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Rodjun V, Montakantikul P, Houngsaitong J, Jitaree K, Nosoongnoen W. Pharmacokinetic/pharmacodynamic (PK/PD) simulation for dosage optimization of colistin and sitafloxacin, alone and in combination, against carbapenem-, multidrug-, and colistin-resistant Acinetobacter baumannii. Front Microbiol 2023; 14:1275909. [PMID: 38098659 PMCID: PMC10720588 DOI: 10.3389/fmicb.2023.1275909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/15/2023] [Indexed: 12/17/2023] Open
Abstract
To the best of our knowledge, to date, no study has investigated the optimal dosage regimens of either colistin or sitafloxacin against drug-resistant Acinetobacter baumannii (A. baumannii) infections by using specific parameters. In the current study, we aimed to explore the optimal dosage regimens of colistin and sitafloxacin, either in monotherapy or in combination therapy, for the treatment of carbapenem-, multidrug-, and colistin-resistant A. baumannii infections. A Monte Carlo simulation was applied to determine the dosage regimen that could achieve the optimal probability of target attainment (PTA) and cumulative fraction of response (CFR) (≥90%) based on the specific parameters of each agent and the minimal inhibitory concentration (MIC) of the clinical isolates. This study explored the dosage regimen of 90, 50, 30, and 10 mL/min for patients with creatinine clearance (CrCL). We also explored the dosage regimen for each patient with CrCL using combination therapy because there is a higher possibility of reaching the desired PTA or CFR. Focusing on the MIC90 of each agent in combination therapy, the dosage regimen for colistin was a loading dose of 300 mg followed by a maintenance dose ranging from 50 mg every 48 h to 225 mg every 12 h and the dosage regimen for sitafloxacin was 325 mg every 48 h to 750 mg every 12 h. We concluded that a lower-than-usual dose of colistin based on specific pharmacokinetic data in combination with a higher-than-usual dose of sitafloxacin could be an option for the treatment of carbapenem-, multidrug-, and colistin-resistant. A. baumannii. The lower dose of colistin might show a low probability of adverse reaction, while the high dose of sitafloxacin should be considered. In the current study, we attempted to find if there is a strong possibility of drug selection against crucial drug-resistant pathogen infections in a situation where there is a lack of new antibiotics. However, further study is needed to confirm the results of this simulation study.
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Affiliation(s)
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Jantana Houngsaitong
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Kamonchanok Jitaree
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Wichit Nosoongnoen
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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Yedle R, Reniguntla MK, Puttaswamy R, Puttarangappa P, Hiremath S, Nanjundappa M, Jayaraman R. Neutropenic Rat Thigh Infection Model for Evaluation of the Pharmacokinetics/Pharmacodynamics of Anti-Infectives. Microbiol Spectr 2023; 11:e0013323. [PMID: 37260385 PMCID: PMC10433970 DOI: 10.1128/spectrum.00133-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023] Open
Abstract
The neutropenic mouse infection model is extensively used to characterize the pharmacokinetics/pharmacodynamics (PK/PD) of anti-infective agents. However, it is difficult to evaluate agents following intravenous (i.v.) infusions using this model. Furthermore, in many drug discovery programs, lead identification and optimization is performed in rats, and pharmacology is performed in mice. Alternative models of infection are needed for robust predictions of PK/PD in humans. The rat is an alternative model of infection which can overcome the shortcomings of the mouse model. However, the rat neutropenic thigh infection (NTI) model has not been adequately characterized for evaluation of the PK/PD of anti-infectives. The aim of this study was to characterize the PK/PD of ciprofloxacin against bacterial pathogens in a rat NTI model. We studied the PK/PD relationships of ciprofloxacin against wild-type Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae in neutropenic Wistar rats following administration of 10, 30, and 100 mg/kg as single intravenous boluses and 30- and 60-min infusions. The PK/PD of ciprofloxacin against all four pathogens was AUC/MIC dependent and independent of the duration of administration at 10, 30, and 100 mg/kg. At human-equivalent rat doses, the PK/PD targets of ciprofloxacin achieved in rats for microbiological cure were similar to those reported in human patients. The neutropenic rat thigh infection model can be used to evaluate anti-infective agents intended to be administered as infusions in the clinic, and it complements the mouse model, increasing the robustness of PK/PD predictions in humans. IMPORTANCE Many antibiotics are administered as intravenous infusions in the clinic, especially in intensive care units. Anti-infective drug discovery companies develop clinical candidates that are intended to be administered as i.v. infusions in the clinic. However, there are no well-characterized models with which they can evaluate the PK/PD of the candidates following i.v. infusions. The neutropenic rat thigh infection model reported in this study helps in evaluating anti-infective agents that are intended to be administered as i.v. infusions in the clinic. The rat model is useful for simulating the clinical conditions for i.v. infusions for treatment of infections, such as acute bacterial skin and skin structure, lung, and urinary tract infections. This model is predictive of efficacy in humans and can serve as an additional confirmatory model, along with the mouse model, for determining the proof of concept and for making robust predictions of efficacy in humans.
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Affiliation(s)
- Randhir Yedle
- TheraIndx Lifesciences Pvt. Ltd., Nelamangala, Bangalore, India
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3
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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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Abstract
Antibiotic resistance is a major global health challenge and, worryingly, several key Gram negative pathogens can become resistant to most currently available antibiotics. Polymyxins have been revived as a last-line therapeutic option for the treatment of infections caused by multidrug-resistant Gram negative bacteria, in particular Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacterales. Polymyxins were first discovered in the late 1940s but were abandoned soon after their approval in the late 1950s as a result of toxicities (e.g., nephrotoxicity) and the availability of "safer" antibiotics approved at that time. Therefore, knowledge on polymyxins had been scarce until recently, when enormous efforts have been made by several research teams around the world to elucidate the chemical, microbiological, pharmacokinetic/pharmacodynamic, and toxicological properties of polymyxins. One of the major achievements is the development of the first scientifically based dosage regimens for colistin that are crucial to ensure its safe and effective use in patients. Although the guideline has not been developed for polymyxin B, a large clinical trial is currently being conducted to optimize its clinical use. Importantly, several novel, safer polymyxin-like lipopeptides are developed to overcome the nephrotoxicity, poor efficacy against pulmonary infections, and narrow therapeutic windows of the currently used polymyxin B and colistin. This review discusses the latest achievements on polymyxins and highlights the major challenges ahead in optimizing their clinical use and discovering new-generation polymyxins. To save lives from the deadly infections caused by Gram negative "superbugs," every effort must be made to improve the clinical utility of the last-line polymyxins. SIGNIFICANCE STATEMENT: Antimicrobial resistance poses a significant threat to global health. The increasing prevalence of multidrug-resistant (MDR) bacterial infections has been highlighted by leading global health organizations and authorities. Polymyxins are a last-line defense against difficult-to-treat MDR Gram negative pathogens. Unfortunately, the pharmacological information on polymyxins was very limited until recently. This review provides a comprehensive overview on the major achievements and challenges in polymyxin pharmacology and clinical use and how the recent findings have been employed to improve clinical practice worldwide.
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Affiliation(s)
- Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Mohammad A K Azad
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Tony Velkov
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Qi Tony Zhou
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
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5
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Niu H, Yang T, Wang J, Wang R, Cai Y. Immunomodulatory Effect of Colistin and its Protective Role in Rats with Methicillin-Resistant Staphylococcus aureus-induced Pneumonia. Front Pharmacol 2021; 11:602054. [PMID: 33551807 PMCID: PMC7854386 DOI: 10.3389/fphar.2020.602054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: Colistin is the last resort of antimicrobials against multi-drug resistant Gram-negative pathogens. Previous studies in Caenorhabditis elegans and macrophages of rats have suggested that colistin possesses the immunomodulatory properties by acting p38/MAPK pathway. Here, we aimed to confirm the immunomodulatory role of colistin in animal models. Methods: Rat model of Methicillin-resistant Staphylococcus aureus (MRSA)-induced pneumonia was established. Plasma concentrations of proinflammatory cytokines, quantitative bacteriology, histology and immunohistochemistry of lungs were assessed to compare the immunomodulatory properties of colistin pre-administration. Results: The numbers of white blood cells and granulocytes were significantly increased in the 9 mg/kg colistin pre-administration group at 72 h after infection. Levels of TNF-α, IL-6 and IL-1β in plasma after colistin pre-administration were lower compared with the infected group without treatment. Colistin pre-treatment resulted in lower bacterial counts, a dramatic decrease of cytokines and improved histopathological injury in infected lung tissues compared with the untreated animals. However, p38/MAPK inhibitor SB203580 did not fully block the above-mentioned effects caused by colistin. Conclusion: Pre-administration of colistin could attenuate an excessive inflammatory reaction and protect the lungs from MRSA-associated damages. However, these effects could not be reversed by blocking the p38/MAPK pathway alone. Collectively, the mechanism underlying the immunoregulatory effects of colistin in mammals needs to be further explored.
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Affiliation(s)
- Hui Niu
- Department of Pharmacy, Center of Medicine Clinical Research, Medical Supplies Center of PLA General Hospital, Beijing, China
| | - Tianli Yang
- Department of Pharmacy, Center of Medicine Clinical Research, Medical Supplies Center of PLA General Hospital, Beijing, China
| | - Jin Wang
- Department of Pharmacy, Center of Medicine Clinical Research, Medical Supplies Center of PLA General Hospital, Beijing, China
| | - Rui Wang
- Department of Pharmacy, Center of Medicine Clinical Research, Medical Supplies Center of PLA General Hospital, Beijing, China
| | - Yun Cai
- Department of Pharmacy, Center of Medicine Clinical Research, Medical Supplies Center of PLA General Hospital, Beijing, China
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Lee W, Cai Y, Lim TP, Teo J, Chua SC, Kwa ALH. In vitro Pharmacodynamics and PK/PD in Animals. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1145:105-116. [PMID: 31364074 DOI: 10.1007/978-3-030-16373-0_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
In the last decade, considerable advancements have been made to identify the pharmacokinetic/pharmacodynamic (PK/PD) index that defines the antimicrobial activity of polymyxins. Dose-fractionation studies performed in hollow-fiber models found that altering the dosing schedule had little impact on the killing or suppression of resistance emergence, alluding to AUC/MIC as the pharmacodynamic index that best describes polymyxin's activity. For in vivo efficacy, the PK/PD index that was the most predictive of the antibacterial effect of colistin against P. aeruginosa and A. baumannii was ƒAUC/MIC.
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Affiliation(s)
- Winnie Lee
- Singapore General Hospital, Singapore, Singapore
| | - Yiying Cai
- Singapore General Hospital, Singapore, Singapore
| | - Tze-Peng Lim
- Singapore General Hospital, Singapore, Singapore
| | - Jocelyn Teo
- Singapore General Hospital, Singapore, Singapore
| | - Sonja Courtney Chua
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Andrea Lay-Hoon Kwa
- Singapore General Hospital, Singapore, Singapore. .,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore. .,Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore.
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7
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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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8
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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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9
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Tran TB, Bergen PJ, Creek DJ, Velkov T, Li J. Synergistic Killing of Polymyxin B in Combination With the Antineoplastic Drug Mitotane Against Polymyxin-Susceptible and -Resistant Acinetobacter baumannii: A Metabolomic Study. Front Pharmacol 2018; 9:359. [PMID: 29713282 PMCID: PMC5911485 DOI: 10.3389/fphar.2018.00359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/27/2018] [Indexed: 12/16/2022] Open
Abstract
Polymyxins are currently used as the last-resort antibiotics against multidrug-resistant Acinetobacter baumannii. As resistance to polymyxins emerges in A. baumannii with monotherapy, combination therapy is often the only remaining treatment option. A novel approach is to employ the combination of polymyxin B with non-antibiotic drugs. In the present study, we employed metabolomics to investigate the synergistic mechanism of polymyxin B in combination with the antineoplastic drug mitotane against polymyxin-susceptible and -resistant A. baumannii. The metabolomes of four A. baumannii strains were analyzed following treatment with polymyxin B, mitotane and the combination. Polymyxin B monotherapy induced significant perturbation in glycerophospholipid (GPL) metabolism and histidine degradation pathways in polymyxin-susceptible strains, and minimal perturbation in polymyxin-resistant strains. Mitotane monotherapy induced minimal perturbation in the polymyxin-susceptible strains, but caused significant perturbation in GPL metabolism, pentose phosphate pathway and histidine degradation in the LPS-deficient polymyxin-resistant strain (FADDI-AB065). The polymyxin B – mitotane combination induced significant perturbation in all strains except the lipid A modified polymyxin-resistant FADDI-AB225 strain. For the polymyxin-susceptible strains, the combination therapy significantly perturbed GPL metabolism, pentose phosphate pathway, citric acid cycle, pyrimidine ribonucleotide biogenesis, guanine ribonucleotide biogenesis, and histidine degradation. Against FADDI-AB065, the combination significantly perturbed GPL metabolism, pentose phosphate pathway, citric acid cycle, and pyrimidine ribonucleotide biogenesis. Overall, these novel findings demonstrate that the disruption of the citric acid cycle and inhibition of nucleotide biogenesis are the key metabolic features associated with synergistic bacterial killing by the combination against polymyxin-susceptible and -resistant A. baumannii.
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Affiliation(s)
- Thien B Tran
- Monash Biomedicine Discovery Institute, Department of Microbiology, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Phillip J Bergen
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Darren J Creek
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Tony Velkov
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, School of Biomedical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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10
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Hua Y, Luo T, Yang Y, Dong D, Wang R, Wang Y, Xu M, Guo X, Hu F, He P. Phage Therapy as a Promising New Treatment for Lung Infection Caused by Carbapenem-Resistant Acinetobacter baumannii in Mice. Front Microbiol 2018; 8:2659. [PMID: 29375524 PMCID: PMC5767256 DOI: 10.3389/fmicb.2017.02659] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022] Open
Abstract
Carbapenem-resistant Acinetobacter baumannii (CRAB) which is noted as a major pathogen associated with healthcare-associated infections has steadily developed beyond antibiotic control. Lytic bacteriophages with the characteristics of infecting and lysing specific bacteria have been used as a potential alternative to traditional antibiotics to solve multidrug-resistant bacterial infections. Here, we isolated A. baumannii-specific lytic phages and evaluated their potential therapeutic effect against lung infection caused by CRAB clinical strains. The combined lysis spectrum of four lytic phages' ranges was 87.5% (42 of 48) against CRAB clinical isolates. Genome sequence and analysis indicated that phage SH-Ab15519 is a novel phage which does not contain the virulence or antibiotic resistance genes. In vivo study indicated that phage SH-Ab15519 administered intranasally can effectively rescue mice from lethal A. baumannii lung infection without deleterious side effects. Our work explores the potential use of phages as an alternative therapeutic agent against the lung infection caused by CRAB strains.
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Affiliation(s)
- Yunfen Hua
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, China.,Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tingting Luo
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, China.,Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqi Yang
- Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dong Dong
- Institute of Antibiotics, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Rui Wang
- Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanjun Wang
- Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mengsha Xu
- College of Pharmaceutical Sciences, Zhejiang University of Technology, Hangzhou, China.,Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaokui Guo
- Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ping He
- Department of Medical Microbiology and Immunology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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11
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Karaiskos I, Antoniadou A, Giamarellou H. Combination therapy for extensively-drug resistant gram-negative bacteria. Expert Rev Anti Infect Ther 2017; 15:1123-1140. [DOI: 10.1080/14787210.2017.1410434] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ilias Karaiskos
- 6th Department of Internal Medicine, Hygeia General hospital, Athens, Greece
| | - Anastasia Antoniadou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens School of Medicine, University General Hospital ATTIKON, Athens, Greece
| | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General hospital, Athens, Greece
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12
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Razavi Nikoo H, Ardebili A, Mardaneh J. Systematic Review of Antimicrobial Resistance of Clinical Acinetobacter baumannii Isolates in Iran: An Update. Microb Drug Resist 2017; 23:744-756. [PMID: 28085571 DOI: 10.1089/mdr.2016.0118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Treatment of Acinetobacter baumannii has become a medical challenge because of the increasing incidence of multiresistant strains and a lack of viable treatment alternatives. This systematic review attempts to investigate the changes in resistance of A. baumannii to different classes of antibiotics in Iran, with emphasis on the antimicrobial activity of polymyxin B (PMB) and colistin (COL). Biomedical databases were searched for English-published articles evaluating microbiological activity of various antimicrobial agents, including PMB and COL. Then, the available data were extracted and analyzed. Thirty-one studies, published from 2009 to 2015, were identified which contain data for 3,018 A. baumannii clinical isolates. With the exception of polymyxins and tigecycline (TIG), there was a high rate of resistance to various groups of antibiotics, including carbapenems. The minimum inhibitory concentration (MIC) ranges for PMB and COL on A. baumannii isolates tested were 0.12-64 μg/ml and 0.001-128 μg/ml, respectively. Polymyxins showed adequate activity with no significant trends in the resistance rate during most of the study period. The incidence of resistance to TIG was estimated low from 2% to 38.4% among the majority of A. baumannii. The present systematic review of the published literatures revealed that multidrug-resistant (including carbapenem-resistant) strains of A. baumannii have increased in Iran. In these circumstances, the older antibiotics, such as COL or PMB, preferably in combination with other antimicrobials (rifampicin, meropenem), could be considered as the therapeutic solution against the healthcare-associated infections. Designing rational dosage regimens for patients to maximize the antimicrobial activity and minimize the emergence and prevalence of resistance is recommended.
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Affiliation(s)
- Hadi Razavi Nikoo
- 1 Laboratory Sciences Research Center, Golestan University of Medical Sciences , Gorgan, Iran
- 2 Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences , Gorgan, Iran
| | - Abdollah Ardebili
- 1 Laboratory Sciences Research Center, Golestan University of Medical Sciences , Gorgan, Iran
- 2 Department of Microbiology, Faculty of Medicine, Golestan University of Medical Sciences , Gorgan, Iran
| | - Jalal Mardaneh
- 3 Department of Microbiology, Faculty of Medicine, Gonabad University of Medical Sciences , Gonabad, Iran
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Cooper TW, Pass SE, Brouse SD, Hall RG. Can Pharmacokinetic and Pharmacodynamic Principles Be Applied to the Treatment of Multidrug-Resistant Acinetobacter? Ann Pharmacother 2017; 45:229-40. [DOI: 10.1345/aph.1p187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE: To discuss treatment options that can be used for treatment of Acinetobacter infections. DATA SOURCES: A MEDLINE search (1966-November 2010) was conducted to identify English-language literature on pharmacotherapy of Acinetobacter and the bibliographies of pertinent articles. Programs and abstracts from infectious diseases meetings were also searched. Search terms included Acinetobacter, multidrug resistance, pharmacokinetics, pharmacodynamics, Monte Carlo simulation, nosocomial pneumonia, carbapenems, polymyxins, sulbactam, aminoglycosides, tetracyclines, tigecycline, rifampin, and fluoroquinolones. DATA SELECTION AND DATA EXTRACTION: All articles were critically evaluated and all pertinent information was included in this review. DATA SYNTHESIS: Multidrug resistant (MDR) Acinetobacter, defined as resistance to 3 or more antimicrobial classes, has increased over the past decade. The incidence of carbapenem-resistant Acinetobacter is also increasing, leading to an increased use of dose optimization techniques and/or alternative antimicrobials, which is driven by local susceptibility patterns. However, Acinetobacter infections that are resistant to all commercially available antibiotics have been reported. General principles are available to guide dose optimization of aminoglycosides, β-lactams, fluoroquinolones, and tigecycline for infections due to gram-negative pathogens. Unfortunately, data specific to patients with Acinetobacter infections are limited. Recent pharmacokinetic-pharmacodynamic information has shed light on colistin dosing. The dilemma with colistin is its concentration-dependent killing, which makes once-daily dosing seem like an attractive option, but its short postantibiotic effect limits a clinician's ability to extend the dosing interval. Localized delivery of antimicrobials is also an attractive option due to the ability to increase drug concentration at the infection site while minimizing systemic adverse events, but more data are needed regarding this approach. CONCLUSIONS: Increased reliance on dosage optimization, combination therapy, and localized delivery of antimicrobials are methods to pursue positive clinical outcomes in MDR Acinetobacter infections since novel antimicrobials will not be available for several years. Well-designed clinical trials with MDR Acinetobacter are needed to define the best treatment options for these patients.
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Lee CR, Lee JH, Park M, Park KS, Bae IK, Kim YB, Cha CJ, Jeong BC, Lee SH. Biology of Acinetobacter baumannii: Pathogenesis, Antibiotic Resistance Mechanisms, and Prospective Treatment Options. Front Cell Infect Microbiol 2017; 7:55. [PMID: 28348979 PMCID: PMC5346588 DOI: 10.3389/fcimb.2017.00055] [Citation(s) in RCA: 510] [Impact Index Per Article: 72.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/13/2017] [Indexed: 12/27/2022] Open
Abstract
Acinetobacter baumannii is undoubtedly one of the most successful pathogens responsible for hospital-acquired nosocomial infections in the modern healthcare system. Due to the prevalence of infections and outbreaks caused by multi-drug resistant A. baumannii, few antibiotics are effective for treating infections caused by this pathogen. To overcome this problem, knowledge of the pathogenesis and antibiotic resistance mechanisms of A. baumannii is important. In this review, we summarize current studies on the virulence factors that contribute to A. baumannii pathogenesis, including porins, capsular polysaccharides, lipopolysaccharides, phospholipases, outer membrane vesicles, metal acquisition systems, and protein secretion systems. Mechanisms of antibiotic resistance of this organism, including acquirement of β-lactamases, up-regulation of multidrug efflux pumps, modification of aminoglycosides, permeability defects, and alteration of target sites, are also discussed. Lastly, novel prospective treatment options for infections caused by multi-drug resistant A. baumannii are summarized.
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Affiliation(s)
- Chang-Ro Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea
| | - Jung Hun Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea
| | - Moonhee Park
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji UniversityYongin, South Korea; DNA Analysis Division, Seoul Institute, National Forensic ServiceSeoul, South Korea
| | - Kwang Seung Park
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea
| | - Il Kwon Bae
- Department of Dental Hygiene, College of Health and Welfare, Silla University Busan, South Korea
| | - Young Bae Kim
- Biotechnology Program, North Shore Community College Danvers, MA, USA
| | - Chang-Jun Cha
- Department of Systems Biotechnology, College of Biotechnology and Natural Resources, Chung-Ang University Anseong, South Korea
| | - Byeong Chul Jeong
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea
| | - Sang Hee Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University Yongin, South Korea
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15
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Zhang X, Guo F, Shao H, Zheng X. Clinical translation of polymyxin-based combination therapy: Facts, challenges and future opportunities. J Infect 2016; 74:118-130. [PMID: 27998750 DOI: 10.1016/j.jinf.2016.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/18/2016] [Accepted: 11/27/2016] [Indexed: 10/20/2022]
Abstract
The emergence and spread of multidrug resistant Gram-negative bacteria has led to a resurgence in the clinical use of polymyxin antibiotics. However, the prevalence of polymyxin resistance is on the rise at an alarming rate, motivating the idea of combination therapy to sustain the revival of these "old" antibiotics. Although ample evidence in favor of combination therapy has emerged, it seems impracticable and confusing to find a promising combination from the diverse reports or gain adequate information on the efficacy and safety profile. With a stagnating discovery pipeline of novel antimicrobials, there is a clear need to fill the knowledge gaps in translating these basic research data to beneficial clinical practice. In this review, we examined the factors and ambiguities that stand as major hurdles in bringing polymyxin combination therapy to bedside care, highlighting the importance and urgency of incorporating translational research insights into areas of difficulty. We also discussed future research priorities that are essential to gather the necessary evidence and insights for promoting the best possible use of polymyxins in combination therapy.
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Affiliation(s)
- Xueli Zhang
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Hua Shao
- Department of Pharmacy, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China.
| | - Xiao Zheng
- State Key Laboratory of Natural Medicines, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China.
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16
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Ceylan B, Arslan F, Sipahi OR, Sunbul M, Ormen B, Hakyemez İN, Turunc T, Yıldız Y, Karsen H, Karagoz G, Tekin R, Hizarci B, Turhan V, Senol S, Oztoprak N, Yılmaz M, Ozdemir K, Mermer S, Kokoglu OF, Mert A. Variables determining mortality in patients with Acinetobacter baumannii meningitis/ventriculitis treated with intrathecal colistin. Clin Neurol Neurosurg 2016; 153:43-49. [PMID: 28013184 DOI: 10.1016/j.clineuro.2016.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/03/2016] [Accepted: 12/13/2016] [Indexed: 12/01/2022]
Abstract
AIM To examine the variables associated with mortality in patients with Acinetobacter baumannii-related central nervous system infections treated with intrathecal colistin. MATERIALS AND METHODS This multi-centre retrospective case control study included patients from 11 centres in Turkey, as well as cases found during a literature review. Only patients with CNS infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii treated with intrathecal colistin were included in this study. The variables associated with mortality were determined by dividing the patients into groups who died or survived during hospitalisation, and who died or survived from Acinetobacter meningitis. RESULTS Among the 77 cases enrolled in the study, 35 were found through a literature review and 42 were cases from our centres. Forty-four cases (57.1%) were male and the median age was 48 years (range: 20-78 years). Thirty-seven patients (48%) died during hospitalisation. The variables associated with increased all-cause mortality during hospitalisation included old age (odds ratio, 1.035; 95% confidence interval (CI), 1.004-1.067; p=0.026) and failure to provide cerebrospinal fluid sterilisation (odds ratio, 0.264; 95% confidence interval, 0.097-0.724; p=0.01). There is a trend (P=0.062) towards higher mortality with using of meropenem during meningitis treatment. Fifteen cases (19%) died from meningitis. There were no significant predictors of meningitis-related mortality. CONCLUSIONS The mortality rate for central nervous system infections caused by multidrug-resistant or extensively drug-resistant Acinetobacter baumannii is high. Old age and failure to provide CSF sterilisation are associated with increased mortality during hospitalisation.
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Affiliation(s)
- Bahadır Ceylan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medipol University, Turkey
| | - Ferhat Arslan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medeniyet University, Goztepe, Istanbul, Turkey.
| | - Oguz Resat Sipahi
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Mustafa Sunbul
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, 19 Mayıs University, Samsun, Turkey
| | - Bahar Ormen
- Department of Infectious Disease and Clinical Microbiology, Atatürk Education and Training Hospital, Izmir, Turkey
| | - İsmail N Hakyemez
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine,Vakıf Gureba Bezmi Alem University, Istanbul, Turkey
| | - Tuba Turunc
- Department of Infectious Diseases and Clinical Microbiology, Baskent University, Adana, Turkey
| | - Yeşim Yıldız
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hasan Karsen
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Harran University, Şanlıurfa, Turkey
| | - Gul Karagoz
- Department of Infectious Diseases and Clinical Microbiology, Umraniye Education and Training Hospital, Istanbul, Turkey
| | - Recep Tekin
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Dicle University, Diyarbakır, Turkey
| | - Burcu Hizarci
- Department of Anesthesiology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Vedat Turhan
- Department of Infectious Diseases and Clinical Microbiology, Sultan Abdulhamid Education and Training Hospital, Istanbul, Turkey
| | - Sebnem Senol
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology, Antalya Education and Training Hospital, Antalya, Turkey
| | - Mesut Yılmaz
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medipol University, Turkey
| | - Kevser Ozdemir
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Sinan Mermer
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Omer F Kokoglu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Sutcu Imam University, Kahramanmaras, Turkey
| | - Ali Mert
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medipol University, Turkey
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17
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Miller SE, Bell CS, McClain MS, Cover TL, Giorgio TD. Dynamic Computational Model of Symptomatic Bacteremia to Inform Bacterial Separation Treatment Requirements. PLoS One 2016; 11:e0163167. [PMID: 27657881 PMCID: PMC5033423 DOI: 10.1371/journal.pone.0163167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/02/2016] [Indexed: 11/21/2022] Open
Abstract
The rise of multi-drug resistance has decreased the effectiveness of antibiotics, which has led to increased mortality rates associated with symptomatic bacteremia, or bacterial sepsis. To combat decreasing antibiotic effectiveness, extracorporeal bacterial separation approaches have been proposed to capture and separate bacteria from blood. However, bacteremia is dynamic and involves host-pathogen interactions across various anatomical sites. We developed a mathematical model that quantitatively describes the kinetics of pathogenesis and progression of symptomatic bacteremia under various conditions, including bacterial separation therapy, to better understand disease mechanisms and quantitatively assess the biological impact of bacterial separation therapy. Model validity was tested against experimental data from published studies. This is the first multi-compartment model of symptomatic bacteremia in mammals that includes extracorporeal bacterial separation and antibiotic treatment, separately and in combination. The addition of an extracorporeal bacterial separation circuit reduced the predicted time of total bacteria clearance from the blood of an immunocompromised rodent by 49%, compared to antibiotic treatment alone. Implementation of bacterial separation therapy resulted in predicted multi-drug resistant bacterial clearance from the blood of a human in 97% less time than antibiotic treatment alone. The model also proposes a quantitative correlation between time-dependent bacterial load among tissues and bacteremia severity, analogous to the well-known ‘area under the curve’ for characterization of drug efficacy. The engineering-based mathematical model developed may be useful for informing the design of extracorporeal bacterial separation devices. This work enables the quantitative identification of the characteristics required of an extracorporeal bacteria separation device to provide biological benefit. These devices will potentially decrease the bacterial load in blood. Additionally, the devices may achieve bacterial separation rates that allow consequent acceleration of bacterial clearance in other tissues, inhibiting the progression of symptomatic bacteremia, including multi-drug resistant variations.
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Affiliation(s)
- Sinead E. Miller
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Charleson S. Bell
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Mark S. McClain
- Department of Medicine, Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Timothy L. Cover
- Department of Medicine, Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, United States of America
| | - Todd D. Giorgio
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States of America
- * E-mail:
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18
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Choi IS, Lee YJ, Wi YM, Kwan BS, Jung KH, Hong WP, Kim JM. Predictors of mortality in patients with extensively drug-resistant Acinetobacter baumannii pneumonia receiving colistin therapy. Int J Antimicrob Agents 2016; 48:175-80. [PMID: 27423416 DOI: 10.1016/j.ijantimicag.2016.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 11/19/2022]
Abstract
The ratio of the area under the free (unbound) concentration-time curve to minimum inhibitory concentration (fAUC/MIC) was proposed to be the pharmacokinetic/pharmacodynamic index most strongly linked to the antibacterial effect of colistin against Acinetobacter baumannii. A retrospective study of patients who received colistin to treat pneumonia caused by extensively drug-resistant (XDR) A. baumannii over a 4-year period was performed to assess the impact of the colistin MIC on mortality. A total of 227 patients were included in the analysis. The 7-day and 14-day mortality rates of patients with XDR A. baumannii pneumonia receiving colistin therapy were 15.0% and 23.8%, respectively. In the multivariate analysis, Acute Physiology and Chronic Health Evaluation (APACHE) II score, days from index culture to first dose of colistin, underlying tumour and septic shock at presentation were independent predictors of mortality in patients with XDR A. baumannii pneumonia receiving colistin therapy. In the univariate analysis, the colistin dose based on ideal body weight (IBW) correlated with patient outcome. Therefore, the use of IBW appeared to be more appropriate to calculate the colistin dosage. In addition, these results highlight the clinical significance of colistin MIC in patients with XDR A. baumannii pneumonia receiving colistin therapy. Although MICs were in the 'susceptible' range, patients infected with isolates with high colistin MICs showed a poorer clinical response rate than patients infected with isolates with low colistin MICs. Further clinical studies are needed to evaluate the roles of colistin MIC for predicting mortality in XDR A. baumannii pneumonia with a high colistin MIC.
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Affiliation(s)
- Ik Sung Choi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Yu Ji Lee
- Division of Nephrology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Yu Mi Wi
- Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea; Department of Medicine, The Graduate School of Yonsei University, Seoul, Republic of Korea.
| | - Byung Soo Kwan
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Kae Hwa Jung
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Woong Pyo Hong
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - June Myong Kim
- Department of Medicine, The Graduate School of Yonsei University, Seoul, Republic of Korea
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19
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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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20
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Combined therapy for multi-drug-resistant Acinetobacter baumannii infection – is there evidence outside the laboratory? J Med Microbiol 2015. [DOI: 10.1099/jmm.0.000144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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21
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Molloy L, Arora H, Gupta S, Sutton J, Abdel-Haq N. Multidrug-Resistant Organisms: Considerations in Antibiotic Selection and Administration. J Pediatr Intensive Care 2015; 4:87-96. [PMID: 31110857 PMCID: PMC6513150 DOI: 10.1055/s-0035-1556751] [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: 09/23/2014] [Accepted: 12/02/2014] [Indexed: 10/23/2022] Open
Abstract
Managing infections caused by multidrug-resistant organisms is a significant clinical challenge. Multidrug-resistant organisms' treatment is complicated in the pediatric population because of the lack of primary data, treatment guidelines, rapidly changing pharmacokinetic/pharmacodynamic parameters, and fewer approved antibiotic indications and dosing guidance. Treatment decisions must incorporate available pediatric data, clinical experience, and careful extrapolation from adult data while considering the unique challenges faced by children with complicated infections.
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Affiliation(s)
- Leah Molloy
- Department of Pharmacy, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Harbir Arora
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Shipra Gupta
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Jesse Sutton
- Department of Pharmacy, Baptist Health Louisville, Louisville, Kentucky, United States
| | - Nahed Abdel-Haq
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, Michigan, United States
- Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan, United States
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22
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Viehman JA, Nguyen MH, Doi Y. Treatment options for carbapenem-resistant and extensively drug-resistant Acinetobacter baumannii infections. Drugs 2015; 74:1315-33. [PMID: 25091170 DOI: 10.1007/s40265-014-0267-8] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acinetobacter baumannii is a leading cause of healthcare-associated infections worldwide. Because of various intrinsic and acquired mechanisms of resistance, most β-lactam agents are not effective against many strains, and carbapenems have played an important role in therapy. Recent trends show many infections are caused by carbapenem-resistant or even extensively drug-resistant (XDR) strains, for which effective therapy is not well established. Evidence to date suggests that colistin constitutes the backbone of therapy, but the unique pharmacokinetic properties of colistin have led many to suggest the use of combination antimicrobial therapy. However, the combination of agents and dosing regimens that delivers the best clinical efficacy while minimizing toxicity is yet to be defined. Carbapenems, sulbactam, rifampin and tigecycline have been the most studied in the context of combination therapy. Most data regarding therapy for invasive, resistant A. baumannii infections come from uncontrolled case series and retrospective analyses, though some clinical trials have been completed and others are underway. Early institution of appropriate antimicrobial therapy is shown to consistently improve survival of patients with carbapenem-resistant and XDR A. baumannii infection, but the choice of empiric therapy in these infections remains an open question. This review summarizes the most current knowledge regarding the epidemiology, mechanisms of resistance, and treatment considerations of carbapenem-resistant and XDR A. baumannii.
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Affiliation(s)
- J Alexander Viehman
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, S319 Falk Medical Building, 3601 Fifth Avenue, Pittsburgh, PA, 15213, USA
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23
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Doi Y, Murray GL, Peleg AY. Acinetobacter baumannii: evolution of antimicrobial resistance-treatment options. Semin Respir Crit Care Med 2015; 36:85-98. [PMID: 25643273 DOI: 10.1055/s-0034-1398388] [Citation(s) in RCA: 174] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The first decade of the 20th century witnessed a surge in the incidence of infections due to several highly antimicrobial-resistant bacteria in hospitals worldwide. Acinetobacter baumannii is one such organism that turned from an occasional respiratory pathogen into a major nosocomial pathogen. An increasing number of A. baumannii genome sequences have broadened our understanding of the genetic makeup of these bacteria and highlighted the extent of horizontal transfer of DNA. Animal models of disease combined with bacterial mutagenesis have provided some valuable insights into mechanisms of A. baumannii pathogenesis. Bacterial factors known to be important for disease include outer membrane porins, surface structures including capsule and lipopolysaccharide, enzymes such as phospholipase D, iron acquisition systems, and regulatory proteins. A. baumannii has a propensity to accumulate resistance to various groups of antimicrobial agents. In particular, carbapenem resistance has become commonplace, accounting for the majority of A. baumannii strains in many hospitals today. Carbapenem-resistant strains are often resistant to all other routinely tested agents. Treatment of carbapenem-resistant A. baumannii infection therefore involves the use of combinations of last resort agents such as colistin and tigecycline, but the efficacy and safety of these approaches are yet to be defined. Antimicrobial-resistant A. baumannii has high potential to spread among ill patients in intensive care units. Early recognition and timely implementation of appropriate infection control measures is crucial in preventing outbreaks.
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Affiliation(s)
- Yohei Doi
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Gerald L Murray
- Department of Microbiology, Monash University, Melbourne, Australia
| | - Anton Y Peleg
- Department of Microbiology, Monash University, Melbourne, Australia
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Zhou Q(T, Sun SP, Chan JGY, Wang P, Barraud N, Rice SA, Wang J, Li J, Chan HK. Novel Inhaled Combination Powder Containing Amorphous Colistin and Crystalline Rifapentine with Enhanced Antimicrobial Activities against Planktonic Cells and Biofilm of Pseudomonas aeruginosa for Respiratory Infections. Mol Pharm 2014; 12:2594-603. [DOI: 10.1021/mp500586p] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Qi (Tony) Zhou
- Advanced
Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
| | - Si-Ping Sun
- Advanced
Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
| | - John Gar Yan Chan
- Advanced
Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
- JHL Biotech, Inc., Zhubei City, Hsinchu County 302, Taiwan, R.O.C
| | - Ping Wang
- Advanced
Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
| | - Nicolas Barraud
- Centre
for Marine Bio-Innovation and School of Biotechnology and Biomolecular
Sciences, The University of New South Wales, Sydney, NSW 2052, Australia
| | - Scott A. Rice
- Centre
for Marine Bio-Innovation and School of Biotechnology and Biomolecular
Sciences, The University of New South Wales, Sydney, NSW 2052, Australia
- Singapore
Centre on Environmental Life Sciences Engineering, and the School
of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Jiping Wang
- Drug
Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical
Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Jian Li
- Drug
Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical
Sciences, Monash University, Parkville, Victoria 3052, Australia
| | - Hak-Kim Chan
- Advanced
Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia
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Durante-Mangoni E, Utili R, Zarrilli R. Combination therapy in severe Acinetobacter baumannii infections: an update on the evidence to date. Future Microbiol 2014; 9:773-89. [DOI: 10.2217/fmb.14.34] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
ABSTRACT: Acinetobacter baumannii is a drug-resistant Gram-negative pathogen increasingly causing hospital-acquired infections in critically ill patients. In this review, we summarize the current mechanisms of antimicrobial resistance in A. baumannii and describe in detail recent in vitro and in vivo experimental data on the activity of antimicrobial combinations against this microorganism. We then introduce the rationale for the use of combination antibiotic therapy in resistant A. baumannii infections. Finally, we present and critically discuss both uncontrolled clinical studies and the few randomized clinical trials of combination antimicrobial therapy for these infections, with a special focus on ongoing multinational trials and optimal approach to future research in this field.
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Affiliation(s)
- Emanuele Durante-Mangoni
- Internal Medicine, University of Naples S.U.N. & AORN dei Colli, Monaldi Hospital, Via L. Bianchi, Naples, Italy
| | - Riccardo Utili
- Internal Medicine, University of Naples S.U.N. & AORN dei Colli, Monaldi Hospital, Via L. Bianchi, Naples, Italy
| | - Raffaele Zarrilli
- Department of Public Health, University of Naples Federico II, Naples, Italy
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Al-Shaer M, Nazer LH, Kherallah M. Rifampicin as Adjunct to Colistin Therapy in the Treatment of Multidrug-Resistant Acinetobacter baumannii. Ann Pharmacother 2014; 48:766-71. [DOI: 10.1177/1060028014528306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate the available evidence regarding the efficacy and safety of rifampicin, as adjunct to colistin, in the treatment of multidrug resistant Acinetobacter baumannii (MDR-AB). Data Sources: We searched MEDLINE (1966 to January 2014) using the following search terms: A baumannii, drug resistance, treatment, colistin, and rifampicin and combinations. In addition, the bibliographies of relevant articles were searched for additional citations. Study Selection and Data Extraction: The search was limited to English-language references and adults. Studies in which colistin was not administered intravenously were excluded. In addition, we excluded meeting abstracts and single case reports. Data Synthesis: The search strategy identified 5 observational studies and 2 randomized controlled trials that evaluated the combination of intravenous colistin and rifampicin for the treatment of MDR-AB. All observational studies included a small sample size, and the microbiological clearance associated with the combination therapy ranged from 60% to 100%. The randomized controlled trials reported reduced time to microbiological clearance and higher microbiological eradication rate in the colistin/rifampicin group compared with colistin alone. However, there was no difference between both groups in the overall mortality, infection-related mortality, and the length of stay. Furthermore, rifampicin was associated with a higher incidence of hepatotoxicity. Conclusions: Studies evaluating the combination of rifampicin and colistin in the treatment of MDR-AB are limited. The currently available evidence does not support the addition of rifampicin to colistin because of the lack of improved clinical outcomes with the combination therapy and the risk of rifampicin-induced hepatotoxicity.
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Affiliation(s)
- Mohammad Al-Shaer
- King Hussein Cancer Center, Amman, Jordan
- Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
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27
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Batirel A, Balkan II, Karabay O, Agalar C, Akalin S, Alici O, Alp E, Altay FA, Altin N, Arslan F, Aslan T, Bekiroglu N, Cesur S, Celik AD, Dogan M, Durdu B, Duygu F, Engin A, Engin DO, Gonen I, Guclu E, Guven T, Hatipoglu CA, Hosoglu S, Karahocagil MK, Kilic AU, Ormen B, Ozdemir D, Ozer S, Oztoprak N, Sezak N, Turhan V, Turker N, Yilmaz H. Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections. Eur J Clin Microbiol Infect Dis 2014; 33:1311-22. [PMID: 24532009 DOI: 10.1007/s10096-014-2070-6] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/24/2014] [Indexed: 02/06/2023]
Abstract
The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.
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Affiliation(s)
- A Batirel
- Infectious Diseases and Clinical Microbiology, Kartal Dr. Lutfi Kirdar Education and Research Hospital, Semsi Denizer Cd. E-5 Karayolu Cevizli Mevkii, 34890, Kartal, Istanbul, Turkey,
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28
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Zhou QT, Gengenbach T, Denman JA, Yu HH, Li J, Chan HK. Synergistic antibiotic combination powders of colistin and rifampicin provide high aerosolization efficiency and moisture protection. AAPS JOURNAL 2013; 16:37-47. [PMID: 24129586 DOI: 10.1208/s12248-013-9537-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 09/17/2013] [Indexed: 11/30/2022]
Abstract
For many respiratory infections caused by multidrug-resistant Gram-negative bacteria, colistin is the only effective antibiotic despite its nephrotoxicity. A novel inhaled combination formulation of colistin with a synergistic antimicrobial component of rifampicin was prepared via co-spray drying, aiming to deliver the drug directly to the respiratory tract and minimize drug resistance and adverse effects. Synergistic antibacterial activity against Acinetobacter baumannii was demonstrated for the combination formulation with high emitted doses (96%) and fine particle fraction total (FPFtotal; 92%). Storage of the spray-dried colistin alone formulation in the elevated relative humidity (RH) of 75% resulted in a substantial deterioration in the aerosolization performance because the amorphous colistin powders absorbed significant amount of water up to 30% by weight. In contrast, the FPFtotal values of the combination formulation stored at various RH were unchanged, which was similar to the aerosolization behavior of the spray-dried rifampicin-alone formulation. Advanced surface chemistry measurements by XPS and ToF-SIMS demonstrated a dominance of rifampicin on the combination particle surfaces, which contributed to the moisture protection at the elevated RH. This study shows a novel inhalable powder formulation of antibiotic combination with the combined beneficial properties of synergistic antibacterial activity, high aerosolization efficiency, and moisture protection.
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Affiliation(s)
- Qi Tony Zhou
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
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29
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Synergistic activity of colistin and rifampin combination against multidrug-resistant Acinetobacter baumannii in an in vitro pharmacokinetic/pharmacodynamic model. Antimicrob Agents Chemother 2013; 57:3738-45. [PMID: 23716052 DOI: 10.1128/aac.00703-13] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Combination therapy may be required for multidrug-resistant (MDR) Acinetobacter baumannii. This study systematically investigated bacterial killing and emergence of colistin resistance with colistin and rifampin combinations against MDR A. baumannii. Studies were conducted over 72 h in an in vitro pharmacokinetic (PK)/pharmacodynamic (PD) model at inocula of ~10(6) and ~10(8) CFU/ml using two MDR clinical isolates of A. baumannii, FADDI-AB030 (colistin susceptible) and FADDI-AB156 (colistin resistant). Three combination regimens achieving clinically relevant concentrations (constant colistin concentration of 0.5, 2, or 5 mg/liter and a rifampin maximum concentration [C(max)] of 5 mg/liter every 24 hours; half-life, 3 h) were investigated. Microbiological response was measured by serial bacterial counts. Population analysis profiles assessed emergence of colistin resistance. Against both isolates, combinations resulted in substantially greater killing at the low inoculum; combinations containing 2 and 5 mg/liter colistin increased killing at the high inoculum. Combinations were additive or synergistic at 6, 24, 48, and 72 h with all colistin concentrations against FADDI-AB030 and FADDI-AB156 in, respectively, 8 and 11 of 12 cases (i.e., all 3 combinations) at the 10(6)-CFU/ml inoculum and 8 and 7 of 8 cases with the 2- and 5-mg/liter colistin regimens at the 10(8)-CFU/ml inoculum. For FADDI-AB156, killing by the combination was ~2.5 to 7.5 and ~2.5 to 5 log(10) CFU/ml greater at the low inoculum (all colistin concentrations) and high inoculum (2 and 5 mg/liter colistin), respectively. Emergence of colistin-resistant subpopulations was completely suppressed in the colistin-susceptible isolate with all combinations at both inocula. Our study provides important information for optimizing colistin-rifampin combinations against colistin-susceptible and -resistant MDR A. baumannii.
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30
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Durante-Mangoni E, Signoriello G, Andini R, Mattei A, De Cristoforo M, Murino P, Bassetti M, Malacarne P, Petrosillo N, Galdieri N, Mocavero P, Corcione A, Viscoli C, Zarrilli R, Gallo C, Utili R. Colistin and rifampicin compared with colistin alone for the treatment of serious infections due to extensively drug-resistant Acinetobacter baumannii: a multicenter, randomized clinical trial. Clin Infect Dis 2013; 57:349-58. [PMID: 23616495 DOI: 10.1093/cid/cit253] [Citation(s) in RCA: 288] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Extensively drug-resistant (XDR) Acinetobacter baumannii may cause serious infections in critically ill patients. Colistin often remains the only therapeutic option. Addition of rifampicin to colistin may be synergistic in vitro. In this study, we assessed whether the combination of colistin and rifampicin reduced the mortality of XDR A. baumannii infections compared to colistin alone. METHODS This multicenter, parallel, randomized, open-label clinical trial enrolled 210 patients with life-threatening infections due to XDR A. baumannii from intensive care units of 5 tertiary care hospitals. Patients were randomly allocated (1:1) to either colistin alone, 2 MU every 8 hours intravenously, or colistin (as above), plus rifampicin 600 mg every 12 hours intravenously. The primary end point was overall 30-day mortality. Secondary end points were infection-related death, microbiologic eradication, and hospitalization length. RESULTS Death within 30 days from randomization occurred in 90 (43%) subjects, without difference between treatment arms (P = .95). This was confirmed by multivariable analysis (odds ratio, 0.88 [95% confidence interval, .46-1.69], P = .71). A significant increase of microbiologic eradication rate was observed in the colistin plus rifampicin arm (P = .034). No difference was observed for infection-related death and length of hospitalization. CONCLUSIONS In serious XDR A. baumannii infections, 30-day mortality is not reduced by addition of rifampicin to colistin. These results indicate that, at present, rifampicin should not be routinely combined with colistin in clinical practice. The increased rate of A. baumannii eradication with combination treatment could still imply a clinical benefit. CLINICAL TRIALS REGISTRATION NCT01577862.
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Affiliation(s)
- Emanuele Durante-Mangoni
- Internal Medicine Section, Department of Cardiothoracic Sciences, University of Naples S.U.N. and AORN Ospedali dei Colli, Monaldi Hospital, Italy
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Karaiskos I, Galani L, Baziaka F, Giamarellou H. Intraventricular and intrathecal colistin as the last therapeutic resort for the treatment of multidrug-resistant and extensively drug-resistant Acinetobacter baumannii ventriculitis and meningitis: a literature review. Int J Antimicrob Agents 2013; 41:499-508. [PMID: 23507414 DOI: 10.1016/j.ijantimicag.2013.02.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Accepted: 02/04/2013] [Indexed: 02/06/2023]
Abstract
Acinetobacter baumannii ventriculitis/meningitis due to the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains has become a clinical entity of considerable importance in recent years. A review of the available literature regarding intraventricular (IVT) or intrathecal (ITH) administration of colistin in MDR and XDR A. baumannii ventriculitis/meningitis was conducted and a total of 83 episodes in 81 patients were identified (71 cases in adults and 10 in children and neonates). Colistin was administered via the IVT and ITH route in 52 and 22 cases, respectively, whilst in 7 cases the exact route was not identified. The median dose of local colistin was 125000 IU (10mg) with a range of 20000 IU (1.6 mg) to 500000 IU (40 mg) in adults, whilst a dose of 2000 IU/kg (0.16 mg/kg) up to 125000 IU (10mg) was used in the paediatric population. The median duration of treatment of IVT/ITH polymyxin E was 18.5 days, whilst the median time to achieve sterilisation of cerebrospinal fluid was 4 days. The rate of successful outcome was 89%, and toxicity related to treatment mainly manifested as reversible chemical ventriculitis/meningitis was reported in nine cases (11%). Nowadays, IVT and ITH colistin represents the last resort treatment of MDR and XDR A. baumannii ventriculitis/meningitis, offering a unique, rather safe and successful mode of therapy.
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Affiliation(s)
- Ilias Karaiskos
- 6th Department of Internal Medicine, Hygeia General Hospital, 4 Erythrou Stavrou Str. & Kifisias Av., Marousi 15123, Athens, Greece
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Intravenous itraconazole against experimental neutropenic Candida parapsilosis infection: efficacy after suppression of bacterial translocation. J Infect Chemother 2013; 19:1080-6. [DOI: 10.1007/s10156-013-0627-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 05/24/2013] [Indexed: 11/26/2022]
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Vila J, Pachón J. Therapeutic options forAcinetobacter baumanniiinfections: an update. Expert Opin Pharmacother 2012; 13:2319-36. [DOI: 10.1517/14656566.2012.729820] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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McConnell MJ, Actis L, Pachón J. Acinetobacter baumannii: human infections, factors contributing to pathogenesis and animal models. FEMS Microbiol Rev 2012; 37:130-55. [PMID: 22568581 DOI: 10.1111/j.1574-6976.2012.00344.x] [Citation(s) in RCA: 358] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 11/30/2022] Open
Abstract
Acinetobacter baumannii has emerged as a medically important pathogen because of the increasing number of infections produced by this organism over the preceding three decades and the global spread of strains with resistance to multiple antibiotic classes. In spite of its clinical relevance, until recently, there have been few studies addressing the factors that contribute to the pathogenesis of this organism. The availability of complete genome sequences, molecular tools for manipulating the bacterial genome, and animal models of infection have begun to facilitate the identification of factors that play a role in A. baumannii persistence and infection. This review summarizes the characteristics of A. baumannii that contribute to its pathogenesis, with a focus on motility, adherence, biofilm formation, and iron acquisition. In addition, the virulence factors that have been identified to date, which include the outer membrane protein OmpA, phospholipases, membrane polysaccharide components, penicillin-binding proteins, and outer membrane vesicles, are discussed. Animal models systems that have been developed during the last 15 years for the study of A. baumannii infection are overviewed, and the recent use of these models to identify factors involved in virulence and pathogenesis is highlighted.
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Affiliation(s)
- Michael J McConnell
- Unit of Infectious Disease, Microbiology, and Preventive Medicine, Institute of Biomedicine of Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain.
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Cai Y, Chai D, Wang R, Liang B, Bai N. Colistin resistance of Acinetobacter baumannii: clinical reports, mechanisms and antimicrobial strategies. J Antimicrob Chemother 2012; 67:1607-15. [PMID: 22441575 DOI: 10.1093/jac/dks084] [Citation(s) in RCA: 388] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colistin is the last resort for treatment of multidrug-resistant Acinetobacter baumannii. Unfortunately, resistance to colistin has been reported all over the world. The highest resistance rate was reported in Asia, followed by Europe. The heteroresistance rate of A. baumannii to colistin is generally higher than the resistance rate. The mechanism of resistance might be loss of lipopolysaccharide or/and the PmrAB two-component system. Pharmacokinetic/pharmacodynamic studies revealed that colistin monotherapy is unable to prevent resistance, and combination therapy might be the best antimicrobial strategy against colistin-resistant A. baumannii. Colistin/rifampicin and colistin/carbapenem are the most studied combinations that showed promising results in vitro, in vivo and in the clinic. New peptides showing good activity against colistin-resistant A. baumannii are also being investigated.
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Affiliation(s)
- Yun Cai
- Department of Clinical Pharmacology, PLA General Hospital, Beijing 100853, People's Republic of China
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36
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Chang KC, Lin MF, Lin NT, Wu WJ, Kuo HY, Lin TY, Yang TL, Chen YC, Liou ML. Clonal spread of multidrug-resistant Acinetobacter baumannii in eastern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2011; 45:37-42. [PMID: 22154678 DOI: 10.1016/j.jmii.2011.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 09/09/2010] [Accepted: 11/24/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE This study was conducted to investigate the molecular epidemiology and antimicrobial susceptibility of multidrug-resistant (MDR) Acinetobacter baumannii to three types of antibiotics. METHODS One hundred and thirty-four specimens of MDR A baumannii were collected from three branches (Taipei, Dalin, and Hualien branches) of Buddhist Tzu Chi Hospital, which are located in northern, southern, and eastern Taiwan, during 2007. Genotyping was performed by pulsed-field gel electrophoresis. Antibiotic susceptibilities to colistin, rifampicin, and tigecycline were determined. The synergistic effects of rifampin and colistin were also evaluated. RESULTS Antibiotic susceptibility testing showed that 10.4%, 47.8% and 45.5% of the MDR A baumannii isolates are resistant to colistin, rifampicin, and tigecycline, respectively. A majority of the rifampicin-resistant isolates (62.7%) were found in the Haulien branch, whereas 62.2% of tigecycline-resistant isolates were found in the Taipei branch. The combination of colistin and rifampicin had a synergistic effect on all of the isolates. Genotyping by pulsed-field gel electrophoresis identified 17, 23, and 11 pulsotypes in the Taipei, Dalin, and Haulien branches, respectively. Furthermore, 74.5% of isolates in the Haulien branch were identified as one of three pulsotypes. Among 37 rifampicin-resistant and 22 tigecycline-resistant MDR A baumannii isolates found in the Haulien branch, 51.3% (19/37) and 50% (11/22) of the isolates belonged to the same clone, respectively. CONCLUSION This study confirms the high prevalence of resistance to rifampicin and tigecycline in MDR A baumannii in the three hospitals that were studied, and the high proportion of identical strains that exist in eastern Taiwan.
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Affiliation(s)
- Kai-Chih Chang
- Department of Laboratory Medicine and Biotechnology, Tzu Chi University, Hualien City, Taiwan
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Ostorhazi E, Rozgonyi F, Szabo D, Binas A, Cassone M, Wade JD, Nolte O, Bethel CR, Bonomo RA, Otvos L. Intramuscularly administered peptide A3-APO is effective against carbapenem-resistant Acinetobacter baumannii in mouse models of systemic infections. Biopolymers 2011; 96:126-9. [PMID: 20564029 DOI: 10.1002/bip.21443] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Most antibacterial peptides exhibit low therapeutic indices in vivo. Peptide A3-APO was shown to exhibit high potency against Escherichia coli bacteremia when added intraperitoneally. To extend the studies to systemic infections against multidrug-resistant organisms, we studied the efficacy of A3-APO in mouse models of carbapenem-resistant Acinetobacter baumannii infection. When administered either intravenously at 2.5 mg/kg or intramuscularly (im) at 5 mg/kg twice or three times to mice infected with a carbapenem-resistant A. baumannii strain, peptide A3-APO reduced the bacterial counts by at least two log10 units and increased the survival rate compared with untreated animals or mice treated with 40 mg/kg imipenem. Unlike after intraperitoneal or intravenous administration, A3-APO did not show toxic effects at 60 mg/kg dose im.
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Affiliation(s)
- Eszter Ostorhazi
- Department of Dermatology, Microbiology Laboratory, Venereology and Dermato-Oncology, Semmelweis University, Budapest, Hungary
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Innate immune responses to systemic Acinetobacter baumannii infection in mice: neutrophils, but not interleukin-17, mediate host resistance. Infect Immun 2011; 79:3317-27. [PMID: 21576323 DOI: 10.1128/iai.00069-11] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Acinetobacter baumannii is a nosocomial pathogen with a high prevalence of multiple-drug-resistant strains, causing pneumonia and sepsis. The current studies further develop a systemic mouse model of this infection and characterize selected innate immune responses to the organism. Five clinical isolates, with various degrees of antibiotic resistance, were assessed for virulence in two mouse strains, and between male and female mice, using intraperitoneal infection. A nearly 1,000-fold difference in virulence was found between bacterial strains, but no significant differences between sexes or mouse strains were observed. It was found that microbes disseminated rapidly from the peritoneal cavity to the lung and spleen, where they replicated. A persistent septic state was observed. The infection progressed rapidly, with mortality between 36 and 48 h. Depletion of neutrophils with antibody to Ly-6G decreased mean time to death and increased mortality. Interleukin-17 (IL-17) promotes the response of neutrophils by inducing production of the chemokine keratinocyte-derived chemoattractant (KC/CXCL1), the mouse homolog of human IL-8. Acinetobacter infection resulted in biphasic increases in both IL-17 and KC/CXCL1. Depletion of neither IL-17 nor KC/CXCL1, using specific antibodies, resulted in a difference in bacterial burdens in organs of infected mice at 10 h postinfection. Comparison of bacterial burdens between IL-17a(-/-) and wild-type mice confirmed that the absence of this cytokine did not sensitize mice to Acinetobacter infection. These studies definitely demonstrate the importance of neutrophils in resistance to systemic Acinetobacter infection. However, neither IL-17 nor KC/CXCL1 alone is required for effective host defense to systemic infection with this organism.
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Lim TP, Tan TY, Lee W, Sasikala S, Tan TT, Hsu LY, Kwa AL. In-vitro activity of polymyxin B, rifampicin, tigecycline alone and in combination against carbapenem-resistant Acinetobacter baumannii in Singapore. PLoS One 2011; 6:e18485. [PMID: 21533030 PMCID: PMC3080872 DOI: 10.1371/journal.pone.0018485] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 03/08/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Carbapenem-resistant Acinetobacter baumannii (CR-AB) is an emerging cause of nosocomial infections worldwide. Combination therapy may be the only viable option until new antibiotics become available. The objective of this study is to identify potential antimicrobial combinations against CR-AB isolated from our local hospitals. METHODS AB isolates from all public hospitals in Singapore were systematically collected between 2006 and 2007. MICs were determined according to CLSI guidelines. All CR-AB isolates were genotyped using a PCR-based method. Clonal relationship was elucidated. Time-kill studies (TKS) were conducted with polymyxin B, rifampicin and tigecycline alone and in combination using clinically relevant (achievable) unbound concentrations. RESULTS 31 CR AB isolates were identified. They are multidrug-resistant, but are susceptible to polymyxin B. From clonal typing, 8 clonal groups were identified and 11 isolates exhibited clonal diversity. In single TKS, polymyxin B, rifampicin and tigecycline alone did not exhibit bactericidal activity at 24 hours. In combination TKS, polymyxin plus rifampicin, polymyxin B plus tigecycline and tigecycline plus rifampicin exhibited bactericidal killing in 13/31, 9/31 and 7/31 isolates respectively at 24 hours. Within a clonal group, there may be no consensus with the types of antibiotics combinations that could still kill effectively. CONCLUSION Monotherapy with polymyxin B may not be adequate against polymyxin B susceptible AB isolates. These findings demonstrate that in-vitro synergy of antibiotic combinations in CR AB may be strain dependant. It may guide us in choosing a pre-emptive therapy for CR AB infections and warrants further investigations.
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Affiliation(s)
- Tze-Peng Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Division of Infectious Diseases, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Thean-Yen Tan
- Department of Microbiology, Changi General Hospital, Singapore, Singapore
| | - Winnie Lee
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - S. Sasikala
- Department of Microbiology, Changi General Hospital, Singapore, Singapore
| | | | - Li-Yang Hsu
- Division of Infectious Diseases, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrea L. Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
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40
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Neonakis IK, Spandidos DA, Petinaki E. Confronting multidrug-resistant Acinetobacter baumannii: a review. Int J Antimicrob Agents 2010; 37:102-9. [PMID: 21130607 DOI: 10.1016/j.ijantimicag.2010.10.014] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 10/08/2010] [Indexed: 11/27/2022]
Abstract
Multidrug-resistant Acinetobacter baumannii (MDR-AB) infections are difficult to treat owing to the extremely limited armamentarium. The present review reports all available treatment options against MDR-AB, including single molecules, combination schemes, and alternative modes of antimicrobial administration. Additionally, a group of recently reported peptides with anti-MDR-AB activity is described.
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Affiliation(s)
- Ioannis K Neonakis
- Department of Microbiology, Medical School, University of Thessaly, Larissa, Greece.
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41
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Huang J, Tang YQ, Sun JY. Intravenous colistin sulfate: A rarely used form of polymyxin E for the treatment of severe multidrug-resistant Gram-negative bacterial infections. ACTA ACUST UNITED AC 2010; 42:260-5. [DOI: 10.3109/00365540903490018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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42
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Drapeau CMJ, Grilli E, Petrosillo N. Rifampicin combined regimens for gram-negative infections: data from the literature. Int J Antimicrob Agents 2009; 35:39-44. [PMID: 19815392 DOI: 10.1016/j.ijantimicag.2009.08.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2009] [Accepted: 08/10/2009] [Indexed: 11/27/2022]
Abstract
Multidrug-resistant (MDR) gram-negative bacterial infections are associated with high morbidity and mortality. Given the lack of availability of new highly effective antimicrobial drugs against multiresistant strains, combination regimens are administered that include rifampicin for its demonstrated in vitro synergism with multiple drugs. A literature review was performed of clinical studies reporting the use of rifampicin in the treatment of MDR gram-negative bacterial infections. Nineteen studies were found, including only one randomised controlled study. Data in the literature on combined therapeutic regimens with rifampicin are limited and refer mostly to uncontrolled studies. Therefore, the real clinical benefit of using rifampicin-containing therapies for the treatment of gram-negative multiresistant bacteria in terms of clinical outcome and survival rates still needs to be assessed.
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Affiliation(s)
- C M J Drapeau
- 2nd Infectious Diseases Division, National Institute for Infectious Diseases 'L. Spallanzani', Via Portuense, 292-00149 Rome, Italy
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Zhang Y, Marrs CF, Simon C, Xi C. Wastewater treatment contributes to selective increase of antibiotic resistance among Acinetobacter spp. THE SCIENCE OF THE TOTAL ENVIRONMENT 2009; 407:3702-6. [PMID: 19321192 DOI: 10.1016/j.scitotenv.2009.02.013] [Citation(s) in RCA: 207] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 01/15/2009] [Accepted: 02/09/2009] [Indexed: 05/17/2023]
Abstract
The occurrence and spread of multi-drug resistant bacteria is a pressing public health problem. The emergence of bacterial resistance to antibiotics is common in areas where antibiotics are heavily used, and antibiotic-resistant bacteria also increasingly occur in aquatic environments. The purpose of the present study was to evaluate the impact of the wastewater treatment process on the prevalence of antibiotic resistance in Acinetobacter spp. in the wastewater and its receiving water. During two different events (high-temperature, high-flow, 31 degrees C; and low-temperature, low-flow, 8 degrees C), 366 strains of Acinetobacter spp. were isolated from five different sites, three in a wastewater treatment plant (raw influent, second effluent, and final effluent) and two in the receiving body (upstream and downstream of the treated wastewater discharge point). The antibiotic susceptibility phenotypes were determined by the disc-diffusion method for 8 antibiotics, amoxicillin/clavulanic acid (AMC), chloramphenicol (CHL), ciprofloxacin (CIP), colistin (CL), gentamicin (GM), rifampin (RA), sulfisoxazole (SU), and trimethoprim (TMP). The prevalence of antibiotic resistance in Acinetobacter isolates to AMC, CHL, RA, and multi-drug (three antibiotics or more) significantly increased (p<0.01) from the raw influent samples (AMC, 8.7%; CHL, 25.2%; RA, 63.1%; multi-drug, 33.0%) to the final effluent samples (AMC, 37.9%; CHL, 69.0%; RA, 84.5%; multi-drug, 72.4%), and was significantly higher (p<0.05) in the downstream samples (AMC, 25.8%; CHL, 48.4%; RA, 85.5%; multi-drug, 56.5%) than in the upstream samples (AMC, 9.5%; CHL, 27.0%; RA, 65.1%; multi-drug, 28.6%). These results suggest that wastewater treatment process contributes to the selective increase of antibiotic resistant bacteria and the occurrence of multi-drug resistant bacteria in aquatic environments.
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Affiliation(s)
- Yongli Zhang
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, USA
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Metallo-β-lactamases in Gram-negative bacteria: introducing the era of pan-resistance? Int J Antimicrob Agents 2009; 33:405.e1-7. [DOI: 10.1016/j.ijantimicag.2008.09.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 09/03/2008] [Indexed: 11/22/2022]
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45
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Bassetti M, Righi E, Esposito S, Petrosillo N, Nicolini L. Drug treatment for multidrug-resistant Acinetobacter baumannii infections. Future Microbiol 2009; 3:649-60. [PMID: 19072182 DOI: 10.2217/17460913.3.6.649] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Acinetobacter baumannii has emerged in the last decades as a major cause of healthcare-associated infections and nosocomial outbreaks. Multidrug-resistant (MDR) A. baumannii is a rapidly emerging pathogen in healthcare settings, where it causes infections that include bacteremia, pneumonia, meningitis, and urinary tract and wound infections. Antimicrobial resistance poses great limits for therapeutic options in infected patients, especially if the isolates are resistant to the carbapenems. Other therapeutic options include sulbactam, aminoglycosides, polymixyns and tigecycline. The discovery of new therapies coupled with the development of controlled clinical trial antibiotic testing combinations and the prevention of transmission of MDR Acinetobacter infection are essential to face this important hospital problem.
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Affiliation(s)
- Matteo Bassetti
- Clinica Malattie Infettive, Azienda Ospedaliera Universitaria San Martino, Largo R Benzi 10, 16132 Genova, Italy.
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King LB, Swiatlo E, Swiatlo A, McDaniel LS. Serum resistance and biofilm formation in clinical isolates of Acinetobacter baumannii. ACTA ACUST UNITED AC 2009; 55:414-21. [PMID: 19220466 DOI: 10.1111/j.1574-695x.2009.00538.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acinetobacter baumannii has few known virulence factors and yet causes a variety of opportunistic infections. Many gram-negative bacteria are directly killed by complement, but we hypothesized that A. baumannii would be resistant to serum killing. A serum bactericidal assay assessed the resistance of seven A. baumannii isolates to serum killing, and C2-deficient serum was used to examine its activation of the alternative pathway. Flow cytometry was utilized to determine whether complement regulator factor H (FH) was bound by A. baumannii, and to assay C3 deposition on cells. A microtiter biofilm assay compared biofilm production among isolates. Of seven isolates, four were serum sensitive and three were serum resistant. The C2-deficient serum demonstrated that A. baumannii can activate the alternative pathway. None of the isolates bound FH. Serum-resistant strains accumulated little C3 when exposed to human serum, while sensitive strains had a high amount of surface C3 deposition. Biofilm production varied extensively among strains. Most serum-resistant isolates formed a substantial amount of biofilm, while sensitive isolates produced negligible amounts of biofilm. Our data indicate that some strains of A. baumannii are resistant to serum killing and produce biofilms and by understanding the resistance mechanisms used by this bacterium, we can further elucidate its complex pathogenicity.
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Affiliation(s)
- Lauren B King
- Department of Microbiology, The University of Mississippi Medical Center, Jackson, MS 39216, USA
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47
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Karageorgopoulos DE, Falagas ME. Current control and treatment of multidrug-resistant Acinetobacter baumannii infections. THE LANCET. INFECTIOUS DISEASES 2009; 8:751-62. [PMID: 19022191 DOI: 10.1016/s1473-3099(08)70279-2] [Citation(s) in RCA: 296] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Institutional outbreaks caused by Acinetobacter baumannii strains that have acquired multiple mechanisms of antimicrobial drug resistance constitute a growing public-health problem. Because of complex epidemiology, infection control of these outbreaks is difficult to attain. Identification of potential common sources of an outbreak, through surveillance cultures and epidemiological typing studies, can aid in the implementation of specific control measures. Adherence to a series of infection control methods including strict environmental cleaning, effective sterilisation of reusable medical equipment, attention to proper hand hygiene practices, and use of contact precautions, together with appropriate administrative guidance and support, are required for the containment of an outbreak. Effective antibiotic treatment of A baumannii infections, such as ventilator-associated pneumonia and bloodstream infections, is also of paramount importance. Carbapenems have long been regarded as the agents of choice, but resistance rates have risen substantially in some areas. Sulbactam has been successfully used in the treatment of serious A baumannii infections; however, the activity of this agent against carbapenem-resistant isolates is decreasing. Polymyxins show reliable antimicrobial activity against A baumannii isolates. Available clinical reports, although consisting of small-sized studies, support their effectiveness and mitigate previous concerns for toxicity. Minocycline, and particularly its derivative, tigecycline, have shown high antimicrobial activity against A baumannii, though relevant clinical evidence is still scarce. Several issues regarding the optimum therapeutic choices for multidrug-resistant A baumannii infections need to be clarified by future research.
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48
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Petrosillo N, Ioannidou E, Falagas M. Colistin monotherapy vs. combination therapy: evidence from microbiological, animal and clinical studies. Clin Microbiol Infect 2008; 14:816-27. [DOI: 10.1111/j.1469-0691.2008.02061.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Falagas ME, Rafailidis PI. Re-emergence of colistin in today's world of multidrug-resistant organisms: personal perspectives. Expert Opin Investig Drugs 2008; 17:973-81. [PMID: 18549335 DOI: 10.1517/13543784.17.7.973] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Infections due to multidrug-resistant Gram-negative bacteria (including Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae) are being reported with increasing frequency from various parts of the world. OBJECTIVE To share personal perspectives on the clinical use of colistin based on the available evidence reported in the literature as well as on knowledge obtained through our clinical experience with the use of colistin in a considerable number of patients during the past 7 years. METHODS Literature review and personal experience. RESULTS/CONCLUSION During the last decade, clinicians in several countries have resorted to colistin (polymyxin E), an antibiotic that has been shown to be clinically effective and acceptably safe for intravenous, aerosolized, and intrathecal/intraventricular administration. However, more data are needed to answer important clinical questions, including the appropriate colistin dosage, comparison of colistin monotherapy with combination therapy, and the possible preventive and therapeutic role of aerosolized colistin.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 15123 Marousi, Athens, Greece.
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50
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Abstract
The global emergence of multidrug-resistant gram-negative bacilli has spurred a renewed interest in polymyxins. Once discarded due to concerns regarding nephrotoxicity and neurotoxicity, polymyxins now hold an important role in the antibiotic armamentarium. However, more reliable information is needed to determine the optimal dosing of these agents. Also, unanswered questions regarding in vitro testing remain, including questions regarding the reliability of automated systems and the establishment of appropriate breakpoints for defining susceptibility. Most contemporary clinical studies examining the use of these agents have involved patients with infections due to multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii strains. It has been reassuring that polymyxin therapy for resistant bacteria has resulted in clinical responses and toxicity rates similar to those for carbapenem therapy for susceptible isolates. While most surveillance studies demonstrated high rates of susceptibility, several reports noted the emergence of polymyxin-resistant nosocomial pathogens. Polymyxins have assumed an important antibiotic niche for therapy for hospital-acquired infections; further studies defining the optimal use of these agents will likely extend the duration of their clinical usefulness.
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