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Li L, Huang X, Liu J, Li C, Lin Z, Ren R, Zhang Y, Ding H, Chen J, Mao Y. Efficacy and Safety Factors Related to Plasma Concentration-Optimized Polymyxin B Therapy in Treating Carbapenem-Resistant Gram-Negative Bacterial Infections in China. Infect Drug Resist 2024; 17:3057-3071. [PMID: 39050834 PMCID: PMC11268568 DOI: 10.2147/idr.s468890] [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: 05/16/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
Background Polymyxin B (PMB)-based combination therapies are used to treat severe carbapenem-resistant gram-negative bacterial (CR-GNB) infections. This observational study investigated the relationship between clinical factors, including PMB concentration, and clinical efficacy and safety. Patients and Methods Polymyxin B regimens were optimized through therapeutic drug monitoring (TDM) and area under the concentration-time curve (AUC). In all, 382 samples were tested from 130 patients. Logistic regression was used to analyze the relationships between variables with clinical efficacy and 30-day mortality factors were analyzed by Cox regression. The sensitivity and specificity of Cmin and AUC for the occurrence of acute kidney injury (AKI) were determined by ROC curve analysis. Results The clinical effectiveness of PMB was 65.4%. Multivariate logistic regression analysis revealed that lung infection, continuous renal replacement therapy, and C-reactive protein were independent factors significantly associated with efficacy. AKI occurred in 14.6% of the patients during treatment; age > 73 years (OR: 3.63; 95% CI: 1.035-12.727; P = 0.044), Cmin greater than 2.3 µg/mL (OR: 7.37; 95% CI: 1.571-34.580; P = 0.011), combined vancomycin (OR: 9.47; 95% CI: 1.732-51.731; P = 0.009), and combined piperacillin-tazobactam (OR: 21.87; 95% CI: 3.139-152.324; P = 0.002) were independent risk factors. The identified PMB cut-offs for predicting AKI were Cmin = 2.3 µg/mL and AUC = 82.0 mg h/L. Conclusion Polymyxin B-based combination regimens are effective in treating CR-GNB infections, particularly bloodstream infections, but have shown unsatisfactory for lung infections. Cmin ≥ 2.3 µg /mL and AUC ≥ 82.0 mg h/L may increase PMB-associated AKI incidence. PMB dose should be adjusted based on TDM to ensure efficacy.
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Affiliation(s)
- Lixia Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jingxian Liu
- Department of Clinical Laboratory, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Chao Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Zhiyan Lin
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Rongrong Ren
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yan Zhang
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Haoshu Ding
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yanfei Mao
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
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Peng L, Zhang Z, Qi X, Zhong Y, Sun T, Chen L, Zhu J, Lv X, Ma P. Efficiency of polymyxin B treatment against nosocomial infection: a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1400757. [PMID: 38863886 PMCID: PMC11165566 DOI: 10.3389/fmed.2024.1400757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/14/2024] [Indexed: 06/13/2024] Open
Abstract
Background Some cohort studies have explored the effects and safety of polymyxin B (PMB) in comparison to other antibiotics for the treatment of nosocomial infections, yielding inconsistent results. This systematic review aims to explore the effectiveness and safety of PMB and compared it with other antibiotics. Methods A systematic literature search was conducted in PubMed, Embase, the Cochrane Library, and Web of Science, searching specific terms to identify quantitative cohort studies or RCTs that compared the effects of PMB with other antibiotics in terms of their efficacy and safety. The Newcastle-Ottawa Scale (NOS) was conducted to evaluate the risk of bias of observational studies. Odds ratios with 95% confidence intervals were used for outcome assessment. We evaluated heterogeneity using the I 2 test. Results A total of 22 observational trials were included in the analysis. The PMB group had a higher mortality rate compared to the control group (odds ratio: 1.84, 95% CI: 1.36-2.50, p<0.00001, I 2 = 73%). while, the ceftazidime-avibactam group demonstrated a distinct advantage with lower mortality rates, despite still exhibiting high heterogeneity (odds ratio 2.73, 95% confidence interval 1.59-4.69; p = 0.0003; I 2 = 53%). Additionally, the PMB group had a lower nephrotoxicity rate compared to the colistin group but exhibited high heterogeneity in the results (odds ratio 0.58, 95% CI 0.36-0.93; p = 0.02; I 2 = 73%). Conclusion In patients with nosocomial infections, PMB is not superior to other antibiotics in terms of mortality, specifically when compared to ceftazidime-avibactam. However, PMB demonstrated an advantage in terms of nephrotoxicity compared to colistin.
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Affiliation(s)
- Liyuan Peng
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xueyan Qi
- Department of Emergency and Critical Care Medicine, Henan Engineering Research Center for Critical Care Medicine, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanjun Zhong
- Critical Care Medicine, The Second Xiangya Hospital, Changsha, Hunan, China
| | - Tongwen Sun
- Department of Emergency and Critical Care Medicine, Henan Engineering Research Center for Critical Care Medicine, Henan Key Laboratory of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lvlin Chen
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Junchen Zhu
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Xiangui Lv
- Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Penglin Ma
- Department of Critical Care Medicine, Guiqian International General Hospital, Guiyang, Guizhou, China
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Slingerland C, Martin NI. Recent Advances in the Development of Polymyxin Antibiotics: 2010-2023. ACS Infect Dis 2024; 10:1056-1079. [PMID: 38470446 PMCID: PMC11019560 DOI: 10.1021/acsinfecdis.3c00630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 03/13/2024]
Abstract
The polymyxins are nonribosomal lipopeptides produced by Paenibacillus polymyxa and are potent antibiotics with activity specifically directed against Gram-negative bacteria. While the clinical use of polymyxins has historically been limited due to their toxicity, their use is on the rise given the lack of alternative treatment options for infections due to multidrug resistant Gram-negative pathogens. The Gram-negative specificity of the polymyxins is due to their ability to target lipid A, the membrane embedded LPS anchor that decorates the cell surface of Gram-negative bacteria. Notably, the mechanisms responsible for polymyxin toxicity, and in particular their nephrotoxicity, are only partially understood with most insights coming from studies carried out in the past decade. In parallel, many synthetic and semisynthetic polymyxin analogues have been developed in recent years in an attempt to mitigate the nephrotoxicity of the natural products. Despite these efforts, to date, no polymyxin analogues have gained clinical approval. This may soon change, however, as at the moment there are three novel polymyxin analogues in clinical trials. In this context, this review provides an update of the most recent insights with regard to the structure-activity relationships and nephrotoxicity of new polymyxin variants reported since 2010. We also discuss advances in the synthetic methods used to generate new polymyxin analogues, both via total synthesis and semisynthesis.
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Affiliation(s)
- Cornelis
J. Slingerland
- Biological
Chemistry Group, Institute of Biology Leiden, Leiden University, Sylviusweg 72, 2333 BE Leiden, The Netherlands
| | - Nathaniel I. Martin
- Biological
Chemistry Group, Institute of Biology Leiden, Leiden University, Sylviusweg 72, 2333 BE Leiden, The Netherlands
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4
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Ballı FN, Ekinci PB, Kurtaran M, Kara E, Dizman GT, Sönmezer MÇ, Hayran M, Demirkan K, Metan G. Battle of polymyxin induced nephrotoxicity: Polymyxin B versus colistin. Int J Antimicrob Agents 2024; 63:107035. [PMID: 37979889 DOI: 10.1016/j.ijantimicag.2023.107035] [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: 06/03/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Nephrotoxicity is the most serious and common adverse effect that limits the use of polymyxins. This study compared polymyxin E (colistin) and polymyxin B regarding drug-related nephrotoxicity. METHODS This study was conducted as a retrospective cohort study in a university hospital between January 2020 and July 2022. Patients older than 18 years and who received colistin or polymyxin B were identified using electronic hospital records. Kidney disease improving global outcome criteria were used for assessing nephrotoxicity. RESULTS A total of 190 patients, 95 in both groups, were evaluated. The incidence of acute kidney injury during the treatment was higher in the colistin group [52.6% (n = 50) and 34.7% (n = 33), P = 0.013]. In patients who were exposed to high-dose, the rate of nephrotoxicity was higher in patients receiving colistin [25% (n = 3) vs. 76.9% (n = 10); P = 0.017]. Nephrotoxicity was reversible in 64.4% (n = 38) of patients and the reversibility rate was similar (70% and 52.6% for colistin and polymyxin; P = 0.248). In the multivariable analysis, colistin treatment [odds ratio (OR): 3.882, 95% confidence interval (95% CI) = (1.829-8.241)], concomitant vasopressor use (OR = 2.08, CI: 1.036-4.179), and age (OR=1.036, CI: 1.014-1.058) were found to be independent markers of nephrotoxicity. CONCLUSION Nephrotoxicity was more common in patients receiving high-dose colistin than polymyxin B. Therefore, the use of appropriate doses of colistin is important in terms of preventing nephrotoxicity. In addition, advancing age and concomitant use of vasopressors contribute to polymyxin-related nephrotoxicity.
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Affiliation(s)
- Fatma Nisa Ballı
- Department of Clinical Pharmacy, Gazi University Faculty of Pharmacy, Ankara, Türkiye; Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Türkiye.
| | - Pınar Bakır Ekinci
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Türkiye
| | - Melek Kurtaran
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Türkiye
| | - Emre Kara
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Türkiye
| | - Gülçin Telli Dizman
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Meliha Çağla Sönmezer
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Mutlu Hayran
- Department of Preventive Oncology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Hacettepe University Faculty of Pharmacy, Ankara, Türkiye
| | - Gökhan Metan
- Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
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5
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Zhang Y, Dong R, Huang Y, Ling X, Ye Z, Jiang S. Acute kidney injury associated with colistin sulfate vs. polymyxin B sulfate therapy: A real-world, retrospective cohort study. Int J Antimicrob Agents 2024; 63:107031. [PMID: 37951480 DOI: 10.1016/j.ijantimicag.2023.107031] [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: 06/30/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE To compare the incidence of acute kidney injury (AKI) in patients treated with colistin sulfate (CS) and polymyxin B sulfate (PMB). METHODS Sociodemographic and laboratory measures of adult patients who received intravenous CS or PMB for at least 72 h for the first time at the study hospital from October 2021 to November 2022 were collected retrospectively. The primary outcome was the incidence of AKI, defined by the Kidney Diseases Improving Global Outcomes criteria. The secondary outcome was 30-day mortality. RESULTS In total, 109 patients were included in the CS cohort and 176 patients were included in the PMB cohort. The incidence of AKI was significantly higher in the PMB cohort compared with the CS cohort (50.6% vs. 18.3%; P<0.001). On multi-variate analysis, CS therapy [hazard ratio (HR) 0.275; P<0.001] was an independent protective factor for AKI, along with higher estimated glomerular filtration rate. Nevertheless, 30-day mortality was similar in the PMB and CS cohorts (21.6% vs. 13.8%; P=0.099). Multi-variate analyses revealed that CS therapy was not associated with 30-day mortality (HR 0.968; P=0.926), while intensive care unit admission, combination with meropenem, Charlson score and stage 3 AKI were independent risk factors for 30-day mortality. After balancing the baseline characteristics of patients using propensity score matching, the main results were unchanged. CONCLUSION The incidence of AKI was significantly lower in the CS cohort compared with the PMB cohort. However, 30-day mortality was similar in the two cohorts.
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Affiliation(s)
- Yanfang Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yizhen Huang
- Department of Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xiao Ling
- Department of Pharmacy, The People's Hospital of Yuhuan, Taizhou, Zhejiang, China
| | - Ziqi Ye
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Saiping Jiang
- Department of Clinical Pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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6
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Slingerland CJ, Lysenko V, Chaudhuri S, Wesseling CMJ, Barnes D, Masereeuw R, Martin NI. Semisynthetic polymyxins with potent antibacterial activity and reduced kidney cell toxicity. RSC Med Chem 2023; 14:2417-2425. [PMID: 37974968 PMCID: PMC10650952 DOI: 10.1039/d3md00456b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/06/2023] [Indexed: 11/19/2023] Open
Abstract
The growing incidence of infections caused by multi-drug resistant Gram-negative bacteria has led to an increased use of last-resort antibiotics such as the polymyxins. Polymyxin therapy is limited by toxicity concerns, most notably nephrotoxicity. Recently we reported the development of a novel class of semisynthetic polymyxins with reduced toxicity wherein the N-terminal lipid and diaminobutyric acid residue are replaced by a cysteine-linked lipid featuring a reductively labile disulfide bond. In the present study we further explored the potential of this approach by also varying the amino acid residue directly adjacent to the polymyxin macrocycle. This led to the identification of new semisynthetic polymyxins that maintain the potent antibacterial activity of the clinically used polymyxin B while exhibiting a further reduction in toxicity toward human proximal tubule epithelial cells. Furthermore, these new polymyxins were found to effectively synergize with novobiocin, rifampicin, and erythromycin against mcr-positive, polymyxin resistant E. coli.
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Affiliation(s)
- Cornelis J Slingerland
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University Sylviusweg 72 2333 BE Leiden The Netherlands
| | - Vladyslav Lysenko
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University Sylviusweg 72 2333 BE Leiden The Netherlands
| | - Samhita Chaudhuri
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University Sylviusweg 72 2333 BE Leiden The Netherlands
| | - Charlotte M J Wesseling
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University Sylviusweg 72 2333 BE Leiden The Netherlands
| | - Devon Barnes
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University 3584 CG Utrecht The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht University 3584 CG Utrecht The Netherlands
| | - Nathaniel I Martin
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University Sylviusweg 72 2333 BE Leiden The Netherlands
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7
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Garcia RCL, Rodrigues RD, Garcia ECL, Rigatto MH. Comparison between Colistin and Polymyxin B in the Treatment of Bloodstream Infections Caused by Carbapenem-Resistant Pseudomonas aeruginosa and Acinetobacter baumannii-calcoaceticus Complex. Antibiotics (Basel) 2023; 12:1317. [PMID: 37627737 PMCID: PMC10451820 DOI: 10.3390/antibiotics12081317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Polymyxins are still widely used for the treatment of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa bloodstream infections (BSIs). This study seeks to evaluate the impact of polymyxin B versus colistin on mortality and nephrotoxicity in BSI caused by these bacteria. We conducted a retrospective cohort study from 2014 to 2021 in Porto Alegre, Brazil. We included patients aged ≥18 years and excluded patients with polymicrobial infection or treatment for ≤48 h. The 30-day mortality was the primary outcome evaluated through Cox regression. We included 259 patients with BSI episodes: 78.8% caused by A. baumannii and 21.2% caused by P. aeruginosa. Polymyxin B did not impact mortality compared to colistin (adjusted hazard ratio (aHR), 0.82; 95% confidence interval (CI), 0.52-1.30; p = 0.40 (when adjusted for COVID-19 comorbidity, p = 0.05), Pitt bacteremia score, p < 0.01; Charlson comorbidity index, p < 0.001; time to start active antimicrobial therapy, p = 0.02). Results were maintained in the subgroups of BSI caused by A. baumannii (aHR, 0.92; 95% CI, 0.55-1.54; p = 0.74), P. aeruginosa (aHR, 0.47; 95% CI, 0.17-1.32; p = 0.15) and critical care patients (aHR, 0.77; 95% CI, 0.47-1.26; p = 0.30). Treatment with polymyxin B or colistin did not impact 30-day mortality in patients with carbapenem-resistant A. baumannii or P. aeruginosa BSI.
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Affiliation(s)
| | - Rodrigo Douglas Rodrigues
- Healthcare-Associated Infection Control Service, Hospital Universitário Professor Polydoro Ernani de São Thiago, Universidade Federal de Santa Catarina, Florianópolis 88036-800, Brazil;
| | | | - Maria Helena Rigatto
- Medical Sciences Post-Graduation Program, Universidade Federal do Rio Grande do Sul, Porto Alegre 90035-003, Brazil;
- Internal Medicine Department, School of Medicine of the Federal University of Rio Grande do Sul, Porto Alegre 90035-903, Brazil
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, 2350 Ramiro Barcelos St, Porto Alegre 90035-903, Brazil
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8
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Simon V, Viswam A, Alexander PS, James E, Sudhindran S. Colistin versus polymyxin B: A pragmatic assessment of renal and neurological adverse effects and effectiveness in multidrug-resistant Gram-negative bacterial infections. Indian J Pharmacol 2023; 55:229-236. [PMID: 37737075 PMCID: PMC10657617 DOI: 10.4103/ijp.ijp_762_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Our study aimed to evaluate the real-world data on renal and neurological adverse effects and effectiveness of colistimethate sodium (CMS) and polymyxin B (PMB). MATERIALS AND METHODS An observational prospective study was performed on inpatients receiving CMS and PMB for multidrug-resistant Gram-negative bacterial infections. CMS dose was titrated to renal function, and serum creatinine was assessed daily. The incidence of nephrotoxicity, the primary outcome, was evaluated based on an increase in serum creatinine from baseline as well as by the Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease criteria. Neurological adverse effects were assessed based on clinical signs and symptoms, and the causality and severity were assessed by the Naranjo scale and modified Hartwig-Siegel scale, respectively. The effectiveness of polymyxin therapy was ascertained by a composite of microbiological eradication of causative bacteria and achievement of clinical cure. Thirty-day all-cause mortality was also determined. RESULTS Between CMS and PMB, the incidence of nephrotoxicity (59.3% vs. 55.6%, P = 0.653) or neurotoxicity (8.3% vs. 5.6%, P = 0.525) did not significantly differ. However, reversal of nephrotoxicity was significantly more with patients receiving CMS than PMB (48.4% vs. 23.3%, P = 0.021). Favorable clinical outcomes (67.6% vs. 37%, P < 0.001) and microbiological eradication of causative bacteria (73.1% vs. 46.3%, P = 0.001) were significantly more with CMS than PMB. Patients treated with CMS had lower all-cause mortality than those with PMB treatment (19.4% vs. 42.6%, P = 0.002). CONCLUSION There is no significant difference in the incidence of renal and neurotoxic adverse effects between CMS and PMB when CMS is administered following renal dose modification. CMS shows better effectiveness and lower mortality compared to PMB.
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Affiliation(s)
- Veneta Simon
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi, Kerala, India
| | - Aathira Viswam
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi, Kerala, India
| | - Pallavi Sarah Alexander
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi, Kerala, India
| | - Emmanuel James
- Department of Pharmacy Practice, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi, Kerala, India
| | - S Sudhindran
- Department of GI Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Health Science Campus, Kochi, Kerala, India
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9
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Pi MY, Cai CJ, Zuo LY, Zheng JT, Zhang ML, Lin XB, Chen X, Zhong GP, Xia YZ. Population pharmacokinetics and limited sampling strategies of polymyxin B in critically ill patients. J Antimicrob Chemother 2023; 78:792-801. [PMID: 36702748 DOI: 10.1093/jac/dkad012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/02/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To characterize the pharmacokinetics (PK) of polymyxin B in Chinese critically ill patients. The factors significantly affecting PK parameters are identified, and a limited sampling strategy for therapeutic drug monitoring of polymyxin B is explored. METHODS Thirty patients (212 samples) were included in a population PK analysis. A limited sampling strategy was developed using Bayesian estimation, multiple linear regression and modified integral equations. Non-linear mixed-effects models were developed using Phoenix NLME software. RESULTS A two-compartment population PK model was used to describe polymyxin B PK. Population estimates of the volumes of central compartment distribution (V) and peripheral compartment distribution (V2), central compartment clearance (CL) and intercompartmental clearance (Q) were 7.857 L, 12.668 L, 1.672 L/h and 7.009 L/h. Continuous renal replacement therapy (CRRT) significantly affected CL, and body weight significantly affected CL and Q. The AUC0-12h of polymyxin B in patients with CRRT was significantly lower than in patients without CRRT. CL and Q increased with increasing body weight. A limited sampling strategy was suggested using a two-sample scheme with plasma at 0.5h and 8h after the end of infusion (C0.5 and C8) for therapeutic drug monitoring in the clinic. CONCLUSIONS A dosing regimen should be based on body weight and the application of CRRT. A two-sample strategy for therapeutic drug monitoring could facilitate individualized treatment with polymyxin B in critically ill patients.
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Affiliation(s)
- Meng-Ying Pi
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Chang-Jie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ling-Yun Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Tao Zheng
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Miao-Lun Zhang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Bin Lin
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Guo-Ping Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Zhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
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10
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Does Monitoring Total and Free Polymyxin B1 Plasma Concentrations Predict Polymyxin B-Induced Nephrotoxicity? A Retrospective Study in Critically Ill Patients. Infect Dis Ther 2022; 11:1591-1608. [PMID: 35689791 PMCID: PMC9334479 DOI: 10.1007/s40121-022-00655-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/04/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The correlation between total and free polymyxin B (PMB including PMB1 and PMB2) exposure in vivo and acute kidney injury (AKI) remains obscure. This study explores the relationships between plasma exposure of PMB1 and PMB2 and nephrotoxicity, and investigates the risk factors for PMB-induced acute kidney injury (AKI) in critically ill patients. METHODS Critically ill patients who used PMB and met the criteria were enrolled. The total plasma concentration and plasma binding of PMB1 and PMB2 were analysed by liquid chromatography-tandem mass spectrometry and equilibrium dialysis. RESULTS A total of 89 patients were finally included, and AKI developed in 28.1% of them. The peak concentration of PMB1 (Cmax (B1)) (adjusted odds ratio (AOR) = 1.68, 95% CI 1.08-2.62, p = 0.023), baseline BUN level (AOR = 1.08, 95% CI 1.01-1.16, p = 0.039) and hypertension (AOR = 3.73, 95% CI 1.21-11.54, p = 0.022) were independent risk factors for PMB-induced AKI. The area under the ROC curve of the model was 0.799. When Cmax (B1) was 5.23 μg/ml or more, the probability of AKI was higher than 50%. The ratio of PMB1/PMB2 decreased after PMB preparation entered into the body. The protein binding rate in critically ill patients indicated significant individual differences. Free Cmax (B) and free Cmax (B1) levels in the AKI group were significantly (p < 0.05) higher than those in the non-AKI group. Total and free concentrations of PMB in patients showed a positive correlation. CONCLUSIONS Both the ROC curve and logistic regression model showed that Cmax (B1) was a good predictor for the probability of PMB-induced AKI. Early therapeutic drug monitoring (TDM) of PMB should be considered in critically ill patients. Compared with Cmin (B), Cmax (B) and Cmax (B1) may be helpful for the early prediction of PMB-induced AKI in critically ill patients.
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11
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Zheng G, Cai J, Zhou S, Du N, Bai H, He J, Bian X. Risk of polymyxin B-induced acute kidney injury with a non adjusted dose versus adjusted dose based on renal function. Per Med 2022; 19:307-314. [PMID: 35762314 DOI: 10.2217/pme-2021-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: To observe the difference in the risk of polymyxin B (PMB)-induced acute kidney injury (AKI) with or without dose adjustment based on the patients renal function. Materials & methods: This retrospective cohort analysis was carried out in 115 patients treated with PMB from November 2018 to October 2019. Results: No significant difference in the incidence of AKI as well as secondary outcomes was observed between these two groups (47.5 vs 37.14%; p = 0.304). Conclusion: Dosing adjustment based on renal function does not significantly lower the risk of PMB-induced AKI. A non adjusted dosing strategy for PMB is recommended in patients exhibiting various levels of renal impairment.
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Affiliation(s)
- Guanhao Zheng
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, 200000, China.,Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200000, China
| | - Jiaqi Cai
- Department of Clinical Laboratory, Kunshan Hospital Affiliated to Nanjing University of Chinese Medicine, Kunshan, 215300, China
| | - Shenghui Zhou
- Department of Pharmacy, Baiyin Central Hospital, Baiyin, 730900, China
| | - Ning Du
- Department of Pharmacy, Qiqihar First Hospital, Qiqihar, 161000, China
| | - Hao Bai
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, 400000, China
| | - Juan He
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, 200000, China
| | - Xiaolan Bian
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, 200000, China.,Department of Pharmacy, Luwan Branch of Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, China
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12
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis 2022; 75:187-212. [PMID: 35439291 PMCID: PMC9890506 DOI: 10.1093/cid/ciac268] [Citation(s) in RCA: 195] [Impact Index Per Article: 97.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. The initial guidance document on infections caused by extended-spectrum β-lactamase producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa) was published on 17 September 2020. Over the past year, there have been a number of important publications furthering our understanding of the management of ESBL-E, CRE, and DTR-P. aeruginosa infections, prompting a rereview of the literature and this updated guidance document. METHODS A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections reviewed, updated, and expanded previously developed questions and recommendations about the treatment of ESBL-E, CRE, and DTR-P. aeruginosa infections. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS Preferred and alternative treatment recommendations are provided with accompanying rationales, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Recommendations apply for both adult and pediatric populations. CONCLUSIONS The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of 24 October 2021. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance/.
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Affiliation(s)
- Pranita D Tamma
- Correspondence: P. D. Tamma, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA ()
| | - Samuel L Aitken
- Department of Pharmacy, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Medical Service and Center for Antimicrobial Resistance and Epidemiology, Louis Stokes Cleveland Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Departments of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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14
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Risk factors for polymyxin B-associated acute kidney injury. Int J Infect Dis 2022; 117:37-44. [DOI: 10.1016/j.ijid.2022.01.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
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15
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Han L, Xu FM, Zhang XS, Zhang CH, Dai Y, Zhou ZY, Wang YX, Chen F, Shi DW, Lin GY, Yu XB. Trough polymyxin B plasma concentration is an independent risk factor for its nephrotoxicity. Br J Clin Pharmacol 2021; 88:1202-1210. [PMID: 34449094 DOI: 10.1111/bcp.15061] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS Data regarding clinical pharmacokinetic/toxicodynamic (PK/TD) of polymyxin B is short of direct quantitative data. This study aims to investigate the risk factors of polymyxin B associated acute kidney injury (AKI) and to assess the relationship between polymyxin B plasma levels and its nephrotoxicity. METHODS A retrospective study was performed in adult patients treated with polymyxin B. Risk factors associated with AKI and plasma trough concentrations of polymyxin B were identified via medical record review. A multivariate logistic regression model was established and the risk of polymyxin B-associated AKI were predicted by a receiver operating characteristic curve, with maximal Youden index used to identify safety thresholds among the study population. RESULTS Fifty-four adult patients were included in the study. AKI was detected in 14 patients during polymyxin B treatment (25.9%, 14 out of 54). Cmin (odds ratio [OR] 2.071; 95% confidence interval [CI] 1.235-3.472) and baseline serum creatinine (OR 1.024; 95% CI 1.005-1.043) were significant independent risk factors for developing AKI. The area under the ROC curve of the combined predictor was larger based on the above factors. When the Youden index was at maximum, the optimal cut-off point was 6.678 of the ROC curve. When Cmin ≥ 3.13 mg/L, the probability of AKI was more than 50%. CONCLUSION In this study, when the calculated combined predictor value was >6.678, there was an increased risk of AKI. Maintaining a polymyxin B Cmin level below 3.13 mg/L may be helpful in reducing the incidence of polymyxin B associated nephrotoxicity.
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Affiliation(s)
- Lu Han
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Fang-Min Xu
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Chun-Hong Zhang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Dai
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zi-Ye Zhou
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ye-Xuan Wang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Fan Chen
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Da-Wei Shi
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guan-Yang Lin
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu-Ben Yu
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
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16
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Lu Q, Li GH, Qu Q, Zhu HH, Luo Y, Yan H, Yuan HY, Qu J. Clinical Efficacy of Polymyxin B in Patients Infected with Carbapenem-Resistant Organisms. Infect Drug Resist 2021; 14:1979-1988. [PMID: 34093026 PMCID: PMC8168961 DOI: 10.2147/idr.s312708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Carbapenem-resistant organisms (CROs) pose great challenges for clinical treatment. Polymyxin B (PMB) is one of the “last resort” choices of CRO infections. We explored the possible factors affecting PMB efficacy. Patients and Methods This retrospective study involved CRO-infected patients treated with PMB for ≥72 h. The endpoint indicator was clinical efficacy. We compared the characteristics (demographics, pathogenic bacteria, PMB treatment) between patients who had “clinical success” (CS) and “clinical failure” (CF). Results A total of 191 patients were enrolled: 110 in the CS group and 81 in the CF group. The total cumulative dose for the CS group was higher than the CF group [1100 (700–1443.75) vs 800 (500–1112.5) mg; P = 0.001]. Treatment duration in the CS group was longer than the CF group [11 (8–14) vs 8 (6–11) days; P < 0.000]. Multivariate logistic regression analysis showed mechanical ventilation, vasoactive agents, multiple-site infection, and total cumulative dose to be independently associated with clinical efficacy. Cox survival analysis for 30-day mortality also showed that the use of vasoactive agents and the total cumulative dose of PMB could influence survival time and mortality rate independently. Conclusion PMB had good efficacy and a low prevalence of adverse reactions. The total cumulative dose, duration of PMB treatment, mechanical ventilation, vasoactive agents, and multiple-site infection were factors associated with the clinical efficacy of PMB.
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Affiliation(s)
- Qiong Lu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Guo-Hua Li
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Hai-Hong Zhu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Yue Luo
- Department of Pharmacy, the People's Hospital of LIUYANG, Liuyang, People's Republic of China
| | - Han Yan
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Hai-Yan Yuan
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
| | - Jian Qu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, People's Republic of China
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17
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America Guidance on the Treatment of Extended-Spectrum β-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa). Clin Infect Dis 2021; 72:e169-e183. [PMID: 33106864 DOI: 10.1093/cid/ciaa1478] [Citation(s) in RCA: 274] [Impact Index Per Article: 91.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Antimicrobial-resistant infections are commonly encountered in US hospitals and result in significant morbidity and mortality. This guidance document provides recommendations for the treatment of infections caused by extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa). METHODS A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections formulated common questions regarding the treatment of ESBL-E, CRE, and DTR-P. aeruginosa infections. Based on review of the published literature and clinical experience, the panel provide recommendations and associated rationale for each recommendation. Because of significant differences in the molecular epidemiology of resistance and the availability of specific anti-infective agents globally, this document focuses on treatment of antimicrobial-resistant infections in the United States. RESULTS Approaches to empiric treatment selection, duration of therapy, and other management considerations are briefly discussed. The majority of guidance focuses on preferred and alternative treatment recommendations for antimicrobial-resistant infections, assuming that the causative organism has been identified and antibiotic susceptibility testing results are known. Treatment recommendations apply to both adults and children. CONCLUSIONS The field of antimicrobial resistance is dynamic and rapidly evolving, and the treatment of antimicrobial-resistant infections will continue to challenge clinicians. This guidance document is current as of 17 September 2020. Updates to this guidance document will occur periodically as new data emerge. Furthermore, the panel will expand recommendations to include other problematic gram-negative pathogens in future versions. The most current version of the guidance including the date of publication can be found at www.idsociety.org/practice-guideline/amr-guidance/.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Department of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Department of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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18
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Truong CB, Durham SH, Qian J. Comparisons of adverse event reporting for colistin versus polymyxin B using the US Food and Drug Administration Adverse Event Reporting System (FAERS). Expert Opin Drug Saf 2021; 20:603-609. [PMID: 33573405 DOI: 10.1080/14740338.2021.1890024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: The polymyxins (colistin and polymyxin B) have recently reemerged in clinical practice. With the same antimicrobial activities, colistin has been more frequently prescribed in most countries, although available evidence on their nephrotoxicity is conflicting.Methods: The US Food and Drug Administration Adverse Event Reporting System (FAERS) data from Q1-2004 to Q1-2020 were used to identify adverse events (AE) reports. We described the reporting patterns and compare the reporting rates of serious AEs, acute kidney diseases (AKD), and death between colistin and polymyxin B using reporting odds ratios (RORs).Results: The annual number of AE reports increased over time for both drugs. Heterogeneity in reporting characteristics was observed in age and reporter region. RORs of serious, AKD, and death AEs were significantly higher for both drugs versus other drugs. RORs of serious and AKD AEs were higher for colistin compared to polymyxin B (p = 0.0479 and p = 0.0306, respectively), but no difference in death RORs was detected (p = 0.2211).Conclusions: This study showed higher reporting rates of serious AEs and AKD for colistin than polymyxin B, but no difference in death. The findings support future research with stronger study design and larger sample size for the safety comparison between colistin and polymyxin B.
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Affiliation(s)
- Cong Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Spencer H Durham
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
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19
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Falagas ME, Kyriakidou M, Voulgaris GL, Vokos F, Politi S, Kechagias KS. Clinical use of intravenous polymyxin B for the treatment of patients with multidrug-resistant Gram-negative bacterial infections: An evaluation of the current evidence. J Glob Antimicrob Resist 2021; 24:342-359. [PMID: 33486122 DOI: 10.1016/j.jgar.2020.12.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES The epidemic dimensions of the emergence of multidrug-resistant (MDR) Gram-negative bacterial infections have led to the revival of old antibiotics, including the polymyxins. METHODS We performed a review and meta-analysis to evaluate the current literature data regarding the effectiveness and safety of intravenous polymyxin B in patients with MDR Gram-negative bacterial infections and the overall mortality and nephrotoxicity in patients treated with intravenous polymyxin B either as monotherapy or combination therapy. RESULTS A total of 5 prospective and 28 retrospective studies, 1 cross-sectional study, 2 retrospective case series and 7 case reports provided data regarding the effectiveness and/or toxicity of intravenous polymyxin B. All-cause mortality of 2910 patients (from 27 studies) who received intravenous polymyxin B was 41.2% (95% CI 35.5-47.0%). All-cause nephrotoxicity of 2994 patients (from 28 studies) treated with intravenous polymyxin B was 40.7% (95% CI 35.0-46.6%). Renal failure among 2111 patients (from 14 studies) was 11.2% (95% CI 8.7-13.9%). CONCLUSION Mortality of patients treated with intravenous polymyxin B is similar to the literature-reported mortality of patients treated with intravenous colistin, while nephrotoxicity associated with polymyxin B use is possibly milder compared with colistin use based on literature data. Head-to-head prospective studies would help to clarify the benefit of polymyxin B over colistin. However, a critical evaluation of the existing worldwide literature data supports the need for availability of the intravenous formulation of polymyxin B as a potentially useful option for the treatment of patients with MDR and extensively drug-resistant (XDR) Gram-negative bacterial infections.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences, Athens, Greece; Department of Medicine, Henry Dunant Hospital Center, Athens, Greece; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Margarita Kyriakidou
- Alfa Institute of Biomedical Sciences, Athens, Greece; School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
| | - Georgios L Voulgaris
- Alfa Institute of Biomedical Sciences, Athens, Greece; Laboratory of Pharmacokinetics and Toxicology, Department of Pharmacy, 401 General Military Hospital, Athens, Greece
| | - Filippos Vokos
- School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
| | - Sevasti Politi
- School of Applied Mathematical and Physical Sciences, National Technical University, Athens, Greece
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20
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Wagenlehner F, Lucenteforte E, Pea F, Soriano A, Tavoschi L, Steele VR, Henriksen AS, Longshaw C, Manissero D, Pecini R, Pogue JM. Systematic review on estimated rates of nephrotoxicity and neurotoxicity in patients treated with polymyxins. Clin Microbiol Infect 2021; 27:S1198-743X(20)30764-3. [PMID: 33359542 DOI: 10.1016/j.cmi.2020.12.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/03/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Nephrotoxicity and neurotoxicity are commonly associated with polymyxin treatment; however, the emergence of multidrug-resistant Gram-negative bacteria with limited therapeutic options has resulted in increased use of polymyxins. OBJECTIVES To determine the rates of nephrotoxicity and neurotoxicity during polymyxin treatment and whether any factors influence these. DATA SOURCES Medline, Embase and Cochrane Library databases were searched on 2 January 2020. STUDY ELIGIBILITY CRITERIA Studies reporting nephrotoxicity and/or neurotoxicity rates in patients with infections treated with polymyxins were included. Reviews, meta-analyses and reports not in English were excluded. PARTICIPANTS Patients hospitalized with infections treated with systemic or inhaled polymyxins were included. For comparative analyses, patients treated with non-polymyxin-based regimens were also included. METHODS Meta-analyses were performed using a random-effects model; subgroup meta-analyses were conducted where data permitted using a mixed-effects model. RESULTS In total, 237 reports of randomized controlled trials, cohort and case-control studies were eligible for inclusion; most were single-arm observational studies. Nephrotoxic events in 35,569 patients receiving polymyxins were analysed. Overall nephrotoxicity rate was 0.282 (95% confidence interval (CI) 0.259-0.307). When excluding studies where >50% of patients received inhaled-only polymyxin treatment or nephrotoxicity assessment was by methods other than internationally recognized criteria (RIFLE, KDIGO or AKIN), the nephrotoxicity rate was 0.391 (95% CI 0.364-0.419). The odds of nephrotoxicity were greater with polymyxin therapies compared to non-polymyxin-based regimens (odds ratio 2.23 (95% CI 1.58-3.15); p < 0.001). Meta-analyses showed a significant effect of polymyxin type, dose, patient age, number of concomitant nephrotoxins and use of diuretics, glycopeptides or vasopressors on the rate of nephrotoxicity. Polymyxin therapies were not associated with a significantly different rate of neurotoxicity than non-polymyxin-based regimens (p 0.051). The overall rate of neurotoxicity during polymyxin therapy was 0.030 (95% CI 0.020-0.043). CONCLUSIONS Polymyxins are associated with a higher risk of nephrotoxicity than non-polymyxin-based regimens.
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Affiliation(s)
- Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Giessen, Germany
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Pea
- Department of Medicine, University of Udine and Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUIUD, Udine, Italy
| | - Alex Soriano
- Infectious Diseases Department, Hospital Clínic of Barcelona, University of Barcelona IDIBAPS, Barcelona, Spain
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | | | | | - Davide Manissero
- University College of London, Institute for Global Health, London, UK
| | | | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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Sisay M, Hagos B, Edessa D, Tadiwos Y, Mekuria AN. Polymyxin-induced nephrotoxicity and its predictors: a systematic review and meta-analysis of studies conducted using RIFLE criteria of acute kidney injury. Pharmacol Res 2020; 163:105328. [PMID: 33276108 DOI: 10.1016/j.phrs.2020.105328] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 01/16/2023]
Abstract
Polymyxins are last-resort antibiotics re-emerged to treat infections caused by multidrug resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacterial infections. However, polymyxin-associated nephrotoxicity has become the main safety concern. Therefore, we conducted this systematic review and meta-analysis on polymyxin-induced nephrotoxicity and its predictors using studies conducted based on the validated RIFLE (Risk, Injury, Failure, Loss of Function and End-stage renal disease) criteria of acute kidney damage. Literature search was carried out through visiting legitimate databases and indexing services including PubMed, MEDLINE (Ovid®), EMBASE (Ovid®), and Scopus to retrieve relevant studies. Following screening and eligibility evaluation, relevant data were extracted from included studies and analyzed using STATA 15.0 and Rev-Man 5.3. Inverse variance method with random effects pooling model was used for the analysis of outcome measures at 95% confidence interval. Besides, meta-regression, meta-influence, and publication bias analyses were conducted. A total of 48 studies involving 6,199 adult patients aged ≥ 18 years were included for systematic review and meta-analysis. The pooled incidence of polymyxin-induced nephrotoxicity was found to be 45% (95% CI: 41- 49%; I2 = 92.52%). Stratifying with RIFLE severity scales, pooled estimates of polymyxin-treated patients identified as 'risk', 'injury' and 'failure' were 17% (95% CI: 14-20%), 13% (95% CI: 11-15%), and 10% (95% CI: 9-11%), respectively. Besides, the pooled incidence of colistin-induced nephrotoxicity was about 48% (95% CI: 42-54%), whereas that of polymyxin B was 38% (95% CI: 32-44%). Likewise, colistin had 37% increased risk of developing nephrotoxicity compared to the polymyxin B treated cohorts (RR = 1.37, 95% CI: 1.13-1.67; I2 = 57%). Older age (AOR = 1.03, 95% CI: 1.01-1.05), daily dose (AOR = 1.46, 95% CI: 1.09-1.96), underlying diabetes mellitus (AOR = 1.81, 95% CI: 1.25-2.63), and concomitant nephrotoxic drugs (AOR = 2.31, 95% CI: 1.79-3.00) were independent risk factors for polymyxin-induced nephrotoxicity. Patients with high serum albumin level were less likely (AOR = 0.69, 95% CI: 0.56-0.85] to experience nephrotoxicity compared to those with low albumin level. Despite the resurgence of these antibiotics for the chemotherapy of MDR/XDR-Gram-negative superbugs, the high incidence of nephrotoxicity has become a contemporary clinical concern. Being elderly, high daily dose, having underlying diseases such as diabetes, and use of concomitant nephrotoxic drugs were independent predictors of nephrotoxicity. Therefore, therapeutic drug monitoring should be done to these patients to outweigh the potential benefits of polymyxin therapy from its risk.
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Affiliation(s)
- Mekonnen Sisay
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Bisrat Hagos
- Department of Social Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Dumessa Edessa
- Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Yohannes Tadiwos
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Abraham Nigussie Mekuria
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
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Lin YW, Aye SM, Rao G, Zhou QT, Chan HK, Li J. Treatment of infections caused by Gram-negative pathogens: current status on the pharmacokinetics/pharmacodynamics of parenteral and inhaled polymyxins in patients. Int J Antimicrob Agents 2020; 56:106199. [PMID: 33075510 PMCID: PMC7723449 DOI: 10.1016/j.ijantimicag.2020.106199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/05/2020] [Accepted: 10/11/2020] [Indexed: 01/12/2023]
Abstract
Polymyxins are increasingly used as a last resort for the treatment of infections caused by multidrug-resistant Gram-negative bacteria in patients. Over the last decade, significant progress has been made in understanding the pharmacokinetics/pharmacodynamics/toxicodynamics (PK/PD/TD) of parenteral and inhaled polymyxins. This mini-review provides an overview of polymyxin chemistry, different dose definitions, and the latest research on their clinical use, toxicities, and PK/PD after intravenous and inhalation administration. Optimising the PK/PD/TD of polymyxins in patients is critical to maximise their efficacy while minimising toxicities and the emergence of resistance.
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Affiliation(s)
- Yu-Wei Lin
- Monash Biomedicine Discovery Institute, Infection and Immunity Program and Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
| | - Su Mon Aye
- Monash Biomedicine Discovery Institute, Infection and Immunity Program and Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
| | - Gauri Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, The University of North Carolina, Chapel Hill, NC 27599, USA
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, Purdue University, West Lafayette, IN 1047907, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, The University of Sydney, Faculty of Medicine and Health, Sydney, NSW 2006, Australia
| | - Jian Li
- Monash Biomedicine Discovery Institute, Infection and Immunity Program and Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia.
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Yang Q, Pogue JM, Li Z, Nation RL, Kaye KS, Li J. Agents of Last Resort: An Update on Polymyxin Resistance. Infect Dis Clin North Am 2020; 34:723-750. [PMID: 33011049 DOI: 10.1016/j.idc.2020.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Polymyxin resistance is a major public health threat, because the polymyxins represent last-line therapeutics for gram-negative pathogens resistant to essentially all other antibiotics. Minimizing any potential emergence and dissemination of polymyxin resistance relies on an improved understanding of mechanisms of and risk factors for polymyxin resistance, infection prevention and stewardship strategies, together with optimization of dosing of polymyxins (eg, combination regimens).
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Affiliation(s)
- Qiwen Yang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.9 Dongdan Santiao, Dongcheng District, Beijing, China.
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, USA
| | - Zekun Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No.9 Dongdan Santiao, Dongcheng District, Beijing, China
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria 3052, Australia
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Jian Li
- Laboratory of Antimicrobial Systems Pharmacology, Department of Microbiology, Monash University, Victoria 3800, Australia
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Tsuji BT, Pogue JM, Zavascki AP, Paul M, Daikos GL, Forrest A, Giacobbe DR, Viscoli C, Giamarellou H, Karaiskos I, Kaye D, Mouton JW, Tam VH, Thamlikitkul V, Wunderink RG, Li J, Nation RL, Kaye KS. International Consensus Guidelines for the Optimal Use of the Polymyxins: Endorsed by the American College of Clinical Pharmacy (ACCP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), International Society for Anti-infective Pharmacology (ISAP), Society of Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). Pharmacotherapy 2020; 39:10-39. [PMID: 30710469 DOI: 10.1002/phar.2209] [Citation(s) in RCA: 522] [Impact Index Per Article: 130.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The polymyxin antibiotics colistin (polymyxin E) and polymyxin B became available in the 1950s and thus did not undergo contemporary drug development procedures. Their clinical use has recently resurged, assuming an important role as salvage therapy for otherwise untreatable gram-negative infections. Since their reintroduction into the clinic, significant confusion remains due to the existence of several different conventions used to describe doses of the polymyxins, differences in their formulations, outdated product information, and uncertainties about susceptibility testing that has led to lack of clarity on how to optimally utilize and dose colistin and polymyxin B. We report consensus therapeutic guidelines for agent selection and dosing of the polymyxin antibiotics for optimal use in adult patients, as endorsed by the American College of Clinical Pharmacy (ACCP), Infectious Diseases Society of America (IDSA), International Society of Anti-Infective Pharmacology (ISAP), Society for Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) endorses this document as a consensus statement. The overall conclusions in the document are endorsed by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). We established a diverse international expert panel to make therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, polymyxin agent selection, dosing, dosage adjustment and monitoring of colistin and polymyxin B, use of polymyxin-based combination therapy, intrathecal therapy, inhalation therapy, toxicity, and prevention of renal failure. The treatment guidelines provide the first ever consensus recommendations for colistin and polymyxin B therapy that are intended to guide optimal clinical use.
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Affiliation(s)
- Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | | | - Alexandre P Zavascki
- Department of Internal Medicine, Medical School, Universidade Federal, do Rio Grande do Sul, Porto Alegre, Brazil.,Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - George L Daikos
- First Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alan Forrest
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniele R Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Helen Giamarellou
- 1st Department of Internal Medicine, Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Ilias Karaiskos
- 1st Department of Internal Medicine, Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Donald Kaye
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Vincent H Tam
- University of Houston College of Pharmacy, Houston, Texas
| | - Visanu Thamlikitkul
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jian Li
- Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan
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Chien HT, Lin YC, Sheu CC, Hsieh KP, Chang JS. Is colistin-associated acute kidney injury clinically important in adults? A systematic review and meta-analysis. Int J Antimicrob Agents 2020; 55:105889. [PMID: 31923573 DOI: 10.1016/j.ijantimicag.2020.105889] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/17/2019] [Accepted: 12/28/2019] [Indexed: 12/18/2022]
Abstract
Colistin is the last-resort antimicrobial agent against infections caused by multidrug-resistance Gram-negative bacteria (MDR-GNB). However, a differing risk of colistin-associated acute kidney injury (CA-AKI) has been demonstrated without affecting mortality, thus the association and its importance needs to be questioned. To assess the impact of this adverse effect, a meta-analysis comparing colistin with other antibiotics in treating MDR-GNB infections was conducted. The PubMed, Embase and Cochrane Library electronic databases were searched up to 31 December 2018 for cohort studies and randomised controlled trials with at least two arms with one arm containing colistin-based treatment. The primary endpoint was the incidence of AKI. The secondary endpoint was 30-day all-cause mortality. A total of 34 studies, including 26 regarding colistin-based therapy versus other antibiotics and 9 regarding colistin monotherapy versus combination therapy, were included. The incidence of CA-AKI was 32.3%. Colistin was associated with an 82% higher incidence of AKI than other antibiotics [odd ratio (OR) = 1.82, 95% confidence interval (CI) 1.13-2.92; P = 0.01]. Most CA-AKI events were mild and reversible without a higher rate of mortality or the requirement for renal replacement therapy (RRT). Only 1.0% of patients required RRT for > 4 weeks. Compared with colistin monotherapy, combination therapy was associated with a significantly lower incidence of AKI (OR = 1.46, 95% CI 1.10-1.94; P = 0.009), particularly in combination with a carbapenem (OR = 1.97, 95% CI 1.30-2.99; P = 0.001). In conclusion, CA-AKI might not be an important limitation of colistin in MDR-GNB therapy.
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Affiliation(s)
- Hsiu-Ting Chien
- Master Program of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pharmacy, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ying-Chi Lin
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; PhD Program in Toxicology, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chau-Chyun Sheu
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Kun-Pin Hsieh
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jung-San Chang
- Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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26
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Paul M, Zusman O, Leibovici L. Meta-analysis of Polymyxin Use in Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:143-153. [PMID: 31364077 DOI: 10.1007/978-3-030-16373-0_11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
In this chapter, we systematically reviewed studies that assessed polymyxin's effectiveness and summarized results through meta-analysis. The outcomes addressed were all-cause mortality, assuming that for patients with severe multidrug-resistant infections survival is the most important outcome, and resistance development, important for future patients. Most clinical data on polymyxins in the literature are from retrospective, observational studies at high risk of bias. The majority of clinical studies were unpowered to examine mortality controlling for other risk factors. The studies had no control of dosage regimens and treatment modifications. We identified several areas of missing data, in particular randomized controlled trials (RCTs) examining treatment options for carbapenem-resistant Gram-negative bacteria, different dosage regimens, polymyxins versus alternative antibiotics (e.g. aminoglycosides, tigecycline), and monotherapy versus specific combination therapies. Ideally, mortality and development of resistance should be examined in RCTs, with further longitudinal studies required for the latter.
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Affiliation(s)
- Mical Paul
- Division of Infectious Diseases, Rambam Health Care Center and The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
| | - Oren Zusman
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva and Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Leonard Leibovici
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva and Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
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27
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Polymyxin Acute Kidney Injury: Dosing and Other Strategies to Reduce Toxicity. Antibiotics (Basel) 2019; 8:antibiotics8010024. [PMID: 30875778 PMCID: PMC6466603 DOI: 10.3390/antibiotics8010024] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 12/20/2022] Open
Abstract
Polymyxins are valuable antimicrobials for the management of multidrug-resistant Gram-negative bacteria; however, nephrotoxicity associated with these drugs is a very common side effect that occurs during treatment. This article briefly reviews nephrotoxic mechanisms and risk factors for polymyxin-associated acute kidney injury (AKI) and discusses dosing strategies that may mitigate kidney damage without compromising antimicrobial activity. Polymyxins have a very narrow therapeutic window and patients requiring treatment with these drugs are frequently severely ill and have multiple comorbidities, which increases the risk of AKI. Notably, there is a significant overlap between therapeutic and toxic plasma polymyxin concentrations that substantially complicates dose selection. Recent dosing protocols for both colistin and polymyxin B have been developed and may help fine tune dose adjustment of these antibiotics. Minimizing exposure to modifiable risk factors, such as other nephrotoxic agents, is strongly recommended. The dose should be carefully selected, particularly in high-risk patients. The administration of oxidative stress-reducing drugs is a promising strategy to ameliorate polymyxin-associated AKI, but still requires support from clinical studies.
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Rigatto MH, Falci DR, Zavascki AP. Clinical Use of Polymyxin B. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:197-218. [PMID: 31364080 DOI: 10.1007/978-3-030-16373-0_14] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Polymyxin B is another clinically available polymyxin that has re-emerged in clinical practice to treat infections caused by multi-drug (MDR) or extensively-drug-resistant (XDR) Gram-negative bacteria (GNB). Its chemical structure is very similar to the structure of polymyxin E (colistin). However, since the latter is administered as a prodrug, there are major pharmacokinetic differences between both polymyxins that may potentially determine different clinical and microbiological outcomes. Studies addressing clinical or microbiological outcomes in patients treated with polymyxin B for MDR or XDR GNB are reviewed in this chapter.
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Affiliation(s)
- Maria Helena Rigatto
- Infectious Diseases Service, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
- Medical School, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Diego R Falci
- Post-Graduate Program in Health and Human Development, Universidade La Salle, Canoas, Brazil
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Alexandre P Zavascki
- Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Pharmacokinetics of Polymyxins in Animals. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:89-103. [DOI: 10.1007/978-3-030-16373-0_7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nation RL, Forrest A. Clinical Pharmacokinetics, Pharmacodynamics and Toxicodynamics of Polymyxins: Implications for Therapeutic Use. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:219-249. [PMID: 31364081 DOI: 10.1007/978-3-030-16373-0_15] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The availability of sensitive, accurate and specific analytical methods for the measurement of polymyxins in biological fluids has enabled an understanding of the pharmacokinetics of these important antibiotics in healthy humans and patients. Colistin is administered as its inactive prodrug colistin methanesulfonate (CMS) and has especially complex pharmacokinetics. CMS undergoes conversion in vivo to the active entity colistin, but the rate of conversion varies from brand to brand and possibly from batch to batch. The extent of conversion is generally quite low and depends on the relative magnitudes of the conversion clearance and other clearance pathways for CMS of which renal excretion is a major component. Formed colistin in the systemic circulation undergoes very extensive tubular reabsorption; the same mechanism operates for polymyxin B which is administered in its active form. The extensive renal tubular reabsorption undoubtedly contributes to the propensity for the polymyxins to cause nephrotoxicity. While there are some aspects of pharmacokinetic behaviour that are similar between the two clinically used polymyxins, there are also substantial differences. In this chapter, the pharmacokinetics of colistin, administered as CMS, and polymyxin B are reviewed, and the therapeutic implications are discussed.
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Affiliation(s)
- Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Alan Forrest
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Thomas R, Velaphi S, Ellis S, Walker AS, Standing JF, Heath P, Sharland M, Dona' D. The use of polymyxins to treat carbapenem resistant infections in neonates and children. Expert Opin Pharmacother 2018; 20:415-422. [PMID: 30576264 DOI: 10.1080/14656566.2018.1559817] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The incidence of healthcare-associated multidrug resistant bacterial infections, particularly due to carbapenem resistant organisms, has been on the rise globally. Among these are the carbapenem resistant Acinetobacter baumannii and Enterobacteriaceae, which have been responsible for numerous outbreaks in neonatal units. The polymyxins (colistin and polymyxin B) are considered to be the last resort antibiotics for treating such infections. However, pharmacokinetic and pharmacodynamic data on the use of polymyxins in neonates and children are very limited, and there are safety concerns. AREAS COVERED In this review, the authors summarize the global burden of multidrug resistance, particularly carbapenem resistance, in the neonatal and paediatric population, and the potential wider use of polymyxins in treating these infections. EXPERT OPINION Both colistin and polymyxin B have similar efficacy in treating multidrug resistant infections but have safety concerns. However, polymyxin B appears to be a better therapeutic option, with more rapid and higher steady state concentrations achieved compared to colistin and less reported nephrotoxicity. There is virtually no data in neonates and children currently; there is therefore an urgent need for pharmacokinetic and safety trials in these populations to determine the optimal drug and dosing regimens and provide recommendations for their use against carbapenem resistant infections.
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Affiliation(s)
- Reenu Thomas
- a Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Sithembiso Velaphi
- a Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - Sally Ellis
- b Global Antibiotic Research and Development Partnership (GARDP) , Drugs for Neglected Diseases initiative , Geneva , Switzerland
| | - A Sarah Walker
- c MRC Clinical Trials Unit at University College London , University College London , London , UK
| | - Joseph F Standing
- d Great Ormond Street Institute of Child Health , University College London , London , UK
| | - Paul Heath
- e Paediatric Infectious Disease Research Group, Institute for Infection and Immunity , St George's University of London , London , UK
| | - Mike Sharland
- e Paediatric Infectious Disease Research Group, Institute for Infection and Immunity , St George's University of London , London , UK
| | - Daniele Dona'
- e Paediatric Infectious Disease Research Group, Institute for Infection and Immunity , St George's University of London , London , UK
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Quintanilha JCF, Duarte NDC, Lloret GR, Visacri MB, Mattos KPH, Dragosavac D, Falcão ALE, Moriel P. Colistin and polymyxin B for treatment of nosocomial infections in intensive care unit patients: pharmacoeconomic analysis. Int J Clin Pharm 2018; 41:74-80. [PMID: 30552622 DOI: 10.1007/s11096-018-0766-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
Abstract
Background The emergence and rapid spread of multidrug-resistant gram-negative bacteria related to nosocomial infections is a growing worldwide problem, and polymyxins have become important due to the lack of new antibiotics. Objectives To evaluate the outcomes and pharmacoeconomic impact of using colistin and polymyxin B to treat nosocomial infections. Setting Neurosurgical, cardiovascular, or transplantation intensive care unit (ICU) at the Clinical Hospital of the University of Campinas (São Paulo, Brazil). Method A retrospective cohort study was conduct in patients in the ICU. The renal function was determined daily during treatment by measuring the serum creatinine. A cost minimization analysis was performed to compare the relative costs of treatment with colistin and polymyxin B. Main outcomes measure The outcomes were 30-day mortality and frequency and onset of nephrotoxicity after beginning treatment. Results Fifty-one patients treated with colistin and 51 with polymyxin B were included. 30-day mortality was observed in 25.49% and 33.33% of patients treated with colistin and polymyxin B, respectively; Nephrotoxicity was observed in 43.14% and 54.90% of patients in colistin and polymyxin B groups, respectively; and onset time of nephrotoxicity was 9.86 ± 13.22 days for colistin and 10.68 ± 9.93 days for polymyxin B group. Colistin treatment had a lower cost per patient compared to the cost for polymyxin B treatment (USD $13,389.37 vs. USD $13,639.16, respectively). Conclusion We found no difference between 30-day mortality and nephrotoxicity between groups; however, colistin proved to be the best option from a pharmacoeconomic point of view.
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Affiliation(s)
- Júlia Coelho França Quintanilha
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Natalia da Costa Duarte
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Gustavo Rafaini Lloret
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Marília Berlofa Visacri
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Karen Prado Herzer Mattos
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Desanka Dragosavac
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Antonio Luis Eiras Falcão
- School of Medical Sciences, University of Campinas (UNICAMP), Tessália Vieira de Camargo 126, 13083-887, Campinas, SP, Brazil
| | - Patricia Moriel
- Faculty of Pharmaceutical Sciences, University of Campinas (UNICAMP), Cândido Portinari 200, 13083-871, Campinas, SP, Brazil.
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Jangra M, Randhawa HK, Kaur M, Srivastava A, Maurya N, Patil PP, Jaswal P, Arora A, Patil PB, Raje M, Nandanwar H. Purification, Characterization and in vitro Evaluation of Polymyxin A From Paenibacillus dendritiformis: An Underexplored Member of the Polymyxin Family. Front Microbiol 2018; 9:2864. [PMID: 30532748 PMCID: PMC6265310 DOI: 10.3389/fmicb.2018.02864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/07/2018] [Indexed: 11/13/2022] Open
Abstract
Nosocomial infections caused by antibiotic-resistant Gram-negative pathogens are of grave concern today. Polymyxins are considered as the last resorts of therapy to treat these multi-drug resistant (MDR) bacteria. But their associated nephrotoxicity and neurotoxicity calls for the development of safer polymyxin therapy until novel and less toxic antibiotics are discovered. No other polymyxin molecule except polymyxin B and E (colistin) is explored thoroughly in literature to demonstrate its clinical relevance. In the present study, we have isolated two antimicrobial compounds named P1 and P2 from the soil isolate Paenibacillus dendritiformis strain PV3-16, which we later identified as polymyxin A2 and A1 respectively. We tested their minimum inhibitory concentrations (MICs) against MDR clinical isolates, performed membrane permeabilization assays and determined their interaction with lipopolysaccharide (LPS). Finally, we studied their toxicity against human Leukemic monocyte cell line (THP-1) and embryonic kidney cell line (HEK 293). Both compounds displayed equal efficacy when compared with standard polymyxins. P1 was 2-4 fold more active in most of the clinical strains tested. Moreover, P1 showed higher affinity toward LPS. In cytotoxicity studies, P1 had IC50 value (>1000 μg/ml) similar to colistin against HEK cells but immune cells, i.e., THP-1 cell lines were more sensitive to polymyxins. P1 showed less toxicity in THP-1 cell line than all other polymyxins checked. To sum up, P1 (polymyxin A2) possessed better efficacy than polymyxin B and E and had least toxicity to immune cells. Since polymyxin A was not investigated thoroughly, we performed the comprehensive in vitro assessment of this molecule. Moreover, this is the first report of isolation and characterization of polymyxin A from P. dendritiformis. This compound should be further investigated for its in vivo efficacy and toxicity to develop it as a drug candidate.
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Affiliation(s)
- Manoj Jangra
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Harmandeep Kaur Randhawa
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Manpreet Kaur
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Anugya Srivastava
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Navdezda Maurya
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Prashant P Patil
- Bacterial Genetics and Genomics Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Pallavi Jaswal
- Cell Biology and Microscopy Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Ashish Arora
- Molecular and Structural Biology Division, CSIR-Central Drug Research Institute, Lucknow, India
| | - Prabhu B Patil
- Bacterial Genetics and Genomics Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Manoj Raje
- Cell Biology and Microscopy Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Hemraj Nandanwar
- Clinical Microbiology and Bioactive Screening Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
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Oliota AF, Penteado ST, Tonin FS, Fernandez-Llimos F, Sanches AC. Nephrotoxicity prevalence in patients treated with polymyxins: a systematic review with meta-analysis of observational studies. Diagn Microbiol Infect Dis 2018; 94:41-49. [PMID: 30635223 DOI: 10.1016/j.diagmicrobio.2018.11.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/06/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
Colistin and polymyxin B are increasingly reintroduced in clinical practice due to the absence of effective antibiotics for the treatment of emerging infections caused by gram-negative bacteria. The synthesis of current evidence on the characteristics of polymyxins, especially regarding nephrotoxicity, is necessary. This study aims to conduct a systematic review and meta-analysis of cohort-type observational studies in order to identify the prevalence of nephrotoxicity in patients treated with either colistin or polymyxin B. PubMed, Scopus, and DOAJ electronic databases were searched, and manual searches were done. Cohort studies evaluating renal damage (nephrotoxicity) in adult patients caused by colistin or polymyxin B were included. Meta-analyses of the prevalence of nephrotoxicity as well as cumulative meta-analysis and meta-regression were conducted. After the systematic searches, 95 cohorts (n = 7911 patients) were included for analysis. The nephrotoxicity prevalence was 26.7% [confidence interval (CI) 95%: 22.8-30.9%] for colistin and 29.8% (CI 23.8-36.7%) for polymyxin B (P = 0.720). The publication year of the studies, the criteria used to classify renal damage, and the nephrotoxicity as primary or secondary outcome showed a significant influence on the adverse event rates.
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Affiliation(s)
- Ana F Oliota
- Center for Medical and Pharmaceutical Sciences, Universidade Estadual do Oeste do Paraná, Cascavel, Brazil
| | - Suelem T Penteado
- Center for Medical and Pharmaceutical Sciences, Universidade Estadual do Oeste do Paraná, Cascavel, Brazil
| | - Fernanda S Tonin
- Postgraduate Program in Pharmaceutical Sciences, Universidade Federal do Paraná, Curitiba, Brazil
| | - Fernando Fernandez-Llimos
- Research Institute for Medicines (iMed.ULisboa), Departament of Social Pharmacy, Faculty of Pharmacy, Universidade de Lisboa, Lisboa, Portugal
| | - Andreia C Sanches
- Center for Medical and Pharmaceutical Sciences, Universidade Estadual do Oeste do Paraná, Cascavel, Brazil.
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Peyko V, Cohen H. A Comparison of Adjusted Versus Unadjusted Doses of Polymyxin B Based on Renal Function and Incidence of Acute Kidney Injury. J Pharm Pract 2018; 33:255-261. [DOI: 10.1177/0897190018798881] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To determine whether or not polymyxin B needs dose adjustments based on renal function by comparing the incidence of acute kidney injury (AKI) in patients whose polymyxin B doses were adjusted versus not adjusted according to renal function. Methods: This was a single-center, prospective study with a retrospective cohort taking place in an acute care community hospital. Forty-two patients treated with polymyxin B were evaluated between April 2012 and December 2015. The primary outcome was incidence of AKI at day 7 after initiation of polymyxin B therapy with secondary outcomes including microbiological cure, clinical cure, and 30-day mortality. Results: There was no difference in the incidence of AKI at day 7 in patients with polymyxin B doses adjusted according to renal function versus patients without polymyxin B dose adjustment (20.0% vs 18.2%; P = .882). There were no differences between groups in occurrence of microbiological cure, clinical cure, or 30-day mortality (27.8% vs 57.1%; P = .065, 70.0% vs 72.7%; P = .845, 40.0% vs 31.8%; P = .581, respectively). Conclusion: The results from this study support the use of polymyxin B without any dose adjustment in the setting of renal impairment.
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Affiliation(s)
- Vincent Peyko
- Department of Pharmacy, Mercy Health St. Elizabeth's Hospital Boardman, OH, USA
| | - Henry Cohen
- Kingsbrook Jewish Medical Center, Brooklyn, NY, USA
- Touro College of Pharmacy, New York, NY, USA
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Personalizing Polymyxin B Dosing Using an Adaptive Feedback Control Algorithm. Antimicrob Agents Chemother 2018; 62:AAC.00483-18. [PMID: 29760144 PMCID: PMC6021635 DOI: 10.1128/aac.00483-18] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 04/12/2018] [Indexed: 01/11/2023] Open
Abstract
Polymyxin B is used as an antibiotic of last resort for patients with multidrug-resistant Gram-negative bacterial infections; however, it carries a significant risk of nephrotoxicity. Herein we present a polymyxin B therapeutic window based on target area under the concentration-time curve (AUC) values and an adaptive feedback control algorithm (algorithm) which allows for the personalization of polymyxin B dosing. The upper bound of this therapeutic window was determined through a pharmacometric meta-analysis of polymyxin B nephrotoxicity data, and the lower bound was derived from murine thigh infection pharmacokinetic (PK)/pharmacodynamic (PD) studies. A previously developed polymyxin B population pharmacokinetic model was used as the backbone for the algorithm. Monte Carlo simulations (MCS) were performed to evaluate the performance of the algorithm using different sparse PK sampling strategies. The results of the nephrotoxicity meta-analysis showed that nephrotoxicity rate was significantly correlated with polymyxin B exposure. Based on this analysis and previously reported murine PK/PD studies, the target AUC0–24 (AUC from 0 to 24 h) window was determined to be 50 to 100 mg · h/liter. MCS showed that with standard polymyxin B dosing without adaptive feedback control, only 71% of simulated subjects achieved AUC values within this window. Using a single PK sample collected at 24 h and the algorithm, personalized dosing regimens could be computed, which resulted in >95% of simulated subjects achieving AUC0–24 values within the target window. Target attainment further increased when more samples were used. Our algorithm increases the probability of target attainment by using as few as one pharmacokinetic sample and enables precise, personalized dosing in a vulnerable patient population.
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Aggarwal R, Dewan A. Comparison of nephrotoxicity of Colistin with Polymyxin B administered in currently recommended doses: a prospective study. Ann Clin Microbiol Antimicrob 2018; 17:15. [PMID: 29571295 PMCID: PMC5865377 DOI: 10.1186/s12941-018-0262-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 03/08/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The most important concern with polymyxins (Colistin and Polymyxin B) use is nephrotoxicity. There is no prospective data comparing nephrotoxicity of these two drugs, when administered in high doses and as per current recommendations. We conducted a prospective study to compare their trend of nephrotoxicity in our patient population. METHODS Our study included adult ICU patients who received more than 48 h of Colistin or Polymyxin B and had no confounding factors for nephrotoxicity. Loading and maintenance doses were given as per a uniform protocol. Nephrotoxicity was defined as twofold increase in serum creatinine, or 50% decrease in estimated baseline creatinine clearance. Patients were followed up for 1 week after therapy. Statistical analysis was performed using SPSS version 20.0. RESULTS 61 patients were included in Colistin group, and 51 patients in Polymyxin B group. Median Colistin dose was 233.3 (IQR 150-300) mg/day and median Polymyxin B dose was 200 (IQR 180-240) mg/day. Median duration of Colistin and Polymyxin B use was 7 (IQR 5-7) days and 7 (IQR 7-9) days respectively. Nephrotoxicity developed in 39.3% patients in Colistin group compared to 11.8% patients in Polymyxin B group. Mean onset of nephrotoxicity was 3.8 ± 0.8 days with Colistin, and 4.2 ± 0.7 days with Polymyxin B therapy. In bivariate analysis, Colistin daily dose ≥ 300 mg was found to be associated with nephrotoxicity. There was no effect of age or BMI on Colistin toxicity. Mean duration of renal failure was 4.9 ± 3.1 days with Colistin use, and 5.0 ± 2.4 days with Polymyxin B use. 75% patients in Colistin group and 83.3% patients in Polymyxin B group who developed nephrotoxicity recovered their renal function by 1 week. CONCLUSIONS Colistin in currently recommended doses is significantly more nephrotoxic than Polymyxin B. Colistin toxicity is dose-dependent, mostly mild to moderate, and is reversible in most cases.
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Affiliation(s)
- Ritesh Aggarwal
- Department of Critical Care Medicine, Max Smart Super Speciality Hospital, Saket, New Delhi, India.
| | - Arun Dewan
- Department of Internal Medicine & Critical Care Medicine, Max Smart Super Speciality Hospital, Saket, New Delhi, India
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Rabanal F, Cajal Y. Recent advances and perspectives in the design and development of polymyxins. Nat Prod Rep 2017. [PMID: 28628170 DOI: 10.1039/c7np00023e] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Covering: 1947-early 2017, particularly from 2005-early 2017The rise of bacterial pathogens with acquired resistance to almost all available antibiotics is becoming a serious public health issue. Polymyxins, antibiotics that were mostly abandoned a few decades ago because of toxicity concerns, are ultimately considered as a last-line therapy to treat infections caused by multi-drug resistant Gram-negative bacteria. This review surveys the progress in understanding polymyxin structure, and their chemistry, mechanisms of antibacterial activity and nephrotoxicity, biomarkers, synergy and combination with other antimicrobial agents and antibiofilm properties. An update of recent efforts in the design and development of a new generation of polymyxin drugs is also discussed. A novel approach considering the modification of the scaffold of polymyxins to integrate metabolism and detoxification issues into the drug design process is a promising new line to potentially prevent accumulation in the kidneys and reduce nephrotoxicity.
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Affiliation(s)
- Francesc Rabanal
- Organic Chemistry Section, Department of Inorganic and Organic Chemistry, Faculty of Chemistry, University of Barcelona, Spain.
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Pogue J, Ortwine J, Kaye K. Clinical considerations for optimal use of the polymyxins: A focus on agent selection and dosing. Clin Microbiol Infect 2017; 23:229-233. [DOI: 10.1016/j.cmi.2017.02.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/12/2017] [Accepted: 02/18/2017] [Indexed: 10/20/2022]
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Nephrotoxicity in Patients with or without Cystic Fibrosis Treated with Polymyxin B Compared to Colistin. Antimicrob Agents Chemother 2017; 61:AAC.02329-16. [PMID: 28167560 DOI: 10.1128/aac.02329-16] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/24/2017] [Indexed: 12/31/2022] Open
Abstract
Nephrotoxicity is the primary adverse effect of the polymyxins. The relative rates of toxicity of polymyxin B and colistin have not been fully elucidated, especially in patients with cystic fibrosis (CF). A retrospective cohort study of adults treated with polymyxin B or colistin for at least 48 h was conducted. The primary endpoint was the incidence of kidney injury assessed by RIFLE (i.e., risk, injury, failure, loss, end-stage renal disease) criteria. Risk factors for kidney injury were evaluated using multivariate Cox regression. A total of 414 patients were evaluated, 220 of whom had CF. In patients without CF, there was no difference in kidney injury with polymyxin B and colistin (42.9% versus 50.3%, P = 0.46). Loop diuretic exposure was a risk factor for kidney injury (adjusted hazard ratio [aHR], 1.82; 95% confidence interval [CI], 1.16 to 2.83) in this population. In patients with CF, polymyxin B and colistin were associated with similar rates of kidney injury (34.5% versus 29.8%, P = 0.77). Diabetes (aHR, 2.68; 95% CI, 1.01 to 7.11), loop diuretics (aHR, 3.02; 95% CI, 1.36 to 6.73), and progressive care unit admission (aHR, 8.21; 95% CI, 2.55 to 26.46) were risk factors for kidney injury, while higher baseline serum creatinine levels (per 1 mg/dl) were protective (aHR, 0.08; 95% CI, 0.01 to 0.48). Total unadjusted kidney injury in polymyxin-treated patients was less frequent in those who had CF (30.5% versus 48.5%, P < 0.001). Polymyxin B and colistin are associated with a high incidence of kidney injury; cystic fibrosis may be protective against polymyxin nephrotoxicity, but further investigation is needed to confirm this conjecture.
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Cooper TW, Pass SE, Brouse SD, Hall RG. Can Pharmacokinetic and Pharmacodynamic Principles Be Applied to the Treatment of Multidrug-Resistant Acinetobacter? Ann Pharmacother 2017; 45:229-40. [DOI: 10.1345/aph.1p187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE: To discuss treatment options that can be used for treatment of Acinetobacter infections. DATA SOURCES: A MEDLINE search (1966-November 2010) was conducted to identify English-language literature on pharmacotherapy of Acinetobacter and the bibliographies of pertinent articles. Programs and abstracts from infectious diseases meetings were also searched. Search terms included Acinetobacter, multidrug resistance, pharmacokinetics, pharmacodynamics, Monte Carlo simulation, nosocomial pneumonia, carbapenems, polymyxins, sulbactam, aminoglycosides, tetracyclines, tigecycline, rifampin, and fluoroquinolones. DATA SELECTION AND DATA EXTRACTION: All articles were critically evaluated and all pertinent information was included in this review. DATA SYNTHESIS: Multidrug resistant (MDR) Acinetobacter, defined as resistance to 3 or more antimicrobial classes, has increased over the past decade. The incidence of carbapenem-resistant Acinetobacter is also increasing, leading to an increased use of dose optimization techniques and/or alternative antimicrobials, which is driven by local susceptibility patterns. However, Acinetobacter infections that are resistant to all commercially available antibiotics have been reported. General principles are available to guide dose optimization of aminoglycosides, β-lactams, fluoroquinolones, and tigecycline for infections due to gram-negative pathogens. Unfortunately, data specific to patients with Acinetobacter infections are limited. Recent pharmacokinetic-pharmacodynamic information has shed light on colistin dosing. The dilemma with colistin is its concentration-dependent killing, which makes once-daily dosing seem like an attractive option, but its short postantibiotic effect limits a clinician's ability to extend the dosing interval. Localized delivery of antimicrobials is also an attractive option due to the ability to increase drug concentration at the infection site while minimizing systemic adverse events, but more data are needed regarding this approach. CONCLUSIONS: Increased reliance on dosage optimization, combination therapy, and localized delivery of antimicrobials are methods to pursue positive clinical outcomes in MDR Acinetobacter infections since novel antimicrobials will not be available for several years. Well-designed clinical trials with MDR Acinetobacter are needed to define the best treatment options for these patients.
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Nephrotoxicity of Polymyxins: Is There Any Difference between Colistimethate and Polymyxin B? Antimicrob Agents Chemother 2017; 61:AAC.02319-16. [PMID: 27993859 DOI: 10.1128/aac.02319-16] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Nephrotoxicity is a common adverse effect of the clinically used polymyxins, colistin and polymyxin B. This adverse effect is dose limiting for both polymyxins, as the plasma polymyxin concentrations associated with renal damage overlap those required for antibacterial effect. Since development of acute kidney injury (AKI) during therapy is highly undesirable, it is extremely important to know whether there is any difference between the nephrotoxic potential of colistin (administered as its inefficient prodrug, colistimethate) and polymyxin B (administered as the active form). Both polymyxins are cytotoxic to renal tubular cells and are prone to cause nephrotoxicity in vivo because of the renal handling mechanisms that facilitate accumulation of these compounds in these cells, processes that are reviewed in this article. Also reviewed are the emerging data that strongly suggest significantly higher rates of AKI in patients treated with colistimethate compared to patients treated with polymyxin B. This finding may be due to differences in pharmacokinetics and renal handling mechanisms of colistimethate and formed colistin versus polymyxin B, and consequently the relative amount of polymyxin material delivered to tubular cells. A lower risk of AKI with polymyxin B is one of several potential advantages over colistimethate. The relative safety and efficacy of the two agents require closer examination in well-designed clinical studies.
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Vardakas KZ, Falagas ME. Colistin versus polymyxin B for the treatment of patients with multidrug-resistant Gram-negative infections: a systematic review and meta-analysis. Int J Antimicrob Agents 2017; 49:233-238. [DOI: 10.1016/j.ijantimicag.2016.07.023] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/15/2016] [Accepted: 07/30/2016] [Indexed: 11/15/2022]
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Satlin MJ, Jenkins SG. Polymyxins. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00151-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Pogue JM, Ortwine JK, Kaye KS. Are there any ways around the exposure-limiting nephrotoxicity of the polymyxins? Int J Antimicrob Agents 2016; 48:622-626. [DOI: 10.1016/j.ijantimicag.2016.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
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Neves FC, Clemente WT, Lincopan N, Paião ID, Neves PR, Romanelli RM, Lima SSS, Paiva LF, Mourão PHO, Nobre-Junior VA. Clinical and microbiological characteristics of OXA-23- and OXA-143-producing Acinetobacter baumannii in ICU patients at a teaching hospital, Brazil. Braz J Infect Dis 2016; 20:556-563. [PMID: 27620658 PMCID: PMC9427641 DOI: 10.1016/j.bjid.2016.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/14/2016] [Accepted: 08/02/2016] [Indexed: 02/06/2023] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii (CRAb) is an important cause of nosocomial infections especially in intensive care units. This study aimed to assess clinical aspects and the genetic background of CRAb among ICU patients at a Brazilian teaching hospital. Methods 56 critically ill patients colonized or infected by CRAb, during ICU stay, were prospectively assessed. Based on imipenem MIC ≥ 4 μg/mL, 28 CRAB strains were screened for the presence of genes encoding metallo-β-lactamases and OXA-type β-lactamases. The blaOXA-type genes were characterized by PCR using primers targeting ISAba-1 or -3. Genetic diversity of blaOXA-positive strains was determined by ERIC-PCR analysis. Results Patient's mean age (±SD) was 61 (±15.1), and 58.9% were male. Eighty-percent of the patients presented risk factors for CRAb colonization, mainly invasive devices (87.5%) and previous antibiotic therapy (77.6%). Thirty-three patients died during hospital stay (59.0%). Resistance to carbapenems was associated with a high prevalence of blaOXA-23 (51.2%) and/or blaOXA-143 (18.6%) genes. ERIC-PCR genotyping identified 10 clusters among OXA-producing CRAb. Three CRAb strains exhibited additional resistance to polymyxin B (MIC ≥ 4 μg/mL), whereas 10 CRAb strains showed tigecycline MICs > 2 μg/mL. Conclusions In this study, clonally unrelated OXA-123- and OXA-143-producing A. baumannii strains in ICU patients were strongly correlated to colonization with infected patients being associated with a poor outcome.
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Affiliation(s)
- Francelli Cordeiro Neves
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais, Hospital das Clínicas Comissão de Controle de Infecção Hospitalar, Belo Horizonte, MG, Brazil.
| | - Wanessa T Clemente
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais, Hospital das Clínicas Comissão de Controle de Infecção Hospitalar, Belo Horizonte, MG, Brazil
| | - Nilton Lincopan
- Universidade de São Paulo, Instituto de Ciências Biomédicas, Departamento de Microbiologia, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Farmácia, Departamento de Análises Clínicas, São Paulo, SP, Brazil
| | - Isabela D Paião
- Universidade de São Paulo, Instituto de Ciências Biomédicas, Departamento de Microbiologia, São Paulo, SP, Brazil
| | - Patrícia R Neves
- Universidade de São Paulo, Instituto de Ciências Biomédicas, Departamento de Microbiologia, São Paulo, SP, Brazil
| | - Roberta M Romanelli
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil; Universidade Federal de Minas Gerais, Hospital das Clínicas Comissão de Controle de Infecção Hospitalar, Belo Horizonte, MG, Brazil
| | - Stella S S Lima
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil
| | - Luciene F Paiva
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte, MG, Brazil
| | | | - Vandack A Nobre-Junior
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Medicina Interna, Belo Horizonte, MG, Brazil
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Pharmacokinetics/pharmacodynamics of colistin and polymyxin B: are we there yet? Int J Antimicrob Agents 2016; 48:592-597. [PMID: 27793510 DOI: 10.1016/j.ijantimicag.2016.09.010] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/30/2016] [Accepted: 09/03/2016] [Indexed: 12/17/2022]
Abstract
The polymyxin antibiotics [colistin and polymyxin B (PMB)] are increasingly used as a last-line option for the treatment of infections caused by extensively drug-resistant Gram-negative bacteria. Despite having similar structures and antibacterial activity in vitro, the two clinically available polymyxins have very different pharmacological properties, as colistin (polymyxin E) is intravenously administered to patients in the form of an inactive prodrug colistin methanesulphonate (sodium). This review will discuss recent progress in the pharmacokinetics/pharmacodynamics and toxicity of colistin and PMB, the factors that affect their pharmacological profiles, and the challenges for the effective use of both polymyxins. Strategies are proposed for optimising their clinical utility based upon the recent pharmacological studies in vitro, in animals and patients. In the 'Bad Bugs, No Drugs' era, polymyxins are a critically important component of the antibiotic armamentarium against difficult-to-treat Gram-negative 'superbugs'. Rational approaches to the use of polymyxins must be pursued to increase their effectiveness and to minimise resistance and toxicity.
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Multicenter Prospective Cohort Study of Renal Failure in Patients Treated with Colistin versus Polymyxin B. Antimicrob Agents Chemother 2016; 60:2443-9. [PMID: 26856846 DOI: 10.1128/aac.02634-15] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/04/2016] [Indexed: 11/20/2022] Open
Abstract
Nephrotoxicity is the main adverse effect of colistin and polymyxin B (PMB). It is not clear whether these two antibiotics are associated with different nephrotoxicity rates. We compared the incidences of renal failure (RF) in patients treated with colistimethate sodium (CMS) or PMB for ≥48 h. A multicenter prospective cohort study was performed that included patients aged ≥18 years. The primary outcome was renal failure (RF) according to Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE) criteria. Multivariate analysis with a Cox regression model was performed. A total of 491 patients were included: 81 in the CMS group and 410 in the PMB group. The mean daily doses in milligrams per kilogram of body weight were 4.2 ± 1.3 and 2.4 ± 0.73 of colistin base activity and PMB, respectively. The overall incidence of RF was 16.9% (83 patients): 38.3% and 12.7% in the CMS and PMB groups, respectively (P< 0.001). In multivariate analysis, CMS therapy was an independent risk factor for RF (hazard ratio, 3.35; 95% confidence interval, 2.05 to 5.48;P< 0.001) along with intensive care unit admission, higher weight, older age, and bloodstream and intraabdominal infections. CMS was also independently associated with a higher risk of RF in various subgroup analyses. The incidence of RF was higher in the CMS group regardless of the patient baseline creatinine clearance. The development of RF during therapy was not associated with 30-day mortality in multivariate analysis. CMS was associated with significantly higher rates of RF than those of PMB. Further studies are required to confirm our findings in other patient populations.
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