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Almyroudi MP, Chang A, Andrianopoulos I, Papathanakos G, Mehta R, Paramythiotou E, Koulenti D. Novel Antibiotics for Gram-Negative Nosocomial Pneumonia. Antibiotics (Basel) 2024; 13:629. [PMID: 39061311 PMCID: PMC11273951 DOI: 10.3390/antibiotics13070629] [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: 06/10/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Nosocomial pneumonia, including hospital-acquired pneumonia and ventilator-associated pneumonia, is the leading cause of death related to hospital-acquired infections among critically ill patients. A growing proportion of these cases are attributed to multi-drug-resistant (MDR-) Gram-negative bacteria (GNB). MDR-GNB pneumonia often leads to delayed appropriate treatment, prolonged hospital stays, and increased morbidity and mortality. This issue is compounded by the increased toxicity profiles of the conventional antibiotics required to treat MDR-GNB infections. In recent years, several novel antibiotics have been licensed for the treatment of GNB nosocomial pneumonia. These novel antibiotics are promising therapeutic options for treatment of nosocomial pneumonia by MDR pathogens with certain mechanisms of resistance. Still, antibiotic resistance remains an evolving global crisis, and resistance to novel antibiotics has started emerging, making their judicious use crucial to prolong their shelf-life. This article presents an up-to-date review of these novel antibiotics and their current role in the antimicrobial armamentarium. We critically present data for the pharmacokinetics/pharmacodynamics, the in vitro spectrum of antimicrobial activity and resistance, and in vivo data for their clinical and microbiological efficacy in trials. Where possible, available data are summarized specifically in patients with nosocomial pneumonia, as this cohort may exhibit 'critical illness' physiology that affects drug efficacy.
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Affiliation(s)
- Maria Panagiota Almyroudi
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Aina Chang
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Haematology, King’s College London, London SE5 9RS, UK
| | - Ioannis Andrianopoulos
- Department of Critical Care, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece
| | - Georgios Papathanakos
- Department of Critical Care, University Hospital of Ioannina, University of Ioannina, 45110 Ioannina, Greece
| | - Reena Mehta
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- School of Cancer & Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, Kings College London, London SE5 9RS, UK
| | | | - Despoina Koulenti
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Antibiotic Optimisation Group, UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane 4029, Australia
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Massol J, Dinh A, Jeannot K, Duran C, Bouchand F, Potron A, Dortet L, Jehl F. Should we, and how to, optimize cefiderocol administration during severe nosocomial pneumonia due to carbapenem-resistant Acinetobacter baumanii? A viewpoint. J Glob Antimicrob Resist 2024; 38:140-145. [PMID: 38844258 DOI: 10.1016/j.jgar.2024.05.014] [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: 10/25/2023] [Revised: 03/02/2024] [Accepted: 05/20/2024] [Indexed: 07/11/2024] Open
Abstract
OBJECTIVES Acinetobacter baumannii is classified by the centre for Disease Control and Prevention (CDC) as an "urgent threat" due to its ability to acquire and develop resistance to multiple classes of antibiotics. As a result, it is one of the most concerning pathogens in healthcare settings, with increasing incidence of infections due to carbapenem-resistant Acinetobacter baumannii (CRAB) associated with high morbidity and mortality rates. Therefore, there are ongoing efforts to find novel treatment options, one of which is cefiderocol. We aim to review available evidence on cefiderocol use for severe nosocomial pneumonia due to carbapenem-resistant Acinetobacter baumannii. METHODS A comprehensive review was conducted from 2017 to 2023, covering articles from databases such as Pubmed, Scopus, and Embase, along with conference proceedings from ECCMID 2023. The primary focus was on severe nosocomial pneumonia due A. baumannii and cefiderocol. DISCUSSION Cefiderocol, targeting periplasmic space Penicillin-Binding Proteins (PBPs) via siderophore transport pathways, exhibits promise against multi-drug resistant Gram-negative bacilli. Its effectiveness in treating CRAB pneumonia remains debated. The CREDIBLE trial reported higher mortality with cefiderocol compared to the best available treatment, while other cohort studies showed contrasting outcomes. Patient variations and pharmacokinetic factors may underlie these discrepancies. The recommended cefiderocol dosage regimen may fall short of desired pharmacokinetic targets, especially in critically ill patients and lung infections. Pulmonary factors hindering cefiderocol's entry into bacteria through iron transporters are overlooked in clinical breakpoints. Optimized dosing or combination regimens may enhance infection site exposure and outcomes. CONCLUSIONS Further research is needed to determine the optimal cefiderocol dosage and administration (mono vs. dual therapy, continuous vs. intermittent infusion), in severe Acinetobacter baumannii nosocomial pneumonia.
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Affiliation(s)
- Julien Massol
- Infectious disease department, Raymond-Poincaré University Hospital, Garches, France.
| | - Aurélien Dinh
- Infectious disease department, Raymond-Poincaré University Hospital, Garches, France
| | - Katy Jeannot
- Bacteriology department, University Hospital of Besançon, Besançon, France
| | - Clara Duran
- Infectious disease department, Raymond-Poincaré University Hospital, Garches, France
| | | | - Anaïs Potron
- Bacteriology department, University Hospital of Besançon, Besançon, France
| | - Laurent Dortet
- Microbiology department, University Hospital of Bicêtre, Kremlin Bicêtre, France
| | - François Jehl
- Microbiology department, University Hospital of Strasbourg, Strasbourg, France
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3
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Oliva A, Liguori L, Covino S, Petrucci F, Cogliati-Dezza F, Curtolo A, Savelloni G, Comi M, Sacco F, Ceccarelli G, Viscido A, Alessandri F, Raponi G, Pugliese F, Mastroianni CM, Venditti M. Clinical effectiveness of cefiderocol for the treatment of bloodstream infections due to carbapenem-resistant Acinetobacter baumannii during the COVID-19 era: a single center, observational study. Eur J Clin Microbiol Infect Dis 2024; 43:1149-1160. [PMID: 38634975 PMCID: PMC11178648 DOI: 10.1007/s10096-024-04833-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND We assessed the clinical effectiveness of cefiderocol (CFDC) in comparison with colistin (COL) for the treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections (BSI). MATERIALS/METHODS Retrospective cohort study including adults with CRAB-BSI. Outcomes were mortality, clinical cure and adverse events during therapy. The average treatment effect of CFDC compared to COL was weighted with the inverse-probability treatment weight (IPTW). RESULTS Overall, 104 patients were included (50 CFDC, 54 COL), median age 66.5 years, median Charlson Comorbidity Index 5, septic shock in 33.6% of patients. Primary BSI accounted for 43.3% of cases, followed by ventilator-associated pneumonia (VAP) (26%), catheter-related BSI (20.2%) and hospital-acquired pneumonia (HAP) (9.6%). Although not significantly, mortality at all time points was lower for CFDC than COL, while clinical cure was higher in CFDC than COL (66% vs. 44.4%, p = 0.027). Adverse events were more frequent in COL than CFDC-group (38.8% vs. 10%, p < 0.0001), primarily attributed to acute kidney injury (AKI) in the COL group. Patients with bacteremic HAP/VAP treated with CFDC had a significant lower 30-d mortality and higher clinical cure than COL (p = 0.008 and p = 0.0008, respectively). Increment of CCI (p = 0.005), ICU (p = 0.025), SARS-CoV2 (p = 0.006) and ECMO (p < 0.0001) were independently associated with 30-d mortality, while receiving CFDC was not associated with survival. CONCLUSIONS CFDC could represent an effective and safe treatment option for CRAB BSI, especially in patients with bacteremic HAP/VAP and frail patients where the risk of acute renal failure during therapy should be avoided.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy.
| | - L Liguori
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - S Covino
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - F Petrucci
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - F Cogliati-Dezza
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - A Curtolo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - G Savelloni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - M Comi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - F Sacco
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - G Ceccarelli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - A Viscido
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - F Alessandri
- Department of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | - G Raponi
- Microbiology and Virology Laboratory, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - F Pugliese
- Department of General and Specialistic Surgery, Sapienza University of Rome, Rome, Italy
| | - C M Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
| | - M Venditti
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome, 00185, Italy
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Onorato L, de Luca I, Monari C, Coppola N. Cefiderocol either in monotherapy or combination versus best available therapy in the treatment of carbapenem-resistant Acinetobacter baumannii infections: A systematic review and meta-analysis. J Infect 2024; 88:106113. [PMID: 38331328 DOI: 10.1016/j.jinf.2024.01.012] [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: 11/12/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND The best treatment for carbapenem-resistant Acinetobacter baumannii (CRAB) infections is still a matter of debate. OBJECTIVES To describe the outcomes of patients treated with cefiderocol for CRAB infections, and to compare the efficacy of cefiderocol versus best available therapy (BAT). DATA SOURCES We searched MEDLINE, the Cochrane Library and EMBASE to screen original reports published up to September 2023. STUDY ELIGIBILITY CRITERIA Randomized controlled trials (RCTs) and observational studies investigating 30-day mortality, clinical failure, microbiological failure or rate of adverse drug reactions of patients treated with cefiderocol or BAT. PARTICIPANTS Patients with infections due to CRAB. INTERVENTIONS Cefiderocol in monotherapy or in combination with other potentially active agents or BAT. ASSESSMENT OF RISK OF BIAS We used the Cochrane Risk of Bias Tool for RCTs, and the Newcastle Ottawa scale for observational studies. METHODS OF DATA SYNTHESIS We conducted a meta-analysis pooling risk ratios (RRs) through random effect models. RESULTS We screened 801 original reports, and 18 studies (2 RCTs, 13 cohort studies and 3 case-series) were included in the analysis, for a total 733 patients treated with cefiderocol, and 473 receiving the BAT. Among patients receiving cefiderocol, the 30-day mortality rate was 42% (95% CI 38-47%), the rate of microbiological failure 48% (95% CI 31-65%), the clinical failure rate 43% (95% CI 32-55%), and the rate of ADRs was 3% (95% CI 1-6%). A lower mortality rate was observed among patients receiving cefiderocol monotherapy as compared to those treated with combination regimens (RR: 0.64; 95% CI: 0.43-0.94, p = 0.024). We found a significantly lower mortality rate (RR: 0.74; 95% CI: 0.57-0.95, p = 0.02) and a lower rate of ADRs (RR: 0.28; 95% CI: 0.09-0.91, p = 0.03) in the group treated with cefiderocol as compared to BAT. No difference was observed in microbiological and clinical failure rate. CONCLUSIONS Our data strengthen the efficacy and safety profile of cefiderocol in CRAB infections.
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Affiliation(s)
- Lorenzo Onorato
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ilaria de Luca
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Caterina Monari
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, Naples, Italy.
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5
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Schellong P, Wennek-Klose J, Spiegel C, Rödel J, Hagel S. Successful outpatient parenteral antibiotic therapy with cefiderocol for osteomyelitis caused by multi-drug resistant Gram-negative bacteria: a case report. JAC Antimicrob Resist 2024; 6:dlae015. [PMID: 38328266 PMCID: PMC10848891 DOI: 10.1093/jacamr/dlae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/15/2024] [Indexed: 02/09/2024] Open
Abstract
Objectives Post-traumatic osteomyelitis attributed to metallo-β-lactamase (MBL)-producing Gram-negative bacteria presents a challenging clinical scenario. Cefiderocol emerges as a viable treatment option within the limited therapeutic options available. Patient/case description In this brief report, we present a case of a Ukrainian patient with osteomyelitis caused by multi-drug resistant Pseudomonas aeruginosa, which was successfully treated with cefiderocol, facilitated in part by outpatient parenteral antibiotic therapy (OPAT). Results and discussion Administration of Cefiderocol via OPAT can present a safe and effective option for treatment of post-traumatic osteomyelitis with multi-drug resistant Pseudomonas aeruginosa. A possible effect on iron homeostasis of extended treatment duration with cefiderocol may be taken into consideration.
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Affiliation(s)
- Paul Schellong
- Institute for Infectious Diseases and Infection Control, Jena University Hospital—Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Janett Wennek-Klose
- Hospital Care, Medipolis Intensive Care & Service GmbH Pharmaceutical OPAT Service Provider, Jena, Germany
| | - Christian Spiegel
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital—Friedrich Schiller University Jena, Jena, Germany
| | - Jürgen Rödel
- Institute of Medical Microbiology, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital—Friedrich Schiller University Jena, Am Klinikum 1, 07747 Jena, Germany
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Longshaw C, Santerre Henriksen A, Dressel D, Malysa M, Silvestri C, Takemura M, Yamano Y, Baba T, Slover CM. Heteroresistance to cefiderocol in carbapenem-resistant Acinetobacter baumannii in the CREDIBLE-CR study was not linked to clinical outcomes: a post hoc analysis. Microbiol Spectr 2023; 11:e0237123. [PMID: 37966262 PMCID: PMC10714777 DOI: 10.1128/spectrum.02371-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
IMPORTANCE The population analysis profiling (PAP) test is considered the "gold standard" method to detect heteroresistance. It exposes bacteria to increasing concentrations of antibiotics at high cell densities to detect any minority resistant subpopulations that might be missed by the low inoculums used for reference susceptibility tests. However, its clinical relevance has not been well established. In the CREDIBLE-CR study, a numerically increased all-cause mortality was observed in the cefiderocol arm relative to the best available therapy arm for patients with Acinetobacter spp. infections. Heteroresistance has independently been proposed by another research group as a potential explanation of the mortality difference. An analysis of the baseline carbapenem-resistant Acinetobacter calcoaceticus-baumannii complex isolates from patients treated with cefiderocol in the CREDIBLE-CR study showed the highest clinical cure rate and the lowest mortality for patients with PAP-heteroresistant isolates compared with PAP-susceptible or PAP-resistant isolates. These findings contradict the abovementioned hypothesis that heteroresistance contributed to the increased mortality.
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Affiliation(s)
| | | | | | | | | | - Miki Takemura
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
| | - Yoshinori Yamano
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Osaka, Japan
| | - Takamichi Baba
- Biostatistics Center, Shionogi & Co., Ltd., Osaka, Japan
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Campogiani L, Crea AMA, Minardi ML, Ansaldo L, Coppola L, Compagno M, Vitale P, Spalliera I, Malagnino V, Teti E, D’agostini C, Pennacchiotti C, Abate DN, Celeste MG, Andreoni M, Iannetta M, Sarmati L. Real-life Data on Cefiderocol Efficacy and Safety to Treat Multidrug-Resistant Acinetobacter baumannii Infections. Open Forum Infect Dis 2023; 10:ofad627. [PMID: 38156051 PMCID: PMC10753918 DOI: 10.1093/ofid/ofad627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023] Open
Abstract
Background The objective of this study was to expand real-life data on cefiderocol efficacy to treat multidrug-resistant Acinetobacter baumannii infections. Methods This was a retrospective monocentric study including patients hospitalized (>24 hours) at Policlinico Tor Vergata, Rome, Italy, between May 1, 2021, and September 1, 2022, treated with cefiderocol (>48 hours). The primary objective was early clinical improvement at 48-72 hours from cefiderocol start; secondary objectives were clinical success (composite outcome of infection resolution and 14-day survival), breakthrough infection, overall 30-day mortality, and cefiderocol-related adverse events. Results Eleven patients were enrolled; 91% males (10/11), with a median age (interquartile range [IQR]) of 69 (59-71) years, 91% had ≥1 comorbidity, and 72.7% (8/11) were hospitalized in internal medicine wards. Six patients with bloodstream infection (54.5%; 4 primary, 2 central line-associated), 2 with pneumonia (18.2%), 2 with urinary tract infections (18.2%), and 1 with intra-abdominal infection (9.1%) were treated. Four patients (36.3%) presented with septic shock at cefiderocol start. Cefiderocol was used as monotherapy in 3/11 patients (27.3%), was combined with colistin in all the other 8 cases, and was used in triple combination with tigecycline in 2 patients. The median duration of treatment (IQR) was 12 (10-14) days. Early clinical improvement was documented in 8/11 patients (72.7%), clinical success in 8/11 patients (72.7%). Overall 30-day mortality was 27.3% (3/11), with death occurring a median (IQR) of 19 (17.5-20.5) days after the start of therapy. No cefiderocol-related adverse events were documented. Conclusions Cefiderocol seems to be a safe and effective option for multidrug-resistant Acinetobacter baumannii infections.
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Affiliation(s)
- Laura Campogiani
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | | | | | - Lorenzo Ansaldo
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Luigi Coppola
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Mirko Compagno
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Pietro Vitale
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
| | - Ilaria Spalliera
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
| | - Vincenzo Malagnino
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Elisabetta Teti
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
| | - C D’agostini
- Laboratory of Clinical Microbiology, Policlinico Tor Vergata, Rome, Italy
- Department of Experimental Medicine, Tor Vergata University, Rome, Italy
| | | | | | | | - Massimo Andreoni
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Marco Iannetta
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
| | - Loredana Sarmati
- Infectious Diseases Clinic, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
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8
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Möhlmann JE, van Luin M, Uijtendaal EV, Zahr N, Sikma MA. Continuous infusion of cefiderocol in a critically ill patient with continuous venovenous haemofiltration. Br J Clin Pharmacol 2023; 89:3753-3757. [PMID: 37675616 DOI: 10.1111/bcp.15901] [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: 04/12/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023] Open
Abstract
Cefiderocol is a broad-spectrum cephalosporin antibiotic and is indicated in patients with difficult-to-treat Gram-negative bacterial infections. Cefiderocol is applied as a 2-4-times daily prolonged 3-h infusion. The therapeutic target of cefiderocol suggests that continuous infusion (CI) may be advantageous, since it is more likely to achieve 100% of time of the unbound concentration above the minimal inhibitory concentration (MIC). However, limited information on cefiderocol as CI has been assessed. We present a case of a critically ill 37-year-old woman with continuous venovenous haemofiltration (CVVH) treated with a CI of cefiderocol for multidrug-resistant Pseudomonas aeruginosa. She received 4 g per 24 h, in accordance with the recommendations for the total daily dose during CVVH with an effluent flow rate of 2.1-3 L/h. We evaluated intraperitoneal, plasma arterial pre- and postfilter and ultrafiltrate (urine) total cefiderocol concentrations and discussed the pharmacokinetics in respect to the CVVH settings. The predicted unbound plasma concentrations during CI resulted in 6.8-9.5-fold higher concentrations than the adopted MIC of 2 mg/L for cefiderocol against P. aeruginosa. The optimal time of the unbound concentration >MIC target of cefiderocol was met during the sampling period, suggesting adequate exposure during the total treatment period. The obtained intraperitoneal concentration indicated adequate cefiderocol exposure at the site of infection. Continuous infusion of 4 g cefiderocol per 24 h led to sufficient plasma concentrations in our anuric critically ill patient treated with CVVH. This case is supportive to the use of cefiderocol as continuous infusion.
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Affiliation(s)
- Julia E Möhlmann
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Esther V Uijtendaal
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Noël Zahr
- Department of Clinical Pharmacy, Pitié-Salpêtrière Hospital Paris, Paris, France
| | - Maaike A Sikma
- Department of Intensive Care and Dutch Poisons Information Centre, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
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Gatti M, Rinaldi M, Bonazzetti C, Gaibani P, Giannella M, Viale P, Pea F. Could an optimized joint pharmacokinetic/pharmacodynamic target attainment of continuous infusion ceftazidime-avibactam be a way to avoid the need for combo therapy in the targeted treatment of deep-seated DTR Gram-negative infections? Antimicrob Agents Chemother 2023; 67:e0096923. [PMID: 37843260 PMCID: PMC10648963 DOI: 10.1128/aac.00969-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
The objective of this study was to assess the relationship between joint pharmacokinetic/pharmacodynamic (PK/PD) target attainment of continuous infusion (CI) ceftazidime-avibactam and the microbiological outcome of documented difficult-to-treat resistant (DTR) Gram-negative infections. A 2-year retrospective cohort study was performed in patients receiving CI ceftazidime-avibactam mono- or combo therapy for documented DTR Gram-negative infections and undergoing therapeutic drug monitoring of both ceftazidime and avibactam. The free fractions of steady-state concentrations (fCss) of ceftazidime and avibactam were calculated. The joint PK/PD target was considered optimal when both the fCss/MIC ratio for ceftazidime ≥4 (equivalent to 100% fT>4xMIC) and the fCss/CT ratio for avibactam >1 (equivalent to 100% fT >CT of 4.0 mg/L) were simultaneously achieved (quasi-optimal if only one of the two and suboptimal if neither of the two was achieved). Multivariate logistic regression analysis was applied for testing potential variables associated with microbiological failure. Fifty-eight patients were treated with CI ceftazidime-avibactam mono- (36) or combo therapy (22) for documented DTR Gram-negative infections [74.2% for primary or secondary bloodstream infections (BSIs)]. Combo therapy was administered more frequently to intensive care unit (ICU) patients (P = 0.023) or for pneumonia (P = 0.001) and less frequently for intra-abdominal infections and BSIs (P = 0.04). Microbiological failure occurred in five cases (8.6%, three in mono- and two in combo therapy). In the multivariate analysis, the suboptimal/quasi-optimal joint PK/PD target emerged as the only independent predictor of microbiological failure (odds ratio [OR] 11.11; 95% confidence interval [CI] 1.31-93.98; P = 0.023), whereas monotherapy was not (P = 0.99). Optimized joint PK/PD target attainment of CI ceftazidime-avibactam monotherapy could represent a way forward for allowing microbiological eradication of DTR Gram-negative infections and could render unnecessary combo therapy.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cecilia Bonazzetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Gaibani
- Operative Unit of Microbiology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Funiciello E, Mula J, Mignone F, Silvestro E, Ragazzi P, Pilloni G, Costa C, D'Avolio A, Garazzino S. Plasmatic and CSF concentrations of cefiderocol in an infant with extensively drug-resistant Pseudomonas aeruginosa meningoencephalitis. J Antimicrob Chemother 2023; 78:2776-2778. [PMID: 37671818 DOI: 10.1093/jac/dkad277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Affiliation(s)
- Elisa Funiciello
- Paediatric Infectious Disease Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Jacopo Mula
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Amedeo di Savoia Hospital, Turin, Italy
| | - Federica Mignone
- Paediatric Infectious Disease Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Erika Silvestro
- Paediatric Infectious Disease Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Paola Ragazzi
- Paediatric Neurosurgery Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Giulia Pilloni
- Paediatric Neurosurgery Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Cristina Costa
- Microbiology Unit, Molinette Hospital, University of Turin, Turin, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Amedeo di Savoia Hospital, Turin, Italy
| | - Silvia Garazzino
- Paediatric Infectious Disease Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
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11
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Gatti M, Campoli C, Latrofa ME, Ramirez S, Sasso T, Mancini R, Caramelli F, Viale P, Pea F. Relationship Between Real-time TDM-guided Pharmacodynamic Target Attainment of Continuous Infusion Beta-lactam Monotherapy and Microbiologic Outcome in the Treatment of Critically Ill Children With Severe Documented Gram-negative Infections. Pediatr Infect Dis J 2023; 42:975-982. [PMID: 37523585 PMCID: PMC10569676 DOI: 10.1097/inf.0000000000004054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES To explore the relationship between real-time therapeutic drug monitoring (TDM)-guided pharmacodynamic target attainment of continuous infusion (CI) beta-lactam monotherapy and microbiological outcome in the treatment of critically ill children with severe documented Gram-negative infections. METHODS Observational, monocentric, retrospective study of critically ill patients receiving CI piperacillin-tazobactam, ceftazidime, or meropenem in monotherapy for documented Gram-negative infections optimized by means of a real-time TDM-guided strategy. Average steady-state beta-lactam concentrations (C ss ) were calculated for each patient, and the beta-lactam C ss /minimum inhibitory concentration (MIC) ratio was selected as a pharmacodynamic parameter of efficacy. The C ss /MIC ratio was defined as optimal if ≥4, quasi-optimal if between 1 and 4, and suboptimal if <1. The relationship between C ss /MIC and microbiological outcome was assessed. RESULTS Forty-six TDM assessments were carried out in 21 patients [median age 2 (interquartile range: 1-8) years]. C ss /MIC ratios were optimal in 76.2% of cases. Patients with optimal C ss /MIC ratios had both a significantly higher microbiological eradication rate (75.0% vs. 0.0%; P = 0.006) and lower resistance development rate (25.0% vs. 80.0%; P = 0.047) than those with quasi-optimal or suboptimal C ss /MIC ratios. Quasi-optimal/suboptimal C ss /MIC ratio occurred more frequently when patients had infections caused by pathogens with MIC values above the European Committee on Antimicrobial Susceptibility Testing clinical breakpoint (100.0% vs. 6.3%; P < 0.001). CONCLUSIONS Real-time TDM-guided pharmacodynamic target attainment of CI beta-lactam monotherapy allowed to maximize treatment efficacy in most critically ill children with severe Gram-negative infections. Attaining early optimal C ss /MIC ratios of CI beta-lactams could be a key determinant associated with microbiologic eradication during the treatment of Gram-negative infections. Larger prospective studies are warranted for confirming our findings.
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Affiliation(s)
- Milo Gatti
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Elena Latrofa
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Tommaso Sasso
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rita Mancini
- LUM Metropolitan Laboratory, AUSL Bologna, Bologna, Italy
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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12
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Barbier F, Hraiech S, Kernéis S, Veluppillai N, Pajot O, Poissy J, Roux D, Zahar JR. Rationale and evidence for the use of new beta-lactam/beta-lactamase inhibitor combinations and cefiderocol in critically ill patients. Ann Intensive Care 2023; 13:65. [PMID: 37462830 DOI: 10.1186/s13613-023-01153-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Healthcare-associated infections involving Gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) phenotype are associated with impaired patient-centered outcomes and poses daily therapeutic challenges in most of intensive care units worldwide. Over the recent years, four innovative β-lactam/β-lactamase inhibitor (BL/BLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, imipenem-relebactam and meropenem-vaborbactam) and a new siderophore cephalosporin (cefiderocol) have been approved for the treatment of certain DTR-GNB infections. The literature addressing their microbiological spectrum, pharmacokinetics, clinical efficacy and safety was exhaustively audited by our group to support the recent guidelines of the French Intensive Care Society on their utilization in critically ill patients. This narrative review summarizes the available evidence and unanswered questions on these issues. METHODS A systematic search for English-language publications in PUBMED and the Cochrane Library database from inception to November 15, 2022. RESULTS These drugs have demonstrated relevant clinical success rates and a reduced renal risk in most of severe infections for whom polymyxin- and/or aminoglycoside-based regimen were historically used as last-resort strategies-namely, ceftazidime-avibactam for infections due to Klebsiella pneumoniae carbapenemase (KPC)- or OXA-48-like-producing Enterobacterales, meropenem-vaborbactam for KPC-producing Enterobacterales, ceftazidime-avibactam/aztreonam combination or cefiderocol for metallo-β-lactamase (MBL)-producing Enterobacterales, and ceftolozane-tazobactam, ceftazidime-avibactam and imipenem-relebactam for non-MBL-producing DTR Pseudomonas aeruginosa. However, limited clinical evidence exists in critically ill patients. Extended-infusion scheme (except for imipenem-relebactam) may be indicated for DTR-GNB with high minimal inhibitory concentrations and/or in case of augmented renal clearance. The potential benefit of combining these agents with other antimicrobials remains under-investigated, notably for the most severe presentations. Other important knowledge gaps include pharmacokinetic information in particular situations (e.g., pneumonia, other deep-seated infections, and renal replacement therapy), the hazard of treatment-emergent resistance and possible preventive measures, the safety of high-dose regimen, the potential usefulness of rapid molecular diagnostic tools to rationalize their empirical utilization, and optimal treatment durations. Comparative clinical, ecological, and medico-economic data are needed for infections in whom two or more of these agents exhibit in vitro activity against the causative pathogen. CONCLUSIONS New BL/BLI combinations and cefiderocol represent long-awaited options for improving the management of DTR-GNB infections. Several research axes must be explored to better define the positioning and appropriate administration scheme of these drugs in critically ill patients.
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Affiliation(s)
- François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'Hôpital, 45000, Orléans, France.
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France.
| | - Sami Hraiech
- Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, and Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, Université Aix-Marseille, Marseille, France
| | - Solen Kernéis
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Nathanaël Veluppillai
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Olivier Pajot
- Réanimation Polyvalente, Hôpital Victor Dupouy, Argenteuil, France
| | - Julien Poissy
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Lille, Inserm U1285, Université de Lille, and CNRS/UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Damien Roux
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- DMU ESPRIT, Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, Colombes, and INSERM/CNRS, Institut Necker Enfants Malades, Université Paris Cité, Paris, France
| | - Jean-Ralph Zahar
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- Département de Microbiologie Clinique, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny and INSERM/IAME, Université de Paris, Paris, France
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13
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Cavallo I, Oliva A, Pages R, Sivori F, Truglio M, Fabrizio G, Pasqua M, Pimpinelli F, Di Domenico EG. Acinetobacter baumannii in the critically ill: complex infections get complicated. Front Microbiol 2023; 14:1196774. [PMID: 37425994 PMCID: PMC10325864 DOI: 10.3389/fmicb.2023.1196774] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Acinetobacter baumannii is increasingly associated with various epidemics, representing a serious concern due to the broad level of antimicrobial resistance and clinical manifestations. During the last decades, A. baumannii has emerged as a major pathogen in vulnerable and critically ill patients. Bacteremia, pneumonia, urinary tract, and skin and soft tissue infections are the most common presentations of A. baumannii, with attributable mortality rates approaching 35%. Carbapenems have been considered the first choice to treat A. baumannii infections. However, due to the widespread prevalence of carbapenem-resistant A. baumannii (CRAB), colistin represents the main therapeutic option, while the role of the new siderophore cephalosporin cefiderocol still needs to be ascertained. Furthermore, high clinical failure rates have been reported for colistin monotherapy when used to treat CRAB infections. Thus, the most effective antibiotic combination remains disputed. In addition to its ability to develop antibiotic resistance, A. baumannii is also known to form biofilm on medical devices, including central venous catheters or endotracheal tubes. Thus, the worrisome spread of biofilm-producing strains in multidrug-resistant populations of A. baumannii poses a significant treatment challenge. This review provides an updated account of antimicrobial resistance patterns and biofilm-mediated tolerance in A. baumannii infections with a special focus on fragile and critically ill patients.
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Affiliation(s)
- Ilaria Cavallo
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Rebecca Pages
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Mauro Truglio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Giorgia Fabrizio
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Martina Pasqua
- Department of Biology and Biotechnology "C. Darwin" Sapienza University of Rome, Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology, San Gallicano Dermatological Institute, IRCCS, Rome, Italy
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology "C. Darwin" Sapienza University of Rome, Rome, Italy
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14
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Viale P, Sandrock CE, Ramirez P, Rossolini GM, Lodise TP. Treatment of critically ill patients with cefiderocol for infections caused by multidrug-resistant pathogens: review of the evidence. Ann Intensive Care 2023; 13:52. [PMID: 37322293 DOI: 10.1186/s13613-023-01146-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
Appropriate antibiotic treatment for critically ill patients with serious Gram-negative infections in the intensive care unit is crucial to minimize morbidity and mortality. Several new antibiotics have shown in vitro activity against carbapenem-resistant Enterobacterales (CRE) and difficult-to-treat resistant Pseudomonas aeruginosa. Cefiderocol is the first approved siderophore beta-lactam antibiotic with potent activity against multidrug-resistant, carbapenem-resistant, difficult-to-treat or extensively drug-resistant Gram-negative pathogens, which have limited treatment options. The spectrum of activity of cefiderocol includes drug-resistant strains of Acinetobacter baumannii, P. aeruginosa, Stenotrophomonas maltophilia, Achromobacter spp. and Burkholderia spp. and CRE that produce serine- and/or metallo-carbapenemases. Phase 1 studies established that cefiderocol achieves adequate concentration in the epithelial lining fluid in the lung and requires dosing adjustment for renal function, including patients with augmented renal clearance and continuous renal-replacement therapy (CRRT); no clinically significant drug-drug interactions are expected. The non-inferiority of cefiderocol versus high-dose, extended-infusion meropenem in all-cause mortality (ACM) rates at day 14 was demonstrated in the randomized, double-blind APEKS-NP Phase 3 clinical study in patients with nosocomial pneumonia caused by suspected or confirmed Gram-negative bacteria. Furthermore, the efficacy of cefiderocol was investigated in the randomized, open-label, pathogen-focused, descriptive CREDIBLE-CR Phase 3 clinical study in its target patient population with serious carbapenem-resistant Gram-negative infections, including hospitalized patients with nosocomial pneumonia, bloodstream infection/sepsis, or complicated urinary tract infections. However, a numerically greater ACM rate with cefiderocol compared with BAT led to the inclusion of a warning in US and European prescribing information. Cefiderocol susceptibility results obtained with commercial tests should be carefully evaluated due to current issues regarding their accuracy and reliability. Since its approval, real-world evidence in patients with multidrug-resistant and carbapenem-resistant Gram-negative bacterial infections suggests that cefiderocol can be efficacious in certain critically ill patient groups, such as those requiring mechanical ventilation for COVID-19 pneumonia with subsequently acquired Gram-negative bacterial superinfection, and patients with CRRT and/or extracorporeal membrane oxygenation. In this article, we review the microbiological spectrum, pharmacokinetics/pharmacodynamics, efficacy and safety profiles and real-world evidence for cefiderocol, and look at future considerations for its role in the treatment of critically ill patients with challenging Gram-negative bacterial infections.
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Affiliation(s)
- Pierluigi Viale
- Infectious Disease Unit, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
- Department of Medical and Surgical Science, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Christian E Sandrock
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, USA.
| | - Paula Ramirez
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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15
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Dalfino L, Stufano M, Bavaro DF, Diella L, Belati A, Stolfa S, Romanelli F, Ronga L, Di Mussi R, Murgolo F, Loconsole D, Chironna M, Mosca A, Montagna MT, Saracino A, Grasso S. Effectiveness of First-Line Therapy with Old and Novel Antibiotics in Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter baumannii: A Real Life, Prospective, Observational, Single-Center Study. Antibiotics (Basel) 2023; 12:1048. [PMID: 37370367 DOI: 10.3390/antibiotics12061048] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Evidence-based, standard antibiotic therapy for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) is a relevant unmet clinical need in the intensive care unit (ICU). We aimed to evaluate the effectiveness of first-line therapy with old and novel CRAB active antibiotics in monomicrobial VAP caused by CRAB. A prospective, observational study was performed in a mixed non-COVID-19 ICU. The primary outcome measure was clinical failure upon first-line targeted therapy. Features independently influencing failure occurrence were also investigated via Cox proportional multivariable analysis. To account for the imbalance in antibiotic treatment allocation, a propensity score analysis with an inverse probability treatment weighting approach was adopted. Of the 90 enrolled patients, 34 (38%) experienced clinical failure. Compared to patients who experienced a clinical resolution of VAP, those who had clinical failure were of an older age (median age 71 (IQR 64-78) vs. 62 (IQR 52-69) years), and showed greater burden of comorbidities (median Charlson comorbidity index 8 (IQR 6-8) vs. 4 (IQR 2-6)), higher frequency of immunodepression (44% vs. 21%), and greater clinical severity at VAP onset (median SOFA score 10 (IQR 9-11) vs. 9 (IQR 7-11)). Lower rates of use of fast molecular diagnostics for nosocomial pneumonia (8.8% vs. 30.3%) and of timely CRAB active therapy administration (65% vs. 89%), and higher rates of colistin-based targeted therapy (71% vs. 46%) were also observed in patients who failed first-line therapy. Overall, CRAB active iv regimens were colistin-based in 50 patients and cefiderocol-based in 40 patients, both always combined with inhaled colistin. According to the backbone agent of first-line regimens, clinical failure was lower in the cefiderocol group, compared to that in the colistin group (25% vs. 48%, respectively). In multivariable Cox regression analysis, the burden of comorbid conditions independently predicted clinical failure occurrence (Charlson index aHR = 1.21, 95% CI = 1.04-1.42, p = 0.01), while timely targeted antibiotic treatment (aHR = 0.40, 95% CI = 0.19-0.84, p = 0.01) and cefiderocol-based first-line regimens (aHR = 0.38, 95% CI = 0.17-0.85, p = 0.02) strongly reduced failure risk. In patients with VAP caused by CRAB, timely active therapy improves infection outcomes and cefiderocol holds promise as a first-line therapeutic option.
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Affiliation(s)
- Lidia Dalfino
- Intensive Care Unit II, Department of Precision Medicine, Ionic Area, University of Bari "A. Moro", 70124 Bari, Italy
| | - Monica Stufano
- Intensive Care Unit II, Department of Precision Medicine, Ionic Area, University of Bari "A. Moro", 70124 Bari, Italy
| | - Davide Fiore Bavaro
- Clinic of Infectious Diseases, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", 70124 Bari, Italy
| | - Lucia Diella
- Clinic of Infectious Diseases, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", 70124 Bari, Italy
| | - Alessandra Belati
- Clinic of Infectious Diseases, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", 70124 Bari, Italy
| | - Stefania Stolfa
- Microbiology and Virology Unit, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Federica Romanelli
- Microbiology and Virology Unit, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Luigi Ronga
- Microbiology and Virology Unit, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Rosa Di Mussi
- Intensive Care Unit II, Department of Precision Medicine, Ionic Area, University of Bari "A. Moro", 70124 Bari, Italy
| | - Francesco Murgolo
- Intensive Care Unit II, Department of Precision Medicine, Ionic Area, University of Bari "A. Moro", 70124 Bari, Italy
| | - Daniela Loconsole
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Maria Chironna
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Adriana Mosca
- Microbiology and Virology Unit, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Maria Teresa Montagna
- Hygiene Section, Department of Interdisciplinary Medicine, University of Bari "A. Moro", 70124 Bari, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", 70124 Bari, Italy
| | - Salvatore Grasso
- Intensive Care Unit II, Department of Precision Medicine, Ionic Area, University of Bari "A. Moro", 70124 Bari, Italy
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16
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Waters J, Shorr AF. Bloodstream Infection and Gram-Negative Resistance: The Role for Newer Antibiotics. Antibiotics (Basel) 2023; 12:977. [PMID: 37370296 DOI: 10.3390/antibiotics12060977] [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: 04/28/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
Gram-negative resistance remains a major challenge. Rates of in vitro resistance to commonly utilized antibiotics have skyrocketed over the last decade. Clinicians now encounter multidrug-resistant organisms routinely. Fortunately, newer agents, such as ceftazidime-avibactam, ceftolozone-tazobactam, meropenem-vaborbactam, and cefiderocol, have been developed and are now available for use against these pathogens. Clinical trials with these novel therapies have focused on multiple infection types ranging from complicated urinary tract infections to nosocomial pneumonia. Nonetheless, there remains little information about the efficacy of these drugs for bacteremia. To better appreciate the types and limitations of the evidence supporting the role for these unique molecules in bloodstream infection, one requires an appreciation of the initial clinical trials supporting the regulatory approval of these antibiotics. Furthermore, physicians must understand the subsequent case series and reports specifically focusing on outcomes for patients with bacteremia treated with these drugs. Despite the limitations of the data and reports relating to treatment for bacteremia with these antibiotics, each agent appears to be efficacious and can provide good outcomes in bloodstream infections due to resistant pathogens.
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Affiliation(s)
- Jessica Waters
- Division of Pulmonary and Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA
| | - Andrew F Shorr
- Division of Pulmonary and Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC 20010, USA
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17
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Gatti M, Rinaldi M, Tonetti T, Gaibani P, Siniscalchi A, Viale P, Pea F. Pharmacokinetics/pharmacodynamics of cefiderocol administered by continuous infusion in a case series of critically ill patients with carbapenem-resistant Acinetobacter baumannii infections undergoing continuous venovenous haemodiafiltration (CVVHDF). Int J Antimicrob Agents 2023:106852. [PMID: 37192727 DOI: 10.1016/j.ijantimicag.2023.106852] [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: 03/14/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVES To assess the pharmacokinetics/pharmacodynamics (PK/PD) of cefiderocol administered by continuous infusion (CI) in a case series of critically ill patients with carbapenem-resistant Acinetobacter baumannii (CRAB) infections undergoing continuous venovenous haemodiafiltration (CVVHDF). METHODS Critically ill patients receiving CI cefiderocol during CVVHDF for documented bloodstream infections (BSIs), ventilator-associated pneumonia (VAP), and/or complicated intrabdominal infections (cIAIs) caused by CRAB and undergoing therapeutic drug monitoring (TDM) from February 2022 to January 2023 were retrospectively assessed. Cefiderocol concentrations were determined at steady-state, and the free fraction (fCss) was calculated. Cefiderocol total clearance (CLtot) was determined at each TDM assessment. fCss/MIC ratio was selected as PD determinant of cefiderocol efficacy and defined as optimal if >4, quasi-optimal if between 1 and 4, and suboptimal if <1. RESULTS Five patients with documented CRAB infections (two BSI+VAP, two VAP, and one BSI+cIAI) were included. The maintenance dose of cefiderocol was always of 2g q8h over 8h by CI. Median average fCss was 26.5 mg/L (21.7-33.6 mg/L). Median CLtot was 4.84 L/h (2.04-5.22 L/h). Median CVVHDF dose was 41.1 mL/kg/h (35.5-44.9 mL/kg/h), and residual diuresis was reported in 4/5 cases. Optimal PK/PD target was attained in all cases with a median cefiderocol fCss/MIC ratio of 14.9 (6.6-33.6). CONCLUSION CI administration of full doses could be a useful strategy for attaining aggressive PK/PD targets with cefiderocol for the treatment of severe CRAB infections among critically ill patients undergoing high-intensity CVVHDF and having residual diuresis.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Gaibani
- Operative Unit of Microbiology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Karvouniaris M, Almyroudi MP, Abdul-Aziz MH, Blot S, Paramythiotou E, Tsigou E, Koulenti D. Novel Antimicrobial Agents for Gram-Negative Pathogens. Antibiotics (Basel) 2023; 12:761. [PMID: 37107124 PMCID: PMC10135111 DOI: 10.3390/antibiotics12040761] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
Gram-negative bacterial resistance to antimicrobials has had an exponential increase at a global level during the last decades and represent an everyday challenge, especially for the hospital practice of our era. Concerted efforts from the researchers and the industry have recently provided several novel promising antimicrobials, resilient to various bacterial resistance mechanisms. There are new antimicrobials that became commercially available during the last five years, namely, cefiderocol, imipenem-cilastatin-relebactam, eravacycline, omadacycline, and plazomicin. Furthermore, other agents are in advanced development, having reached phase 3 clinical trials, namely, aztreonam-avibactam, cefepime-enmetazobactam, cefepime-taniborbactam, cefepime-zidebactam, sulopenem, tebipenem, and benapenem. In this present review, we critically discuss the characteristics of the above-mentioned antimicrobials, their pharmacokinetic/pharmacodynamic properties and the current clinical data.
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Affiliation(s)
- Marios Karvouniaris
- Intensive Care Unit, AHEPA University Hospital, 546 36 Thessaloniki, Greece;
| | | | - Mohd Hafiz Abdul-Aziz
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
| | - Stijn Blot
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Department of Internal Medicine and Pediatrics, Ghent University, 9000 Ghent, Belgium
| | | | - Evdoxia Tsigou
- Intensive Care Department, ‘Aghioi Anargyroi’ Hospital of Kifissia, 145 64 Athens, Greece;
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia; (M.H.A.-A.); (S.B.)
- Second Critical Care Department, Attikon University Hospital, 124 62 Athens, Greece;
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Prinz C, Streit F, Schumann C, Dudakova A, Lanckohr C, Schanz J, Bohn M, Groß U, Meissner K, Moerer O, Harnisch LO. Feasibility of Continuous Infusion of Cefiderocol in Conjunction with the Establishment of Therapeutic Drug Monitoring in Patients with Extensively Drug-Resistant Gram-Negative Bacteria. Clin Drug Investig 2023; 43:307-314. [PMID: 37017874 PMCID: PMC10075148 DOI: 10.1007/s40261-023-01257-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Resistance to antibacterial substances is a huge and still emerging issue, especially with regard to Gram-negative bacteria and in critically ill patients. We report a study in six patients infected with extensively drug-resistant Gram-negative bacteria in a limited outbreak who were successfully managed with a quasi-continuous infusion of cefiderocol. METHODS Patients were initially treated with prolonged infusions of cefiderocol over 3 h every 8 h, and the application mode was then switched to a quasi-continuous infusion of 2 g over 8 h, i.e. 6 g in 24 h. Therapeutic drug monitoring (TDM) was established using an in-house liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. RESULTS Determined trough plasma concentrations were a median of 50.00 mg/L [95% confidence interval (CI) 27.20, 74.60] and steady-state plasma concentrations were a median of 90.96 mg/L [95% CI 37.80, 124]. No significant differences were detected with respect to acute kidney injury/continuous renal replacement therapy. Plasma concentrations determined from different modes of storage were almost equal when frozen or cooled, but markedly reduced when stored at room temperature. CONCLUSIONS (Quasi) continuous application of cefiderocol 6 g/24 h in conjunction with TDM is a feasible mode of application; the sample for TDM should either be immediately analyzed, cooled, or frozen prior to analysis.
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Affiliation(s)
- Carolin Prinz
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Frank Streit
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratories, University of Göttingen Medical Center, Robert-Koch-Str.40, 37099, Göttingen, Germany
| | - Christian Schumann
- Pharmacy, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Anna Dudakova
- Institute for Medical Microbiology and Virology, University of Göttingen Medical Center, Kreuzbergring 57, 37075, Göttingen, Germany
| | - Christian Lanckohr
- Institute of Hygiene, University Medical Center Münster, Robert-Koch-Str. 41, 48149, Münster, Germany
| | - Julie Schanz
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratories, University of Göttingen Medical Center, Robert-Koch-Str.40, 37099, Göttingen, Germany
| | - Matthias Bohn
- Pharmacy, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Uwe Groß
- Institute for Medical Microbiology and Virology, University of Göttingen Medical Center, Kreuzbergring 57, 37075, Göttingen, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Lars-Olav Harnisch
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany.
- Department of Anaesthesiology, Georg-August University of Göttingen, University Medical Center, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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20
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Fendian ÁM, Albanell-Fernández M, Tuset M, Pitart C, Castro P, Soy D, Bodro M, Soriano A, Del Río A, Martínez JA. Real-Life Data on the Effectiveness and Safety of Cefiderocol in Severely Infected Patients: A Case Series. Infect Dis Ther 2023; 12:1205-1216. [PMID: 36943617 PMCID: PMC10029777 DOI: 10.1007/s40121-023-00776-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/08/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Real-life data about cefiderocol use to treat extensively drug-resistant bacteria are scarce. We aim to report our early experience in patients with difficult-to-treat infections and limited therapeutic options. METHODS Patients treated with cefiderocol from March 2018 to April 2022 in a tertiary-care hospital in Spain were included. Demographic, clinical, and microbiological data were collected up to 90 days after the end of treatment or until death. Survival status was recorded at 30 and 90 days. RESULTS Ten patients were included, seven of them critically ill. Ventilator-associated pneumonia (40%) and bacteremia (40%) were the main infections. Multidrug-resistant or extensively drug-resistant P. aeruginosa was the most frequently isolated pathogen (70%, of which six patients were infected with bacteria with difficult-to-treat resistance), followed by A. baumannii, E. coli, and A. xylosoxidans (10% each). Seven patients received combination therapy. Clinical and microbiological cures were achieved in 90% and 80% of patients, respectively. Two previously susceptible strains (20%) developed resistance to cefiderocol. Overall, 30-day and 90-day mortality rates were 10% and 50%, respectively, although two out of five patients died due to the infection. No serious adverse events were reported, except for one patient who developed thrombocytopenia. CONCLUSION Cefiderocol seems to be an effective and safe rescue therapy for patients infected with difficult-to-treat pathogens, although there is a definite risk of the emergence of resistance.
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Affiliation(s)
- Ángel Marcos Fendian
- Pharmacy Service, Division of Medicines, Hospital Clinic of Barcelona, Barcelona, Spain.
| | | | - Montse Tuset
- Pharmacy Service, Division of Medicines, Hospital Clinic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Cristina Pitart
- Department of Microbiology, Hospital Clinic, University of Barcelona, ISGLOBAL, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Dolors Soy
- Pharmacy Service, Division of Medicines, Hospital Clinic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Department of Pharmacology, Toxicology and Therapeutic Chemistry, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Marta Bodro
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ana Del Río
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | - José Antonio Martínez
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Bovo F, Lazzarotto T, Ambretti S, Gaibani P. Comparison of Broth Microdilution, Disk Diffusion and Strip Test Methods for Cefiderocol Antimicrobial Susceptibility Testing on KPC-Producing Klebsiella pneumoniae. Antibiotics (Basel) 2023; 12:antibiotics12030614. [PMID: 36978482 PMCID: PMC10045316 DOI: 10.3390/antibiotics12030614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
The aim of this study was to compare the reference broth microdilution (BMD) method with the Disk Diffusion (DD) test and strip test against a collection of 75 well-characterized Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) clinical strains to assess cefiderocol (CFD) antimicrobial activity. Whole-genome sequencing was performed on KPC-Kp strains by Illumina iSeq100 platform. The Categorical Agreement (CA) between the BMD method and DD test was 92% (69/75) with a Major Error (ME) of 16.7% (6/36). Additionally, the CA between the BMD method and test strip was 90.7% (68/75) with a Very Major Error (VME) of 17.9% (7/39) and 82.7% (62/75) between the strip test and DD with a ME of 30.2%. KPC-Kp strains showing resistance to CFD were 27 out of 75 (36%) by three methods. Specifically, 51.9% (14/27) of KPC-Kp resistant to CFD harbored blaKPC-3, while 48.1% (13/27) harbored mutated blaKPC-3. Moreover, KPC-Kp strains carrying a mutated blaKPC-3 gene exhibited high MIC values (p value < 0.001) compared to wild-type blaKPC-3. In conclusion, the DD test resulted as a valid alternative to the BMD method to determine the in vitro susceptibility to CFD, while the strip test exhibited major limitations.
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Affiliation(s)
- Federica Bovo
- Microbiology Operative Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Operative Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Simone Ambretti
- Microbiology Operative Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Paolo Gaibani
- Microbiology Operative Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Hypoalbuminemia and Pharmacokinetics: When the Misunderstanding of a Fundamental Concept Leads to Repeated Errors over Decades. Antibiotics (Basel) 2023; 12:antibiotics12030515. [PMID: 36978382 PMCID: PMC10044130 DOI: 10.3390/antibiotics12030515] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Surprisingly, misinterpretation of the influence of hypoalbuminemia on pharmacokinetics and the clinical effects of drugs seems to be a current problem, even though hypoalbuminemia has no impact on the pharmacologically active exposure. Exceptions to this fact are highly protein-bound anaesthetics with high elimination capacity (i.e., <5 drugs on the market). To assess the frequency of misinterpretation of the influence of hypoalbuminemia on pharmacokinetics and the clinical effects of drugs between 1975 and 2021, a PubMed literature review was conducted. Each paragraph on albumin binding was classified as correct, ambiguous or incorrect, creating two acceptable categories: (1) content without any errors, and (2) content containing some incorrect and/or ambiguous statements. The analyses of these articles showed that fewer than 11% of articles contained no interpretation errors. In order to contain this misinterpretation, several measures are proposed: (1) Make the message accessible to a wide audience by offering a simplified and didactic video representation of the lack of impact of albumin binding to drugs. (2) Precise terminology (unbound/free form/concentration) should be used for highly bound drugs. (3) Unbound/free forms should be systematically quantified for highly plasma protein bound drugs for clinical trials as well as for therapeutic drug monitoring.
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Hoellinger B, Simand C, Jeannot K, Garijo C, Cristinar M, Reisz F, Danion F, Ursenbach A, Lefebvre N, Boyer P, Hansmann Y, Studer A, Schramm F, Ruch Y. Real-world clinical outcome of cefiderocol for treatment of multidrug-resistant non-fermenting, gram negative bacilli infections: a case series. Clin Microbiol Infect 2023; 29:393-395. [PMID: 36410645 DOI: 10.1016/j.cmi.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Baptiste Hoellinger
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
| | - Célestine Simand
- Department of Hematology, Institute for Cancer Strasbourg-Europe, Strasbourg University, Strasbourg, France
| | - Katy Jeannot
- Centre National de Référence de la Résistance aux Antibiotiques, Laboratoire Associé, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Carlos Garijo
- Service de Réanimation Médicale de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mircea Cristinar
- Service de Réanimation Chirurgicale du Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Fanny Reisz
- Department of Pharmacy, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - François Danion
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Axel Ursenbach
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Nicolas Lefebvre
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre Boyer
- Department of Bacteriology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Yves Hansmann
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Antoine Studer
- Service de Médecine Intensive Réanimation du Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Frédéric Schramm
- Department of Bacteriology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Yvon Ruch
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Optimization of Therapy and the Risk of Probiotic Use during Antibiotherapy in Septic Critically Ill Patients: A Narrative Review. Medicina (B Aires) 2023; 59:medicina59030478. [PMID: 36984479 PMCID: PMC10056847 DOI: 10.3390/medicina59030478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023] Open
Abstract
Optimizing the entire therapeutic regimen in septic critically ill patients should be based not only on improving antibiotic use but also on optimizing the entire therapeutic regimen by considering possible drug–drug or drug–nutrient interactions. The aim of this narrative review is to provide a comprehensive overview on recent advances to optimize the therapeutic regimen in septic critically ill patients based on a pharmacokinetics and pharmacodynamic approach. Studies on recent advances on TDM-guided drug therapy optimization based on PK and/or PD results were included. Studies on patients <18 years old or with classical TDM-guided therapy were excluded. New approaches in TDM-guided therapy in septic critically ill patients based on PK and/or PD parameters are presented for cefiderocol, carbapenems, combinations beta-lactams/beta-lactamase inhibitors (piperacillin/tazobactam, ceftolozane/tazobactam, ceftazidime/avibactam), plazomicin, oxazolidinones and polymyxins. Increased midazolam toxicity in combination with fluconazole, nephrotoxic synergism between furosemide and aminoglycosides, life-threatening hypoglycemia after fluoroquinolone and insulin, prolonged muscle weakness and/or paralysis after neuromuscular blocking agents and high-dose corticosteroids combinations are of interest in critically ill patients. In the real-world practice, the use of probiotics with antibiotics is common; even data about the risk and benefits of probiotics are currently spares and inconclusive. According to current legislation, probiotic use does not require safety monitoring, but there are reports of endocarditis, meningitis, peritonitis, or pneumonia associated with probiotics in critically ill patients. In addition, probiotics are associated with risk of the spread of antimicrobial resistance. The TDM-guided method ensures a true optimization of antibiotic therapy, and particular efforts should be applied globally. In addition, multidrug and drug–nutrient interactions in critically ill patients may increase the likelihood of adverse events and risk of death; therefore, the PK and PD particularities of the critically ill patient require a multidisciplinary approach in which knowledge of clinical pharmacology is essential.
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Escalante J, Nishimura B, Tuttobene MR, Subils T, Mezcord V, Actis LA, Tolmasky ME, Bonomo RA, Ramirez MS. The Iron Content of Human Serum Albumin Modulates the Susceptibility of Acinetobacter baumannii to Cefiderocol. Biomedicines 2023; 11:639. [PMID: 36831178 PMCID: PMC9953112 DOI: 10.3390/biomedicines11020639] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/15/2023] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
The mortality rates of patients infected with Acinetobacter baumannii who were treated with cefiderocol (CFDC) were not as favorable as those receiving the best available treatment for pulmonary and bloodstream infections. Previous studies showed that the presence of human serum albumin (HSA) or HSA-containing fluids, such as human serum (HS) or human pleural fluid (HPF), in the growth medium is correlated with a decrease in the expression of genes associated with high-affinity siderophore-mediated iron uptake systems. These observations may explain the complexities of the observed clinical performance of CFDC in pulmonary and bloodstream infections, because ferric siderophore transporters enhance the penetration of CFDC into the bacterial cell. The removal of HSA from HS or HPF resulted in a reduction in the minimal inhibitory concentration (MIC) of CFDC. Concomitant with these results, an enhancement in the expression of TonB-dependent transporters known to play a crucial role in transporting iron was observed. In addition to inducing modifications in iron-uptake gene expression, the removal of HSA also decreased the expression of β-lactamases genes. Taken together, these observations suggest that environmental HSA has a role in the expression levels of select A. baumannii genes. Furthermore, the removal of iron from HSA had the same effect as the removal of HSA upon the expression of genes associated with iron uptake systems, also suggesting that at least one of the mechanisms by which HSA regulates the expression of certain genes is through acting as an iron source.
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Affiliation(s)
- Jenny Escalante
- Center for Applied Biotechnology Studies, Department of Biological Science, College of Natural Sciences and Mathematics, California State University Fullerton, Fullerton, CA 92831, USA
| | - Brent Nishimura
- Center for Applied Biotechnology Studies, Department of Biological Science, College of Natural Sciences and Mathematics, California State University Fullerton, Fullerton, CA 92831, USA
| | - Marisel R. Tuttobene
- Área Biología Molecular, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario S2000, Argentina
- Instituto de Biología Molecular y Celular de Rosario (IBR, CONICET-UNR), Rosario S2000, Argentina
| | - Tomás Subils
- Instituto de Procesos Biotecnológicos y Químicos de Rosario (IPROBYQ, CONICET-UNR), Rosario S2000, Argentina
| | - Vyanka Mezcord
- Center for Applied Biotechnology Studies, Department of Biological Science, College of Natural Sciences and Mathematics, California State University Fullerton, Fullerton, CA 92831, USA
| | - Luis A. Actis
- Department of Microbiology, Miami University, Oxford, OH 45056, USA
| | - Marcelo E. Tolmasky
- Center for Applied Biotechnology Studies, Department of Biological Science, College of Natural Sciences and Mathematics, California State University Fullerton, Fullerton, CA 92831, USA
| | - Robert A. Bonomo
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Research Service and GRECC, Cleveland, OH 44106, USA
- Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH 44106, USA
| | - María Soledad Ramirez
- Center for Applied Biotechnology Studies, Department of Biological Science, College of Natural Sciences and Mathematics, California State University Fullerton, Fullerton, CA 92831, USA
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Larcher R, Laffont-Lozes P, Loubet P, Laureillard D, Naciri T, Sotto A. Re: 'Real world clinical outcome of cefiderocol for treatment of multidrug-resistant nonfermenting gram-negative bacilli infections' by Hoellinger et al. Clin Microbiol Infect 2023:S1198-743X(23)00047-2. [PMID: 36739087 DOI: 10.1016/j.cmi.2023.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Romaric Larcher
- PhyMedExp (Physiology and Experimental Medicine), INSERM (French Institute of Health and Medical Research), CNRS (French National Centre for Scientific Research), University of Montpellier, France and Department of Infectious and Tropical Diseases, Nîmes University Hospital, France.
| | - Paul Laffont-Lozes
- Department of Infectious and Tropical Diseases and Department of Pharmacy, Nîmes University Hospital, France
| | - Paul Loubet
- VBIC (Bacterial Virulence and Chronic Infection), INSERM (French Institute of Health and Medical Research), Montpellier University, Department of Infectious and Tropical Diseases, Nîmes University Hospital, France
| | - Didier Laureillard
- Department of Infectious and Tropical Diseases, Nîmes University Hospital, France
| | - Tayma Naciri
- Department of Infectious and Tropical Diseases, Nîmes University Hospital, France
| | - Albert Sotto
- VBIC (Bacterial Virulence and Chronic Infection), INSERM (French Institute of Health and Medical Research), Montpellier University, Department of Infectious and Tropical Diseases, Nîmes University Hospital, France
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Gatti M, Pea F. Jumping into the future: overcoming pharmacokinetic/pharmacodynamic hurdles to optimize the treatment of severe difficult to treat-Gram-negative infections with novel beta-lactams. Expert Rev Anti Infect Ther 2023; 21:149-166. [PMID: 36655779 DOI: 10.1080/14787210.2023.2169131] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The choice of best therapeutic strategy for difficult-to-treat resistance (DTR) Gram-negative infections currently represents an unmet clinical need. AREAS COVERED This review provides a critical reappraisal of real-world evidence supporting the role of pharmacokinetic/pharmacodynamic (PK/PD) optimization of novel beta-lactams in the management of DTR Gram-negative infections. The aim was to focus on prolonged and/or continuous infusion administration, penetration rates into deep-seated infections, and maximization of PK/PD targets in special renal patient populations. Retrieved findings were applied to the three most critical clinical scenarios of Gram-negative resistance phenotypes (i.e. carbapenem-resistant Enterobacterales; difficult-to-treat resistant Pseudomonas aeruginosa, and carbapenem-resistant Acinetobacter baumannii). EXPERT OPINION Several studies supported the role of PK/PD optimization of beta-lactams in the management of DTR Gram-negative infections for both maximizing clinical efficacy and preventing resistance emergence. Optimizing antimicrobial therapy with novel beta-lactams based on the so called 'antimicrobial therapy puzzle' PK/PD concepts may represent a definitive jump into the future toward a personalized patient management of DTR Gram negative infections. Establishing a dedicated and coordinated multidisciplinary team and implementing a real-time TDM-guided personalized antimicrobial exposure optimization of novel beta-lactams based on expert clinical pharmacological interpretation, could represent crucial cornerstones for the proper management of DTR Gram-negative infections.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy.,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Italy.,Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Fast and Sensitive Analysis of Cefiderocol in Human Plasma Microsamples by Liquid Chromatography-Isotope Dilution Tandem Mass Spectrometry for Therapeutic Drug Monitoring. Antibiotics (Basel) 2023; 12:antibiotics12020213. [PMID: 36830124 PMCID: PMC9952754 DOI: 10.3390/antibiotics12020213] [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: 12/21/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Cefiderocol (C) is a parenteral siderophore cephalosporin with relevant inter-individual pharmacokinetic variability among critically ill patients, which may potentially affect effective drug exposure. Therapeutic drug monitoring (TDM) may concur in improving the real-time management of C therapy in clinics. In this study, we developed and validated a fast and sensitive Liquid Chromatography-Isotope Dilution Tandem Mass Spectrometry (LC-ITD-MS/MS) method for measuring C in human plasma microsamples, as small as 3 microliters. Analysis was preceded by a user-friendly pre-analytical single-step and was performed by means of a very fast chromatographic run of 4 min, followed by positive electrospray ionization and detection on a high sensitivity triple quadrupole tandem mass spectrometer operated in multiple reaction monitoring mode. The straightforward analytical procedure was successfully validated, based on the European Medicines Agency (EMA) guidelines, in terms of specificity, sensitivity, linearity, precision, accuracy, matrix effect, extraction recovery, limit of quantification, and stability. The novel method was successfully applied to TDM of C in more than 50 cases of critically carbapenem-resistant Gram-negative bacterial infections and enabled us to optimize antibiotic therapy.
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Chou A, Ramsey D, Amenta E, Trautner BW. Real-world experience with cefiderocol therapy for Pseudomonas aeruginosa and other multidrug resistant gram-negative infections within the Veterans Health Administration, 2019-2022. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e90. [PMID: 37179761 PMCID: PMC10173288 DOI: 10.1017/ash.2023.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 05/15/2023]
Abstract
Objective Single-center and regional studies have reported outcomes after treatment with cefiderocol, a novel siderophore cephalosporin. We report on real-world use, clinical outcomes, and microbiological outcomes with cefiderocol therapy within the Veterans' Health Administration (VHA). Design Prospective, observational descriptive study. Setting Veterans' Health Administration, 132 sites across the United States, during 2019-2022. Patients This study included patients admitted to any VHA medical center who received cefiderocol for ≥2 days. Methods Data were obtained from the VHA Corporate Data Warehouse and through manual chart review. We extracted clinical and microbiologic characteristics and outcomes. Results In total, 8,763,652 patients received 1,142,940,842 prescriptions during the study period. Of these, 48 unique individuals received cefiderocol. The median age of this cohort was 70.5 years (IQR, 60.5-74), and the median Charlson comorbidity score was 6 (IQR, 3-9). The most common infectious syndromes were lower respiratory tract infection in 23 patients (47.9%) and urinary tract infection in 14 patients (29.2%). The most common pathogen cultured was P. aeruginosa in 30 patients (62.5%). The clinical failure rate was 35.4% (17 of 48), and 15 (88.2%) of these 17 patients died within 3 days of clinical failure. The 30-day and 90-day all-cause mortality rates were 27.1% (13 of 48) and 45.8% (22 of 48), respectively. The 30-day and 90-day microbiologic failure rates were 29.2% (14 of 48) and 41.7% (20 of 48), respectively. Conclusions In this nationwide VHA cohort clinical and microbiologic failure occurred in >30% of patients treated with cefiderocol, and >40% of these died within 90 days. Cefiderocol is not widely used, and many of the patients who received it had substantial comorbidities.
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Affiliation(s)
- Andrew Chou
- Michael E. DeBakey, Veterans’ Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Corresponding author: Andrew Chou, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), 2450 Holcombe Boulevard, Suite 01Y, Houston, TX, 77021. E-mail:
| | - David Ramsey
- Michael E. DeBakey, Veterans’ Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Eva Amenta
- Michael E. DeBakey, Veterans’ Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Barbara W. Trautner
- Michael E. DeBakey, Veterans’ Affairs Medical Center, Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Pharmacokinetic/Pharmacodynamic Analysis of Continuous-Infusion Fosfomycin in Combination with Extended-Infusion Cefiderocol or Continuous-Infusion Ceftazidime-Avibactam in a Case Series of Difficult-to-Treat Resistant Pseudomonas aeruginosa Bloodstream Infections and/or Hospital-Acquired Pneumonia. Antibiotics (Basel) 2022; 11:antibiotics11121739. [PMID: 36551398 PMCID: PMC9774893 DOI: 10.3390/antibiotics11121739] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives: To perform a pharmacokinetic/pharmacodynamic (PK/PD) analysis of continuous-infusion (CI) fosfomycin combined with extended-infusion (EI) cefiderocol or CI ceftazidime-avibactam in a case series of severe difficult-to-treat Pseudomonas aeruginosa (DTR-PA) infections. Methods: A single-center retrospective study of patients who were treated with CI fosfomycin plus EI cefiderocol or CI ceftazidime-avibactam for severe DTR-PA infections and who underwent therapeutic drug monitoring (TDM), from 1 September 2021 to 30 June 2022 was performed. Concentrations were measured at steady-state (Css) for CI fosfomycin and ceftazidime-avibactam and at trough (Cmin) for EI cefiderocol. Joint PK/PD targets of combination therapy were analyzed (thresholds: area-under-the curve to minimum inhibitory concentration (AUC/MIC) ratio > 40.8 for fosfomycin; ceftazidime Css/MIC ratio ≥ 4 coupled with avibactam Css > 4 mg/L for ceftazidime-avibactam; Cmin/MIC ratio ≥ 4 for cefiderocol). Joint PK/PD targets of the combination therapy were analyzed and defined as optimal when both were achieved, quasi-optimal if only one of the two was achieved, and suboptimal if none of the two was achieved). The relationship between joint PK/PD target attainment and microbiological response was assessed. Results: Six patients (three pneumonia, two BSI + pneumonia, and one BSI) were included. The joint PK/PD targets were optimal in four cases and quasi-optimal in the other two. Microbiological eradication (ME) occurred in 4/4 of patients with optimal joint PK/PD targets and in one of the two patients with quasi-optimal joint PK/PD targets. Conclusions: Attaining optimal joint PK/PD targets with a combo-therapy of CI fosfomycin plus EI cefiderocol or CI ceftazidime-avibactam could represent an effective strategy for granting favorable microbiological outcomes in patients with DTR-PA pneumonia and/or BSI.
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Pharmacokinetics, Pharmacodynamics, and Dosing Considerations of Novel β-Lactams and β-Lactam/β-Lactamase Inhibitors in Critically Ill Adult Patients: Focus on Obesity, Augmented Renal Clearance, Renal Replacement Therapies, and Extracorporeal Membrane Oxygenation. J Clin Med 2022; 11:jcm11236898. [PMID: 36498473 PMCID: PMC9738279 DOI: 10.3390/jcm11236898] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Dose optimization of novel β-lactam antibiotics (NBLA) has become necessary given the increased prevalence of multidrug-resistant infections in intensive care units coupled with the limited number of available treatment options. Unfortunately, recommended dose regimens of NBLA based on PK/PD indices are not well-defined for critically ill patients presenting with special situations (i.e., obesity, extracorporeal membrane oxygenation (ECMO), augmented renal clearance (ARC), and renal replacement therapies (RRT)). This review aimed to discuss and summarize the available literature on the PK/PD attained indices of NBLA among critically ill patients with special circumstances. DATA SOURCES PubMed, MEDLINE, Scopus, Google Scholar, and Embase databases were searched for studies published between January 2011 and May 2022. STUDY SELECTION AND DATA EXTRACTION Articles relevant to NBLA (i.e., ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, ceftobiprole, imipenem/relebactam, and meropenem/vaborbactam) were selected. The MeSH terms of "obesity", "augmented renal clearance", "renal replacement therapy", "extracorporeal membrane oxygenation", "pharmacokinetic", "pharmacodynamic" "critically ill", and "intensive care" were used for identification of articles. The search was limited to adult humans' studies that were published in English. A narrative synthesis of included studies was then conducted accordingly. DATA SYNTHESIS Available evidence surrounding the use of NBLA among critically ill patients presenting with special situations was limited by the small sample size of the included studies coupled with high heterogeneity. The PK/PD target attainments of NBLA were reported to be minimally affected by obesity and/or ECMO, whereas the effect of renal functionality (in the form of either ARC or RRT) was more substantial. CONCLUSION Critically ill patients presenting with special circumstances might be at risk of altered NBLA pharmacokinetics, particularly in the settings of ARC and RRT. More robust, well-designed trials are still required to define effective dose regimens able to attain therapeutic PK/PD indices of NBLA when utilized in those special scenarios, and thus aid in improving the patients' outcomes.
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Hetzler L, Kollef MH, Yuenger V, Micek ST, Betthauser KD. New antimicrobial treatment options for severe Gram-negative infections. Curr Opin Crit Care 2022; 28:522-533. [PMID: 35942725 DOI: 10.1097/mcc.0000000000000968] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review will provide rationale for the development of new antibiotics to treat severe or multidrug-resistant (MDR) Gram-negative infections. It will also provide an overview of recently approved and pipeline antibiotics for severe/MDR Gram-negative infections. RECENT FINDINGS MDR Gram-negative infections are recognized as critical threats by global and national organizations and carry a significant morbidity and mortality risk. Increasing antibiotic resistance amongst Gram-negative bacteria, including carbapenem-resistant Acinetobacter baumannii , extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales and Pseudomonas aeruginosa , with difficult-to-treat-resistance has made both empiric and definitive treatment of these infections increasingly problematic. In recent years, several antibiotics have been approved for treatment of MDR Gram-negative infections and ongoing clinical trials are poised to provide additional options to clinicians' armamentarium. These agents include various β-lactam/β-lactamase inhibitor combinations, eravacycline, plazomicin and cefiderocol. SUMMARY Severe/MDR Gram-negative infections continue to be important infections due to their impact on patient outcomes, especially in critically ill and immunocompromised hosts. The availability of new antibiotics offers an opportunity to improve empiric and definitive treatment of these infections.
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Affiliation(s)
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine
| | | | - Scott T Micek
- Department of Pharmacy Practice, Barnes-Jewish Hospital
- Department of Pharmacy Practice
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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Gaibani P, Amadesi S, Lazzarotto T, Ambretti S. Genome characterization of a Klebsiella pneumoniae co-producing OXA-181 and KPC-121 resistant to ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam and cefiderocol isolated from a critically ill patient. J Glob Antimicrob Resist 2022; 30:262-264. [PMID: 35777673 DOI: 10.1016/j.jgar.2022.06.021] [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: 05/02/2022] [Revised: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES Carbapenemase-producing Enterobacterales (CPE) represent a public health concern. The limited antimicrobial options against CPE have led to the development of novel antimicrobial molecules. In the present study, we characterized the genetic determinants associated with the resistance to ceftazidime/avibactam (CAZ-AVI), meropenem/vaborbactam (MER-VAB), imipenem/relebactam (IMI-REL) and cefiderocol (CFD) in a carbapenemase-producing Klebsiella pneumoniae strain isolated from a critically ill patient. METHODS Genomic DNA was sequenced using Illumina iSeq 100 and Minion Oxford Nanopore platforms. Assemblies were performed with a de novo approach using short-read, hybrid and long-lead assembly approaches. Final assembly was manually curated and carefully verified. Circular elements were screened for antimicrobial-resistance genes, porins, virulence factors and prophage regions. RESULTS KPC-Kp (KPC-producing Klebsiella pneumoniae) BO743 was resistant to all novel β-lactams including CAZ-AVI, MER-VAB, IMI-REL and CFD. The genome of strain BO743 is composed of a single chromosome of 5 347 606 bp and three circular plasmids of 363 634 bp (pBO743-363Kb), 120 290 bp (pBO743-120Kb) and 54 339 bp (pBO743-54Kb). Sequence analysis demonstrated that KPC-Kp BO743 co-harboured blaOXA-181 and novel blaKPC-121 located, respectively, on the pBO743-54Kb and pBO743-120Kb plasmids. KPC-121 differed by a serine insertion at position 181 than KPC-3. CONCLUSION The description of the genome of KPC-Kp cross-resistant to novel βL-βLICs and cefiderocol reveals the presence of numerous antimicrobial resistance genes including blaOXA-181 and novel variant blaKPC-121. The characterization of this multidrug-resistant phenotype provides evidence that needs further attention and monitoring of such MDR clinical isolates.
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Affiliation(s)
- Paolo Gaibani
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Stefano Amadesi
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Section of Microbiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Simone Ambretti
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Maseda E, Suárez de la Rica A. The role of cefiderocol in clinical practice. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35 Suppl 2:39-44. [PMID: 36193984 PMCID: PMC9632056 DOI: 10.37201/req/s02.06.2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Cefiderocol is a new antimicrobial with a chemical structure similar to ceftazidime and cefepime. In this review we will focus on the role of cefiderocol in different clinical scenarios produced by resistant Gram-negative microorganisms, especially to carbapenems. In infections caused by Gram-negative microorganisms, inappropriate antibiotic treatment increased the risk of mortality almost fourfold. In patients with hospital-acquired infection and septic shock; with sepsis and poor functional reserve due to fragility; in immunocompromised patients; and in those with local ecology, individual history of colonization or previous infection and risk factors for carbapenem-resistant Enterobacteriaceae (CRE) such as the presence of chronic multi-morbidities, the best option would be to start an active empirical treatment against gram-negative bacteria resistant to carbapenems and later in 24-36 h with the information obtained from the cultures we could decide on a definitive empirical or directed treatment and avoid unnecessary overuse of these antibiotics. Cefiderocol would be in these cases a good candidate due to its excellent in vitro activity against all classes of beta-lactamase-producing Gram-negatives (including carbapenemase class A, B and D producers), as well as against non-fermenting Gram-negatives such as P. aeruginosa, Acinetobacter spp. and S. maltophilia. It is necessary to optimize the use of new antibiotics such as cefiderocol, guaranteeing the best available treatment to patients while delaying the emergence and spread of resistance.
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Affiliation(s)
- E Maseda
- Emilio Maseda, Servicio de Anestesia y Reanimación. Hospital Valdecilla, Santander, Spain.
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Relationship between Pharmacokinetic/Pharmacodynamic Target Attainment and Microbiological Outcome in Critically Ill COVID-19 Patients with Documented Gram-Negative Superinfections Treated with TDM-Guided Continuous-Infusion Meropenem. Pharmaceutics 2022; 14:pharmaceutics14081585. [PMID: 36015211 PMCID: PMC9412264 DOI: 10.3390/pharmaceutics14081585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/23/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives: The objective of this study was to explore the relationship between pharmacokinetic/pharmacodynamic (PK/PD) target attainment of continuous-infusion (CI) meropenem and microbiological outcome in critical COVID-19 patients with documented Gram-negative superinfections. Methods: Patients receiving CI meropenem for documented Gram-negative infections at the COVID ICU of the IRCCS Azienda Ospedaliero-Universitaria di Bologna and undergoing therapeutic drug monitoring from January 2021 to February 2022 were retrospectively assessed. Average steady-state meropenem concentrations (Css) were calculated and the Css/MIC ratio was selected as a pharmacodynamic parameter of meropenem efficacy. The Css/MIC ratio was defined as optimal if ≥4, quasi-optimal if between 1 and 4, and suboptimal if <1. The relationship between Css/MIC and microbiological outcome was assessed. Results: Overall, 43 critical COVID-19 patients with documented Gram-negative infections were retrieved. Combination therapy was implemented in 26 cases. Css/MIC ratios were optimal in 27 (62.8%), quasi-optimal in 7 (16.3%), and suboptimal in 9 cases (20.9%). Microbiological failure occurred in 21 patients (48.8%), with no difference between monotherapy and combination therapy (43.8% vs. 53.8%; p = 0.53). The microbiological failure rate was significantly lower in patients with an optimal Css/MIC ratio compared to those with a quasi-optimal or suboptimal Css/MIC ratio (33.3% vs. 75.0%; p = 0.01). Conclusion: Suboptimal attainment of meropenem PK/PD targets may be a major determinant impacting on microbiological failure in critical COVID-19 patients with Gram-negative superinfections.
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Cefiderocol: Systematic Review of Mechanisms of Resistance, Heteroresistance and In Vivo Emergence of Resistance. Antibiotics (Basel) 2022; 11:antibiotics11060723. [PMID: 35740130 PMCID: PMC9220290 DOI: 10.3390/antibiotics11060723] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/26/2022] [Accepted: 05/26/2022] [Indexed: 12/04/2022] Open
Abstract
Cefiderocol appears promising, as it can overcome most β-lactam resistance mechanisms (including β-lactamases, porin mutations, and efflux pumps). Resistance is uncommon according to large multinational cohorts, including against isolates resistant to carbapenems, ceftazidime/avibactam, ceftolozane/tazobactam, and colistin. However, alarming proportions of resistance have been reported in some recent cohorts (up to 50%). A systematic review was conducted in PubMed and Scopus from inception to May 2022 to review mechanisms of resistance, prevalence of heteroresistance, and in vivo emergence of resistance to cefiderocol during treatment. A variety of mechanisms, typically acting in concert, have been reported to confer resistance to cefiderocol: β-lactamases (especially NDM, KPC and AmpC variants conferring resistance to ceftazidime/avibactam, OXA-427, and PER- and SHV-type ESBLs), porin mutations, and mutations affecting siderophore receptors, efflux pumps, and target (PBP-3) modifications. Coexpression of multiple β-lactamases, often in combination with permeability defects, appears to be the main mechanism of resistance. Heteroresistance is highly prevalent (especially in A. baumannii), but its clinical impact is unclear, considering that in vivo emergence of resistance appears to be low in clinical studies. Nevertheless, cases of in vivo emerging cefiderocol resistance are increasingly being reported. Continued surveillance of cefiderocol’s activity is important as this agent is introduced in clinical practice.
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Multiple drugs. REACTIONS WEEKLY 2022. [PMCID: PMC9073424 DOI: 10.1007/s40278-022-14737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Giacobbe DR, Roberts JA, Abdul-Aziz MH, de Montmollin E, Timsit JF, Bassetti M. Treatment of ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacteria with novel agents: a contemporary, multidisciplinary ESGCIP perspective. Expert Rev Anti Infect Ther 2022; 20:963-979. [PMID: 35385681 DOI: 10.1080/14787210.2022.2063838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION : In the past 15 years, treatment of VAP caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) has represented an intricate challenge for clinicians. AREAS COVERED In this perspective article, we discuss the available clinical data about novel agents for the treatment of CR-GNB VAP, together with general PK/PD principles for the treatment of VAP, in the attempt to provide some suggestions for optimizing antimicrobial therapy of CR-GNB VAP in the daily clinical practice. EXPERT OPINION Recently, novel BL and BL/BLI combinations have become available that have shown potent in vitro activity against CR-GNB and have attracted much interest as novel, less toxic, and possibly more efficacious options for the treatment of CR-GNB VAP compared with previous standard of care. Besides randomized controlled trials, a good solution to enrich our knowledge on how to use these novel agents at best in the near future, while at the same time remaining adherent to current evidence-based guidelines, is to improve our collaboration to conduct larger multinational observational studies to collect sufficiently large populations treated in real life with those novel agents for which guidelines currently do not provide a recommendation (in favor or against) for certain causative organisms.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
| | - Jason A Roberts
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,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
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
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Drwiega EN, Griffith NC, Danziger LH. Pharmacokinetic evaluation of cefiderocol for the treatment of multidrug resistant Gram-negative infections. Expert Opin Drug Metab Toxicol 2022; 18:245-259. [PMID: 35594628 DOI: 10.1080/17425255.2022.2081148] [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: 09/21/2021] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cefiderocol is a siderophore cephalosporin antibiotic and first of its kind approved by the Food and Drug Administration for the treatment of complicated urinary tract infections (cUTI) and hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) in patients 18 years or older caused by susceptible organisms. Cefiderocol's unique mechanism of iron chelation improves Gram-negative membrane penetration as the bacteria's iron uptake mechanism recognizes the chelated iron antibiotic and iron for entry. This also allows for the evasion of cefiderocol from cell entry-related resistance mechanisms. AREAS COVERED This review covers the mechanism of action, resistance mechanisms, pharmacokinetics in various patient populations, and pharmacodynamics. Relevant literature evaluating efficacy and safety are discussed. EXPERT OPINION Limited treatment options are available for the treatment of carbapenem-resistantorganisms. Clinical trials have demonstrated that cefiderocol is no worse than alternative treatment options for cUTIs and HABP/VABP, but more data are currently available to support the use of beta-lactam beta-lactamase inhibitor agents, where susceptible. Mortality differences demonstrated in patients with pneumonia and bloodstream infections must further be explored and logistical and practical considerations regarding susceptibility testing and use as monotherapy vs. combination therapy must be considered prior to confidently recommending cefiderocol for regular use in systemic infections.
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Affiliation(s)
- Emily N Drwiega
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Nicole C Griffith
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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Berry AV, Kuti JL. Pharmacodynamic Thresholds for Beta-Lactam Antibiotics: A Story of Mouse Versus Man. Front Pharmacol 2022; 13:833189. [PMID: 35370708 PMCID: PMC8971958 DOI: 10.3389/fphar.2022.833189] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/24/2022] [Indexed: 01/20/2023] Open
Abstract
Beta-lactams remain a critical member of our antibiotic armamentarium and are among the most commonly prescribed antibiotic classes in the inpatient setting. For these agents, the percentage of time that the free concentration remains above the minimum inhibitory concentration (%fT > MIC) of the pathogen has been shown to be the best predictor of antibacterial killing effects. However, debate remains about the quantity of fT > MIC exposure needed for successful clinical response. While pre-clinical animal based studies, such as the neutropenic thigh infection model, have been widely used to support dosing regimen selection for clinical development and susceptibility breakpoint evaluation, pharmacodynamic based studies in human patients are used validate exposures needed in the clinic and for guidance during therapeutic drug monitoring (TDM). For the majority of studied beta-lactams, pre-clinical animal studies routinely demonstrated the fT > MIC should exceed approximately 40–70% fT > MIC to achieve 1 log reductions in colony forming units. In contrast, clinical studies tend to suggest higher exposures may be needed, but tremendous variability exists study to study. Herein, we will review and critique pre-clinical versus human-based pharmacodynamic studies aimed at determining beta-lactam exposure thresholds, so as to determine which targets may be best suited for optimal dosage selection, TDM, and for susceptibility breakpoint determination. Based on our review of murine and clinical literature on beta-lactam pharmacodynamic thresholds, murine based targets specific to each antibiotic are most useful during dosage regimen development and susceptibility breakpoint assessment, while a range of exposures between 50 and 100% fT > MIC are reasonable to define the beta-lactam TDM therapeutic window for most infections.
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Outcomes with Cefiderocol Treatment in Patients with Bacteraemia Enrolled into Prospective Phase 2 and Phase 3 Randomised Clinical Studies. Infect Dis Ther 2022; 11:853-870. [PMID: 35184255 PMCID: PMC8960491 DOI: 10.1007/s40121-022-00598-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/26/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction A post hoc, descriptive analysis of three prospective, randomised, controlled clinical studies investigating cefiderocol in gram-negative bacterial infections was conducted to assess its efficacy in patients with baseline bacteraemia. Methods Data from APEKS-cUTI (NCT02321800), APEKS-NP (NCT03032380) and CREDIBLE-CR (NCT02714595) studies were assessed individually. Patients received cefiderocol 2g, q8h, for 7–14 days or comparators (imipenem/cilastatin [APEKS-cUTI], meropenem [APEKS-NP] or best available therapy [BAT; CREDIBLE-CR]). Bacteraemia and clinical outcomes were assessed at early assessment (EA), end of treatment (EOT) and test of cure (TOC) for patients in the intention-to-treat populations with baseline blood samples positive for aerobic gram-negative species. Eradication, persistence or recurrence of baseline blood pathogen was confirmed from follow-up blood cultures; in the absence of follow-up blood cultures, clinical response, administration of additional antibiotics and vital status were used to assess bacteraemia outcome. Results Of 885 patients randomised, 84 had bacteraemia and 89 (cefiderocol: 55, comparators: 34) gram-negative pathogens were isolated, namely Enterobacterales (n = 62) and non-fermenters (n = 27). At EA, on-therapy bacteraemia eradication rates in APEKS-cUTI, APEKS-NP and CREDIBLE-CR were 100% (19/19), 50.0% (4/8) and 72.0% (18/25) with cefiderocol. Corresponding rates for comparators were 77.8% (7/9), 100% (10/10) and 69.2% (9/13), respectively. Persistence in blood at EA was seen in six patients overall (cefiderocol: 3, comparators: 3); indeterminate responses were common (cefiderocol: 8, comparators: 3), usually due to lack of blood cultures. Clinical cure/improvement rates at EA in APEKS-cUTI, APEKS-NP and CREDIBLE-CR were 100% (19/19), 62.5% (5/8) and 64.0% (16/25) with cefiderocol. Corresponding rates for comparators were 77.8% (7/9), 90.0% (9/10) and 30.8% (4/13), respectively. Bacteraemia eradication rates with cefiderocol in APEKS-cUTI, APEKS-NP and CREDIBLE-CR were 89.5%, 37.5% and 60.0% at EOT and 78.9%, 12.5% and 44.0% at TOC. Conclusion This descriptive analysis suggests that cefiderocol may be a useful treatment option for gram-negative bacteraemia, including pathogens resistant to other antibiotics. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-022-00598-9.
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Gatti M, Viaggi B, Rossolini GM, Pea F, Viale P. An Evidence-Based Multidisciplinary Approach Focused on Creating Algorithms for Targeted Therapy of Infection-Related Ventilator-Associated Complications (IVACs) Caused by Pseudomonas aeruginosa and Acinetobacter baumannii in Critically Ill Adult Patients. Antibiotics (Basel) 2021; 11:antibiotics11010033. [PMID: 35052910 PMCID: PMC8773303 DOI: 10.3390/antibiotics11010033] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 12/13/2022] Open
Abstract
(1) Background: To develop evidence-based algorithms for targeted antibiotic therapy of infection-related ventilator-associated complications (IVACs) caused by non-fermenting Gram-negative pathogens. (2) Methods: A multidisciplinary team of four experts had several rounds of assessments for developing algorithms devoted to targeted antimicrobial therapy of IVACs caused by two non-fermenting Gram-negative pathogens. A literature search was performed on PubMed-MEDLINE (until September 2021) to provide evidence for supporting therapeutic choices. Quality and strength of evidence was established according to a hierarchical scale of the study design. Six different algorithms with associated recommendations in terms of therapeutic choice and dosing optimization were suggested according to the susceptibility pattern of two non-fermenting Gram-negative pathogens: multi-susceptible Pseudomonas aeruginosa (PA), multidrug-resistant (MDR) metallo-beta-lactamase (MBL)-negative-PA, MBL-positive-PA, carbapenem-susceptible Acinetobacter baumannii (AB), and carbapenem-resistant AB. (3) Results: Piperacillin–tazobactam or fourth-generation cephalosporins represent the first therapeutic choice in IVACs caused by multi-susceptible PA. A carbapenem-sparing approach favouring the administration of novel beta-lactam/beta-lactamase inhibitors should be pursued in the management of MDR-MBL-negative PA infections. Cefiderocol should be used as first-line therapy for the management of IVACs caused by MBL-producing-PA or carbapenem-resistant AB. Fosfomycin-based combination therapy, as well as inhaled colistin, could be considered as a reasonable alternative for the management of IVACs due to MDR-PA and carbapenem-resistant AB. (4) Conclusions: The implementation of algorithms focused on prompt revision of antibiotic regimens guided by results of conventional and rapid diagnostic methodologies, appropriate place in therapy of novel beta-lactams, implementation of strategies for sparing the broadest-spectrum antibiotics, and pharmacokinetic/pharmacodynamic optimization of antibiotic dosing regimens is strongly suggested.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (P.V.)
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi University Hospital, 50134 Florence, Italy;
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Microbiology and Virology Unit, Florence Careggi University Hospital, 50134 Florence, Italy
- IRCCS Fondazione Don Carlo Gnocchi, 50143 Florence, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (P.V.)
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence:
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.G.); (P.V.)
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40126 Bologna, Italy
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Volpicelli L, Venditti M, Ceccarelli G, Oliva A. Place in Therapy of the Newly Available Armamentarium for Multi-Drug-Resistant Gram-Negative Pathogens: Proposal of a Prescription Algorithm. Antibiotics (Basel) 2021; 10:antibiotics10121475. [PMID: 34943687 PMCID: PMC8698671 DOI: 10.3390/antibiotics10121475] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 11/18/2021] [Accepted: 11/25/2021] [Indexed: 12/24/2022] Open
Abstract
The worldwide propagation of antimicrobial resistance represents one of the biggest threats to global health and development. Multi-drug-resistant organisms (MDROs), including carbapenem-resistant non-fermenting Gram-negatives and Enterobacterales, present a heterogeneous and mutating spread. Infections by MDRO are often associated with an unfavorable outcome, especially among critically ill populations. The polymyxins represented the backbone of antibiotic regimens for Gram-negative MDROs in recent decades, but their use presents multiple pitfalls. Luckily, new agents with potent activity against MDROs have become available in recent times and more are yet to come. Now, we have the duty to make the best use of these new therapeutic tools in order not to prematurely compromise their effectiveness and at the same time improve patients’ outcomes. We reviewed the current literature on ceftazidime/avibactam, meropenem/vaborbactam and cefiderocol, focusing on antimicrobial spectrum, on the prevalence and mechanisms of resistance development and on the main in vitro and clinical experiences available so far. Subsequently, we performed a step-by-step construction of a speculative algorithm for a reasoned prescription of these new antibiotics, contemplating both empirical and targeted use. Attention was specifically posed on patients with life-risk conditions and in settings with elevated prevalence of MDRO.
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