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Kassegne L, Veziris N, Fraisse P. [A pharmacologic approach to treatment of Mycobacterium abscessus pulmonary disease]. Rev Mal Respir 2024; 41:29-42. [PMID: 38016833 DOI: 10.1016/j.rmr.2023.10.010] [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: 02/11/2023] [Accepted: 10/22/2023] [Indexed: 11/30/2023]
Abstract
Mycobacterium abscessus is a fast-growing non-tuberculous mycobacteria complex causing pulmonary infections, comprising the subspecies abscessus, massiliense and bolletii. Differences are based predominantly on natural inducible macrolide resistance, active in most Mycobacterium abscessus spp abscessus species and in Mycobacterium abscessus spp bolletii but inactive in Mycobacterium abscessus spp massiliense. Therapy consists in long-term treatment, combining multiple antibiotics. Prognosis is poor, as only 40% of patients experience cure. Pharmacodynamic and pharmacokinetic data on M. abscessus have recently been published, showing that therapy ineffectiveness might be explained by intrinsic bacterial resistance (macrolides…) and by the unfavorable pharmacokinetics of the recommended antibiotics. Other molecules and inhaled antibiotics are promising.
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Affiliation(s)
- L Kassegne
- Service de pneumologie, pôle de pathologie thoracique, nouvel hôpital civil, Strasbourg, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France.
| | - N Veziris
- Département de bactériologie, Inserm U1135, Centre d'immunologie et des maladies infectieuses (CIMI-Paris), Centre national de référence des mycobactéries et de la résistance des mycobactéries aux antituberculeux, Groupe hospitalier AP-HP, Sorbonne université, site Saint-Antoine, Paris, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France
| | - P Fraisse
- Service de pneumologie, pôle de pathologie thoracique, nouvel hôpital civil, Strasbourg, France; Groupe pour l'enseignement et la recherche en pneumo-infectiologie de la SPLF, 66, boulevard Saint-Michel, 75006 Paris, France
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2
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Dugernier J, Le Pennec D, Maerckx G, Allimonnier L, Hesse M, Castanares-Zapatero D, Depoortere V, Vecellio L, Reychler G, Michotte JB, Goffette P, Docquier MA, Raftopoulos C, Jamar F, Laterre PF, Ehrmann S, Wittebole X. Inhaled drug delivery: a randomized study in intubated patients with healthy lungs. Ann Intensive Care 2023; 13:125. [PMID: 38072870 PMCID: PMC10710976 DOI: 10.1186/s13613-023-01220-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/24/2023] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND The administration technique for inhaled drug delivery during invasive ventilation remains debated. This study aimed to compare in vivo and in vitro the deposition of a radiolabeled aerosol generated through four configurations during invasive ventilation, including setups optimizing drug delivery. METHODS Thirty-one intubated postoperative neurosurgery patients with healthy lungs were randomly assigned to four configurations of aerosol delivery using a vibrating-mesh nebulizer and specific ventilator settings: (1) a specific circuit for aerosol therapy (SCAT) with the nebulizer placed at 30 cm of the wye, (2) a heated-humidified circuit switched off 30 min before the nebulization or (3) left on with the nebulizer at the inlet of the heated-humidifier, (4) a conventional circuit with the nebulizer placed between the heat and moisture exchanger filter and the endotracheal tube. Aerosol deposition was analyzed using planar scintigraphy. RESULTS A two to three times greater lung delivery was measured in the SCAT group, reaching 19.7% (14.0-24.5) of the nominal dose in comparison to the three other groups (p < 0.01). Around 50 to 60% of lung doses reached the outer region of both lungs in all groups. Drug doses in inner and outer lung regions were significantly increased in the SCAT group (p < 0.01), except for the outer right lung region in the fourth group due to preferential drug trickling from the endotracheal tube and the trachea to the right bronchi. Similar lung delivery was observed whether the heated humidifier was switched off or left on. Inhaled doses measured in vitro correlated with lung doses (R = 0.768, p < 0.001). CONCLUSION Optimizing the administration technique enables a significant increase in inhaled drug delivery to the lungs, including peripheral airways. Before adapting mechanical ventilation, studies are required to continue this optimization and to assess its impact on drug delivery and patient outcome in comparison to more usual settings.
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Affiliation(s)
- Jonathan Dugernier
- Soins Intensifs, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium.
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL et Dermatologie, Université Catholique de Louvain, 1200, Brussels, Belgium.
- Physiothérapie, Département des Thérapies, Hôpital Pourtales, Réseau Hospitalier Neuchâtelois, 2000, Neuchâtel, Switzerland.
- Haute École Arc Santé, HES-SO, University of Applied Sciences and Arts of Western Switzerland, 2000, Neuchâtel, Switzerland.
| | - Déborah Le Pennec
- Centre d'Etude des Pathologies Respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Guillaume Maerckx
- Soins Intensifs, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL et Dermatologie, Université Catholique de Louvain, 1200, Brussels, Belgium
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | - Laurine Allimonnier
- Centre d'Etude des Pathologies Respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Michel Hesse
- Médecine Nucléaire, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | | | - Virginie Depoortere
- Médecine Nucléaire, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | - Laurent Vecellio
- Centre d'Etude des Pathologies Respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Gregory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL et Dermatologie, Université Catholique de Louvain, 1200, Brussels, Belgium
- Secteur de Kinésithérapie et Ergothérapie, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
- Pneumologie, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | - Jean-Bernard Michotte
- School of Health Sciences (HESAV), HES-SO, University of Applied Sciences and Arts of Western Switzerland, 1011, Lausanne, Switzerland
| | - Pierre Goffette
- Radiologie Interventionnelle, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | | | | | - François Jamar
- Médecine Nucléaire, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| | | | - Stephan Ehrmann
- Centre d'Etude des Pathologies Respiratoires, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France
- Université de Tours, Tours, France
| | - Xavier Wittebole
- Soins Intensifs, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
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Motos A, Yang H, Li Bassi G, Yang M, Meli A, Battaglini D, Cabrera R, Bobi J, Pagliara F, Frigola G, Camprubí-Rimblas M, Fernández-Barat L, Rigol M, Ferrer-Segarra A, Kiarostami K, Martinez D, Nicolau DP, Artigas A, Pelosi P, Vila J, Torres A. Inhaled amikacin for pneumonia treatment and dissemination prevention: an experimental model of severe monolateral Pseudomonas aeruginosa pneumonia. Crit Care 2023; 27:60. [PMID: 36788582 PMCID: PMC9930251 DOI: 10.1186/s13054-023-04331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Pseudomonas aeruginosa pneumonia is commonly treated with systemic antibiotics to ensure adequate treatment of multidrug resistant (MDR) bacteria. However, intravenous (IV) antibiotics often achieve suboptimal pulmonary concentrations. We therefore aimed to evaluate the effect of inhaled amikacin (AMK) plus IV meropenem (MEM) on bactericidal efficacy in a swine model of monolateral MDR P. aeruginosa pneumonia. METHODS We ventilated 18 pigs with monolateral MDR P. aeruginosa pneumonia for up to 102 h. At 24 h after the bacterial challenge, the animals were randomized to receive 72 h of treatment with either inhaled saline (control), IV MEM only, or IV-MEM plus inhaled AMK (MEM + AMK). We dosed IV MEM at 25 mg/kg every 8 h and inhaled AMK at 400 mg every 12 h. The primary outcomes were the P. aeruginosa burden and histopathological injury in lung tissue. Secondary outcomes included the P. aeruginosa burden in tracheal secretions and bronchoalveolar lavage fluid, the development of antibiotic resistance, the antibiotic distribution, and the levels of inflammatory markers. RESULTS The median (25-75th percentile) P. aeruginosa lung burden for animals in the control, MEM only, and MEM + AMK groups was 2.91 (1.75-5.69), 0.72 (0.12-3.35), and 0.90 (0-4.55) log10 CFU/g (p = 0.009). Inhaled therapy had no effect on preventing dissemination compared to systemic monotherapy, but it did have significantly higher bactericidal efficacy in tracheal secretions only. Remarkably, the minimum inhibitory concentration of MEM increased to > 32 mg/L after 72-h exposure to monotherapy in 83% of animals, while the addition of AMK prevented this increase (p = 0.037). Adjunctive therapy also slightly affected interleukin-1β downregulation. Despite finding high AMK concentrations in pulmonary samples, we found no paired differences in the epithelial lining fluid concentration between infected and non-infected lungs. Finally, a non-significant trend was observed for higher amikacin penetration in low-affected lung areas. CONCLUSIONS In a swine model of monolateral MDR P. aeruginosa pneumonia, resistant to the inhaled AMK and susceptible to the IV antibiotic, the use of AMK as an adjuvant treatment offered no benefits for either the colonization of pulmonary tissue or the prevention of pathogen dissemination. However, inhaled AMK improved bacterial eradication in the proximal airways and hindered antibiotic resistance.
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Affiliation(s)
- Ana Motos
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Hua Yang
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Gianluigi Li Bassi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Queensland University of Technology, UnitingCare Hospitals, Wesley Medical Research, Brisbane, Australia
| | - Minlan Yang
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Andrea Meli
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Denise Battaglini
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Roberto Cabrera
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Joaquim Bobi
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesco Pagliara
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Gerard Frigola
- Department of Pathology, Hospital Clinic, Barcelona, Spain
| | - Marta Camprubí-Rimblas
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Critical Care Center, ParcTaulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Laia Fernández-Barat
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Montserrat Rigol
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Antoni Ferrer-Segarra
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Anestesiologia i Reanimació, Hospital del Mar - Parc de Salut Mar, Barcelona, Spain
| | - Kasra Kiarostami
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Antonio Artigas
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Critical Care Center, ParcTaulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jordi Vila
- Barcelona Centre for International Health Research (CRESIB), ISGlobal, Barcelona, Spain
- Department of Clinical Microbiology, Centre for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, Madrid, Spain
| | - Antoni Torres
- Servei de Pneumologia i Al•lèrgia Respiratòria, Pneumology Department, Hospital Clínic, Thorax Institute, Calle Villarroel 170, Esc 6/8 Planta 2, 08036, Barcelona, Spain.
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- University of Barcelona, Barcelona, Spain.
- Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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4
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Katiyar SK, Gaur SN, Solanki RN, Sarangdhar N, Suri JC, Kumar R, Khilnani GC, Chaudhary D, Singla R, Koul PA, Mahashur AA, Ghoshal AG, Behera D, Christopher DJ, Talwar D, Ganguly D, Paramesh H, Gupta KB, Kumar T M, Motiani PD, Shankar PS, Chawla R, Guleria R, Jindal SK, Luhadia SK, Arora VK, Vijayan VK, Faye A, Jindal A, Murar AK, Jaiswal A, M A, Janmeja AK, Prajapat B, Ravindran C, Bhattacharyya D, D'Souza G, Sehgal IS, Samaria JK, Sarma J, Singh L, Sen MK, Bainara MK, Gupta M, Awad NT, Mishra N, Shah NN, Jain N, Mohapatra PR, Mrigpuri P, Tiwari P, Narasimhan R, Kumar RV, Prasad R, Swarnakar R, Chawla RK, Kumar R, Chakrabarti S, Katiyar S, Mittal S, Spalgais S, Saha S, Kant S, Singh VK, Hadda V, Kumar V, Singh V, Chopra V, B V. Indian Guidelines on Nebulization Therapy. Indian J Tuberc 2022; 69 Suppl 1:S1-S191. [PMID: 36372542 DOI: 10.1016/j.ijtb.2022.06.004] [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: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/16/2023]
Abstract
Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.
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Affiliation(s)
- S K Katiyar
- Department of Tuberculosis & Respiratory Diseases, G.S.V.M. Medical College & C.S.J.M. University, Kanpur, Uttar Pradesh, India.
| | - S N Gaur
- Vallabhbhai Patel Chest Institute, University of Delhi, Respiratory Medicine, School of Medical Sciences and Research, Sharda University, Greater NOIDA, Uttar Pradesh, India
| | - R N Solanki
- Department of Tuberculosis & Chest Diseases, B. J. Medical College, Ahmedabad, Gujarat, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil School of Medicine, Navi Mumbai, Maharashtra, India
| | - J C Suri
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Raj Kumar
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, National Centre of Allergy, Asthma & Immunology; University of Delhi, Delhi, India
| | - G C Khilnani
- PSRI Institute of Pulmonary, Critical Care, & Sleep Medicine, PSRI Hospital, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Dhruva Chaudhary
- Department of Pulmonary & Critical Care Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rupak Singla
- Department of Tuberculosis & Respiratory Diseases, National Institute of Tuberculosis & Respiratory Diseases (formerly L.R.S. Institute), Delhi, India
| | - Parvaiz A Koul
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Ashok A Mahashur
- Department of Respiratory Medicine, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
| | - A G Ghoshal
- National Allergy Asthma Bronchitis Institute, Kolkata, West Bengal, India
| | - D Behera
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - D J Christopher
- Department of Pulmonary Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Deepak Talwar
- Metro Centre for Respiratory Diseases, Noida, Uttar Pradesh, India
| | | | - H Paramesh
- Paediatric Pulmonologist & Environmentalist, Lakeside Hospital & Education Trust, Bengaluru, Karnataka, India
| | - K B Gupta
- Department of Tuberculosis & Respiratory Medicine, Pt. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences Rohtak, Haryana, India
| | - Mohan Kumar T
- Department of Pulmonary, Critical Care & Sleep Medicine, One Care Medical Centre, Coimbatore, Tamil Nadu, India
| | - P D Motiani
- Department of Pulmonary Diseases, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - P S Shankar
- SCEO, KBN Hospital, Kalaburagi, Karnataka, India
| | - Rajesh Chawla
- Respiratory and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Randeep Guleria
- All India Institute of Medical Sciences, Department of Pulmonary Medicine & Sleep Disorders, AIIMS, New Delhi, India
| | - S K Jindal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Luhadia
- Department of Tuberculosis and Respiratory Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
| | - V K Arora
- Indian Journal of Tuberculosis, Santosh University, NCR Delhi, National Institute of TB & Respiratory Diseases Delhi, India; JIPMER, Puducherry, India
| | - V K Vijayan
- Vallabhbhai Patel Chest Institute, Department of Pulmonary Medicine, University of Delhi, Delhi, India
| | - Abhishek Faye
- Centre for Lung and Sleep Disorders, Nagpur, Maharashtra, India
| | | | - Amit K Murar
- Respiratory Medicine, Cronus Multi-Specialty Hospital, New Delhi, India
| | - Anand Jaiswal
- Respiratory & Sleep Medicine, Medanta Medicity, Gurugram, Haryana, India
| | - Arunachalam M
- All India Institute of Medical Sciences, New Delhi, India
| | - A K Janmeja
- Department of Respiratory Medicine, Government Medical College, Chandigarh, India
| | - Brijesh Prajapat
- Pulmonary and Critical Care Medicine, Yashoda Hospital and Research Centre, Ghaziabad, Uttar Pradesh, India
| | - C Ravindran
- Department of TB & Chest, Government Medical College, Kozhikode, Kerala, India
| | - Debajyoti Bhattacharyya
- Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, Army Hospital (Research & Referral), New Delhi, India
| | | | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - J K Samaria
- Centre for Research and Treatment of Allergy, Asthma & Bronchitis, Department of Chest Diseases, IMS, BHU, Varanasi, Uttar Pradesh, India
| | - Jogesh Sarma
- Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Lalit Singh
- Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
| | - M K Sen
- Department of Respiratory Medicine, ESIC Medical College, NIT Faridabad, Haryana, India; Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Mahendra K Bainara
- Department of Pulmonary Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nilkanth T Awad
- Department of Pulmonary Medicine, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, M.K.C.G. Medical College, Berhampur, Orissa, India
| | - Naveed N Shah
- Department of Pulmonary Medicine, Chest Diseases Hospital, Government Medical College, Srinagar, Jammu & Kashmir, India
| | - Neetu Jain
- Department of Pulmonary, Critical Care & Sleep Medicine, PSRI, New Delhi, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine & Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Orissa, India
| | - Parul Mrigpuri
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Pawan Tiwari
- School of Excellence in Pulmonary Medicine, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - R Narasimhan
- Department of EBUS and Bronchial Thermoplasty Services at Apollo Hospitals, Chennai, Tamil Nadu, India
| | - R Vijai Kumar
- Department of Pulmonary Medicine, MediCiti Medical College, Hyderabad, Telangana, India
| | - Rajendra Prasad
- Vallabhbhai Patel Chest Institute, University of Delhi and U.P. Rural Institute of Medical Sciences & Research, Safai, Uttar Pradesh, India
| | - Rajesh Swarnakar
- Department of Respiratory, Critical Care, Sleep Medicine and Interventional Pulmonology, Getwell Hospital & Research Institute, Nagpur, Maharashtra, India
| | - Rakesh K Chawla
- Department of, Respiratory Medicine, Critical Care, Sleep & Interventional Pulmonology, Saroj Super Speciality Hospital, Jaipur Golden Hospital, Rajiv Gandhi Cancer Hospital, Delhi, India
| | - Rohit Kumar
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - S Chakrabarti
- Department of Pulmonary, Critical Care & Sleep Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care & Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sonam Spalgais
- Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | | | - Surya Kant
- Department of Respiratory (Pulmonary) Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - V K Singh
- Centre for Visceral Mechanisms, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Kumar
- All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Virendra Singh
- Mahavir Jaipuria Rajasthan Hospital, Jaipur, Rajasthan, India
| | - Vishal Chopra
- Department of Chest & Tuberculosis, Government Medical College, Patiala, Punjab, India
| | - Visweswaran B
- Interventional Pulmonology, Yashoda Hospitals, Hyderabad, Telangana, India
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5
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Initial In Vivo Evaluation of a Novel Amikacin-Deoxycholate Hydrophobic Salt Delivers New Insights on Amikacin Partition in Blood and Tissues. Pharmaceutics 2021; 13:pharmaceutics13010085. [PMID: 33435166 PMCID: PMC7827485 DOI: 10.3390/pharmaceutics13010085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 12/19/2022] Open
Abstract
In this study, an initial in vivo evaluation of a new amikacin-deoxycholate hydrophobic salt aimed at potentiating amikacin action against hard-to-treat lung infections was undertaken by quantifying, for the first time, amikacin in whole blood. Pharmacokinetic evaluation after intranasal administration in a murine model showed higher drug retention in the lungs compared to blood, with no significant differences between the salt and the free drug. Upon repeated administrations, the two treatments resulted in nonsignificant tissue damage and mild higher inflammation for the hydrophobic salt. Whole-blood analysis highlighted an unreported high partition of amikacin in blood components up to 48 h, while significant lung levels were measured up to 72 h. Such a new observation was considered responsible for the nearly overlapping pharmacokinetic profiles of the two treatments. To overcome such an issue, a dry powder in an inhalable form may be best suited. Moreover, if confirmed in humans, and considering the current once-a-day regimen for amikacin aerosols, important yet-to-be-explored clinical implications may be postulated for such amikacin persistence in the organism.
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6
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Aerosol Therapy for Pneumonia in the Intensive Care Unit. Clin Chest Med 2019; 39:823-836. [PMID: 30390752 DOI: 10.1016/j.ccm.2018.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Antibiotic aerosolization in patients with ventilator-associated pneumonia (VAP) allows very high concentrations of antimicrobial agents in the respiratory secretions, far more than those achievable using the intravenous route. However, data in critically ill patients with pneumonia are limited. Administration of aerosolized antibiotics might increase the likelihood of clinical resolution, but no significant improvements in important outcomes have been consistently documented. Thus, aerosolized antibiotics should be restricted to the treatment of extensively resistant gram-negative pneumonia. In these cases, the use of a vibrating-mesh nebulizer seems to be more efficient, but specific settings and conditions are required to improve lung delivery.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Guillaume Hékimian
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Nicolas Bréchot
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France
| | - Jean Chastre
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris Cedex 13 75651, France; Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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7
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Heffernan AJ, Sime FB, Lipman J, Dhanani J, Andrews K, Ellwood D, Grimwood K, Roberts JA. Intrapulmonary pharmacokinetics of antibiotics used to treat nosocomial pneumonia caused by Gram-negative bacilli: A systematic review. Int J Antimicrob Agents 2019; 53:234-245. [DOI: 10.1016/j.ijantimicag.2018.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/09/2018] [Accepted: 11/17/2018] [Indexed: 01/31/2023]
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8
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Torres A, Motos A, Battaglini D, Li Bassi G. Inhaled amikacin for severe Gram-negative pulmonary infections in the intensive care unit: current status and future prospects. Crit Care 2018; 22:343. [PMID: 30558658 PMCID: PMC6297966 DOI: 10.1186/s13054-018-1958-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/16/2018] [Indexed: 11/25/2022] Open
Abstract
Recently, the use of nebulized antibiotics in the intensive care unit, in particular amikacin, has been the subject of much discussion, owing to unconvincing results from the latest randomized clinical trials. Here, we examine and reappraise the evidence in favor and against this therapeutic strategy; we then discuss the potential factors that might have played a role in the negative findings of recent clinical trials. Also, we call attention to several factors that are seldom considered by study developers and regulatory agencies, to promote translational research in this field and improve the design of future randomized clinical trials.
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Affiliation(s)
- Antoni Torres
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain. .,University of Barcelona, Barcelona, Spain.
| | - Anna Motos
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain
| | - Denise Battaglini
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain.,University of Genoa, Genoa, Italy
| | - Gianluigi Li Bassi
- Department of Pulmonary and Critical Care Medicine, Hospital Clinic, Calle Villarroel 170, Barcelona, 08036, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomedica En Red- Enfermedades Respiratorias (CIBERES), Barcelona, Spain.,University of Barcelona, Barcelona, Spain
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9
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Antibacterial Activity of Human Simulated Epithelial Lining Fluid Concentrations of Ceftazidime-Avibactam Alone or in Combination with Amikacin Inhale (BAY41-6551) against Carbapenem-Resistant Pseudomonas aeruginosa and Klebsiella pneumoniae. Antimicrob Agents Chemother 2018; 62:AAC.00113-18. [PMID: 29914950 DOI: 10.1128/aac.00113-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 04/03/2018] [Indexed: 12/28/2022] Open
Abstract
The role of inhalational combination therapy when treating carbapenem-resistant Pseudomonas aeruginosa and Klebsiella pneumoniae with newer beta-lactam/beta-lactamase inhibitors has not been established. Using a 72-h in vitro pharmacodynamic chemostat model, we simulated the human exposures achieved in epithelial lining fluid (ELF) following intravenous treatment with ceftazidime-avibactam (CZA) 2.5 g every 8 h (q8h) alone and in combination with inhaled amikacin (AMK-I) 400 mg q12h, a reformulated aminoglycoside designed for inhalational administration, against three P. aeruginosa isolates (CZA [ceftazidime/avibactam] MICs, 4/4 to 8/4 μg/ml; AMK-I MICs, 8 to 64 μg/ml) and three K. pneumoniae isolates (CZA MICs, 1/4 to 8/4 μg/ml; AMK-I MICs, 32 to 64 μg/ml). Combination therapy resulted in a significant reduction in 72-h CFU compared with that of CZA monotherapy against two of three P. aeruginosa isolates (-4.14 log10 CFU/ml, P = 0.027; -1.42 log10 CFU/ml, P = 0.020; and -0.4 log10 CFU/ml, P = 0.298) and two of three K. pneumoniae isolates (0.04 log10 CFU/ml, P = 0.963; -4.34 log10 CFU/ml, P < 0.001; and -2.34 log10 CFU/ml, P = 0.021). When measured by the area under the bacterial growth curve (AUBC) over 72 h, significant reductions were observed in favor of the combination regimen against all six isolates tested. AMK-I combination therapy successfully suppressed CZA resistance development in one K. pneumoniae isolate harboring blaKPC-3 that was observed during CZA monotherapy. These studies suggest a beneficial role for combination therapy with intravenous CZA and inhaled AMK when treating pneumonia caused by carbapenem-resistant Gram-negative bacteria.
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10
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Antimicrobial molecules in the lung: formulation challenges and future directions for innovation. Future Med Chem 2018; 10:575-604. [PMID: 29473765 DOI: 10.4155/fmc-2017-0162] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Inhaled antimicrobials have been extremely beneficial in treating respiratory infections, particularly chronic infections in a lung with cystic fibrosis. The pulmonary delivery of antibiotics has been demonstrated to improve treatment efficacy, reduce systemic side effects and, critically, reduce drug exposure to commensal bacteria compared with systemic administration, reducing selective pressure for antimicrobial resistance. This review will explore the specific challenges of pulmonary delivery of a number of differing antimicrobial molecules, and the formulation and technological approaches that have been used to overcome these difficulties. It will also explore the future challenges being faced in the development of inhaled products and respiratory infection treatment, and identify future directions of innovation, with a particular focus on respiratory infections caused by multiple drug-resistant pathogens.
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11
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Inhaled Antibiotics. Crit Care Med 2018; 46:159-161. [DOI: 10.1097/ccm.0000000000002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Dugernier J, Ehrmann S, Sottiaux T, Roeseler J, Wittebole X, Dugernier T, Jamar F, Laterre PF, Reychler G. Aerosol delivery during invasive mechanical ventilation: a systematic review. Crit Care 2017; 21:264. [PMID: 29058607 PMCID: PMC5651640 DOI: 10.1186/s13054-017-1844-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 09/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This systematic review aimed to assess inhaled drug delivery in mechanically ventilated patients or in animal models. Whole lung and regional deposition and the impact of the ventilator circuit, the artificial airways and the administration technique for aerosol delivery were analyzed. METHODS In vivo studies assessing lung deposition during invasive mechanical ventilation were selected based on a systematic search among four databases. Two investigators independently assessed the eligibility and the risk of bias. RESULTS Twenty-six clinical and ten experimental studies were included. Between 30% and 43% of nominal drug dose was lost to the circuit in ventilated patients. Whole lung deposition of up to 16% and 38% of nominal dose (proportion of drug charged in the device) were reported with nebulizers and metered-dose inhalers, respectively. A penetration index inferior to 1 observed in scintigraphic studies indicated major proximal deposition. However, substantial concentrations of antibiotics were measured in the epithelial lining fluid (887 (406-12,819) μg/mL of amikacin) of infected patients and in sub-pleural specimens (e.g., 197 μg/g of amikacin) dissected from infected piglets, suggesting a significant distal deposition. The administration technique varied among studies and may explain a degree of the variability of deposition that was observed. CONCLUSIONS Lung deposition was lower than 20% of nominal dose delivered with nebulizers and mostly occurred in proximal airways. Further studies are needed to link substantial concentrations of antibiotics in infected pulmonary fluids to pulmonary deposition. The administration technique with nebulizers should be improved in ventilated patients in order to ensure an efficient but safe, feasible and reproducible technique.
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Affiliation(s)
- Jonathan Dugernier
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Médecine Physique, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Stephan Ehrmann
- Université François Rabelais, UMR 1100, F-37032, Tours, France.,INSERM, Centre d'étude des Pathologies Respiratoires, UMR 1100, F-37032, Tours, France.,CHRU de Tours, Réanimation polyvalente, F-37044, Tours, France
| | - Thierry Sottiaux
- Soins Intensifs, Clinique Notre-Dame de Grace, Chaussée de Nivelles 212, 6041, Charleroi, Belgium
| | - Jean Roeseler
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Xavier Wittebole
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Thierry Dugernier
- Soins Intensifs, Clinique Saint-Pierre, Avenue Reine Fabiola 9, 1340, Ottignies, Belgium
| | - François Jamar
- Médecine Nucléaire, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Pierre-François Laterre
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Gregory Reychler
- Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Médecine Physique, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Pneumologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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13
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Kollef MH, Bassetti M, Francois B, Burnham J, Dimopoulos G, Garnacho-Montero J, Lipman J, Luyt CE, Nicolau DP, Postma MJ, Torres A, Welte T, Wunderink RG. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 2017; 43:1187-1197. [PMID: 28160023 PMCID: PMC6204331 DOI: 10.1007/s00134-017-4682-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/06/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Bruno Francois
- Service de Réanimation Polyvalente, Inserm CIC-1435, CHU Dupuytren, Limoges, France
| | - Jason Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - George Dimopoulos
- Department of Critical Care, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Seville, Spain
- Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, Australia
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Herston, Brisbane, QLD, Australia
| | - Charles-Edouard Luyt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS 1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-infective Research and Development and Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Maarten J Postma
- Unit of PharmacoTherapy, Epidemiology & Economics, Department of Pharmacy and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antonio Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, CIBERES, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Tobias Welte
- Department of Pulmonology, Hannover Medical School, Hannover, Germany
| | - Richard G Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Wood GC, Swanson JM. An Update on Aerosolized Antibiotics for Treating Hospital-Acquired and Ventilator-Associated Pneumonia in Adults. Ann Pharmacother 2017; 51:1112-1121. [PMID: 28778127 DOI: 10.1177/1060028017723934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE A significant percentage of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) have poor outcomes with intravenous antibiotics. It is not clear if adding aerosolized antibiotics improves treatment. This review is an update on using aerosolized antibiotics for treating HAP/VAP in adults. DATA SOURCES PubMed search using the terms "aerosolized antibiotics pneumonia," "nebulized antibiotics pneumonia," and "inhaled antibiotics pneumonia." Reference lists from identified articles were also searched. STUDY SELECTION AND DATA EXTRACTION Clinical studies of aerosolized antibiotics for treating HAP/VAP in adults from July 2010 to March 2017. This article updates a previous review on this topic written in mid-2010. DATA SYNTHESIS The size and quality of studies have improved dramatically in the recent time period compared to previous studies. However, there still are not large randomized controlled trials available. Colistin and aminoglycosides were the most commonly studied agents, and the most common pathogens were Pseudomonas and Acinetobacter. The clinical efficacy of adding aerosolized antibiotics was mixed. Approximately half of the studies showed better outcomes, and none showed worse outcomes. Aerosolized antibiotics appear to be relatively safe, though pulmonary adverse events can occur. Attention to proper administration technique in mechanically ventilated patients is required, including the use of vibrating plate nebulizers. CONCLUSIONS Adding aerosolized antibiotics to intravenous antibiotics may improve the outcomes of adult patients with HAP/VAP in some settings. It seems reasonable to add aerosolized antibiotics in patients with multidrug-resistant organisms or who appear to be failing therapy. Clinicians should pay attention to potential adverse events and proper administration technique.
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Affiliation(s)
| | - Joseph M Swanson
- 1 University of Tennessee Health Science Center, Memphis, TN, USA
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15
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Rello J, Rouby JJ, Sole-Lleonart C, Chastre J, Blot S, Luyt CE, Riera J, Vos MC, Monsel A, Dhanani J, Roberts JA. Key considerations on nebulization of antimicrobial agents to mechanically ventilated patients. Clin Microbiol Infect 2017; 23:640-646. [PMID: 28347790 DOI: 10.1016/j.cmi.2017.03.018] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 11/30/2022]
Abstract
Nebulized antibiotics have an established role in patients with cystic fibrosis or bronchiectasis. Their potential benefit to treat respiratory infections in mechanically ventilated patients is receiving increasing interest. In this consensus statement of the European Society of Clinical Microbiology and Infectious Diseases, the body of evidence of the therapeutic utility of aerosolized antibiotics in mechanically ventilated patients was reviewed and resulted in the following recommendations: Vibrating-mesh nebulizers should be preferred to jet or ultrasonic nebulizers. To decrease turbulence and limit circuit and tracheobronchial deposition, we recommend: (a) the use of specifically designed respiratory circuits avoiding sharp angles and characterized by smooth inner surfaces, (b) the use of specific ventilator settings during nebulization including use of a volume controlled mode using constant inspiratory flow, tidal volume 8 mL/kg, respiratory frequency 12 to 15 bpm, inspiratory:expiratory ratio 50%, inspiratory pause 20% and positive end-expiratory pressure 5 to 10 cm H2O and (c) the administration of a short-acting sedative agent if coordination between the patient and the ventilator is not obtained, to avoid patient's flow triggering and episodes of peak decelerating inspiratory flow. A filter should be inserted on the expiratory limb to protect the ventilator flow device and changed between each nebulization to avoid expiratory flow obstruction. A heat and moisture exchanger and/or conventional heated humidifier should be stopped during the nebulization period to avoid a massive loss of aerosolized particles through trapping and condensation. If these technical requirements are not followed, there is a high risk of treatment failure and adverse events in mechanically ventilated patients receiving nebulized antibiotics for pneumonia.
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Affiliation(s)
- J Rello
- European Study Group for Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain.
| | - J J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | | | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, European Study Group for Infections in Critically Ill Patients (ESGCIP), Ghent, Belgium
| | - C E Luyt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Riera
- Critical Care Department, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Vall d'Hebron Institut of Research, Barcelona, Spain
| | - M C Vos
- Department of Medical Microbiology and Infectious Diseases, European Study Group of Nosocomial Infections (ESGNI), Rotterdam, The Netherlands
| | - A Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, University Pierre et Marie Curie (UPMC) of Paris 6, Paris, France
| | - J Dhanani
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
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16
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Poulakou G, Siakallis G, Tsiodras S, Arfaras-Melainis A, Dimopoulos G. Nebulized antibiotics in mechanically ventilated patients: roadmap and challenges. Expert Rev Anti Infect Ther 2017; 15:211-229. [DOI: 10.1080/14787210.2017.1268052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Poulakou
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Siakallis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - S Tsiodras
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - A Arfaras-Melainis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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17
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Dugernier J, Reychler G, Wittebole X, Roeseler J, Depoortere V, Sottiaux T, Michotte JB, Vanbever R, Dugernier T, Goffette P, Docquier MA, Raftopoulos C, Hantson P, Jamar F, Laterre PF. Aerosol delivery with two ventilation modes during mechanical ventilation: a randomized study. Ann Intensive Care 2016; 6:73. [PMID: 27447788 PMCID: PMC4958090 DOI: 10.1186/s13613-016-0169-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Volume-controlled ventilation has been suggested to optimize lung deposition during nebulization although promoting spontaneous ventilation is targeted to avoid ventilator-induced diaphragmatic dysfunction. Comparing topographic aerosol lung deposition during volume-controlled ventilation and spontaneous ventilation in pressure support has never been performed. The aim of this study was to compare lung deposition of a radiolabeled aerosol generated with a vibrating-mesh nebulizer during invasive mechanical ventilation, with two modes: pressure support ventilation and volume-controlled ventilation. METHODS Seventeen postoperative neurosurgery patients without pulmonary disease were randomly ventilated in pressure support or volume-controlled ventilation. Diethylenetriaminepentaacetic acid labeled with technetium-99m (2 mCi/3 mL) was administrated using a vibrating-mesh nebulizer (Aerogen Solo(®), provided by Aerogen Ltd, Galway, Ireland) connected to the endotracheal tube. Pulmonary and extrapulmonary particles deposition was analyzed using planar scintigraphy. RESULTS Lung deposition was 10.5 ± 3.0 and 15.1 ± 5.0 % of the nominal dose during pressure support and volume-controlled ventilation, respectively (p < 0.05). Higher endotracheal tube and tracheal deposition was observed during pressure support ventilation (27.4 ± 6.6 vs. 20.7 ± 6.0 %, p < 0.05). A similar penetration index was observed for the right (p = 0.210) and the left lung (p = 0.211) with both ventilation modes. A high intersubject variability of lung deposition was observed with both modes regarding lung doses, aerosol penetration and distribution between the right and the left lung. CONCLUSIONS In the specific conditions of the study, volume-controlled ventilation was associated with higher lung deposition of nebulized particles as compared to pressure support ventilation. The clinical benefit of this effect warrants further studies. Clinical trial registration NCT01879488.
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Affiliation(s)
- Jonathan Dugernier
- Soins Intensifs, Médecine Physique, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Université catholique de Louvain, 1200, Brussels, Belgium.
| | - Gregory Reychler
- Médecine Physique, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique (IREC), Pneumologie, ORL & Dermatologie, Université catholique de Louvain, 1200, Brussels, Belgium
| | - Xavier Wittebole
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Jean Roeseler
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Virginie Depoortere
- Médecine Nucléaire, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Thierry Sottiaux
- Soins Intensifs, Clinique Notre-Dame de Grâce, Chaussée de Nivelles 212, Gosselies, Belgium
| | - Jean-Bernard Michotte
- Haute Ecole de Santé Vaud, Filière physiothérapie, University of Applied Sciences and Arts Western Switzerland, Avenue de Beaumont 21, 1011, Lausanne, Switzerland
| | - Rita Vanbever
- Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Thierry Dugernier
- Soins Intensifs, Clinique Saint-Pierre, Avenue Reine Fabiola 9, 1340, Ottignies, Belgium
| | - Pierre Goffette
- Radiologie Interventionnelle, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Marie-Agnes Docquier
- Anesthésiologie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Christian Raftopoulos
- Neurochirurgie, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Philippe Hantson
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - François Jamar
- Médecine Nucléaire, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Pierre-François Laterre
- Soins Intensifs, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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Nicolau DP, Dimopoulos G, Welte T, Luyt CE. Can we improve clinical outcomes in patients with pneumonia treated with antibiotics in the intensive care unit? Expert Rev Respir Med 2016; 10:907-18. [PMID: 27181707 DOI: 10.1080/17476348.2016.1190277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pneumonia in the intensive care unit (ICU) is associated with high morbidity, mortality and healthcare costs. However, treatment outcomes with conventional intravenous (IV) antibiotics remain suboptimal, and there is an urgent need for improved therapy options. AREAS COVERED We review how clinical outcomes in patients with pneumonia treated in the ICU could be improved; we discuss the importance of choosing appropriate outcome measures in clinical trials, highlight the current suboptimal outcomes in patients with pneumonia, and outline potential solutions. We have included key studies and papers based on our clinical expertise, therefore a systematic literature review was not conducted. Expert commentary: Reasons for poor outcomes in patients with nosocomial pneumonia in the ICU include inappropriate initial therapy, increasing bacterial resistance and the complexities of IV dosing in critically ill patients. Robust clinical trial endpoints are needed to enable an accurate assessment of the success of new treatment approaches, but progress in this field has been slow. In addition, only very few new antimicrobials are currently in development for nosocomial pneumonia; two potential alternative solutions to improve outcomes could therefore include the optimization of pharmacokinetic/pharmacodynamics (PK/PD) and dosing of existing therapies, and the refinement of antimicrobial delivery by inhalation.
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Affiliation(s)
- David P Nicolau
- a Center for Anti-infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - George Dimopoulos
- b Department of Critical Care Medicine, Medical School , University of Athens , Athens , Greece
| | - Tobias Welte
- c Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany
| | - Charles-Edouard Luyt
- d Service de Réanimation, Institut de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris , Paris , France.,e UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition , Sorbonne Universités , Paris , France
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Vincent JL, Bassetti M, François B, Karam G, Chastre J, Torres A, Roberts JA, Taccone FS, Rello J, Calandra T, De Backer D, Welte T, Antonelli M. Advances in antibiotic therapy in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:133. [PMID: 27184564 PMCID: PMC4869332 DOI: 10.1186/s13054-016-1285-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infections occur frequently in critically ill patients and their management can be challenging for various reasons, including delayed diagnosis, difficulties identifying causative microorganisms, and the high prevalence of antibiotic-resistant strains. In this review, we briefly discuss the importance of early infection diagnosis, before considering in more detail some of the key issues related to antibiotic management in these patients, including controversies surrounding use of combination or monotherapy, duration of therapy, and de-escalation. Antibiotic pharmacodynamics and pharmacokinetics, notably volumes of distribution and clearance, can be altered by critical illness and can influence dosing regimens. Dosing decisions in different subgroups of patients, e.g., the obese, are also covered. We also briefly consider ventilator-associated pneumonia and the role of inhaled antibiotics. Finally, we mention antibiotics that are currently being developed and show promise for the future.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, 33100, Udine, Italy
| | - Bruno François
- Service de Réanimation Polyvalente, CHU de Dupuytren, 87042, Limoges, France
| | - George Karam
- Infectious Disease Section, Louisiana State University School of Medicine, 70112, New Orleans, LA, USA
| | - Jean Chastre
- Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
| | - Antoni Torres
- Department of Pulmonary Medicine, Hospital Clinic of Barcelona, IDIBAPS-Ciberes, 08036, Barcelona, Spain
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Royal Brisbane and Women's Hospital, 4029 Herston, Brisbane, Australia
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jordi Rello
- Department of Intensive care, CIBERES, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, 08035, Barcelona, Spain
| | - Thierry Calandra
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, 1011, Lausanne, Switzerland
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, 1420, Braine L'Alleud, Belgium
| | - Tobias Welte
- Department of Respiratory Medicine, Medizinische Hochschule, 30625, Hannover, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
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So W, Crandon JL, Hamada Y, Nicolau DP. Antibacterial activity of achievable epithelial lining fluid exposures of Amikacin Inhale with or without meropenem. J Antimicrob Chemother 2015; 71:428-37. [PMID: 26559690 DOI: 10.1093/jac/dkv370] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/11/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES While Amikacin Inhale (BAY41-6551), an integrated drug-device combination under development, achieves an estimated amikacin epithelial lining fluid (ELF) concentration of ∼ 5000 mg/L, its target site pharmacodynamics are unknown. We evaluated the pharmacodynamics of ELF exposure of inhaled amikacin ± meropenem. METHODS ELF exposures of inhaled amikacin (400 mg every 12 h), intravenous meropenem (2 g every 8 h) and a combination of both were studied in an in vitro pharmacodynamic model. Seven Klebsiella pneumoniae and 10 Pseudomonas aeruginosa with amikacin/meropenem MICs of 1 to 32,768/≤ 0.125 to >128 mg/L were included. Efficacy was assessed over 24-72 h. RESULTS The mean ± SD 0 h bacterial density was 6.5 ± 0.1 log10 cfu/mL. Controls grew to 8.0 ± 0.5 log10 cfu/mL by the end of the experiments. Simulation of inhaled amikacin monotherapy rapidly achieved and sustained bactericidal activity near the limit of detection over 24 h for all 13 isolates with amikacin MIC ≤ 256 mg/L except only ∼ 2 log10 cfu/mL reduction was observed in K. pneumoniae 375 (amikacin/meropenem MIC 64/32 mg/L) and P. aeruginosa 1544 (amikacin/meropenem MIC 64/128 mg/L). No activity was seen against the three isolates with amikacin MIC ≥ 2048 mg/L. Among the six isolates tested with meropenem monotherapy, five (meropenem MIC ≥ 16 mg/L) grew similarly to the controls while one (meropenem MIC 2 mg/L) achieved ∼ 2.5 log10 cfu/mL decrease. Among seven isolates tested in combination, four (amikacin/meropenem MIC ≤ 64/32 mg/L), including K. pneumoniae 375, maintained limit of detection until 72 h, whereas P. aeruginosa 1544 sustained a 1 log reduction. Combination therapy had no activity against the two isolates with amikacin MIC ≥ 2048 mg/L. CONCLUSIONS Inhaled amikacin monotherapy showed bactericidal activity against most isolates tested with amikacin MICs ≤ 256 mg/L. Adjunct inhaled amikacin plus meropenem sustained this activity for 72 h for the tested isolates with amikacin/meropenem MIC ≤ 64/32 mg/L.
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Affiliation(s)
- Wonhee So
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Jared L Crandon
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Yukihiro Hamada
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Loo CY, Lee WH, Young PM, Cavaliere R, Whitchurch CB, Rohanizadeh R. Implications and emerging control strategies for ventilator-associated infections. Expert Rev Anti Infect Ther 2015; 13:379-93. [DOI: 10.1586/14787210.2015.1007045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Guillon A, Mercier E, Lanotte P, Haguenoer E, Darrouzain F, Barc C, Sarradin P, Si-Tahar M, Heuzé-Vourc'h N, Diot P, Vecellio L. Aerosol Route to Administer Teicoplanin in Mechanical Ventilation: In Vitro Study, Lung Deposition and Pharmacokinetic Analyses in Pigs. J Aerosol Med Pulm Drug Deliv 2015; 28:290-8. [PMID: 25616054 DOI: 10.1089/jamp.2014.1164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKROUND Glycopeptides given intravenously achieve low airway concentrations. Nebulization of teicoplanin may be an efficient way of delivering a high concentration of this antibiotic to the lung. This multistep study assessed the feasibility of teicoplanin nebulization during mechanical ventilation by evaluating: the stability of its antibiotic effect; epithelial tolerance; lung deposition and systemic absorption in ventilated pigs. METHODS Nebulized and non-nebulized teicoplanin activity was tested on Staphylococcus aureus cultures. The cytotoxic effect of teicoplanin on human respiratory epithelial cells was assessed by measuring lactate dehydrogenase activity released, cell viability, and transepithelial electrical resistance. Volume median diameter of particles of nebulized teicoplanin was measured by laser diffraction during mechanical ventilation. The deposited mass of teicoplanin nebulized with a vibrating mesh nebulizer in ventilated piglets was assessed by scintigraphy. Blood pharmacokinetics of teicoplanin administered either intravenously or by nebulization was compared. RESULTS No decrease of antibiotic activity was observed after nebulization. In vitro cytotoxicity of teicoplanin was only observed with 1000 times the dose recommended for intravenous administration. Volume median diameter of particles was 2.5±0.1 μm. Of the initial nebulizer charge of teicoplanin, 24±7% was present in the lungs of ventilated pigs after the nebulization. Amount absorbed in blood was low (3.4%±0.9%) after nebulization, and blood stream elimination half-life value was 25.4 h. CONCLUSIONS Teicoplanin was administered efficiently by nebulization during mechanical ventilation, without any effect on its pharmacological properties or any cytotoxicity. The pharmacokinetic parameters are promising in view of its time-dependent killing process. All the results of our multi-step study highlighted the potential of teicoplanin to be nebulized during mechanical ventilation.
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Affiliation(s)
- Antoine Guillon
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,2 INSERM, U1100, Centre d'Etude des Pathologies Respiratoires , Tours, France .,3 CHRU de Tours, Service de Réanimation Polyvalente , Tours, France
| | - Emmanuelle Mercier
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,2 INSERM, U1100, Centre d'Etude des Pathologies Respiratoires , Tours, France .,3 CHRU de Tours, Service de Réanimation Polyvalente , Tours, France
| | - Philippe Lanotte
- 4 Université François Rabelais de Tours , UMR1282 ISP, Tours, France .,5 INRA , UMR 1282 ISP, Nouzilly, France .,6 Service de Bactériologie-Virologie , Tours, France
| | - Eve Haguenoer
- 4 Université François Rabelais de Tours , UMR1282 ISP, Tours, France .,6 Service de Bactériologie-Virologie , Tours, France
| | | | - Céline Barc
- 8 INRA , UE1277, Plate-Forme d'Infectiologie Expérimentale, Nouzilly, France
| | - Pierre Sarradin
- 8 INRA , UE1277, Plate-Forme d'Infectiologie Expérimentale, Nouzilly, France
| | - Mustapha Si-Tahar
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,2 INSERM, U1100, Centre d'Etude des Pathologies Respiratoires , Tours, France
| | - Nathalie Heuzé-Vourc'h
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,2 INSERM, U1100, Centre d'Etude des Pathologies Respiratoires , Tours, France
| | - Patrice Diot
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,2 INSERM, U1100, Centre d'Etude des Pathologies Respiratoires , Tours, France
| | - Laurent Vecellio
- 1 Université François Rabelais de Tours , EA6305, Tours, France .,9 Aerodrug, Université François Rabelais , Faculté de Médecine, Tours, France
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Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:480. [PMID: 25405992 PMCID: PMC4281952 DOI: 10.1186/s13054-014-0480-6] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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Luyt CE, Bréchot N, Combes A, Trouillet JL, Chastre J. Delivering antibiotics to the lungs of patients with ventilator-associated pneumonia: an update. Expert Rev Anti Infect Ther 2013; 11:511-21. [PMID: 23627857 DOI: 10.1586/eri.13.36] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ventilator-associated pneumonia is a serious hospital-acquired infection, with 20-70% crude mortality and 10-40% estimated attributable mortality. Insufficient antibiotic concentrations at the infection site when these drugs are given intravenously may lead to poor outcomes, particularly when difficult-to-treat pathogens are responsible; for example, Pseudomonas aeruginosa, extended spectrum beta lactamase-producing Gram-negative bacilli, Acinetobacter spp. and/or methicillin-resistant Staphylococcus aureus. Direct drug delivery to the infection site via aerosolization combined with intravenous administration achieves concentrations exceeding MICs of the pathogens, even those with impaired susceptibility. Experimental and recent clinical results demonstrated our markedly improved ability to deliver aerosolized antibiotics to the lung with new-generation devices, for example, vibrating-mesh nebulizers. Convincing clinical data from a large randomized trial are still lacking to support the routine administration of aerosolized antibiotics to treat ventilator-associated pneumonia, even though some small-randomized trials' observations are encouraging.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, Boulevard de l'Hôpital, 75651 Paris Cedex 13, France.
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Niederman MS, Chastre J, Corkery K, Fink JB, Luyt CE, García MS. BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with Gram-negative pneumonia. Intensive Care Med 2011; 38:263-71. [PMID: 22147112 DOI: 10.1007/s00134-011-2420-0] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/05/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To conduct a multicenter, randomized, placebo-controlled, double-blind, phase II study of BAY41-6551 (NCT01004445), an investigational drug-device combination of amikacin, formulated for inhalation, and a proprietary Pulmonary Drug Delivery System, for the treatment of Gram-negative pneumonia in mechanically ventilated patients. METHODS Sixty-nine mechanically ventilated patients with Gram-negative pneumonia, a clinical pulmonary infection score ≥6, at risk for multidrug-resistant organisms, were randomized to BAY41-6551 400 mg every 12 h (q12h), 400 mg every 24 h (q24h) with aerosol placebo, or placebo q12h for 7-14 days, plus standard intravenous antibiotics. The combined primary endpoint was a tracheal aspirate amikacin maximum concentration ≥6,400 μg/mL (25 × 256 μg/mL reference minimum inhibitory concentration) and a ratio of area under the aspirate concentration-time curve (0-24 h) to minimum inhibitory concentration ≥100 on day 1. RESULTS The primary endpoint was achieved in 50% (6/12) and 16.7% (3/18) of patients in the q12h and q24h groups, respectively. Clinical cure rates, in the 48 patients getting ≥7 days of therapy, were 93.8% (15/16), 75.0% (12/16), and 87.5% (14/16) in the q12h, q24h, and placebo groups, respectively (p = 0.467). By the end of aerosol therapy, the mean number of antibiotics per patient per day was 0.9 in the q12h, 1.3 in the q24h, and 1.9 in the placebo groups, respectively (p = 0.02 for difference between groups). BAY41-6551 was well tolerated and attributed to two adverse events in one patient (mild bronchospasm). CONCLUSIONS BAY41-6551 400 mg q12h warrants further clinical evaluation.
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Affiliation(s)
- Michael S Niederman
- Department of Medicine, Winthrop-University Hospital, 222 Station Plaza N., Suite 509, Mineola, NY 11501, USA.
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Abu-Salah T, Dhand R. Inhaled antibiotic therapy for ventilator-associated tracheobronchitis and ventilator-associated pneumonia: an update. Adv Ther 2011; 28:728-47. [PMID: 21833701 DOI: 10.1007/s12325-011-0051-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Indexed: 02/06/2023]
Abstract
Ventilator-associated pneumonia (VAP) remains a leading cause of morbidity and mortality in mechanically-ventilated patients in the Intensive Care Unit (ICU). Ventilator-associated tracheobronchitis (VAT) was previously believed to be an intermediate stage between colonization of the lower respiratory tract and VAP. More recent data, however, suggest that VAT may be a separate entity that increases morbidity and mortality, independently of the occurrence of VAP. Some, but not all, patients with VAT progress to develop VAP. Although inhaled antibiotics alone could be effective for the treatment of VAP, the current consensus of opinion favors their role as adjuncts to systemic antimicrobial therapy for VAP. Inhaled antibiotics are increasingly employed for salvage therapy in patients with VAP due to multi-drug resistant Gram-negative bacteria. In contrast to VAP, VAT could be effectively treated with inhaled antibiotic therapy alone or in combination with systemic antimicrobials.
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Affiliation(s)
- Tareq Abu-Salah
- Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, MO 65212, USA
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