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Treatment options for K. pneumoniae, P. aeruginosa and A. baumannii co-resistant to carbapenems, aminoglycosides, polymyxins and tigecycline: an approach based on the mechanisms of resistance to carbapenems. Infection 2020; 48:835-851. [PMID: 32875545 PMCID: PMC7461763 DOI: 10.1007/s15010-020-01520-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023]
Abstract
The management of carbapenem-resistant infections is often based on polymyxins, tigecycline, aminoglycosides and their combinations. However, in a recent systematic review, we found that Gram-negative bacteria (GNB) co-resistant to carbapanems, aminoglycosides, polymyxins and tigecycline (CAPT-resistant) are increasingly being reported worldwide. Clinical data to guide the treatment of CAPT-resistant GNB are scarce and based exclusively on few case reports and small case series, but seem to indicate that appropriate (in vitro active) antimicrobial regimens, including newer antibiotics and synergistic combinations, may be associated with lower mortality. In this review, we consolidate the available literature to inform clinicians dealing with CAPT-resistant GNB about treatment options by considering the mechanisms of resistance to carbapenems. In combination with rapid diagnostic methods that allow fast detection of carbapenemase production, the approach proposed in this review may guide a timely and targeted treatment of patients with infections by CAPT-resistant GNB. Specifically, we focus on the three most problematic species, namely Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii. Several treatment options are currently available for CAPT-resistant K. pneumonia. Newer β-lactam-β-lactamase combinations, including the combination of ceftazidime/avibactam with aztreonam against metallo-β-lactamase-producing isolates, appear to be more effective compared to combinations of older agents. Options for P. aeruginosa (especially metallo-β-lactamase-producing strains) and A. baumannii remain limited. Synergistic combination of older agents (e.g., polymyxin- or fosfomycin-based synergistic combinations) may represent a last resort option, but their use against CAPT-resistant GNB requires further study.
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Marsot A, Hraiech S, Cassir N, Daviet F, Parzy G, Blin O, Papazian L, Guilhaumou R. Aminoglycosides in critically ill patients: which dosing regimens for which pathogens? Int J Antimicrob Agents 2020; 56:106124. [PMID: 32739478 DOI: 10.1016/j.ijantimicag.2020.106124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 06/17/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Modifications of antibiotic pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We aimed to determine optimised amikacin (AMK), gentamicin (GEN) and tobramycin (TOB) intravenous dosing regimens in this patient population. Patients admitted to the medical ICU and treated with AMK, GEN or TOB were included. Analyses were performed using a parametric population approach. Monte Carlo simulations were performed and the probability of target attainment (PTA) was calculated using Cmax/MIC ≥ 8 and trough concentrations as targets. A total of 117 critically ill hospitalised patients were studied. Median values (interindividual variability, ɷ2) of clearance were 3.51 (0.539), 3.53 (0.297), 2.70 (0.339) and 5.07 (0.339) L/h for AMK, GEN, TOB, and TOB in cystic fibrosis (CF), respectively. Median values (ɷ2) of central volume of distribution were 30.2 (0.215), 20.0 (0.109) and 25.6 (0.177) L for AMK, GEN and TOB, respectively. Simulations showed that doses should be adjusted to actual body weight and creatinine clearance (CLCR) for AMK and GEN, and according to CLCR and presence of CF for TOB. In conclusion, our recommendations for treating Pseudomonas aeruginosa infections in this population include using initial doses of 35 mg/kg for AMK or 10 mg/kg for TOB (CF and non-CF patients). GEN demonstrated the best rates of target attainment against Staphylococcus aureus infections with a dose of 5 mg/kg. As high aminoglycoside doses are required in this population, efficacy and safety targets are conflicting and therapeutic drug monitoring remains an important tool to manage this issue.
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Affiliation(s)
- A Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.
| | - S Hraiech
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - N Cassir
- Aix-Marseille Université, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - F Daviet
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - G Parzy
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - O Blin
- IHU Méditerranée Infection, Marseille, France
| | - L Papazian
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - R Guilhaumou
- Aix-Marseille Univ., APHM, INSERM, CIC CPCET Service de Pharmacologie Clinique et Pharmacovigilance, INS Inst Neurosci Syst, Marseille, France
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Baudin F, Pouzot-Nevoret C, Louzier V, Goy-Thollot I, Barthélemy A, Junot S, Bonnet-Garin JM, Allaouchiche B. Animal ICU… Why not also use the existing veterinary ICUs? Ann Intensive Care 2019; 9:93. [PMID: 31420772 PMCID: PMC6702538 DOI: 10.1186/s13613-019-0568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/08/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Florent Baudin
- Service de réanimation pédiatrique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Bron, France. .,Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France.
| | - Céline Pouzot-Nevoret
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France.,Intensive Care Unit (SIAMU), VetAgro Sup, Université de Lyon, 69280, Marcy l'Etoile, France
| | - Vanessa Louzier
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France
| | - Isabelle Goy-Thollot
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France.,Intensive Care Unit (SIAMU), VetAgro Sup, Université de Lyon, 69280, Marcy l'Etoile, France
| | - Anthony Barthélemy
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France.,Intensive Care Unit (SIAMU), VetAgro Sup, Université de Lyon, 69280, Marcy l'Etoile, France
| | - Stéphane Junot
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France
| | - Jeanne-Marie Bonnet-Garin
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France
| | - Bernard Allaouchiche
- Agressions Pulmonaires et Circulatoires dans le Sepsis (APCSe), VetAgro Sup, UPSP 2016.A101, Université de Lyon, 69280, Marcy l'étoile, France.,Département d'anesthésie et de reanimation, Hospices Civils de Lyon, Lyon Sud Teaching Hospital, 69495, Pierre-Bénite, France
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