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Gaviraghi A, de Nicolò A, Venuti F, Stroffolini G, Quaranta M, Cat Genova E, Ponzetta L, Alladio F, Marinaro L, D'Avolio A, Calcagno A. Low azithromycin maximal concentrations in patients concomitantly taking rifampicin: time to move away from rifampicin in the treatment of non-tuberculous mycobacteria? Antimicrob Agents Chemother 2024; 68:e0023424. [PMID: 38785450 PMCID: PMC11232375 DOI: 10.1128/aac.00234-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Affiliation(s)
- Alberto Gaviraghi
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, Verona, Italy
| | - Amedeo de Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Stroffolini
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, Verona, Italy
| | - Matilde Quaranta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
| | - Elena Cat Genova
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Laura Ponzetta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
| | - Francesca Alladio
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, Verona, Italy
| | - Letizia Marinaro
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Turin, Italy
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2
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Chung CH, Chang DC, Rhoads NM, Shay MR, Srinivasan K, Okezue MA, Brunaugh AD, Chandrasekaran S. Transfer learning predicts species-specific drug interactions in emerging pathogens. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.06.04.597386. [PMID: 38895385 PMCID: PMC11185605 DOI: 10.1101/2024.06.04.597386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Machine learning (ML) algorithms are necessary to efficiently identify potent drug combinations within a large candidate space to combat drug resistance. However, existing ML approaches cannot be applied to emerging and under-studied pathogens with limited training data. To address this, we developed a transfer learning and crowdsourcing framework (TACTIC) to train ML models on data from multiple bacteria. TACTIC was built using 2,965 drug interactions from 12 bacterial strains and outperformed traditional ML models in predicting drug interaction outcomes for species that lack training data. Top TACTIC model features revealed genetic and metabolic factors that influence cross-species and species-specific drug interaction outcomes. Upon analyzing ~600,000 predicted drug interactions across 9 metabolic environments and 18 bacterial strains, we identified a small set of drug interactions that are selectively synergistic against Gram-negative (e.g., A. baumannii) and non-tuberculous mycobacteria (NTM) pathogens. We experimentally validated synergistic drug combinations containing clarithromycin, ampicillin, and mecillinam against M. abscessus, an emerging pathogen with growing levels of antibiotic resistance. Lastly, we leveraged TACTIC to propose selectively synergistic drug combinations to treat bacterial eye infections (endophthalmitis).
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Affiliation(s)
- Carolina H. Chung
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - David C. Chang
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Nicole M. Rhoads
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Pharmacology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeline R. Shay
- Cellular and Molecular Biology Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Karthik Srinivasan
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Mercy A. Okezue
- Department of Pharmaceutical Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, USA
| | - Ashlee D. Brunaugh
- Department of Pharmaceutical Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, USA
| | - Sriram Chandrasekaran
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Cellular and Molecular Biology Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Program in Chemical Biology, University of Michigan, Ann Arbor, MI, 48109, USA
- Center for Bioinformatics and Computational Medicine, Ann Arbor, MI, 48109, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
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3
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Zimenkov D. Variability of Mycobacterium avium Complex Isolates Drug Susceptibility Testing by Broth Microdilution. Antibiotics (Basel) 2022; 11:1756. [PMID: 36551413 PMCID: PMC9774755 DOI: 10.3390/antibiotics11121756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/09/2022] Open
Abstract
Non-tuberculous mycobacteria are widely distributed in environments and are capable of infecting humans, particularly those with a compromised immune system. The most prevalent species that cause nontuberculous mycobacterial lung diseases are slow-growing bacteria from the Mycobacterium avium complex (MAC), mainly M. avium or M. intracellulare. The key treatment of MAC infections includes macrolides, ethambutol, and rifampicin; however, the therapy outcomes are unsatisfactory. Phenotypic drug susceptibility testing is a conditional recommendation prior to treatment, and critical concentrations for clarithromycin, amikacin, moxifloxacin, and linezolid have been established. In this review, data from studies on the determination of MIC of clinical isolates using the broth microdilution method were summarized. A significant variation in the MIC distributions from different studies was found. The main reasons could impact the findings: insufficient reproducibility of the phenotypic testing and variation in species lineages identified in different laboratories, which could have various intrinsic susceptibility to drugs. For most of the drugs analyzed, the MICs are too high, which could undermine the treatment efficiency. Further improvement of treatment outcomes demands the validation of microbiological resistance criteria together with the identification of molecular mechanisms of resistance.
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Affiliation(s)
- Danila Zimenkov
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia
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4
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Ito M, Koga Y, Hachisu Y, Murata K, Sunaga N, Maeno T, Hisada T. Treatment strategies with alternative treatment options for patients with Mycobacterium avium complex pulmonary disease. Respir Investig 2022; 60:613-624. [PMID: 35781424 DOI: 10.1016/j.resinv.2022.05.006] [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: 02/02/2022] [Revised: 05/06/2022] [Accepted: 05/29/2022] [Indexed: 10/17/2022]
Abstract
Diseases caused by Mycobacterium avium complex (MAC) infection in the lungs are increasing worldwide. The recurrence rate of MAC-pulmonary disease (PD) has been reported to be as high as 25-45%. A significant percentage of recurrences occurs because of reinfection with a new genotype from the environment. A focus on reducing exposure to MAC organisms from the environment is therefore an essential component of the management of this disease as well as standard MAC-PD treatment. A macrolide-containing three-drug regimen is recommended over a two-drug regimen as a standard treatment, and azithromycin is recommended rather than clarithromycin. Both the 2007 and 2020 guidelines recommend a treatment duration of MAC-PD of at least one year after the culture conversion. Previous clinical studies have reported that ethambutol could prevent macrolide resistance. Furthermore, the concomitant use of aminoglycoside, amikacin liposomal inhalation, clofazimine, linezolid, bedaquiline, and fluoroquinolone with modification of guideline-based therapy has been studied. Long-term management of MAC-PD remains challenging because of the discontinuation of multi-drug regimens and the acquisition of macrolide resistance. Moreover, the poor compliance of guideline-based therapy for MAC-PD treatment worldwide is concerning since it causes macrolide resistance. Therefore, in this review, we focus on MAC-PD treatment and summarize various treatment options when standard treatment cannot be maintained, with reference to the latest ATS/ERS/ESCMID/IDSA clinical practice guidelines revised in 2020.
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Affiliation(s)
- Masashi Ito
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Yasuhiko Koga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan.
| | - Yoshimasa Hachisu
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan; Department of Respiratory Medicine, Maebashi Red Cross Hospital, Gunma 371-0813, Japan
| | - Keisuke Murata
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan; Department of Respiratory Medicine, Shibukawa Medical Center, Gunma 377-0280, Japan
| | - Noriaki Sunaga
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Toshitaka Maeno
- Department of Respiratory Medicine, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Takeshi Hisada
- Gunma University Graduate School of Health Sciences, Gunma 371-8514, Japan
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Iketani O, Komeya A, Enoki Y, Taguchi K, Uno S, Uwamino Y, Matsumoto K, Kizu J, Hasegawa N. Impact of rifampicin on the pharmacokinetics of clarithromycin and 14-hydroxy clarithromycin in patients with multidrug combination therapy for pulmonary Mycobacterium avium complex infection. J Infect Chemother 2021; 28:61-66. [PMID: 34706852 DOI: 10.1016/j.jiac.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 09/11/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Clarithromycin (CAM), ethambutol (EB), and rifampicin (RFP) combination therapy is used to treat pulmonary Mycobacterium avium complex (MAC) infection; however, serum CAM concentration decreases due to RFP-mediated induction of CYP3A activity. Therefore, we investigated the pharmacokinetics of CAM, 14-hydroxy clarithromycin (14-OH CAM), EB, and RFP in patients receiving this three-drug combination therapy. METHODS CAM monotherapy was started, EB was added 2 weeks later, and RFP was added 2 weeks after that. Serum CAM, 14-OH CAM, EB, and RFP concentrations were measured before and at 2, 4, 6, and 12 or 24 h after administration on days 14, 28, and 42, and pharmacokinetic parameters were calculated. RESULTS Median area under the curve (AUC) of CAM decreased by 92.1% from 0 to 12 h after concomitant administration of RFP compared with CAM monotherapy [1.7 (interquartile range [IQR], 1.4-1.8) μg·h/mL vs. 21.5 (IQR, 17.7-32.3) μg·h/mL, respectively]. In contrast, median AUC of 14-OH CAM was not significantly different between concomitant administration of RFP [9.1 (IQR, 7.9-10.9) μg·h/mL] and CAM monotherapy [8.2 (IQR, 6.3-9.3) μg·h/mL]. AUCs of CAM and 14-OH CAM did not change in CAM+EB combination therapy. CONCLUSIONS When RFP is combined with CAM in the treatment of pulmonary MAC infection, the blood concentration of CAM significantly decreased and that of the active metabolite 14-OH CAM increased, but not significantly. Our results suggest that combination therapy with CAM and RFP needs to be reconsidered and may require dose modification in the treatment of pulmonary MAC infection.
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Affiliation(s)
- Osamu Iketani
- Division of Infectious Diseases and Infection Control, Keio University Hospital, Tokyo, Japan.
| | - Akari Komeya
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Shunsuke Uno
- Division of Infectious Diseases and Infection Control, Keio University Hospital, Tokyo, Japan
| | - Yoshifumi Uwamino
- Division of Infectious Diseases and Infection Control, Keio University Hospital, Tokyo, Japan; Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Junko Kizu
- Pharmaceutical Common Achievement Tests Organization, Tokyo, Japan
| | - Naoki Hasegawa
- Division of Infectious Diseases and Infection Control, Keio University Hospital, Tokyo, Japan
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6
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Ultra-short-course and intermittent TB47-containing oral regimens produce stable cure against Buruli ulcer in a murine model and prevent the emergence of resistance for Mycobacterium ulcerans. Acta Pharm Sin B 2021; 11:738-749. [PMID: 33777679 PMCID: PMC7982501 DOI: 10.1016/j.apsb.2020.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 12/13/2022] Open
Abstract
Buruli ulcer (BU), caused by Mycobacterium ulcerans, is currently treated with rifampin-streptomycin or rifampin-clarithromycin daily for 8 weeks recommended by World Health Organization (WHO). These options are lengthy with severe side effects. A new anti-tuberculosis drug, TB47, targeting QcrB in cytochrome bc1:aa3 complex is being developed in China. TB47-containing regimens were evaluated in a well-established murine model using an autoluminescent M. ulcerans strain. High-level TB47-resistant spontaneous M. ulcerans mutants were selected and their qcrB genes were sequenced. The in vivo activities of TB47 against both low-level and high-level TB47-resistant mutants were tested in BU murine model. Here, we show that TB47-containing oral 3-drug regimens can completely cure BU in ≤2 weeks for daily use or in ≤3 weeks given twice per week (6 doses in total). All high-level TB47-resistant mutants could only be selected using the low-level mutants which were still sensitive to TB47 in mice. This is the first report of double mutations in QcrB in mycobacteria. In summary, TB47-containing regimens have promise to cure BU highly effectively and prevent the emergence of drug resistance. Novel QcrB mutations found here may guide the potential clinical molecular diagnosis of resistance and the discovery of new drugs against the high-level resistant mutants.
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7
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Riccardi N, Canetti D, Rodari P, Besozzi G, Saderi L, Dettori M, Codecasa LR, Sotgiu G. Tuberculosis and pharmacological interactions: A narrative review. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2020; 2:100007. [PMID: 34909643 PMCID: PMC8663953 DOI: 10.1016/j.crphar.2020.100007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 02/04/2023] Open
Abstract
Even if major improvements in therapeutic regimens and treatment outcomes have been progressively achieved, tuberculosis (TB) remains the leading cause of death from a single infectious microorganism. To improve TB treatment success as well as patients' quality of life, drug-drug-interactions (DDIs) need to be wisely managed. Comprehensive knowledge of anti-TB drugs, pharmacokinetics and pharmacodynamic (PK/PD) parameters, potential patients' changes in absorption and distribution, possible side effects and interactions, is mandatory to built effective anti-TB regimens. Optimization of treatments and adherence to international guidelines can help bend the curve of TB-related mortality and, ultimately, decrease the likelihood of treatment failure and drop-out during anti-TB treatment. Aim of this paper is to describe the most relevant DDIs between anti-TB and other drugs used in daily clinical practice, providing an updated and "easy-to-use" guide to minimize adverse effects, drop-outs and, in the long run, increase treatment success.
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Affiliation(s)
- Niccolò Riccardi
- StopTB Italia Onlus, Milan, Italy
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Diana Canetti
- StopTB Italia Onlus, Milan, Italy
- Clinic of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Rodari
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | | | - Laura Saderi
- StopTB Italia Onlus, Milan, Italy
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Marco Dettori
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Luigi R. Codecasa
- StopTB Italia Onlus, Milan, Italy
- Regional TB Reference Centre, Villa Marelli Inst., Niguarda Hospital, Milan, Italy
| | - Giovanni Sotgiu
- StopTB Italia Onlus, Milan, Italy
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
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8
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Şahiner HS, Kum C. Effects of rifampicin on plasma pharmacokinetics of tulathromycin in goats. J Vet Pharmacol Ther 2020; 44:374-380. [PMID: 33155304 DOI: 10.1111/jvp.12928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/27/2022]
Abstract
We investigated the pharmacokinetic profile of co-administration of tulathromycin with rifampicin. Healthy male goats were allocated to three groups (n = 8) as Group A (single dose 2.5 mg/kg tulathromycin s.c.), B (10 mg kg-1 day-1 rifampicin p.o. daily for 7 days and single dose 2.5 mg/kg tulathromycin s.c. on 8th day), and C (10 mg kg-1 day-1 rifampicin p.o. daily for 21 days and single dose 2.5 mg/kg tulathromycin s.c. on 8th day). Blood samples were collected from jugular veins. Plasma samples were analyzed for tulathromycin by liquid chromatography-mass spectrometry (LC-MS/MS). Peak plasma concentration (Cmax ) values of tulathromycin were 1,390 ± 173, 958 ± 106, and 807 ± 116 ng/ml in groups A, B, and C, respectively. Cmax value of group A was greater than other groups (p < .05). Mean residence time based on time zero to last sample time (MRTlast ) values were 52 ± 1, 56 ± 4 and 66 ± 4 hr in A, B, and C groups, respectively whereas mean residence time based on time zero extrapolated to infinity (MRTINF_obs ) values were 69 ± 4, 85 ± 5, and 86 ± 4 hr, respectively. MRTlast and MRTINF_obs values were greater in B and C groups than group A (p < .05). These findings suggest that rifampicin administration may change several pharmacokinetic parameters of tulathromycin in goats.
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Affiliation(s)
- Hande Sultan Şahiner
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydın Adnan Menderes University, Aydın, Turkey
| | - Cavit Kum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Aydın Adnan Menderes University, Aydın, Turkey
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9
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Griffith DE, Aksamit TR. Managing Mycobacterium avium Complex Lung Disease With a Little Help From My Friend. Chest 2020; 159:1372-1381. [PMID: 33080299 DOI: 10.1016/j.chest.2020.10.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/13/2020] [Accepted: 10/16/2020] [Indexed: 12/26/2022] Open
Abstract
Management of Mycobacterium avium complex (MAC) lung disease is complicated, frequently unsuccessful, and frustrating to patients and clinicians. The initial treatment effort may not be directed solely at MAC infection, rather it is often initiating airway clearance measures for bronchiectasis. The next important steps are deciding who to treat and when to initiate therapy. Definitive or unambiguous guidance for these decisions is often elusive. The evidence supporting the current macrolide-based regimen for treating MAC lung disease is compelling. This regimen has been recommended in consensus nontuberculous mycobacterial treatment guidelines from 1997, 2007, and 2020, although clinician compliance with these recommendations is inconsistent. Understanding the idiosyncrasies of MAC antibiotic resistance is crucial for optimal antibiotic management. As a corollary, the importance of avoiding development of macrolide resistance due to inadequate therapy cannot be overstated. An inhaled liposome amikacin preparation is now approved for treating refractory MAC lung disease and holds promise for an even broader role in MAC therapy. Surgery is also an important therapeutic adjunct for selected patients. Microbiologic recurrences due either to new infection or treatment relapse/failure are common and require the same level of rigorous assessment and clinical judgment for determining their significance as initial MAC isolates. In summary, treatment of patients with MAC lung disease is rarely straight forward and requires familiarity with multiple factors directly and indirectly related to MAC lung disease. The many nuances of MAC lung disease therapy defy simple treatment algorithms; however, with patience, attention to detail, and perseverance, the outcome for most patients is favorable.
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Affiliation(s)
| | - Timothy R Aksamit
- Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, MN
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10
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Risk Factors Associated with Antibiotic Treatment Failure of Buruli Ulcer. Antimicrob Agents Chemother 2020; 64:AAC.00722-20. [PMID: 32571813 DOI: 10.1128/aac.00722-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/03/2020] [Indexed: 11/20/2022] Open
Abstract
Combination antibiotic therapy is highly effective in curing Buruli ulcer (BU) caused by Mycobacterium ulcerans Treatment failures have been uncommonly reported with the recommended 56 days of antibiotics, and little is known about risk factors for treatment failure. We analyzed treatment failures among BU patients treated with ≥56 days of antibiotics from a prospective observational cohort at Barwon Health, Victoria, from 1 January 1998 to 31 December 2018. Treatment failure was defined as culture-positive recurrence within 12 months of commencing antibiotics under the following conditions: (i) following failure to heal the initial lesion or (ii) a new lesion developing at the original or at a new site. A total of 430 patients received ≥56 days of antibiotic therapy, with a median duration of 56 days (interquartile range [IQR], 56 to 80). Seven (1.6%) patients experienced treatment failure. For six adult patients experiencing treatment failure, all were male, weighed >90 kg, did not have surgery, and received combination rifampin-clarithromycin (median rifampin dose, 5.6 mg per kg of body weight per day; median clarithromycin dose, 8.1 mg/kg/day). When compared to those who did not fail treatment on univariate analysis, treatment failure was significantly associated with a weight of >90 kg (P < 0.001), male gender (P = 0.02), immune suppression (P = 0.04), and a first-line regimen of rifampin-clarithromycin compared to a regimen of rifampin-fluoroquinolone (P = 0.05). There is a low rate of treatment failure in Australian BU patients treated with rifampin-based oral combination antibiotic therapy. Our study raises the possibility that treatment failure risk may be increased in males, those with a body weight of >90 kg, those with immune suppression, and those taking rifampin-clarithromycin antibiotic regimens, but future pharmacokinetic and pharmacodynamics studies are required to determine the validity of these hypotheses.
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11
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Wang Y, Bahar MA, Jansen AME, Kocks JWH, Alffenaar JWC, Hak E, Wilffert B, Borgsteede SD. Improving antibacterial prescribing safety in the management of COPD exacerbations: systematic review of observational and clinical studies on potential drug interactions associated with frequently prescribed antibacterials among COPD patients. J Antimicrob Chemother 2020; 74:2848-2864. [PMID: 31127283 PMCID: PMC6814093 DOI: 10.1093/jac/dkz221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 04/13/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Guidelines advise the use of antibacterials (ABs) in the management of COPD exacerbations. COPD patients often have multiple comorbidities, such as diabetes mellitus and cardiac diseases, leading to polypharmacy. Consequently, drug–drug interactions (DDIs) may frequently occur, and may cause serious adverse events and treatment failure. Objectives (i) To review DDIs related to frequently prescribed ABs among COPD patients from observational and clinical studies. (ii) To improve AB prescribing safety in clinical practice by structuring DDIs according to comorbidities of COPD. Methods We conducted a systematic review by searching PubMed and Embase up to 8 February 2018 for clinical trials, cohort and case–control studies reporting DDIs of ABs used for COPD. Study design, subjects, sample size, pharmacological mechanism of DDI and effect of interaction were extracted. We evaluated levels of DDIs and quality of evidence according to established criteria and structured the data by possible comorbidities. Results In all, 318 articles were eligible for review, describing a wide range of drugs used for comorbidities and their potential DDIs with ABs. DDIs between ABs and co-administered drugs could be subdivided into: (i) co-administered drugs altering the pharmacokinetics of ABs; and (ii) ABs interfering with the pharmacokinetics of co-administered drugs. The DDIs could lead to therapeutic failures or toxicities. Conclusions DDIs related to ABs with clinical significance may involve a wide range of indicated drugs to treat comorbidities in COPD. The evidence presented can support (computer-supported) decision-making by health practitioners when prescribing ABs during COPD exacerbations in the case of co-medication.
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Affiliation(s)
- Yuanyuan Wang
- Department of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Muh Akbar Bahar
- Department of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.,Faculty of Pharmacy, Hasanuddin University, Makassar, Indonesia
| | - Anouk M E Jansen
- Department of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Janwillem W H Kocks
- Department of General Practice and Elderly Care Medicine, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Faculty of Medicine and Health, School of Pharmacy and Westmead Hospital, University of Sydney, Sydney, Australia
| | - Eelko Hak
- Department of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Bob Wilffert
- Department of PharmacoTherapy, -Epidemiology & -Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sander D Borgsteede
- Department of Clinical Decision Support, Health Base Foundation, Houten, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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12
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Intermittent Treatment with Azithromycin and Ethambutol for Noncavitary Mycobacterium avium Complex Pulmonary Disease. Antimicrob Agents Chemother 2019; 64:AAC.01787-19. [PMID: 31611366 DOI: 10.1128/aac.01787-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 10/10/2019] [Indexed: 11/20/2022] Open
Abstract
We evaluated the efficacy of intermittent azithromycin and ethambutol therapy for noncavitary Mycobacterium avium complex pulmonary disease (MAC-PD). Twenty-nine (76%) of 38 patients achieved sputum culture conversion after 12 months of treatment, and sputum smear positivity was an independent factor for failure to achieve culture conversion (adjusted odds ratio, 26.7; 95% confidence interval, 2.1 to 339.9; P = 0.011). Intermittent azithromycin and ethambutol may be an optional treatment regimen for noncavitary MAC-PD.
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Kim HJ, Lee JS, Kwak N, Cho J, Lee CH, Han SK, Yim JJ. Role of ethambutol and rifampicin in the treatment of Mycobacterium avium complex pulmonary disease. BMC Pulm Med 2019; 19:212. [PMID: 31711459 PMCID: PMC6849249 DOI: 10.1186/s12890-019-0982-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/31/2019] [Indexed: 12/18/2022] Open
Abstract
Background A three-drug regimen (macrolide, ethambutol, and rifampicin) is recommended for the treatment of Mycobacterium avium complex pulmonary disease (MAC-PD). Although macrolide has proven efficacy, the role of ethambutol and rifampicin in patients without acquired immune deficiency syndrome is not proven with clinical studies. We aimed to clarify the roles of ethambutol and rifampicin in the treatment of MAC-PD. Methods Patients treated for MAC-PD between March 1st, 2009 and October 31st, 2018 were reviewed retrospectively. Rates of culture conversion, microbiological cure, treatment failure, and recurrence were compared according to the maintenance (≥6 months) of ethambutol or rifampicin with macrolide. Results Among the 237 patients, 122 (51.5%) maintained ethambutol and rifampicin with macrolide, 58 (24.5%) maintained ethambutol and macrolide, 32 (13.5%) maintained rifampicin and macrolide, and 25 (10.6%) maintained macrolide only. Culture conversion was reached for 190/237 (80.2%) patients and microbiological cure was achieved for 129/177 (72.9%) who completed the treatment. Treatment failure despite ≥12 months of treatment was observed in 66/204 (32.4%), and recurrence was identified in 16/129 (12.4%) who achieved microbiological cure. Compared with maintenance of macrolide only, maintenance of ethambutol, rifampicin or both with macrolide were associated with higher odds of culture conversion [odds ratio (OR), 95% confidence interval (CI): 18.06, 3.67–88.92; 15.82, 2.38–105.33; and 17.12, 3.93–74.60, respectively]. Higher odds of microbiological cure were associated with maintenance of both ethambutol and rifampicin with macrolide (OR, 95% CI: 5.74, 1.54–21.42) and macrolide and ethambutol (OR, 95% CI: 5.12, 1.72–15.24) but not macrolide and rifampicin. Maintenance of both ethambutol and rifampicin with macrolide was associated with lower odds of treatment failure (OR, 95% CI: 0.09, 0.01–0.53) compared with macrolide only, while maintenance of one of these with macrolide was not. Maintenance of both ethambutol and rifampicin or one of these with macrolide did not decrease the probability of recurrence when compared with macrolide only. Conclusions Maintenance (≥6 months) of ethambutol and rifampicin with macrolide was associated with the most favorable treatment outcomes among patients with MAC-PD. Given the association between ongoing ethambutol use and microbiological cure, clinicians should maintain ethambutol unless definite adverse events develop.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jong Sik Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Mediplex Sejong Hospital, 20 Gyeyangmunhwa-ro Gyeyang-gu, Incheon, 21080, Republic of Korea
| | - Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jaeyoung Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.
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Shortening Buruli Ulcer Treatment with Combination Therapy Targeting the Respiratory Chain and Exploiting Mycobacterium ulcerans Gene Decay. Antimicrob Agents Chemother 2019; 63:AAC.00426-19. [PMID: 31036687 DOI: 10.1128/aac.00426-19] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/20/2019] [Indexed: 01/15/2023] Open
Abstract
Buruli ulcer is treatable with antibiotics. An 8-week course of rifampin (RIF) and either streptomycin (STR) or clarithromycin (CLR) cures over 90% of patients. However, STR requires injections and may be toxic, and CLR shares an adverse drug-drug interaction with RIF and may be poorly tolerated. Studies in a mouse footpad infection model showed that increasing the dose of RIF or using the long-acting rifamycin rifapentine (RPT), in combination with clofazimine (CFZ), a relatively well-tolerated antibiotic, can shorten treatment to 4 weeks. CFZ is reduced by a component of the electron transport chain (ETC) to produce reactive oxygen species toxic to bacteria. Synergistic activity of CFZ with other ETC-targeting drugs, the ATP synthase inhibitor bedaquiline (BDQ) and the bc 1:aa 3 oxidase inhibitor Q203 (now named telacebec), was recently described against Mycobacterium tuberculosis Recognizing that M. tuberculosis mutants lacking the alternative bd oxidase are hypersusceptible to Q203 and that Mycobacterium ulcerans is a natural bd oxidase-deficient mutant, we tested the in vitro susceptibility of M. ulcerans to Q203 and evaluated the treatment-shortening potential of novel 3- and 4-drug regimens combining RPT, CFZ, Q203, and/or BDQ in a mouse footpad model. The MIC of Q203 was extremely low (0.000075 to 0.00015 μg/ml). Footpad swelling decreased more rapidly in mice treated with Q203-containing regimens than in mice treated with RIF and STR (RIF+STR) and RPT and CFZ (RPT+CFZ). Nearly all footpads were culture negative after only 2 weeks of treatment with regimens containing RPT, CFZ, and Q203. No relapse was detected after only 2 weeks of treatment in mice treated with any of the Q203-containing regimens. In contrast, 15% of mice receiving RIF+STR for 4 weeks relapsed. We conclude that it may be possible to cure patients with Buruli ulcer in 14 days or less using Q203-containing regimens rather than currently recommended 56-day regimens.
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Oxazolidinones Can Replace Clarithromycin in Combination with Rifampin in a Mouse Model of Buruli Ulcer. Antimicrob Agents Chemother 2019; 63:AAC.02171-18. [PMID: 30559131 DOI: 10.1128/aac.02171-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/07/2018] [Indexed: 01/06/2023] Open
Abstract
Rifampin (RIF) plus clarithromycin (CLR) for 8 weeks is now the standard of care for Buruli ulcer (BU) treatment, but CLR may not be an ideal companion for rifamycins due to bidirectional drug-drug interactions. The oxazolidinone linezolid (LZD) was previously shown to be active against Mycobacterium ulcerans infection in mice but has dose- and duration-dependent toxicity in humans. Sutezolid (SZD) and tedizolid (TZD) may be safer than LZD. Here, we evaluated the efficacy of these oxazolidinones in combination with rifampin in a murine BU model. Mice with M. ulcerans-infected footpads received control regimens of RIF plus either streptomycin (STR) or CLR or test regimens of RIF plus either LZD (1 of 2 doses), SZD, or TZD for up to 8 weeks. All combination regimens reduced the swelling and bacterial burden in footpads after two weeks of treatment compared with RIF alone. RIF+SZD was the most active test regimen, while RIF+LZD was also no less active than RIF+CLR. After 4 and 6 weeks of treatment, neither CLR nor the oxazolidinones added significant bactericidal activity to RIF alone. By the end of 8 weeks of treatment, all regimens rendered footpads culture negative. We conclude that SZD and LZD warrant consideration as alternative companion agents to CLR in combination with RIF to treat BU, especially when CLR is contraindicated, intolerable, or unavailable. Further evaluation could prove SZD superior to CLR in this combination.
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Abstract
Nontuberculous mycobacteria (NTM) are important emerging cystic fibrosis (CF) pathogens, with estimates of prevalence ranging from 6% to 13%. Diagnosis of NTM disease in patients with CF is challenging, as the infection may remain indolent in some, without evidence of clinical consequence, whereas other patients suffer significant morbidity and mortality. Treatment requires prolonged periods of multiple drugs and varies depending on NTM species, resistance pattern, and extent of disease. The development of a disease-specific approach to the diagnosis and treatment of NTM infection in CF patients is a research priority, as a lifelong strategy is needed for this high-risk population.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, 13123 East 16th Avenue, Box B-395, Aurora, CO 80045, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Aurora, CO 80045, USA
| | - Charles L Daley
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Aurora, CO 80045, USA.
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Converse PJ, Almeida DV, Tasneen R, Saini V, Tyagi S, Ammerman NC, Li SY, Anders NM, Rudek MA, Grosset JH, Nuermberger EL. Shorter-course treatment for Mycobacterium ulcerans disease with high-dose rifamycins and clofazimine in a mouse model of Buruli ulcer. PLoS Negl Trop Dis 2018; 12:e0006728. [PMID: 30102705 PMCID: PMC6107292 DOI: 10.1371/journal.pntd.0006728] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/23/2018] [Accepted: 07/30/2018] [Indexed: 01/18/2023] Open
Abstract
Starting in 2004, the standard regimen for treatment of Buruli ulcer (BU) recommended by the World Health Organization has been daily treatment for eight weeks with rifampin (RIF) and streptomycin. Based on recent clinical trials, treatment with an all-oral regimen of RIF and clarithromycin (CLR) may be an effective alternative. With the achievement of an all-oral regimen, a new goal is to find a regimen that can shorten the duration of treatment without compromising efficacy. We recently observed that increasing the dose of RIF from the standard 10 mg/kg dose to 20 or 40 mg/kg, or replacing RIF with the more potent long-acting rifamycin, rifapentine (RPT) at 10 mg/kg or 20 mg/kg increased the bactericidal activity of the RIF+CLR regimen in a mouse model of BU. We also recently showed that replacing CLR with clofazimine(CFZ) at 25 mg/kg may have greater sterilizing activity than the RIF+CLR regimen. Here, we demonstrate that combining high-dose rifamycins with CFZ at a lower dose of 12.5 mg/kg results in similar reductions in swelling, bacterial burden and mycolactone concentrations in mouse footpads compared to the standard regimens and more rapid sterilization of footpads as determined by the proportions of footpads harboring viable bacteria three months after completion of treatment. The potential of these high-dose rifamycin and CFZ combinations to shorten BU treatment to four weeks warrants evaluation in a clinical trial. Buruli ulcer, a neglected tropical skin disease caused by Mycobacterium ulcerans, is treatable since 2004 with antibiotics instead of surgery. Treatment with either rifampin plus streptomycin or, more recently, rifampin plus clarithromycin requires taking the drugs daily for 8 weeks. Streptomycin is administered by injection and may result in hearing loss. Clarithromycin often causes gastrointestinal discomfort. Our goal is to identify a regimen that is both shorter and associated with fewer side effects. Rifampin, previously an expensive drug, is well tolerated not only at the standard dose of 10 mg/kg but at doses of 20 and 40 mg/kg. The related rifamycin, rifapentine, has a longer half-life and is also well tolerated. We tested in a mouse model of Buruli ulcer whether higher doses of these rifamycins together with clofazimine, a drug that has transient skin pigmentation side effects but no toxicities, could effectively reduce lesion size, the number of bacteria, and production of the mycolactone toxin, in a shorter time than that for the existing drug regimens. We found that treatment for 4 weeks with a high dose rifamycin plus clofazimine is as effective as 8 weeks of the current standard regimens of rifampin plus streptomycin or rifampin plus clarithromycin.
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Affiliation(s)
- Paul J. Converse
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
- * E-mail:
| | - Deepak V. Almeida
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Rokeya Tasneen
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Vikram Saini
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Sandeep Tyagi
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Nicole C. Ammerman
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Si-Yang Li
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Nicole M. Anders
- Analytical Pharmacology Core, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michelle A. Rudek
- Analytical Pharmacology Core, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jacques H. Grosset
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
| | - Eric L. Nuermberger
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research, Baltimore, Maryland, United States of America
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Jarand J, Davis JP, Cowie RL, Field SK, Fisher DA. Long-term Follow-up of Mycobacterium avium Complex Lung Disease in Patients Treated With Regimens Including Clofazimine and/or Rifampin. Chest 2016; 149:1285-93. [DOI: 10.1378/chest.15-0543] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 10/07/2015] [Accepted: 10/09/2015] [Indexed: 01/15/2023] Open
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Increasing Experience with Primary Oral Medical Therapy for Mycobacterium ulcerans Disease in an Australian Cohort. Antimicrob Agents Chemother 2016; 60:2692-5. [PMID: 26883709 DOI: 10.1128/aac.02853-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/20/2022] Open
Abstract
Buruli ulcer (BU) is a necrotizing infection of subcutaneous tissue that is caused by Mycobacterium ulcerans and is responsible for disfiguring skin lesions. The disease is endemic to specific geographic regions in the state of Victoria in southeastern Australia. Growing evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has evolved our practice to the use of primarily oral medical therapy. An observational cohort study was performed on all confirmed M. ulcerans cases treated with primary rifampin-based medical therapy at Barwon Health between October 2010 and December 2014 and receiving 12 months of follow-up. One hundred thirty-two patients were managed with primary medical therapy. The median age of patients was 49 years, and nearly 10% had diabetes mellitus. Lesions were ulcerative in 83.3% of patients and at WHO stage 1 in 78.8% of patients. The median duration of therapy was 56 days, with 22 patients (16.7%) completing fewer than 56 days of antimicrobial treatment. Antibiotic-associated complications requiring cessation of one or more antibiotics occurred in 21 (15.9%) patients. Limited surgical debridement was performed on 30 of these medically managed patients (22.7%). Cure was achieved, with healing within 12 months, in 131 of 132 patients (99.2%), and cosmetic outcomes were excellent. Primary rifampin-based oral medical therapy for M. ulcerans disease, combined with either clarithromycin or a fluoroquinolone, has an excellent rate of cure and an acceptable toxicity profile in Australian patients. We advocate for further research to determine the optimal and safest minimum duration of medical therapy for BU.
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Floto RA, Olivier KN, Saiman L, Daley CL, Herrmann JL, Nick JA, Noone PG, Bilton D, Corris P, Gibson RL, Hempstead SE, Koetz K, Sabadosa KA, Sermet-Gaudelus I, Smyth AR, van Ingen J, Wallace RJ, Winthrop KL, Marshall BC, Haworth CS. US Cystic Fibrosis Foundation and European Cystic Fibrosis Society consensus recommendations for the management of non-tuberculous mycobacteria in individuals with cystic fibrosis. Thorax 2016; 71 Suppl 1:i1-22. [PMID: 26666259 PMCID: PMC4717371 DOI: 10.1136/thoraxjnl-2015-207360] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Non-tuberculous mycobacteria (NTM) are ubiquitous environmental organisms that can cause chronic pulmonary infection, particularly in individuals with pre-existing inflammatory lung disease such as cystic fibrosis (CF). Pulmonary disease caused by NTM has emerged as a major threat to the health of individuals with CF but remains difficult to diagnose and problematic to treat. In response to this challenge, the US Cystic Fibrosis Foundation (CFF) and the European Cystic Fibrosis Society (ECFS) convened an expert panel of specialists to develop consensus recommendations for the screening, investigation, diagnosis and management of NTM pulmonary disease in individuals with CF. Nineteen experts were invited to participate in the recommendation development process. Population, Intervention, Comparison, Outcome (PICO) methodology and systematic literature reviews were employed to inform draft recommendations. An anonymous voting process was used by the committee to reach consensus. All committee members were asked to rate each statement on a scale of: 0, completely disagree, to 9, completely agree; with 80% or more of scores between 7 and 9 being considered ‘good’ agreement. Additionally, the committee solicited feedback from the CF communities in the USA and Europe and considered the feedback in the development of the final recommendation statements. Three rounds of voting were conducted to achieve 80% consensus for each recommendation statement. Through this process, we have generated a series of pragmatic, evidence-based recommendations for the screening, investigation, diagnosis and treatment of NTM infection in individuals with CF as an initial step in optimising management for this challenging condition.
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Affiliation(s)
- R Andres Floto
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
| | - Kenneth N Olivier
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, Pediatric Infectious Diseases, New York, New York, USA
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, Colorado, USA
| | - Jean-Louis Herrmann
- INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France AP-HP, Service de Microbiologie, Hôpital Raymond Poincaré, Garches, France
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Peadar G Noone
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Diana Bilton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Paul Corris
- Department of Respiratory Medicine, Freeman Hospital, High Heaton, Newcastle, UK
| | - Ronald L Gibson
- Department of Pediatrics University of Washington School of Medicine, Seattle, Washington, USA
| | - Sarah E Hempstead
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karsten Koetz
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kathryn A Sabadosa
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Isabelle Sermet-Gaudelus
- Service de Pneumo-Pédiatrie, Université René Descartes, Hôpital Necker-Enfants Malades, Paris, France
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, UK
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Richard J Wallace
- Department of Microbiology, University of Texas Health Science Center, Tyler, Texas, USA
| | | | | | - Charles S Haworth
- Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
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Abstract
Pulmonary infections are the most frequent diseases caused by nontuberculous mycobacteria (NTM). Common causative organisms of pulmonary infection are slowly growing mycobacteria including Mycobacterium avium complex and Mycobacterium kansasii, and rapidly growing mycobacteria including Mycobacterium abscessus complex. Clinical concern has been raised over the increasing incidence of NTM lung disease combined with the poor treatment outcomes of these chronic infectious diseases. Since treatment guidelines of the American Thoracic Society/Infectious Disease Society of America were published in 2007 there have been continuous efforts to improve the outcomes of NTM lung disease, albeit slowly and with limitations. Here, we focus on recent advances in the antibiotic treatment of NTM lung disease.
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Affiliation(s)
- Young Ae Kang
- a Division of Pulmonology, Department of Internal Medicine , Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine , Seoul , South Korea
| | - Won-Jung Koh
- b Division of Pulmonary and Critical Care Medicine, Department of Medicine , Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , South Korea
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Crabol Y, Catherinot E, Veziris N, Jullien V, Lortholary O. Rifabutin: where do we stand in 2016? J Antimicrob Chemother 2016; 71:1759-71. [PMID: 27009031 DOI: 10.1093/jac/dkw024] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rifabutin is a spiro-piperidyl-rifamycin structurally closely related to rifampicin that shares many of its properties. We attempted to address the reasons why this drug, which was recently recognized as a WHO Essential Medicine, still had a far narrower range of indications than rifampicin, 24 years after its launch. In this comprehensive review of the classic and more recent rifabutin experimental and clinical studies, the current state of knowledge about rifabutin is depicted, relying on specific pharmacokinetics, pharmacodynamics, antimicrobial properties, resistance data and side effects compared with rifampicin. There are consistent in vitro data and clinical studies showing that rifabutin has at least equivalent activity/efficacy and acceptable tolerance compared with rifampicin in TB and non-tuberculous mycobacterial diseases. Clinical studies have emphasized the clinical benefits of low rifabutin liver induction in patients with AIDS under PIs, in solid organ transplant patients under immunosuppressive drugs or in patients presenting intolerable side effects related to rifampicin. The contribution of rifabutin for rifampicin-resistant, but rifabutin-susceptible, Mycobacterium tuberculosis isolates according to the present breakpoints has been challenged and is now controversial. Compared with rifampicin, rifabutin's lower AUC is balanced by higher intracellular penetration and lower MIC for most pathogens. Clinical studies are lacking in non-mycobacterial infections.
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Affiliation(s)
- Yoann Crabol
- APHP-Hôpital Necker-Enfants malades, Service de Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Paris, France
| | | | - Nicolas Veziris
- AP-HP, Hôpital Pitié-Salpêtrière, Laboratoire de Bactériologie-Hygiène, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Paris, France UPMC, INSERM, Centre d'Immunologie et des Maladies Infectieuses, E13, Paris, France
| | - Vincent Jullien
- AP-HP, Hôpital Européen Georges-Pompidou, Pharmacology Department, Paris, France Université Paris Descartes, Sorbonne Paris Cité, Inserm U1129, Paris, France
| | - Olivier Lortholary
- APHP-Hôpital Necker-Enfants malades, Service de Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Paris, France Université Paris Descartes, Sorbonne Paris Cité, Paris, France IHU Imagine, Paris, France
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Kadota T, Matsui H, Hirose T, Suzuki J, Saito M, Akaba T, Kobayashi K, Akashi S, Kawashima M, Tamura A, Nagai H, Akagawa S, Kobayashi N, Ohta K. Analysis of drug treatment outcome in clarithromycin-resistant Mycobacterium avium complex lung disease. BMC Infect Dis 2016; 16:31. [PMID: 26818764 PMCID: PMC4730784 DOI: 10.1186/s12879-016-1384-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 01/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the isolation of clarithromycin (CAM)-resistant Mycobacterium avium complex (MAC) indicates a poor treatment outcome and increased mortality, there have been only a few reports on drug treatment for CAM-resistant MAC lung disease. We aimed to reveal the effectiveness of the continuation of a macrolide and the use of a multidrug regimen in the treatment of CAM-resistant MAC lung disease. METHODS Among patients with MAC pulmonary disease as defined by the 2007 criteria of the American Thoracic Society and the Infectious Diseases Society of America statement, those with CAM-resistant MAC (minimum inhibitory concentration ≥32 μg/ml) isolated, newly diagnosed and treated from January 2009 to June 2013 were analysed in this study. Effectiveness was measured based on culture conversion rate and improvement of radiological findings. RESULTS Thirty-three HIV-negative patients were analysed in this study. Twenty-six were treated with a regimen containing CAM or azithromycin (AZM), and 21 patients were treated with three or more drugs except macrolide. The median duration to be evaluated was 10.4 months after beginning the treatment regimen. Sputum conversion (including cases of inability to expectorate sputum) was achieved in 12 (36%) patients. Radiological effectiveness improved in 4 (12%) patients, was unchanged in 11 (33%) patients and worsened in 18 (55%) patients. In the multivariate analysis, CRP <1.0 mg/dl (p = 0.017, odds ratio 12, 95% confidence interval (CI) 1.6-95) was found to be the only significant risk factor for radiological non-deterioration, and no significant risk factors for microbiological improvement were found. CONCLUSIONS Our results suggested that continuation of macrolides or the addition of a new quinolone or injectable aminoglycoside to therapy with rifampicin and ethambutol would not improve clinical outcome after the emergence of CAM-resistant MAC. However, further prospective study is required to evaluate the precise clinical efficacy and effectiveness of these drugs.
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Affiliation(s)
- Tsukasa Kadota
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan. .,Division of Respiratory Disease, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Hirotoshi Matsui
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Takashi Hirose
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Junko Suzuki
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Minako Saito
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Tomohiro Akaba
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Kouichi Kobayashi
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Shunsuke Akashi
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Masahiro Kawashima
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Atsuhisa Tamura
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Hideaki Nagai
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Shinobu Akagawa
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Nobuyuki Kobayashi
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
| | - Ken Ohta
- Center for Pulmonary Diseases, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan.,Asthma and Allergy Center, National Hospital Organization Tokyo National Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo, 204-8585, Japan
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Martiniano SL, Nick JA, Daley CL. Nontuberculous Mycobacterial Infections in Cystic Fibrosis. Clin Chest Med 2015; 37:83-96. [PMID: 26857770 DOI: 10.1016/j.ccm.2015.11.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nontuberculous mycobacteria (NTM) are important emerging cystic fibrosis (CF) pathogens, with estimates of prevalence ranging from 6% to 13%. Diagnosis of NTM disease in patients with CF is challenging, as the infection may remain indolent in some, without evidence of clinical consequence, whereas other patients suffer significant morbidity and mortality. Treatment requires prolonged periods of multiple drugs and varies depending on NTM species, resistance pattern, and extent of disease. The development of a disease-specific approach to the diagnosis and treatment of NTM infection in CF patients is a research priority, as a lifelong strategy is needed for this high-risk population.
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Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, 13123 East 16th Avenue, Box B-395, Aurora, CO 80045, USA
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Aurora, CO 80045, USA
| | - Charles L Daley
- Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Department of Medicine, University of Colorado Anschutz Medical Campus, 13001 E. 17th Place, Aurora, CO 80045, USA.
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25
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Shimomura H, Andachi S, Aono T, Kigure A, Yamamoto Y, Miyajima A, Hirota T, Imanaka K, Majima T, Masuyama H, Tatsumi K, Aoyama T. Serum concentrations of clarithromycin and rifampicin in pulmonary Mycobacterium avium complex disease: long-term changes due to drug interactions and their association with clinical outcomes. J Pharm Health Care Sci 2015; 1:32. [PMID: 26819743 PMCID: PMC4728759 DOI: 10.1186/s40780-015-0029-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/22/2015] [Indexed: 01/15/2023] Open
Abstract
Background Concomitant use of clarithromycin (CAM) and rifampicin (RFP) for the treatment of pulmonary Mycobacterium avium complex (MAC) disease affects the systemic concentrations of both drugs due to CYP3A4–related interactions. To date, however, there has been no report that investigates the long–term relationship between the drug concentrations, CYP3A4 activity, and clinical outcomes. Our aim was to investigate the time course of the drug levels in long–term treatment of subjects with pulmonary MAC disease, and examine the correlation of these concentrations with CYP3A4 activity and clinical outcomes. Methods Urine and blood samples from nine outpatients with pulmonary MAC disease were collected on days 1, 15, and 29 (for four subjects, sample collections were continued on days 57, 85, 113, 141, 169, 225, 281, 337, and 365). Serum drug concentrations and urinary levels of endogenous cortisol (F) and 6 beta-hydroxycortisol (6βOHF), the metabolite of F by CYP3A4, were measured, and evaluated 6βOHF/F ratio as a CYP3A4 activity marker. In addition, the clinical outcomes of 4 subjects were evaluated based on examination of sputum cultures and chest images. Results The mean 6βOHF/F ratio increased from 2.63 ± 0.85 (n = 9) on the first day to 6.96 ± 1.35 on day 15 and maintained a level more than double initial value thereafter. The serum CAM concentration decreased dramatically from an initial 2.28 ± 0.61 μg/mL to 0.73 ± 0.23 μg/mL on day 15. In contrast, the serum concentration of 14-hydroxy-CAM (M-5), the major metabolite of CAM, increased 2.4-fold by day 15. Thereafter, both CAM and M-5 concentrations remained constant until day 365. The explanation for the low levels of serum CAM in pulmonary MAC disease patients is that RFP-mediated CYP3A4 induction reached a maximum by day 15 and remained high thereafter. Sputum cultures of three of four subjects converted to negative, but relapse occurred in all three cases. Conclusions Our study demonstrated that serum CAM concentrations in pulmonary MAC disease patients were continuously low because of RFP-mediated CYP3A4 induction, which may be responsible for the unsatisfactory clinical outcomes.
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Affiliation(s)
- Hitoshi Shimomura
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Sena Andachi
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Takahiro Aono
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Akira Kigure
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Yosuke Yamamoto
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Atsushi Miyajima
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Takashi Hirota
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
| | - Keiko Imanaka
- Department of Pharmacy, Chemotherapy Research Institute, Kaken Hospital, 6-1-14 Konodai, Ichikawa, Chiba 272-0827 Japan
| | - Toru Majima
- Department of Respiratory medicine, Chemotherapy Research Institute, Kaken Hospital, 6-1-14 Konodai, Ichikawa, Chiba 272-0827 Japan
| | - Hidenori Masuyama
- Department of Respiratory medicine, Chemotherapy Research Institute, Kaken Hospital, 6-1-14 Konodai, Ichikawa, Chiba 272-0827 Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670 Japan
| | - Takao Aoyama
- Faculty of Pharmaceutical Sciences, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510 Japan
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Activity of clarithromycin or rifampin alone or in combination against experimental Rhodococcus equi infection in mice. Antimicrob Agents Chemother 2015; 59:3633-6. [PMID: 25824218 DOI: 10.1128/aac.04941-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/23/2015] [Indexed: 01/07/2023] Open
Abstract
Treatment of mice with the combination of clarithromycin with rifampin resulted in a significantly lower number of Rhodococcus equi CFU in the organs of mice than treatment with either drug alone or placebo. There was no significant difference in the number of R. equi CFU between mice treated with clarithromycin monotherapy, rifampin monotherapy, or placebo. The combination of clarithromycin with rifampin conferred a clear advantage over either drug as monotherapy in this model of chronic R. equi infection.
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27
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Sugawara M, Ishii N, Nakanaga K, Suzuki K, Umebayashi Y, Makigami K, Aihara M. Exploration of a standard treatment for Buruli ulcer through a comprehensive analysis of all cases diagnosed in Japan. J Dermatol 2015; 42:588-95. [PMID: 25809502 DOI: 10.1111/1346-8138.12851] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 02/07/2015] [Indexed: 11/29/2022]
Abstract
Buruli ulcer (BU) is a refractory skin ulcer caused by Mycobacterium ulcerans or M. ulcerans ssp. shinshuense, a subspecies thought to have originated in Japan or elsewhere in Asia. Although BU occurs most frequently in tropical and subtropical areas such as Africa and Australia, the occurrence in Japan has gradually increased in recent years. The World Health Organization recommends multidrug therapy consisting of a combination of oral rifampicin (RFP) and i.m. streptomycin (SM) for the treatment of BU. However, surgical interventions are often required when chemotherapy alone is ineffective. As a first step in developing a standardized regimen for BU treatment in Japan, we analyzed detailed records of treatments and prognoses in 40 of the 44 BU cases that have been diagnosed in Japan. We found that a combination of RFP (450 mg/day), levofloxacin (LVFX; 500 mg/day) and clarithromycin (CAM; at a dose of 800 mg/day instead of 400 mg/day) was superior to other chemotherapies performed in Japan. This simple treatment with oral medication increases the probability of patient adherence, and may often eliminate the need for surgery.
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Affiliation(s)
- Mariko Sugawara
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,West Yokohama Sugawara Dermatology Clinic, Yokohama, Japan
| | - Norihisa Ishii
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazue Nakanaga
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Koichi Suzuki
- Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yoshihiro Umebayashi
- Department of Dermatology and Plastic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Michiko Aihara
- Department of Environmental Immuno-Dermatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Egelund EF, Fennelly KP, Peloquin CA. Medications and Monitoring in Nontuberculous Mycobacteria Infections. Clin Chest Med 2015; 36:55-66. [DOI: 10.1016/j.ccm.2014.11.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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29
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Martiniano SL, Nick JA. Nontuberculous Mycobacterial Infections in Cystic Fibrosis. Clin Chest Med 2015; 36:101-15. [DOI: 10.1016/j.ccm.2014.11.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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30
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Cross GB, Le Q, Webb B, Jenkin GA, Korman TM, Francis M, Woolley I. Mycobacterium haemophilum bone and joint infection in HIV/AIDS: case report and literature review. Int J STD AIDS 2015; 26:974-81. [PMID: 25577597 DOI: 10.1177/0956462414565403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 11/18/2014] [Indexed: 11/15/2022]
Abstract
We report a case of disseminated Mycobacterium haemophilum osteomyelitis in a patient with advanced HIV infection, who later developed recurrent immune reconstitution inflammatory syndrome after commencement of antiretroviral therapy. We review previous reports of M. haemophilum bone and joint infection associated with HIV infection and describe the management of M. haemophilum-associated immune reconstitution inflammatory syndrome, including the role of surgery as an adjunctive treatment modality and the potential drug interactions between antiretroviral and antimycobacterial agents.
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Affiliation(s)
- Gail B Cross
- Departments of Microbiology, Monash Health, Melbourne, Australia Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - Quynh Le
- Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - Brooke Webb
- Departments of Microbiology, Monash Health, Melbourne, Australia
| | - Grant A Jenkin
- Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - Tony M Korman
- Departments of Microbiology, Monash Health, Melbourne, Australia Infectious Diseases, Monash Health, Melbourne, VIC, Australia Department of Medicine, Monash Health, Melbourne, VIC, Australia
| | - Michelle Francis
- Departments of Microbiology, Monash Health, Melbourne, Australia
| | - Ian Woolley
- Infectious Diseases, Monash Health, Melbourne, VIC, Australia Department of Medicine, Monash Health, Melbourne, VIC, Australia Department of Infectious Diseases, Monash University, VIC, Australia
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31
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Treatment outcomes of refractory MAC pulmonary disease treated with drugs with unclear efficacy. J Infect Chemother 2014; 20:602-6. [DOI: 10.1016/j.jiac.2014.05.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/06/2014] [Accepted: 05/23/2014] [Indexed: 01/15/2023]
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32
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Wallace RJ, Brown-Elliott BA, McNulty S, Philley JV, Killingley J, Wilson RW, York DS, Shepherd S, Griffith DE. Macrolide/Azalide therapy for nodular/bronchiectatic mycobacterium avium complex lung disease. Chest 2014; 146:276-282. [PMID: 24457542 PMCID: PMC4694082 DOI: 10.1378/chest.13-2538] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/17/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND There is no large study validating the appropriateness of current treatment guidelines for Mycobacterium avium complex (MAC) lung disease. This is a retrospective single-center review evaluating the efficacy of macrolide/azalide-containing regimens for nodular/bronchiectatic (NB) MAC lung disease. METHODS Patients were treated according to contemporary guidelines with evaluation of microbiologic responses. Macrolide susceptibility of MAC isolates was done at initiation of therapy, 6 to 12 months during therapy, and on the first microbiologic recurrence isolate. Microbiologic recurrence isolates also underwent genotyping for comparison with the original isolates. RESULTS One hundred eighty patients completed > 12 months of macrolide/azalide multidrug therapy. Sputum conversion to culture negative occurred in 154 of 180 patients (86%). There were no differences in response between clarithromycin or azithromycin regimens. Treatment regimen modification occurred more frequently with daily (24 of 30 [80%]) vs intermittent (2 of 180 [1%]) therapy (P = .0001). No patient developed macrolide resistance during treatment. Microbiologic recurrences during therapy occurred in 14% of patients: 73% with reinfection MAC isolates, 27% with true relapse isolates (P = .03). Overall, treatment success (ie, sputum conversion without true microbiologic relapse) was achieved in 84% of patients. Microbiologic recurrences occurred in 74 of 155 patients (48%) after completion of therapy: 75% reinfection isolates, 25% true relapse isolates. CONCLUSIONS Current guidelines for macrolide/azalide-based therapies for NB MAC lung disease result in favorable microbiologic outcomes for most patients without promotion of macrolide resistance. Intermittent therapy is effective and significantly better tolerated than daily therapy. Microbiologic recurrences during or after therapy are common and most often due to reinfection MAC genotypes.
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Affiliation(s)
- Richard J Wallace
- Department of Medicine, University of Texas Health Science Center at Tyler, Tyler, TX; Department of Microbiology, University of Texas Health Science Center at Tyler, Tyler, TX; Department of Pathology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Barbara A Brown-Elliott
- Department of Microbiology, University of Texas Health Science Center at Tyler, Tyler, TX; Department of Medicine, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Steven McNulty
- Department of Microbiology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Julie V Philley
- Department of Medicine, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Jessica Killingley
- Department of Microbiology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Rebecca W Wilson
- Department of Pathology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Deanna S York
- Department of Microbiology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - Sara Shepherd
- Department of Pathology, University of Texas Health Science Center at Tyler, Tyler, TX
| | - David E Griffith
- Department of Medicine, University of Texas Health Science Center at Tyler, Tyler, TX.
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O'Brien DP, Ford N, Vitoria M, Christinet V, Comte E, Calmy A, Stienstra Y, Eholie S, Asiedu K. Management of BU-HIV co-infection. Trop Med Int Health 2014; 19:1040-7. [DOI: 10.1111/tmi.12342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D. P. O'Brien
- Manson Unit; Médecins Sans Frontières; London UK
- Department of Infectious Diseases; Barwon Health; Geelong Vic. Australia
- Department of Medicine and Infectious Diseases; Royal Melbourne Hospital; University of Melbourne; Melbourne Vic. Australia
| | - N. Ford
- HIV Department; World Health Organisation; Geneva Switzerland
| | - M. Vitoria
- HIV Department; World Health Organisation; Geneva Switzerland
| | - V. Christinet
- Department of HIV; University Hospitals of Geneva; Geneva Switzerland
| | - E. Comte
- Medical Unit; Médecins Sans Frontières; Geneva Switzerland
| | - A. Calmy
- Department of HIV; University Hospitals of Geneva; Geneva Switzerland
| | - Y. Stienstra
- Department of Internal Medicine and Infectious Diseases; University Medical Center; University of Groningen; Groningen The Netherlands
| | - S. Eholie
- Unit of Tropical and Infectious Diseases; Treichville University Teaching Hospital; Abidjan Côte d'Ivoire
| | - K. Asiedu
- Department of Control of Neglected Tropical Diseases; World Health Organisation; Geneva Switzerland
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Egelund EF, Mohamed MF, Fennelly KP, Peloquin CA. Concomitant Use of Carbamazepine and Rifampin in a Patient With Mycobacterium avium Complex and Seizure Disorder. J Pharm Technol 2014; 30:93-96. [PMID: 34860865 DOI: 10.1177/8755122514523934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Objectives. To report a probable interaction between rifampin and carbamazepine, likely leading to a seizure, and to review conflicting reports regarding this interaction. Case Summary. A 55-year-old female was treated with carbamazepine 200 mg 3 times daily for grand mal seizures, with excellent control. A 6-hour postdose carbamazepine concentration was 10.7 µg/mL (therapeutic range = 4-10 µg/mL). After she was diagnosed with pulmonary Mycobacterium avium complex, she received rifampin 300 mg twice daily, ethambutol 800 mg daily, and clarithromycin 500 mg twice daily. At first clinic visit, rifampin was changed to 600 mg daily, and clarithromycin was replaced with azithromycin 250 mg daily. A 4-hour postdose carbamazepine concentration was 7.1 µg/mL. Two weeks later, the patient experienced a seizure (no carbamazepine concentration reported at that time), but admitted to missing doses of carbamazepine. After experiencing 2 more seizures, the patient stopped taking rifampin. Subsequently, the carbamazepine dose was increased to 400 mg twice daily and rifampin was restarted at 600 mg daily. Two follow-up peak carbamazepine concentrations were 4.7 µg/mL and 4.4 µg/mL, with no reported seizures. No additional factors were identified as potential causes of the seizures or the lower carbamazepine concentrations. A Drug Interaction Probability Scale score of 6 indicates a probable interaction. Discussion. Conflicting reports exist regarding the effect of rifampin on carbamazepine concentrations, likely reflecting rifampin's ability to display time-dependent, mixed effects on transporters and cytochrome P450 enzymes. Conclusions. Our case report describes a patient who experienced seizures after the addition of rifampin to her regimen, followed by lower peak concentrations of carbamazepine. Therapeutic drug monitoring in patients receiving both rifampin and carbamazepine is recommended to help clinicians optimize drug therapy.
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van Ingen J, Ferro BE, Hoefsloot W, Boeree MJ, van Soolingen D. Drug treatment of pulmonary nontuberculous mycobacterial disease in HIV-negative patients: the evidence. Expert Rev Anti Infect Ther 2014; 11:1065-77. [PMID: 24124798 DOI: 10.1586/14787210.2013.830413] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pulmonary disease (PD) caused by nontuberculous mycobacteria is an emerging infection mainly in countries where the incidence of tuberculosis is in decline. It affects an elderly population, often with underlying chronic lung diseases, but its epidemiology shows significant regional variation. Guidelines and recommendations for treatment of these infections exist, but build strongly on expert opinion, as very few good quality clinical trials have been performed in this field. Only for the most frequent causative agents, the Mycobacterium avium complex, Mycobacterium kansasii and Mycobacterium abscessus, a reasonable number of trials and case series is now available. For the less frequent causative agents of pulmonary nontuberculous mycobacterial (NTM) disease (Mycobacterium xenopi, Mycobacterium malmoense, Mycobacterium fortuitum, Mycobacterium chelonae) data is mostly limited to a few very small case series. Within this review, we have collected and combined evidence from all available trials and case series. From the data of these trials and case series, we reconstruct a more evidence-based overview of possible drug treatment regimens and their outcomes.
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Affiliation(s)
- Jakko van Ingen
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
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36
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Simultaneous determination of rifampicin, clarithromycin and their metabolites in dried blood spots using LC–MS/MS. Talanta 2014; 121:9-17. [DOI: 10.1016/j.talanta.2013.12.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 12/11/2013] [Accepted: 12/22/2013] [Indexed: 11/19/2022]
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37
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Stout JE. Evaluation and management of patients with pulmonary nontuberculous mycobacterial infections. Expert Rev Anti Infect Ther 2014; 4:981-93. [PMID: 17181415 DOI: 10.1586/14787210.4.6.981] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nontuberculous mycobacteria (NTM) are emerging pathogens increasingly associated with chronic pulmonary disease. NTM are environmental saprophytes found in soil, dust and water and, unlike Mycobacterium tuberculosis, NTM are not transmitted from person to person. Pulmonary disease caused by NTM is a particular problem in older people without underlying immune compromise. The diagnosis of NTM pulmonary disease usually requires either multiple respiratory cultures that grow NTM or heavy growth of NTM from a single bronchoscopy or lung-biopsy specimen. High resolution computed tomography is the most useful radiographic study for diagnosis and to determine the extent of disease. Treatment includes multiple medications with activity against the particular NTM species, as single-drug therapy is likely to select for resistant organisms. Data demonstrating the effectiveness of specific drug regimens for NTM pulmonary disease are limited. Clarithromycin and azithromycin form the backbone of most treatment regimens because these drugs are active against many NTM species. Drug tolerability and cost are the major barriers to successful treatment of NTM pulmonary disease. Adjunctive therapies, including mucus clearance techniques and appetite stimulants, are unproven but may be of value in management of NTM pulmonary disease. Multicenter, randomized trials of macrolide-based therapies are sorely needed to determine the safest and most effective treatments for NTM pulmonary disease.
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Affiliation(s)
- Jason E Stout
- Duke University Medical Center, Division of Infectious Diseases and International Health, Box 3306, Department of Medicine, Durham, NC 27710, USA.
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Efficacy of Clarithromycin and Ethambutol forMycobacterium aviumComplex Pulmonary Disease. A Preliminary Study. Ann Am Thorac Soc 2014; 11:23-9. [DOI: 10.1513/annalsats.201308-266oc] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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39
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Kakuda TN, Woodfall B, De Marez T, Peeters M, Vandermeulen K, Aharchi F, Hoetelmans RMW. Pharmacokinetic evaluation of the interaction between etravirine and rifabutin or clarithromycin in HIV-negative, healthy volunteers: results from two Phase 1 studies. J Antimicrob Chemother 2013; 69:728-34. [DOI: 10.1093/jac/dkt421] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Magis-Escurra C, Alffenaar J, Hoefnagels I, Dekhuijzen P, Boeree M, van Ingen J, Aarnoutse R. Pharmacokinetic studies in patients with nontuberculous mycobacterial lung infections. Int J Antimicrob Agents 2013; 42:256-61. [DOI: 10.1016/j.ijantimicag.2013.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/09/2013] [Accepted: 05/15/2013] [Indexed: 11/16/2022]
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Troubleshooting carry-over of LC–MS/MS method for rifampicin, clarithromycin and metabolites in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 917-918:1-4. [DOI: 10.1016/j.jchromb.2012.12.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/13/2012] [Accepted: 12/16/2012] [Indexed: 11/24/2022]
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Koh WJ, Jeong BH, Jeon K, Lee SY, Shin SJ. Therapeutic Drug Monitoring in the Treatment ofMycobacterium aviumComplex Lung Disease. Am J Respir Crit Care Med 2012; 186:797-802. [DOI: 10.1164/rccm.201206-1088oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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van Ingen J, Egelund EF, Levin A, Totten SE, Boeree MJ, Mouton JW, Aarnoutse RE, Heifets LB, Peloquin CA, Daley CL. The Pharmacokinetics and Pharmacodynamics of PulmonaryMycobacterium aviumComplex Disease Treatment. Am J Respir Crit Care Med 2012; 186:559-65. [DOI: 10.1164/rccm.201204-0682oc] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Máiz-Carro L, Navas-Elorza E. Nontuberculous Mycobacterial Pulmonary Infection in Patients with Cystic Fibrosis. ACTA ACUST UNITED AC 2012; 1:107-17. [PMID: 14720065 DOI: 10.1007/bf03256600] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The prevalence of nontuberculous mycobacteria (NTM) recovered from patients with cystic fibrosis (CF) appears to be increasing, probably related to improved surveillance and microbiological procedures and an increase in the life expectancy of patients with CF. The distinction between active lung infection and colonization is often difficult to assess in patients with CF because of the marked overlap in the clinical and radiological presentation of CF lung disease and lung disease caused by NTM infection. The possibility of active NTM lung infection should be considered in those patients with compatible radiographic changes and/or progressive deterioration in lung function who do not improve with specific antibiotic therapy and who have repeatedly positive sputum cultures and smears for NTM. Patients with repeatedly positive results of acid-fast smears are more likely to be infected than colonized. Pseudomonas overgrowth may confuse the results of sputum and bronchoalveolar lavage fluid cultures. Decontamination of respiratory samples from patients with CF with 5% oxalic acid results in improved bacteriological recovery of NTM. Skin tests are of limited value as a screening tool for NTM. Since the course of NTM lung infection is often slow, careful follow-up with repeated sputum cultures, chest radiographs and computed tomography (CT) scans may be needed. Treatment of NTM lung disease in patients with CF presents great difficulties because of abnormal gastrointestinal drug absorption and pharmacokinetics in this patient population. Treatment varies according to the mycobacterial species isolated. Long-term multidrug regimens including rifampin (rifampicin) and ethambutol are usually required. Monitoring serum drug levels is a useful indicator of correct dosage in order to prevent adverse effects due to potential drug interactions and altered pharmacokinetics in patients with CF.
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Affiliation(s)
- Luis Máiz-Carro
- Department of Pulmonology (Cystic Fibrosis Unit), Hospital Ramón y Cajal, Madrid, Spain.
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Resistance mechanisms and drug susceptibility testing of nontuberculous mycobacteria. Drug Resist Updat 2012; 15:149-61. [DOI: 10.1016/j.drup.2012.04.001] [Citation(s) in RCA: 218] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Peters J, Eggers K, Oswald S, Block W, Lütjohann D, Lämmer M, Venner M, Siegmund W. Clarithromycin Is Absorbed by an Intestinal Uptake Mechanism That Is Sensitive to Major Inhibition by Rifampicin: Results of a Short-Term Drug Interaction Study in Foals. Drug Metab Dispos 2011; 40:522-8. [DOI: 10.1124/dmd.111.042267] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Peters J, Block W, Oswald S, Freyer J, Grube M, Kroemer HK, Lämmer M, Lütjohann D, Venner M, Siegmund W. Oral Absorption of Clarithromycin Is Nearly Abolished by Chronic Comedication of Rifampicin in Foals. Drug Metab Dispos 2011; 39:1643-9. [DOI: 10.1124/dmd.111.039206] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Pharmacokinetics of rifampin and clarithromycin in patients treated for Mycobacterium ulcerans infection. Antimicrob Agents Chemother 2010; 54:3878-83. [PMID: 20585115 DOI: 10.1128/aac.00099-10] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In a randomized controlled trial in Ghana, treatment of Mycobacterium ulcerans infection with streptomycin (SM)-rifampin (RIF) for 8 weeks was compared with treatment with SM-RIF for 4 weeks followed by treatment with RIF-clarithromycin (CLA) for 4 weeks. The extent of the interaction of RIF and CLA combined on the pharmacokinetics of the two compounds is unknown in this population and was therefore studied in a subset of patients. Patients received CLA at a dose of 7.5 mg/kg of body weight once daily, rounded to the nearest 125 mg. RIF was administered at a dose of 10 mg/kg, rounded to the nearest 150 mg. SM was given at a dose of 15 mg/kg once daily as an intramuscular injection. Plasma samples were drawn at steady state and analyzed by liquid chromatography-tandem mass spectroscopy. Pharmacokinetic parameters were calculated with the MW/Pharm (version 3.60) program. Comedication with CLA resulted in a 60% statistically nonsignificant increase in the area under the plasma concentration-time curve (AUC) for RIF of 25.8 mg x h/liter (interquartile ratio [IQR], 21.7 to 31.5 mg x h/liter), whereas the AUC of RIF was 15.2 mg x h/liter (IQR, 15.0 to 17.5 mg x h/liter) in patients comedicated with SM (P = 0.09). The median AUCs of CLA and 14-hydroxyclarithromycin (14OH-CLA) were 2.9 mg x h/liter (IQR, 1.5 to 3.8 mg x h/liter) and 8.0 mg x h/liter (IQR, 6.7 to 8.6 mg x h/liter), respectively. The median concentration of CLA was above the MIC of M. ulcerans, but that of 14OH-CLA was not. In further clinical studies, a dose of CLA of 7.5 mg/kg twice daily should be used (or with an extended-release formulation, 15 mg/kg should be used) to ensure higher levels of exposure to CLA and an increase in the time above the MIC compared to those achieved with the currently used dose of 7.5 mg/kg once daily.
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