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Toirac B, Aguilera-Correa JJ, Mediero A, Esteban J, Jiménez-Morales A. The Antimicrobial Activity of Micron-Thin Sol-Gel Films Loaded with Linezolid and Cefoxitin for Local Prevention of Orthopedic Prosthesis-Related Infections. Gels 2023; 9:gels9030176. [PMID: 36975625 PMCID: PMC10048042 DOI: 10.3390/gels9030176] [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: 01/30/2023] [Revised: 02/13/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023] Open
Abstract
Orthopedic prosthesis-related infections (OPRI) are an essential health concern. OPRI prevention is a priority and a preferred option over dealing with poor prognosis and high-cost treatments. Micron-thin sol-gel films have been noted for a continuous and effective local delivery system. This study aimed to perform a comprehensive in vitro evaluation of a novel hybrid organic-inorganic sol-gel coating developed from a mixture of organopolysiloxanes and organophosphite and loaded with different concentrations of linezolid and/or cefoxitin. The kinetics of degradation and antibiotics release from the coatings were measured. The inhibition of biofilm formation of the coatings against Staphylococcus aureus, S. epidermidis, and Escherichia coli strains was studied, as well as the cell viability and proliferation of MC3T3-E1 osteoblasts. The microbiological assays demonstrated that sol-gel coatings inhibited the biofilm formation of the evaluated Staphylococcus species; however, no inhibition of the E. coli strain was achieved. A synergistic effect of the coating loaded with both antibiotics was observed against S. aureus. The cell studies showed that the sol-gels did not compromise cell viability and proliferation. In conclusion, these coatings represent an innovative therapeutic strategy with potential clinical use to prevent staphylococcal OPRI.
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Affiliation(s)
- Beatriz Toirac
- Materials Science and Engineering and Chemical Engineering Department, Carlos III University of Madrid, 28911 Madrid, Spain
| | - John Jairo Aguilera-Correa
- Clinical Microbiology Department, IIS-Fundación Jiménez Díaz, UAM, 28040 Madrid, Spain
- CIBERINFEC-Consorcio Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, 28029 Madrid, Spain
| | - Aranzazu Mediero
- Bone and Joint Unit, IIS-Fundación Jiménez Díaz, UAM, 28040 Madrid, Spain
| | - Jaime Esteban
- Clinical Microbiology Department, IIS-Fundación Jiménez Díaz, UAM, 28040 Madrid, Spain
- CIBERINFEC-Consorcio Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, 28029 Madrid, Spain
| | - Antonia Jiménez-Morales
- Materials Science and Engineering and Chemical Engineering Department, Carlos III University of Madrid, 28911 Madrid, Spain
- CIBERINFEC-Consorcio Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, 28029 Madrid, Spain
- Alvaro Alonso Barba Technological Institute of Chemistry and Materials, Carlos III University of Madrid, 28911 Madrid, Spain
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2
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Karanja CW, Naganna N, Abutaleb NS, Dayal N, Onyedibe KI, Aryal U, Seleem MN, Sintim HO. Isoquinoline Antimicrobial Agent: Activity against Intracellular Bacteria and Effect on Global Bacterial Proteome. Molecules 2022; 27:5085. [PMID: 36014324 PMCID: PMC9416421 DOI: 10.3390/molecules27165085] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/16/2022] Open
Abstract
A new class of alkynyl isoquinoline antibacterial compounds, synthesized via Sonogashira coupling, with strong bactericidal activity against a plethora of Gram-positive bacteria including methicillin- and vancomycin-resistant Staphylococcus aureus (S. aureus) strains is presented. HSN584 and HSN739, representative compounds in this class, reduce methicillin-resistant S. aureus (MRSA) load in macrophages, whilst vancomycin, a drug of choice for MRSA infections, was unable to clear intracellular MRSA. Additionally, both HSN584 and HSN739 exhibited a low propensity to develop resistance. We utilized comparative global proteomics and macromolecule biosynthesis assays to gain insight into the alkynyl isoquinoline mechanism of action. Our preliminary data show that HSN584 perturb S. aureus cell wall and nucleic acid biosynthesis. The alkynyl isoquinoline moiety is a new scaffold for the development of potent antibacterial agents against fatal multidrug-resistant Gram-positive bacteria.
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Affiliation(s)
- Caroline W. Karanja
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN 47907, USA
| | - Nimishetti Naganna
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN 47907, USA
| | - Nader S. Abutaleb
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, 625 Harrison Street, West Lafayette, IN 47907, USA
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, 1410 Prices Fork Rd, Blacksburg, VA 24061, USA
| | - Neetu Dayal
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN 47907, USA
| | - Kenneth I. Onyedibe
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN 47907, USA
- Purdue Institute of Inflammation, Immunology and Infectious Disease, West Lafayette, IN 47907, USA
| | - Uma Aryal
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, 625 Harrison Street, West Lafayette, IN 47907, USA
- Purdue Proteomics Facility, Bindley Bioscience Center, Purdue University, West Lafayette, IN 47907, USA
| | - Mohamed N. Seleem
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, 625 Harrison Street, West Lafayette, IN 47907, USA
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, 1410 Prices Fork Rd, Blacksburg, VA 24061, USA
| | - Herman O. Sintim
- Department of Chemistry, Purdue University, 560 Oval Drive, West Lafayette, IN 47907, USA
- Purdue Institute of Inflammation, Immunology and Infectious Disease, West Lafayette, IN 47907, USA
- Institute for Drug Discovery, Purdue University, 720 Clinic Drive, West Lafayette, IN 47907, USA
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3
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Ya’u Sabo Ajingi, Nujarin Jongruja. Antimicrobial Peptide Engineering: Rational Design, Synthesis, and Synergistic Effect. RUSSIAN JOURNAL OF BIOORGANIC CHEMISTRY 2020. [DOI: 10.1134/s1068162020040044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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4
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Hollmann A, Martinez M, Maturana P, Semorile LC, Maffia PC. Antimicrobial Peptides: Interaction With Model and Biological Membranes and Synergism With Chemical Antibiotics. Front Chem 2018; 6:204. [PMID: 29922648 PMCID: PMC5996110 DOI: 10.3389/fchem.2018.00204] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/17/2018] [Indexed: 01/10/2023] Open
Abstract
Antimicrobial peptides (AMPs) are promising novel antibiotics since they have shown antimicrobial activity against a wide range of bacterial species, including multiresistant bacteria; however, toxicity is the major barrier to convert antimicrobial peptides into active drugs. A profound and proper understanding of the complex interactions between these peptides and biological membranes using biophysical tools and model membranes seems to be a key factor in the race to develop a suitable antimicrobial peptide therapy for clinical use. In the search for such therapy, different combined approaches with conventional antibiotics have been evaluated in recent years and demonstrated to improve the therapeutic potential of AMPs. Some of these approaches have revealed promising additive or synergistic activity between AMPs and chemical antibiotics. This review will give an insight into the possibilities that physicochemical tools can give in the AMPs research and also address the state of the art on the current promising combined therapies between AMPs and conventional antibiotics, which appear to be a plausible future opportunity for AMPs treatment.
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Affiliation(s)
- Axel Hollmann
- Laboratory of Molecular Microbiology, Institute of Basic and Applied Microbiology, National University of Quilmes, Bernal, Argentina.,Centro de Investigación en Biofísica Aplicada y Alimentos, Consejo Nacional de Investigaciones Científicas y Técnicas and National University of Santiago del Estero, Santiago del Estero, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Melina Martinez
- Laboratory of Molecular Microbiology, Institute of Basic and Applied Microbiology, National University of Quilmes, Bernal, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Patricia Maturana
- Centro de Investigación en Biofísica Aplicada y Alimentos, Consejo Nacional de Investigaciones Científicas y Técnicas and National University of Santiago del Estero, Santiago del Estero, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Liliana C Semorile
- Laboratory of Molecular Microbiology, Institute of Basic and Applied Microbiology, National University of Quilmes, Bernal, Argentina
| | - Paulo C Maffia
- Laboratory of Molecular Microbiology, Institute of Basic and Applied Microbiology, National University of Quilmes, Bernal, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
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5
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Anirudhan TS, Mohan AM. Novel pH sensitive dual drug loaded-gelatin methacrylate/methacrylic acid hydrogel for the controlled release of antibiotics. Int J Biol Macromol 2018; 110:167-178. [DOI: 10.1016/j.ijbiomac.2018.01.220] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 01/19/2023]
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6
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Novel Cell-Killing Mechanisms of Hydroxyurea and the Implication toward Combination Therapy for the Treatment of Fungal Infections. Antimicrob Agents Chemother 2017; 61:AAC.00734-17. [PMID: 28893786 DOI: 10.1128/aac.00734-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/28/2017] [Indexed: 01/17/2023] Open
Abstract
We have previously reported that an erg11 mutation affecting ergosterol synthesis and a hem13 mutation in the heme synthesis pathway significantly sensitize the fission yeast Schizosaccharomyces pombe to hydroxyurea (HU) (1, 2). Here we show that treatment with inhibitors of Erg11 and heme biosynthesis phenocopies the two mutations in sensitizing wild-type cells to HU. Importantly, HU synergistically interacts with the heme biosynthesis inhibitor sampangine and several Erg11 inhibitors, the antifungal azoles, in causing cell lethality. Since the synergistic drug interactions are also observed in the phylogenetically divergent Saccharomyces cerevisiae and the opportunistic fungal pathogen Candida albicans, the synergism is likely conserved in eukaryotes. Interestingly, our genetic data for S. pombe has also led to the discovery of a robust synergism between sampangine and the azoles in C. albicans Thus, combinations of HU, sampangine, and the azoles can be further studied as a new method for the treatment of fungal infections.
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7
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Mohammadi M, Khayat H, Sayehmiri K, Soroush S, Sayehmiri F, Delfani S, Bogdanovic L, Taherikalani M. Synergistic Effect of Colistin and Rifampin Against Multidrug Resistant Acinetobacter baumannii: A Systematic Review and Meta-Analysis. Open Microbiol J 2017; 11:63-71. [PMID: 28553417 PMCID: PMC5427699 DOI: 10.2174/1874285801711010063] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/26/2017] [Accepted: 02/08/2017] [Indexed: 11/22/2022] Open
Abstract
The existence of infections caused by multidrug resistant (MDR) Acinetobacter baumannii is a growing problem because of the difficulty to treat them. We examined the published literature and focused our analysis on the investigation of the synergism of colistin and rifampin against MDR A. baumannii isolates via systematic review and meta-analysis. A systematic literature search was performed using the following 4 databases (PubMed, Scopus, EMBASE and ISI Web of Sciences). The related articles were evaluated during the period from December 2014 to January 2015. Information based on resistance and sensitivity to antibiotics, the minimum inhibitory concentration and the effects of two antibiotics on each other including synergism, antagonism, relative synergism and additive antagonism were extracted. A meta-analysis of 17 studies including 448 samples was brought into process and 2% (95% CI 0-4%) and 72% (95% CI 56-89%) resistance to colistin and rifampin were observed, respectively. 42% of all isolates showed MIC = 4 µg/ml (95% CI 14-69%) to rifampin and 30% MIC= 2 µg/ml to colistin (95% CI 3.8-78%). MIC50 and MIC90 for both rifampin and colistin were 2 µg/ml and 4 µg/ml, respectively. 63% of the strains demonstrated synergy (95% CI 37-90%), 7% were highlighted as relative synergism (95% CI 0.0- 13%), 3% showed an additive effect (95% CI -0.0-7%) and 14% were indifferent (95% CI 6-23%). The antagonistic effect was not observed in this combination. Synergy rates of time-kill assay in rifampin and colistin combinations were generally higher than those of check bored microdilution and E-test method. The results demonstrated that the combination therapy could be more useful when compared to monotherapy and that this strategy might reduce the resistance rate to rifampin in MDR A. baumannii isolates.
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Affiliation(s)
- Maryam Mohammadi
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Hatef Khayat
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Koroush Sayehmiri
- Department of Biostatistics, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Setareh Soroush
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fatemeh Sayehmiri
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Delfani
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Lidija Bogdanovic
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Morovat Taherikalani
- Razi Herbal Medicines Research Center & Department of Microbiology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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8
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Tran TH, Yanofsky R, Johnston DL, Dix D, Gillmeister B, Ethier MC, Portwine C, Price V, Mitchell D, Cellot S, Lewis V, Zelcer S, Silva M, Michon B, Bowes L, Stobart K, Brossard J, Beyene J, Sung L. Second Bacteremia During Antibiotic Treatment in Children With Acute Myeloid Leukemia: A Report From the Canadian Infections in Acute Myeloid Leukemia Research Group. J Pediatric Infect Dis Soc 2014; 3:228-33. [PMID: 26625386 DOI: 10.1093/jpids/pit086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/12/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND The risk of second bacteremia during antibiotic treatment for initial bacteremia is unknown in high-risk populations. Our objectives were to describe the prevalence of second bacteremia during treatment and identify risk factors in children with acute myeloid leukemia (AML). METHODS We conducted a retrospective, population-based cohort study that included children and adolescents with de novo, non-M3 AML who were diagnosed and treated between January 1, 1995 and December 31, 2004 at 15 Canadian centers. Patients were monitored for bacteremia during chemotherapy until completion of treatment, hematopoietic stem cell transplantation, relapse, refractory disease, or death. RESULTS There were 290 episodes of bacteremia occurring in 185 (54.3%) of 341 children. Eighteen (6.2%) had a second bacteremia while receiving antibiotic treatment. Two episodes of second bacteremia were complicated by sepsis; there were no infection-related deaths. Eleven episodes (61.1%) had either an initial Gram-positive and subsequent Gram-negative bacteremia or initial Gram-negative followed by Gram-positive bacteremia. Days receiving corticosteroids (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.12; P < .0001), cumulative dose of corticosteroids (OR, 1.04; 95% CI, 1.00-1.08; P = .035), and days of neutropenia from start of course to initial bacteremia (OR, 1.07; 95% CI, 1.02-1.12; P = .007) were significantly associated with second bacteremia. CONCLUSIONS In pediatric AML, 6% of patients will experience a second bacteremia during antibiotic treatment; duration of corticosteroid exposure and neutropenia are risk factors. These patients remain at high risk for second bacteremia after identification of the initial bacteremia and warrant continued broad-spectrum treatment during profound neutropenia.
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Affiliation(s)
- Thai Hoa Tran
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | | | - Donna L Johnston
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - David Dix
- Pediatric Hematology/Oncology, British Columbia Children's Hospital, Vancouver, Canada
| | - Biljana Gillmeister
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Marie-Chantal Ethier
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Carol Portwine
- Hematology/Oncology, McMaster Children's Hospital, Hamilton, Canada
| | - Vicky Price
- Pediatrics, IWK Health Centre, Halifax, Canada
| | - David Mitchell
- Hematology/Oncology, Montreal Children's Hospital, Canada
| | - Sonia Cellot
- Hematology/Oncology, Hopital Sainte-Justine, Montreal, Canada
| | - Victor Lewis
- Hematology/Oncology/Transplant Program, Alberta Children's Hospital, Calgary, Canada
| | - Shayna Zelcer
- Hematology/Oncology, London Health Sciences Centre, Canada
| | - Mariana Silva
- Hematology/Oncology, Cancer Centre of Southeastern Ontario at Kingston, Canada
| | - Bruno Michon
- Pediatric Hematology/Oncology, Centre Hospitalier Universitaire de Quebec, Canada
| | - Lynette Bowes
- Hematology/Oncology, Janeway Child Health Centre, St John's, Canada
| | - Kent Stobart
- Stollery Children's Hospital, University of Alberta Edmonton, Canada
| | - Josée Brossard
- Hematology/Oncology, Centre Hospitalier Universitaire de Sherbrooke, Canada
| | - Joseph Beyene
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada Population Genomics Program, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Lillian Sung
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
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9
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Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence 2013; 5:80-97. [PMID: 24184742 PMCID: PMC3916387 DOI: 10.4161/viru.26913] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.
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Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine; Section of Infectious Diseases; Health Sciences Centre; Winnipeg, MB Canada
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10
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Ko KS, Steffey ME, Brandvold KR, Soellner MB. Development of a chimeric c-Src kinase and HDAC inhibitor. ACS Med Chem Lett 2013; 4:779-783. [PMID: 24015327 DOI: 10.1021/ml400175d] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
On the basis of synergism observed between a selective c-Src kinase inhibitor with an HDAC inhibitor, the development of the first chimeric c-Src kinase and HDAC inhibitor is described. The optimized chimeric inhibitor is shown to be a potent c-Src and HDAC inhibitor. Chimeric inhibitor 4 is further shown to be highly efficacious in cancer cell lines and significantly more efficacious than a dual-targeting strategy using discrete c-Src and HDAC inhibitors.
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Affiliation(s)
- Kristin S. Ko
- Department
of Medicinal Chemistry and ‡Department of Chemistry, University of Michigan, 930 North University Avenue,
Ann Arbor, Michigan 48109, United States
| | - Michael E. Steffey
- Department
of Medicinal Chemistry and ‡Department of Chemistry, University of Michigan, 930 North University Avenue,
Ann Arbor, Michigan 48109, United States
| | - Kristoffer R. Brandvold
- Department
of Medicinal Chemistry and ‡Department of Chemistry, University of Michigan, 930 North University Avenue,
Ann Arbor, Michigan 48109, United States
| | - Matthew B. Soellner
- Department
of Medicinal Chemistry and ‡Department of Chemistry, University of Michigan, 930 North University Avenue,
Ann Arbor, Michigan 48109, United States
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11
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Combination therapy for treatment of infections with gram-negative bacteria. Clin Microbiol Rev 2012; 25:450-70. [PMID: 22763634 DOI: 10.1128/cmr.05041-11] [Citation(s) in RCA: 526] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa, those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.
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12
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Abad CL, Kumar A, Safdar N. Antimicrobial therapy of sepsis and septic shock--when are two drugs better than one? Crit Care Clin 2011; 27:e1-27. [PMID: 21440195 DOI: 10.1016/j.ccc.2010.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In clinical practice, physicians frequently use combination therapy despite the conflicting evidence for its effectiveness. The results of recent studies have contributed to our understanding of this important issue. In this article, we examine the evidence for, or against, the use of combination drug therapy compared with monotherapy in the management of serious infections, sepsis, and septic shock.
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Affiliation(s)
- Cybéle L Abad
- Department of Internal Medicine, Section of Infectious Diseases, University of Wisconsin Hospital and Clinics, 1685 Highland Avenue, Madison, WI 53705, USA
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13
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Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: a propensity-matched analysis. Crit Care Med 2010; 38:1773-85. [PMID: 20639750 DOI: 10.1097/ccm.0b013e3181eb3ccd] [Citation(s) in RCA: 297] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Septic shock represents the major cause of infection-associated mortality in the intensive care unit. The possibility that combination antibiotic therapy of bacterial septic shock improves outcome is controversial. Current guidelines do not recommend combination therapy except for the express purpose of broadening coverage when resistant pathogens are a concern. OBJECTIVE To evaluate the therapeutic benefit of early combination therapy comprising at least two antibiotics of different mechanisms with in vitro activity for the isolated pathogen in patients with bacterial septic shock. DESIGN Retrospective, propensity matched, multicenter, cohort study. SETTING Intensive care units of 28 academic and community hospitals in three countries between 1996 and 2007. SUBJECTS A total of 4662 eligible cases of culture-positive, bacterial septic shock treated with combination or monotherapy from which 1223 propensity-matched pairs were generated. MEASUREMENTS AND MAIN RESULTS The primary outcome of study was 28-day mortality. Using a Cox proportional hazards model, combination therapy was associated with decreased 28-day mortality (444 of 1223 [36.3%] vs. 355 of 1223 [29.0%]; hazard ratio, 0.77; 95% confidence interval, 0.67-0.88; p = .0002). The beneficial impact of combination therapy applied to both Gram-positive and Gram-negative infections but was restricted to patients treated with beta-lactams in combination with aminoglycosides, fluoroquinolones, or macrolides/clindamycin. Combination therapy was also associated with significant reductions in intensive care unit (437 of 1223 [35.7%] vs. 352 of 1223 [28.8%]; odds ratio, 0.75; 95% confidence interval, 0.63-0.92; p = .0006) and hospital mortality (584 of 1223 [47.8%] vs. 457 of 1223 [37.4%]; odds ratio, 0.69; 95% confidence interval, 0.59-0.81; p < .0001). The use of combination therapy was associated with increased ventilator (median and [interquartile range], 10 [0-25] vs. 17 [0-26]; p = .008) and pressor/inotrope-free days (median and [interquartile range], 23 [0-28] vs. 25 [0-28]; p = .007) up to 30 days. CONCLUSION Early combination antibiotic therapy is associated with decreased mortality in septic shock. Prospective randomized trials are needed.
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A survival benefit of combination antibiotic therapy for serious infections associated with sepsis and septic shock is contingent only on the risk of death: a meta-analytic/meta-regression study. Crit Care Med 2010; 38:1651-64. [PMID: 20562695 DOI: 10.1097/ccm.0b013e3181e96b91] [Citation(s) in RCA: 212] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess whether a potential benefit with combination antibiotic therapy is restricted to the most critically ill subset of patients, particularly those with septic shock. DATA SOURCES OVID MEDLINE (1950-October 2009), EMBASE (1980-October 2009), the Cochrane Central Register of Controlled Trials (to third quarter 2009), the ClinicalTrial.gov database, and the SCOPUS database. STUDY SELECTION Randomized or observational studies of antimicrobial therapy of serious bacterial infections potentially associated with sepsis or septic shock. Fifty studies met entry criteria. DATA EXTRACTION Study design, mortality/clinical response, and other variables were extracted independently by two reviewers. When possible, study datasets were split into mutually exclusive groups with and without shock or critical illness. DATA SYNTHESIS Although a pooled odds ratio indicated no overall mortality/clinical response benefit with combination therapy (odds ratio, 0.856; 95% confidence interval, 0.71-1.03; p = .0943; I = 45.1%), stratification of datasets by monotherapy mortality risk demonstrated substantial benefit in the most severely ill subset (monotherapy risk of death >25%; odds ratio of death, 0.51; 95% confidence interval, 0.41-0.64; I = 8.6%). Of those datasets that could be stratified by the presence of shock/critical illness, the more severely ill group consistently demonstrated increased efficacy of a combination therapy strategy (odds ratio, 0.49; 95% confidence interval, 0.35-0.70; p < .0001; I = 0%). An increased risk of death was found in low-risk patients (risk of death <or=15% in the monotherapy arm) exposed to combination therapy (odds ratio, 1.53; 95% confidence interval, 1.16-2.03; p = .003; I = 8.2%). Meta-regression indicated that efficacy of combination therapy was dependent only on the risk of death in the monotherapy group. CONCLUSION Combination antibiotic therapy improves survival and clinical response of high-risk, life-threatening infections, particularly those associated with septic shock but may be detrimental to low-risk patients.
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Vidaillac C, Leonard SN, Sader HS, Jones RN, Rybak MJ. In vitro activity of ceftaroline alone and in combination against clinical isolates of resistant gram-negative pathogens, including beta-lactamase-producing Enterobacteriaceae and Pseudomonas aeruginosa. Antimicrob Agents Chemother 2009; 53:2360-6. [PMID: 19349512 PMCID: PMC2687221 DOI: 10.1128/aac.01452-08] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 12/10/2008] [Accepted: 03/27/2009] [Indexed: 01/07/2023] Open
Abstract
Ceftaroline is a novel broad-spectrum cephalosporin that exhibits bactericidal activity against many gram-positive and -negative pathogens. However, the activity of ceftaroline cannot be solely relied upon for eradication of multidrug-resistant gram-negative isolates, such as Pseudomonas aeruginosa and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, which represent a current clinical concern. As drug combinations might be beneficial by potential synergy, we evaluated the in vitro activity of ceftaroline combined with meropenem, aztreonam, cefepime, tazobactam, amikacin, levofloxacin, and tigecycline. Susceptibility testing was performed for 20 clinical P. aeruginosa isolates, 10 ESBL-producing Escherichia coli isolates, 10 ESBL-producing Klebsiella pneumoniae isolates, and 10 AmpC-derepressed Enterobacter cloacae isolates. Time-kill experiments were performed for 10 isolates using antimicrobials at one-fourth the MIC. Ceftaroline exhibited a MIC range of 0.125 to 1,024 microg/ml and was reduced 2- to 512-fold by combination with tazobactam (4 microg/ml) for ESBL-producing strains. In time-kill experiments, ceftaroline plus amikacin was synergistic against 90% of the isolates (and indifferent for one P. aeruginosa isolate). Ceftaroline plus tazobactam was indifferent for E. cloacae and P. aeruginosa strains but synergistic against 100% of E. coli and K. pneumoniae isolates. Combinations of ceftaroline plus meropenem or aztreonam were also synergistic for all E. coli and E. cloacae isolates, respectively, but indifferent against 90% of the other isolates. Finally, combinations of ceftaroline plus either tigecycline, levofloxacin, or cefepime were indifferent for 100% of the isolates. No antagonism was observed with any combination. Ceftaroline plus amikacin appeared as the most likely synergistic combination. This represents a promising therapeutic option, and further studies are warranted to elucidate the clinical value of ceftaroline combinations against resistant gram-negative pathogens.
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Affiliation(s)
- Céline Vidaillac
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave., Detroit, MI 48201, USA
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Combination Antimicrobial Treatment Versus Monotherapy: The Contribution of Meta-analyses. Infect Dis Clin North Am 2009; 23:277-93. [DOI: 10.1016/j.idc.2009.01.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Cunha BA. Ventilator-associated pneumonia: monotherapy is optimal if chosen wisely. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:141. [PMID: 16677419 PMCID: PMC1550899 DOI: 10.1186/cc4908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Traditionally, ventilator-associated pneumonia (VAP) has been treated either with double drug therapy or with monotherapy. Double drug therapy has been used to increase spectrum, for possible synergy, and to decrease the emergence of resistance. VAP therapy should be directed primarily against Pseudomonas aeruginosa, which also provides aerobic Gram-negative coverage, the usual pathogens in VAP. The potent anti-P. aeruginosa antibiotics available today have sufficient activity that double drug coverage is unnecessary. Double drug therapy does not decrease resistance if a 'high resistance potential' antibiotic is used in the combination. The study by Damas and colleagues in this issue of Critical Care supports monotherapy for VAP. Optimal therapy for VAP involves selecting a potent anti-P. aeruginosa antibiotic with a 'low resistance potential' that minimizes drug-drug interactions, minimizes resistance, and is cost effective. Monotherapy of VAP should be the standard of care.
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Affiliation(s)
- Burke A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, USA.
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18
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Abstract
Antimicrobial resistance in the ICU is characterized by increasing overall resistance rates among gram-negative and gram-positive pathogens and increased frequency of multidrug-resistant organisms. In addition to basic principles of appropriate drug selection for empiric and definitive therapy, other specific strategies that may decrease problems of resistance through improved use of antimicrobials include appropriate application of pharmacokinetic and pharmacodynamic principles to antimicrobial use, aggressive dosing of antimicrobials, use of broad-spectrum and combination antimicrobial therapy for initial treatment, decreased duration of antimicrobial therapy, hospital formulary-based antimicrobial restrictions, use of antimicrobial protocols and guidelines, programs for restriction of target antimicrobials, scheduled antimicrobial rotation, and use of antimicrobial management programs. Combinations of various approaches may offer the best potential for effectively intervening in and reducing the spread of resistant pathogens in critically ill patients.
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Affiliation(s)
- Douglas N Fish
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Health Sciences Center, Campus Box C-238, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Nguyen HB, Rivers EP, Abrahamian FM, Moran GJ, Abraham E, Trzeciak S, Huang DT, Osborn T, Stevens D, Talan DA. Severe sepsis and septic shock: review of the literature and emergency department management guidelines. Ann Emerg Med 2006; 48:28-54. [PMID: 16781920 DOI: 10.1016/j.annemergmed.2006.02.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 01/20/2006] [Accepted: 02/14/2006] [Indexed: 01/09/2023]
Abstract
Severe sepsis and septic shock are as common and lethal as other acute life-threatening conditions that emergency physicians routinely confront such as acute myocardial infarction, stroke, and trauma. Recent studies have led to a better understanding of the pathogenic mechanisms and the development of new or newly applied therapies. These therapies place early and aggressive management of severe sepsis and septic shock as integral to improving outcome. This independent review of the literature examines the recent pathogenic, diagnostic, and therapeutic advances in severe sepsis and septic shock for adults, with particular relevance to emergency practice. Recommendations are provided for therapies that have been shown to improve outcomes, including early goal-directed therapy, early and appropriate antimicrobials, source control, recombinant human activated protein C, corticosteroids, and low tidal volume mechanical ventilation.
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20
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Sader HS, Fritsche TR, Jones RN. Potency and spectrum trends for cefepime tested against 65746 clinical bacterial isolates collected in North American medical centers: results from the SENTRY Antimicrobial Surveillance Program (1998-2003). Diagn Microbiol Infect Dis 2006; 52:265-73. [PMID: 16105569 DOI: 10.1016/j.diagmicrobio.2005.02.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 02/05/2005] [Indexed: 11/25/2022]
Abstract
We evaluated the antimicrobial spectrum and potency of cefepime and selected comparators agents against clinical bacterial strains collected in North America over a 6-year period (1998-2003). Isolates were consecutively collected from bloodstream (44%), respiratory tract (41%), urinary tract (6%), and skin/soft tissue (5%) infections in 48 medical centers. Isolates were susceptibility tested by reference broth microdilution methods in a central laboratory. Oxacillin-resistant staphylococci and enterococci were excluded from the analysis. Imipenem (MIC90 = 1 microg/mL, 99.9% susceptible) was the most active compound tested against Enterobacteriaceae (22860 isolates tested) followed by cefepime (MIC90 = 0.25 microg/mL, 99.5% susceptible) > amikacin (99.4% susceptible) > ceftriaxone (95.6% susceptible) > aztreonam (95.1% susceptible). Among comparators, the lowest susceptibility rate for Enterobacteriaceae was observed with ciprofloxacin (92.8% susceptible). Imipenem was also the most active compound against ESBL-producing Klebsiella spp. and Escherichia coli (99.3% and 100% susceptible, respectively), followed by amikacin (81.4% and 97.2% susceptible, respectively) and cefepime (92.5% and 93.8% susceptible, respectively). Cefepime activity against Pseudomonas aeruginosa (85.2% susceptible) was similar to that of imipenem (86.9% susceptible). Against oxacillin-susceptible Staphylococcus aureus, cefepime (MIC90 = 4 microg/mL, 100.0% susceptible) was 4-fold more active than ceftazidime (MIC90 = 16 microg/mL, 86.4% susceptible) and showed a higher susceptibility rate than ciprofloxacin (93.2% susceptible). Cefepime was the most active compound tested against Streptococcus pneumoniae (MIC90 = 1 microg/mL, 97.4% susceptible), ranked after gatifloxacin and levofloxacin (99.2% susceptible). The activity of cefepime remained stable during the study period evaluated with the susceptibility rates varying from 99.3% to 99.8% among the Enterobacteriaceae and 84.4% to 88.4% among P. aeruginosa isolates. In summary, cefepime has retained broad activity and spectrum against Enterobacteriaceae, P. aeruginosa, and Gram-positive cocci (except oxacillin-resistant staphylococci and enterococci) isolated from North American medical centers in the 1998-2003 period. Continued resistance surveillance is critical to monitor the effectiveness of widely used parenteral antimicrobial agents such as cefepime.
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Roy-Leon JE, Lauzon WD, Toye B, Singhal N, Cameron DW. In vitro and in vivo activity of combination antimicrobial agents on Haemophilus ducreyi. J Antimicrob Chemother 2005; 56:552-8. [PMID: 16046468 DOI: 10.1093/jac/dki270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Development of single dose antibiotic treatments for chancroid has been followed by drug-resistant Haemophilus ducreyi in endemic areas. We examined the activity and interactions of antimicrobial agents and combinations against H. ducreyi. METHODS We evaluated the in vitro susceptibility of three virulent strains of H. ducreyi to ceftriaxone, azithromycin, rifabutin and streptomycin, and each two-drug combination by the agar dilution method. We then tested each two-antibiotic combination for activity by the chequerboard method. Lastly, we chose the antibiotic combination with the lowest fractional inhibitory concentration index (FICI) and tested combined sub-therapeutic doses, the highest doses which had no effect alone on lesion healing compared with controls, for in vivo interaction in the temperature-dependent rabbit model of H. ducreyi infection. RESULTS Each H. ducreyi strain was susceptible in vitro to each antibiotic and two-antibiotic combination, and combined ceftriaxone and streptomycin had the lowest FICI at 0.63. In five treated animals versus three untreated controls, combined sub-therapeutic doses of ceftriaxone (0.05 mg/kg) and streptomycin (10 mg/kg) reduced mean (SD) duration of culture positivity from 7.3 (1.1) to 2.6 (1.7) days (P<0.001), time to 50% reduction in lesion size from 9.7 (1.5) to 5.8 (0.8) days (P<0.005), and time to resolution of ulcer from 11.7 (2.3) to 6.6 (1.7) days (P<0.05). CONCLUSIONS Ceftriaxone and streptomycin have in vivo synergic interaction against H. ducreyi lesions in the temperature-dependent rabbit model of infection. Antibiotic combinations may be evaluated clinically as single-dose therapy for chancroid.
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Affiliation(s)
- Josée E Roy-Leon
- Faculty of Medicine, Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Canada
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22
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Safdar N, Handelsman J, Maki DG. Does combination antimicrobial therapy reduce mortality in Gram-negative bacteraemia? A meta-analysis. THE LANCET. INFECTIOUS DISEASES 2004; 4:519-27. [PMID: 15288826 DOI: 10.1016/s1473-3099(04)01108-9] [Citation(s) in RCA: 258] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The use of combination antimicrobial therapy for bacteraemia caused by Gram-negative bacilli is controversial. We did a meta-analysis of published studies to determine whether a combination of two or more antimicrobials reduces mortality in patients with Gram-negative bacteraemia. Criteria for inclusion were: analytic studies of patients with documented Gram-negative bacteraemia that included patients receiving a single antibiotic (monotherapy) and patients receiving two or more antibiotics (combination therapy). Data on mortality (outcome) had to be provided. A pooled odds ratio was calculated with the random effects model of DerSimonian and Laird. Assessment of heterogeneity was done with the Breslow-Day test and reasons for heterogeneity were explored. 17 studies met the inclusion criteria, five prospective cohort studies, two prospective randomised trials, and ten retrospective cohort studies. Most studies used beta-lactams or aminoglycosides alone and in combination. The summary odds ratio was 0.96 (95% CI 0.70-1.32), indicating no mortality benefit with combination therapy. Subgroup analyses adjusting for year of publication, study design, and severity of illness did not change the results. Considerable heterogeneity was present in the main analyses. Analysis of only Pseudomonas aeruginosa bacteraemias showed a significant mortality benefit (OR 0.50, 95% CI 0.30-0.79). Our analysis does not support the routine use of combination antimicrobial therapy for Gram-negative bacteraemia, beyond settings where infection by P aeruginosa is strongly suspected or more than one drug would be desirable to assure in-vitro efficacy.
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Affiliation(s)
- Nasia Safdar
- Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, USA
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Ersoz G, Oztuna V, Coskun B, Eskandari MM, Bayarslan C, Kaya A. Addition of fusidic acid impregnated bone cement to systemic teicoplanin therapy in the treatment of rat osteomyelitis. J Chemother 2004; 16:51-5. [PMID: 15077999 DOI: 10.1179/joc.2004.16.1.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We compared the efficacy of the combination of fusidic acid impregnated bone cement and systemic teicoplanin to systemic teicoplanin alone in implant-related osteomyelitis model in the rats. Foreign bodies were implanted into the medullary channels of 30 rat tibias after intramedullary inoculation of methicillin-resistant Staphylococcus aureus. Following proof of induction of osteomyelitis in the rats on the 21st day, a bone cement rod including 1/40 ratio of fusidic acid was inserted into the medullary channel of the tibias in the study group. Teicoplanin was administered i.m. at 20 mg/kg/day for 14 days to both the study and control groups. At the end of the treatment, the tibias were examined macroscopically, microbiologically and histopathologically. The elimination rate with the teicoplanin+fusidic acid combination was 81.8%, while with teicoplanin alone was 55.6% (p=0.33). Although the difference between the two groups was not statistically significant, the combination treatment had a positive effect in eliminating the microorganism.
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Affiliation(s)
- G Ersoz
- Department of Clinical Microbiology and Infectious Diseases, Mersin University School of Medicine, Mersin, Turkey.
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24
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Jones RN, Sader HS, Beach ML. Contemporary in vitro spectrum of activity summary for antimicrobial agents tested against 18569 strains non-fermentative Gram-negative bacilli isolated in the SENTRY Antimicrobial Surveillance Program (1997-2001). Int J Antimicrob Agents 2004; 22:551-6. [PMID: 14659650 DOI: 10.1016/s0924-8579(03)00245-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The frequency of occurrence and antimicrobial susceptibility patterns of 18569 non-fermentative Gram-negative bacilli consecutively collected as part of the SENTRY Antimicrobial Surveillance Program were summarized. The isolates were tested by the broth microdilution method in three coordinator laboratories using common reagents and reference methodologies. The most frequently isolated pathogen was Pseudomonas aeruginosa (11968 isolates; 64.5%) followed by Acinetobacter spp. (3468 isolates; 18.7%) and Stenotrophomonas maltophilia (1488 isolates; 8.0%). The lowest resistance rates for P. aeruginosa documented were for amikacin (8%), meropenem (10%) and cefepime (10%), and all fluoroquinolones tested showed similar resistance rates (22-24%). The most active compounds against Acinetobacter spp. were the carbapenems, imipenem (11% resistance) and meropenem (12% resistance) followed by cefepime (31% resistance) and gatifloxacin (32% resistance). Very few compounds showed reasonable in vitro activity against S. maltophilia, with the most active antimicrobial agents being trimethoprim/sulphamethoxazole, gatifloxacin and levofloxacin (5-6% resistance). Resistance surveillance among these organisms remains necessary to guide empirical antimicrobial therapy, especially for these less frequently isolated and difficult to test pathogens.
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Affiliation(s)
- Ronald N Jones
- The JONES Group/JMI Laboratories Inc, 345 Beaver Kreek Centre, Suite A, North Liberty, IA 52317, USA
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Glowacki RC, Schwartz DN, Itokazu GS, Wisniewski MF, Kieszkowski P, Weinstein RA. Antibiotic combinations with redundant antimicrobial spectra: clinical epidemiology and pilot intervention of computer-assisted surveillance. Clin Infect Dis 2003; 37:59-64. [PMID: 12830409 DOI: 10.1086/376623] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2002] [Accepted: 04/18/2003] [Indexed: 11/03/2022] Open
Abstract
Redundant antibiotic combinations are a potentially remediable source of antibiotic overuse. At a public teaching hospital, we determined the incidence, cost, and indications for such combinations and measured the effects of a pharmacist-based intervention. Of 1189 inpatients receiving >or=2 antibiotics, computer-assisted screening identified 192 patients (16.1%) receiving potentially redundant combinations. Chart reviews showed that 137 episodes (71%) were inappropriate. Physician overprescribing errors were found in 77 episodes (56%); most involved redundant coverage for gram-positive or anaerobic organisms. In 76 episodes (55%), lapses in the medication ordering and distribution system led to the persistence in the pharmacy records of regimens no longer active according to the patient charts. The incidence of redundant antibiotic combinations was significantly higher in the intensive care unit and surgery services, compared with medical services. Interventions to discontinue redundant agents were successful in 134 (98%) of the 137 episodes. Potential drug cost savings and reduction in redundant antibiotic combination days were 10,800 dollars and 584 days, respectively; pharmacist time for patient review and intervention cost 2880 dollars. Use of redundant antibiotic combinations was common, and a pharmacist-based intervention was feasible, with a potential annualized cost savings of 48,000 dollars.
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Affiliation(s)
- Robert C Glowacki
- John H. Stroger, Jr., Hospital of Cook County, and University of Illinois at Chicago College of Pharmacy, Chicago, IL 60612, USA.
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Abstract
Aminoglycosides remain as a efficacious class of antimicrobials, commonly used in the clinical practice. In spite of the existence of several mechanisms of resistance, they continue being active against most of the aerobic Gram-negative bacilli. Currently, although aminoglycosides may be used as monotherapy in the urinary tract infections, they are mainly used in combination with b-lactam antibiotics in severe infections caused by Gram-negative bacilli. The knowledge about the pharmacokinetic and pharmacodynamic parameters of aminoglycosides has suggested their use in an once-daily dosing regimen. This dosing has shown as efficacious as multiple-daily dosing regimen in several studies, which also have shown a trend toward a lower toxicity. Among the adverse events, nephrotoxicity and ototoxicity require a careful evaluation during its administration.
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Affiliation(s)
- Julián Palomino
- Servicio de Enfermedades Infecciosas. Hospital Universitario Virgen del Rocío. Sevilla. España.
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