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Motos A, Yang H, Li Bassi G, Yang M, Meli A, Battaglini D, Cabrera R, Bobi J, Pagliara F, Frigola G, Camprubí-Rimblas M, Fernández-Barat L, Rigol M, Ferrer-Segarra A, Kiarostami K, Martinez D, Nicolau DP, Artigas A, Pelosi P, Vila J, Torres A. Inhaled amikacin for pneumonia treatment and dissemination prevention: an experimental model of severe monolateral Pseudomonas aeruginosa pneumonia. Crit Care 2023; 27:60. [PMID: 36788582 PMCID: PMC9930251 DOI: 10.1186/s13054-023-04331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Pseudomonas aeruginosa pneumonia is commonly treated with systemic antibiotics to ensure adequate treatment of multidrug resistant (MDR) bacteria. However, intravenous (IV) antibiotics often achieve suboptimal pulmonary concentrations. We therefore aimed to evaluate the effect of inhaled amikacin (AMK) plus IV meropenem (MEM) on bactericidal efficacy in a swine model of monolateral MDR P. aeruginosa pneumonia. METHODS We ventilated 18 pigs with monolateral MDR P. aeruginosa pneumonia for up to 102 h. At 24 h after the bacterial challenge, the animals were randomized to receive 72 h of treatment with either inhaled saline (control), IV MEM only, or IV-MEM plus inhaled AMK (MEM + AMK). We dosed IV MEM at 25 mg/kg every 8 h and inhaled AMK at 400 mg every 12 h. The primary outcomes were the P. aeruginosa burden and histopathological injury in lung tissue. Secondary outcomes included the P. aeruginosa burden in tracheal secretions and bronchoalveolar lavage fluid, the development of antibiotic resistance, the antibiotic distribution, and the levels of inflammatory markers. RESULTS The median (25-75th percentile) P. aeruginosa lung burden for animals in the control, MEM only, and MEM + AMK groups was 2.91 (1.75-5.69), 0.72 (0.12-3.35), and 0.90 (0-4.55) log10 CFU/g (p = 0.009). Inhaled therapy had no effect on preventing dissemination compared to systemic monotherapy, but it did have significantly higher bactericidal efficacy in tracheal secretions only. Remarkably, the minimum inhibitory concentration of MEM increased to > 32 mg/L after 72-h exposure to monotherapy in 83% of animals, while the addition of AMK prevented this increase (p = 0.037). Adjunctive therapy also slightly affected interleukin-1β downregulation. Despite finding high AMK concentrations in pulmonary samples, we found no paired differences in the epithelial lining fluid concentration between infected and non-infected lungs. Finally, a non-significant trend was observed for higher amikacin penetration in low-affected lung areas. CONCLUSIONS In a swine model of monolateral MDR P. aeruginosa pneumonia, resistant to the inhaled AMK and susceptible to the IV antibiotic, the use of AMK as an adjuvant treatment offered no benefits for either the colonization of pulmonary tissue or the prevention of pathogen dissemination. However, inhaled AMK improved bacterial eradication in the proximal airways and hindered antibiotic resistance.
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Affiliation(s)
- Ana Motos
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Hua Yang
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Gianluigi Li Bassi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Queensland University of Technology, UnitingCare Hospitals, Wesley Medical Research, Brisbane, Australia
| | - Minlan Yang
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Andrea Meli
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Denise Battaglini
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Roberto Cabrera
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Joaquim Bobi
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Pagliara
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Gerard Frigola
- Department of Pathology, Hospital Clinic, Barcelona, Spain
| | - Marta Camprubí-Rimblas
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Critical Care Center, ParcTaulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Laia Fernández-Barat
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Montserrat Rigol
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Antoni Ferrer-Segarra
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Anestesiologia i Reanimació, Hospital del Mar - Parc de Salut Mar, Barcelona, Spain
| | - Kasra Kiarostami
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Antonio Artigas
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Critical Care Center, ParcTaulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jordi Vila
- Barcelona Centre for International Health Research (CRESIB), ISGlobal, Barcelona, Spain
- Department of Clinical Microbiology, Centre for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, Madrid, Spain
| | - Antoni Torres
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- University of Barcelona, Barcelona, Spain.
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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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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Liu Z, Zhang T, Wu K, Li Z, Chen X, Jiang S, Du L, Lu S, Lin C, Wu J, Wang X. Metagenomic Analysis Reveals A Possible Association Between Respiratory Infection and Periodontitis. GENOMICS, PROTEOMICS & BIOINFORMATICS 2022; 20:260-273. [PMID: 34252627 PMCID: PMC9684085 DOI: 10.1016/j.gpb.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 01/05/2023]
Abstract
Periodontitis is an inflammatory disease that is characterized by progressive destruction of the periodontium and causes tooth loss in adults. Periodontitis is known to be associated with dysbiosis of the oral microflora, which is often linked to various diseases. However, the complexity of plaque microbial communities of periodontitis, antibiotic resistance, and enhanced virulence make this disease difficult to treat. In this study, using metagenomic shotgun sequencing, we investigated the etiology, antibiotic resistance genes (ARGs), and virulence genes (VirGs) of periodontitis. We revealed a significant shift in the composition of oral microbiota as well as several functional pathways that were represented significantly more abundantly in periodontitis patients than in controls. In addition, we observed several positively selected ARGs and VirGs with the Ka/Ks ratio > 1 by analyzing our data and a previous periodontitis dataset, indicating that ARGs and VirGs in oral microbiota may be subjected to positive selection. Moreover, 5 of 12 positively selected ARGs and VirGs in periodontitis patients were found in the genomes of respiratory tract pathogens. Of note, 91.8% of the background VirGs with at least one non-synonymous single-nucleotide polymorphism for natural selection were also from respiratory tract pathogens. These observations suggest a potential association between periodontitis and respiratory infection at the gene level. Our study enriches the knowledge of pathogens and functional pathways as well as the positive selection of antibiotic resistance and pathogen virulence in periodontitis patients, and provides evidence at the gene level for an association between periodontitis and respiratory infection.
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Affiliation(s)
- Zhenwei Liu
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Tao Zhang
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Keke Wu
- Wenzhou Center for Disease Control and Prevention, Wenzhou 325000, China
| | - Zhongshan Li
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Xiaomin Chen
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Shan Jiang
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Lifeng Du
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China
| | - Saisai Lu
- Rheumatology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 352000, China
| | - Chongxiang Lin
- Department of Stomatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Jinyu Wu
- Institute of Genomic Medicine, Wenzhou Medical University, Wenzhou 325000, China,Corresponding authors.
| | - Xiaobing Wang
- Rheumatology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 352000, China,Corresponding authors.
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van der Laan R, Snabilié A, Obradovic M. Meeting the challenges of NTM-PD from the perspective of the organism and the disease process: innovations in drug development and delivery. Respir Res 2022; 23:376. [PMID: 36566170 PMCID: PMC9789522 DOI: 10.1186/s12931-022-02299-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022] Open
Abstract
Non-tuberculous mycobacterial pulmonary disease (NTM-PD) poses a substantial patient, healthcare, and economic burden. Managing NTM-PD remains challenging, and factors contributing to this include morphological, species, and patient characteristics as well as the treatment itself. This narrative review focusses on the challenges of NTM-PD from the perspective of the organism and the disease process. Morphological characteristics of non-tuberculous mycobacteria (NTM), antimicrobial resistance mechanisms, and an ability to evade host defences reduce NTM susceptibility to many antibiotics. Resistance to antibiotics, particularly macrolides, is of concern, and is associated with high mortality rates in patients with NTM-PD. New therapies are desperately needed to overcome these hurdles and improve treatment outcomes in NTM-PD. Amikacin liposome inhalation suspension (ALIS) is the first therapy specifically developed to treat refractory NTM-PD caused by Mycobacterium avium complex (MAC) and is approved in the US, EU and Japan. It provides targeted delivery to the lung and effective penetration of macrophages and biofilms and has demonstrated efficacy in treating refractory MAC pulmonary disease (MAC-PD) in the Phase III CONVERT study. Several other therapies are currently being developed including vaccination, bacteriophage therapy, and optimising host defences. Newly developed antibiotics have shown potential activity against NTM-PD and include benzimidazole, delamanid, and pretomanid. Antibiotics commonly used to treat other infections have also been repurposed for NTM-PD, including clofazimine and bedaquiline. Data from larger-scale studies are needed to determine the potential of many of these therapies for treating NTM-PD.
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Masterson CH, McCarthy SD, O'Toole D, Laffey JG. The role of cells and their products in respiratory drug delivery: the past, present, and future. Expert Opin Drug Deliv 2020; 17:1689-1702. [PMID: 32842784 DOI: 10.1080/17425247.2020.1814732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Cell-based delivery systems offer considerable promise as novel and innovative therapeutics to target the respiratory system. These systems consist of cells and/or their extracellular vesicles that deliver their contents, such as anti-microbial peptides, micro RNAs, and even mitochondria to the lung, exerting direct therapeutic effects. AREAS COVERED The purpose of this article is to critically review the status of cell-based therapies in the delivery of therapeutics to the lung, evaluate current progress, and elucidate key challenges to the further development of these novel approaches. An overview as to how these cells and/or their products may be modified to enhance efficacy is given. More complex delivery cell-based systems, including cells or vesicles that are genetically modified to (over)express specific therapeutic products, such as proteins and therapeutic nucleic acids are also discussed. Focus is given to the use of the aerosol route to deliver these products directly into the lung. EXPERT OPINION The use of biological carriers to deliver chemical or biological agents demonstrates great potential in modern medicine. The next generation of drug delivery systems may comprise 'cell-inspired' drug carriers that are entirely synthetic, developed using insights from cell-based therapeutics to overcome limitations of current generation synthetic carriers.
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Affiliation(s)
- Claire H Masterson
- Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland , Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway , Galway, Ireland
| | - Sean D McCarthy
- Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland , Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway , Galway, Ireland
| | - Daniel O'Toole
- Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland , Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway , Galway, Ireland
| | - John G Laffey
- Anaesthesia, School of Medicine, Clinical Sciences Institute, National University of Ireland , Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway , Galway, Ireland.,Department of Anaesthesia, Galway University Hospitals, SAOLTA University Health Group , Galway, Ireland
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Nebulized Amikacin and Fosfomycin for Severe Pseudomonas aeruginosa Pneumonia: An Experimental Study. Crit Care Med 2020; 47:e470-e477. [PMID: 30882478 DOI: 10.1097/ccm.0000000000003724] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Latest trials failed to confirm merits of nebulized amikacin for critically ill patients with nosocomial pneumonia. We studied various nebulized and IV antibiotic regimens in a porcine model of severe Pseudomonas aeruginosa pneumonia, resistant to amikacin, fosfomycin, and susceptible to meropenem. DESIGN Prospective randomized animal study. SETTING Animal Research, University of Barcelona, Spain. SUBJECTS Thirty female pigs. INTERVENTIONS The animals were randomized to receive nebulized saline solution (CONTROL); nebulized amikacin every 6 hours; nebulized fosfomycin every 6 hours; IV meropenem alone every 8 hours; nebulized amikacin and fosfomycin every 6 hours; amikacin and fosfomycin every 6 hours, with IV meropenem every 8 hours. Nebulization was performed through a vibrating mesh nebulizer. The primary outcome was lung tissue bacterial concentration. Secondary outcomes were tracheal secretions P. aeruginosa concentration, clinical variables, lung histology, and development of meropenem resistance. MEASUREMENTS AND MAIN RESULTS We included five animals into each group. Lung P. aeruginosa burden varied among groups (p < 0.001). In particular, IV meropenem and amikacin and fosfomycin + IV meropenem groups presented lower P. aeruginosa concentrations versus amikacin and fosfomycin, amikacin, CONTROL, and fosfomycin groups (p < 0.05), without significant difference between these two groups undergoing IV meropenem treatment. The sole use of nebulized antibiotics resulted in dense P. aeruginosa accumulation at the edges of the interlobular septa. Amikacin, amikacin and fosfomycin, and amikacin and fosfomycin + IV meropenem effectively reduced P. aeruginosa in tracheal secretions (p < 0.001). Pathognomonic clinical variables of respiratory infection did not differ among groups. Resistance to meropenem increased in IV meropenem group versus amikacin and fosfomycin + meropenem (p = 0.004). CONCLUSIONS Our findings corroborate that amikacin and fosfomycin alone efficiently reduced P. aeruginosa in tracheal secretions, with negligible effects in pulmonary tissue. Combination of amikacin and fosfomycin with IV meropenem does not increase antipseudomonal pulmonary tissue activity, but it does reduce development of meropenem-resistant P. aeruginosa, in comparison with the sole use of IV meropenem. Our findings imply potential merits for preemptive use of nebulized antibiotics in order to reduce resistance to IV meropenem.
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Niederman MS, Alder J, Bassetti M, Boateng F, Cao B, Corkery K, Dhand R, Kaye KS, Lawatscheck R, McLeroth P, Nicolau DP, Wang C, Wood GC, Wunderink RG, Chastre J. Inhaled amikacin adjunctive to intravenous standard-of-care antibiotics in mechanically ventilated patients with Gram-negative pneumonia (INHALE): a double-blind, randomised, placebo-controlled, phase 3, superiority trial. THE LANCET. INFECTIOUS DISEASES 2019; 20:330-340. [PMID: 31866328 DOI: 10.1016/s1473-3099(19)30574-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/31/2019] [Accepted: 09/26/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Treatment of ventilated pneumonia is often unsuccessful, even when patients are treated according to established guidelines. Therefore, we aimed to investigate the efficacy of the combination drug device Amikacin Inhale as an adjunctive therapy to intravenous standard-of-care antibiotics for pneumonia caused by Gram-negative pathogens in intubated and mechanically ventilated patients. METHODS INHALE was a prospective, double-blind, randomised, placebo-controlled, phase 3 study comprising two trials (INHALE 1 and INHALE 2) done in 153 hospital intensive-care units in 25 countries. Eligible patients were aged 18 years or older; had pneumonia that had been diagnosed by chest radiography and that was documented as being caused by or showing two risk factors for a Gram-negative, multidrug-resistant pathogen; were intubated and mechanically ventilated; had impaired oxygenation within 48 h before screening; and had a modified Clinical Pulmonary Infection Score of at least 6. Patients were stratified by region and disease severity (according to their Acute Physiology and Chronic Health Evaluation [APACHE] II score) and randomly assigned (1:1) via an interactive voice-recognition system to receive 400 mg amikacin (Amikacin Inhale) or saline placebo, both of which were aerosolised, administered every 12 h for 10 days via the same synchronised inhalation system, and given alongside standard-of-care intravenous antibiotics. All patients and all staff involved in administering devices and monitoring outcomes were masked to treatment assignment. The primary endpoint, survival at days 28-32, was analysed in all patients who received at least one dose of study drug, were infected with a Gram-negative pathogen, and had an APACHE II score of at least 10 at diagnosis. Safety analyses were done in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, numbers NCT01799993 and NCT00805168. FINDINGS Between April 13, 2013, and April 7, 2017, 807 patients were assessed for eligibility and 725 were randomly assigned to Amikacin Inhale (362 patients) or aerosolised placebo (363 patients). 712 patients received at least one dose of study drug (354 in the Amikacin Inhale group and 358 in the placebo group), although one patient assigned to Amikacin Inhale received placebo in error and was included in the placebo group for safety analyses. 508 patients (255 in the Amikacin Inhale group and 253 in the placebo group) were assessed for the primary endpoint. We found no between-group difference in survival: 191 (75%) patients in the Amikacin Inhale group versus 196 (77%) patients in the placebo group survived until days 28-32 (odds ratio 0·841, 95% CI 0·554-1·277; p=0·43). Similar proportions of patients in the two treatment groups had a treatment-emergent adverse event (295 [84%] of 353 patients in the Amikacin Inhale group vs 303 [84%] of 359 patients in the placebo group) or a serious treatment-emergent adverse event (101 [29%] patients vs 97 [27%] patients). INTERPRETATION Our findings do not support use of inhaled amikacin adjunctive to standard-of-care intravenous therapy in mechanically ventilated patients with Gram-negative pneumonia. FUNDING Bayer AG.
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Affiliation(s)
- Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA.
| | - Jeff Alder
- Anti-Infective Consulting, Margaretville, NY, USA
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Policlinico San Martino Hospital, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - G Christopher Wood
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, University of Tennessee, Memphis, TN, USA
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jean Chastre
- Intensive Care Unit, Sorbonne University Hospitals, Paris, France
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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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9
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Lamy B, Serrano DR, O’Connell P, Couet W, Marchand S, Healy AM, Tewes F. Use of leucine to improve aerodynamic properties of ciprofloxacin-loaded maltose microparticles for inhalation. ACTA ACUST UNITED AC 2019. [DOI: 10.34154/2019-ejpr.01(01).pp-02-11/euraass] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ciprofloxacin (CIP) apparent permeability and absorption rate across the pulmonary epithelium can be controlled by its complexation with copper (II) ion. The aim of the current study was to formulate CIP-Cu-loaded microparticles comprising three main excipients, calcium carbonate, maltose and L-leucine, and to process by spray drying so as to generate particles with suitable aerodynamic properties for pulmonary delivery using a dry powder inhaler. Different maltose:calcium carbonate ratios were used to prepare microparticles, and the role of the excipients on the particles’ physicochemical properties, stability, and aerosolization characteristics were investigated. All the formulations without L-leucine were fully X-ray amorphous. In the presence of L-leucine, diffraction peaks of low intensity were observed, which were attributed to the crystallization of the L-leucine at the particle surfaces. The addition of L-leucine modified the particle morphology and reduced the median geometric and aerodynamic diameters to 3.2 and 3.4 µm, respectively. The fine particle fraction of powder emitted from a Handihaler® device was increased up to 65.4%, predicting high total lung deposition. Stability studies showed that the powder X-ray diffraction pattern did not change over 21 months of storage in desiccated conditions, suggesting a good physical stability of the optimized formulation comprised of CIP-Cu, maltose and L-Leucine.
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Affiliation(s)
- Barbara Lamy
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
| | - Dolores Remedios Serrano
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland AND Departamento de Farmacia y Tecnologia Farmaceutica, Facultad de Farmacia, Universidad Complutense de Madrid, Plaza Ramon y Cajal s/n, Madrid, 28040, Spain
| | - Peter O’Connell
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - William Couet
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France AND Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Sandrine Marchand
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France AND Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Anne Marie Healy
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - Frederic Tewes
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
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10
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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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11
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Nebulized Versus IV Amikacin as Adjunctive Antibiotic for Hospital and Ventilator-Acquired Pneumonia Postcardiac Surgeries: A Randomized Controlled Trial. Crit Care Med 2017; 46:45-52. [PMID: 28857848 DOI: 10.1097/ccm.0000000000002695] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Nebulized antibiotics offer high efficacy due to significant local concentrations and safety with minimal blood levels. This study evaluates the efficacy and nephrotoxicity of nebulized versus IV amikacin in postcardiothoracic surgical patients with nosocomial pneumonia caused by multidrug-resistant Gram- negative bacilli. DESIGN Prospective, randomized, controlled study on surgical patients divided into two groups. SETTING Postcardiac surgery ICU. INTERVENTIONS The first gtroup was administered IV amikacin 20 mg/kg once daily. The second group was prescribed amikacin nebulizer 400 mg twice daily. Both groups were co-administered IV piperacillin/tazobactam empirically. PATIENTS Recruited patients were diagnosed by either hospital-acquired pneumonia or ventilator-associated pneumonia where 56 (42.1%) patients were diagnosed with hospital-acquired pneumonia, 51 (38.34%) patients were diagnosed with early ventilator-associated pneumonia, and 26 (19.54%) patients with late ventilator-associated pneumonia. MEASUREMENTS AND MAIN RESULTS Clinical cure in both groups assessed on day 7 of treatment was the primary outcome. Efficacy was additionally evaluated through assessing the length of hospital stay, ICU stay, days on amikacin, days on mechanical ventilator, mechanical ventilator-free days, days to reach clinical cure, and mortality rate. Lower nephrotoxicity in the nebulized group was observed through significant preservation of kidney function (p < 0.001). Although both groups were comparable regarding length of hospital stay, nebulizer group showed shorter ICU stay (p = 0.010), lower number of days to reach complete clinical cure (p = 0.001), fewer days on mechanical ventilator (p = 0.035), and fewer days on amikacin treatment (p = 0.022). CONCLUSION Nebulized amikacin showed better clinical cure rates, less ICU stay, and fewer days to reach complete recovery compared to IV amikacin for surgical patients with nosocomial pneumonia. It is also a less nephrotoxic option associated with less deterioration in kidney function.
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12
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Lamy B, Tewes F, Serrano DR, Lamarche I, Gobin P, Couet W, Healy AM, Marchand S. New aerosol formulation to control ciprofloxacin pulmonary concentration. J Control Release 2017; 271:118-126. [PMID: 29277683 DOI: 10.1016/j.jconrel.2017.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/07/2023]
Abstract
Ciprofloxacin (CIP) apparent permeability across a pulmonary epithelium model can be controlled by the affinity of its complex with a metal cation. The higher the complex affinity, the larger is the reduction in CIP apparent permeability. The aim of this study was to evaluate if the control of the CIP apparent permeability observed in vitro could be transposed in vivo to control the CIP lung-to-blood absorption rate and CIP concentrations in the lung epithelial lining fluid (ELF) after intratracheal (IT) administration. Two types of innovative inhalable microparticles loaded with the low-affinity CIP-calcium complex (CIP-Ca) or with the high-affinity CIP-copper complex (CIP-Cu) were formulated and characterized. Then, ELF and plasma pharmacokinetics of CIP were studied in rats after IT administration of these two types of microparticles and of a CIP solution (2.5mg/kg). The presence of Cu2+ had little effect on the microparticle properties and the dry powder had aerodynamic properties which allowed it to reach the lungs. CIP concentrations in ELF were much higher after CIP-Cu microparticles IT administration compared to the other two formulations, with mean AUCELF to AUCu,plasma ratios equal to 1069, 203 and 9.8 after CIP-Cu microparticles, CIP-Ca microparticles and CIP solution pulmonary administration, respectively. No significant modification of lung toxicity markers was found (lactate dehydrogenase and total protein). CIP complexation with Cu2+ seems to be an interesting approach to obtain high CIP concentrations in the ELF of lungs after dry powder IT administration.
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Affiliation(s)
- Barbara Lamy
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
| | - Frederic Tewes
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France.
| | - Dolores Remedios Serrano
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - Isabelle Lamarche
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France
| | - Patrice Gobin
- Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - William Couet
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France; Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France
| | - Anne Marie Healy
- Synthesis and Solid State Pharmaceutical Centre, School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Panoz Institute, Dublin 2, Ireland
| | - Sandrine Marchand
- INSERM, U1070, UFR de Médecine Pharmacie, Université de Poitiers, 1 rue Georges Bonnet, TSA 51106, 86073 Poitiers Cedex 9, France; Laboratoire de Toxicologie-Pharmacocinétique, CHU of Poitiers, 2 rue de la Milétrie, 86000 Poitiers, France.
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13
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In vitro evaluation of aerosol delivery of aztreonam lysine (AZLI): an adult mechanical ventilation model. Expert Opin Drug Deliv 2017; 14:1447-1453. [PMID: 29041861 DOI: 10.1080/17425247.2017.1393411] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The delivery profile of Aztreonam lysine (AZLI) during mechanical ventilation (MV) is unknown. We evaluated the amount of AZLI drug delivered using an in vitro model of adult MV. METHODS An adult lung model designed to mimic current clinical practice was used. Both nebulizers were placed before a Y-piece and 4 settings were tested: A) Aeroneb solo® [AS] with a t-piece; B) AS with the spacer; C) M-Neb® [MN] with a t-piece and D) MN with the spacer. Performance was evaluated in terms of: 1) Mass median aerodynamic diameter (MMAD); 2) Geometric standard deviation (GSD), 3) Fine particle dose (FPD), 4) Fine particle fraction (FPF), 5) Inhalable mass (IM), and 6) Recovery rate (RR). RESULTS Both devices showed an adequate delivery of AZLI during MV, with MMAD between 2.4-2.5 µm and 87% of FPF. The FPD (38.8 and 31.7), IM (44.8 and 36.1) and RR (30 and 24) were similar for AS and MN respectively. Nebulizer aerosol delivery increased (50 and 70% respectively) for both nebulizers when using the spacer. CONCLUSION Both AS and MN showed a good aerosol delivery profile for AZLI during in vitro mechanical ventilation. Better aerosol delivery performance was obtained using the spacer.
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14
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Palmer LB, Sweeney DA, Metersky ML, Kalil AC. Reply to Daniels et al. Clin Infect Dis 2016; 64:387-388. [PMID: 27803095 DOI: 10.1093/cid/ciw727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lucy B Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, State University of New York at Stony Brook
| | - Daniel A Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego
| | - Mark L Metersky
- Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
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15
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Bassetti M, Luyt CE, Nicolau DP, Pugin J. Characteristics of an ideal nebulized antibiotic for the treatment of pneumonia in the intubated patient. Ann Intensive Care 2016; 6:35. [PMID: 27090532 PMCID: PMC4835402 DOI: 10.1186/s13613-016-0140-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023] Open
Abstract
Gram-negative pneumonia in patients who are intubated and mechanically ventilated is associated with increased morbidity and mortality as well as higher healthcare costs compared with those who do not have the disease. Intravenous antibiotics are currently the standard of care for pneumonia; however, increasing rates of multidrug resistance and limited penetration of some classes of antimicrobials into the lungs reduce the effectiveness of this treatment option, and current clinical cure rates are variable, while recurrence rates remain high. Inhaled antibiotics may have the potential to improve outcomes in this patient population, but their use is currently restricted by a lack of specifically formulated solutions for inhalation and a limited number of devices designed for the nebulization of antibiotics. In this article, we review the challenges clinicians face in the treatment of pneumonia and discuss the characteristics that would constitute an ideal inhaled drug/device combination. We also review inhaled antibiotic options currently in development for the treatment of pneumonia in patients who are intubated and mechanically ventilated.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Santa Maria Misericordia University Hospital, Udine, Italy.
| | - Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, USA
| | - Jérôme Pugin
- Service des Soins Intensifs, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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16
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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Abstract
PURPOSE OF REVIEW Despite multiple protocols for the prevention of ventilator-associated pneumonia (VAP), respiratory infections have not been eliminated in the ICU. The profound disruption in both airway integrity and mucociliary clearance caused by the endotracheal tube makes it unlikely there will ever be a zero rate of respiratory infection in critically ill ventilated patients or a 100% cure rate when infection is present. In fact, options for treatment are diminishing as bacteria resistant to most, or in some hospitals all, systemic antibiotics increase in prevalence from our liberal use of systemic antibiotics. Inhaled therapy with proper delivery will result in the high concentrations of antibiotics needed in the treatment of increasingly resistant organisms. RECENT FINDINGS Data from many recent investigations have focused on inhaled antibiotics as: adjunctive therapy to systemic antibiotic for VAP, monotherapy for VAP, and as monotherapy for ventilator-associated tracheobronchitis. The clinical outcomes of these studies will be reviewed as well as their effect on multidrug-resistant organisms. SUMMARY The present review will focus on the rationale for inhaled therapy, the current studies examining the delivery and clinical efficacy of inhaled antibiotics, and the potential role for this mode of delivery actually decreasing antibiotic resistance in the respiratory tract.
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Antibióticos nebulizados. ¿Una opción adecuada para el tratamiento de la infección respiratoria relacionada con la ventilación mecánica? Med Intensiva 2015; 39:97-100. [DOI: 10.1016/j.medin.2014.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 11/21/2022]
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Characterization of a human powered nebulizer compressor for resource poor settings. Biomed Eng Online 2014; 13:77. [PMID: 24939567 PMCID: PMC4074310 DOI: 10.1186/1475-925x-13-77] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/02/2014] [Indexed: 01/25/2023] Open
Abstract
Background Respiratory disease accounts for three of the ten leading causes of death worldwide. Many of these diseases can be treated and diagnosed using a nebulizer. Nebulizers can also be used to safely and efficiently deliver vaccines. Unfortunately, commercially available nebulizers are not designed for use in regions of the world where lung disease is most prevalent: they are electricity-dependent, cost-prohibitive, and not built to be reliable in harsh operating conditions or under frequent use. To overcome these limitations, the Human Powered Nebulizer compressor (HPN) was developed. The HPN does not require electricity; instead airflow is generated manually through a hand-crank or bicycle-style pedal system. A health care worker or other trained individual operates the device while the patient receives treatment. This study demonstrates functional specifications of the HPN in comparison with a standard commercially available electric jet nebulizer compressor, the DeVilbiss Pulmo-Aide 5650D (Pulmo-Aide). Methods Pressure and flow characteristics were measured with a rotameter and pressure transducer, respectively. Volume nebulized by each compressor was determined by mass, and particle size distribution was determined via laser diffraction. The Hudson RCI Micro Mist nebulizer mouthpiece was used with both compressors. Results The pressure and flow generated by the HPN and Pulmo-Aide were: 15.17 psi and 10.5 L/min; and 14.65 psi and 11.2 L/min, respectively. The volume of liquid delivered by each was equivalent, 1.097 ± 0.107 mL (mean ± s.e.m., n = 13) for the HPN and 1.092 ± 0.116 mL for the Pulmo-Aide. The average particle size was also equivalent, 5.38 ± 0.040 micrometers (mean ± s.e.m., n = 7) and 5.40 ± 0.025 micrometers, respectively. Conclusions Based on these characteristics, the HPN’s performance is equivalent to a popular commercially available electric nebulizer compressor. The findings presented in this paper, combined with the results of two published clinical studies, suggest that the HPN could serve as an important diagnostic and therapeutic tool in the fight against global respiratory health challenges including: tuberculosis, chronic obstructive pulmonary disease, asthma, and lower respiratory infections.
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Biopharmaceutical characterization of nebulized antimicrobial agents in rats: 2. Colistin. Antimicrob Agents Chemother 2014; 58:3950-6. [PMID: 24798284 DOI: 10.1128/aac.02819-14] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The purpose of this study was to investigate the pharmacokinetic properties of colistin following intrapulmonary administration of colistin sulfate in rats. Colistin was infused or delivered in nebulized form at a dose of 0.35 mg/kg of body weight in rats, and plasma drug concentrations were measured for 4 h after administration. Bronchoalveolar lavages (BAL) were also conducted at 0.5, 2, and 4 h after intravenous (i.v.) administration and administration via nebulized drug to estimate epithelial lining fluid (ELF) drug concentrations. Unbound colistin plasma concentrations at distribution equilibrium (2 h postdosing) were almost identical after i.v. infusion and nebulized drug inhalation. ELF drug concentrations were undetectable in BAL samples after i.v. administration, but they were about 1,800 times higher than unbound plasma drug levels at 2 h and 4 h after administration of the nebulized drug. Simultaneous pharmacokinetic modeling of plasma and ELF drug concentrations was performed with a model characterized by a fixed physiological volume of ELF (VELF), a passive diffusion clearance (QELF) between plasma and ELF, and a nonlinear influx transfer from ELF to the central compartment, which was assessed by reducing the nebulized dose of colistin by 10-fold (0.035 mg kg(-1)). The km was estimated to be 133 μg ml(-1), and the Vmax, in-to-Km ratio was equal to 2.5 × 10(-3) liter h(-1) kg(-1), which was 37 times higher than the QELF (6.7 × 10(-5) liter h(-1) kg(-1)). This study showed that with the higher ELF drug concentrations after administration via nebulized aerosol than after intravenous administration, for antibiotics with low permeability such as colistin, nebulization offers a real potential over intravenous administration for the treatment of pulmonary infections.
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Abstract
The development of inhaled antibiotics to treat lung infection is an active field, with four approved products in the USA and more in the late stages of clinical development. The efficacies of TOBI® tobramycin (Novartis) and Cayston® aztreonam lysate (Gilead), the approved inhaled antibiotics for cystic fibrosis (CF) patients colonized with Pseudomonas aeruginosa, have been well documented. Recent approvals for a second-generation tobramycin solution, Bethkis®, and a tobramycin powder formulation in a dry-powder inhaler (DPI), TOBI Podhaler®, indicate that the inhaled antibiotic marketplace in CF is becoming very competitive. Other indications are also receiving interest. While there have been a number of recent reviews from a clinical, technical or regulatory perspective in the field of inhaled antibiotics, as well as others focused on a specific product or data from a recent clinical trial, there have not been any that describe the patent coverage of these products. This review addresses that missing piece.
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Population pharmacokinetics of colistin methanesulfonate in rats: achieving sustained lung concentrations of colistin for targeting respiratory infections. Antimicrob Agents Chemother 2013; 57:5087-95. [PMID: 23917323 DOI: 10.1128/aac.01127-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Colistin methanesulfonate (CMS), the inactive prodrug of colistin, is administered by inhalation for the management of respiratory infections. However, limited pharmacokinetic data are available for CMS and colistin following pulmonary delivery. This study investigates the pharmacokinetics of CMS and colistin following intravenous (i.v.) and intratracheal (i.t.) administration in rats and determines the targeting advantage after direct delivery into the lungs. In addition to plasma, bronchoalveolar lavage (BAL) fluid was collected to quantify drug concentrations in lung epithelial lining fluid (ELF). The resulting data were analyzed using a population modeling approach in S-ADAPT. A three-compartment model described the disposition of both compounds in plasma following i.v. administration. The estimated mean clearance from the central compartment was 0.122 liters/h for CMS and 0.0657 liters/h for colistin. Conversion of CMS to colistin from all three compartments was required to fit the plasma data. The fraction of the i.v. dose converted to colistin in the systemic circulation was 0.0255. Two BAL fluid compartments were required to reflect drug kinetics in the ELF after i.t. dosing. A slow conversion of CMS (mean conversion time [MCTCMS] = 3.48 h) in the lungs contributed to high and sustained concentrations of colistin in ELF. The fraction of the CMS dose converted to colistin in ELF (fm,ELF = 0.226) was higher than the corresponding fractional conversion in plasma after i.v. administration. In conclusion, pulmonary administration of CMS achieves high and sustained exposures of colistin in lungs for targeting respiratory infections.
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Affiliation(s)
- Dawn E Jaroszewski
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
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