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Kazemian H, Karami‐Zarandi M, Heidari H, Ghanavati R, Khoshnood S. Antimicrobial combination effects against multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa strains: A cross-sectional study. Health Sci Rep 2024; 7:e2061. [PMID: 38690004 PMCID: PMC11058283 DOI: 10.1002/hsr2.2061] [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: 08/11/2023] [Revised: 03/23/2024] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Background and Aims Emergence of multidrug resistance in non-fermenting Gram-negative bacilli is a threat to public health. Combination therapy is a strategy for the treatment of antibiotic-resistant infections. Methods In this cross-sectional study, a total of 63 nonduplicate clinical isolates of Acinetobacter baumannii and Pseudomonas aeruginosa were collected from various specimens. Identification of bacterial isolates was performed by phenotypic and molecular tests. Antibiotic susceptibility patterns and detection of β-lactamase genes were determined using the broth microdilution and polymerase chain reaction (PCR) techniques, respectively. Then, the combined effects analysis was determined by the checkerboard method. Based on the status of resistance to carbapenems (imipenem and meropenem), 25 isolates of each genus were selected for further investigation. Results For A. baumannii, bla OXA-23, bla OXA-58, and bla OXA-48 genes were positive in 21 (84%), 17 (68%), and 11 (44%) of isolates, respectively. In P. aeruginosa isolates, bla VIM was the most common gene (44%) and other genes including bla IMP, bla NDM, and bla OXA-23 were found in nine (36%), six (24%), and three (12%) isolates, respectively. Meropenem (MER)-tigecycline (TIG) had a significant synergistic effect against 20 (80%) A. baumannii (p value < 0.001). This combination was also efficient against 5 (20%) P. aeruginosa isolates. Moreover, the other combination, tigecycline-amikacin (TIG-AMK) was effective against 10 (40%) A. baumannii isolates. The combination of colistin (COL) and MER showed a significant synergistic effect against 21 (84%) A. baumannii (p value < 0.001) and 17 (68%) P. aeruginosa isolates (p value < 0.001). Conclusion The MER-TIG and COL-MER combinations are promising options against resistant bacteria. Our study could be helpful for the development of a new treatment recommendation.
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Affiliation(s)
- Hossein Kazemian
- Clinical Microbiology Research CenterIlam University of Medical SciencesIlamIran
- Department of Microbiology, Faculty of MedicineIlam University of Medical SciencesIlamIran
| | - Morteza Karami‐Zarandi
- Department of Microbiology, Faculty of MedicineZanjan University of Medical SciencesZanjanIran
| | - Hamid Heidari
- Department of Microbiology, Faculty of MedicineShahid Sadoughi University of Medical SciencesYazdIran
| | - Roya Ghanavati
- School of Paramedical SciencesBehbahan Faculty of Medical SciencesBehbahanIran
| | - Saeed Khoshnood
- Clinical Microbiology Research CenterIlam University of Medical SciencesIlamIran
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Heil EL, Claeys KC, Kline EG, Rogers TM, Squires KM, Iovleva A, Doi Y, Banoub M, Noval MM, Luethy PM, Shields RK. Early initiation of three-drug combinations for the treatment of carbapenem-resistant A. baumannii among COVID-19 patients. J Antimicrob Chemother 2023; 78:1034-1040. [PMID: 36869724 PMCID: PMC10319978 DOI: 10.1093/jac/dkad042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES We evaluated the clinical characteristics and outcomes of patients with COVID-19 who received three-drug combination regimens for treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) infections during a single-centre outbreak. Our objective was to describe the clinical outcomes and molecular characteristics and in vitro synergy of antibiotics against CRAB isolates. MATERIALS AND METHODS Patients with severe COVID-19 admitted between April and July 2020 with CRAB infections were retrospectively evaluated. Clinical success was defined as resolution of signs/symptoms of infection without need for additional antibiotics. Representative isolates underwent whole-genome sequencing (WGS) and in vitro synergy of two- or three-drug combinations was assessed by checkerboard and time-kill assays, respectively. RESULTS Eighteen patients with CRAB pneumonia or bacteraemia were included. Treatment regimens included high-dose ampicillin-sulbactam, meropenem, plus polymyxin B (SUL/MEM/PMB; 72%), SUL/PMB plus minocycline (MIN; 17%) or other combinations (12%). Clinical resolution was achieved in 50% of patients and 30-day mortality was 22% (4/18). Seven patients had recurrent infections, during which further antimicrobial resistance to SUL or PMB was not evident. PMB/SUL was the most active two-drug combination by checkerboard. Paired isolates collected before and after treatment with SUL/MEM/PMB did not demonstrate new gene mutations or differences in the activity of two- or three-drug combinations. CONCLUSIONS Use of three-drug regimens for severe CRAB infections among COVID-19 resulted in high rates of clinical response and low mortality relative to previous studies. The emergence of further antibiotic resistance was not detected phenotypically or through WGS analysis. Additional studies are needed to elucidate preferred antibiotic combinations linked to the molecular characteristics of infecting strains.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Science, and Health Outcomes Research, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, USA
| | - Kimberly C Claeys
- Department of Practice, Science, and Health Outcomes Research, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, USA
| | - Ellen G Kline
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tara M Rogers
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin M Squires
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alina Iovleva
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yohei Doi
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mandee M Noval
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Ardebili A, Izanloo A, Rastegar M. Polymyxin combination therapy for multidrug-resistant, extensively-drug resistant, and difficult-to-treat drug-resistant gram-negative infections: is it superior to polymyxin monotherapy? Expert Rev Anti Infect Ther 2023; 21:387-429. [PMID: 36820511 DOI: 10.1080/14787210.2023.2184346] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The increasing prevalence of infections with multidrug-resistant (MDR), extensively-drug resistant (XDR) or difficult-to-treat drug resistant (DTR) Gram-negative bacilli (GNB), including Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter species, and Escherichia coli poses a severe challenge. AREAS COVERED The rapid growing of multi-resistant GNB as well as the considerable deceleration in development of new anti-infective agents have made polymyxins (e.g. polymyxin B and colistin) a mainstay in clinical practices as either monotherapy or combination therapy. However, whether the polymyxin-based combinations lead to better outcomes remains unknown. This review mainly focuses on the effect of polymyxin combination therapy versus monotherapy on treating GNB-related infections. We also provide several factors in designing studies and their impact on optimizing polymyxin combinations. EXPERT OPINION An abundance of recent in vitro and preclinical in vivo data suggest clinical benefit for polymyxin-drug combination therapies, especially colistin plus meropenem and colistin plus rifampicin, with synergistic killing against MDR, XDR, and DTR P. aeruginosa, K. pneumoniae and A. baumannii. The beneficial effects of polymyxin-drug combinations (e.g. colistin or polymyxin B + carbapenem against carbapenem-resistant K. pneumoniae and carbapenem-resistant A. baumannii, polymyxin B + carbapenem + rifampin against carbapenem-resistant K. pneumoniae, and colistin + ceftolozan/tazobactam + rifampin against PDR-P. aeruginosa) have often been shown in clinical setting by retrospective studies. However, high-certainty evidence from large randomized controlled trials is necessary. These clinical trials should incorporate careful attention to patient's sample size, characteristics of patient's groups, PK/PD relationships and dosing, rapid detection of resistance, MIC determinations, and therapeutic drug monitoring.
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Affiliation(s)
- Abdollah Ardebili
- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran.,Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Ahdieh Izanloo
- Department of Biology, Faculty of Sciences, Golestan University, Gorgan, Iran
| | - Mostafa Rastegar
- Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
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Alosaimy S, Morrisette T, Lagnf AM, Rojas LM, King MA, Pullinger BM, Hobbs ALV, Perkins NB, Veve MP, Bouchard J, Gore T, Jones B, Truong J, Andrade J, Huang G, Cosimi R, Kang-Birken SL, Molina KC, Biagi M, Pierce M, Scipione MR, Zhao JJ, Davis SL, Rybak MJ. Clinical Outcomes of Eravacycline in Patients Treated Predominately for Carbapenem-Resistant Acinetobacter baumannii. Microbiol Spectr 2022; 10:e0047922. [PMID: 36190427 PMCID: PMC9602915 DOI: 10.1128/spectrum.00479-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/01/2022] [Indexed: 11/20/2022] Open
Abstract
Forty-six patients were treated with eravacycline (ERV) for Acinetobacter baumannii infections, where 69.5% of isolates were carbapenem resistant (CRAB). Infections were primarily pulmonary (58.3%), and most patients received combination therapy (84.4%). The median (IQR) ERV duration was 6.9 days (5.1 to 11.1). Thirty-day mortality was 23.9% in the cohort and 21.9% in CRAB patients. One patient experienced an ERV-possible adverse event. IMPORTANCE Acinetobacter baumannii, particularly when carbapenem resistant (CRAB), is one of the most challenging pathogens in the health care setting. This is complicated by the fact that there is no consensus guideline regarding management of A. baumannii infections. However, the recent Infectious Diseases Society of America guidelines for treatment of resistant Gram-negative infections provided expert recommendations for CRAB management. The panel suggest using minocycline among tetracycline derivatives rather than eravacycline (ERV) until sufficient clinical data are available. Therefore, we present the largest multicenter real-world cohort in patients treated with ERV for A. baumannii, where the majority of isolates were CRAB (69.5%). Our analysis demonstrate that patients treated with ERV-based regimens achieved a 30-day mortality of 23.9% and had a low incidence of ERV-possible adverse events (2.1%). This study is important as it fills the gap in the literature regarding the use of a novel tetracycline (i.e., ERV) in the treatment of this challenging health care infection.
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Affiliation(s)
- Sara Alosaimy
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Taylor Morrisette
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Abdalhamid M. Lagnf
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | | | - Madeline A. King
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania, USA
- Cooper University Hospital, Camden, New Jersey, USA
| | - Benjamin M. Pullinger
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, Pennsylvania, USA
- Cooper University Hospital, Camden, New Jersey, USA
| | - Athena L. V. Hobbs
- Methodist University Hospital, Memphis, Tennessee, USA
- Cardinal Health, Memphis, Tennessee, USA
| | - Nicholson B. Perkins
- University of Tennessee Health Science Center College of Pharmacy, Memphis, Tennessee, USA
| | - Michael P. Veve
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- University of Tennessee Medical Center, Knoxville, Tennessee, USA
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jeannette Bouchard
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Tristan Gore
- College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
| | - Bruce Jones
- St. Joseph’s/Candler Health System, Savannah, Georgia, USA
| | | | | | - Glen Huang
- University of California Los Angeles, Los Angeles, California, USA
| | - Reese Cosimi
- Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
| | | | - Kyle C. Molina
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Mark Biagi
- SwedishAmerican Hospital, Rockford, Illinois, USA
- University of Illinois at Chicago, Rockford, Illinois, USA
| | | | - Marco R. Scipione
- Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
| | - Jing J. Zhao
- Department of Pharmacy, Harper University Hospital, Detroit Medical Center, Detroit, Michigan, USA
| | - Susan L. Davis
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy, Detroit Receiving Hospital, Detroit Medical Center, Detroit, Michigan, USA
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA
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Simsek C, Karatas M, Tatar E, Yildirim AM, Tasli Alkan F, Uslu A. Kidney Transplantation From Infected Donors With Particular Emphasis on Multidrug-Resistant Organisms: A Single-Center Cohort Study. EXP CLIN TRANSPLANT 2022; 20:61-68. [PMID: 35384809 DOI: 10.6002/ect.mesot2021.o25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Prevention of sepsis-related organ dysfunction in septic donors is crucial. In this study, septic donors were followed-up based on donor Sequential Organ Failure Assessment criteria. MATERIALS AND METHODS Between January 2014 and 2020 at our center, 29 primary kidney transplant recipients received organs from 20 septic donors. All donors received either pathogen-specific or broad-spectrum antibiotics at least 48 hours before procurement, and all recipients received similar treatment posttransplant for an average of 7 to 14 days. Donor eligibility was determined according to the sum of donor-Sequential Organ Failure Assessment scores obtained from 6 parameters: Pao2/Fio2 ratio; platelet count; serum bilirubin, creatinine, and lactate levels; and presence of hypotension. The cut-off value for bacteremic donor acceptance was below 12 points. RESULTS Fever (≥38 °C) persisted in 5 donors in the last 24 hours before organ removal. However, in these 5 donors, the mean donor-Sequential Organ Failure Assessment score was 6.5 ± 1.1, mean arterial pressure was >70 mm Hg, and serum lactate levels were <2 mmol/L. Fifteen donors had systemic inflammatory response syndrome scores of ≤2 with corresponding donor-Sequential Organ Failure Assessment scores of 7.9 ± 1.2; none had systemic inflammatory response syndrome scores >3, which would have indicated severe organ failure. In 28 recipients (97%), no donor-related infections were observed in the perioperative first month and afterwards. CONCLUSIONS Treatment of donors and recipients with a common protocol greatly reduced the risk of donor-induced infection transmission. In addition, we found the donor-Sequential Organ Failure Assessment criteria to be a helpful tool in predicting organ failure in infected donors.
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Affiliation(s)
- Cenk Simsek
- From the Department of General Surgery and Transplantation,University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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A Comparison of Colistin versus Colistin Plus Meropenem for the Treatment of Carbapenem-Resistant Acinetobacter baumannii in Critically Ill Patients: A Propensity Score-Matched Analysis. Antibiotics (Basel) 2020; 9:antibiotics9100647. [PMID: 32998187 PMCID: PMC7599589 DOI: 10.3390/antibiotics9100647] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 11/17/2022] Open
Abstract
Carbapenem-resistant Acinetobacter baumannii (CRAB), an important nosocomial pathogen, occurs particularly in the intensive care unit (ICU). Thus, the aim of this study was to compare the efficacy and safety of documented treatment with colistin monotherapy versus colistin plus meropenem in critically ill patients with CRAB infections at Chiang Mai University Hospital (CMUH). We conducted a retrospective cohort study of critically ill patients with CRAB infections in an ICU from 2015 to 2017, who received colistin monotherapy versus colistin plus meropenem. After propensity score matching, an adjusted odds ratio (aOR) of a 30-day mortality rate in patients who received colistin plus meropenem was 0.43 compared to those who received colistin monotherapy (95% CI, 0.23–0.82, p = 0.01). aORs of clinical response and microbiological response were also higher in patients who received colistin plus meropenem (1.81, 95% CI 1.01–3.26, p = 0.048 and 2.08, 95% CI 1.11–3.91, p = 0.023, respectively). There was no significant difference in nephrotoxicity (aOR, 0.76, 95% CI, 0.43–1.36, p = 0.363) between colistin monotherapy and colistin plus meropenem. In conclusion, the addition of meropenem to colistin caused a reduction in 30-day mortality, higher clinical and microbiological responses, and did not increase nephrotoxicity compared to colistin monotherapy. Furthermore, 30-day mortality was significantly related with age, receiving vasopressor, having malignancy, and the APACHE II score.
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7
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Karakonstantis S. A systematic review of implications, mechanisms, and stability of in vivo emergent resistance to colistin and tigecycline in Acinetobacter baumannii. J Chemother 2020; 33:1-11. [PMID: 32677578 DOI: 10.1080/1120009x.2020.1794393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The potential of A. baumannii for acquired resistance to last resort antibiotics (colistin and tigecycline) during treatment has important clinical implications, especially when dealing with patients failing to improve despite treatment with an active antimicrobial. However, the relevant literature remains scattered. Therefore, a systematic search was conducted in PubMed and Scopus. Several studies reported emergence of resistance to colistin or tigecycline during treatment, in most cases (86%) resulting in persistent or recurrent infections, especially in cases of emergent resistance without fitness cost. Lipopolysaccharide modification in the case of colistin and overexpression of efflux pumps in the case of tigecycline were the main mechanisms of resistance. Emergent colistin resistance is often associated with fitness cost which may result in re-emergence of the fitter and more virulent colistin susceptible strain after cessation of antibiotic pressure. Prospective studies are needed to determine the frequency of emergent resistance during treatment and its impact on patient outcomes.
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Affiliation(s)
- Stamatis Karakonstantis
- Internal Medicine Department, General Hospital of Heraklion Venizeleio, Heraklion, Crete, Greece.,School of medicine, University of Crete, Heraklion, Crete, Greece
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8
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Karakonstantis S, Saridakis I. Colistin heteroresistance in Acinetobacter spp.: systematic review and meta-analysis of the prevalence and discussion of the mechanisms and potential therapeutic implications. Int J Antimicrob Agents 2020; 56:106065. [PMID: 32599229 DOI: 10.1016/j.ijantimicag.2020.106065] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/30/2020] [Accepted: 06/20/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Colistin is one of the few remaining options for carbapenem-resistant Acinetobacter baumannii (A. baumannii); however, emergence of resistance from heteroresistant populations is possible. This review aimed to systematically search and consolidate the literature on the prevalence, mechanisms and therapeutic implications of colistin heteroresistance in Acinetobacter spp. METHODS A systematic search was conducted in PubMed and Scopus. The pooled prevalence of colistin heteroresistance was calculated using meta-analysis of proportions with the Freeman-Tukey transformation and the random-effects (DerSimonian and Laird) method. RESULTS Based on 15 studies the prevalence of colistin heteroresistance was 33% (95% CI 16-53%) but considerable heterogeneity was observed (I2 = 96%, P < 0.001). Prior exposure to colistin was associated with a higher proportion of resistant subpopulations. Colistin heteroresistance may result from chromosomal mutations in resistant subpopulations (predominantly in PmrAB and lpx genes) resulting in lipopolysaccharide modification or loss, or overexpression of efflux pumps. No dosage scheme of colistin monotherapy can prevent the emergence of resistant subpopulations in vitro, but few studies have reported in vivo emergence of resistance from heteroresistant A. baumannii during treatment, and studies examining the correlation between heteroresistance and clinical/microbiological outcomes are lacking. Several colistin-based combinations have been shown in vitro to prevent the emergence of the resistant subpopulations but none have been translated so far into clinical benefit. Reasons for this discrepancy are discussed. CONCLUSIONS Colistin heteroresistance was common but highly variable between studies. The impact of colistin heteroresistance (frequency of emergent resistance during treatment and correlation with treatment outcomes) requires further study.
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Affiliation(s)
- Stamatis Karakonstantis
- School of Medicine, University of Crete, Heraklion, Crete, Greece; Internal Medicine Department, General Hospital of Heraklion Venizeleio, Heraklion, Crete, Greece.
| | - Ioannis Saridakis
- Internal Medicine Department, General Hospital of Heraklion Venizeleio, Heraklion, Crete, Greece
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9
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Nutman A, Lellouche J, Temkin E, Daikos G, Skiada A, Durante-Mangoni E, Dishon-Benattar Y, Bitterman R, Yahav D, Daitch V, Bernardo M, Iossa D, Zusman O, Friberg LE, Mouton JW, Theuretzbacher U, Leibovici L, Paul M, Carmeli Y. Colistin plus meropenem for carbapenem-resistant Gram-negative infections: in vitro synergism is not associated with better clinical outcomes. Clin Microbiol Infect 2020; 26:1185-1191. [PMID: 32251844 DOI: 10.1016/j.cmi.2020.03.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In vitro models showing synergism between polymyxins and carbapenems support combination treatment for carbapenem-resistant Gram-negative (CRGN) infections. We tested the association between the presence of in vitro synergism and clinical outcomes in patients treated with colistin plus meropenem. METHODS This was a secondary analysis of AIDA, a randomized controlled trial comparing colistin with colistin-meropenem for severe CRGN infections. We tested in vitro synergism using a checkerboard assay. Based on the fractional inhibitory concentration (ΣFIC) index for each colistin-meropenem combination, we categorized results as synergistic, antagonistic or additive/indifferent. The primary outcome was clinical failure at 14 days. Secondary outcomes were 14- and 28-day mortality and microbiological failure. RESULTS The sample included 171 patients with infections caused by carbapenem-resistant Acinetobacter baumannii (n = 131), Enterobacteriaceae (n = 37) and Pseudomonas aeuruginosa (n = 3). In vitro testing showed synergism for 73 isolates, antagonism for 20 and additivism/indifference for 78. In patients who received any colistin plus meropenem, clinical failure at 14 days was 59/78 (75.6%) in the additivism/indifference group (reference category), 54/73 (74.0%) in the synergism group (adjusted odds ratio (aOR) 0.76, 95% CI 0.31-1.83), and 11/20 (55%) in the antagonism group (aOR 0.77, 95% CI 0.22-2.73). There was no significant difference between groups for any secondary outcome. Comparing the synergism group to patients treated with colistin monotherapy, synergism was not protective against 14-day clinical failure (aOR 0.52, 95% CI 0.26-1.04) or 14-day mortality (aOR1.09, 95% CI 0.60-1.96). DISCUSSION In vitro synergism between colistin and meropenem via checkerboard method did not translate into clinical benefit.
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Affiliation(s)
- Amir Nutman
- National Institute for Infection Control and Antibiotic Resistance, Tel Aviv Medical Centre, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Jonathan Lellouche
- National Institute for Infection Control and Antibiotic Resistance, Tel Aviv Medical Centre, Tel-Aviv, Israel
| | - Elizabeth Temkin
- National Institute for Infection Control and Antibiotic Resistance, Tel Aviv Medical Centre, Tel-Aviv, Israel
| | - George Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece; National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece; National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy; AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Yael Dishon-Benattar
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Cheryl Spencer Institute for Nursing Research, University of Haifa, Haifa, Israel
| | - Roni Bitterman
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Infectious Diseases Unit, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Vered Daitch
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Infectious Diseases Unit, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel
| | - Mariano Bernardo
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy; AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Domenico Iossa
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy; AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Oren Zusman
- Department of Medicine E, Rabin Medical Centre, Beilinson Hospital, Peta Tikva, Israel
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands
| | | | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Medicine E, Rabin Medical Centre, Beilinson Hospital, Peta Tikva, Israel
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Techion - Israel Institute of Technology, Haifa, Israel
| | - Yehuda Carmeli
- National Institute for Infection Control and Antibiotic Resistance, Tel Aviv Medical Centre, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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10
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Shafiekhani M, Mirjalili M, Vazin A. Prevalence, Risk Factors And Treatment Of The Most Common Gram-Negative Bacterial Infections In Liver Transplant Recipients: A Review. Infect Drug Resist 2020; 12:3485-3495. [PMID: 32009806 PMCID: PMC6859291 DOI: 10.2147/idr.s226217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/10/2019] [Indexed: 11/23/2022] Open
Abstract
Advances in surgical techniques and immunosuppressive agents have made solid organ transplant (Tx) an important strategy for treatment of end-stage organ failures. However, the incidence of infections following Tx due to Gram-negative pathogens is on the rise. These infections are associated with increased mortality and morbidity in patients following transplantation, including liver Tx. Thus, managing infections in liver Tx recipients is a big challenge, requiring prompt medical attention. Considering the important effect of Gram-negative bacterial infections on the outcomes of liver Tx recipients, the most prevalent Gram-negative pathogens including Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli will be discussed in this review.
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Affiliation(s)
- Mojtaba Shafiekhani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.,Shiraz Organ Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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11
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Geisinger E, Huo W, Hernandez-Bird J, Isberg RR. Acinetobacter baumannii: Envelope Determinants That Control Drug Resistance, Virulence, and Surface Variability. Annu Rev Microbiol 2019; 73:481-506. [DOI: 10.1146/annurev-micro-020518-115714] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acinetobacter baumannii has emerged as an important nosocomial pathogen, particularly for patients in intensive care units and with invasive indwelling devices. The most recent clinical isolates are resistant to several classes of clinically important antibiotics, greatly restricting the ability to effectively treat critically ill patients. The bacterial envelope is an important driver of A. baumannii disease, both at the level of battling against antibiotic therapy and at the level of protecting from host innate immune function. This review provides a comprehensive overview of key features of the envelope that interface with both the host and antimicrobial therapies. Carbohydrate structures that contribute to protecting from the host are detailed, and mutations that alter these structures, resulting in increased antimicrobial resistance, are explored. In addition, protein complexes involved in both intermicrobial and host-microbe interactions are described. Finally we discuss regulatory mechanisms that control the nature of the cell envelope and its impact on host innate immune function.
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Affiliation(s)
- Edward Geisinger
- Department of Biology, Northeastern University, Boston, Massachusetts 02115, USA
| | - Wenwen Huo
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
| | - Juan Hernandez-Bird
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
| | - Ralph R. Isberg
- Department of Molecular Biology and Microbiology, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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12
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Pouch SM, Patel G. Multidrug-resistant Gram-negative bacterial infections in solid organ transplant recipients-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13594. [PMID: 31102483 DOI: 10.1111/ctr.13594] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of infections due to multidrug-resistant (MDR) Gram-negative bacilli in the pre- and post-transplant period. MDR Gram-negative bacilli, including carbapenem-resistant Enterobacteriaceae, MDR Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii, remain a threat to successful organ transplantation. Clinicians now have access to at least five novel agents with activity against some of these organisms, with others in the advanced stages of clinical development. No agent, however, provides universal and predictable activity against any of these pathogens, and very little is available to treat infections with MDR nonfermenting Gram-negative bacilli including A baumannii. Despite advances, empiric antibiotics should be tailored to local microbiology and targeted regimens should be tailored to susceptibilities. Source control remains an important part of the therapeutic armamentarium. Morbidity and mortality associated with infections due to MDR Gram-negative organisms remain unacceptably high. Heightened infection control and antimicrobial stewardship initiatives are needed to prevent these infections, curtail their transmission, and limit the evolution of MDR Gram-negative pathogens, especially in the setting of organ transplantation.
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Affiliation(s)
| | - Gopi Patel
- Icahn School of Medicine at Mount Sinai, New York, New York
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13
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Oh DH, Kim YC, Kim EJ, Jung IY, Jeong SJ, Kim SY, Park MS, Kim A, Lee JG, Paik HC. Multidrug-resistant Acinetobacter baumannii infection in lung transplant recipients: risk factors and prognosis. Infect Dis (Lond) 2019; 51:493-501. [PMID: 31081415 DOI: 10.1080/23744235.2018.1556400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Backgrounds: Infectious complication is an important cause of poor outcome of lung transplantation (LT). Infections with Acinetobacter baumannii (A. baumannii) are problematic, because of limited therapeutic option due to increasing resistance to antibiotics. However, there are few studies on A. baumannii infection in lung transplant recipients. Thus, we aimed to investigate epidemiology and risk factors for infection with A. baumannii in lung transplant recipients. Methods: Lung transplant recipients ≥18 years of age in a university hospital were enrolled in this retrospective cohort study. Risk factors for infection with multidrug resistant A. baumannii and 90-day mortality were analysed. Results: Fifty-one of 96 lung transplant recipients experienced A. baumannii infection. Infected patients had a significantly higher 90-day mortality rate than uninfected (19.6% vs. 2.2%, p = .009). High blood urea nitrogen (BUN) before transplantation (odds ratio [OR] 1.16; p = .008), long duration of surgery (OR 1.16; p = .029) and hypoalbuminemia before transplantation (OR 4.01; p = .037) were independent risk factors for infection with multidrug resistant A. baumannii. On multivariate analysis, severe thrombocytopenia (OR 28.69; p = .005), high serum creatinine (OR 1.48; p = .042) and infection with multidrug resistant A. baumannii (OR 22.58; p = .031) were independent risk factors for 90-day mortality. Conclusions: Prolonged surgery, high BUN and hypoalbuminemia before LT were significant risk factors for infection with multidrug resistant A. baumannii. Severe thrombocytopenia, high serum creatinine and infection with multidrug resistant A. baumannii infection were independent risk factors for 90-day mortality.
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Affiliation(s)
- Dong Hyun Oh
- a Department of Internal Medicine, Division of Infectious Disease , Seoul Medical Center , Seoul , South Korea
| | - Yong Chan Kim
- b Department of Internal Medicine, Division of Infectious Disease , Yonsei University College of Medicine , Seoul , South Korea
| | - Eun Jin Kim
- b Department of Internal Medicine, Division of Infectious Disease , Yonsei University College of Medicine , Seoul , South Korea
| | - In Young Jung
- b Department of Internal Medicine, Division of Infectious Disease , Yonsei University College of Medicine , Seoul , South Korea
| | - Su Jin Jeong
- b Department of Internal Medicine, Division of Infectious Disease , Yonsei University College of Medicine , Seoul , South Korea
| | - Song Yee Kim
- c Department of Internal Medicine, Division of Pulmonology , Institute of Chest Diseases, Yonsei University College of Medicine , Seoul , South Korea
| | - Moo Suk Park
- c Department of Internal Medicine, Division of Pulmonology , Institute of Chest Diseases, Yonsei University College of Medicine , Seoul , South Korea
| | - Anes Kim
- d Department of Thoracic and Cardiovascular Surgery , Yonsei University College of Medicine , Seoul , South Korea
| | - Jin Gu Lee
- d Department of Thoracic and Cardiovascular Surgery , Yonsei University College of Medicine , Seoul , South Korea
| | - Hyo Chae Paik
- d Department of Thoracic and Cardiovascular Surgery , Yonsei University College of Medicine , Seoul , South Korea
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14
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Romero M, Freire J, Pastene E, García A, Aranda M, González C. Propolis polyphenolic compounds affect the viability and structure of Helicobacter pylori in vitro. REVISTA BRASILEIRA DE FARMACOGNOSIA 2019. [DOI: 10.1016/j.bjp.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Bergen PJ, Smith NM, Bedard TB, Bulman ZP, Cha R, Tsuji BT. Rational Combinations of Polymyxins with Other Antibiotics. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:251-288. [PMID: 31364082 DOI: 10.1007/978-3-030-16373-0_16] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Combinations of antimicrobial agents are often used in the management of infectious diseases. Antimicrobial agents used as part of combination therapy are often selected empirically. As regrowth and the emergence of polymyxin (either colistin or polymyxin B) resistance has been observed with polymyxin monotherapy, polymyxin combination therapy has been suggested as a possible means by which to increase antimicrobial activity and reduce the development of resistance. This chapter provides an overview of preclinical and clinical investigations of CMS/colistin and polymyxin B combination therapy. In vitro data and animal model data suggests a potential clinical benefit with many drug combinations containing clinically achievable concentrations of polymyxins, even when resistance to one or more of the drugs in combination is present and including antibiotics normally inactive against Gram-negative organisms. The growing body of data on the emergence of polymyxin resistance with monotherapy lends theoretical support to a benefit with combination therapy. Benefits include enhanced bacterial killing and a suppression of polymyxin resistant subpopulations. However, the complexity of the critically ill patient population, and high rates of treatment failure and death irrespective of infection-related outcome make demonstrating a potential benefit for polymyxin combinations extremely challenging. Polymyxin combination therapy in the clinic remains a heavily debated and controversial topic. When combinations are selected, optimizing the dosage regimens for the polymyxin and the combinatorial agent is critical to ensure that the benefits outweigh the risk of the development of toxicity. Importantly, patient characteristics, pharmacokinetics, the site of infection, pathogen and resistance mechanism must be taken into account to define optimal and rational polymyxin combination regimens in the clinic.
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Affiliation(s)
- Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Parkville Campus, Melbourne, VIC, Australia.
| | - Nicholas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Tyler B Bedard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Zackery P Bulman
- University of Illinois Chicago, College of Pharmacy, Chicago, IL, USA
| | - Raymond Cha
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
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16
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Laishram S, Pragasam AK, Bakthavatchalam YD, Veeraraghavan B. An update on technical, interpretative and clinical relevance of antimicrobial synergy testing methodologies. Indian J Med Microbiol 2018; 35:445-468. [PMID: 29405135 DOI: 10.4103/ijmm.ijmm_17_189] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Testing for antimicrobial interactions has gained popularity in the last decade due to the increasing prevalence of drug-resistant organisms and limited options for the treatment of these infections. In vitro combination testing provides information, on which two or more antimicrobials can be combined for a good clinical outcome. Amongst the various in vitro methods of drug interactions, time-kill assay (TKA), checkerboard (CB) assay and E-test-based methods are most commonly used. Comparative performance of these methods reveals the TKA as the most promising method to detect synergistic combinations followed by CB assay and E-test. Various combinations of antimicrobials have been tested to demonstrate synergistic activity. Promising results were obtained for the combinations of meropenem plus colistin and rifampicin plus colistin against Acinetobacter baumannii, colistin plus carbapenem and carbapenem plus fluoroquinolones against Pseudomonas aeruginosa and colistin/polymyxin B plus rifampicin/meropenem against Klebsiella pneumoniae. Antagonism was detected in only few instances. The presence of synergy or antagonism with a combination seems to correlate with minimum inhibitory concentration of the agent and molecular mechanism involved in the resistance. Further studies need to be conducted to assess the utility of in vitro testing to predict clinical outcome and direct therapy for drug-resistant organisms.
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Affiliation(s)
- Shakti Laishram
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu,, India
| | - Agila Kumari Pragasam
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu,, India
| | | | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu,, India
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17
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Colistin Does Not Potentiate Ceftazidime-Avibactam Killing of Carbapenem-Resistant Enterobacteriaceae In Vitro or Suppress Emergence of Ceftazidime-Avibactam Resistance. Antimicrob Agents Chemother 2018; 62:AAC.01018-18. [PMID: 29891598 DOI: 10.1128/aac.01018-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/04/2018] [Indexed: 11/20/2022] Open
Abstract
We tested ceftazidime-avibactam and colistin against 24 carbapenem-resistant Enterobacteriaceae (CRE) isolates by time-kill studies. Ceftazidime-avibactam at 0.25×, 1×, and 4× the MIC was bactericidal against 8%, 21%, and 88% of the isolates, respectively. Colistin (2 μg/ml) was bactericidal against 83% (12 h) and 42% (24 h) of the isolates. In combination, synergy and antagonism were identified against 13% and 46% of the isolates, respectively. The combination did not suppress ceftazidime-avibactam resistance. Colistin plus ceftazidime-avibactam did not provide a benefit over ceftazidime-avibactam against most CRE isolates.
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18
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Abstract
With the increasing incidence of multi-drug resistant strains, especially carbapenem resistant strains, polymyxsins (mainly colistin and polymyxin B) based regimens seem to be a revival as an effective treatment of last resort in these infections. Evidence from 47 clinical trials or case series we reviewed showed that polymyxins based regimens are effective and have less toxicity compared with previous trials. When used alone, the mortality of intravenous polymyxsins ranged from 0% to 74.3%, clinical response (cure and improvement) rate was 7-82.1%, and microbiological eradication was 27.3-73.9%. The main reasons for the combination therapy are to get potential synergistic effects and to prevent the selection of heteroresistant strains. Several studies showed combination therapy seemed to be more effective than monotherapy, though a few doubts remain. Clinically, polymyxsins can be used in combination with several antibiotics, such as carberpenem, sulbactam, tigecycline, fosfomycin, glycopeptide, rifampicin and so on, but the optimal combination regimen is yet to be confirmed. The optimal dose of polymyxins is also controversial. With the limited clinical evidence, it's suggested loading dose regimens may be more effective, but more attention should be paid to adverse effects. Although recommended in some studies, high dose polymxins regimens with inconsistent clinical evidence need more trials to confirm. It is important to note that concerning dosing regimens, colistin and polymyxin B are not quite the same. In renal impaired patients polymyxin B should be prescribed without dosing adjustment. Risk of renal failure may increase in the following situations, such as the combination of intravenous colistin plus intravenous vancomycin, higher doses-colistin, and intravenous colistin combined with inhalational colistin. In conclusion, there're still controversies in combination regimens, dosing strategies and so on. Prospective trials of lager sample size are needed.
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Affiliation(s)
- Yun Yu
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
| | - Aihua Fei
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
| | - Zengbin Wu
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
| | - Chengjin Gao
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
| | - Shuming Pan
- Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
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Yuan X, Liu T, Wu D, Wan Q. Epidemiology, susceptibility, and risk factors for acquisition of MDR/XDR Gram-negative bacteria among kidney transplant recipients with urinary tract infections. Infect Drug Resist 2018; 11:707-715. [PMID: 29785131 PMCID: PMC5957067 DOI: 10.2147/idr.s163979] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Multiple drug resistant/extensively drug resistant (MDR/XDR) Gram-negative urinary tract infections (UTIs) represent a growing threat to kidney transplant recipients. This retrospective study aimed to assess the incidence and microbiological profile of MDR/XDR Gram-negative UTIs, to identify drug susceptibility of MDR/XDR bacteria, and to determine the potential risk factors for MDR/XDR UTIs in kidney recipients. Materials and methods During the study period, 1569 patients underwent consecutive kidney transplantation in two transplantation centers. We studied the demographics, clinical characteristics, and urine culture data from kidney recipients with MDR/XDR Gram-negative UTIs, and verified the risk factors associated with MDR/XDR infections. Results Eighty-one kidney recipients yielded 88 episodes of MDR/XDR Gram-negative UTIs with five patients (6.2%) succumbing to all-cause in-hospital mortality. The most frequently isolated bacterium was Escherichia coli (62.5%). Almost all MDR/XDR Gram-negative bacteria were resistant to first- and second-generation cephalosporin, and monocyclic beta-lactam. They were relatively sensitive to meropenem, amikacin, and tigecycline. As for the 12 XDR bacteria, all of them were resistant to meropenem and 25% of them were resistant to tigecycline. All XDR Acinetobacter baumannii and E. coli were susceptible to tigecycline. Nosocomial infection (odds ratio [OR] = 11.429, 95% CI = 1.311–99.625, P = 0.027) was the only independent predictor of MDR/XDR Gram-negative UTIs. Non-fermenting bacterial infection (OR = 20.161, 95% CI = 3.409–119.240, P = 0.001), polycystic kidney disease (OR = 39.871, 95% CI = 1.979–803.384, P = 0.016), and serum creatinine level > 1.5 mg/dL (OR = 8.688, 95% CI = 1.354–55.747, P = 0.023) were significantly different between XDR and MDR Gram-negative UTIs. Conclusion Meropenem, amikacin, and/or tigecycline can be prescribed for MDR/XDR Gram-negative infections. Tigecycline can also be prescribed for XDR A. baumannii and E. coli. Nosocomial infection was a risk factor for MDR/XDR Gram-negative UTIs, while XDR UTIs were associated with non-fermenting bacterial infection, polycystic kidney disease, and impaired renal function.
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Affiliation(s)
- Xiuhong Yuan
- Psychosomatic Health Institute, the Third Xiangya Hospital of Central South University, Changsha, China
| | - Taohua Liu
- Clinical Medicine, Xiangya School of Medicine, Central South University, Changsha, China
| | - Di Wu
- Department of Transplant Surgery, the Third Xiangya Hospital of Central South University, Changsha, China
| | - Qiquan Wan
- Department of Transplant Surgery, the Third Xiangya Hospital of Central South University, Changsha, China
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Antibiotic resistance of pathogenic Acinetobacter species and emerging combination therapy. J Microbiol 2017; 55:837-849. [PMID: 29076065 DOI: 10.1007/s12275-017-7288-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 01/08/2023]
Abstract
The increasing antibiotic resistance of Acinetobacter species in both natural and hospital environments has become a serious problem worldwide in recent decades. Because of both intrinsic and acquired antimicrobial resistance (AMR) against last-resort antibiotics such as carbapenems, novel therapeutics are urgently required to treat Acinetobacter-associated infectious diseases. Among the many pathogenic Acinetobacter species, A. baumannii has been reported to be resistant to all classes of antibiotics and contains many AMR genes, such as bla ADC (Acinetobacter-derived cephalosporinase). The AMR of pathogenic Acinetobacter species is the result of several different mechanisms, including active efflux pumps, mutations in antibiotic targets, antibiotic modification, and low antibiotic membrane permeability. To overcome the limitations of existing drugs, combination theraphy that can increase the activity of antibiotics should be considered in the treatment of Acinetobacter infections. Understanding the molecular mechanisms behind Acinetobacter AMR resistance will provide vital information for drug development and therapeutic strategies using combination treatment. Here, we summarize the classic mechanisms of Acinetobacter AMR, along with newly-discovered genetic AMR factors and currently available antimicrobial adjuvants that can enhance drug efficacy in the treatment of A. baumannii infections.
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21
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Evolution of Drug-resistant Acinetobacter baumannii After DCD Renal Transplantation. Sci Rep 2017; 7:1968. [PMID: 28512290 PMCID: PMC5434021 DOI: 10.1038/s41598-017-01683-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/22/2017] [Indexed: 11/24/2022] Open
Abstract
Infection after renal transplantation remains a major cause of morbidity and death, especially infection from the extensively drug-resistant bacteria, A. baumannii. A total of fourteen A. baumannii isolates were isolated from the donors’ preserved fluid from DCD (donation after cardiac death) renal transplantation and four isolates in the recipients’ draining liquid at the Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, from March 2013 to November 2014. An outbreak of A. baumannii emerging after DCD renal transplantation was tracked to understand the transmission of the pathogen. PFGE displayed similar DNA patterns between isolates from the same hospital. Antimicrobial susceptibility tests against thirteen antimicrobial agents were determined using the K-B diffusion method and eTest. Whole-genome sequencing was applied to investigate the genetic relationship of the isolates. With the clinical data and research results, we concluded that the A. baumannii isolates 3R1 and 3R2 was probably transmitted from the donor who acquired the bacteria during his stay in the ICU, while isolate 4R1 was transmitted from 3R1 and 3R2 via medical manipulation. This study demonstrated the value of integration of clinical profiles with molecular methods in outbreak investigation and their importance in controlling infection and preventing serious complications after DCD transplantation.
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Mohammadi M, Khayat H, Sayehmiri K, Soroush S, Sayehmiri F, Delfani S, Bogdanovic L, Taherikalani M. Synergistic Effect of Colistin and Rifampin Against Multidrug Resistant Acinetobacter baumannii: A Systematic Review and Meta-Analysis. Open Microbiol J 2017; 11:63-71. [PMID: 28553417 PMCID: PMC5427699 DOI: 10.2174/1874285801711010063] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/26/2017] [Accepted: 02/08/2017] [Indexed: 11/22/2022] Open
Abstract
The existence of infections caused by multidrug resistant (MDR) Acinetobacter baumannii is a growing problem because of the difficulty to treat them. We examined the published literature and focused our analysis on the investigation of the synergism of colistin and rifampin against MDR A. baumannii isolates via systematic review and meta-analysis. A systematic literature search was performed using the following 4 databases (PubMed, Scopus, EMBASE and ISI Web of Sciences). The related articles were evaluated during the period from December 2014 to January 2015. Information based on resistance and sensitivity to antibiotics, the minimum inhibitory concentration and the effects of two antibiotics on each other including synergism, antagonism, relative synergism and additive antagonism were extracted. A meta-analysis of 17 studies including 448 samples was brought into process and 2% (95% CI 0-4%) and 72% (95% CI 56-89%) resistance to colistin and rifampin were observed, respectively. 42% of all isolates showed MIC = 4 µg/ml (95% CI 14-69%) to rifampin and 30% MIC= 2 µg/ml to colistin (95% CI 3.8-78%). MIC50 and MIC90 for both rifampin and colistin were 2 µg/ml and 4 µg/ml, respectively. 63% of the strains demonstrated synergy (95% CI 37-90%), 7% were highlighted as relative synergism (95% CI 0.0- 13%), 3% showed an additive effect (95% CI -0.0-7%) and 14% were indifferent (95% CI 6-23%). The antagonistic effect was not observed in this combination. Synergy rates of time-kill assay in rifampin and colistin combinations were generally higher than those of check bored microdilution and E-test method. The results demonstrated that the combination therapy could be more useful when compared to monotherapy and that this strategy might reduce the resistance rate to rifampin in MDR A. baumannii isolates.
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Affiliation(s)
- Maryam Mohammadi
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Hatef Khayat
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Koroush Sayehmiri
- Department of Biostatistics, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Setareh Soroush
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fatemeh Sayehmiri
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Delfani
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Lidija Bogdanovic
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Morovat Taherikalani
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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Li J, Yang X, Chen L, Duan X, Jiang Z. In Vitro Activity of Various Antibiotics in Combination with Tigecycline Against Acinetobacter baumannii: A Systematic Review and Meta-Analysis. Microb Drug Resist 2017; 23:982-993. [PMID: 28437233 DOI: 10.1089/mdr.2016.0279] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Given that tigecycline-based combination therapy is recognized as a valuable option for the treatment of tigecycline-resistant Acinetobacter baumannii, we conducted this systematic review and meta-analysis to assess the overall evidence of its effectiveness. The synergy rate was defined as the primary outcome that was calculated separately for time-kill, Etest, and checkerboard microdilution methods. The secondary outcomes were bactericidal activity and the efficacy of combination treatment on the development of resistance. In total, 37 published papers and 16 conference proceedings were included. Nine classes consisting of 22 antibiotic types in combination with tigecycline against 1,159 A. baumannii strains were reported in the analysis. For the time-kill studies, combination therapy showed a synergy rate of 37.9% (95% confidence interval [CI], 30.7-46.5); the highest synergy rate was 67.4% (95% CI, 27.3-91.9) for tigecycline in combination with colistin. Moreover, combination with amikacin or colistin could efficiently inhibit the development of tigecycline resistance. Compared with checkerboard microdilution and Etest methods, time-kill studies always showed higher synergy rates. Altogether, these results suggest that the in vitro tigecycline-based combinations resulted in moderate synergy rates and that several combinations could suppress the resistance of A. baumannii to tigecycline, which should be further confirmed in animal models and clinical trials.
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Affiliation(s)
- Jian Li
- 1 Department of Pharmacy, Guangzhou General Hospital of Guangzhou Military Command , Guangzhou, China .,2 Guangzhou Key Laboratory of Rational Drug Use for the Elderly with Chronic Disease , Guangzhou, China
| | - Xianghai Yang
- 1 Department of Pharmacy, Guangzhou General Hospital of Guangzhou Military Command , Guangzhou, China .,2 Guangzhou Key Laboratory of Rational Drug Use for the Elderly with Chronic Disease , Guangzhou, China .,3 School of Traditional Chinese Medicine, Guangdong Pharmaceutical University , Guangzhou, China
| | - Lidan Chen
- 4 Department of Laboratory Medicine, Guangzhou General Hospital of Guangzhou Military Command , Guangzhou, China
| | - Xinran Duan
- 1 Department of Pharmacy, Guangzhou General Hospital of Guangzhou Military Command , Guangzhou, China .,2 Guangzhou Key Laboratory of Rational Drug Use for the Elderly with Chronic Disease , Guangzhou, China .,3 School of Traditional Chinese Medicine, Guangdong Pharmaceutical University , Guangzhou, China
| | - Zhihui Jiang
- 1 Department of Pharmacy, Guangzhou General Hospital of Guangzhou Military Command , Guangzhou, China .,2 Guangzhou Key Laboratory of Rational Drug Use for the Elderly with Chronic Disease , Guangzhou, China .,5 College of Pharmacy, Jinan University , Guangzhou, China
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Kim YK, Lee JH, Lee HK, Chung BC, Yu SJ, Lee HY, Park JH, Kim S, Kim HK, Kiem S, Jang HJ. Efficacy of nebulized colistin-based therapy without concurrent intravenous colistin for ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii. J Thorac Dis 2017; 9:555-567. [PMID: 28449463 PMCID: PMC5394082 DOI: 10.21037/jtd.2017.02.61] [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] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although there have been studies regarding the role of nebulized colistin as adjunctive therapy of ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB), a paucity of information on the efficacy of nebulized colistin as monotherapy is available. METHODS We retrospectively reviewed 219 patients with VAP caused by CRAB treated with either intravenous (n=93) or nebulized colistin (n=126), from March 2010 to November 2015. Factors related to clinical failure was assessed using propensity-score-matched analysis. RESULTS Of 219 patients, 39 patients from each group (n=78) were matched after covariate adjustment using propensity score. There were no significant differences in baseline characteristics as well as the rates of clinical failure between the propensity-score-matched groups [Odds ratio (OR), 0.48; 95% confidence interval (CI), 0.19-1.19; P=0.11], while a significantly lower rate of acute kidney injury (AKI) during colistin therapy (18% vs. 49%, P=0.004) was observed in nebulized colistin group. In addition, multivariable analysis revealed that nebulized colistin did not significantly alter the rate of clinical failure [adjusted odds ratio (aOR), 0.36; 95% CI, 0.12-1.09; P=0.070]. Instead, medical intensive care unit (ICU) admission (aOR, 7.14; 95% CI, 1.60-32.00; P=0.010), and septic shock (aOR, 3.93; 95% CI, 1.27-12.17; P=0.018) were independent risk factors for clinical failure. CONCLUSIONS Our findings suggest that nebulized colistin-based therapy, even without concurrent administration of intravenous colistin, may be an effective and safe treatment option for VAP caused by CRAB.
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Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jae Ha Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun-Kyung Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byung Cheol Chung
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Seung Jung Yu
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Ho-Young Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jin-Han Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sunyoung Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyeon-Kuk Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sungmin Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hang-Jea Jang
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Park GC, Choi JA, Jang SJ, Jeong SH, Kim CM, Choi IS, Kang SH, Park G, Moon DS. In Vitro Interactions of Antibiotic Combinations of Colistin, Tigecycline, and Doripenem Against Extensively Drug-Resistant and Multidrug-Resistant Acinetobacter baumannii. Ann Lab Med 2017; 36:124-30. [PMID: 26709259 PMCID: PMC4713845 DOI: 10.3343/alm.2016.36.2.124] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 11/11/2015] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Acinetobacter baumannii infections are difficult to treat owing to the emergence of various antibiotic resistant isolates. Because treatment options are limited for multidrug-resistant (MDR) A. baumannii infection, the discovery of new therapies, including combination therapy, is required. We evaluated the synergistic activity of colistin, doripenem, and tigecycline combinations against extensively drug-resistant (XDR) A. baumannii and MDR A. baumannii. METHODS Time-kill assays were performed for 41 XDR and 28 MDR clinical isolates of A. baumannii by using colistin, doripenem, and tigecycline combinations. Concentrations representative of clinically achievable levels (colistin 2 μg/mL, doripenem 8 μg/mL) and achievable tissue levels (tigecycline 2 μg/mL) for each antibiotic were used in this study. RESULTS The colistin-doripenem combination displayed the highest rate of synergy (53.6%) and bactericidal activity (75.4%) in 69 clinical isolates of A. baumannii. Among them, the-doripenem-tigecycline combination showed the lowest rate of synergy (14.5%) and bactericidal activity (24.6%). The doripenem-tigecycline combination showed a higher antagonistic interaction (5.8%) compared with the colistin-tigecycline (1.4%) combination. No antagonism was observed for the colistin-doripenem combination. CONCLUSIONS The colistin-doripenem combination is supported in vitro by the high rate of synergy and bactericidal activity and lack of antagonistic reaction in XDR and MDR A. baumannii. It seems to be necessary to perform synergy tests to determine the appropriate combination therapy considering the antagonistic reaction found in several isolates against the doripenem-tigecycline and colistin-tigecycline combinations. These findings should be further examined in clinical studies.
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Affiliation(s)
- Gyun Cheol Park
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Ji Ae Choi
- Research Center for Resistant Cells, College of Medicine, Chosun University, Gwangju, Korea
| | - Sook Jin Jang
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea.,Research Center for Resistant Cells, College of Medicine, Chosun University, Gwangju, Korea.
| | - Seok Hoon Jeong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea.
| | - Choon-Mee Kim
- Premedical Science, College of Medicine, Chosun University, Gwangju, Korea
| | - In Sun Choi
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Seong Ho Kang
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Geon Park
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Dae Soo Moon
- Department of Laboratory Medicine, College of Medicine, Chosun University, Gwangju, Korea
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Carbapenem-Resistant Pseudomonas aeruginosa Bacteremia: Risk Factors for Mortality and Microbiologic Treatment Failure. Antimicrob Agents Chemother 2016; 61:AAC.01243-16. [PMID: 27821456 DOI: 10.1128/aac.01243-16] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022] Open
Abstract
We reviewed 37 patients treated for bacteremia due to carbapenem-resistant (CR) Pseudomonas aeruginosa Although 65% of isolates were multiple-drug resistant, therapeutic options were available, as all were susceptible to ≥1 antibiotic. A total of 92% of patients received active antimicrobial therapy, but only 57% received early active therapy (within 48 h). Fourteen-day mortality was 19%. Microbiologic failure occurred in 29%. The Pitt bacteremia score (P = 0.046) and delayed active therapy (P = 0.027) were predictive of death and microbiologic failure, respectively.
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Synergistic combinations of polymyxins. Int J Antimicrob Agents 2016; 48:607-613. [PMID: 27865626 DOI: 10.1016/j.ijantimicag.2016.09.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/15/2016] [Accepted: 09/15/2016] [Indexed: 01/19/2023]
Abstract
The proliferation of extensively drug-resistant Gram-negative pathogens has necessitated the therapeutic use of colistin and polymyxin B. However, treatment failures with polymyxin monotherapies and the emergence of polymyxin resistance have catalysed the search for polymyxin combinations that synergistically kill polymyxin-susceptible and -resistant organisms. This mini-review examines recent (2011-2016) in vitro and in vivo studies that have attempted to identify synergistic polymyxin combinations against Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii. Clinical evidence for the use of combination regimens is also discussed.
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Correlation of Checkerboard Synergy Testing with Time-Kill Analysis and Clinical Outcomes of Extensively Drug-Resistant Acinetobacter baumannii Respiratory Infections. Antimicrob Agents Chemother 2016; 60:6892-6895. [PMID: 27527089 DOI: 10.1128/aac.00981-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/10/2016] [Indexed: 11/20/2022] Open
Abstract
We tested 76 extensively drug-resistant (XDR) Acinetobacter baumannii isolates by the checkerboard method using only wells containing serum-achievable concentrations (SACs) of drugs. Checkerboard results were correlated by time-kill assay and clinical outcomes. Minocycline-colistin was the best combination in vitro, as it inhibited growth in one or more SAC wells in all isolates. Patients who received a combination that inhibited growth in one or more SAC wells demonstrated better microbiological clearance than those who did not (88% versus 30%; P = 0.025). The checkerboard platform may have clinical utility for XDR A. baumannii infections.
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Kroth LV, Barreiro FF, Saitovitch D, Traesel MA, d'Avila DOL, Poli-de-Figueiredo CE. Does Thymoglobulin Induction Increase Susceptibility to Carbapenem-Resistant Acinetobacter baumannii Sepsis-related Death in Expanded Criteria Donors? Transplant Proc 2016; 48:2294-2297. [PMID: 27742282 DOI: 10.1016/j.transproceed.2016.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Solid organ transplant recipients are susceptible to antibiotic-resistant infections and carbapenem-resistant Acinetobacter baumannii (CRAB) has recently been recognized as a serious complication in solid organ recipients. High mortality rates have been described. METHODS We retrospectively analyzed 807 transplantations and detected 10 patients who died 24 hours after the diagnosis of septicemia, all with CRAB-positive blood cultures. Recipients were followed up for at least 1 year and were stratified into the following groups: Group 1, patients alive; Group 2, patients that died due to other causes except Acinetobacter infection; and Group 3, patients who died within 24 hours of CRAB diagnosis. RESULTS CRAB-positive patients died a median of 3.17 (range, 1.81-18.7) months after transplantation. In these patients, expanded criteria donors (ECDs) were more frequent (P < .001), as were the use of anti-thymocyte globulin (ATG) induction (P = .02) and delayed graft function (P = .01). For ECD recipients, death rate from any cause, whether induced with ATG or not, was 25% and 20.6%, respectively (odds ratio [OR], 1.28; confidence interval [CI] 95%, 0.56-2.91; P = .68). The death rate from CRAB-related sepsis was 10.3% and 0% whether receiving ATG or not, respectively (OR, 15.49; CI 95%, 0.87-277.16; P = .014). There was a 25.75-fold increase in the death rate in ECD kidney recipients induced with thymoglobulin and with CRAB-related sepsis. CONCLUSION Transplants from ECDs and induced with thymoglobulin may be at increased risk of CRAB death in 24 hours when compared with patients with standard donors and induced with thymoglobulin.
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Affiliation(s)
- L V Kroth
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil.
| | - F F Barreiro
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil
| | - D Saitovitch
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil
| | - M A Traesel
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil
| | - D O L d'Avila
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil
| | - C E Poli-de-Figueiredo
- Nephrology Unit, Hospital São Lucas da PUCRS, Programa de Pós-graduação em Medicina e Ciências da Saúde, Porto Alegre, Brazil
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Comparative pharmacodynamics of four different carbapenems in combination with polymyxin B against carbapenem-resistant Acinetobacter baumannii. Int J Antimicrob Agents 2016; 48:719-724. [PMID: 27773498 DOI: 10.1016/j.ijantimicag.2016.07.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/08/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
Abstract
The objective of this study was to determine the comparative pharmacodynamics of four different carbapenems in combination with polymyxin B (PMB) against carbapenem-resistant Acinetobacter baumannii isolates using time-kill experiments at two different inocula. Two A. baumannii strains (03-149-1 and N16870) with carbapenem minimum inhibitory concentrations (MICs) ranging from 8 to 64 mg/L were investigated in 48-h time-kill experiments using starting inocula of 106 CFU/mL and 108 CFU/mL. Concentration arrays of ertapenem, doripenem, meropenem and imipenem at 0.25×, 0.5×, 1×, 1.5× and 2× published maximum serum concentration (Cmax) values (Cmax concentrations of 12, 21, 48 and 60 mg/L, respectively) were investigated in the presence of 1.5 mg/L PMB. Use of carbapenems without PMB resulted in drastic re-growth. All carbapenem combinations were able to achieve a ≥3 log10 CFU/mL reduction by 4 h against both strains at 106 CFU/mL, whereas maximum reductions against strain 03-149-1 at 108 CFU/mL were 1.0, 3.2, 2.2 and 3.3 log10 CFU/mL for ertapenem, doripenem, meropenem and imipenem, respectively. None of the combinations were capable of reducing 108 CFU/mL of N16870 by ≥2 log10 CFU/mL. Ertapenem combinations consistently displayed the least activity, whereas doripenem, meropenem and imipenem combinations had similar activities that were poorly predicted by carbapenem MICs. As doripenem, meropenem, or imipenem displayed similar pharmacodyanmics in combination, the decision of which carbapenem to use in combination with PMB may be based on toxicodynamic profiles if drastic discordance in MICs is not present.
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Clinical Efficacy of Polymyxin Monotherapy versus Nonvalidated Polymyxin Combination Therapy versus Validated Polymyxin Combination Therapy in Extensively Drug-Resistant Gram-Negative Bacillus Infections. Antimicrob Agents Chemother 2016; 60:4013-22. [PMID: 27090177 DOI: 10.1128/aac.03064-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 04/12/2016] [Indexed: 11/20/2022] Open
Abstract
Polymyxins have emerged as a last-resort treatment of extensively drug-resistant (XDR) Gram-negative Bacillus (GNB) infections, which present a growing threat. Individualized polymyxin-based antibiotic combinations selected on the basis of the results of in vitro combination testing may be required to optimize therapy. A retrospective cohort study of hospitalized patients receiving polymyxins for XDR GNB infections from 2009 to 2014 was conducted to compare the treatment outcomes between patients receiving polymyxin monotherapy (MT), nonvalidated polymyxin combination therapy (NVCT), and in vitro combination testing-validated polymyxin combination therapy (VCT). The primary and secondary outcomes were infection-related mortality and microbiological eradication, respectively. Adverse drug reactions (ADRs) between treatment groups were assessed. A total of 291 patients (patients receiving MT, n = 58; patients receiving NVCT, n = 203; patients receiving VCT, n = 30) were included. The overall infection-related mortality rate was 23.0% (67 patients). In the multivariable analysis, treatment of XDR GNB infections with MT (adjusted odds ratio [aOR], 8.49; 95% confidence interval [CI], 1.56 to 46.05) and NVCT (aOR, 5.75; 95% CI, 1.25 to 25.73) was associated with an increased risk of infection-related mortality compared to that with treatment with VCT. A higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score (aOR, 1.14; 95% CI 1.07 to 1.21) and a higher Charlson comorbidity index (aOR, 1.28; 95% CI, 1.11 to 1.47) were also independently associated with an increased risk of infection-related mortality. No increase in the incidence of ADRs was observed in the VCT group. The use of an individualized antibiotic combination which was selected on the basis of the results of in vitro combination testing was associated with significantly lower rates of infection-related mortality in patients with XDR GNB infections. Future prospective randomized studies will be required to validate these findings.
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Uwingabiye J, Frikh M, Lemnouer A, Bssaibis F, Belefquih B, Maleb A, Dahraoui S, Belyamani L, Bait A, Haimeur C, Louzi L, Ibrahimi A, Elouennass M. Acinetobacter infections prevalence and frequency of the antibiotics resistance: comparative study of intensive care units versus other hospital units. Pan Afr Med J 2016; 23:191. [PMID: 27347280 PMCID: PMC4907753 DOI: 10.11604/pamj.2016.23.191.7915] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/07/2016] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION This study aims to determine the Acinetobacter sp clinical isolates frequency and its antibiotic susceptibility pattern by comparing results obtained from the Intensive Care Units (ICUs) to that of other units at the Mohammed V Military Teaching Hospital in Rabat. METHODS This is a retrospective study over a 2-years period where we collected all clinical isolates of Acinetobacter sp obtained from samples for infection diagnosis performed on hospitalized patients between 2012 to 2014. RESULTS During the study period, 441 clinical and non-repetitive isolates of Acinetobacter sp were collected representing 6.94% of all bacterial clinical isolates (n = 6352) and 9.6% of Gram negative rods (n = 4569). More than a half of the isolates were from the ICUs and were obtained from 293 infected patients of which 65, 2% (191 cases) were males (sex ratio = 1.9) and the median age was 56 years (interquartile range: 42-68 years). Acinetobacter clinical isolates were obtained from respiratory samples (44.67%) followed by blood cultures (14.51%). The resistance to ciprofloxacin, ceftazidime, piperacillin / tazobactam, imipenem, amikacin, tobramycin, netilmicin, rifampicin and colistin was respectively 87%, 86%, 79%, 76%; 52%, 43%, 33% 32% and 1.7%. The difference in resistance between the ICUs and the other units was statistically significant (p <0.05) except for colistin, tetracycline and rifampicin. CONCLUSION This paper shows that solving the problem of prevalence and high rate of multidrug resistant Acinetobacter infection which represents a therapeutic impasse, requires the control of the hospital environment and optimizing hands hygiene and antibiotics use in the hospital.
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Affiliation(s)
- Jean Uwingabiye
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Mohammed Frikh
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Abdelhay Lemnouer
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Fatna Bssaibis
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Bouchra Belefquih
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Adil Maleb
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc
| | - Souhail Dahraoui
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Lahcen Belyamani
- Service des Urgences, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc
| | - Abdelouahed Bait
- Services des Réanimations, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc
| | - Charki Haimeur
- Services des Réanimations, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc
| | - Lhoussain Louzi
- Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Azeddine Ibrahimi
- Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc; Laboratoire de Biotechnologie, Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
| | - Mostafa Elouennass
- Service de Bactériologie, Hôpital Militaire d'Instruction Mohammed V, Rabat, Maroc; Equipe de recherche: Épidémiologie et Résistance Bactérienne (ERB), Université Mohammed V, Faculté de Médecine et de Pharmacie, Rabat, Maroc
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Bergen PJ, Bulman ZP, Landersdorfer CB, Smith N, Lenhard JR, Bulitta JB, Nation RL, Li J, Tsuji BT. Optimizing Polymyxin Combinations Against Resistant Gram-Negative Bacteria. Infect Dis Ther 2015; 4:391-415. [PMID: 26645096 PMCID: PMC4675771 DOI: 10.1007/s40121-015-0093-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Indexed: 01/01/2023] Open
Abstract
Polymyxin combination therapy is increasingly used clinically. However, systematic investigations of such combinations are a relatively recent phenomenon. The emerging pharmacodynamic (PD) and pharmacokinetic (PK) data on CMS/colistin and polymyxin B suggest that caution is required with monotherapy. Given this situation, polymyxin combination therapy has been suggested as a possible way to increase bacterial killing and reduce the development of resistance. Considerable in vitro data have been generated in support of this view, particularly recent studies utilizing dynamic models. However, most existing animal data are of poor quality with major shortcomings in study design, while clinical data are generally limited to retrospective analysis and small, low-power, prospective studies. This article provides an overview of clinical and preclinical investigations of CMS/colistin and polymyxin B combination therapy.
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Affiliation(s)
- Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Zackery P Bulman
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia.,Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Nicholas Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Justin R Lenhard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.
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The Distribution, Drug Resistance, and Clinical Characteristics of Acinetobacter baumannii Infections in Solid Organ Transplant Recipients. Transplant Proc 2015; 47:2860-4. [DOI: 10.1016/j.transproceed.2015.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/24/2015] [Indexed: 01/09/2023]
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Bergen PJ, Bulman ZP, Saju S, Bulitta JB, Landersdorfer C, Forrest A, Li J, Nation RL, Tsuji BT. Polymyxin combinations: pharmacokinetics and pharmacodynamics for rationale use. Pharmacotherapy 2015; 35:34-42. [PMID: 25630411 DOI: 10.1002/phar.1537] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Since their reintroduction into the clinic in the 1980s, the polymyxin antibiotics colistin-administered intravenously as an inactive prodrug, colistin methanesulfonate (CMS)-and polymyxin B have assumed an important role as salvage therapy for otherwise untreatable gram-negative infections. However, the emerging pharmacodynamic and pharmacokinetic data on CMS/colistin and polymyxin B indicate that polymyxin monotherapy is unlikely to generate plasma concentrations that are reliably efficacious. Additionally, regrowth and the emergence of resistance with monotherapy are commonly reported even when concentrations exceed those achieved clinically. Given this situation, polymyxin combination therapy, which is increasingly being used clinically, has been suggested as a possible means of increasing antimicrobial activity and reducing the development of resistance. Although considerable in vitro data support this view, investigations of polymyxin combination therapy in patients have only recently commenced. The currently available clinical data for polymyxin combinations are generally limited to retrospective analyses and small, low-powered, prospective studies using traditional dosage regimens that achieve low plasma concentrations. Considering the potential for rapid development of resistance to polymyxins, well-designed clinical trials that include higher-dose polymyxin regimens are urgently required to provide a more definitive answer regarding the role of polymyxin combination therapy compared with monotherapy. In this article, we provide an overview of key in vitro and clinical investigations examining CMS/colistin and polymyxin B combination therapy.
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Affiliation(s)
- Phillip J Bergen
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York
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Lee HY, Lee HY, Shin SB, Shin KS, Lee BW, Kim HW, Lee S, Kim SC. Lung Transplantation in a Patient with Pre-transplant Colonization of Extensively Drug-resistant Acinetobacter baumannii. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
The interaction between host immunity and infections in the context of a suppressed immune system presents an opportunity to study the interaction of colonization and infection with the development of acute and chronic pulmonary morbidity and mortality. This article summarizes presentations at the Pittsburgh International Lung Conference about comorbid consequences in two categories of immunosuppressed hosts: HIV-infected individuals and lung transplant recipients. Specifically, chronic obstructive pulmonary disease, pulmonary hypertension, and chronic lung rejection after transplant are three diseases that may be consequences of colonization or infection by viruses or fungi, whether HIV itself or the opportunistic infections Pneumocystis and cytomegalovirus. In the fourth section, we discuss unique aspects of infections after lung transplant as well as the battle against multidrug-resistant organisms in this population and theorize that the immunosuppressed population may provide a unique group of patients in which to study ways to overcome nosocomial pathogenic challenges. These host-pathogen interactions serve as models for developing new strategies to reduce acute and chronic morbidity due to colonization and subclinical infection, and potential therapeutic avenues, which are often overlooked in the clinical arena.
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Gao F, Ye Q, Wan Q, Liu S, Zhou J. Distribution and resistance of pathogens in liver transplant recipients with Acinetobacter baumannii infection. Ther Clin Risk Manag 2015. [PMID: 25848296 DOI: 10.2147/tcrm.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Drug-resistant Acinetobacter baumannii has become a major problem in liver transplant recipients. The aim of this study was to investigate the clinical presentation, distribution, and drug susceptibility characteristics in liver recipients with A. baumannii infection. METHODS We retrospectively investigated 17 liver recipients who developed A. baumannii infection between January 1, 2007 and December 31, 2014. The distribution of A. baumannii and drug susceptibility characteristics were reviewed. RESULTS Infectious complications due to A. baumannii appeared in 17 liver recipients, with a total of 24 episodes. Approximately 63% (15/24) of A. baumannii infections occurred within 2 weeks after transplantation. The most common source of infection was multiple culture-positive sites (35.3%, n=6), followed by the intra-abdominal/biliary tract (23.5%, n=4) and lung (23.5%, n=4). Eight patients (47.1%) had a body temperature of 38°C or higher at the onset of A. baumannii infection. Nine, seven, and 12 recipients had a serum creatinine level of >1.5 mg/dL, a white blood cell count of >15,000/mm(3), and a platelet count of <50,000/mm(3), respectively. There were five (29.4%) cases of septic shock and eight (47.1%) deaths. The rate of antibiotic resistance of A. baumannii to ten of 12 antibiotics investigated was more than 60%. Among the 24 infections caused by A. baumannii, 75% were carbapenem-resistant. The rods were relatively sensitive to tigecycline and cefoperazone-sulbactam. CONCLUSION The clinical manifestations of A. baumannii infection included a high body temperature, a decreased platelet count, an elevated white blood cell count, and onset in the early period after transplantation as well as high mortality. The antibiotic resistance rate of A. baumannii was extremely high. Prevention measures and combination antibiotic therapy are needed to improve the outcomes of liver recipients with A. baumannii infections.
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Affiliation(s)
- Fei Gao
- Infectious Disease Department of Henan Province People's Hospital, Zhengzhou, People's Republic of China
| | - Qifa Ye
- Department of Transplant Surgery, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China ; Department of Transplant Surgery, Zhongnan Hospital, Wuhan University, Wuhan, People's Republic of China
| | - Qiquan Wan
- Department of Transplant Surgery, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Shan Liu
- Adelphi University College of Nursing and Public Health, New York, NY, USA
| | - Jiandang Zhou
- Department of Clinical Laboratory of Microbiology, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Gao F, Ye Q, Wan Q, Liu S, Zhou J. Distribution and resistance of pathogens in liver transplant recipients with Acinetobacter baumannii infection. Ther Clin Risk Manag 2015; 11:501-5. [PMID: 25848296 PMCID: PMC4381901 DOI: 10.2147/tcrm.s82251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Drug-resistant Acinetobacter baumannii has become a major problem in liver transplant recipients. The aim of this study was to investigate the clinical presentation, distribution, and drug susceptibility characteristics in liver recipients with A. baumannii infection. Methods We retrospectively investigated 17 liver recipients who developed A. baumannii infection between January 1, 2007 and December 31, 2014. The distribution of A. baumannii and drug susceptibility characteristics were reviewed. Results Infectious complications due to A. baumannii appeared in 17 liver recipients, with a total of 24 episodes. Approximately 63% (15/24) of A. baumannii infections occurred within 2 weeks after transplantation. The most common source of infection was multiple culture-positive sites (35.3%, n=6), followed by the intra-abdominal/biliary tract (23.5%, n=4) and lung (23.5%, n=4). Eight patients (47.1%) had a body temperature of 38°C or higher at the onset of A. baumannii infection. Nine, seven, and 12 recipients had a serum creatinine level of >1.5 mg/dL, a white blood cell count of >15,000/mm3, and a platelet count of <50,000/mm3, respectively. There were five (29.4%) cases of septic shock and eight (47.1%) deaths. The rate of antibiotic resistance of A. baumannii to ten of 12 antibiotics investigated was more than 60%. Among the 24 infections caused by A. baumannii, 75% were carbapenem-resistant. The rods were relatively sensitive to tigecycline and cefoperazone-sulbactam. Conclusion The clinical manifestations of A. baumannii infection included a high body temperature, a decreased platelet count, an elevated white blood cell count, and onset in the early period after transplantation as well as high mortality. The antibiotic resistance rate of A. baumannii was extremely high. Prevention measures and combination antibiotic therapy are needed to improve the outcomes of liver recipients with A. baumannii infections.
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Affiliation(s)
- Fei Gao
- Infectious Disease Department of Henan Province People's Hospital, Zhengzhou, People's Republic of China
| | - Qifa Ye
- Department of Transplant Surgery, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China ; Department of Transplant Surgery, Zhongnan Hospital, Wuhan University, Wuhan, People's Republic of China
| | - Qiquan Wan
- Department of Transplant Surgery, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Shan Liu
- Adelphi University College of Nursing and Public Health, New York, NY, USA
| | - Jiandang Zhou
- Department of Clinical Laboratory of Microbiology, Third Xiangya Hospital, Central South University, Changsha, People's Republic of China
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Vourli S, Frantzeskaki F, Meletiadis J, Stournara L, Armaganidis A, Zerva L, Dimopoulos G. Synergistic interactions between colistin and meropenem against extensively drug-resistant and pandrug-resistant Acinetobacter baumannii isolated from ICU patients. Int J Antimicrob Agents 2015; 45:670-1. [PMID: 25795317 DOI: 10.1016/j.ijantimicag.2015.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 12/30/2022]
Affiliation(s)
- S Vourli
- Clinical Microbiology Laboratory, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece.
| | - F Frantzeskaki
- Critical Care Medicine, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
| | - J Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
| | - L Stournara
- Critical Care Medicine, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
| | - A Armaganidis
- Critical Care Medicine, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
| | - L Zerva
- Clinical Microbiology Laboratory, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
| | - G Dimopoulos
- Critical Care Medicine, Attikon University Hospital, 1 Rimini Street, Haidari, 12462 Athens, Greece
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Patel G, Perez F, Hujer AM, Rudin SD, Augustine JJ, Jacobs GH, Jacobs MR, Bonomo RA. Fulminant endocarditis and disseminated infection caused by carbapenem-resistant Acinetobacter baumannii in a renal-pancreas transplant recipient. Transpl Infect Dis 2015; 17:289-96. [PMID: 25661804 DOI: 10.1111/tid.12351] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/13/2014] [Accepted: 12/11/2014] [Indexed: 01/23/2023]
Abstract
Acinetobacter baumannii is an important cause of healthcare-associated infections, and is particularly problematic among patients who undergo organ transplantation. We describe a case of fulminant sepsis caused by carbapenem-resistant A. baumannii harboring the blaOXA-23 carbapenemase gene and belonging to international clone II. This isolate led to the death of a patient 6 days after simultaneous kidney-pancreas transplantation. Autopsy findings revealed acute mitral valve endocarditis, myocarditis, splenic and renal emboli, peritonitis, and pneumonia. This case highlights the severe nature of certain A. baumannii infections and the vulnerability of transplanted patients to the increasingly intractable "high-risk" clones of multidrug-resistant organisms.
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Affiliation(s)
- G Patel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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42
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Engineered cationic antimicrobial peptides to overcome multidrug resistance by ESKAPE pathogens. Antimicrob Agents Chemother 2014; 59:1329-33. [PMID: 25421473 DOI: 10.1128/aac.03937-14] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multidrug resistance constitutes a threat to the medical achievements of the last 50 years. In this study, we demonstrated the abilities of two de novo engineered cationic antibiotic peptides (eCAPs), WLBU2 and WR12, to overcome resistance from 142 clinical isolates representing the most common multidrug-resistant (MDR) pathogens and to display a lower propensity to select for resistant bacteria in vitro compared to that with colistin and LL37. The results warrant an exploration of eCAPs for use in clinical settings.
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Multidrug-resistant Gram-negative bacteria in solid organ transplant recipients with bacteremias. Eur J Clin Microbiol Infect Dis 2014; 34:431-7. [PMID: 25388855 DOI: 10.1007/s10096-014-2271-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/28/2014] [Indexed: 12/11/2022]
Abstract
Bloodstream infections (BSIs) remain as life-threatening complications and are associated with significant morbidity and mortality among solid organ transplant (SOT) recipients. Multidrug-resistant (MDR) Gram-negative bacteria can cause serious bacteremias in these recipients. Reviews have aimed to investigate MDR Gram-negative bacteremias; however, they were lacking in SOT recipients in the past. To better understand the characteristics of bacteremias due to MDR Gram-negative bacteria, optimize preventive and therapeutic strategies, and improve the outcomes of SOT recipients, this review summarize the epidemiology, clinical and laboratory characteristics, and explores the mechanisms, prevention, and treatment of MDR Gram-negative bacteria.
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Ni W, Shao X, Di X, Cui J, Wang R, Liu Y. In vitro synergy of polymyxins with other antibiotics for Acinetobacter baumannii: a systematic review and meta-analysis. Int J Antimicrob Agents 2014; 45:8-18. [PMID: 25465524 DOI: 10.1016/j.ijantimicag.2014.10.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 10/01/2014] [Indexed: 01/27/2023]
Abstract
In order to provide preliminary guidance for rational antibiotic combination therapy in the clinic, a systematic review and meta-analysis was performed to evaluate the in vitro synergistic activity of polymyxins combined with other antibiotics against Acinetobacter baumannii. An extensive literature search was undertaken without restriction according to region, publication type or language. All available in vitro synergy tests on antibiotic combinations consisting of polymyxins were included. The primary outcome assessed was the in vitro activity of combination therapy on bacterial kill or inhibition. In total, 70 published studies and 31 conference proceedings reporting testing of polymyxins in combination with 11 classes consisting of 28 antibiotic types against 1484 A. baumannii strains were included in the analysis. In time-kill studies, high in vitro synergy and bactericidal activity were found for polymyxins combined with several antibiotic classes such as carbapenems and glycopeptides. Carbapenems or rifampicin combination could efficiently suppress the development of colistin resistance and displayed a >50% synergy rate against colistin-resistant strains. Synergy rates of chequerboard microdilution and Etest methods in most antibiotic combinations were generally lower than those of time-kill assays. The benefits of these antibiotic combinations should be further demonstrated by well-designed clinical studies.
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Affiliation(s)
- Wentao Ni
- Department of Respiratory Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Xiaodi Shao
- Department of Clinical Pharmacology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Xiuzhen Di
- Department of Clinical Pharmacology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Junchang Cui
- Department of Respiratory Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Rui Wang
- Department of Clinical Pharmacology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Youning Liu
- Department of Respiratory Diseases, Chinese People's Liberation Army General Hospital, Beijing 100853, China.
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Santoro-Lopes G, Gouvêa EFD. Multidrug-resistant bacterial infections after liver transplantation: An ever-growing challenge. World J Gastroenterol 2014; 20:6201-6210. [PMID: 24876740 PMCID: PMC4033457 DOI: 10.3748/wjg.v20.i20.6201] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/20/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are a leading cause of morbidity and mortality among solid organ transplant recipients. Over the last two decades, various multidrug-resistant (MDR) pathogens have emerged as relevant causes of infection in this population. Although this fact reflects the spread of MDR pathogens in health care facilities worldwide, several factors relating to the care of transplant donor candidates and recipients render these patients particularly prone to the acquisition of MDR bacteria and increase the likelihood of MDR infectious outbreaks in transplant units. The awareness of this high vulnerability of transplant recipients to infection leads to the more frequent use of broad-spectrum empiric antibiotic therapy, which further contributes to the selection of drug resistance. This vicious cycle is difficult to avoid and leads to a scenario of increased complexity and narrowed therapeutic options. Infection by MDR pathogens is more frequently associated with a failure to start appropriate empiric antimicrobial therapy. The lack of appropriate treatment may contribute to the high mortality occurring in transplant recipients with MDR infections. Furthermore, high therapeutic failure rates have been observed in patients infected with extensively-resistant pathogens, such as carbapenem-resistant Enterobacteriaceae, for which optimal treatment remains undefined. In such a context, the careful implementation of preventive strategies is of utmost importance to minimize the negative impact that MDR infections may have on the outcome of liver transplant recipients. This article reviews the current literature regarding the incidence and outcome of MDR infections in liver transplant recipients, and summarizes current preventive and therapeutic recommendations.
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Abstract
Combination antibiotic therapy for Gram-negative sepsis is controversial. The present review provides a brief summary of the existing knowledge on combination therapy for severe infections with multidrug-resistant Pseudomonas spp., Acinetobacter spp., and Enterobacteriaceae. Empirical combination antibiotic therapy is recommended for severe sepsis and septic shock to reduce mortality related to inappropriate antibiotic treatment. Because definitive combination therapy has not been proven superior to monotherapy in meta-analyses, it is generally advised to de-escalate antibiotic therapy when the antibiotic susceptibility profile is known, although it cannot be excluded that some subgroups of patients might still benefit from continued combination therapy. Definitive combination therapy is recommended for carbapenemase-producing Enterobacteriaceae and should also be considered for severe infections with Pseudomonas and Acinetobacter spp. when beta-lactams cannot be used. Because resistance to broad-spectrum beta-lactams is increasing in Gram-negative bacteria and because no new antibiotics are expected to become available in the near future, the antibacterial potential of combination therapy should be further explored. In vitro data suggest that combinations can be effective even if the bacteria are resistant to the individual antibiotics, although existing evidence is insufficient to support the choice of combinations and explain the synergistic effects observed. In vitro models can be used to screen for effective combinations that can later be validated in animal or clinical studies. Further, in the absence of clinical evidence, in vitro data might be useful in supporting therapeutic decisions for severe infections with multidrug-resistant Gram-negative bacteria.
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Affiliation(s)
- Thomas Tängdén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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47
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Freire M, Van Der Heijden I, do Prado G, Cavalcante L, Boszczowski I, Bonazzi P, Rossi F, Guimarães T, D'Albuquerque L, Costa S, Abdala E. Polymyxin use as a risk factor for colonization or infection with polymyxin-resistantAcinetobacter baumanniiafter liver transplantation. Transpl Infect Dis 2014; 16:369-78. [DOI: 10.1111/tid.12210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/22/2013] [Accepted: 11/24/2013] [Indexed: 11/29/2022]
Affiliation(s)
- M.P. Freire
- Infection Control Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - I.M. Van Der Heijden
- Microbiology Research Laboratory; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - G.V.B. do Prado
- Infection Control Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - L.S. Cavalcante
- Microbiology Research Laboratory; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - I. Boszczowski
- Infection Control Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - P.R. Bonazzi
- Liver and Gastrointestinal Transplant Division; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - F. Rossi
- Microbiology Laboratory; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - T. Guimarães
- Infection Control Service; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - L.A.C. D'Albuquerque
- Liver and Gastrointestinal Transplant Division; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
| | - S.F. Costa
- Microbiology Research Laboratory; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
- Department of Infectious Diseases; University of São Paulo School of Medicine; São Paulo Brazil
| | - E. Abdala
- Liver and Gastrointestinal Transplant Division; Hospital das Clínicas; University of São Paulo School of Medicine; São Paulo Brazil
- Department of Infectious Diseases; University of São Paulo School of Medicine; São Paulo Brazil
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Patel G, Rana MM, Huprikar S. Multidrug-resistant bacteria in organ transplantation: an emerging threat with limited therapeutic options. Curr Infect Dis Rep 2013; 15:504-13. [PMID: 24101302 DOI: 10.1007/s11908-013-0371-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Multidrug-resistant organisms (MDROs) are an emerging threat in solid organ transplantation (SOT). The changing epidemiology of these MDROs is reviewed along with the growing evidence regarding risk factors and outcomes associated with both colonization and infection in SOT. The management of these infections is complicated by the lack of antimicrobial agents available to treat these infections, and only a handful of new agents, especially for the treatment of MDR GNR infections, are being evaluated in clinical trials. Due to the increased prevalence of MDROs and limited treatment options, as well as organ shortages, transplant candidacy and use of organs from donors with evidence of MDRO colonization and/or infection remain controversial. Increasing collaboration between transplant programs, individual practitioners, infection control programs, and researchers in antimicrobial development will be needed to face this challenge.
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Affiliation(s)
- Gopi Patel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1090, New York, NY, 10029, USA,
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In vitro responses of Acinetobacter baumannii to two- and three-drug combinations following exposure to colistin and doripenem. Antimicrob Agents Chemother 2013; 58:1195-9. [PMID: 24247139 DOI: 10.1128/aac.01779-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We compared in vitro killing of colistin, doripenem, and sulbactam by time-kill methods against Acinetobacter baumannii isolates collected from patients before and after colistin-doripenem treatment (initial and recurrent isolates, respectively). Colistin-doripenem bactericidal activity against recurrent isolates was attenuated (mean log10 kill, -5.74 versus -2.88; P = 0.01) but was restored by adding sulbactam. Doripenem MICs rather than colistin MICs correlated with the activity of colistin-doripenem. Among colistin-resistant isolates, colistin-doripenem-sulbactam combinations achieved greater killing than colistin-doripenem alone (-5.65 versus -2.43; P = 0.04).
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Systematic review and meta-analysis of in vitro synergy of polymyxins and carbapenems. Antimicrob Agents Chemother 2013; 57:5104-11. [PMID: 23917322 DOI: 10.1128/aac.01230-13] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Our objective was to examine the evidence of in vitro synergy of polymyxin-carbapenem combination therapy against Gram-negative bacteria (GNB). A systematic review and meta-analysis were performed. All studies examining in vitro interactions of antibiotic combinations consisting of any carbapenem with colistin or polymyxin B against any GNB were used. A broad search was conducted with no language, date, or publication status restrictions. Synergy rates, defined as a fractional inhibitory concentration index of ≤0.5 or a >2-log reduction in CFU, were pooled separately for time-kill, checkerboard, and Etest methods in a mixed-effect meta-analysis of rates. We examined whether the synergy rate depended on the testing method, type of antibiotic, bacteria, and resistance to carbapenems. Pooled rates with 95% confidence intervals (CI) are shown. Thirty-nine published studies and 15 conference proceeding were included, reporting on 246 different tests on 1,054 bacterial isolates. In time-kill studies, combination therapy showed synergy rates of 77% (95% CI, 64 to 87%) for Acinetobacter baumannii, 44% (95% CI, 30 to 59%) for Klebsiella pneumoniae, and 50% (95% CI, 30 to 69%) for Pseudomonas aeruginosa, with low antagonism rates for all. Doripenem showed high synergy rates for all three bacteria. For A. baumannii, meropenem was more synergistic than imipenem, whereas for P. aeruginosa the opposite was true. Checkerboard and Etest studies generally reported lower synergy rates than time-kill studies. The use of combination therapy led to less resistance development in vitro. The combination of a carbapenem with a polymyxin against GNB, especially A. baumannii, is supported in vitro by high synergy rates, with low antagonism and less resistance development. These findings should be examined in clinical studies.
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