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Bakthavatchalam YD, Manoharan Y, Shankar A, Gunasekaran K, Walia K, Veeraraghavan B. Understanding the rationale and clinical impact of the revised CLSI 2024 minocycline susceptibility breakpoints against Stenotrophomonas maltophilia. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04932-6. [PMID: 39297907 DOI: 10.1007/s10096-024-04932-6] [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: 03/13/2024] [Accepted: 08/23/2024] [Indexed: 09/21/2024]
Abstract
Stenotrophomonas maltophilia is challenging to treat due to the presence of multiple intrinsic and acquired resistance mechanisms. TMP-SMZ is the standard care of therapy for treating S. maltophilia infections; levofloxavin and minocycline are the preferred potential alternatives. Recently, in 2024, CLSI has lowered the susceptibility breakpoints for minocycline against S. maltophilia. Applying the revised minocycline's susceptibility breakpoint of ≤ 1 mg/L, susceptibility to minocycline dropped significantly from 77% (previous breakpoint, ≤ 4 mg/L) to 35% (revised breakpoint of ≤ 1 mg/L). In the wake of this change, minocycline's dependency has been questioned for treating S. maltophilia infections.
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Affiliation(s)
| | - Yuvashri Manoharan
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, India
| | - Abirami Shankar
- Department of Medicine, Christian Medical College, Vellore, India
| | - Karthik Gunasekaran
- Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | - Kamini Walia
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, 632004, India.
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Barrasa H, Morán MA, Fernández-Ciriza L, Isla A, Solinís MÁ, Canut-Blasco A, Rodríguez-Gascón A. Optimizing Antibiotic Therapy for Stenotrophomonas maltophilia Infections in Critically Ill Patients: A Pharmacokinetic/Pharmacodynamic Approach. Antibiotics (Basel) 2024; 13:553. [PMID: 38927219 PMCID: PMC11201243 DOI: 10.3390/antibiotics13060553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/04/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Stenotrophomonas maltophilia is an opportunistic, multidrug-resistant non-fermentative Gram-negative bacillus, posing a significant challenge in clinical treatment due to its numerous intrinsic and acquired resistance mechanisms. This study aimed to evaluate the adequacy of antibiotics used for the treatment of S. maltophilia infections in critically ill patients using a pharmacokinetic/pharmacodynamic (PK/PD) approach. The antibiotics studied included cotrimoxazole, levofloxacin, minocycline, tigecycline, cefiderocol, and the new combination aztreonam/avibactam, which is not yet approved. By Monte Carlo simulations, the probability of target attainment (PTA), the PK/PD breakpoints, and the cumulative fraction of response (CFR) were estimated. PK parameters and MIC distributions were sourced from the literature, the European Committee on Antimicrobial Susceptibility Testing (EUCAST), and the SENTRY Antimicrobial Surveillance Program collection. Cefiderocol 2 g q8h, minocycline 200 mg q12h, tigecycline 100 mg q12h, and aztreonam/avibactam 1500/500 mg q6h were the best options to treat empirically infections due to S. maltophilia. Cotrimoxazole provided a higher probability of treatment success for the U.S. isolates than for European isolates. For all antibiotics, discrepancies between the PK/PD breakpoints and the clinical breakpoints defined by EUCAST (or the ECOFF) and CLSI were detected.
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Affiliation(s)
- Helena Barrasa
- Intensive Care Unit, Araba University Hospital, Osakidetza Basque Health Service, 01009 Vitoria-Gasteiz, Spain
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
| | - Miguel Angel Morán
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
- Infectious Disease Division, Araba University Hospital, Osakidetza Basque Health Service, 01009 Vitoria-Gasteiz, Spain
| | - Leire Fernández-Ciriza
- Microbiology Laboratory, Biomedical Diagnostic Service, Hospital San Pedro, 26006 Logroño, Spain;
| | - Arantxa Isla
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Lascaray Research Centre, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain
| | - María Ángeles Solinís
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Lascaray Research Centre, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain
| | - Andrés Canut-Blasco
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
- Microbiology Service, Araba University Hospital, Osakidetza Basque Health Service, 01009 Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Bioaraba Health Research Institute, 01009 Vitoria-Gasteiz, Spain; (M.A.M.); (A.I.); (M.Á.S.); (A.C.-B.)
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Lascaray Research Centre, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain
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3
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Gill EL, Gill CM, McEvoy C. Validation of a Stenotrophomonas maltophilia bloodstream infection prediction score in the hematologic malignancy population. Ann Hematol 2024; 103:1745-1752. [PMID: 38453704 PMCID: PMC11009769 DOI: 10.1007/s00277-024-05686-z] [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: 01/18/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
Stenotrophomonas maltophilia (SM) bloodstream infections (BSIs) contribute to significant mortality in hematologic malignancy (HM) and hematopoietic stem cell transplantation (HSCT) patients. A risk score to predict SM BSI could reduce time to appropriate antimicrobial therapy (TTAT) and improve patient outcomes. A single center cohort study of hospitalized adults with HM/HSCT was conducted. Patients had ≥ 1 blood culture with a Gram-negative (GN) organism. A StenoSCORE was calculated for each patient. The StenoSCORE2 was developed using risk factors for SM BSI identified via logistic regression. Receiver operating characteristic (ROC) curves were plotted. Sensitivity and specificity for the StenoSCORE and StenoSCORE2 were calculated. Thirty-six SM patients and 534 non-SM patients were assessed. A StenoSCORE ≥ 33 points was 80% sensitive, 68% specific, and accurately classified 69% of GN BSIs. StenoSCORE2 variables included acute leukemia, prolonged neutropenia, mucositis, ICU admission, recent meropenem and/or cefepime exposure. The StenoSCORE2 performed better than the StenoSCORE (ROC AUC 0.84 vs. 0.77). A StenoSCORE2 ≥ 4 points was 86% sensitive, 76% specific, and accurately classified 77% of GN BSIs. TTAT was significantly longer for patients with SM BSI compared with non-SM BSI (45.16 h vs. 0.57 h; p < 0.0001). In-hospital and 28-day mortality were significantly higher for patients with SM BSI compared to non-SM BSI (58.3% vs. 18.5% and 66.7% vs. 26.4%; p-value < 0.0001). The StenoSCORE and StenoSCORE2 performed well in predicting SM BSIs in patients with HM/HSCT and GN BSI. Clinical studies evaluating whether StenoSCORE and/or StenoSCORE2 implementation improves TTAT and clinical outcomes are warranted.
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Affiliation(s)
- Emily L Gill
- Department of Pharmacy, Barnes Jewish Hospital, 216 S. Kingshighway Blvd, Mailstop 90-52-41, Saint Louis, MO, 63110, USA.
| | - Christian M Gill
- Department of Pharmacy, SSM-Health St. Louis University Hospital, Saint Louis, MO, USA
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Colleen McEvoy
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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Rox K, Jansen R, Lukežič T, Greweling-Pils M, Herrmann J, Miethke M, Hüttel S, Hennessen F, Abou Fayad A, Holzhausen C, Lundberg CV, Teague J, Sudarman E, Bülter L, Hesterkamp T, Stadler M, Brönstrup M, Müller R. Pharmacokinetic and pharmacodynamic evaluation of the atypical tetracyclines chelocardin and amidochelocardin in murine infection models. Microbiol Spectr 2024; 12:e0128923. [PMID: 38047701 PMCID: PMC10783034 DOI: 10.1128/spectrum.01289-23] [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: 04/01/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE There is a strong need to find novel treatment options against urinary tract infections associated with antimicrobial resistance. This study evaluates two atypical tetracyclines, namely chelocardin (CHD) and amidochelocardin (CDCHD), with respect to their pharmacokinetics and pharmacodynamics. We show CHD and CDCHD are cleared at high concentrations in mouse urine. Especially, CDCHD is highly effective in an ascending urinary tract infection model, suggesting further preclinical evaluation.
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Affiliation(s)
- Katharina Rox
- Department of Chemical Biology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
| | - Rolf Jansen
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Tadeja Lukežič
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
| | - Marina Greweling-Pils
- Mouse Pathology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Jennifer Herrmann
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
| | - Marcus Miethke
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
| | - Stephan Hüttel
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Fabienne Hennessen
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
| | - Antoine Abou Fayad
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
| | - Cornelia Holzhausen
- Mouse Pathology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | | | | | - Enge Sudarman
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Lisa Bülter
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Translational Product Development Office, German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
| | - Thomas Hesterkamp
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Translational Product Development Office, German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
| | - Marc Stadler
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Drugs, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
| | - Mark Brönstrup
- Department of Chemical Biology, Helmholtz Centre for Infection Research (HZI), Braunschweig, Germany
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
| | - Rolf Müller
- German Centre for Infection Research (DZIF), Partner Site Braunschweig-Hannover, Braunschweig, Germany
- Department of Microbial Natural Products, Helmholtz Institute for Pharmaceutical Research Saarland (HIPS), Helmholtz Centre for Infection Research (HZI) and Department of Pharmacy, Saarland University Campus, Saarbrücken, Germany
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Rai S, Dash D, Agarwal N. Introducing the new face of CLSI M100 in 2023: An explanatory review. Indian J Med Microbiol 2023; 46:100432. [PMID: 37945125 DOI: 10.1016/j.ijmmb.2023.100432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The CLSI annual update of its M100 document is eagerly awaited every year. This year's update, the M100-Ed33, was published in February, and will significantly affect clinical practices. OBJECTIVE To highlight and explain the rationale of the changes and their clinical impact. CONTENT The major changes this year are mostly focused on PK/PD data, selective and cascade reporting of the antibiotics and therapy related comments. The CLSI has moved away from its classical grouping of antibiotics (A, B, U, O) to a tier-based approach (Tier 1, 2, 3, 4) which will aid in cascade reporting during an antibiotic susceptibility testing (AST). Rather than non-fastidious, fastidious and anaerobe grouping, the tables have been made organism specific. The aminoglycosides breakpoints have been changed for both Enterobacterales and Pseudomonas aeruginosa while for P. aeruginosa, the breakpoints of piperacillin - tazobactam (TZP) are also updated. These updates are mostly based on attainment of drug plasma level for bacterial stasis rather than bactericidal effect of the antibiotics. It is noteworthy, that these breakpoint changes are made, keeping in view that the aminoglycosides for all organisms should be used in combination therapy. For P. aeruginosa, gentamicin has been removed, while amikacin has been restricted for urinary isolates only.
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Affiliation(s)
- Sumit Rai
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
| | - Debabrata Dash
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
| | - Nidhima Agarwal
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
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Kunz Coyne AJ, Herbin S, Caniff K, Rybak MJ. Steno-sphere: Navigating the enigmatic world of emerging multidrug-resistant Stenotrophomonas maltophilia. Pharmacotherapy 2023; 43:833-846. [PMID: 37199104 DOI: 10.1002/phar.2828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 05/19/2023]
Abstract
Stenotrophomonas maltophilia is an opportunistic pathogen and frequent cause of serious nosocomial infections. Patient populations at greatest risk for these infections include the immunocompromised and those with chronic respiratory illnesses and prior antibiotic exposure, notably to carbapenems. Its complex virulence and resistance profile drastically limit available antibiotics, and incomplete breakpoint and pharmacokinetic/pharmacodynamic (PK/PD) data to inform dose optimization further complicates therapeutic approaches. Clinical comparison data of first-line agents, including trimethoprim-sulfamethoxazole (TMP-SMX), quinolones, and minocycline, are limited to conflicting observational data with no clear benefit of a single agent or combination therapy. Newer antibiotic approaches, including cefiderocol and aztreonam- avibactam, are promising alternatives for extensively drug-resistant isolates; however, clinical outcomes data are needed. The potential clinical utility of bacteriophage for compassionate use in treating S. maltophilia infections remains to be determined since data is limited to in-vitro and sparse in-vivo work. This article provides a review of available literature for S. maltophilia infection management focused on related epidemiology, resistance mechanisms, identification, susceptibility testing, antimicrobial PK/PD, and emerging therapeutic strategies.
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Affiliation(s)
- Ashlan J Kunz Coyne
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | | | - Kaylee Caniff
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
- School of Medicine, Wayne State University, Detroit, Michigan, USA
- Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, Michigan, USA
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Maraolo AE, Licciardi F, Gentile I, Saracino A, Belati A, Bavaro DF. Stenotrophomonas maltophilia Infections: A Systematic Review and Meta-Analysis of Comparative Efficacy of Available Treatments, with Critical Assessment of Novel Therapeutic Options. Antibiotics (Basel) 2023; 12:910. [PMID: 37237813 PMCID: PMC10215754 DOI: 10.3390/antibiotics12050910] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/08/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Stenotrophomonas maltophilia (SM) represents a challenging pathogen due to its resistance profile. A systematic review of the available evidence was conducted to evaluate the best treatment of SM infections to date, focusing on trimethoprim/sulfamethoxazole (TMP/SMX), fluoroquinolones (FQs), and tetracycline derivatives (TDs). MATERIALS PubMed/MEDLINE and Embase were searched from inception to 30 November 2022. The primary outcome was all-cause mortality. Secondary outcomes included clinical failure, adverse events, and length of stay. A random effects meta-analysis was performed. This study was registered with PROSPERO (CRD42022321893). RESULTS Twenty-four studies, all retrospective, were included. A significant difference in terms of overall mortality was observed when comparing as a monotherapy TMP/SMX versus FQs (odds ratio (OR) 1.46, 95% confidence interval (CI) 1.15-1.86, I2 = 33%; 11 studies, 2407 patients). The prediction interval (PI) did not touch the no effect line (1.06-1.93), but the results were not robust for the unmeasured confounding (E-value for point estimate of 1.71). When comparing TMP/SMX with TDs, the former showed an association with higher mortality but not significant and with a wide PI (OR 1.95, 95% CI 0.79-4.82, PI 0.01-685.99, I2 = 0%; 3 studies, 346 patients). Monotherapies in general exerted a protective effect against death opposed to the combination regimens but were not significant (OR 0.71, 95% CI 0.41-1.22, PI 0.16-3.08, I2 = 0%; 4 studies, 438 patients). CONCLUSIONS Against SM infections, FQs and, possibly, TDs seem to be reasonable alternative choices to TMP/SMX. Data from clinical trials are urgently needed to better inform therapeutic choices in this setting by also taking into account newer agents.
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Affiliation(s)
- Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, AORN Dei Colli, 80131 Naples, Italy
| | - Federica Licciardi
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131 Naples, Italy; (F.L.); (I.G.)
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, 80131 Naples, Italy; (F.L.); (I.G.)
| | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari, 70124 Bari, Italy; (A.S.); (A.B.); (D.F.B.)
| | - Alessandra Belati
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari, 70124 Bari, Italy; (A.S.); (A.B.); (D.F.B.)
| | - Davide Fiore Bavaro
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari, 70124 Bari, Italy; (A.S.); (A.B.); (D.F.B.)
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Sarzynski SH, Lawandi A, Warner S, Demirkale CY, Strich JR, Dekker JP, Babiker A, Li W, Kadri SS. Association between minimum inhibitory concentration values and mortality risk in patients with Stenotrophomonas maltophilia infections: a retrospective cohort study of electronic health records from 148 US hospitals. JAC Antimicrob Resist 2023; 5:dlad049. [PMID: 37124072 PMCID: PMC10141776 DOI: 10.1093/jacamr/dlad049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Background Clinical data informing antimicrobial susceptibility breakpoints for Stenotrophomonas maltophilia infections are lacking. We sought to leverage real-world data to identify MIC values within the currently defined susceptible range that could discriminate mortality risk for patients with S. maltophilia infections and guide future breakpoint revisions. Methods Inpatients with S. maltophilia infection who received single-agent targeted therapy with levofloxacin or trimethoprim/sulfamethoxazole were identified in the Cerner HealthFacts electronic health record database. Encounters were restricted to those with MIC values reported to be in the susceptible range for both agents. Curation for exact (non-range) MIC values yielded sequentially granular model populations. Logistic regression was used to calculate adjusted OR (aOR) of mortality or hospice discharge associated with different susceptible-range MICs, controlling for patient- and centre-related factors, and infection site, polymicrobial infection and receipt of empirical therapy. Results Seventy-three of 851 levofloxacin-treated patients had levofloxacin MIC of exactly 2 mg/L (current Clinical and Laboratory Standards Institute (CLSI) susceptibility breakpoint) and served as the reference category for levofloxacin breakpoint models. In breakpoint model I (n = 501), aOR of mortality associated with infection due to isolates with levofloxacin MIC of ≤1 versus 2 mg/L were similar [aOR = 1.79 (95% CI 0.88-3.62), P = 0.11]. In breakpoint model IIa (n = 358), aOR of mortality associated with MIC ≤0.5 versus 2 mg/L were also similar [aOR 0.1.36 (95% CI 0.65-2.83), P = 0.41]. However, breakpoint model IIb (n = 297) displayed higher aOR of mortality associated with an MIC of 1 versus 2 mg/L [aOR 2.36 (95% CI 1.14-4.88), P = 0.02]. Only 9/645 trimethoprim/sulfamethoxazole-treated patients had trimethoprim/sulfamethoxazole MIC of exactly 2/38 mg/L precluding informative models for this agent. Conclusions In this retrospective study of real-world patients with S. maltophilia infection, risk-adjusted survival data do not appear to stratify patients clinically within current susceptible-range MIC breakpoint for levofloxacin (≤2 mg/L) by mortality.
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Affiliation(s)
| | - Alexander Lawandi
- Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive B10, 2C145, Bethesda, MD 20892, USA
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive B10, 2C145, Bethesda, MD 20892, USA
| | - Cumhur Y Demirkale
- Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive B10, 2C145, Bethesda, MD 20892, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Drive B10, 2C145, Bethesda, MD 20892, USA
| | - John P Dekker
- Bacterial Pathogenesis and Antimicrobial Resistance Unit, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Ahmed Babiker
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Willy Li
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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9
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Clinical Efficacy and Safety Analysis of Levofloxacin for the Prevention of Infection after Traumatic Osteoarthrosis and Internal Fixation: Systematic Review and Meta-Analysis. Emerg Med Int 2022; 2022:8788365. [PMID: 36213001 PMCID: PMC9537031 DOI: 10.1155/2022/8788365] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/28/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Levofloxacin has been widely used in clinical anti-infection treatment; however, its adverse reactions to levofloxacin were also obvious in patients. Herein we aimed to systematically evaluate the clinical efficacy and safety of systemic administration of levofloxacin in the prevention of postoperative infection after traumatic osteoarthrosis and internal fixation. Methods PubMed, Cochrane Library, OVID, EBSCO, CNKI, VIP database, and Wanfang Database were searched from December 1993 to December 2021. Meanwhile, China ADR Information Bulletin and WHO Pharmaceutical were searched manually. Newsletter and FDA Drug Safety Newsletter, also to retrieve the Websites of Chinese, Chinese, and drug regulatory authorities; To obtain data on adverse events in children with systemic administration of levofloxacin. The literature was screened according to inclusion and exclusion criteria. The risk of bias was evaluated for the included RCT literature. Results There was a statistical difference in the comparison of the incidence of fever between the experimental group and the control group (OR = 2.29, 95% CI (1.75,2.98),P < 0.00001, I2 = 0%, Z = 6.11); elevated white blood cell count (OR = 1.82, 95% CI (1.31,2.52),P=0.0003, I2 = 0%, Z = 3.60); incidence of wound infection (OR = 2.11, 95% CI (1.54,2.90),P < 0.00001, I2 = 0%, Z = 4.64); adverse drug reaction (OR = 1.82, 95% CI (1.21,2.74),P=0.004, I2 = 0%, Z = 2.86). Conclusion In the clinical use of levofloxacin, adverse drug reactions including fever, elevated white blood cell count, and wound infection should be concerned.
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10
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Efficacy of Cefiderocol in Experimental Stenotrophomonas maltophilia Pneumonia in Persistently Neutropenic Rabbits. Antimicrob Agents Chemother 2022; 66:e0061822. [PMID: 36154614 PMCID: PMC9578435 DOI: 10.1128/aac.00618-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Stenotrophomonas maltophilia is an important cause of pneumonia in immunocompromised patients. Cefiderocol is a parenteral siderophore cephalosporin with potent in vitro activity against S. maltophilia. We evaluated the efficacy of cefiderocol in a neutropenic rabbit model of S. maltophilia pneumonia in comparison to trimethoprim-sulfamethoxazole (TMP-SMX). The cefiderocol area under the plasma drug concentration-time curve extrapolated to 8 h (AUC0–8) was lower (423.0 ± 40.9 μg·h/mL versus 713.6 ± 40.1 μg·h/mL) and clearance higher (252.77 ± 38.9 mL/h/kg versus 142.6 ± 32.9 mL/h/kg) in infected versus noninfected rabbits. We studied a clinical bloodstream S. maltophilia isolate with an MIC of 0.03 μg/mL of cefiderocol. Time spent above the MIC of cefiderocol for the majority of S. maltophilia isolates in rabbits recapitulated the plasma concentration-time profile observed in adult humans at the licensed dose of 2 g given intravenously (i.v.). Experimental groups consisted of 120 mg/kg cefiderocol i.v. every 8 hours (q8h); TMP-SMX, 5 mg/kg i.v. Q12h, and untreated controls (UCs). Treatment was administered for 10 days. Survival in cefiderocol-treated rabbits (87%) was greater than that in TMP-SMX-treated (25%; P < 0.05) and UC (0%; P < 0.05) groups. There was no residual bacterial burden in lung tissue or bronchoalveolar lavage (BAL) fluid in the cefiderocol group. Residual bacterial burden was present in lung tissue and BAL fluid in the TMP-SMX group but was decreased in comparison to UCs (P < 0.001). Lung weights (markers of pulmonary injury) were decreased in cefiderocol-treated versus TMP-SMX (P < 0.001) and UC (P < 0.001) groups. Cefiderocol is highly active in treatment of experimental S. maltophilia pneumonia, laying the foundation for future clinical investigations against this lethal infection in immunocompromised patients.
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Lasko MJ, Tabor-Rennie JL, Nicolau DP, Kuti JL. Trimethoprim/sulfamethoxazole pharmacodynamics against Stenotrophomonas maltophilia in the in vitro chemostat model. J Antimicrob Chemother 2022; 77:3187-3193. [PMID: 36101486 DOI: 10.1093/jac/dkac304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Trimethoprim/sulfamethoxazole has historically been the treatment of choice for infection caused by Stenotrophomonas maltophilia. This study sought to define the pharmacodynamic indices and magnitude of exposure required for stasis and 1 log10 cfu reductions. METHODS Pharmacodynamic studies were conducted using the in vitro chemostat model over 24 h against three trimethoprim/sulfamethoxazole-susceptible S. maltophilia isolates with MICs from 0.25/4.75 to 2/38 mg/L. The primary endpoint was the change in cfu at 24 h relative to baseline. The log ratio of the area under the cfu curve (LR AUcfu) was a secondary endpoint. Trimethoprim and sulfamethoxazole exposures required for stasis and 1 log10 cfu/mL reduction were determined. RESULTS Trimethoprim/sulfamethoxazole exposures achieved stasis and 1 log10 cfu/mL reductions in 9/16 (56%) and 2/16 (13%) of experiments. Both the fAUC/MIC and fCmax/MIC were identified as equivalent pharmacodynamic drivers, with stasis achieved at an fAUC/MIC of 67.4 and 30.0 for trimethoprim and sulfamethoxazole, respectively. Clinically meaningful exposures required to achieve 1 log10 cfu/mL reductions were not quantifiable. The LR AUcfu analysis supported the lack of overall bacterial burden reduction against S. maltophilia. CONCLUSIONS In this in vitro chemostat model, trimethoprim/sulfamethoxazole monotherapy, even at higher doses, achieved limited activity against susceptible S. maltophilia.
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Affiliation(s)
- Maxwell J Lasko
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA.,Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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Vialichka A, Biagi M, Meyer K, Wu T, Shajee A, Tan X, Wenzler E. Activity of Delafloxacin and Levofloxacin against Stenotrophomonas maltophilia at Simulated Plasma and Intrapulmonary pH Values. Microbiol Spectr 2022; 10:e0270521. [PMID: 35862943 PMCID: PMC9431699 DOI: 10.1128/spectrum.02705-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Fluoroquinolones have become a popular treatment option for Stenotrophomonas maltophilia infections. Although levofloxacin is most commonly used, delafloxacin demonstrates comparable in vitro activity when evaluated under standard susceptibility testing conditions at neutral pH. At acidic pH, the activity of the anionic delafloxacin is improved, while the activity of the zwitterionic levofloxacin is reduced. Because the human respiratory tract has a pH of ~6.6 and is the most common site of S. maltophilia infection, it is vital to understand the activity of these agents in this environment. Therefore, levofloxacin and delafloxacin were tested against clinical S. maltophilia isolates via broth microdilution testing (n = 37) and time-kill analysis (n = 5) in neutral cation-adjusted Mueller-Hinton broth (CAMHB) (pH 7.3) and acidic CAMHB (aCAMHB) (pH 6.5). In CAMHB, MIC50 values were similar between levofloxacin and delafloxacin (8 mg/L versus 8 mg/L). In aCAMHB, levofloxacin MICs did not change, while delafloxacin MICs decreased by a median of 4 log2 dilutions (MIC50 values of 8 mg/L versus 0.25 mg/L). In time-kill analyses, levofloxacin and delafloxacin at the maximum drug concentration for the free drug (fCmax) were bactericidal against 3 and 2 isolates in CAMHB, respectively. In aCAMHB, levofloxacin was not bactericidal against any isolate, while delafloxacin was bactericidal against the same 2 isolates. Relative to CAMHB, levofloxacin activity was reduced by 2.5 log10 CFU/mL in aCAMHB, whereas delafloxacin activity was increased 2.7 log10 CFU/mL. Although the bactericidal activity of levofloxacin against S. maltophilia was attenuated in an acidic environment in this study, the increased potency of delafloxacin at pH 6.5 did not translate into improved bactericidal activity in time-kill analyses, compared to pH 7.3. IMPORTANCE Stenotrophomonas maltophilia most often infects the lungs, where the physiologic environment is naturally slightly acidic (pH ~6.6), compared to most parts of the body (such as the bloodstream), which have neutral pH values (~7.4). Pneumonia due to S. maltophilia is often treated with the antibiotic levofloxacin, despite the activity of levofloxacin being known to be impaired at acidic pH. Unfortunately, currently available methods for susceptibility testing of levofloxacin against S. maltophilia are performed at a neutral pH and therefore may not accurately represent the activity of levofloxacin at the site of infection in the lungs. A similar but newer antibiotic in the same class as levofloxacin, namely, delafloxacin, is not affected by being in an acidic environment and may actually work better at lower pH values. Therefore, the purpose of this study was to investigate whether one drug might be better than the other in this setting by testing each agent's ability to kill S. maltophilia at pH 7.3 and pH 6.5. These findings could then be used to design confirmatory studies that may ultimately impact which drug is given to patients with lung infections due to S. maltophilia.
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Affiliation(s)
- Alesia Vialichka
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mark Biagi
- College of Pharmacy, University of Illinois Chicago, Rockford, Illinois, USA
| | - Kevin Meyer
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Tiffany Wu
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Aisha Shajee
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Xing Tan
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
| | - Eric Wenzler
- College of Pharmacy, University of Illinois Chicago, Chicago, Illinois, USA
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