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Qiu Z, Huang R, Wu Y, Li X, Sun C, Ma Y. Decoding the Structural Diversity: A New Horizon in Antimicrobial Prospecting and Mechanistic Investigation. Microb Drug Resist 2024; 30:254-272. [PMID: 38648550 DOI: 10.1089/mdr.2023.0232] [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] [Indexed: 04/25/2024] Open
Abstract
The escalating crisis of antimicrobial resistance (AMR) underscores the urgent need for novel antimicrobials. One promising strategy is the exploration of structural diversity, as diverse structures can lead to diverse biological activities and mechanisms of action. This review delves into the role of structural diversity in antimicrobial discovery, highlighting its influence on factors such as target selectivity, binding affinity, pharmacokinetic properties, and the ability to overcome resistance mechanisms. We discuss various approaches for exploring structural diversity, including combinatorial chemistry, diversity-oriented synthesis, and natural product screening, and provide an overview of the common mechanisms of action of antimicrobials. We also describe techniques for investigating these mechanisms, such as genomics, proteomics, and structural biology. Despite significant progress, several challenges remain, including the synthesis of diverse compound libraries, the identification of active compounds, the elucidation of complex mechanisms of action, the emergence of AMR, and the translation of laboratory discoveries to clinical applications. However, emerging trends and technologies, such as artificial intelligence, high-throughput screening, next-generation sequencing, and open-source drug discovery, offer new avenues to overcome these challenges. Looking ahead, we envisage an exciting future for structural diversity-oriented antimicrobial discovery, with opportunities for expanding the chemical space, harnessing the power of nature, deepening our understanding of mechanisms of action, and moving toward personalized medicine and collaborative drug discovery. As we face the continued challenge of AMR, the exploration of structural diversity will be crucial in our search for new and effective antimicrobials.
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Affiliation(s)
- Ziying Qiu
- School of Pharmacy, Binzhou Medical University, Yantai, China
| | - Rongkun Huang
- School of Pharmacy, Binzhou Medical University, Yantai, China
| | - Yuxuan Wu
- School of Pharmacy, Binzhou Medical University, Yantai, China
| | - Xinghao Li
- School of Pharmacy, Binzhou Medical University, Yantai, China
| | - Chunyu Sun
- School of Pharmacy, Binzhou Medical University, Yantai, China
| | - Yunqi Ma
- School of Pharmacy, Binzhou Medical University, Yantai, China
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Rogers R, Rice LB. State-of-the-Art Review: Persistent Enterococcal Bacteremia. Clin Infect Dis 2024; 78:e1-e11. [PMID: 38018162 DOI: 10.1093/cid/ciad612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Indexed: 11/30/2023] Open
Abstract
Persistent enterococcal bacteremia is a commonly encountered and morbid syndrome without a strong evidence base for optimal management practices. Here we highlight reports on the epidemiology of enterococcal bacteremia to better describe and define persistent enterococcal bacteremia, discuss factors specific to Enterococcus species that may contribute to persistent infections, and describe a measured approach to diagnostic and therapeutic strategies for patients with these frequently complicated infections. The diagnosis of persistent enterococcal bacteremia is typically clinically evident in the setting of repeatedly positive blood culture results; instead, the challenge is to determine in an accurate, cost-effective, and minimally invasive manner whether any underlying nidus of infection (eg, endocarditis or undrained abscess) is present and contributing to the persistent bacteremia. Clinical outcomes for patients with persistent enterococcal bacteremia remain suboptimal. Beyond addressing host immune status if relevant and pursuing source control for all patients, management decisions primarily involve the selection of the proper antimicrobial agent(s). Options for antimicrobial therapy are often limited in the setting of intrinsic and acquired antimicrobial resistance among enterococcal clinical isolates. The synergistic benefit of combination antimicrobial therapy has been demonstrated for enterococcal endocarditis, but it is not clear at present whether a similar approach will provide any clinical benefit to some or all patients with persistent enterococcal bacteremia.
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Affiliation(s)
- Ralph Rogers
- Division of Infectious Diseases and Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Louis B Rice
- Division of Infectious Diseases and Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Cairns KA, Udy AA, Peel TN, Abbott IJ, Dooley MJ, Peleg AY. Therapeutics for Vancomycin-Resistant Enterococcal Bloodstream Infections. Clin Microbiol Rev 2023; 36:e0005922. [PMID: 37067406 PMCID: PMC10283489 DOI: 10.1128/cmr.00059-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Vancomycin-resistant enterococci (VRE) are common causes of bloodstream infections (BSIs) with high morbidity and mortality rates. They are pathogens of global concern with a limited treatment pipeline. Significant challenges exist in the management of VRE BSI, including drug dosing, the emergence of resistance, and the optimal treatment for persistent bacteremia and infective endocarditis. Therapeutic drug monitoring (TDM) for antimicrobial therapy is evolving for VRE-active agents; however, there are significant gaps in the literature for predicting antimicrobial efficacy for VRE BSIs. To date, TDM has the greatest evidence for predicting drug toxicity for the three main VRE-active antimicrobial agents daptomycin, linezolid, and teicoplanin. This article presents an overview of the treatment options for VRE BSIs, the role of antimicrobial dose optimization through TDM in supporting clinical infection management, and challenges and perspectives for the future.
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Affiliation(s)
- Kelly A. Cairns
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Trisha N. Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Iain J. Abbott
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michael J. Dooley
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Anton Y. Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Infection Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
- Centre to Impact AMR, Monash University, Clayton, Victoria, Australia
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Chen TT, Chang YF, Wu YC. Clinical Use of Intravenous Fosfomycin in Critical Care Patients in Taiwan. Pathogens 2023; 12:841. [PMID: 37375531 DOI: 10.3390/pathogens12060841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
This retrospective study aimed to evaluate the clinical use and side effects of fosfomycin in critically ill patients in Taiwan. Forty-two patients (mean age, 69.9 years; female, 69%) who received fosfomycin were included from a teaching hospital in Taiwan from January 2021 to December 2021. We analyzed the prescription pattern of intravenous fosfomycin and evaluated patient safety profiles, clinical successes, and microbiological cure rates. The main indication was urinary tract infections (35.6%), and the most frequently identified pathogen was Escherichia coli (18.2%). The overall clinical success was 83.4%, with one multidrug-resistant pathogen isolated from eight patients (19.0%). The average dose of fosfomycin given was 11.1 ± 5.2 g/day. The average duration of therapy was 8.7 ± 5.9 days, with a median duration of 8 days, where fosfomycin was mostly (83.3%) given in combination. Fosfomycin was given 12 hourly to a maximum number (47.6%) of cases. The incidence rates of adverse drug reactions (hypernatremia and hypokalemia) were 33.33% (14/42) and 28.57% (12/42), respectively. The overall survival rate was 73.8%. Intravenous fosfomycin may be an effective and safe antibiotic to use in combination with other drugs for empirical broad-spectrum or highly suspected multidrug-resistant infections in critically ill patients.
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Affiliation(s)
- Tzu-Ting Chen
- Department of Pharmacy, Taipei Medical University Hospital, Taipei Medical University, Taipei 11031, Taiwan
| | - Yun-Fu Chang
- Graduate Institute of Doctor of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
| | - Yea-Chwen Wu
- Graduate Institute of Doctor of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan
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Tseng TC, Chuang YC, Yang JL, Lin CY, Huang SH, Wang JT, Chen YC, Chang SC. The Combination of Daptomycin with Fosfomycin is More Effective than Daptomycin Alone in Reducing Mortality of Vancomycin-Resistant Enterococcal Bloodstream Infections: A Retrospective, Comparative Cohort Study. Infect Dis Ther 2023; 12:589-606. [PMID: 36629997 PMCID: PMC9925660 DOI: 10.1007/s40121-022-00754-1] [Citation(s) in RCA: 2] [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: 10/06/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION High-dose daptomycin-based combinations are recommended for vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI). Preclinical data have shown a synergistic effect of daptomycin/fosfomycin combinations against VRE. However, clinical studies comparing daptomycin monotherapy with daptomycin/fosfomycin combinations are unavailable. METHODS An observational study of VRE-BSI was performed between 2010-2021 on patients receiving daptomycin monotherapy (≥ 8 mg/kg) or daptomycin combined with intravenous fosfomycin. Patients treated with concomitant β-lactam combinations were excluded. The primary outcome was in-hospital mortality. Outcomes were analyzed using multivariable logistic regression and augmented inverse probability weighting (AIPW) analyses. RESULTS Among 224 patients, 176 received daptomycin monotherapy, and 48 received fosfomycin combinations. The median daptomycin and fosfomycin doses were 9.8 mg/kg and 12 g/day, respectively. In-hospital mortality was 77.3% and 47.9% in the daptomycin monotherapy and fosfomycin combination groups (P < 0.001), respectively. Multivariable logistic regression analysis predicted lower mortality with fosfomycin combination treatment (adjusted odds ratio, 0.35; 95% confidence interval (CI), 0.17-0.73; P = 0.005). AIPW demonstrated a 17.8% reduced mortality with fosfomycin combinations (95% CI, - 30.6- - 4.9%; P = 0.007). The survival benefit was significant, especially among patients with a lower Pitt bacteremia score or fosfomycin minimum inhibitory concentration (MIC) ≤ 64 mg/l. Fosfomycin combination resulted in higher hypernatremia (10.4% vs. 2.8%, P = 0.04) and hypokalemia (33.3% vs. 15.3%, P = 0.009) compared to daptomycin monotherapy. CONCLUSION The combination of high-dose daptomycin with fosfomycin improved the survival rate of patients with VRE-BSI compared to daptomycin alone. The benefit of the combination was most pronounced for VRE with fosfomycin MIC ≤ 64 mg/l and for patients with a low Pitt bacteremia score.
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Affiliation(s)
- Tai-Chung Tseng
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Jia-Ling Yang
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Chi-Ying Lin
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100, Taiwan
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The combination of daptomycin with β-lactam antibiotics is more effective than daptomycin alone for vancomycin-resistant Enterococcus faecium bloodstream infection. J Infect Public Health 2022; 15:1396-1402. [DOI: 10.1016/j.jiph.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
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