitial fluid and epithelial lining fluid concentrations without increasing systemic concentrations.
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Bihan K, Zahr N, Becquemin MH, Lu X, Bertholon JF, Vezinet C, Arbelot C, Monsel A, Rouby JJ, Langeron O, Lu Q. Influence of diluent volume of colistimethate sodium on aerosol characteristics and pharmacokinetics in ventilator-associated pneumonia caused by MDR bacteria. J Antimicrob Chemother 2019; 73:1639-1646. [PMID: 29506194 DOI: 10.1093/jac/dky044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/23/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives Nebulized colistimethate sodium (CMS) can be used to treat ventilator-associated pneumonia caused by MDR bacteria. The influence of the diluent volume of CMS on aerosol delivery has never been studied. The main objectives of the study were to compare aerosol particle characteristics and plasma and urine pharmacokinetics between two diluent volumes in patients treated with nebulized CMS. Methods A crossover study was conducted in eight patients receiving nebulized CMS every 8 h. After inclusion, nebulization started with 4 million international units (MIU) of CMS diluted either in 6 mL (experimental dilution) or in 12 mL (recommended dilution) of normal saline in a random order. For each diluent volume, CMS aerosol particle sizes were measured and plasma and urine samples were collected every 2 h. Nebulization time and stability of colistin in normal saline were assessed. Results The mass median aerodynamic diameters were 1.4 ± 0.2 versus 0.9 ± 0.2 μm (P < 0.001) for 6 and 12 mL diluent volumes, respectively. The plasma area under the concentration-time curve from 0 to 8 h (AUC0-8) of colistinA+B was 6.6 (4.3-17.0) versus 6.7 (3.6-14.0) μg·h/mL (P = 0.461) for each dilution. The total amount of colistin and CMS eliminated in the urine represented, respectively, 17% and 13% of the CMS initially placed in the nebulizer chamber for 6 and 12 mL diluent volumes (P = 0.4). Nebulization time was shorter [66 (58-75) versus 93 (69-136) min, P = 0.042] and colistin stability was better with the 6 mL diluent volume. Conclusions Nebulization with a higher concentration of CMS in saline (4 MIU in 6 mL) decreases nebulization time and improves colistin stability without changing plasma and urine pharmacokinetics or aerosol particle characteristics for lung deposition.
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Affiliation(s)
- Kevin Bihan
- Department of Pharmacology and CIC-1421, F-75013, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Noël Zahr
- Department of Pharmacology and CIC-1421, F-75013, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Marie-Hélène Becquemin
- Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Xiao Lu
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France.,Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Jean-François Bertholon
- Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Corinne Vezinet
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Charlotte Arbelot
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Qin Lu
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
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Lee W, Cai Y, Lim TP, Teo J, Chua SC, Kwa ALH. In vitro Pharmacodynamics and PK/PD in Animals. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:105-116. [PMID: 31364074 DOI: 10.1007/978-3-030-16373-0_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
In the last decade, considerable advancements have been made to identify the pharmacokinetic/pharmacodynamic (PK/PD) index that defines the antimicrobial activity of polymyxins. Dose-fractionation studies performed in hollow-fiber models found that altering the dosing schedule had little impact on the killing or suppression of resistance emergence, alluding to AUC/MIC as the pharmacodynamic index that best describes polymyxin's activity. For in vivo efficacy, the PK/PD index that was the most predictive of the antibacterial effect of colistin against P. aeruginosa and A. baumannii was ƒAUC/MIC.
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Affiliation(s)
- Winnie Lee
- Singapore General Hospital, Singapore, Singapore
| | - Yiying Cai
- Singapore General Hospital, Singapore, Singapore
| | - Tze-Peng Lim
- Singapore General Hospital, Singapore, Singapore
| | - Jocelyn Teo
- Singapore General Hospital, Singapore, Singapore
| | - Sonja Courtney Chua
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Andrea Lay-Hoon Kwa
- Singapore General Hospital, Singapore, Singapore. .,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore. .,Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore.
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35
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Chai G, Park H, Yu S, Zhou F, Li J, Xu Q, Zhou QT. Evaluation of co-delivery of colistin and ciprofloxacin in liposomes using an in vitro human lung epithelial cell model. Int J Pharm 2019; 569:118616. [PMID: 31415873 DOI: 10.1016/j.ijpharm.2019.118616] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 01/15/2023]
Abstract
Respiratory tract infections caused by multidrug-resistant Gram-negative bacteria are serious burdens to the public. Our previous findings indicated that co-loading of colistin and ciprofloxacin via liposomes improved in vitro antimicrobial activities against multidrug resistant Pseudomonas aeruginosa as compared to the monotherapies. The current study aims to investigate the transport behavior of colistin and ciprofloxacin in liposomes using the in vitro Calu-3 cell monolayer, which is a lung epithelial model cultured under the air-interfaced condition. The cell viability results demonstrated that there was no obvious toxicity of cells exposed to single or co-administered drugs at the concentration ≤500 μg/mL. Transport of ciprofloxacin into the cells was easier than that of colistin, which reached a plateau rapidly. Colistin was less trapped in the mucus or adhered to the apical cell membrane, and less transported across the cell monolayer than ciprofloxacin. The deposition of ciprofloxacin on the apical side increased over time (from 1 to 4 h). There was no drug-drug interaction observed during the transport of ciprofloxacin and colistin across the cell monolayer, when they were dosed together in the solution form. The amount of drug transported across the cell monolayer was decreased in both agents when loaded in liposomes. Both drugs were more trapped in the mucus or more adhered to the apical side cell membrane of the cell monolayer when they were in liposomes. This study demonstrated that co-delivery of colistin and ciprofloxacin in a single liposome can reduce transport capacity of both drugs across the lung epithelial cell monolayer and enhance drug retention on the lung epithelial surfaces; therefore, it is a promising approach to treat the respiratory infections caused by multidrug resistant Pseudomonas aeruginosa.
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Affiliation(s)
- Guihong Chai
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Heejun Park
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Shihui Yu
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Fanfan Zhou
- School of Pharmacy, The University of Sydney, NSW 2006, Australia
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
| | - Qingguo Xu
- Department of Pharmaceutics, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA.
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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37
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Abstract
Pneumonia, including community-acquired bacterial pneumonia, hospital-acquired bacterial pneumonia, and ventilator-acquired bacterial pneumonia, carries unacceptably high morbidity and mortality. Despite advances in antimicrobial therapy, emergence of multidrug resistance and high rates of treatment failure have made optimization of antibiotic efficacy a priority. This review focuses on pharmacokinetic and pharmacodynamic approaches to antibacterial optimization within the lung environment and in the setting of critical illness. Strategies for including these approaches in drug development programs as well as clinical practice are described and reviewed.
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Affiliation(s)
- Ana Motos
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; Division of Animal Experimentation, Department of Pulmonary and Critical Care, Hospital Clinic, 170 Villarroel Street, Barcelona 08036, Spain
| | - James M Kidd
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; Division of Infectious Diseases, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA.
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Aerosol Therapy for Pneumonia in the Intensive Care Unit. Clin Chest Med 2019; 39:823-836. [PMID: 30390752 DOI: 10.1016/j.ccm.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antibiotic aerosolization in patients with ventilator-associated pneumonia (VAP) allows very high concentrations of antimicrobial agents in the respiratory secretions, far more than those achievable using the intravenous route. However, data in critically ill patients with pneumonia are limited. Administration of aerosolized antibiotics might increase the likelihood of clinical resolution, but no significant improvements in important outcomes have been consistently documented. Thus, aerosolized antibiotics should be restricted to the treatment of extensively resistant gram-negative pneumonia. In these cases, the use of a vibrating-mesh nebulizer seems to be more efficient, but specific settings and conditions are required to improve lung delivery.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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Can Nebulised Colistin Therapy Improve Outcomes in Critically Ill Children with Multi-Drug Resistant Gram-Negative Bacterial Pneumonia? Antibiotics (Basel) 2019; 8:antibiotics8020040. [PMID: 30979085 PMCID: PMC6627821 DOI: 10.3390/antibiotics8020040] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/06/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022] Open
Abstract
In the past decade, multidrug-resistant (MDR) gram-negative bacteria have become a major problem, especially for patients in intensive care units. Recently, colistin became the last resort therapy for MDR gram-negative bacteria infections. However, nebulised colistin use was limited to adult patients. Thus, we investigated the efficacy and safety of nebulised colistin treatment against MDR microorganisms in the paediatric intensive care unit (PICU). Data of all patients admitted for various critical illnesses (January 2016 to January 2019) were reviewed. Differences between groups (with and without a history of nebulised colistin) were compared. Of 330 patients, 23 (6.97%) used nebulised colistin. Significant relationships were found between nebulised colistin usage and several prognostic factors (inotropic drug use (p = 0.009), non-invasive mechanical ventilation (p ≤ 0.001), duration in PICU (p ≤ 0.001), and C-reactive protein level (p = 0.003)). The most common microorganism in tracheal aspirate and sputum cultures was Pseudomonas aeruginosa (13 patients). The most common underlying diagnosis was cystic fibrosis, noted in 6 patients. No serious nephrotoxicity and neurotoxicity occurred. This study showed that colistin can be safely used directly in the airway of critically ill children. However, nebulised colistin use did not have a positive effect on mortality and prognosis.
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40
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Landersdorfer CB, Wang J, Wirth V, Chen K, Kaye KS, Tsuji BT, Li J, Nation RL. Pharmacokinetics/pharmacodynamics of systemically administered polymyxin B against Klebsiella pneumoniae in mouse thigh and lung infection models. J Antimicrob Chemother 2019; 73:462-468. [PMID: 29149294 DOI: 10.1093/jac/dkx409] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/09/2017] [Indexed: 11/14/2022] Open
Abstract
Background The pharmacokinetic/pharmacodynamic (PK/PD) relationship for polymyxin B against Klebsiella pneumoniae infections is not known. Methods Dose-fractionation studies with subcutaneous polymyxin B were conducted in neutropenic mice in which infection with three strains of K. pneumoniae had been produced in thighs or lungs. Dosing (thigh infection 0.5-120 mg/kg/day; lung infection 5-120 mg/kg/day) commenced 2 h after inoculation, and bacterial burden was measured 24 h later. Plasma exposure measures for unbound polymyxin B were from population pharmacokinetic analysis of single doses and plasma protein binding by ultracentrifugation. The inhibitory sigmoid dose-effect model was employed to determine the relationship between exposure and efficacy. Antibacterial activities of polymyxin B and colistin against thigh infection were compared at equimolar doses generating exposures resulting in maximal antibacterial activity. Results The pharmacokinetics of polymyxin B were well described by a model comprising parallel linear and saturable pathways for absorption and elimination. Plasma binding of polymyxin B was constant (P > 0.05) over the range ∼0.9-37 mg/L; average (±SD) percentage bound was 91.4 ± 1.65. In thigh infection, antibacterial effect was well correlated with fAUC/MIC (R2 = 0.89). Target values of fAUC/MIC for stasis and 1 log10 kill were 1.22-13.5 and 3.72-28.0, respectively; 2 log10 kill was not achieved for any strain, even at the highest tolerated dose. There was no difference (P > 0.05) in antibacterial activity between polymyxin B and colistin with equimolar doses. It was not possible to achieve stasis in lung infection, even at the highest dose tolerated by mice. Conclusions The results will assist in the design of optimized dosage regimens of polymyxin B.
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Affiliation(s)
- Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo State University of New York, Buffalo, NY, USA
| | - Jiping Wang
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Veronika Wirth
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Ke Chen
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo State University of New York, Buffalo, NY, USA.,Laboratory for Antimicrobial Pharmacodynamics, NYS Centre of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Pharmacokinetics of Polymyxins in Animals. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:89-103. [DOI: 10.1007/978-3-030-16373-0_7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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42
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Szychowiak P, Pocquet J, Ehrmann S. Antibiothérapie nébulisée en réanimation : état des connaissances et perspectives. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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43
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Torres A, Motos A, Battaglini D, Li Bassi G. Inhaled amikacin for severe Gram-negative pulmonary infections in the intensive care unit: current status and future prospects. Crit Care 2018; 22:343. [PMID: 30558658 PMCID: PMC6297966 DOI: 10.1186/s13054-018-1958-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/16/2018] [Indexed: 11/25/2022] Open
Abstract
Recently, the use of nebulized antibiotics in the intensive care unit, in particular amikacin, has been the subject of much discussion, owing to unconvincing results from the latest randomized clinical trials. Here, we examine and reappraise the evidence in favor and against this therapeutic strategy; we then discuss the potential factors that might have played a role in the negative findings of recent clinical trials. Also, we call attention to several factors that are seldom considered by study developers and regulatory agencies, to promote translational research in this field and improve the design of future randomized clinical trials.
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Affiliation(s)
- Antoni Torres
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain. .,University of Barcelona, Barcelona, Spain.
| | - Anna Motos
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain
| | - Denise Battaglini
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain.,University of Genoa, Genoa, Italy
| | - Gianluigi Li Bassi
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
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Mangal S, Xu R, Park H, Zemlyanov D, Shetty N, Lin YW, Morton D, Chan HK, Li J, Zhou QT. Understanding the Impacts of Surface Compositions on the In-Vitro Dissolution and Aerosolization of Co-Spray-Dried Composite Powder Formulations for Inhalation. Pharm Res 2018; 36:6. [PMID: 30406281 DOI: 10.1007/s11095-018-2527-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 10/17/2018] [Indexed: 01/26/2023]
Abstract
PURPOSE Dissolution behavior of dry powder inhaler (DPI) antibiotic formulations in the airways may affect their efficacy especially for poorly-soluble antibiotics such as azithromycin. The main objective of this study was to understand the effects of surface composition on the dissolution of spray dried azithromycin powders by itself and in combination with colistin. METHODS Composite formulations of azithromycin (a poorly water-soluble molecule) and colistin (a water-soluble molecule) were produced by spray drying. The resultant formulations were characterized for particle size, morphology, surface composition, solid-state properties, solubility and dissolution. RESULTS The results demonstrate that surfaces composition has critical impacts on the dissolution of composite formulations. Colistin was shown to increase the solubility of azithromycin. For composite formulations with no surface colistin, azithromycin released at a similar dissolution rate as the spray-dried azithromycin alone. An increase in surface colistin concentration was shown to accelerate the dissolution of azithromycin. The dissolution of colistin from the composite formulations was significantly slower than the spray-dried pure colistin. In addition, FTIR spectrum showed intermolecular interactions between azithromycin and colistin in the composite formulations, which could contribute to the enhanced solubility and dissolution of azithromycin. CONCLUSIONS Our study provides fundamental understanding of the effects of surface concentration of colistin on azithromycin dissolution of co-spray-dried composite powder formulations.
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Affiliation(s)
- Sharad Mangal
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Rongkun Xu
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Heejun Park
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Dmitry Zemlyanov
- Birck Nanotechnology Center, Purdue University, 1205 West State Street, West Lafayette, Indiana, 47907, USA
| | - Nivedita Shetty
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA
| | - Yu-Wei Lin
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, 3800, Australia
| | - David Morton
- Drug Delivery, Dynamics & Deposition, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC, 3052, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, VIC, 3800, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, Indiana, 47907, USA.
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Jean SS, Hsieh TC, Lee WS, Hsueh PR, Hsu CW, Lam C. Treatment outcomes of patients with non-bacteremic pneumonia caused by extensively drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex isolates: Is there any benefit of adding tigecycline to aerosolized colistimethate sodium? Medicine (Baltimore) 2018; 97:e12278. [PMID: 30278498 PMCID: PMC6181533 DOI: 10.1097/md.0000000000012278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Few therapeutic options exist for various infections caused by extensively drug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (XDR-Acb) complex isolates, including pneumonia. This study investigated the clinical efficacy between aerosolized colistimethate sodium (AS-CMS, 2 million units thrice a day) treatment alone or in combination with standard-dose tigecycline (TGC) in patients with non-bacteremic pneumonia due to XDR-Acb, and explored the factors influencing patients' 30-day mortality.A 1:1 case (n = 106; receiving TGC plus AS-CMS) control (receiving AS-CMS alone with matching scores) observational study was conducted among adult patients with non-bacteremic XDR-Acb complex pneumonia in a Taiwanese medical center from January 2014 through December 2016. The clinically relevant data were retrospectively recorded. The primary endpoint was 30-day case fatality. Secondary endpoints investigated that if the co-morbidities, XDR-A. baumannii as a pneumonic pathogen, therapy-related factors, or airway colonization with colistin-resistant Acb negatively influenced the 14-day clinical condition of enrolled patients.A higher 30-day mortality rate was noted among the group receiving combination therapy (34.0% vs 22.6%; P = .17). The ≥7-day AS-CMS therapy successfully eradicated > 90% of airway XDR-Acb isolates. Nevertheless, follow-up sputum specimens from 10 (6.4% [10/156]) patients were colonized with colistin-resistant Acb isolates. After the conditional factors were adjusted by multivariate logistic analysis, the only factor independently predicting the 30-day case-fatality was the failure of treating XDR-Acb pneumonia at 14 days (adjusted odds ratio [aOR] = 38.2; 95% confidence interval [CI] = 9.96-142.29; P < .001). Cox proportional regression analysis found that chronic obstructive pulmonary disease (COPD) (adjusted hazard ratio [aHR] = 2.08; 95% CI = 1.05-4.10; P = .035), chronic renal failure (aHR = 3.00; 95% CI = 1.52-5.90; P = .002), non-invasive ventilation use (aHR = 2.68; 95% CI = 1.37-5.25; P = .004), and lack of TGC therapy (aHR = 0.52; 95% CI = 0.27-1.00; P = .049) adversely influenced the 14-day clinical outcomes. Conversely, the emergence of colistin-resistant Acb isolates in the follow-up sputum samples was not statistically significantly associated with curing or improving XDR-Acb pneumonia.In conclusion, aggressive pulmonary hygiene care, the addition of TGC, and corticosteroid dose tapering were beneficial in improving the 14-day patients' outcomes.
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Affiliation(s)
- Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, Departments of Emergency and Intensive Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Tai-Chin Hsieh
- Division of General Medicine and Infectious disease, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wen-Sen Lee
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Infectious Disease, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chin-Wan Hsu
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, Departments of Emergency and Intensive Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Carlos Lam
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Emergency Medicine, Departments of Emergency and Intensive Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Kukut Hatipoglu M, Hickey AJ, Garcia-Contreras L. Pharmacokinetics and pharmacodynamics of high doses of inhaled dry powder drugs. Int J Pharm 2018; 549:306-316. [PMID: 30077761 DOI: 10.1016/j.ijpharm.2018.07.050] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/17/2018] [Accepted: 07/22/2018] [Indexed: 12/13/2022]
Abstract
For many years, administration of drugs by inhalation has been the mainstay treatment for obstructive respiratory disorders such as asthma and chronic obstructive pulmonary disease. Antibiotics and other drugs have been administered for decades as aerosols to treat other pulmonary disease in a clinical setting, but it was until the early 1980's that colistin was formally marketed as a solution for nebulization in Europe (Colomycin, Pharmax, Bexley). The solubility of other drugs and the size of the dose required to achieve therapeutic concentrations at the site of action, made treatment times long and difficult to be performed at home. High dose dry powder delivery is a potentially effective way to deliver low potency drugs such as antibiotics. There are three major barriers to achieving the desired pharmacodynamic effect with these compounds: aerosol delivery, lung deposition and clearance. The powder formulation and device technology influence aerosol generation and may influence the size of the dose that can be achieved by inhalation in one puff. The site of deposition in the lungs is dictated by mechanisms of deposition which are influenced by the aerosol properties, particularly aerodynamic particle size distribution and the anatomy and physiology of the lungs. Finally, mechanisms of clearance dictate the local and systemic disposition of the drug, which in turn affects its pharmacokinetics and ultimately the pharmacodynamic effect and efficacy of treatment. Each of these factors will be considered and the implications for antimicrobial agent delivery as a high dose delivery example will be given.
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Affiliation(s)
- Manolya Kukut Hatipoglu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | | | - Lucila Garcia-Contreras
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States.
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Zinne N, Krueger M, Hoeltig D, Tuemmler B, Boyle EC, Biancosino C, Hoeffler K, Braubach P, Rajab TK, Ciubotaru A, Rohde J, Waldmann KH, Haverich A. Treatment of infected lungs by ex vivo perfusion with high dose antibiotics and autotransplantation: A pilot study in pigs. PLoS One 2018; 13:e0193168. [PMID: 29505574 PMCID: PMC5837087 DOI: 10.1371/journal.pone.0193168] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/06/2018] [Indexed: 11/30/2022] Open
Abstract
The emergence of multi-drug resistant bacteria threatens to end the era of antibiotics. Drug resistant bacteria have evolved mechanisms to overcome antibiotics at therapeutic doses and further dose increases are not possible due to systemic toxicity. Here we present a pilot study of ex vivo lung perfusion (EVLP) with high dose antibiotic therapy followed by autotransplantation as a new therapy of last resort for otherwise incurable multidrug resistant lung infections. Severe Pseudomonas aeruginosa pneumonia was induced in the lower left lungs (LLL) of 18 Mini-Lewe pigs. Animals in the control group (n = 6) did not receive colistin. Animals in the conventional treatment group (n = 6) received intravenous application of 2 mg/kg body weight colistin daily. Animals in the EVLP group (n = 6) had their LLL explanted and perfused ex vivo with a perfusion solution containing 200 μg/ml colistin. After two hours of ex vivo treatment, autotransplantation of the LLL was performed. All animals were followed for 4 days following the initiation of treatment. In the control and conventional treatment groups, the infection-related mortality rate after five days was 66.7%. In the EVLP group, there was one infection-related mortality and one procedure-related mortality, for an overall mortality rate of 33.3%. Moreover, the clinical symptoms of infection were less severe in the EVLP group than the other groups. Ex vivo lung perfusion with very high dose antibiotics presents a new therapeutic option of last resort for otherwise incurable multidrug resistant pneumonia without toxic side effects on other organs.
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Affiliation(s)
- Norman Zinne
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
- * E-mail:
| | - Marcus Krueger
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Doris Hoeltig
- Clinic for Swine, Small Ruminants, Forensic Medicine, and Ambulatory Service, University of Veterinary Medicine Hannover, Hannover, Lower Saxony, Germany
| | - Burkhard Tuemmler
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Lower Saxony, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Hannover, Lower Saxony, Germany
| | - Erin C. Boyle
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christian Biancosino
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Klaus Hoeffler
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Peter Braubach
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Hannover, Lower Saxony, Germany
- Institute for Pathology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Taufiek K. Rajab
- Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anatol Ciubotaru
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Judith Rohde
- Department of Infectious Diseases, Institute for Microbiology, University of Veterinary Medicine Hannover, Hannover, Lower Saxony, Germany
| | - Karl-Heinz Waldmann
- Clinic for Swine, Small Ruminants, Forensic Medicine, and Ambulatory Service, University of Veterinary Medicine Hannover, Hannover, Lower Saxony, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Hannover, Lower Saxony, Germany
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Mechanism-Based Pharmacokinetic/Pharmacodynamic Modeling of Aerosolized Colistin in a Mouse Lung Infection Model. Antimicrob Agents Chemother 2018; 62:AAC.01965-17. [PMID: 29263069 DOI: 10.1128/aac.01965-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/13/2017] [Indexed: 12/24/2022] Open
Abstract
Optimized dosage regimens of aerosolized colistin (as colistin methanesulfonate [CMS]) are urgently required to maximize bacterial killing against multidrug-resistant Gram-negative bacteria while minimizing toxicity. This study aimed to develop a mechanism-based pharmacokinetic (PK)/pharmacodynamic (PD) model (MBM) for aerosolized colistin based upon PK/PD data in neutropenic infected mice and to perform a deterministic simulation with the PK of aerosolized colistin (as CMS) in critically ill patients. In vivo time-kill experiments were carried out with three different strains of Pseudomonas aeruginosa An MBM was developed in S-ADAPT and evaluated by assessing its ability to predict the PK/PD index associated with efficacy in mice. A deterministic simulation with human PK data was undertaken to predict the efficacy of current dosage regimens of aerosolized colistin in critically ill patients. In the final MBM, the total bacterial population for each isolate consisted of colistin-susceptible and -resistant subpopulations. The antimicrobial efficacy of aerosolized colistin was best described by a sigmoidal Emax model whereby colistin enhanced the rate of bacterial death. Deterministic simulation with human PK data predicted that an inhalational dosage regimen of 60 mg colistin base activity (CBA) every 12 h is needed to achieve a ≥2-log10 bacterial reduction (as the number of CFU per lung) in critically ill patients at 24 h after commencement of inhaled therapy. In conclusion, the developed MBM is a useful tool for optimizing inhalational dosage regimens of colistin. Clinical studies are warranted to validate and refine our MBM for aerosolized colistin.
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Antimicrobial molecules in the lung: formulation challenges and future directions for innovation. Future Med Chem 2018; 10:575-604. [PMID: 29473765 DOI: 10.4155/fmc-2017-0162] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Inhaled antimicrobials have been extremely beneficial in treating respiratory infections, particularly chronic infections in a lung with cystic fibrosis. The pulmonary delivery of antibiotics has been demonstrated to improve treatment efficacy, reduce systemic side effects and, critically, reduce drug exposure to commensal bacteria compared with systemic administration, reducing selective pressure for antimicrobial resistance. This review will explore the specific challenges of pulmonary delivery of a number of differing antimicrobial molecules, and the formulation and technological approaches that have been used to overcome these difficulties. It will also explore the future challenges being faced in the development of inhaled products and respiratory infection treatment, and identify future directions of innovation, with a particular focus on respiratory infections caused by multiple drug-resistant pathogens.
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50
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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