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Chiang TT, Chiang MH, Tang HJ, Shi ZY, Ho MW, Chou CH, Lin SY, Lu PL, Wu TS, Shie SS, Liu JW, Chang FY, Chuang YC, Wang FD, Yang YS. Multicenter study on clinical outcomes and poor prognostic factors in patients with Klebsiella pneumoniae bacteremia receiving cefoperazone/sulbactam treatment. Eur J Clin Microbiol Infect Dis 2024; 43:1777-1785. [PMID: 38995342 PMCID: PMC11349846 DOI: 10.1007/s10096-024-04892-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Infections caused by Klebsiella pneumoniae are common and result in high mortality rates. In vitro studies demonstrated the potency of cefoperazone/sulbactam (CPZ/SUL) against Klebsiella pneumoniae. However, the clinical efficacy of CPZ/SUL for the treatment of K. pneumoniae bacteremia has not been studied. OBJECTIVES This study aimed to associate the clinical outcomes of patients with bacteremia with the minimal inhibitory concentrations (MICs) of CPZ/SUL against the causative K. pneumoniae isolates. METHODS This multicenter, retrospective study was conducted in Taiwan between July 2017 and April 2021. Patients with K. pneumoniae bacteremia treated with CPZ/SUL were enrolled in this study. CPZ/SUL MICs were determined using the agar dilution method. Data on the patients' clinical outcomes and characteristics were collected and analyzed. RESULTS In total, 201 patients were enrolled. Among the causative K. pneumoniae isolates, 180 (89.5%) were susceptible to CPZ/SUL. Most patients (n = 156, 77.6%) had favorable outcomes. The 30-day mortality rate was 11.9% (n = 24). Multivariate risk analyses showed that higher APACHE II score (Odds Ratio [OR], 1.14; Confidence Interval [CI], 1.07-1.21; p < 0.001), metastatic tumors (OR, 5.76; CI, 2.31-14.40; p < 0.001), and causative K. pneumoniae CPZ/SUL MICs > 16 µg/ml (OR, 4.30; CI, 1.50-12.27; p = 0.006) were independently associated with unfavorable outcomes. CONCLUSION Patients with K. pneumoniae bacteremia treated with CPZ/SUL at a ratio 1:1 had favorable outcomes when the CPZ/SUL MICs were ≤ 16 µg/ml. Patients with higher APACHE II scores and metastatic tumors had unfavorable outcomes.
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Affiliation(s)
- Tsung-Ta Chiang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri- Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei, 11490, Taiwan
| | - Ming-Hsien Chiang
- Department of Nutritional Sciences, Fu-Jen Catholic University, New Taipei City, Taiwan
- Institute of Biology and Anatomy, National Defense Medical Center, Tipei, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Zhi-Yuan Shi
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mao-Wang Ho
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hui Chou
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shang-Yi Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ting-Shu Wu
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shian-Sen Shie
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jien-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Feng-Yee Chang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri- Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei, 11490, Taiwan
| | | | - Fu-Der Wang
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.
- National Yang-Ming Chiao-Tung University, Taipei, Taiwan.
| | - Ya-Sung Yang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri- Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Taipei, 11490, Taiwan.
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Evaluation of Piperacillin/Sulbactam, Piperacillin/Tazobactam and Cefoperazone/Sulbactam Dosages in Gram-Negative Bacterial Bloodstream Infections by Monte Carlo Simulation. Antibiotics (Basel) 2023; 12:antibiotics12020363. [PMID: 36830273 PMCID: PMC9952708 DOI: 10.3390/antibiotics12020363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/07/2023] [Accepted: 02/01/2023] [Indexed: 02/12/2023] Open
Abstract
The optimal regimens of piperacillin/sulbactam (PIS 2:1), piperacillin/tazobactam (PTZ 8:1), and cefoperazone/sulbactam (CSL 2:1) are not well defined in patients based on renal function. This study was conducted to identify optimal regimens of BLBLIs in these patients. The antimicrobial sensitivity test was performed by a two-fold agar dilution method. Monte Carlo simulation (MCS) was used to simulate the probability of target attainment (PTA) and the cumulative fraction of response (CFR) for various dosing regimens in patients with different renal functions. For strains with an MIC ≤ 8/4 mg/L, PIS 4.5 g q6h achieved 99.03%PTA in the subset of patients with creatinine clearance (CrCL) > 90 mL/min. For patients with CrCL 60-90 mL/min, PIS 4.5 g q6h achieved 81.2% CFR; for those with CrCL 40-59 mL/min, PIS 4.5 g q8h achieved 80.25% CFR. However, for patients infected by ESBL-producing Enterobacteriaceae, PIS 4.5 g q6h achieved a CFR lower than 80%. For patients infected by A. baumannii with a CrCL of 31-60 mL/min, PIS 6.0 g q8h and 4.5 g q6h achieved 81.24% and 82.42% CFR, respectively. For those infected by P. aeruginosa, PIS 4.5 g q6h reached 90% CFR. PIS and PTZ achieved a similar CFR when piperacillin was at the same dose. The CFRs of CSL were much lower than those of the other two agents in Enterobacteriaceae and P. aeruginosa infections. The antibacterial spectrum of PIS is superior to that of PTZ and CSL. Higher dosages and dosing adjustment according to renal function should be considered to treat Gram-negative bacterial BSIs.
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Zhou Y, Zhang J, Chen Y, Wu J, Guo B, Wu X, Zhang Y, Wang M, Ya R, Huang H. Combined PK/PD Index May Be a More Appropriate PK/PD Index for Cefoperazone/Sulbactam against Acinetobacter baumannii in Patients with Hospital-Acquired Pneumonia. Antibiotics (Basel) 2022; 11:703. [PMID: 35625347 PMCID: PMC9138011 DOI: 10.3390/antibiotics11050703] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/18/2022] [Accepted: 05/21/2022] [Indexed: 02/06/2023] Open
Abstract
Cefoperazone/sulbactam (CPZ/SUL) is a β-lactam and β-lactamase inhibitor combination therapy for the treatment of respiratory tract infections. Using data from a prospective, multiple-center, open-label clinical trial in 54 patients with hospital-acquired pneumonia or ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii (Ab), we showed that a combined PK/PD index %(T > MICcpz*T > MICsul) is a more appropriate PK/PD index against Ab, compared to the PK/PD index (%T > MIC) for a single drug. For a 2 h infusion, the PK/PD cutoff of CPZ/SUL (2 g/1 g, q8h) for clinical and microbiological efficacy was 4/2 and 1/0.5 mg/L, respectively. The corresponding cumulative fraction of response was 46.5% and 25.3%, respectively. Results based on the combined PK/PD index were quite similar to that based on the joint probability of target attainment. The two drugs have interaction from the viewpoint of PK/PD. When the dose of one drug was too high, the PK/PD cutoff was often determined by another drug in which the dose was maintained. In most cases, sulbactam exerted the main effect against infection by Ab in the complex CPZ/SUL, which was similar to the literature reports. When the MIC of CPZ was 8, 16, or 32 mg/L, a CPZ/SUL 2 g/1 g (q8h), 2 g/2 g (q8h), or 2 g/2 g (q6h) (infusion was all 3 h) was recommended, respectively. A clinical efficacy and safety study to confirm simulation results is warranted.
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Affiliation(s)
- Yingjie Zhou
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jufang Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Beining Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaojie Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yingyuan Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Ru Ya
- Yonghe Branch of Huashan Hospital, Fudan University, Shanghai 200436, China; (R.Y.); (H.H.)
| | - Hao Huang
- Yonghe Branch of Huashan Hospital, Fudan University, Shanghai 200436, China; (R.Y.); (H.H.)
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Cefoperazone/sulbactam: New composites against multiresistant gram negative bacteria? INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2021; 88:104707. [PMID: 33418147 DOI: 10.1016/j.meegid.2021.104707] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/27/2020] [Accepted: 12/31/2020] [Indexed: 01/29/2023]
Abstract
Sulbactam, a class A β-lactamase inhibitor, added to cefoperazone either at a fixed 8 mg/L level of sulbactam or at a level of fixed cefoperazone: sulbactam ratio (2:1) would constitute a combination form of cefoperazone/sulbactam, which has better activities against Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii than cefoperazone alone. Cefoperazone/sulbactam (1:1 or 1:2) has greater in-vitro activity against most multidrug-resistant organisms (ESBL- and AmpC-producing Enterobacteriaceae and carbapenem-resistant A. baumannii except for carbapenem-resistant P. aeruginosa) than a 2:1 ratio. However, increased sulbactam concentration may induce AmpC production. Besides, sulbactam concentration might not be readily achievable in serum if the susceptibility rates were defined by the breakpoints of higher sulbactam composites, such as ≤16/16 (1:1) or 16/32 (1:2) mg/L. Carbapenemases (KPC-, OXA-type enzymes and metallo-β-lactamases) can't be inhibited by sulbactam. Some in-vitro studies showed that increasing sulbactam composites of cefoperazone/sulbactam had no effect on carbapenem-resistant P. aeruginosa, suggesting the presence of carbapenemases or AmpC overproduction that could not be overcome by increasing sulbactam levels to recover cefoperazone activity. Sulbactam alone has good intrinsic activity against carbapenem-resistant Acinetobacter strains sometimes even in the presence of carbapenemase genes, suggesting unsteady levels of carbapenemases. In conclusion, appropriate composites of cefoperazone and β-lactamase inhibitor sulbactam may expand the clinical use if the pharmacokinetic optimization could be achieved in the human serum.
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Katayama H, Yasuhara M, Hori R. Effect of acute renal failure on the disposition of cefoperazone. J Pharm Pharmacol 1999; 51:361-6. [PMID: 10344639 DOI: 10.1211/0022357991772376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The effect of acute renal failure on the disposition of cefoperazone was investigated. Rats, 3 days after uranyl nitrate treatment, were used to model acute renal failure. Although plasma-protein binding of cefoperazone decreased significantly in acute renal failure compared with control rats, the plasma clearance of total (bound plus unbound) drug after intravenous administration (50 mg kg(-1)) did not differ significantly between the two groups (5.61+/-2.37 mL min(-1) for control and 4.75+/-2.82 mL min(-1) for acute renal failure). Consequently the plasma clearance of the unbound drug in acute renal failure (6.14+/-1.16 mL min(-1)) was significantly lower than in control rats (15.6+/-3.7 mL min(-1), P < 0.025). Plasma clearance of the drug (both total and unbound) was also dependent on bile flow, and clearance of the unbound drug in acute renal failure rats was lower than in control rats with identical bile flow rates. To examine the mechanism of reduced unbound cefoperazone clearance, an in-vitro experiment using a simultaneous perfusion system of rat liver and kidney was performed. By changing perfusate plasma protein from bovine serum albumin to human serum albumin, the plasma clearance of the total cefoperazone changed to one-sixth in proportion to the unbound cefoperazone in the perfusate plasma. On the other hand, the plasma clearance of the total and unbound drug in acute renal failure rats decreased significantly compared with controls. These results demonstrate that the plasma clearance of unbound cefoperazone, which is mainly eliminated by the liver, decreased in acute renal failure in rats, probably due to changes in hepatic transport.
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Affiliation(s)
- H Katayama
- Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Hiroshima, Japan
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