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Murray TS, Stanley G, Koff JL. Novel Approaches to Multidrug-Resistant Infections in Cystic Fibrosis. Infect Dis Clin North Am 2024; 38:149-162. [PMID: 38280761 DOI: 10.1016/j.idc.2023.12.002] [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] [Indexed: 01/29/2024]
Abstract
Patients with cystic fibrosis (CF) often develop respiratory tract infections with pathogenic multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus, and a variety of gram-negative organisms that include Pseudomonas aeruginosa, Burkholderia sp., Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM). Despite the introduction of new therapies to address underlying cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, MDRO infections remain a problem and novel antimicrobial interventions are still needed. Therapeutic approaches include improving the efficacy of existing drugs by adjusting the dose based on differences in CF patient pharmacokinetics/pharmacodynamics, the development of inhaled formulations to reduce systemic adverse events, and the use of newer beta-lactam/beta-lactamase combinations. Alternative innovative therapeutic approaches include the use of gallium and bacteriophages to treat MDRO pulmonary infections including those with extreme antibiotic resistance. However, additional clinical trials are required to determine the optimal dosing and efficacy of these different strategies and to identify patients with CF most likely to benefit from these new treatment options.
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Affiliation(s)
- Thomas S Murray
- Department of Pediatrics, Section Infectious Diseases and Global Health, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
| | - Gail Stanley
- Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-441 South, New Haven, CT 06520-8057, USA; Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy.
| | - Jonathan L Koff
- Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy; Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-455A South, New Haven, CT 06520-8057, USA.
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Minichmayr IK, Wicha SG, Matzneller P, Kloft C, Zeitlinger M. Impact of Key Components of Intensified Ceftaroline Dosing on Pharmacokinetic/Pharmacodynamic Target Attainment. Clin Pharmacokinet 2024; 63:121-131. [PMID: 38007714 PMCID: PMC10786958 DOI: 10.1007/s40262-023-01325-4] [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] [Accepted: 10/30/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Ceftaroline fosamil is a β-lactam antibiotic approved as a 600 mg twice daily dose (≤1 h infusion, 'standard dosing') or a 600 mg thrice daily dose (2 h infusion) to treat complicated skin and soft tissue infections caused by Staphylococcus aureus (minimum inhibitory concentration [MIC] 2-4 mg/L). We sought to systematically evaluate the relative impact of the three key components of the intensified dosing regimen (i.e. shortened dosing interval, prolonged infusion duration and increased total daily dose [TDD]) on the pharmacokinetic/pharmacodynamic (PK/PD) target attainment given different grades of bacterial susceptibility. METHODS A population PK model was developed using data from 12 healthy volunteers (EudraCT-2012-005134-11) receiving standard or intensified dosing. PK/PD target attainment (ƒT>MIC = 35% and 100%) after 24 h was compared following systematically varied combinations of the (1) dosing interval (every 12 h [q12h]→ every 8 h [q8h]); (2) infusion duration (1 h→2 h); and (3) individual and total daily dose (400→900 mg, i.e. TDD 1200→1800 mg), as well as for varying susceptibility of S. aureus (MIC 0.032-8 mg/L). RESULTS A two-compartment model with linear elimination adequately described ceftaroline concentrations (n = 274). The relevance of the dosing components dosing interval/infusion duration/TDD for ƒT>MIC systematically changed with pathogen susceptibility. For susceptible pathogens with MIC ≤1 mg/L, shortened dosing intervals appeared as the main driver of the improved target attainment associated with the intensified dosing regimen, followed by increased TDD and infusion duration. For less susceptible pathogens, the advantage of q8h dosing and 2 h infusions declined, and increased TDD improved ƒT>MIC the most. CONCLUSION The analysis calls to mind consideration of dose increases when prolonging the infusion duration in the case of low bacterial susceptibility.
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Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - Peter Matzneller
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Service of Rheumatology, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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3
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Fresán D, Luque S, Benítez-Cano A, Sorlí L, Montero MM, De-Antonio M, Vega V, Roberts JA, Horcajada JP, Grau S. Real-world experience of therapeutic drug monitoring and PK/PD achievement of ceftaroline administered by different infusion regimens in patients with confirmed infections caused by Gram-positive bacteria. J Antimicrob Chemother 2023; 78:2810-2815. [PMID: 37823445 DOI: 10.1093/jac/dkad296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Ceftaroline is a novel cephalosporin active against MDR Gram-positive (GP) bacteria. For β-lactam antibiotics, such as ceftaroline, prolonged infusions and therapeutic drug monitoring (TDM) are used for dosage optimization based on their pharmacokinetics/pharmacodynamics (PK/PD). OBJECTIVES To describe our experience with TDM and PK/PD target attainment of ceftaroline administered by intermittent and prolonged infusion in a cohort of patients with MDR-GP bacterial infections. METHODS Patients treated with ceftaroline administered by continuous (24 h), extended (3 h/6 h) and intermittent infusion (1 h) and undergoing TDM of plasma concentrations were included. A 100%fT>4×MIC was the pre-specified PK/PD target and 100%fT>10×MIC was considered overexposure. Dose recommendations were made based on TDM results and each patient's clinical condition. RESULTS Twelve patients [83.3% male, median age of 73 (38-83) years] were included. Nine patients (75%) achieved 100%fT>4×MIC, all under prolonged infusions. In one patient, the 100%fT was >10×MIC but no toxicity was observed. Based on TDM results, initial doses were recommended to be maintained in eight patients, decreased in three and increased in one. CONCLUSIONS The administration of ceftaroline by prolonged infusion together with TDM may be a useful strategy for achieving the desired PK/PD target in these patients. However, more studies evaluating the relationship between PK/PD attainment and clinical outcomes are needed.
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Affiliation(s)
- Daniel Fresán
- Pharmacy Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Sonia Luque
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
| | - Adela Benítez-Cano
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Luisa Sorlí
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - María Milagro Montero
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Marta De-Antonio
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Victoria Vega
- Analytical Department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Juan P Horcajada
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Murray TS, Stanley G, Koff JL. Novel Approaches to Multidrug-Resistant Infections in Cystic Fibrosis. Clin Chest Med 2022; 43:667-676. [PMID: 36344073 DOI: 10.1016/j.ccm.2022.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with cystic fibrosis (CF) often develop respiratory tract infections with pathogenic multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus, and a variety of gram-negative organisms that include Pseudomonas aeruginosa, Burkholderia sp., Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM). Despite the introduction of new therapies to address underlying cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction, MDRO infections remain a problem and novel antimicrobial interventions are still needed. Therapeutic approaches include improving the efficacy of existing drugs by adjusting the dose based on differences in CF patient pharmacokinetics/pharmacodynamics, the development of inhaled formulations to reduce systemic adverse events, and the use of newer beta-lactam/beta-lactamase combinations. Alternative innovative therapeutic approaches include the use of gallium and bacteriophages to treat MDRO pulmonary infections including those with extreme antibiotic resistance. However, additional clinical trials are required to determine the optimal dosing and efficacy of these different strategies and to identify patients with CF most likely to benefit from these new treatment options.
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Affiliation(s)
- Thomas S Murray
- Department of Pediatrics, Section Infectious Diseases and Global Health, Yale University School of Medicine, PO Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA.
| | - Gail Stanley
- Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-441 South, New Haven, CT 06520-8057, USA; Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy.
| | - Jonathan L Koff
- Adult Cystic Fibrosis Program; Yale University Center for Phage Biology & Therapy; Department of Internal Medicine, Section Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, PO Box 208057, 300 Cedar Street TAC-455A South, New Haven, CT 06520-8057, USA.
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Chauzy A, Gregoire N, Ferrandière M, Lasocki S, Ashenoune K, Seguin P, Boisson M, Couet W, Marchand S, Mimoz O, Dahyot-Fizelier C. Population pharmacokinetic/pharmacodynamic study suggests continuous infusion of ceftaroline daily dose in ventilated critical care patients with early-onset pneumonia and augmented renal clearance. J Antimicrob Chemother 2022; 77:3173-3179. [PMID: 36059138 DOI: 10.1093/jac/dkac299] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Ceftaroline could be suitable to treat early-onset ventilator-associated pneumonia (VAP) because of its antibacterial spectrum. However, augmented renal clearance (ARC) is frequent in ICU patients and may affect ceftaroline pharmacokinetics and efficacy. The objective of the study was to explore the impact of ARC on ceftaroline pharmacokinetics and evaluate whether the currently recommended dosing regimen (600 mg every 12 h) is appropriate to treat VAP in ICU patients. METHODS A population pharmacokinetic model was developed using pharmacokinetic data from 18 patients with measured creatinine clearance (CLCR) ranging between 83 and 309 mL/min. Monte Carlo simulations were conducted to determine the PTA and the cumulative fraction of response (CFR) against Streptococcus pneumoniae and MRSA for five dosing regimens. Study registered at ClinicalTrials.gov (NCT03025841). RESULTS Ceftaroline clearance increased non-linearly with CLCR, with lower concentrations and lower probability of reaching pharmacokinetic/pharmacodynamic targets when CLCR increases. For the currently recommended dosing regimen, the probability of having unbound ceftaroline concentrations above the MIC over the entire dose range is greater than 90% for MICs below 0.125 mg/L. Considering the distribution of MICs, this regimen would not be effective against MRSA infections (CFR between 21% and 67% depending on CLCR), but would be effective against S. pneumoniae infections (CFR >86%). CONCLUSIONS The recommended dosing regimen of ceftaroline seems sufficient for covering S. pneumoniae in ICU patients with ARC, but not for MRSA. Among the dosing regimens tested it appears that a constant infusion (50 mg/h) after a loading dose of 600 mg could be more appropriate for MRSA infections.
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Affiliation(s)
- Alexia Chauzy
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France
| | - Nicolas Gregoire
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,CHU de Poitiers, Laboratoire de Toxicologie-Pharmacocinétique, Poitiers, France
| | - Martine Ferrandière
- Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Tours, Service d'Anesthésie-Réanimation, Tours, France
| | - Sigismond Lasocki
- Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU d'Angers, Service d'Anesthésie-Réanimation, Angers, France
| | - Karim Ashenoune
- Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Nantes, Service d'Anesthésie-Réanimation, Hôtel Dieu - HME, Nantes, France
| | - Philippe Seguin
- Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Rennes, Service d'Anesthésie-Réanimation, Pontchaillou, Rennes, France
| | - Matthieu Boisson
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Poitiers, Service d'Anesthésie-Réanimation et Médecine Périopératoire, Poitiers, France
| | - William Couet
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,CHU de Poitiers, Laboratoire de Toxicologie-Pharmacocinétique, Poitiers, France
| | - Sandrine Marchand
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,CHU de Poitiers, Laboratoire de Toxicologie-Pharmacocinétique, Poitiers, France
| | - Olivier Mimoz
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Poitiers, Service des Urgences & SAMU 86, Poitiers, France
| | - Claire Dahyot-Fizelier
- INSERM U1070, Pharmacologie des Anti-infectieux et Antibiorésistance, Poitiers, France.,Université de Poitiers, UFR de Médecine Pharmacie, Poitiers, France.,Groupe ATLANREA, CHU de Nantes, Nantes, France.,CHU de Poitiers, Service d'Anesthésie-Réanimation et Médecine Périopératoire, Poitiers, France
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6
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Esquivel MD, Monogue ML, Smith GS, Finklea JD, Sanders JM. Ceftaroline versus vancomycin for treatment of acute pulmonary exacerbations of cystic fibrosis in adults. J Glob Antimicrob Resist 2022; 28:67-70. [PMID: 34936925 DOI: 10.1016/j.jgar.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Vancomycin remains a first-line treatment for methicillin-resistant Staphylococcus aureus (MRSA)-mediated acute pulmonary exacerbations (APEs) in adult cystic fibrosis (CF) patients; however, optimal alternatives remain poorly defined. The aim of this study was to determine the safety and efficacy of ceftaroline for MRSA-mediated APEs of CF in adults. METHODS We conducted a retrospective, observational cohort study comparing ceftaroline with vancomycin for the treatment of MRSA-mediated APEs in adult CF patients. The primary endpoint was the return to at least 90% of baseline lung function measured by discharge FEV1% predicted in comparison with baseline FEV1% predicted. RESULTS A total of 55 patients were included in the analysis (22 receiving ceftaroline and 33 receiving vancomycin). Of the patients included in the analysis, 13 patients (59%) in the ceftaroline group and 24 patients (73%) in the vancomycin group met the primary outcome (P = 0.38). FEV1 measurements at baseline, admission and discharge were not different between treatments. Secondary outcomes including 30-day re-admission rate, 30-day mortality, treatment duration and adverse events (neutropenia, Clostridioides difficile infection and acute kidney injury) were similar between groups. CONCLUSION Our small cohort study supports ceftaroline as an alternative treatment option for MRSA-mediated APE of CF in adults.
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Affiliation(s)
- Marc D Esquivel
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marguerite L Monogue
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Greg S Smith
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James D Finklea
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James M Sanders
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Esposito S, Carrothers TJ, Riccobene T, Stone GG, Kantecki M. Ceftaroline Fosamil for Treatment of Pediatric Complicated Skin and Soft Tissue Infections and Community-Acquired Pneumonia. Paediatr Drugs 2021; 23:549-563. [PMID: 34462863 PMCID: PMC8563558 DOI: 10.1007/s40272-021-00468-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 12/12/2022]
Abstract
Community-acquired pneumonia (CAP)/community-acquired bacterial pneumonia (CABP) and complicated skin and soft tissue infection (cSSTI)/acute bacterial skin and skin structure infection (ABSSSI) represent major causes of morbidity and mortality in children. β-Lactams are the cornerstone of antibiotic treatment for many serious bacterial infections in children; however, most of these agents have no activity against methicillin-resistant Staphylococcus aureus (MRSA). Ceftaroline fosamil, a β-lactam with broad-spectrum in vitro activity against Gram-positive pathogens (including MRSA and multidrug-resistant Streptococcus pneumoniae) and common Gram-negative organisms, is approved in the European Union and the United States for children with CAP/CABP or cSSTI/ABSSSI. Ceftaroline fosamil has completed a pediatric investigation plan including safety, efficacy, and pharmacokinetic evaluations in patients with ages ranging from birth to 17 years. It has demonstrated similar clinical and microbiological efficacy to best available existing treatments in phase III-IV trials in patients aged ≥ 2 months to < 18 years with CABP or ABSSSI, with a safety profile consistent with the cephalosporin class. It is also approved in the European Union for neonates with CAP or cSSTI, and in the US for neonates with ABSSSI. Ceftaroline fosamil dosing for children (including renal function adjustments) is supported by pharmacokinetic/pharmacodynamic modeling and simulations in appropriate age groups, and includes the option of 5- to 60-min intravenous infusions for standard doses, and a high dose for cSSTI patients with MRSA isolates, with a ceftaroline minimum inhibitory concentration of 2-4 mg/L. Considered together, these data suggest ceftaroline fosamil may be beneficial in the management of CAP/CABP and cSSTI/ABSSSI in children.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Building 15, Via Gramsci 14, 43126, Parma, Italy.
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8
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Epps QJ, Epps KL, Young DC, Zobell JT. State of the art in cystic fibrosis pharmacology optimization of antimicrobials in the treatment of cystic fibrosis pulmonary exacerbations: III. Executive summary. Pediatr Pulmonol 2021; 56:1825-1837. [PMID: 33656280 DOI: 10.1002/ppul.25353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022]
Abstract
Acute pulmonary exacerbations are complications of cystic fibrosis (CF) and are associated with increased morbidity and mortality. Methicillin-resistant Staphylococcus aureus (MRSA) and Aspergillus fumigatus are organisms that have been detected in the lungs of CF patients. The focus of this review is to provide an overview of the classes of antimicrobials used for MRSA and allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity reaction caused by A. fumigatus. The current anti-MRSA antibiotics and medications for ABPA dosing recommendations are discussed. This article also reviews the findings from the MRSA utilization surveys and the pharmacokinetic and pharmacodynamic differences between CF and non-CF patients. Antimethicillin S. aureus antibiotics include ceftaroline, clindamycin, fluoroquinolone derivatives (ciprofloxacin, levofloxacin), glycopeptide derivatives (telavancin, vancomycin), linezolid, rifampin, sulfamethoxazole/trimethoprim, and tetracycline derivatives (doxycycline, minocycline, tigecycline). Medications used for ABPA include corticosteroids, amphotericin B, azole antifungals (isavuconazole, itraconazole, posaconazole, voriconazole), and a monoclonal antibody, omalizumab.
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Affiliation(s)
- Quovadis J Epps
- Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences, Jacksonville, Florida, USA
| | - Kevin L Epps
- Department of Pharmacy, The Mayo Clinic, Jacksonville, Florida, USA
| | - David C Young
- Department of Pharmacotherapy, L.S. Skaggs Pharmacy Institute, University of Utah College of Pharmacy, Salt Lake City, Utah, USA.,Department of Pharmacy, University of Utah Adult Cystic Fibrosis Center, Salt Lake City, Utah, USA
| | - Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA.,Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA
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9
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Pharmacokinetics and pharmacodynamics of antibiotics in cystic fibrosis: a narrative review. Int J Antimicrob Agents 2021; 58:106381. [PMID: 34157401 DOI: 10.1016/j.ijantimicag.2021.106381] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis affects several organs, predisposing patients to severe bacterial respiratory infections, including those caused by methicillin-resistant Staphylococcus aureus. Cystic fibrosis is also associated with a wide spectrum of pathological changes that can significantly affect the absorption, distribution, metabolism, and/or elimination of several drugs, including antibacterial agents. Therefore, awareness of the pharmacokinetic derangements in patients with cystic fibrosis is mandatory for the optimisation of antibiotic therapy. This review discusses the basic principles of pharmacokinetics and the pathophysiology of the pharmacokinetics changes associated with cystic fibrosis; it also provides an update of available data for the most widely used antibiotics. Evidence accumulated in the last few years has clearly shown that a significant number of cystic fibrosis patients treated with conventional dosing schemes have sub-therapeutic antibiotic concentrations, increasing their risk of therapeutic failure and/or the emergence of resistant pathogens. Some proposals to optimise antibiotic therapies in this clinical setting based on therapeutic drug monitoring are also discussed.
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10
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Ferguson CL, Cowart MC, Jordan-Villegas A, Laham F. High-level ceftaroline resistance in a paediatric patient with invasive methicillin-resistant Staphylococcus aureus infection without previous ceftaroline exposure. J Clin Pharm Ther 2021; 46:524-527. [PMID: 33236793 DOI: 10.1111/jcpt.13316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AN OBJECTIVE Our objective is to report a paediatric case of high-level ceftaroline resistance without previous ceftaroline exposure. CASE DESCRIPTION A 20-month-old, 12 kg, female with invasive MRSA infection presented with high-level ceftaroline resistance with no previous ceftaroline exposure. WHAT IS NEW AND CONCLUSION To our knowledge, our case is the first report of high-level ceftaroline resistance evident in a paediatric patient with invasive infection due to MRSA, without history of prior ceftaroline exposure. This case illustrates the importance of weighing the risk of resistance with the benefits of use when starting therapy empirically prior to susceptibility results, even in patients without previous drug exposure.
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Affiliation(s)
- Chelsea L Ferguson
- Department of Pharmacy, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Mallory C Cowart
- Department of Pharmacy, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
| | | | - Federico Laham
- Department of Pediatrics, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL, USA
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Pharmacokinetic and Pharmacodynamic Optimization of Antibiotic Therapy in Cystic Fibrosis Patients: Current Evidences, Gaps in Knowledge and Future Directions. Clin Pharmacokinet 2021; 60:409-445. [PMID: 33486720 DOI: 10.1007/s40262-020-00981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Antibiotic therapy is one of the main treatments for cystic fibrosis (CF). It aims to eradicate bacteria during early infection, calms down the inflammatory process, and leads to symptom resolution of pulmonary exacerbations. CF can modify both the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of antibiotics, therefore specific PK/PD endpoints should be determined in the context of CF. Currently available data suggest that optimal PK/PD targets cannot be attained in sputum with intravenous aminoglycosides. Continuous infusion appears preferable for β-lactam antibiotics, but optimal concentrations in sputum are unlikely to be reached, with some possible exceptions such as meropenem and ceftolozane. Usual doses are likely suboptimal for fluoroquinolones and linezolid, whereas daily doses of 45-60 mg/kg and 200 mg could be convenient for vancomycin and doxycycline, respectively. Weekly azithromycin doses of 22-30 mg/kg could also be appropriate for its anti-inflammatory effect. The difficulty with achieving optimal concentrations supports the use of combined treatments and the inhaled administration route, as very high local concentrations, concomitantly with low systemic exposure, can be obtained with the inhaled route for aminoglycosides, colistin, and fluoroquinolones, thus minimizing the risk of toxicity.
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12
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Antibiotics in Adult Cystic Fibrosis Patients: A Review of Population Pharmacokinetic Analyses. Clin Pharmacokinet 2021; 60:447-470. [PMID: 33447944 DOI: 10.1007/s40262-020-00970-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lower respiratory tract infections are common in adult patients with cystic fibrosis (CF) and are frequently caused by Pseudomonas aeruginosa, resulting in chronic lung inflammation and fibrosis. The progression of multidrug-resistant strains of P. aeruginosa and alterations in the pharmacokinetics of many antibiotics in CF make optimal antimicrobial therapy a challenge, as reflected by high between- and inter-individual variability (IIV). OBJECTIVES This review provides a synthesis of population pharmacokinetic models for various antibiotics prescribed in adult CF patients, and aims at identifying the most reported structural models, covariates and sources of variability influencing the dose-concentration relationship. METHODS A literature search was conducted using the PubMed database, from inception to August 2020, and articles were retained if they met the inclusion/exclusion criteria. RESULTS A total of 19 articles were included in this review. One-, two- and three-compartment models were reported to best describe the pharmacokinetics of various antibiotics. The most common covariates were lean body mass and creatinine clearance. After covariate inclusion, the IIV (range) in total body clearance was 27.2% (10.40-59.7%) and 25.9% (18.0-33.9%) for β-lactams and aminoglycosides, respectively. IIV in total body clearance was estimated at 36.3% for linezolid and 22.4% for telavancin. The IIV (range) in volume of distribution was 29.4% (8.8-45.9%) and 15.2 (11.6-18.0%) for β-lactams and aminoglycosides, respectively, and 26.9% for telavancin. The median (range) of residual variability for all studies, using a combined (proportional and additive) model, was 12.7% (0.384-30.80%) and 0.126 mg/L (0.007-1.88 mg/L), respectively. CONCLUSION This is the first review that highlights key aspects of different population pharmacokinetic models of antibiotics prescribed in adult CF patients, effectively proposing relevant information for clinicians and researchers to optimize antibiotic therapy in CF.
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13
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Branstetter J, Searcy H, Benner K, Yarbrough A, Crowder C, Troxler B. Ceftaroline vs vancomycin for the treatment of acute pulmonary exacerbations in pediatric patients with cystic fibrosis. Pediatr Pulmonol 2020; 55:3337-3342. [PMID: 32803907 DOI: 10.1002/ppul.25029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Respiratory infection with methicillin-resistant Staphylococcus aureus (MRSA) is an increasing complication in cystic fibrosis (CF) that results in accelerated lung function decline and mortality. Vancomycin is considered a first-line intravenous treatment agent for MRSA associated acute pulmonary exacerbations (APEs); however, rates of vancomycin intolerance and resistance have been observed. These factors have led to the exploration of additional treatment options for treating MRSA associated APEs. METHODS This is a retrospective chart review conducted at a CF center including patients 0 to 21 years of age with CF admitted for an APE and treated with either vancomycin or ceftaroline between January 2016 and August 2018. The primary endpoint was to determine ceftaroline efficacy compared to vancomycin in the treatment of MRSA associated APEs. RESULTS There were 180 patients included in the study with 90 patients in each antibiotic group. Admission to discharge forced expiratory volume in 1 second (FEV1 ) improved in the ceftaroline (66.5% vs 81.1%; P < .001) and vancomycin (65.5% vs 77.3%; P < .001) treatment groups. No difference existed in mean change in FEV1 (14.1% vs 13.5%; P = .25) or readmissions (15% vs 22; P = .27) between ceftaroline and vancomycin groups, respectively. DISCUSSION In this retrospective study, no difference existed between ceftaroline and vancomycin with regard to observed improvement in lung function from admission to discharge. Additionally, no difference was observed in mean FEV1 or readmission rate between the two groups. Ceftaroline may represent an effective and safe intravenous antimicrobial option for targeting MRSA in pediatric CF patients with APEs.
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Affiliation(s)
- Joshua Branstetter
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Heather Searcy
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama
| | - Kim Benner
- Department of Pharmacy Practice, McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - April Yarbrough
- Department of Pharmacy, Children's of Alabama, Birmingham, Alabama
| | - Carly Crowder
- Department of Pharmacy, Intermountain Healthcare, Taylorsville, Utah
| | - Brad Troxler
- Division of Pediatric Pulmonology, University of Alabama at Birmingham, Birmingham, Alabama
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Varela MC, Roch M, Taglialegna A, Long SW, Saavedra MO, Rose WE, Davis JJ, Hoffman LR, Hernandez RE, Rosato RR, Rosato AE. Carbapenems drive the collateral resistance to ceftaroline in cystic fibrosis patients with MRSA. Commun Biol 2020; 3:599. [PMID: 33093601 PMCID: PMC7582194 DOI: 10.1038/s42003-020-01313-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/30/2020] [Indexed: 01/14/2023] Open
Abstract
Chronic airways infection with methicillin-resistant Staphylococcus aureus (MRSA) is associated with worse respiratory disease cystic fibrosis (CF) patients. Ceftaroline is a cephalosporin that inhibits the penicillin-binding protein (PBP2a) uniquely produced by MRSA. We analyzed 335 S. aureus isolates from CF sputum samples collected at three US centers between 2015-2018. Molecular relationships demonstrated that high-level resistance of preceding isolates to carbapenems were associated with subsequent isolation of ceftaroline resistant CF MRSA. In vitro evolution experiments showed that pre-exposure of CF MRSA to meropenem with further selection with ceftaroline implied mutations in mecA and additional mutations in pbp1 and pbp2, targets of carbapenems; no effects were achieved by other β-lactams. An in vivo pneumonia mouse model showed the potential therapeutic efficacy of ceftaroline/meropenem combination against ceftaroline-resistant CF MRSA infections. Thus, the present findings highlight risk factors and potential therapeutic strategies offering an opportunity to both prevent and address antibiotic resistance in this patient population.
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Affiliation(s)
- Maria Celeste Varela
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Melanie Roch
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Agustina Taglialegna
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Scott W Long
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Matthew Ojeda Saavedra
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA
| | - Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - James J Davis
- Argonne National Laboratory (DOE), Lemont, IL, USA
- Computation Institute, University of Chicago, Chicago, IL, USA
| | - Lucas R Hoffman
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Rafael E Hernandez
- Department of Pediatrics and Department of Microbiology, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Roberto R Rosato
- Houston Methodist Cancer Center, Houston Methodist Hospital, Houston, USA
| | - Adriana E Rosato
- Department of Pathology and Genomic Medicine, Center for Molecular and Translational Human Infectious Diseases Research, Houston Methodist Research Institute, Houston, TX, USA.
- Riverside University Health System-Medical Center, 26520 Cactus Avenue, Moreno Valley, CA, 92555, USA.
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15
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Epps QJ, Epps KL, Young DC, Zobell JT. State of the art in cystic fibrosis pharmacology-Optimization of antimicrobials in the treatment of cystic fibrosis pulmonary exacerbations: I. Anti-methicillin-resistant Staphylococcus aureus (MRSA) antibiotics. Pediatr Pulmonol 2020; 55:33-57. [PMID: 31609097 DOI: 10.1002/ppul.24537] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 09/19/2019] [Indexed: 12/22/2022]
Abstract
Acute pulmonary exacerbations (APE) are a complication of cystic fibrosis (CF) and are associated with morbidity and mortality. Methicillin-resistant Staphylococcus aureus (MRSA) is one of many organisms that has been detected in the airways of patients with CF. This review provides an evidence-based summary of pharmacokinetic/pharmacodynamic (PK/PD), tolerability, and efficacy studies utilizing anti-MRSA antibiotics (ie, ceftaroline, clindamycin, fluoroquinolone derivatives (ciprofloxacin, levofloxacin), glycopeptide derivatives (telavancin, vancomycin), linezolid, rifampin, sulfamethoxazole/trimethoprim (SMZ/TMP), and tetracycline derivatives (doxycycline, minocycline, tigecycline) in the treatment of APE and identifies areas where further study is warranted. A recent utilization study of antimicrobials for anti-MRSA has shown some CF Foundation accredited care centers and affiliate programs are using doses higher than the FDA-approved doses. Further studies are needed to determine the PK/PD properties in CF patients with clindamycin, minocycline, rifampin, SMZ/TMP, telavancin, and tigecycline; as well as, efficacy and tolerability studies with ciprofloxacin, clindamycin, doxycycline, levofloxacin, minocycline, rifampin, SMZ/TMP, in CF patients with MRSA.
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Affiliation(s)
- Quovadis J Epps
- Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences, Jacksonville, Florida
| | - Kevin L Epps
- Department of Pharmacy, The Mayo Clinic, Jacksonville, Florida
| | - David C Young
- L.S. Skaggs Pharmacy Institute, University of Utah College of Pharmacy, Salt Lake City, Utah
- University of Utah Adult Cystic Fibrosis Center, Salt Lake City, Utah
| | - Jeffery T Zobell
- Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah
- Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah
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Esposito S, Pennoni G, Mencarini V, Palladino N, Peccini L, Principi N. Antimicrobial Treatment of Staphylococcus aureus in Patients With Cystic Fibrosis. Front Pharmacol 2019; 10:849. [PMID: 31447669 PMCID: PMC6692479 DOI: 10.3389/fphar.2019.00849] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
Staphylococcus aureus is a ubiquitous human commensal pathogen. It is commonly isolated in cystic fibrosis (CF) patients and is considered one of the main causes of the recurrent acute pulmonary infections and progressive decline in lung function that characterize this inherited life-threatening multisystem disorder. However, the true role of S. aureus in CF patients is not completely understood. The main aim of this narrative review is to discuss the present knowledge of the role of S. aureus in CF patients. Literature review showed that despite the fact that the availability and use of drugs effective against S. aureus have coincided with a significant improvement in the prognosis of lung disease in CF patients, clearly evidencing the importance of S. aureus therapy, how to use old and new drugs to obtain the maximal effectiveness has not been precisely defined. The most important problem remains that the high frequency with which S. aureus is carried in healthy subjects prevents the differentiation of simple colonization from infection. Moreover, although experts recommend antibiotic administration in CF patients with symptoms and in those with persistent detection of S. aureus, the best antibiotic approach has not been defined. All these problems are complicated by the evidence that the most effective antibiotic against methicillin-resistant S. aureus (MRSA) cannot be used in patients with CF with the same schedules used in patients without CF. Further studies are needed to solve these problems and to assure CF patients the highest level of care.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
| | - Guido Pennoni
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Valeria Mencarini
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Nicola Palladino
- Pediatric Unit, Cystic Fibrosis Center of Umbria Region, Branca Hospital, Branca, Italy
| | - Laura Peccini
- Pediatric Clinic, Cystic Fibrosis Center of Umbria Region, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Perugia, Italy
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