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Das S, Riccobene T, Carrothers TJ, Wright JG, MacPherson M, Cristinacce A, McFadyen L, Xie R, Luckey A, Raber S. Dose selection for aztreonam-avibactam, including adjustments for renal impairment, for Phase IIa and Phase III evaluation. Eur J Clin Pharmacol 2024; 80:529-543. [PMID: 38252170 PMCID: PMC10937790 DOI: 10.1007/s00228-023-03609-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 12/12/2023] [Indexed: 01/23/2024]
Abstract
PURPOSE A series of iterative population pharmacokinetic (PK) modeling and probability of target attainment (PTA) analyses based on emerging data supported dose selection for aztreonam-avibactam, an investigational combination antibiotic for serious Gram-negative bacterial infections. METHODS Two iterations of PK models built from avibactam data in infected patients and aztreonam data in healthy subjects with "patient-like" assumptions were used in joint PTA analyses (primary target: aztreonam 60% fT > 8 mg/L, avibactam 50% fT > 2.5 mg/L) exploring patient variability, infusion durations, and adjustments for moderate (estimated creatinine clearance [CrCL] > 30 to ≤ 50 mL/min) and severe renal impairment (> 15 to ≤ 30 mL/min). Achievement of > 90% joint PTA and the impact of differential renal clearance were considerations in dose selection. RESULTS Iteration 1 simulations for Phase I/IIa dose selection/modification demonstrated that 3-h and continuous infusions provide comparable PTA; avibactam dose drives joint PTA within clinically relevant exposure targets; and loading doses support more rapid joint target attainment. An aztreonam/avibactam 500/137 mg 30-min loading dose and 1500/410 mg 3-h maintenance infusions q6h were selected for further evaluation. Iteration 2 simulations using expanded PK models supported an alteration to the regimen (500/167 mg loading; 1500/500 mg q6h maintenance 3-h infusions for CrCL > 50 mL/min) and selection of doses for renal impairment for Phase IIa/III clinical studies. CONCLUSION A loading dose plus 3-h maintenance infusions of aztreonam-avibactam in a 3:1 fixed ratio q6h optimizes joint PTA. These analyses supported dose selection for the aztreonam-avibactam Phase III clinical program. CLINICAL TRIAL REGISTRATION NCT01689207; NCT02655419; NCT03329092; NCT03580044.
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Affiliation(s)
- Shampa Das
- AstraZeneca, Alderley Park, Macclesfield, UK
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | | | | | - Merran MacPherson
- Wright Dose Ltd, Altrincham, Cheshire, UK
- UCB, Braine-l'Alleude, Wallonia, Belgium
| | | | | | | | - Alison Luckey
- , Pfizer, New York, NY, USA
- Present Address: GARDP (Global Antibiotics Research & Development Partnership), Geneva, Switzerland
| | - Susan Raber
- Global Product Development, Pfizer Inc, 10555 Science Center Dr, San Diego, CA, 92121, USA.
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Rossolini GM, Arhin FF, Kantecki M. In vitro activity of aztreonam-avibactam and comparators against Metallo-β-Lactamase-producing Enterobacterales from ATLAS Global Surveillance Program, 2016-2020. J Glob Antimicrob Resist 2024; 36:123-131. [PMID: 38154750 DOI: 10.1016/j.jgar.2023.12.027] [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: 09/15/2023] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVES Metallo-β-lactamase (MBL)-producing Enterobacterales are a major challenge worldwide due to limited treatment options. Aztreonam-avibactam (ATM-AVI), which is under clinical development, has shown activity against MBL-positive isolates. This study evaluated the prevalence of MBL producers and the nature of enzymes among a global collection of clinical isolates of Enterobacterales from the Antimicrobial Testing Leadership and Surveillance program (ATLAS) surveillance program (2016-2020), and the antimicrobial activity of ATM-AVI and comparators against this collection. METHODS Non-duplicate clinical isolates of Enterobacterales (N = 106 686) collected across 63 countries were analysed. Antimicrobial susceptibility was performed using broth microdilution. Minimum inhibitory concentrations (MICs) were interpreted using Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing breakpoints. Provisional pharmacokinetic/pharmacodynamic breakpoint of ≤8 mg/L was considered for ATM-AVI. β-lactamase genes were characterized by polymerase chain reaction and sequencing. The Cochran Armitage Trend test was used to determine significant trends in percentage of isolates over time. RESULTS Overall, MBL-positive isolates were 1.6% of total Enterobacterales isolates globally, with a significant increasing trend observed over time, globally and across regions (P < 0.05). New Delhi MBL (NDM) was the most common MBL (83.3%). ATM-AVI demonstrated potent activity against MBL-positive isolates (MIC ≤8 mg/L: 99.4% isolates inhibited; MIC90, 1 mg/L). Consistent activity was also noted across different regions. Potent activity was demonstrated against different NDM variants and MBL-positive isolates co-carrying other carbapenemases (98.1% and 99.7% isolates inhibited at ≤8 mg/L, respectively). About 0.6% MBL-positive isolates (10/1707) had MICs >8 mg/L for ATM-AVI. CONCLUSION ATM-AVI demonstrated potent activity against MBL-positive isolates, including NDM variants and MBL-positive isolates co-carrying other carbapenemases, and may represent a good option for treating infections caused by MBL-positive Enterobacterales.
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Affiliation(s)
- Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy.
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Piérard D, Hermsen ED, Kantecki M, Arhin FF. Antimicrobial Activities of Aztreonam-Avibactam and Comparator Agents against Enterobacterales Analyzed by ICU and Non-ICU Wards, Infection Sources, and Geographic Regions: ATLAS Program 2016-2020. Antibiotics (Basel) 2023; 12:1591. [PMID: 37998793 PMCID: PMC10668788 DOI: 10.3390/antibiotics12111591] [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: 09/19/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 11/25/2023] Open
Abstract
Increasing antimicrobial resistance among multidrug-resistant (MDR), extended-spectrum β-lactamase (ESBL)- and carbapenemase-producing Enterobacterales (CPE), in particular metallo-β-lactamase (MBL)-positive strains, has led to limited treatment options in these isolates. This study evaluated the activity of aztreonam-avibactam (ATM-AVI) and comparator antimicrobials against Enterobacterales isolates and key resistance phenotypes stratified by wards, infection sources and geographic regions as part of the ATLAS program between 2016 and 2020. Minimum inhibitory concentrations (MICs) were determined per Clinical and Laboratory Standards Institute (CLSI) guidelines. The susceptibility of antimicrobials were interpreted using CLSI and European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints. A tentative pharmacokinetic/pharmacodynamic breakpoint of 8 µg/mL was considered for ATM-AVI activity. ATM-AVI inhibited ≥99.2% of Enterobacterales isolates across wards and ≥99.7% isolates across infection sources globally and in all regions at ≤8 µg/mL. For resistance phenotypes, ATM-AVI demonstrated sustained activity across wards and infection sources by inhibiting ≥98.5% and ≥99.1% of multidrug-resistant (MDR) isolates, ≥98.6% and ≥99.1% of ESBL-positive isolates, ≥96.8% and ≥90.9% of carbapenem-resistant (CR) isolates, and ≥96.8% and ≥97.4% of MBL-positive isolates, respectively, at ≤8 µg/mL globally and across regions. Overall, our study demonstrated that ATM-AVI represents an important therapeutic option for infections caused by Enterobacterales, including key resistance phenotypes across different wards and infection sources.
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Affiliation(s)
- Denis Piérard
- Department of Microbiology and Infection Control, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, B-1090 Brussels, Belgium;
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Liu E, Prinzi AM, Borjan J, Aitken SL, Bradford PA, Wright WF. #AMRrounds: a systematic educational approach for navigating bench to bedside antimicrobial resistance. JAC Antimicrob Resist 2023; 5:dlad097. [PMID: 37583473 PMCID: PMC10424884 DOI: 10.1093/jacamr/dlad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Abstract
Antimicrobial resistance (AMR) continues to serve as a major global health crisis. Clinicians practising in this modern era are faced with ongoing challenges in the therapeutic management of patients suffering from antimicrobial-resistant infections. A strong educational understanding and synergistic application of clinical microbiology, infectious disease and pharmacological concepts can assist the adventuring clinician in the navigation of such cases. Important items include mobilizing laboratory testing for pathogen identification and susceptibility data, harnessing an understanding of intrinsic pathogen resistance, acknowledging epidemiological resistance trends, recognizing acquired AMR mechanisms, and consolidating these considerations when constructing an ideal pharmacological plan. In this article, we outline a novel framework by which to systematically approach clinical AMR, encourage AMR-related education and optimize therapeutic decision-making in AMR-related illnesses.
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Affiliation(s)
- Elaine Liu
- Division of Pharmacy and Division of Infectious Diseases, The Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Baltimore, MD, USA
| | - Andrea M Prinzi
- US Medical Affairs, bioMérieux, Salt Lake City, UT 84104, USA
| | - Jovan Borjan
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Samuel L Aitken
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | | | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD, USA
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Harris H, Tao L, Jacobs EB, Bergman Y, Adebayo A, Tekle T, Lewis S, Dahlquist A, Abbey TC, Wenzler E, Humphries R, Simner PJ. Multicenter Evaluation of an MIC-Based Aztreonam and Ceftazidime-Avibactam Broth Disk Elution Test. J Clin Microbiol 2023; 61:e0164722. [PMID: 37070979 PMCID: PMC10204635 DOI: 10.1128/jcm.01647-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/22/2023] [Indexed: 04/19/2023] Open
Abstract
Due to limited therapeutic options, there is a clinical need to assess the in vitro activity of the combination of aztreonam (ATM) and ceftazidime-avibactam (CZA) to guide the therapeutic management of multidrug-resistant (MDR) Gram-negative organism infections. We set out to develop a practical MIC-based broth disk elution (BDE) method to determine the in vitro activity of the combination ATM-CZA using readily available supplies and compare it to reference broth microdilution (BMD). For the BDE method, a 30-μg ATM disk, a 30/20-μg CZA disk, both disks in combination, and no disks were added to 4 separate 5-mL cation-adjusted Mueller-Hinton broth (CA-MHB) tubes, using various manufacturers. Three testing sites performed both BDE and reference BMD testing of bacterial isolates in parallel from a single 0.5 McFarland standard inoculum and after overnight incubation, assessed them for growth (not susceptible) or no growth (susceptible) at a final concentration of 6/6/4 μg/mL ATM-CZA. During the first phase, the precision and accuracy of the BDE were analyzed by testing 61 Enterobacterales isolates at all sites. This testing yielded 98.3% precision between sites, with 98.3% categorical agreement and 1.8% major errors (ME). During the second phase, at each site, we evaluated unique, clinical isolates of metallo-β-lactamase (MBL)-producing Enterobacterales (n = 75), carbapenem-resistant Pseudomonas aeruginosa (n = 25), Stenotrophomonas maltophilia (n = 46), and Myroides sp. (n = 1). This testing resulted in 97.9% categorical agreement, with 2.4% ME. Different results were observed for different disk and CA-MHB manufacturers, requiring a supplemental ATM-CZA-not-susceptible quality control organism to ensure the accuracy of results. The BDE is a precise and effective methodology for determining susceptibility to the combination ATM-CZA.
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Affiliation(s)
- Harley Harris
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lili Tao
- Department of Pathology, Microbiology, and Immunology, Division of Laboratory Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily B. Jacobs
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yehudit Bergman
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ayomikun Adebayo
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tsigedera Tekle
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shawna Lewis
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ashley Dahlquist
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Taylor C. Abbey
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Eric Wenzler
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Romney Humphries
- Department of Pathology, Microbiology, and Immunology, Division of Laboratory Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patricia J. Simner
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Karvouniaris M, Almyroudi MP, Abdul-Aziz MH, Blot S, Paramythiotou E, Tsigou E, Koulenti D. Novel Antimicrobial Agents for Gram-Negative Pathogens. Antibiotics (Basel) 2023; 12:761. [PMID: 37107124 PMCID: PMC10135111 DOI: 10.3390/antibiotics12040761] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Gram-negative bacterial resistance to antimicrobials has had an exponential increase at a global level during the last decades and represent an everyday challenge, especially for the hospital practice of our era. Concerted efforts from the researchers and the industry have recently provided several novel promising antimicrobials, resilient to various bacterial resistance mechanisms. There are new antimicrobials that became commercially available during the last five years, namely, cefiderocol, imipenem-cilastatin-relebactam, eravacycline, omadacycline, and plazomicin. Furthermore, other agents are in advanced development, having reached phase 3 clinical trials, namely, aztreonam-avibactam, cefepime-enmetazobactam, cefepime-taniborbactam, cefepime-zidebactam, sulopenem, tebipenem, and benapenem. In this present review, we critically discuss the characteristics of the above-mentioned antimicrobials, their pharmacokinetic/pharmacodynamic properties and the current clinical data.
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Affiliation(s)
- Marios Karvouniaris
- Intensive Care Unit, AHEPA University Hospital, 546 36 Thessaloniki, Greece;
| | | | - Mohd Hafiz Abdul-Aziz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
| | - Stijn Blot
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Department of Internal Medicine and Pediatrics, Ghent University, 9000 Ghent, Belgium
| | | | - Evdoxia Tsigou
- Intensive Care Department, ‘Aghioi Anargyroi’ Hospital of Kifissia, 145 64 Athens, Greece;
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Second Critical Care Department, Attikon University Hospital, 124 62 Athens, Greece;
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Meropenem-Vaborbactam Activity against U.S. Multidrug-Resistant Enterobacterales Strains, Including Carbapenem-Resistant Isolates. Microbiol Spectr 2023; 11:e0450722. [PMID: 36622238 PMCID: PMC9927278 DOI: 10.1128/spectrum.04507-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Carbapenems are a common first-line therapy for serious Gram-negative infections, but carbapenem-resistant Enterobacterales (CRE) isolates have become an urgent health concern. Klebsiella pneumoniae serine carbapenemases (KPCs) now have been disseminated worldwide and are endemic in many hospitals globally. Isolates producing metallo-β-lactamases (MBLs) or class D OXA-48 carbapenemases are also increasingly common in Europe, although they are less common in the United States. Meropenem-vaborbactam is a combination of the carbapenem meropenem and vaborbactam, which is a β-lactamase inhibitor with activity against serine carbapenemases, including KPC-producing isolates. We examined the susceptibility of U.S. multidrug-resistant (MDR) isolates to meropenem-vaborbactam. A total of 1,697 MDR Enterobacterales isolates were collected in 31 U.S. medical centers in 2016 to 2020. Susceptibility testing was performed using the Clinical and Laboratory Standards Institute (CLSI) broth microdilution method. Whole-genome sequencing was performed for all CRE strains (MIC values of >2 mg/L for imipenem or meropenem). The rate of susceptibility of all MDR Enterobacterales strains to meropenem-vaborbactam was 99.1%, and 86.2% of the isolates were susceptible to meropenem. There were 222 CRE isolates (13.1%). KPC was the most common carbapenemase (81.1%). Thirteen CRE isolates produced NDM (n = 7), VIM (n = 3), and/or OXA-48-like (n = 4) carbapenemases; 29 CRE isolates (13.1%) had no detected carbapenemase. The rate of susceptibility of all CRE strains to meropenem-vaborbactam was 93.2%, and the rate of susceptibility of the KPC-producing isolates to meropenem-vaborbactam was 98.9%. The primary carbapenemase in the United States continues to be KPC, while MBL and OXA-48-like carbapenemases remain uncommon. Overall, the rate of susceptibility of these U.S. MDR organisms to meropenem-vaborbactam was 99.1%, indicating that meropenem-vaborbactam is a valuable treatment option for Gram-negative infections caused by U.S. MDR organisms. IMPORTANCE Carbapenems are a common first-line therapy for serious Gram-negative infections, but CRE isolates have become an urgent health concern. Meropenem-vaborbactam is a combination of the carbapenem meropenem and vaborbactam, which is a β-lactamase inhibitor with activity against serine carbapenemases, including KPC-producing isolates. We examined the susceptibility of U.S. MDR Gram-negative isolates to meropenem-vaborbactam. A total of 1,697 U.S. MDR Enterobacterales isolates collected in 2016 to 2020 were tested. Susceptibility testing was performed using the CLSI broth microdilution method. Whole-genome sequencing was performed for all CRE strains (MIC values of >2 mg/L for imipenem or meropenem). The rate of susceptibility of all MDR Enterobacterales strains to meropenem-vaborbactam was 99.1%, and 86.2% of the isolates were susceptible to meropenem. A total of 13.1% of the isolates were CRE strains, and KPC was the most common carbapenemase. Overall, the rate of susceptibility of these U.S. MDR organisms to meropenem-vaborbactam indicates that meropenem-vaborbactam is a valuable treatment option for Gram-negative infections caused by U.S. MDR Gram-negative pathogens.
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Zhu J, Bai Y, Chen X, Hu L, Zhang W, Liu C, Shao H, Sun J, Chen Y. Ultrasensitive detection of β-lactamase-associated drug-resistant bacteria using a novel mass-tagged probe-mediated cascaded signal amplification strategy. Chem Sci 2022; 13:12799-12807. [PMID: 36519064 PMCID: PMC9645384 DOI: 10.1039/d2sc01530g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/11/2022] [Indexed: 09/19/2023] Open
Abstract
The emergence and spread of drug-resistant bacteria (DRB) is a global health threat. Early and accurate detection of DRB is a critical step in the treatment of DRB infection. However, traditional assays for DRB detection are time-consuming and have inferior analytical sensitivity and quantification capability. Herein, a mass-tagged probe (MP-CMSA)-mediated enzyme- and light-assisted cascaded signal amplification strategy was developed for the ultrasensitive detection of β-lactamase (BLA), an enzyme closely associated with most DRB. Each MP-CMSA probe contained multiple poly(amidoamine) (PAMAM) dendrimer molecules immobilized on a streptavidin agarose bead via a BLA-cleavable linker, and each dendrimer was modified with multiple mass tags via a photo-cleavable linker. In BLA detection, BLA could cleave the BLA-cleavable linker, leading to dendrimers shedding from the MP-CMSA probe to achieve enzyme-assisted signal amplification. Then, each dendrimer can further release mass tags under UV light to achieve light-assisted signal amplification. After this cascaded signal amplification, the released mass tags were ultimately quantified by mass spectrometry. Consequently, the sensitivity of BLA detection can be significantly enhanced by four orders of magnitude with a detection limit of 50.0 fM. Finally, this approach was applied to the blood samples from patients with DRB. This platform provides a potential strategy for the sensitive, rapid and quantitative detection of DRB infection.
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Affiliation(s)
- Jianhua Zhu
- School of Pharmacy, Nanjing Medical University 818 Tian Yuan East Road Nanjing 211166 China +86-25-86868467 +86-25-86868326
| | - Yunfei Bai
- State Key Laboratory of Bioelectronics, School of Biological Sciences and Medical Engineering, Southeast University Nanjing 210096 China
| | - Xiuyu Chen
- School of Pharmacy, Nanjing Medical University 818 Tian Yuan East Road Nanjing 211166 China +86-25-86868467 +86-25-86868326
| | - Linlin Hu
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University Nanjing 210009 China +86-25-83262630 +86-25-83262630
- Office of Clinical Trial Institution, Zhongda Hospital, School of Medicine, Southeast University Nanjing 210009 China
| | - Wenjun Zhang
- School of Pharmacy, Nanjing Medical University 818 Tian Yuan East Road Nanjing 211166 China +86-25-86868467 +86-25-86868326
| | - Chunyan Liu
- School of Pharmacy, Nanjing Medical University 818 Tian Yuan East Road Nanjing 211166 China +86-25-86868467 +86-25-86868326
| | - Hua Shao
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University Nanjing 210009 China +86-25-83262630 +86-25-83262630
| | - Jianguo Sun
- State Key Laboratory of Natural Medicines, China Pharmaceutical University Nanjing 210009 China +86-25-83271176 +86-25-83271176
| | - Yun Chen
- School of Pharmacy, Nanjing Medical University 818 Tian Yuan East Road Nanjing 211166 China +86-25-86868467 +86-25-86868326
- State Key Laboratory of Reproductive Medicine 210029 China
- Key Laboratory of Cardiovascular & Cerebrovascular Medicine Nanjing 211166 China
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