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Roilides E, Bradley JS, Lonchar J, Huntington JA, Wickremasingha P, Su FH, Bruno CJ, Johnson MG. Subgroup analysis of phase 2 study of ceftolozane/tazobactam in neonates and young infants with pyelonephritis. Microbiol Spectr 2023; 11:e0180023. [PMID: 37698430 PMCID: PMC10581202 DOI: 10.1128/spectrum.01800-23] [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: 06/15/2023] [Accepted: 07/13/2023] [Indexed: 09/13/2023] Open
Abstract
Ceftolozane/tazobactam is approved for the treatment of patients from birth to <18 y old with complicated urinary tract infections (cUTI). This post hoc analysis evaluated the safety, efficacy, and pharmacokinetics (PK) of ceftolozane/tazobactam compared with meropenem in neonates and young infants. NCT03230838 was a phase 2, randomized, active comparator-controlled, double-blind study of patients from birth to <18 y of age with cUTI, including pyelonephritis, given ceftolozane/tazobactam or meropenem in a 3:1 ratio. This subset analysis included only neonates and young infants < 3 mo of age. The microbiologic modified intent-to-treat population (mMITT) included 20 patients (ceftolozane/tazobactam, n = 14; meropenem, n = 6). All patients had pyelonephritis at baseline; two patients in each treatment group had bacteremia (overall 4/20, 20%). Escherichia coli was the most common baseline pathogen (overall 16/20, 80%). Safety and efficacy results were similar between treatment groups and consistent with the overall pediatric population. There were no serious drug-related adverse events (AEs), no discontinuations due to AEs, and no AEs leading to death in either treatment group. For the ceftolozane/tazobactam and meropenem treatment groups, clinical cure rates in the mMITT population were 92.9% and 100%, respectively. The population PK analysis of neonates and young infants demonstrated similar ceftolozane and tazobactam exposures to those of adults, achieving pharmacodynamic targets associated with clinical and microbiologic cure. Ceftolozane/tazobactam has a favorable safety profile and achieves high clinical cure and microbiologic eradication rates in neonates and young infants < 3 mo of age with cUTI and pyelonephritis. IMPORTANCE Extrapolation of antibacterial agent pharmacokinetics from adults to newborns and young infants may not be appropriate; similarly, the clinical manifestations of infectious diseases and outcomes following antibacterial treatment may not be similar. Ceftolozane/tazobactam is an antibacterial drug combination active against Pseudomonas aeruginosa and other multidrug-resistant gram-negative bacteria. A clinical study led to the approval for ceftolozane/tazobactam in patients from birth to 18 y of age who have complicated urinary tract infections, including those with serious kidney infections. Based on data collected during that clinical study, we compared newborns and young infants who were treated with ceftolozane/tazobactam (14 patients) and those who were treated with meropenem (6 patients). We found that ceftolozane/tazobactam treatment of newborns and young infants up to 3 mo of age who have complicated urinary tract infections demonstrated a favorable safety profile and high clinical cure and microbiologic eradication rates, similar to meropenem.
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Affiliation(s)
- Emmanuel Roilides
- Third Department of Pediatrics, Infectious Diseases Unit, School of Medicine, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - John S. Bradley
- Department of Pediatrics, University of California, San Diego School of Medicine and Rady Children’s Hospital of San Diego, San Diego, California, USA
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Kontou A, Kourti M, Iosifidis E, Sarafidis K, Roilides E. Use of Newer and Repurposed Antibiotics against Gram-Negative Bacteria in Neonates. Antibiotics (Basel) 2023; 12:1072. [PMID: 37370391 DOI: 10.3390/antibiotics12061072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Antimicrobial resistance has become a significant public health problem globally with multidrug resistant Gram negative (MDR-GN) bacteria being the main representatives. The emergence of these pathogens in neonatal settings threatens the well-being of the vulnerable neonatal population given the dearth of safe and effective therapeutic options. Evidence from studies mainly in adults is now available for several novel antimicrobial compounds, such as new β-lactam/β-lactamase inhibitors (e.g., ceftazidime-avibactam, meropenem-vaborbactam, imipenem/cilastatin-relebactam), although old antibiotics such as colistin, tigecycline, and fosfomycin are also encompassed in the fight against MDR-GN infections that remain challenging. Data in the neonatal population are scarce, with few clinical trials enrolling neonates for the evaluation of the efficacy, safety, and dosing of new antibiotics, while the majority of old antibiotics are used off-label. In this article we review data about some novel and old antibiotics that are active against MDR-GN bacteria causing sepsis and are of interest to be used in the neonatal population.
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Affiliation(s)
- Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Maria Kourti
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Poggi C, Dani C. New Antimicrobials for the Treatment of Neonatal Sepsis Caused by Multi-Drug-Resistant Bacteria: A Systematic Review. Antibiotics (Basel) 2023; 12:956. [PMID: 37370275 DOI: 10.3390/antibiotics12060956] [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: 04/30/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Infections by multi-drug-resistant (MDR) organisms are sharply increasing in newborns worldwide. In low and middle-income countries, a disproportionate amount of neonatal sepsis caused by MDR Gram negatives was recently reported. Newborns with infections by MDR organisms with limited treatment options may benefit from novel antimicrobials. METHODS We performed a literature search investigating the use in newborns, infants and children of novel antimicrobials for the treatment of MDR Gram negatives, namely ceftazidime/avibactam, ceftolozane/tazobactam, cefiderocol, meropenem/vaborbactam, imipenem/relebactam, and Gram positives with resistance of concern, namely ceftaroline and dalbavancin. PubMed, EMBASE, and Web of Science were searched. RESULTS A total of 50 records fulfilled the inclusion criteria. Most articles were case reports or case series, and ceftazidime/avibactam was the most studied agent. All studies showed favorable efficacy and safety profile in newborns and across different age cohorts. CONCLUSIONS novel antibiotics may be considered in newborns for the treatment of MDR Gram negatives with limited treatment options and for Gram positives with resistance concerns. Further studies are needed to address their effectiveness and safety in newborns.
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Affiliation(s)
- Chiara Poggi
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, 50141 Florence, Italy
| | - Carlo Dani
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, 50141 Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50141 Florence, Italy
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
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Principe L, Lupia T, Andriani L, Campanile F, Carcione D, Corcione S, De Rosa FG, Luzzati R, Stroffolini G, Steyde M, Decorti G, Di Bella S. Microbiological, Clinical, and PK/PD Features of the New Anti-Gram-Negative Antibiotics: β-Lactam/β-Lactamase Inhibitors in Combination and Cefiderocol—An All-Inclusive Guide for Clinicians. Pharmaceuticals (Basel) 2022; 15:ph15040463. [PMID: 35455461 PMCID: PMC9028825 DOI: 10.3390/ph15040463] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 01/27/2023] Open
Abstract
Bacterial resistance mechanisms are continuously and rapidly evolving. This is particularly true for Gram-negative bacteria. Over the last decade, the strategy to develop new β-lactam/β-lactamase inhibitors (BLs/BLIs) combinations has paid off and results from phase 3 and real-world studies are becoming available for several compounds. Cefiderocol warrants a separate discussion for its peculiar mechanism of action. Considering the complexity of summarizing and integrating the emerging literature data of clinical outcomes, microbiological mechanisms, and pharmacokinetic/pharmacodynamic properties of the new BL/BLI and cefiderocol, we aimed to provide an overview of data on the following compounds: aztreonam/avibactam, cefepime/enmetazobactam, cefepime/taniborbactam, cefepime/zidebactam, cefiderocol, ceftaroline/avibactam, ceftolozane/tazobactam, ceftazidime/avibactam, imipenem/relebactam, meropenem/nacubactam and meropenem/vaborbactam. Each compound is described in a dedicated section by experts in infectious diseases, microbiology, and pharmacology, with tables providing at-a-glance information.
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Affiliation(s)
- Luigi Principe
- Clinical Pathology and Microbiology Unit, “San Giovanni di Dio” Hospital, I-88900 Crotone, Italy;
| | - Tommaso Lupia
- Unit of Infectious Diseases, Cardinal Massaia Hospital, I-14100 Asti, Italy; (T.L.); (F.G.D.R.)
| | - Lilia Andriani
- Clinical Pathology and Microbiology Unit, Hospital of Sondrio, I-23100 Sondrio, Italy;
| | - Floriana Campanile
- Department of Biomedical and Biotechnological Sciences, Section of Microbiology, University of Catania, I-95123 Catania, Italy;
| | - Davide Carcione
- Laboratory of Microbiology and Virology, IRCCS San Raffaele Scientific Institute, I-20132 Milan, Italy;
| | - Silvia Corcione
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Francesco Giuseppe De Rosa
- Unit of Infectious Diseases, Cardinal Massaia Hospital, I-14100 Asti, Italy; (T.L.); (F.G.D.R.)
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
| | - Giacomo Stroffolini
- Infectious diseases Unit, Department of Medical Sciences, University of Torino, I-10124 Torino, Italy; (S.C.); (G.S.)
| | - Marina Steyde
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
| | - Giuliana Decorti
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
- Institute for Maternal and Child Health–IRCCS Burlo Garofolo, I-34137 Trieste, Italy
- Correspondence: ; Tel.: +39 40-378-5362
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, I-34149 Trieste, Italy; (R.L.); (M.S.); (S.D.B.)
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Finding the Dose for Ceftolozane-Tazobactam in Critically Ill Children with and without Acute Kidney Injury. Antibiotics (Basel) 2020; 9:antibiotics9120887. [PMID: 33321721 PMCID: PMC7763445 DOI: 10.3390/antibiotics9120887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/07/2020] [Accepted: 12/07/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Ceftolozane-tazobactam is a new antibiotic against multidrug-resistant pathogens such as Pseudomonas aeruginosas. Ceftolozane-tazobactam dosage is still uncertain in children, especially in those with renal impairment or undergoing continuous renal replacement therapy (CRRT). Methods: Evaluation of different ceftolozane-tazobactam dosing regimens in three critically ill children. Ceftolozane pharmacokinetics (PK) were characterized by obtaining the patient’s specific parameters by Bayesian estimation based on a population PK model. The clearance (CL) in patient C undergoing CRRT was estimated using the prefilter, postfilter, and ultrafiltrate concentrations simultaneously. Variables such as blood, dialysate, replacement, and ultrafiltrate flow rates, and hematocrit were integrated in the model. All PK analyses were performed using NONMEM v.7.4. Results: Patient A (8 months of age, 8.7 kg) with normal renal function received 40 mg/kg every 6 h: renal clearance (CLR) was 0.88 L/h; volume of distribution (Vd) Vd1 = 3.45 L, Vd2 = 0.942 L; terminal halflife (t1/2,β) = 3.51 h, dosing interval area under the drug concentration vs. time curve at steady-state (AUCτ,SS) 397.73 mg × h × L−1. Patient B (19 months of age, 11 kg) with eGFR of 22 mL/min/1.73 m2 received 36 mg/kg every 8 h: CLR = 0.27 L/h; Vd1 = 1.13 L; Vd2 = 1.36; t1/2,β = 6.62 h; AUCSS 1481.48 mg × h × L−1. Patient C (9 months of age, 5.8 kg), with severe renal impairment undergoing CRRT received 30 mg/kg every 8 h: renal replacement therapy clearance (CLRRT) 0.39 L/h; Vd1 = 0.74 L; Vd2= 1.17; t 1/2,β = 3.51 h; AUCτ,SS 448.72 mg × h × L−1. No adverse effects attributable to antibiotic treatment were observed. Conclusions: Our results suggest that a dose of 35 mg/kg every 8 h can be appropriate in critically ill septic children with multi-drug resistance Pseudomonas aeruginosa infections. A lower dose of 10 mg/kg every 8 h could be considered for children with severe AKI. For patients with CRRT and a high effluent rate, a dose of 30 mg/kg every 8 h can be considered.
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Garazzino S, Altieri E, Silvestro E, Pruccoli G, Scolfaro C, Bignamini E. Ceftolozane/Tazobactam for Treating Children With Exacerbations of Cystic Fibrosis Due to Pseudomonas aeruginosa: A Review of Available Data. Front Pediatr 2020; 8:173. [PMID: 32432060 PMCID: PMC7214539 DOI: 10.3389/fped.2020.00173] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/26/2020] [Indexed: 12/18/2022] Open
Abstract
Ceftolozane-tazobactam is a novel fifth-generation cephalosporin/β-lactamase inhibitor combination recently approved for treatment of both complicated intra-abdominal and urinary tract infections in adults. Considering its potent bactericidal activity against Pseudomonas aeruginosa, it might represent an important option also for treating children with exacerbations of cystic fibrosis due to Pseudomonas aeruginosa when other alternative treatments have been exhausted. We hereby review available data on the use of ceftolozane-tazobactam in children, focusing on cystic fibrosis.
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Affiliation(s)
- Silvia Garazzino
- Department of Child Pathology and Treatment "Regina Margherita", Unit of Infectious Diseases, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elena Altieri
- Department of Child Pathology and Treatment "Regina Margherita", Unit of Infectious Diseases, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Erika Silvestro
- Department of Child Pathology and Treatment "Regina Margherita", Unit of Infectious Diseases, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giulia Pruccoli
- Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Carlo Scolfaro
- Department of Child Pathology and Treatment "Regina Margherita", Unit of Infectious Diseases, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elisabetta Bignamini
- Division of Pulmonology, Pediatric Cystic Fibrosis Centre, Città della Salute e della Scienza di Torino, Turin, Italy
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