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Shah HP, Shah R, Lockwood D, Yang N, Rohrbaugh T, Rutter MJ, Maurrasse SE. Assessing National Trends and Perceived Safety of Off-Label Ciprofloxacin-Dexamethasone Use by Pediatric Otolaryngologists. Laryngoscope 2024; 134:2922-2930. [PMID: 38149706 DOI: 10.1002/lary.31211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/13/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Off-label use of Ciprodex® (ciprofloxacin-dexamethasone: CPD), an antibiotic-steroid combination solution, in the airway has been reported by pediatric otolaryngologists with anecdotal success. We examined national trends regarding off-label CPD use including prevalence, common indications, prescriber patterns, adverse events, and accessibility. METHODS 15-item cross-sectional survey was distributed to American Society of Pediatric Otolaryngology members from January-April 2022. Univariate analyses were performed to compare responses for users of off-label CPD versus non-users. Ease of access was compared across geographies and practice types using multivariate logistic regressions. RESULTS Of the 163 complete responses (26.6% response rate), 156 (95.7%) reported using off-label CPD. Most common indications for off-label CPD were tracheal granulation (87.8%, n = 137) and choanal atresia (82.1%, n = 128). Ease of access was significantly increased in the Midwest (OR:18.79, 95%CI:3.63-1.24, p = 0.001) and West (OR:29.92, 95%CI:3.55-682.00, p = 0.006). Ease of access was significantly lower at tertiary referral centers (OR:0.11, 95%CI:0.01-0.64, p = 0.041) and private practices (OR:0.04, 95%CI:0.002-0.33, p = 0.009) compared to academic free-standing children's hospitals. Two-thirds of respondents reported feeling "Very Comfortable" with the safety profile of off-label CPD; 99.4% (n = 156) felt that the benefits outweighed the risks of off-label use. Seven respondents (4.5%) reported adverse events (e.g., local allergic reaction, cushingoid symptoms) from off-label use. CONCLUSIONS Our findings (26.6% response rate) suggest that off-label CPD is commonly used by pediatric otolaryngologists, many of whom reported feeling that the benefits of off-label CPD outweigh the risks. Our results establish a baseline for future efforts to assess the efficacy and safety of off-label CPD and to improve its accessibility. LEVEL OF EVIDENCE V Laryngoscope, 134:2922-2930, 2024.
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Affiliation(s)
- Hemali P Shah
- Yale University School of Medicine, New Haven, Connecticut, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Medstar Georgetown University Hospital, Washington, DC, U.S.A
| | - Rema Shah
- Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Donovan Lockwood
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Nan Yang
- Yale University School of Public Health, New Haven, Connecticut, U.S.A
| | - Tagan Rohrbaugh
- Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael J Rutter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Sarah E Maurrasse
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Brčić J, Tong A, Wender PA, Cegelski L. Conjugation of Vancomycin with a Single Arginine Improves Efficacy against Mycobacteria by More Effective Peptidoglycan Targeting. J Med Chem 2023; 66:10226-10237. [PMID: 37477249 PMCID: PMC10783851 DOI: 10.1021/acs.jmedchem.3c00565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Drug resistant bacterial infections have emerged as one of the greatest threats to public health. The discovery and development of new antimicrobials and anti-infective strategies are urgently needed to address this challenge. Vancomycin is one of the most important antibiotics for the treatment of Gram-positive infections. Here, we introduce the vancomycin-arginine conjugate (V-R) as a highly effective antimicrobial against actively growing mycobacteria and difficult-to-treat mycobacterial biofilm populations. Further improvement in efficacy through combination treatment of V-R to inhibit peptidoglycan synthesis and ethambutol to inhibit arabinogalactan synthesis underscores the ability to identify compound synergies to more effectively target the Achilles heel of the cell-wall assembly. Moreover, we introduce mechanistic activity data and a molecular model derived from a d-Ala-d-Ala-bound vancomycin structure that we hypothesize underlies the molecular basis for the antibacterial improvement attributed to the arginine modification that is specific to peptidoglycan chemistry employed by mycobacteria and distinct from Gram-positive pathogens.
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Affiliation(s)
- Jasna Brčić
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA
| | - Alan Tong
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA
| | - Paul A. Wender
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA
- Department of Chemical and Systems Biology, Stanford University, Stanford, CA 94305, USA
| | - Lynette Cegelski
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA
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3
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Lynch JP, Zhanel GG. Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy. Semin Respir Crit Care Med 2022; 43:191-218. [PMID: 35062038 DOI: 10.1055/s-0041-1740109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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4
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2199-2208. [DOI: 10.1093/jac/dkac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/25/2022] [Indexed: 11/14/2022] Open
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5
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[Infections due to multidrug-resistant pathogens : Pathogens, resistance mechanisms and established treatment options]. Anaesthesist 2020; 68:711-730. [PMID: 31555833 DOI: 10.1007/s00101-019-00645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The increase in resistant pathogens has long been a global problem. Complicated life-threatening infections due to multidrug-resistant pathogens (MRD) meanwhile occur regularly in intensive care medicine. An important and also potentially modifiable factor of the rapid spread of resistance is the irrational use of broad spectrum antibiotics in human medicine. In addition to many other resistance mechanisms, beta-lactamases play an important role in Gram-negative pathogens. They are not uncommonly the leading reason of difficult to treat infections and the failure of known routinely used broad spectrum antibiotics, such as cephalosporins, (acylamino)penicillins and carbapenems. Strategies for containment of MRDs primaríly target the rational use of antibiotics. In this respect interdisciplinary treatment teams, e.g. antibiotic stewardship (ABS) and infectious diseases stewardship (IDS) play a major role.
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6
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Foligno S, Loi B, Pezza L, Piastra M, Autilio C, De Luca D. Extrapulmonary Surfactant Therapy: Review of Available Data and Research/Development Issues. J Clin Pharmacol 2020; 60:1561-1572. [PMID: 32578234 DOI: 10.1002/jcph.1675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/21/2020] [Indexed: 11/07/2022]
Abstract
Since the discovery of surfactant, a large amount of knowledge has been accumulated about its biology and pharmacology. Surfactant is the cornerstone of neonatal respiratory critical care, but its proteins and phospholipids are produced in various tissues and organs, with possible roles only partially similar to that played in the alveoli. As surfactant research is focused mainly on its respiratory applications, knowledge about the possible role of surfactant in extrapulmonary disorders has never been summarized. Here we aim to comprehensively review the data about surfactant biology and pharmacology in organs other than the lung, especially focusing in the more promising surfactant extrapulmonary roles. We also review any preclinical or clinical data available about the therapeutic use of surfactant in these contexts. We offer a summary of knowledge and research/development milestones, as possible useful guidance for researchers of multidisciplinary background.
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Affiliation(s)
- Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Barbara Loi
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Lucilla Pezza
- Pediatric Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital "A.Gemelli"-IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Piastra
- Pediatric Intensive Care Unit, Department of Anesthesia and Critical Care, University Hospital "A.Gemelli"-IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Chiara Autilio
- Department of Biochemistry and Molecular Biology, Faculty of Biology, and Research Institut-Hospital "12 de Octubre,", Complutense University, Madrid, Spain
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center, "A. Béclère," South Paris University Hospitals, Assistance Publique-Hopitaux de Paris (APHP), Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris/Saclay University, Paris, France
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7
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Stratilo CW, Jager S, Crichton M, Blanchard JD. Evaluation of liposomal ciprofloxacin formulations in a murine model of anthrax. PLoS One 2020; 15:e0228162. [PMID: 31978152 PMCID: PMC6980410 DOI: 10.1371/journal.pone.0228162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 01/08/2020] [Indexed: 01/01/2023] Open
Abstract
The in vivo efficacy of liposomal encapsulated ciprofloxacin in two formulations, lipoquin and apulmiq, were evaluated against the causative agent of anthrax, Bacillus anthracis. Liposomal encapsulated ciprofloxacin is attractive as a therapy since it allows for once daily dosing and achieves higher concentrations of the antibiotic at the site of initial mucosal entry but lower systemic drug concentrations. The in vivo efficacy of lipoquin and apulmiq delivered by intranasal instillation was studied at different doses and schedules in both a post exposure prophylaxis (PEP) therapy model and in a delayed treatment model of murine inhalational anthrax. In the mouse model of infection, the survival curves for all treatment cohorts differed significantly from the vehicle control. Ciprofloxacin, lipoquin and apulmiq provided a high level of protection (87-90%) after 7 days of therapy when administered within 24 hours of exposure. Reducing therapy to only three days still provided protection of 60-87%, if therapy was provided within 24 hours of exposure. If treatment was initiated 48 hours after exposure the survival rate was reduced to 46-65%. These studies suggest that lipoquin and apulmiq may be attractive therapies as PEP and as part of a treatment cocktail for B. anthracis.
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Affiliation(s)
- Chad W. Stratilo
- Bio Threat Defence Section, Suffield Research Centre, Defence Research and Development Canada, Ralston, Alberta, Canada
- * E-mail:
| | - Scott Jager
- Bio Threat Defence Section, Suffield Research Centre, Defence Research and Development Canada, Ralston, Alberta, Canada
| | - Melissa Crichton
- Bio Threat Defence Section, Suffield Research Centre, Defence Research and Development Canada, Ralston, Alberta, Canada
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Chorepsima S, Kechagias KS, Kalimeris G, Triarides NA, Falagas ME. Spotlight on inhaled ciprofloxacin and its potential in the treatment of non-cystic fibrosis bronchiectasis. Drug Des Devel Ther 2018; 12:4059-4066. [PMID: 30568427 PMCID: PMC6267620 DOI: 10.2147/dddt.s168014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Non-cystic fibrosis bronchiectasis (NCFB) is a severe chronic illness characterized by irreversible dilation of airways and thickening of bronchial walls, chronic inflammation, repeated infections, and progressive obstruction of the airways. In contrast to cystic fibrosis bronchiectasis (CFB), which is a well-defined genetic disorder, NCFB is a heterogeneous disease caused by many different medical entities. Inhaled antibiotics are effective for patients with CFB, but their efficacy in NCFB has not been proven. The main pathogens involved in the colonization of patients with bronchiectasis are Haemophilus influenza, Moraxella catarrhalis, Staphylococcus aureus, and Pseudomonas aeruginosa. The latter is associated with increased morbidity and mortality. In addition, in NCFB, P. aeruginosa strains are frequently more resistant than those in CFB. At present, there are no approved inhaled antibiotic therapies for NCFB patients. Inhaled ciprofloxacin has been under investigation in the last few years. In two phase II randomized, double-blind, placebo-controlled trials, the use of inhaled ciprofloxacin was significantly associated with reduction in sputum bacterial density and greater eradication rates. In four phase III randomized, double-blind, placebo-controlled trials, the results regarding the time of the first exacerbation and the rate of exacerbations were inconsistent. Specifically, ORBIT-4 and RESPIRE-1 trials showed clinical benefit (prolongation of the time of the first exacerbation and reduced rate of exacerbations in the treatment group compared to the placebo group), whereas the ORBIT-3 and RESPIRE-2 failed to achieve their primary endpoints. The RESPIRE-1 was the first trial that examined the 14-days on/off course separate from the standard 28-days on/off regimen, which is based on CFB protocol treatments. The current data on the efficacy of inhaled ciprofloxacin are encouraging, but further evaluation is needed to determine the appropriate target group and the ideal duration of treatment.
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Affiliation(s)
- Stamatia Chorepsima
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | | | - Georgios Kalimeris
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Nikolaos A Triarides
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece,
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece, .,Department of Medicine, Henry Dunant Hospital Center, Athens, Greece, .,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA,
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9
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Breaking the Vicious Cycle of Antibiotic Killing and Regrowth of Biofilm-Residing Pseudomonas aeruginosa. Antimicrob Agents Chemother 2018; 62:AAC.01635-18. [PMID: 30297365 DOI: 10.1128/aac.01635-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/01/2018] [Indexed: 11/20/2022] Open
Abstract
Biofilm-residing bacteria embedded in an extracellular matrix are protected from diverse physicochemical insults. In addition to the general recalcitrance of biofilm bacteria, high bacterial loads in biofilm-associated infections significantly diminish the efficacy of antimicrobials due to a low per-cell antibiotic concentration. Accordingly, present antimicrobial treatment protocols that have been established to serve the eradication of acute infections fail to clear biofilm-associated chronic infections. In the present study, we applied automated confocal microscopy on Pseudomonas aeruginosa to monitor dynamic killing of biofilm-grown bacteria by tobramycin and colistin in real time. We revealed that the time required for surviving bacteria to repopulate the biofilm could be taken as a measure for effectiveness of the antimicrobial treatment. It depends on the (i) nature and concentration of the antibiotic, (ii) duration of antibiotic treatment, (iii) application as monotherapy or combination therapy, and (iv) interval of drug administration. The vicious cycle of killing and repopulation of biofilm bacteria could also be broken in an in vivo model system by applying successive antibiotic dosages at intervals that do not allow full reconstitution of the biofilm communities. Treatment regimens that consider the important aspects of antimicrobial killing kinetics bear the potential to improve control of biofilm regrowth. This is an important and underestimated factor that is bound to ensure sustainable treatment success of chronic infections.
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10
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El-Halfawy OM, Naguib MM, Valvano MA. Novel antibiotic combinations proposed for treatment of Burkholderia cepacia complex infections. Antimicrob Resist Infect Control 2017; 6:120. [PMID: 29204272 PMCID: PMC5702217 DOI: 10.1186/s13756-017-0279-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 11/17/2017] [Indexed: 12/15/2022] Open
Abstract
Effective strategies to manage Burkholderia cepacia complex (Bcc) infections in cystic fibrosis (CF) patients are lacking. We tested combinations of clinically available antibiotics and show that moxifloxacin-ceftazidime could inhibit 16 Bcc clinical isolates at physiologically achievable concentrations. Adding low dose of colistin improved the efficacy of the combo, especially at conditions mimicking CF respiratory secretions.
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Affiliation(s)
- Omar M El-Halfawy
- Department of Microbiology and Immunology, University of Western Ontario, London, ON Canada.,Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Marwa M Naguib
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL UK.,Department of Microbiology and Immunology, Faculty of Pharmacy, Damanhour University, Damanhour, Egypt
| | - Miguel A Valvano
- Department of Microbiology and Immunology, University of Western Ontario, London, ON Canada.,Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL UK
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11
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Kłodzińska SN, Priemel PA, Rades T, Mørck Nielsen H. Inhalable Antimicrobials for Treatment of Bacterial Biofilm-Associated Sinusitis in Cystic Fibrosis Patients: Challenges and Drug Delivery Approaches. Int J Mol Sci 2016; 17:E1688. [PMID: 27735846 PMCID: PMC5085720 DOI: 10.3390/ijms17101688] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/05/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023] Open
Abstract
Bacterial biofilm-associated chronic sinusitis in cystic fibrosis (CF) patients caused by Pseudomonas aeruginosa infections and the lack of available treatments for such infections constitute a critical aspect of CF disease management. Currently, inhalation therapies to combat P. aeruginosa infections in CF patients are focused mainly on the delivery of antimicrobials to the lower respiratory tract, disregarding the sinuses. However, the sinuses constitute a reservoir for P. aeruginosa growth, leading to re-infection of the lungs, even after clearing an initial lung infection. Eradication of P. aeruginosa from the respiratory tract after a first infection has been shown to delay chronic pulmonary infection with the bacteria for up to two years. The challenges with providing a suitable treatment for bacterial sinusitis include: (i) identifying a suitable antimicrobial compound; (ii) selecting a suitable device to deliver the drug to the sinuses and nasal cavities; and (iii) applying a formulation design, which will mediate delivery of a high dose of the antimicrobial directly to the site of infection. This review highlights currently available inhalable antimicrobial formulations for treatment and management of biofilm infections caused by P. aeruginosa and discusses critical issues related to novel antimicrobial drug formulation design approaches.
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Affiliation(s)
- Sylvia Natalie Kłodzińska
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Petra Alexandra Priemel
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Thomas Rades
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
| | - Hanne Mørck Nielsen
- Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark.
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12
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Biopharmaceutical Characterization of Nebulized Antimicrobial Agents in Rats. 4. Aztreonam. Antimicrob Agents Chemother 2016; 60:3196-8. [PMID: 26926626 DOI: 10.1128/aac.00165-16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/24/2016] [Indexed: 01/31/2023] Open
Abstract
The aim of this study was to determine aztreonam (ATM) membrane permeability using Calu-3 cells and its plasma and pulmonary epithelial lining fluid (ELF) pharmacokinetics in rats after intratracheal nebulization and intravenous administration (15 mg · kg(-1)). ATM exhibits low Calu-3 permeability (0.07 ± 0.02 × 10(-6) cm · s(-1)), and a high area under the ELF/unbound plasma concentration time curve between 0 and infinity (AUCELF/AUCu,plasma) ratio of 1,069 was observed after nebulization in rats. These results confirm that ATM is a low-permeability molecule and a good candidate for nebulization.
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13
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Abdellatif S, Trifi A, Daly F, Mahjoub K, Nasri R, Ben Lakhal S. Efficacy and toxicity of aerosolised colistin in ventilator-associated pneumonia: a prospective, randomised trial. Ann Intensive Care 2016; 6:26. [PMID: 27033711 PMCID: PMC4816935 DOI: 10.1186/s13613-016-0127-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 03/14/2016] [Indexed: 01/08/2023] Open
Abstract
Background Cases of ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) gram-negative bacilli (GNB) mainly Acinetobacter baumannii, Pseudomonas aeruginosa and enterobacteria are common in hospitalised patients of Tunisian intensive care units (ICUs). Parenteral colistin has been used for the therapy of VAP caused by MDR GNB at Tunisian hospitals over the past few years with a favourable clinical response. However, its use fell out of favour because of the reported drug-related nephrotoxicity and neurotoxicity. Objectives To determine whether aerosolised (AS) colistin was beneficial and safe in therapy of gram-negative VAP. Methods This was a randomised, single-blind study, in 149 critically ill adults who developed gram-negative VAP. Included patients were divided into two groups whether they received AS colistin (intervention group; n = 73) or intravenous (IV) colistin (control group; n = 76). AS colistin was given as 4 million units (MU) by nebulisation three times per 24 h. IV colistin was given as a loading dose of 9 MU followed by 4.5 MU two times per 24 h. Patients were followed during 28 days. Primary outcome was cure of VAP assessed at day 14 of therapy and defined as resolution of clinical signs of VAP and bacteriological eradication. Secondary outcomes were incidence of acute renal failure (ARF), mechanical ventilation length, ICU length of stay and 28-day mortality. Results were analysed based on intention-to-treat concept. Results The patient’s baseline characteristics and distribution of pathogens VAP in both groups were similar. The clinical cure rate was 67.1 % in AS group and 72 % in IV group (p = 0.59). When administered in monotherapy or in combination, the AS regimen was as effective as IV regimen. Patients in AS group had significantly lower incidence of ARF (17.8 vs 39.4 %, p = 0.004), more favourable improvement of P/F ratio (349 vs 316 at day 14, p = 0.012), shortened time to bacterial eradication (TBE) (9.89 vs 11.26 days, p = 0.023) and earlier weaning from ventilator in ICU survivors with a mean gain in ventilator-free days of 5 days. No difference was shown in the length of stay and the 28-day mortality. Conclusion Aerosolised colistin seems to be beneficial. It provided a therapeutic effectiveness non-inferior to parenteral colistin in therapy of MDR bacilli VAP with a lower nephrotoxicity, a better improvement of P/F ratio, a shortened bacterial eradication time and earlier weaning from ventilator in ICU survivors. Trial registration ClinicalTrials.gov Identifier: NCT02683603
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Affiliation(s)
- Sami Abdellatif
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia
| | - Ahlem Trifi
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia.
| | - Foued Daly
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia
| | - Khaoula Mahjoub
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia
| | - Rochdi Nasri
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia
| | - Salah Ben Lakhal
- Medical Intensive Care Unit, Tunis Faculty of Medicine, El Manar University, University Hospital Center La Rabta, Tunis, Tunisia
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Abstract
PURPOSE OF REVIEW Treatment options for individuals with cystic fibrosis (CF) have improved survival significantly over the past two decades. One important treatment modality is inhaled antibiotics to treat chronic infection of the airways. This review includes those antibiotics that are currently in use, those that are in clinical trials. It also includes review of nonantibiotic antimicrobials, a growing area of investigation in CF. RECENT FINDINGS There are currently three inhaled antibiotics that are approved for use in patients with cystic fibrosis: tobramycin, aztreonam, and colistimethate. Tobramycin and colistimethate now are available as solution and new dry powder formulations, which are helping the treatment burden which has increased in CF. New antibiotics are in trial, although recently two did not meet primary outcomes in large clinical trials. Of particular interest is the development of nonantibiotic antimicrobials, which may allow treatment of intrinsically antibiotic resistant organisms. SUMMARY Inhaled antibiotics remain an important treatment option in cystic fibrosis due to chronic airway infection as a hallmark of the disease. Although there are now multiple options for treatment, improvements in this treatment class are needed to treat intrinsically resistant organisms. New formulation of antibiotics and nonantibiotic antimicrobials are being evaluated to add to our armamentarium.
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15
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Yu H, Teo J, Chew JW, Hadinoto K. Dry powder inhaler formulation of high-payload antibiotic nanoparticle complex intended for bronchiectasis therapy: Spray drying versus spray freeze drying preparation. Int J Pharm 2016; 499:38-46. [DOI: 10.1016/j.ijpharm.2015.12.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/02/2015] [Accepted: 12/30/2015] [Indexed: 01/25/2023]
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Biopharmaceutical Characterization of Nebulized Antimicrobial Agents in Rats: 3. Tobramycin. Antimicrob Agents Chemother 2015; 59:6646-7. [PMID: 26239992 DOI: 10.1128/aac.01647-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/27/2015] [Indexed: 02/02/2023] Open
Abstract
The aim of this study was to determine the biopharmaceutical characteristics of tobramycin (TOB) after nebulization in rats. TOB was administered by intravenous (i.v.) bolus or intratracheal nebulization (3 mg · kg(-1)), and concentrations were determined in plasma and epithelial lining fluid (ELF) by liquid chromatography-tandem mass spectrometry. The ratio of the TOB concentration in ELF to the plasma area under the curve (AUC) was more than 200 times as high after NEB as after i.v. bolus administration, indicating that TOB nebulization offers a biopharmaceutical advantage over i.v. administration.
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