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Arns B, Horvath JDC, Rech GS, Sesin GP, Agani CAJO, da Rosa BS, Dos Santos TM, Brochier LSB, Cavalcanti AB, Tomazini BM, Pereira AJ, Veiga VC, Nascimento GM, Kalil AC, Zavascki AP. A Randomized, Open-Label, Non-inferiority Clinical Trial Assessing 7 Versus 14 Days of Antimicrobial Therapy for Severe Multidrug-Resistant Gram-Negative Bacterial Infections: The OPTIMISE Trial Protocol. Infect Dis Ther 2024; 13:237-250. [PMID: 38102448 PMCID: PMC10828314 DOI: 10.1007/s40121-023-00897-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Shorter courses of antimicrobials have been shown to be non-inferior to longer, "traditional" duration of therapies, including for some severe healthcare-associated infections, with a few exceptions. However, evidence is lacking regarding shorter regimes against severe infections by multidrug-resistant Gram-negative bacteria (MDR-GNB), which are often caused by distinct strains and commonly treated with second-line antimicrobials. In the duratiOn of theraPy in severe infecTIons by MultIdrug-reSistant gram-nEgative bacteria (OPTIMISE) trial, we aim to assess the non-inferiority of 7-day versus 14-day antimicrobial therapy in critically ill patients with severe infections caused by MDR-GNB. METHODS This is a randomized, multicenter, open-label, parallel controlled trial to assess the non-inferiority of 7-day versus 14-day of adequate antimicrobial therapy for intensive care unit (ICU)-acquired severe infections by MDR-GNB. Adult patients with severe infections by MDR-GNB initiated after 48 h of ICU admission are screened for eligibility. Patients are eligible if they proved to be hemodynamically stable and without fever for at least 48 h on the 7th day of adequate antimicrobial therapy. After consenting, patients are 1:1 randomized to discontinue antimicrobial therapy on the 7th (± 1) day or to continue for a total of 14th (± 1) days. PLANNED OUTCOMES The primary outcome is treatment failure, defined as death or relapse of infection within 28 days after randomization. Non-inferiority will be achieved if the upper edge of the two-tailed 95% confidence interval of the difference between the clinical failure rate in the 7-day and the 14-day group is not higher than 10%. CONCLUSION The OPTIMISE trial is the first randomized controlled trial specifically designed to assess the duration of antimicrobial therapy in patients with severe infections by MDR-GNB. TRIAL REGISTRATION ClinicalTrials.gov, NCT05210387. Registered on 27 January 2022. Seven Versus 14 Days of Antibiotic Therapy for Multidrug-resistant Gram-negative Bacilli Infections (OPTIMISE).
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Affiliation(s)
- Beatriz Arns
- Responsabilidade Social-PROADI, Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Infectious Diseases and Infection Control Service, Hospital Moinhos de Vento, 910 Ramiro Barcelos St, Porto Alegre, RS, 90035-000, Brazil
| | | | - Gabriela Soares Rech
- Responsabilidade Social-PROADI, Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | | | | | | | | | | | | | | | | | | | | | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Alexandre P Zavascki
- Infectious Diseases and Infection Control Service, Hospital Moinhos de Vento, 910 Ramiro Barcelos St, Porto Alegre, RS, 90035-000, Brazil.
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Bai XR, Cao JR, Wang ZZ, Li WC, Chen DD, Lou R, Qu X, Yan SY. Clinical Efficacy, Antibiotic Resistance Genes, Virulence Factors and Outcome of Hospital-Acquired Pneumonia Induced by Klebsiella pneumoniae Carbapenemase 2-Producing with Tigecycline Treatment in the ICU. Infect Drug Resist 2022; 15:5545-5555. [PMID: 36168639 PMCID: PMC9509680 DOI: 10.2147/idr.s381280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Tigecycline is an agent for carbapenemase-producing Klebsiella pneumonia (KPC-KP), given its penetration into lung tissues. Our study focused on the molecular and clinical efficacy of tigecycline for hospital-acquired pneumonia (HAP) in the ICU. Patients and Methods A retrospective cohort study of 52 adult KPC-KP HAP patients by searching hospital medical records from January 2018 to December 2020 was established to investigate the epidemiology of KPC-KP infections for tigecycline treatment and the associated clinical efficacy of tigecycline. The KPC-KP isolates underwent multilocus sequence typing. Molecular typing, antimicrobial resistance, and virulence profiling were also analyzed by whole-genome sequencing of KPC-KP. Results Among 52 patients with KPC-KP, the ICU mortality rate was 14/52 (27%), and there was no significant statistical difference in mortality between the effective group and failure group (p = 0.754). However, the duration of tigecycline was statistically different between the two groups of patients (14.4 vs 10 days, p=0.046). The total bacterial clearance rate was 6/52 (11.5%). There was no significant statistical difference in both groups (p=0.416). Antibiotic resistance genes (aac3iia) and virulence gene (AREO-iutA, Capsule-wzc) were negatively correlated with clinical efficacy (p = 0.011, OR = 1.237). Conclusions Blakpc was the main carbapenemase in all K. pneumoniae strains. ST11-KL64 KPC-KP was the most common virulence factors in KPC-KP isolates. This study suggested that antibiotic resistance genes (aac3iia) and virulence gene (AREO-iutA, Capsule-wzc) were independent mortality risk factors for patients with Klebsiella pneumoniae carbapenemase-2 producing K. pneumoniae infections, when during the tigecycline treatment. Molecular analysis of K. pneumoniae may provide an option when choosing the antimicrobial treatment.
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Affiliation(s)
- Xiang-Rong Bai
- Department of Pharmacy, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Jing-Rong Cao
- Department of Clinical Laboratory, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Zhi-Zhou Wang
- Department of Pharmacy, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Wen-Chao Li
- Department of Pharmacy, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Dian-Dian Chen
- Department of Clinical Laboratory, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Ran Lou
- Department of Intensive Medicine, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Xin Qu
- Intensive Care Unit, Department of Neurosurgery, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
| | - Su-Ying Yan
- Department of Pharmacy, Xuan Wu Hospital Capital Medical University, National Gerontic Disease Clinical Research Center, Beijing, 100053, People's Republic of China
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Amann LF, Alraish R, Broeker A, Kaffarnik M, Wicha SG. Tigecycline Dosing Strategies in Critically Ill Liver-Impaired Patients. Antibiotics (Basel) 2022; 11:antibiotics11040479. [PMID: 35453230 PMCID: PMC9028393 DOI: 10.3390/antibiotics11040479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/04/2022] Open
Abstract
This study investigated tigecycline exposure in critically ill patients from a population pharmacokinetic perspective to support rational dosing in intensive care unit (ICU) patients with acute and chronic liver impairment. A clinical dataset of 39 patients served as the basis for the development of a population pharmacokinetic model. The typical tigecycline clearance was strongly reduced (8.6 L/h) as compared to other populations. Different models were developed based on liver and kidney function-related covariates. Monte Carlo simulations were used to guide dose adjustments with the most predictive covariates: Child–Pugh score, total bilirubin, and MELD score. The best performing covariate, guiding a dose reduction to 25 mg q12h, was Child–Pugh score C, whereas patients with Child–Pugh score A/B received the standard dose of 50 mg q12h. Of note, the obtained 24 h steady-state area under the concentration vs. time curve (AUCss) range using this dosing strategy was predicted to be equivalent to high-dose tigecycline exposure (100 mg q12h) in non-ICU patients. In addition, 26/39 study participants died, and therapy failure was most correlated with chronic liver disease and renal failure, but no correlation between drug exposure and survival was observed. However, tigecycline in special patient populations needs further investigations to enhance clinical outcome.
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Affiliation(s)
- Lisa F. Amann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Rawan Alraish
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Magnus Kaffarnik
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
- Correspondence: ; Tel.: +49-40-42838-3487
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Yang T, Mei H, Wang J, Cai Y. Therapeutic Drug Monitoring of Tigecycline in 67 Infected Patients and a Population Pharmacokinetics/Microbiological Evaluation of A. baumannii Study. Front Microbiol 2021; 12:678165. [PMID: 34220762 PMCID: PMC8241901 DOI: 10.3389/fmicb.2021.678165] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022] Open
Abstract
Background The widespread use of antibiotics has led to the emergence of multidrug-resistant (MDR) bacteria such as multidrug-resistant Acinetobacter baumannii (AB). Tigecycline (TGC), as the first glycylcycline antibiotic approved by FDA, is a broad-spectrum antibiotic which remains highly effective to treat AB infections. Objective To confirm the TGC treatment dosage and effectiveness to treat AB infections in the Chinese population by performing therapeutic drug monitoring (TDM). Methods This study was performed from October 2018 through March 2019 at the PLA General Hospital. A high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method was validated and employed to determine the plasma concentrations of TGC in patients with infectious diseases. The minimum inhibitory concentration (MIC) of TGC to clinically isolated AB was determined by broth microdilution method, agar dilution method, and disk diffusion method. Moreover, a model of population pharmacokinetics/pharmacodynamics (PPK/PD) was constructed. Results A total of 186 plasma samples from 67 patients were detected by the validated HPLC-MS/MS method. The MIC values determined by the broth microdilution method were more sensitive and accurate than the other two methods. The microbial and clinical PK/PD breakpoints were reached when the maintenance dose of TGC was 100 mg. Conclusion Our study established a validated HPLC-MS/MS method to monitor the plasma concentrations of TGC. In view of the MIC range to AB isolates in our hospital and the PPK/PD modeling results, we recommend a relatively high dose of 100 mg q12h regimen to achieve the optimal clinical efficacy and antimicrobial response.
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Affiliation(s)
- Tianli Yang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital, Beijing, China
| | - Hekun Mei
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital, Beijing, China
| | - Jin Wang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital, Beijing, China
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center of Chinese PLA General Hospital, Beijing, China
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Leng B, Yan G, Wang C, Shen C, Zhang W, Wang W. Dose optimisation based on pharmacokinetic/pharmacodynamic target of tigecycline. J Glob Antimicrob Resist 2021; 25:315-322. [PMID: 33957288 DOI: 10.1016/j.jgar.2021.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 02/07/2023] Open
Abstract
Tigecycline, a new first-in-class glycylcycline antibiotic, has shown promising efficacy against a broad range of micro-organisms. It is widely prescribed for various infections, with most prescriptions being considered for off-label use. However, only a few years after its approval by the US Food and Drug Administration (FDA), tigecycline is suspected of increasing all-cause mortality. Some clinicians have suggested such unfavourable outcomes correlate with inadequate drug exposure at the infection site. The pharmacokinetic/pharmacodynamic (PK/PD) profile of a drug plays an important role in predicting its antibiotic effect, which for tigecycline is determined as the ratio of area under the concentration-time curve (AUC) to minimum inhibitory concentration (MIC). In this study, PK/PD targets based on infection sites, bacterial isolates and patient populations are discussed. Generally, a higher dosage of tigecycline for the treatment of serious infections has been recommended in previous reports. However, the latest finding of tigecycline's atypical protein binding property requires consideration when recommending further use. In addition, combination therapy with other antibiotics provides another option by potentially lowering the MICs of multidrug-resistant bacteria.
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Affiliation(s)
- Bing Leng
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China
| | - Genquan Yan
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China
| | - Cuicui Wang
- Medical Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China
| | - Chengwu Shen
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China
| | - Wen Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China
| | - Wei Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Huaiyin District, Jinan 250021, China; Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
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