1
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Liu Q, Zhou J, Zheng Y, Xu B, Li D, Liu M, Zhang X, Wu X. Three methods to optimise polymyxin B dosing using estimated AUC after first dose: validation with the data generated by Monte Carlo simulation. Xenobiotica 2024:1-9. [PMID: 38884560 DOI: 10.1080/00498254.2024.2370051] [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: 04/06/2024] [Accepted: 06/16/2024] [Indexed: 06/18/2024]
Abstract
To achieve the AUC-guided dosing, we proposed three methods to estimate polymyxin B AUC across 24 h at steady state (AUCSS,24h) using limited concentrations after its first dose.Monte Carlo simulation based on a well-established population PK model was performed to generate the PK profiles of 1000 patients with normal or abnormal renal function. Polymyxin B AUCSS,24h was estimated for each subject using three methods (two-point PK approach, three-point PK approach, and four-point PK approach) based on limited concentration data in its first dose and compared with the actual AUC at steady state calculated using the linear-trapezoidal formula.In patients with normal renal function, the mean bias of two-point PK approach, three-point PK approach, and four-point PK approach was -8.73%, 1.37%, and -0.48%, respectively. The corresponding value was -11.15%, 1.99%, and -0.28% in patients with renal impairment, respectively. The largest mean bias of two-point PK approach, three-point PK approach, and four-point PK approach was -12.63%, -6.47%, and -0.54% when the sampling time shifted.The Excel calculators designed based on the three methods can be potentially used to optimise the dosing regimen of polymyxin B in the clinic.
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Affiliation(s)
- Qingxia Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianxing Zhou
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - You Zheng
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Baohua Xu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Dandan Li
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaohan Zhang
- College of Arts and Sciences, University of Virginia, Charlottesville, VA, USA
| | - Xuemei Wu
- School of Pharmacy, Fujian Medical University, Fuzhou, China
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
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2
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Shad A, Rewell SSJ, Macowan M, Gandasasmita N, Wang J, Chen K, Marsland B, O'Brien TJ, Li J, Semple BD. Modelling lung infection with Klebsiella pneumoniae after murine traumatic brain injury. J Neuroinflammation 2024; 21:122. [PMID: 38720343 PMCID: PMC11080247 DOI: 10.1186/s12974-024-03093-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/05/2024] [Indexed: 05/12/2024] Open
Abstract
Pneumonia is a common comorbidity in patients with severe traumatic brain injury (TBI), and is associated with increased morbidity and mortality. In this study, we established a model of intratracheal Klebsiella pneumoniae administration in young adult male and female mice, at 4 days following an experimental TBI, to investigate how K. pneumoniae infection influences acute post-TBI outcomes. A dose-response curve determined the optimal dose of K. pneumoniae for inoculation (1 x 10^6 colony forming units), and administration at 4 days post-TBI resulted in transient body weight loss and sickness behaviors (hypoactivity and acute dyspnea). K. pneumoniae infection led to an increase in pro-inflammatory cytokines in serum and bronchoalveolar lavage fluid at 24 h post-infection, in both TBI and sham (uninjured) mice. By 7 days, when myeloperoxidase + neutrophil numbers had returned to baseline in all groups, lung histopathology was observed with an increase in airspace size in TBI + K. pneumoniae mice compared to TBI + vehicle mice. In the brain, increased neuroinflammatory gene expression was observed acutely in response to TBI, with an exacerbated increase in Ccl2 and Hmox1 in TBI + K. pneumoniae mice compared to either TBI or K. pneumoniae alone. However, the presence of neuroinflammatory immune cells in the injured brain, and the extent of damage to cortical and hippocampal brain tissue, was comparable between K. pneumoniae and vehicle-treated mice by 7 days. Examination of the fecal microbiome across a time course did not reveal any pronounced effects of either injury or K. pneumoniae on bacterial diversity or abundance. Together, these findings demonstrate that K. pneumoniae lung infection after TBI induces an acute and transient inflammatory response, primarily localized to the lungs with some systemic effects. However, this infection had minimal impact on secondary injury processes in the brain following TBI. Future studies are needed to evaluate the potential longer-term consequences of this dual-hit insult.
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Affiliation(s)
- Ali Shad
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
| | - Sarah S J Rewell
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
| | - Matthew Macowan
- Department of Immunology, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Natasha Gandasasmita
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
| | - Jiping Wang
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Ke Chen
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Ben Marsland
- Department of Immunology, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia
- Alfred Health, Prahran, VIC, Australia
- GIN Discovery Program, The School of Translational Medicine, Monash University, Melbourne, VIC, Australia
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
| | - Jian Li
- Department of Microbiology, Monash Biomedical Discovery Institute, Monash University, Clayton, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, The School of Translational Medicine, Monash University, Level 6 Alfred Centre, 99 Commercial Rd, Melbourne, VIC, 3004 VIC, Australia.
- Alfred Health, Prahran, VIC, Australia.
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia.
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3
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Li X, Cheng Y, Zhang B, Chen B, Chen Y, Huang Y, Lin H, Zhou L, Zhang H, Liu M, Que W, Qiu H. A systematic evaluation of population pharmacokinetic models for polymyxin B in patients with liver and/or kidney dysfunction. J Pharmacokinet Pharmacodyn 2024:10.1007/s10928-024-09916-9. [PMID: 38625507 DOI: 10.1007/s10928-024-09916-9] [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: 11/23/2023] [Accepted: 03/21/2024] [Indexed: 04/17/2024]
Abstract
Polymyxin B (PMB) is considered a last-line treatment for multidrug-resistant (MDR) gram-negative bacterial infections. Model-informed precision dosing with population pharmacokinetics (PopPK) models could help to individualize PMB dosing regimens and improve therapy. However, the external prediction ability of the established PopPK models has not been fully elaborated. This study aimed to systemically evaluate eleven PMB PopPK models from ten published literature based on a new independent population, which was divided into four different populations, patients with liver dysfunction, kidney dysfunction, liver and kidney dysfunction, and normal liver and kidney function. The whole data set consisted of 146 patients with 391 PMB concentrations. The prediction- and simulation-based diagnostics and Bayesian forecasting were conducted to evaluate model predictability. In the overall evaluation process, none of the models exhibited satisfactory predictive ability in both prediction- and simulation-based diagnostic simultaneously. However, the evaluation of the models in the subgroup of patients with normal liver and kidney function revealed improved predictive performance compared to those with liver and/or kidney dysfunction. Bayesian forecasting demonstrated enhanced predictability with the incorporation of two to three prior observations. The external evaluation highlighted a lack of consistency between the prediction results of published models and the external validation dataset. Nonetheless, Bayesian forecasting holds promise in improving the predictive performance of the models, and feedback from therapeutic drug monitoring is crucial in optimizing individual dosing regimens.
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Affiliation(s)
- Xueyong Li
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Bingqing Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Bo Chen
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yiying Chen
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Yingbing Huang
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China
| | - Hailing Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Lili Zhou
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, 350001, People's Republic of China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China
| | - Wancai Que
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China.
| | - Hongqiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, 29 Xin Quan Rd, Fuzhou, 350001, Fujian, People's Republic of China.
- College of Pharmacy, Fujian Medical University, Fuzhou, 350004, People's Republic of China.
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4
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Franzone JP, Mackow N, van Duin D. Current treatment options for pneumonia caused by carbapenem-resistant Acinetobacter baumannii. Curr Opin Infect Dis 2024; 37:137-143. [PMID: 38179988 PMCID: PMC10922681 DOI: 10.1097/qco.0000000000001001] [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] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to briefly summarize the challenges associated with the treatment of pneumonia caused by carbapenem-resistant Acinetobacter baumannii (CRAB), discuss its carbapenem-resistance, and review the literature supporting the current treatment paradigm and therapeutic options. RECENT FINDINGS In a multicenter, randomized, and controlled trial the novel β-lactam-β-lactamase inhibitor sulbactam-durlobactam was compared to colistin, both in addition to imipenem-cilastatin. The drug met the prespecified criteria for noninferiority for 28-day all-cause mortality while demonstrating higher clinical cure rates in the treatment of CRAB pneumonia. In an international, randomized, double-blind, placebo controlled trial colistin monotherapy was compared to colistin combined with meropenem. In this trial, combination therapy was not superior to monotherapy in the treatment of drug-resistant gram-negative organisms including CRAB pneumonia. SUMMARY CRAB pneumonia is a preeminent public health threat without an agreed upon first line treatment strategy. Historically, there have been drawbacks to available treatment modalities without a clear consensus on the first-line treatment regimen. CRAB pneumonia is a top priority for the continued development of antimicrobials, adjuvant therapies and refinement of current treatment strategies.
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Affiliation(s)
- John P. Franzone
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Natalie Mackow
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
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5
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Ahmed MU, Li J, Zhou Q(T. Tobramycin Reduces Pulmonary Toxicity of Polymyxin B via Inhibiting the Megalin-Mediated Drug Uptake in the Human Lung Epithelial Cells. Pharmaceutics 2024; 16:389. [PMID: 38543283 PMCID: PMC10975719 DOI: 10.3390/pharmaceutics16030389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 04/01/2024] Open
Abstract
Accumulation of polymyxins in the lung epithelial cells can lead to increased mitochondrial oxidative stress and pulmonary toxicity. Aminoglycosides and polymyxins are used, via intravenous and pulmonary delivery, against multidrug-resistant Gram-negative pathogens. Our recent in vitro and animal studies demonstrated that the co-administration of polymyxins with aminoglycosides decreases polymyxin-induced pulmonary toxicity. The aim of this study was to investigate the in vitro transport and uptake of polymyxin B and tobramycin in human lung epithelial Calu-3 cells and the mechanism of reduced pulmonary toxicity resulting from this combination. Transport, intracellular localization, and accumulation of polymyxin B and tobramycin were investigated using doses of 30 mg/L polymyxin B, 70 mg/L tobramycin, and the combination of both. Adding tobramycin significantly (p < 0.05) decreased the polymyxin B-induced cytotoxicity in Calu-3 cells. The combination treatment significantly reduced the transport and uptake of polymyxin B and tobramycin in Calu-3 cells, compared to each drug alone, which supported the reduced pulmonary toxicity. We hypothesized that cellular uptake of polymyxin B and tobramycin shared a common transporter, megalin. We further investigated the megalin expression of Calu-3 cells using confocal microscopy and evaluated megalin activity using a megalin substrate, FITC-BSA, and a megalin inhibitor, sodium maleate. Both polymyxin B and tobramycin significantly inhibited FITC-BSA uptake by Calu-3 cells in a concentration-dependent manner. Sodium maleate substantially inhibited polymyxin B and tobramycin transport and cellular accumulation in the Calu-3 cell monolayer. Our study demonstrated that the significantly reduced uptake of polymyxin B and tobramycin in Calu-3 cells is attributed to the mechanism of action that determines that polymyxin B and tobramycin share a common transporter, megalin.
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Affiliation(s)
- Maizbha Uddin Ahmed
- Department of Industrial and Molecular Pharmaceutics, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
| | - Jian Li
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, VIC 3800, Australia
| | - Qi (Tony) Zhou
- Department of Industrial and Molecular Pharmaceutics, College of Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907, USA
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6
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Wang P, Liu S, Sun T, Yang J. Daily fluid intake as a novel covariate affecting the population pharmacokinetics of polymyxin B in patients with sepsis. Int J Antimicrob Agents 2024; 63:107099. [PMID: 38280575 DOI: 10.1016/j.ijantimicag.2024.107099] [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: 07/31/2023] [Revised: 12/08/2023] [Accepted: 01/18/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Polymyxin B dosing in patients with sepsis is difficult because pathophysiological changes and supportive therapies alter drug pharmacokinetics (PK). This study aimed to investigate the impact of fluid management and renal function on the PK of polymyxin B and to propose alternative dosing regimens. METHODS Patients (aged ≥ 18 y) with sepsis and receiving intravenous polymyxin B for ≥ 96 h were enrolled. Blood samples were collected at steady state. Plasma concentrations were measured by liquid chromatography-tandem mass spectrometry and subjected to population PK modelling. Monte Carlo simulations were used to optimise dosage regimens. RESULTS Eighty-three patients with a median (range) daily fluid intake of 4.2 (1.3-8.4) L and a creatinine clearance (CrCL) of 87.5 (17.3-309.7) mL/min were included. Polymyxin B PK was adequately characterised by a two-compartment model. The PK covariate analysis revealed daily fluid intake statistically significantly affected central volume of distribution and central compartment clearance (CL), and CrCL influenced CL. Simulation indicated that a decreased dosing would be suitable for patients with renal dysfunction (CrCL < 40 mL/min), and therapeutic drug monitoring is recommended to avoid exposure fluctuation when patients have fluid overload. CONCLUSIONS Fluid management as well as renal function are essential factors affecting polymyxin B PK for patients with sepsis, which can help optimise dosage regimens.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shaohua Liu
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General Intensive Care Unit, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Jing Yang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China; Henan Engineering Research Center for Application & Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China.
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7
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Lai X, Chow SH, Le Brun AP, Muir BW, Bergen PJ, White J, Yu HH, Wang J, Danne J, Jiang JH, Short FL, Han ML, Strugnell RA, Song J, Cameron NR, Peleg AY, Li J, Shen HH. Polysaccharide-Targeting Lipid Nanoparticles to Kill Gram-Negative Bacteria. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2305052. [PMID: 37798622 DOI: 10.1002/smll.202305052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/16/2023] [Indexed: 10/07/2023]
Abstract
The rapid increase and spread of Gram-negative bacteria resistant to many or all existing treatments threaten a return to the preantibiotic era. The presence of bacterial polysaccharides that impede the penetration of many antimicrobials and protect them from the innate immune system contributes to resistance and pathogenicity. No currently approved antibiotics target the polysaccharide regions of microbes. Here, describe monolaurin-based niosomes, the first lipid nanoparticles that can eliminate bacterial polysaccharides from hypervirulent Klebsiella pneumoniae, are described. Their combination with polymyxin B shows no cytotoxicity in vitro and is highly effective in combating K. pneumoniae infection in vivo. Comprehensive mechanistic studies have revealed that antimicrobial activity proceeds via a multimodal mechanism. Initially, lipid nanoparticles disrupt polysaccharides, then outer and inner membranes are destabilized and destroyed by polymyxin B, resulting in synergistic cell lysis. This novel lipidic nanoparticle system shows tremendous promise as a highly effective antimicrobial treatment targeting multidrug-resistant Gram-negative pathogens.
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Affiliation(s)
- Xiangfeng Lai
- Department of Materials Science and Engineering, Faculty of Engineering, Monash University, Clayton, Victoria, 3800, Australia
| | - Seong Hoong Chow
- Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, 3800, Australia
| | - Anton P Le Brun
- Australian Centre for Neutron Scattering, Australian Nuclear Science and Technology Organisation, Locked Bag 2001, Kirrawee DC, New South Wales, 2232, Australia
| | | | - Phillip J Bergen
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Jacinta White
- CSIRO Manufacturing, Clayton, Victoria, 3168, Australia
| | - Heidi H Yu
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Jiping Wang
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Jill Danne
- Monash Ramaciotti Centre for Cryo-Electron Microscopy, A Node of Microscopy Australia, Monash University, Clayton, Victoria, 3800, Australia
| | - Jhih-Hang Jiang
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Francesca L Short
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Mei-Ling Han
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Richard A Strugnell
- Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria, 3000, Australia
| | - Jiangning Song
- Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, 3800, Australia
| | - Neil R Cameron
- Department of Materials Science and Engineering, Faculty of Engineering, Monash University, Clayton, Victoria, 3800, Australia
| | - Anton Y Peleg
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Jian Li
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
| | - Hsin-Hui Shen
- Department of Materials Science and Engineering, Faculty of Engineering, Monash University, Clayton, Victoria, 3800, Australia
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, 3800, Australia
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8
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Jiang X, Patil NA, Xu Y, Wickremasinghe H, Zhou QT, Zhou F, Thompson PE, Wang L, Xiao M, Roberts KD, Velkov T, Li J. Structure-Interaction Relationship of Polymyxins with Lung Surfactant. J Med Chem 2023; 66:16109-16119. [PMID: 38019899 DOI: 10.1021/acs.jmedchem.3c01497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Multidrug-resistant Gram-negative bacteria present an urgent and formidable threat to the global public health. Polymyxins have emerged as a last-resort therapy against these 'superbugs'; however, their efficacy against pulmonary infection is poor. In this study, we integrated chemical biology and molecular dynamics simulations to examine how the alveolar lung surfactant significantly reduces polymyxin antibacterial activity. We discovered that lung surfactant is a phospholipid-based permeability barrier against polymyxins, compromising their efficacy against target bacteria. Next, we unraveled the structure-interaction relationship between polymyxins and lung surfactant, elucidating the thermodynamics that govern the penetration of polymyxins through this critical surfactant layer. Moreover, we developed a novel analog, FADDI-235, which exhibited potent activity against Gram-negative bacteria, both in the presence and absence of lung surfactant. These findings shed new light on the sequestration mechanism of lung surfactant on polymyxins and importantly pave the way for the rational design of new-generation lipopeptide antibiotics to effectively treat Gram-negative bacterial pneumonia.
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Affiliation(s)
- Xukai Jiang
- National Glycoengineering Research Center, Shandong University, Qingdao 266237, China
| | - Nitin A Patil
- Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Melbourne 3800, Australia
| | - Yuwen Xu
- Shandong Institute for Food and Drug Control, Jinan 250000, China
| | - Hasini Wickremasinghe
- Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Melbourne 3800, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette 47907, United States of America
| | - Fanfan Zhou
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney 2006, Australia
| | - Philip E Thompson
- Medicinal Chemistry, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne 3052, Australia
| | - Lushan Wang
- State Key Laboratory of Microbial Technology, Shandong University, Qingdao 266237, China
| | - Min Xiao
- National Glycoengineering Research Center, Shandong University, Qingdao 266237, China
| | - Kade D Roberts
- Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Melbourne 3800, Australia
| | - Tony Velkov
- Department of Biochemistry and Pharmacology, University of Melbourne, Melbourne 3010, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Melbourne 3800, Australia
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9
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Li X, Cheng Y, Chen B, Chen Y, Huang Y, Zhang B, Que W, Liu M, Zhang H, Qiu H. Population pharmacokinetics of polymyxin B in patients with liver dysfunction. Br J Clin Pharmacol 2023; 89:3561-3572. [PMID: 37461291 DOI: 10.1111/bcp.15855] [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: 05/22/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
AIMS Polymyxin B (PMB) is widely used to treat infections caused by multidrug-resistant Gram-negative pathogens. Currently, the pharmacokinetic data of PMB in patients with liver dysfunction are limited. This study aimed to develop a population pharmacokinetic (PopPK) model of PMB in patients with liver dysfunction and identify the factors affecting PMB pharmacokinetics. METHODS We conducted a retrospective pharmacokinetic study involving 136 adults with different levels of liver function. Nonlinear mixed effects modelling was used to develop a PopPK model of PMB. Monte Carlo simulation was used to design PMB dosage schedules across various liver and renal functions. RESULTS PMB pharmacokinetic analyses included 401 steady-state concentrations in 136 adult patients. A one-compartment pharmacokinetic model with first-order absorption and elimination was used to describe the data. The typical population value of PMB clearance was 2.43 L/h and the volume of distribution was 23.11 L. This study revealed that creatinine clearance (CrCL) and Child-Pugh class were significantly associated with PMB pharmacokinetic parameters; however, clinically relevant variations of dose-normalized drug exposure were not significant. For patients with a minimum inhibitory concentration of ≤0.5 mg/L, the appropriate dose was 40-75 mg/12-h. When the dose exceeded 100 mg/12-h, the risk of nephrotoxicity increased significantly. CONCLUSIONS This study provided PMB pharmacokinetic information for patients with liver dysfunction. Patients with renal and liver dysfunctions may not require an initial dose adjustment. Rather than PopPK-guided dose adjustment, therapeutic drug monitoring of PMB plays a more direct role in optimizing dosing regimens based on its therapeutic window.
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Affiliation(s)
- Xueyong Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bo Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yiying Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Yingbin Huang
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Bingqing Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
| | - Wancai Que
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hongqiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
- College of Pharmacy, Fujian Medical University, Fuzhou, China
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10
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Shi R, Fu Y, Gan Y, Wu D, Zhou S, Huang M. Use of polymyxin B with different administration methods in the critically ill patients with ventilation associated pneumonia: a single-center experience. Front Pharmacol 2023; 14:1222044. [PMID: 37719858 PMCID: PMC10502420 DOI: 10.3389/fphar.2023.1222044] [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: 05/16/2023] [Accepted: 08/22/2023] [Indexed: 09/19/2023] Open
Abstract
Background: Whether nebulized polymyxin B should be used as an adjunctive therapy or substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia (VAP) remains controversial. This study's aim is to evaluate the efficacy and safety of different administration ways of polymyxin B in the treatment of ventilator-associated pneumonia caused by extensively drug-resistant Gram-negative bacteria(XDR-GNB). Methods: This retrospective cohort study enrolled ventilator-associated pneumonia patients caused by XDR-GNB treated with polymyxin B in the intensive care unit. Patients were categorized by the administration methods as intravenous (IV) group, inhaled (IH) group, and the intravenous combined with inhaled (IV + IH) group. Microbiological outcome and clinical outcome were compared in each group. The side effects were also explored. Results: A total of 111 patients were enrolled and there was no difference in demographic and clinical characteristics among the three groups. In terms of efficacy, clinical cure or improvement was achieved in 21 patients (55.3%) in the intravenous group, 19 patients (50%) in the IH group, and 20 patients (57.1%) in IV + IH group (p = 0.815). All three groups showed high success rates in microbiological eradication, as 29 patients with negative cultures after medication in inhaled group. Among all the patients who had negative bacterial cultures after polymyxin B, the inhaled group had significantly shorter clearance time than the intravenous group (p = 0.002), but with no significant difference in 28-day mortality. Compared with intravenous group, a trend towards a lower risk of acute kidney injury was observed in inhaled group (p = 0.025). Conclusion: From the perspective of minimal systemic renal toxicity, nebulized polymyxin B as a substitution strategy to intravenous polymyxin B for the treatment of ventilator-associated pneumonia caused by XDR-GNB is feasible.
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Affiliation(s)
- Rupeng Shi
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanyuan Fu
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yujing Gan
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Danying Wu
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Suming Zhou
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Huang
- Department of Geriatric ICU, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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11
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Hanafin PO, Kwa A, Zavascki AP, Sandri AM, Scheetz MH, Kubin CJ, Shah J, Cherng BPZ, Yin MT, Wang J, Wang L, Calfee DP, Bolon M, Pogue JM, Purcell AW, Nation RL, Li J, Kaye KS, Rao GG. A population pharmacokinetic model of polymyxin B based on prospective clinical data to inform dosing in hospitalized patients. Clin Microbiol Infect 2023; 29:1174-1181. [PMID: 37217076 DOI: 10.1016/j.cmi.2023.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVES To develop a population pharmacokinetic (PK) model with data from the largest polymyxin B-treated patient population studied to date to optimize its dosing in hospitalized patients. METHODS Hospitalized patients receiving intravenous polymyxin B for ≥48 hours were enrolled. Blood samples were collected at steady state and drug concentrations were analysed by liquid chromotography tandem mass spectrometry (LC-MS/MS). Population PK analysis and Monte Carlo simulations were performed to determine the probability of target attainment (PTA). RESULTS One hundred and forty-two patients received intravenous polymyxin B (1.33-6 mg/kg/day), providing 681 plasma samples. Twenty-four patients were on renal replacement therapy, including 13 on continuous veno-venous hemodiafiltration (CVVHDF). A 2-compartment model adequately described the PK with body weight as a covariate on the volume of distribution that affected Cmax, but it did not impact clearance or exposure. Creatinine clearance was a statistically significant covariate on clearance, although clinically relevant variations of dose-normalized drug exposure were not observed across a wide creatinine clearance range. The model described higher clearance in CVVHDF patients than in non-CVVHDF patients. Maintenance doses of ≥2.5 mg/kg/day or ≥150 mg/day had a PTA ≥90% (for non-pulmonary infections target) at a steady state for minimum inhibitory concentrations ≤2 mg/L. The PTA at a steady state for CVVHDF patients was lower. DISCUSSION Fixed loading and maintenance doses of polymyxin B seemed to be more appropriate than weight-based dosing regimens in patients weighing 45-90 kg. Higher doses may be needed in patients on CVVHDF. Substantial variability in polymyxin B clearance and volume of distribution was found, suggesting that therapeutic drug monitoring may be indicated.
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Affiliation(s)
- Patrick O Hanafin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Alexandre P Zavascki
- Infectious Diseases Service, Hospital Moinhos de Vento, Porto Alegre, Brazil; Department of Internal Medicine, Medical School, Universidade Federal, Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Ana Maria Sandri
- Infection Control Department, Hospital São Lucas da Pontifícia Universidade Católica Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
| | - Christine J Kubin
- New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jayesh Shah
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Benjamin P Z Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Lu Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - David P Calfee
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Maureen Bolon
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL, USA; Department of Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Anthony W Purcell
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia; Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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12
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Zheng Y, Xu B, Chen S, Liu M, Huang H, Wang J, Wu X. Population Pharmacokinetic Modeling Using Polymyxin B Free Plasma Concentrations From Published Reports and Evaluation of Dosage Regimens Based on Monte Carlo Simulation in Critically Ill Patients. J Clin Pharmacol 2023; 63:1036-1044. [PMID: 37125471 DOI: 10.1002/jcph.2261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/02/2023]
Abstract
A population pharmacokinetic (pop PK) model of polymyxin B was developed using nonlinear mixed-effects (NONMEM) modeling based on free plasma concentrations to determine whether dose adjustment is required in critically ill patients. One thousand pharmacokinetic profiles for virtual patients with a body weight of 70 kg were simulated using Monte Carlo simulation at different dose scenarios, and area under the concentration-time curve of free drug (fAUC) was computed. The probability of target attainment (PTA) at each minimum inhibitory concentration (MIC) was calculated using fAUC/MIC as a pharmacokinetic/pharmacodynamic (PK/PD) index. The final population PK model was a 2-compartment model. PTA showed that 3.5 mg/kg/day regimens of polymyxin B effectively achieved the fAUC/MIC target of 10 (one log10 kill) against Pseudomonas aeruginosa strains with MIC of 1 mg/L or less (PTA, 90.7% or greater), while the dose regimen were ineffective against strains with an MIC of 2 mg/L or greater (PTA, 56.9% or less). For Klebsiella pneumoniae, the fAUC/MIC target of 17.4 (one log10 kill) was achieved in more than 90.4% of cases for MIC of 0.5 mg/L or less with 3 mg/kg/day regimens. However, the PTA decreased dramatically as MICs increased above 1 mg/L (PTA, 56.1% or less). The polymyxin B dosage regimen of 3.5 mg/kg/day and 3 mg/kg/day are sufficient to treat P. aeruginosa infections with an MIC of 1 mg/L or less and K. pneumoniae infections with an MIC of 0.5 mg/L or less, respectively. The current recommended dose (1.5-3 mg/kg/day) of polymyxin B appears inadequate to attain the PK/PD target for therapeutic efficacy against infections caused by P. aeruginosa and K. pneumoniae isolates when MIC is above the values.
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Affiliation(s)
- You Zheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Shengyang Chen
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Huiping Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
- School of Pharmacy, Fujian Medical University, Fuzhou, Fujian, China
| | - Jingting Wang
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
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13
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Zhao J, Zhu Y, Han ML, Lu J, Yu HH, Wickremasinghe H, Zhou QT, Bergen P, Rao G, Velkov T, Lin YW, Li J. Model-informed dose optimisation of polymyxin-rifampicin combination therapy against multidrug-resistant Acinetobacter baumannii. Int J Antimicrob Agents 2023; 62:106902. [PMID: 37380093 DOI: 10.1016/j.ijantimicag.2023.106902] [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: 07/14/2022] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES Antimicrobial resistance is a major global threat. Because of the stagnant antibiotic pipeline, synergistic antibiotic combination therapy has been proposed to treat rapidly emerging multidrug-resistant (MDR) pathogens. We investigated antimicrobial synergy of polymyxin/rifampicin combination against MDR Acinetobacter baumannii. METHODS In vitro static time-kill studies were performed over 48 h at an initial inoculum of ∼107 CFU/mL against three polymyxin-susceptible but MDR A. baumannii isolates. Membrane integrity was examined at 1 and 4 h post-treatment to elucidate the mechanism of synergy. Finally, a semi-mechanistic PK/PD model was developed to simultaneously describe the time course of bacterial killing and prevention of regrowth by mono- and combination therapies. RESULTS Polymyxin B and rifampicin alone produced initial killing against MDR A. baumannii but were associated with extensive regrowth. Notably, the combination showed synergistic killing across all three A. baumannii isolates with bacterial loads below the limit of quantification for up to 48 h. Membrane integrity assays confirmed the role of polymyxin-driven outer membrane remodelling in the observed synergy. Subsequently, the mechanism of synergy was incorporated into a PK/PD model to describe the enhanced uptake of rifampicin due to polymyxin-induced membrane permeabilisation. Simulations with clinically utilised dosing regimens confirmed the therapeutic potential of this combination, particularly in the prevention of bacterial regrowth. Finally, results from a neutropenic mouse thigh infection model confirmed the in vivo synergistic killing of the combination against A. baumannii AB5075. CONCLUSION Our results showed that polymyxin B combined with rifampicin is a promising option to treat bloodstream and tissue infection caused by MDR A. baumannii and warrants clinical evaluations.
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Affiliation(s)
- Jinxin Zhao
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Yan Zhu
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Mei-Ling Han
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Jing Lu
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Heidi H Yu
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Hasini Wickremasinghe
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana
| | - Phillip Bergen
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Gauri Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Tony Velkov
- Department of Biochemistry and Pharmacology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Yu-Wei Lin
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia.
| | - Jian Li
- Monash Biomedicine Discovery Institute, Infection Program and Department of Microbiology, Monash University, Clayton, Victoria, Australia.
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14
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Jiao Y, Yan J, Vicchiarelli M, Sutaria DS, Lu P, Reyna Z, Spellberg B, Bonomo RA, Drusano GL, Louie A, Luna BM, Bulitta JB. Individual Components of Polymyxin B Modeled via Population Pharmacokinetics to Design Humanized Dosage Regimens for a Bloodstream and Lung Infection Model in Immune-Competent Mice. Antimicrob Agents Chemother 2023; 67:e0019723. [PMID: 37022153 PMCID: PMC10190254 DOI: 10.1128/aac.00197-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
Polymyxin B is a "last-line-of-defense" antibiotic approved in the 1960s. However, the population pharmacokinetics (PK) of its four main components has not been reported in infected mice. We aimed to determine the PK of polymyxin B1, B1-Ile, B2, and B3 in a murine bloodstream and lung infection model of Acinetobacter baumannii and develop humanized dosage regimens. A linear 1-compartment model, plus an epithelial lining fluid (ELF) compartment for the lung model, best described the PK. Clearance and volume of distribution were similar among the four components. The bioavailability fractions were 72.6% for polymyxin B1, 12.0% for B1-Ile, 11.5% for B2, and 3.81% for B3 for the lung model and were similar for the bloodstream model. While the volume of distribution was comparable between both models (17.3 mL for the lung and ~27 mL for the bloodstream model), clearance was considerably smaller for the lung (2.85 mL/h) compared to that of the bloodstream model (5.59 mL/h). The total drug exposure (AUC) in ELF was high due to the saturable binding of polymyxin B presumably to bacterial lipopolysaccharides. However, the modeled unbound AUC in ELF was ~16.7% compared to the total drug AUC in plasma. The long elimination half-life (~4 h) of polymyxin B enabled humanized dosage regimens with every 12 h dosing in mice. Daily doses that optimally matched the range of drug concentrations observed in patients were 21 mg/kg for the bloodstream and 13 mg/kg for the lung model. These dosage regimens and population PK models support translational studies for polymyxin B at clinically relevant drug exposures.
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Affiliation(s)
- Yuanyuan Jiao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Jun Yan
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael Vicchiarelli
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, Florida, USA
| | - Dhruvitkumar S. Sutaria
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Peggy Lu
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Zeferino Reyna
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Brad Spellberg
- Los Angeles County-USC (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert A. Bonomo
- Department of Molecular Biology and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
- Deparment of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Biochemistry, Case Western Reserve University, Cleveland, Ohio, USA
- Deparment of Pharmacology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Proteomics and Bioinformatics, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - George L. Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, Florida, USA
| | - Arnold Louie
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, Florida, USA
| | - Brian M. Luna
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
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15
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Gill CM, Nicolau DP. In Vivo Pharmacodynamic Profile of EVER206, a Novel Polymyxin Antimicrobial, against Gram-Negative Bacteria in the Murine Thigh Infection Model. Antimicrob Agents Chemother 2023; 67:e0173822. [PMID: 37022170 PMCID: PMC10190685 DOI: 10.1128/aac.01738-22] [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: 12/30/2022] [Accepted: 03/15/2023] [Indexed: 04/07/2023] Open
Abstract
The objective was to determine the magnitude of the EVER206 free-plasma area under the concentration time curve (fAUC)/MIC target associated with bacteriostasis and 1-log10 kill against clinically relevant Gram-negative bacteria in the murine thigh model. Twenty-seven clinical isolates (Pseudomonas aeruginosa, n = 10; Escherichia coli, n = 9; Klebsiella pneumoniae, n = 5; Enterobacter cloacae, n = 2; and Klebsiella aerogenes, n = 1) were tested. Mice were pretreated with cyclophosphamide (induce neutropenia) and uranyl nitrate (increase the exposure of test compound through predictable renal dysfunction). Two hours postinoculation, five doses of EVER206 were administered subcutaneously. EVER206 pharmacokinetics were determined in infected mice. Data were fit using maximum effect (Emax) models to elucidate the fAUC/MIC targets for stasis and 1-log10 bacterial kill (reported as mean [range] by species). EVER206 MICs (mg/L) ranged from 0.25 to 2 mg/L (P. aeruginosa), 0.06 to 2 mg/L (E. coli), 0.06 to 0.125 mg/L (E. cloacae), 0.06 mg/L (K. aerogenes), and 0.06 to 2 mg/L (K. pneumoniae). In vivo, the mean 0-h baseline bacterial burden was 5.57 ± 0.39 log10 CFU/thigh. Stasis was achieved in 9/10 P. aeruginosa (fAUC/MIC, 88.13 [50.33 to 129.74]), 9/9 E. coli (fAUC/MIC, 112.84 [19.19 to 279.38]), 2/2 E. cloacae (fAUC/MIC, 259.28 [124.08 to 394.47]), 0/1 K. aerogenes, and 4/5 K. pneumoniae (fAUC/MIC, 99.26 [62.3 to 144.43]) isolates tested. 1-log10 kill was achieved in 9/10 for P. aeruginosa (fAUC/MIC, 106.43 [55.22 to 152.08]), 3/9 for E. coli (fAUC/MIC, 258.96 [74.08 to 559.4]), and 1/2 for E. cloacae (fAUC/MIC, 255.33). Using the murine thigh model, the fAUC/MIC targets of EVER206 were assessed across a broad MIC distribution. Integrating these data with microbiologic and clinical exposure data will aid in determining the clinical dose of EVER206.
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Affiliation(s)
- Christian M. Gill
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P. Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, Connecticut, USA
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16
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Zhang B, Li X, Chen Y, Chen B, Cheng Y, Lin H, Que W, Liu M, Zhou L, Zhang H, Qiu H, Wu C. Determination of polymyxin B in human plasma and epithelial lining fluid using LC-MS/MS and its clinical application in therapeutic drug monitoring. J Pharm Biomed Anal 2023; 227:115291. [PMID: 36822067 DOI: 10.1016/j.jpba.2023.115291] [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: 12/02/2022] [Revised: 02/08/2023] [Accepted: 02/12/2023] [Indexed: 02/15/2023]
Abstract
Polymyxin B (PB) is currently one of the last resort treatment options against carbapenem-resistant gram-negative bacterial pathogens. Pharmacokinetics/pharmacodynamics (PK/PD) guided therapeutic drug monitoring (TDM) of antibiotics is critical for optimizing dosage regimens to maximize efficacy, minimize toxicity, and delay the emergence of resistance. Currently, methods for determining PB in human plasma and epithelial lining fluid (ELF) are limited. In this study, we developed and validated a simple method for PB determination in human plasma and ELF using LC-MS/MS. Protein precipitation of the sample was conducted with 0.1% formic acid-acetonitrile. Polymyxin B1 and B2 were separated on a C18 column and detected within 4 min by the mass spectrometer in the positive mode coupled with multiple reaction monitoring. The calibration curve range was 0.156-10.0 and 0.0156-1.00 μg/mL in the plasma for polymyxin B1 and B2, respectively, and was 0.0625-2.00 and 0.00625-0.200 μg/mL for polymyxin B1 and B2, respectively in bronchoalveolar lavage fluid. The accuracy of the intra- and inter-assay studies ranged from 80.6% to 114.9%, and the coefficients of variation for intra- and inter-day assays were less than 14.8%. Among a considerable number of patients, the average steady-state plasma concentration of PB was suboptimal. Moreover, the exposure to PB in patients with acute kidney injury (AKI) was considerably higher than that in patients without AKI. Meanwhile, a higher concentration of PB in ELF could be achieved than that in plasma after PB nebulization treatment. The established method was proven to be rapid, simple, and suitable for TDM of PB and PK/PD studies in human plasma and ELF.
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Affiliation(s)
- Bingqing Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China; College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China
| | - Xueyong Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China; College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China
| | - Yiying Chen
- College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China
| | - Bo Chen
- College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China
| | - Yu Cheng
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Hailing Lin
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Wancai Que
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Lili Zhou
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Hui Zhang
- Department of Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China
| | - Hongqiang Qiu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China; College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China.
| | - Chaoyang Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, People's Republic of China; College of Pharmacy, Fujian Medical University, Fuzhou 350004, People's Republic of China.
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17
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van der Meijden A, Aranzana-Climent V, van der Spek H, de Winter BCM, Couet W, Meletiadis J, Muller AE, van den Berg S. Pharmacokinetic and pharmacodynamic properties of polymyxin B in Escherichia coli and Klebsiella pneumoniae murine infection models. J Antimicrob Chemother 2023; 78:832-839. [PMID: 36718051 PMCID: PMC10377753 DOI: 10.1093/jac/dkad022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/02/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although polymyxin B has been in use since the late 1950s, there have been limited studies done to unravel its pharmacokinetics (PK) and pharmacodynamics (PD) index. METHODS We determined, in neutropenic infected mice, the PK, plasma protein binding and PK/PD index best correlating with efficacy for Escherichia coli and Klebsiella pneumoniae strains. RESULTS The pharmacokinetic profile showed non-linear PK; dose was significantly correlated with absorption rate and clearance. The inhibitory sigmoid dose-effect model for the fCmax/MIC index of E. coli fitted best, but was only modestly higher than the R2 of %fT>MIC and fAUC/MIC (R2 0.91-0.93). For K. pneumoniae the fAUC/MIC index had the best fit, which was slightly higher than the R2 of %fT>MIC and fCmax/MIC (R2 0.85-0.91). Static targets of polymyxin B fAUC/MIC were 27.5-102.6 (median 63.5) and 5.9-60.5 (median 11.6) in E. coli and in K. pneumoniae isolates, respectively. A 1 log kill effect was only reached in two E. coli isolates and one K. pneumoniae. The PTA with the standard dosing was low for isolates with MIC >0.25 mg/L. CONCLUSIONS This study confirms that fAUC/MIC can describe the exposure-response relationship for polymyxin B. The 1 log kill effect was achieved in the minority of the isolates whereas polymyxin B PK/PD targets cannot be attained for the majority of clinical isolates with the standard dosing regimen, indicating that polymyxin B may be not effective against serious infections as monotherapy.
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Affiliation(s)
- Aart van der Meijden
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Heleen van der Spek
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,CATOR, Center for Antimicrobial Treatment Optimization Rotterdam, Rotterdam, The Netherlands.,Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - William Couet
- INSERM U1070, CHU de Poitiers et Université de Poitiers, Poitiers, France
| | - Joseph Meletiadis
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Clinical Microbiology Laboratory, Attikon University General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,CATOR, Center for Antimicrobial Treatment Optimization Rotterdam, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden MC, The Hague, The Netherlands
| | - Sanne van den Berg
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,CATOR, Center for Antimicrobial Treatment Optimization Rotterdam, Rotterdam, The Netherlands
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18
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Pi MY, Cai CJ, Zuo LY, Zheng JT, Zhang ML, Lin XB, Chen X, Zhong GP, Xia YZ. Population pharmacokinetics and limited sampling strategies of polymyxin B in critically ill patients. J Antimicrob Chemother 2023; 78:792-801. [PMID: 36702748 DOI: 10.1093/jac/dkad012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/02/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To characterize the pharmacokinetics (PK) of polymyxin B in Chinese critically ill patients. The factors significantly affecting PK parameters are identified, and a limited sampling strategy for therapeutic drug monitoring of polymyxin B is explored. METHODS Thirty patients (212 samples) were included in a population PK analysis. A limited sampling strategy was developed using Bayesian estimation, multiple linear regression and modified integral equations. Non-linear mixed-effects models were developed using Phoenix NLME software. RESULTS A two-compartment population PK model was used to describe polymyxin B PK. Population estimates of the volumes of central compartment distribution (V) and peripheral compartment distribution (V2), central compartment clearance (CL) and intercompartmental clearance (Q) were 7.857 L, 12.668 L, 1.672 L/h and 7.009 L/h. Continuous renal replacement therapy (CRRT) significantly affected CL, and body weight significantly affected CL and Q. The AUC0-12h of polymyxin B in patients with CRRT was significantly lower than in patients without CRRT. CL and Q increased with increasing body weight. A limited sampling strategy was suggested using a two-sample scheme with plasma at 0.5h and 8h after the end of infusion (C0.5 and C8) for therapeutic drug monitoring in the clinic. CONCLUSIONS A dosing regimen should be based on body weight and the application of CRRT. A two-sample strategy for therapeutic drug monitoring could facilitate individualized treatment with polymyxin B in critically ill patients.
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Affiliation(s)
- Meng-Ying Pi
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Chang-Jie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ling-Yun Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Tao Zheng
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Miao-Lun Zhang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Bin Lin
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Guo-Ping Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Zhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
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19
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Zha L, Zhang X, Cheng Y, Xu Q, Liu L, Chen S, Lu Z, Guo J, Tefsen B. Intravenous Polymyxin B as Adjunctive Therapy to High-Dose Tigecycline for the Treatment of Nosocomial Pneumonia Due to Carbapenem-Resistant Acinetobacter baumannii and Klebsiella pneumoniae: A Propensity Score-Matched Cohort Study. Antibiotics (Basel) 2023; 12:antibiotics12020273. [PMID: 36830183 PMCID: PMC9952519 DOI: 10.3390/antibiotics12020273] [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: 11/29/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/03/2023] Open
Abstract
Although the combination of polymyxin and tigecycline is widely used in treating carbapenem-resistant bacterial infections, the benefit of this combination is still uncertain. To assess whether adding polymyxin B to the high-dose tigecycline regimen would result in better clinical outcomes than the high-dose tigecycline therapy in patients with pneumonia caused by carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii, we conducted a propensity score-matched cohort study in a single center between July 2019 and December 2021. Of the 162 eligible patients, 102 were included in the 1:1 matched cohort. The overall 14-day mortality in the matched cohort was 24.5%. Compared with high-dose tigecycline, the combination therapy was not associated with better clinical outcomes, and showed similar 14-day mortality (OR, 0.72, 95% CI 0.27-1.83, p = 0.486), clinical cure (OR, 1.09, 95% CI 0.48-2.54, p = 0.823), microbiological cure (OR, 0.96, 95% CI 0.39-2.53, p = 0.928) and rate of nephrotoxicity (OR 0.85, 95% CI 0.36-1.99, p = 0.712). Subgroup analyses also did not demonstrate any statistical differences. Based on these results, it is reasonable to recommend against adding polymyxin B to the high-dose tigecycline regimen in treating pneumonia caused by carbapenem-resistant K. pneumoniae and A. baumannii.
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Affiliation(s)
- Lei Zha
- Department of Respiratory Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu 241000, China
- Institute of Infection and Global Health, University of Liverpool, Liverpool L69 7BE, UK
| | - Xue Zhang
- Department of Intensive Care Unit, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yusheng Cheng
- Department of Respiratory Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu 241000, China
| | - Qiancheng Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu 241000, China
| | - Lingxi Liu
- Department of Intensive Care Unit, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Simin Chen
- Department of Intensive Care Unit, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zhiwei Lu
- Department of Respiratory Medicine, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu 241000, China
| | - Jun Guo
- Department of Intensive Care Unit, West China Hospital, Sichuan University, Chengdu 610041, China
- Correspondence: (J.G.); (B.T.)
| | - Boris Tefsen
- Division of Microbiology, Department of Biology, Utrecht University, 3584 CH Utrecht, The Netherlands
- Natural Sciences, Ronin Institute, Montclair, NJ 07043, USA
- Correspondence: (J.G.); (B.T.)
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20
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Yu Z, Liu X, Du X, Chen H, Zhao F, Zhou Z, Wang Y, Zheng Y, Bergen PJ, Li X, Sun R, Fang L, Li W, Fan Y, Wu H, Guo B, Li J, Yu Y, Zhang J. Pharmacokinetics/pharmacodynamics of polymyxin B in patients with bloodstream infection caused by carbapenem-resistant Klebsiella pneumoniae. Front Pharmacol 2022; 13:975066. [PMID: 36588676 PMCID: PMC9800617 DOI: 10.3389/fphar.2022.975066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction: Polymyxin B is a last-line therapy for carbapenem-resistant microorganisms. However, a lack of clinical pharmacokinetic/pharmacodynamic (PK/PD) data has substantially hindered dose optimization and breakpoint setting. Methods: A prospective, multi-center clinical trial was undertaken with polymyxin B [2.5 mg/kg loading dose (3-h infusion), 1.25 mg/kg/12 h maintenance dose (2-h infusion)] for treatment of carbapenem-resistant K. pneumoniae (CRKP) bloodstream infections (BSI). Safety, clinical and microbiological efficacy were evaluated. A validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was applied to determine the concentrations of polymyxin B in blood samples. Population pharmacokinetic (PK) modeling and Monte Carlo simulations were conducted to examine the susceptibility breakpoint for polymyxin B against BSI caused by CRKP. Results: Nine patients were enrolled and evaluated for safety. Neurotoxicity (5/9), nephrotoxicity (5/9), and hyperpigmentation (1/9) were recorded. Blood cultures were negative within 3 days of commencing therapy in all 8 patients evaluated for microbiological efficacy, and clinical cure or improvement occurred in 6 of 8 patients. Cmax and Cmin following the loading dose were 5.53 ± 1.80 and 1.62 ± 0.41 mg/L, respectively. With maintenance dosing, AUCss,24 h was 79.6 ± 25.0 mg h/L and Css,avg 3.35 ± 1.06 mg/L. Monte Carlo simulations indicated that a 1 mg/kg/12-hourly maintenance dose could achieve >90% probability of target attainment (PTA) for isolates with minimum inhibitory concentration (MIC) ≤1 mg/L. PTA dropped substantially for MICs ≥2 mg/L, even with a maximally recommended daily dose of 1.5 mg/kg/12-hourly. Conclusion: This is the first clinical PK/PD study evaluating polymyxin B for BSI. These results will assist to optimize polymyxin B therapy and establish its breakpoints for CRKP BSI.
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Affiliation(s)
- Zhenwei Yu
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaofen Liu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoxing Du
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Huiying Chen
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Zhao
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhihui Zhou
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yang Zheng
- Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Phillip J. Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Xi Li
- Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Renhua Sun
- Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Li Fang
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wanzhen Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Hailan Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Beining Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Yunsong Yu
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China,*Correspondence: Yunsong Yu, ; Jing Zhang,
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China,Phase I Clinical Trial Center, Huashan Hospital, Fudan University, Shanghai, China,*Correspondence: Yunsong Yu, ; Jing Zhang,
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21
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Paranos P, Vourli S, Pournaras S, Meletiadis J. Assessing Clinical Potential of Old Antibiotics against Severe Infections by Multi-Drug-Resistant Gram-Negative Bacteria Using In Silico Modelling. Pharmaceuticals (Basel) 2022; 15:ph15121501. [PMID: 36558952 PMCID: PMC9781251 DOI: 10.3390/ph15121501] [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: 10/15/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 12/02/2022] Open
Abstract
In the light of increasing antimicrobial resistance among gram-negative bacteria and the lack of new more potent antimicrobial agents, new strategies have been explored. Old antibiotics, such as colistin, temocillin, fosfomycin, mecillinam, nitrofurantoin, minocycline, and chloramphenicol, have attracted the attention since they often exhibit in vitro activity against multi-drug-resistant (MDR) gram-negative bacteria, such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. The current review provides a summary of the in vitro activity, pharmacokinetics and PK/PD characteristics of old antibiotics. In silico modelling was then performed using Monte Carlo simulation in order to combine all preclinical data with human pharmacokinetics and determine the probability of target (1-log kill in thigh/lung infection animal models) attainment (PTA) of different dosing regimens. The potential of clinical efficacy of a drug against severe infections by MDR gram-negative bacteria was considered when PTA was >95% at the epidemiological cutoff values of corresponding species. In vitro potent activity against MDR gram-negative pathogens has been shown for colistin, polymyxin B, temocillin (against E. coli and K. pneumoniae), fosfomycin (against E. coli), mecillinam (against E. coli), minocycline (against E. coli, K. pneumoniae, A. baumannii), and chloramphenicol (against E. coli) with ECOFF or MIC90 ≤ 16 mg/L. When preclinical PK/PD targets were combined with human pharmacokinetics, Monte Carlo analysis showed that among the old antibiotics analyzed, there is clinical potential for polymyxin B against E. coli, K. pneumoniae, and A. baumannii; for temocillin against K. pneumoniae and E. coli; for fosfomycin against E. coli and K. pneumoniae; and for mecillinam against E. coli. Clinical studies are needed to verify the potential of those antibiotics to effectively treat infections by multi-drug resistant gram-negative bacteria.
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Affiliation(s)
- Paschalis Paranos
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Sophia Vourli
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Spyros Pournaras
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, 3015 CN Rotterdam, The Netherlands
- Correspondence: ; Tel.: +30-210-583-1909
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22
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Chen H, Li P. Commentary: Population pharmacokinetics of colistin sulfate in critically ill patients: Exposure and clinical efficacy. Front Pharmacol 2022; 13:992085. [PMID: 36176436 PMCID: PMC9514206 DOI: 10.3389/fphar.2022.992085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/17/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Huadong Chen
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, China
| | - Piaopiao Li
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, China
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23
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Wang PL, Liu P, Zhang QW, Yuan WH, Wang D, Zhang XJ, Yang J. Population pharmacokinetics and clinical outcomes of polymyxin B in paediatric patients with multidrug-resistant Gram-negative bacterial infections. J Antimicrob Chemother 2022; 77:3000-3008. [PMID: 35924405 DOI: 10.1093/jac/dkac265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/15/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Current polymyxin B dosing in children relies on scant data. OBJECTIVES To build a population pharmacokinetic (PK) model for polymyxin B in paediatric patients and assess the likely appropriateness of different dosages. METHODS A total of 19 paediatric patients were enrolled to receive intravenous polymyxin B (1.33-2.53 mg/kg/day), and the median age was 12.5 (range 3.2-17.8) years. Serial plasma samples were collected at steady-state and modelled by population PK analysis. Clinical efficacy and nephrotoxicity of polymyxin B treatment were also assessed. RESULTS PK data were adequately described by a two-compartment model with first-order elimination, and weight was a significant covariate of polymyxin B clearance. Clinical success occurred in 14 of 19 patients (73.7%) and only one patient developed acute kidney injury. The 28 day mortality was 10.5% (2/19). The steady-state polymyxin B exposure was 36.97 ± 9.84 mg·h/L, lower than the therapeutic exposure of 50-100 mg·h/L. With the AUC24h/MIC target of 50, the dosage of 1.5-3.0 mg/kg/day had a probability of target attainments over 90% when MICs were <0.5 mg/L. CONCLUSIONS Dose adjustment of polymyxin B needs to consider the MIC of infecting pathogens. Current polymyxin B dosing for paediatric patients may be acceptable when MICs are <0.5 mg/L.
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Affiliation(s)
- Pei Le Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- Department of Pediatric Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi Wen Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Wen Hua Yuan
- Department of Pediatric Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dao Wang
- Department of Pediatrics, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao Jian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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24
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Fan Y, Li Y, Chen Y, Yu J, Liu X, Li W, Guo B, Li X, Wang J, Wu H, Wang Y, Hu J, Guo Y, Hu F, Xu X, Cao G, Wu J, Zhang Y, Zhang J, Wu X. Pharmacokinetics and Pharmacodynamics of Colistin Methanesulfonate in Healthy Chinese Subjects after Multi-Dose Regimen. Antibiotics (Basel) 2022; 11:antibiotics11060798. [PMID: 35740204 PMCID: PMC9220111 DOI: 10.3390/antibiotics11060798] [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] [Received: 04/21/2022] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 01/27/2023] Open
Abstract
Colistin methanesulfonate (CMS) is an important treatment option for infections caused by carbapenem-resistant Gram-negative organisms (CROs). This study evaluated the pharmacokinetic/pharmacodynamic (PK/PD) profiles and safety of CMS in Chinese subjects following a recommended dosage. A total of 12 healthy Chinese subjects received CMS injections at 2.5 mg/kg once every 12 h for 7 consecutive days. The PK/PD profiles of the active form of CMS, colistin, against CROs were analyzed with the Monte Carlo simulation method. No serious adverse events were observed. The average steady-state plasma concentrations of CMS and colistin were 4.41 ± 0.75 μg/mL and 1.27 ± 0.27 μg/mL, and the steady-state exposures (AUC0−12,ss) were 52.93 ± 9.05 h·μg/mL and 15.28 ± 3.29 h·μg/mL, respectively. Colistin, at its minimum inhibitory concentration (MIC) of 0.5 μg/mL, has >90% probability to reduce CROs by ≥1 log. The PK/PD breakpoints for the ≥1 log kill were ≥MIC90 for carbapenem-resistant Klebsiella pneumoniae and Pseudomonas aeruginosa, but were ≤MIC50 for carbapenem-resistant Acinetobacter baumannii. The recommended dose regimen of CMS for 7 consecutive days was safe in Chinese subjects. The systemic exposure of colistin showed a high probability of being sufficient for most CROs, but was not sufficient for some carbapenem-resistant A. baumannii.
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Affiliation(s)
- Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yi Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jicheng Yu
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaofen Liu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Wanzhen Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- 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.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xin Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jingjing Wang
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Hailan Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yu Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jiali Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yan Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaoyong Xu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Guoying Cao
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jufang Wu
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yingyuan Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- 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.F.); (Y.L.); (X.L.); (W.L.); (B.G.); (X.L.); (H.W.); (Y.W.); (J.H.); (Y.G.); (F.H.); (X.X.); (Y.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
- Correspondence: (J.Z.); (X.W.)
| | - Xiaojie Wu
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China; (Y.C.); (J.Y.); (J.W.); (G.C.); (J.W.)
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China
- Correspondence: (J.Z.); (X.W.)
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Jia X, Yin Z, Zhang W, Guo C, Du S, Zhang X. Effectiveness and Nephrotoxicity of Intravenous Polymyxin B in Carbapenem-Resistant Gram-Negative Bacterial Infections Among Chinese Children. Front Pharmacol 2022; 13:902054. [PMID: 35712713 PMCID: PMC9197179 DOI: 10.3389/fphar.2022.902054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background: No clinical study on the use of polymyxin B in Chinese children has been reported, thus making it difficult for pediatric clinicians to rationally select these drugs. Methods: A retrospective analysis of children treated with polymyxin B during hospitalization in a hospital from June 2019 to June 2021 was conducted to analyze its effectiveness and the incidence of acute kidney injury (AKI) during treatment with polymyxin B. Results: A total of 55 children were included in this study, and the results showed that the intravenous polymyxin B-based regimen had an effective rate of 52.7% in the treatment of Carbapenem-resistant Gram-negative bacterial (CR-GNB) infection in children. The results of the subgroup analysis showed that the course of treatment was longer in the favorable clinical response group than in the unfavorable outcome group (p = 0.027) and that electrolyte disturbances in children during the course of treatment could lead to unfavorable clinical outcomes (p = 0.042). The risk of incidence of AKI during treatment was 27.3%, and the all-cause mortality rate in the children on their discharge from the hospital was 7.3%. Conclusion: Polymyxin B can be used as a salvage therapy for CR-GNB infection in children when no other susceptible antibiotics are available, and the monitoring of kidney function should be strengthened.
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Affiliation(s)
- Xuedong Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- The Precision Clinical Pharmacy Key Laboratory of Henan, Zhengzhou, China
- *Correspondence: Xuedong Jia, ; Shuzhang Du,
| | - Zhao Yin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- The Precision Clinical Pharmacy Key Laboratory of Henan, Zhengzhou, China
| | - Wan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- The Precision Clinical Pharmacy Key Laboratory of Henan, Zhengzhou, China
| | - Conghui Guo
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuzhang Du
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- The Precision Clinical Pharmacy Key Laboratory of Henan, Zhengzhou, China
- *Correspondence: Xuedong Jia, ; Shuzhang Du,
| | - Xiaojian Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- The Precision Clinical Pharmacy Key Laboratory of Henan, Zhengzhou, China
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26
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Population pharmacokinetics of polymyxin B in critically ill patients receiving continuous venovenous hemofiltration. Int J Antimicrob Agents 2022; 60:106599. [DOI: 10.1016/j.ijantimicag.2022.106599] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 11/22/2022]
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Luo X, Zhang Y, Liang P, Zhu H, Li M, Ding X, Zhang J. Population Pharmacokinetics of Polymyxin B and Dosage Strategy in Critically Ill Patients With/without Continuous Renal Replacement Therapy. Eur J Pharm Sci 2022; 175:106214. [DOI: 10.1016/j.ejps.2022.106214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/14/2022] [Accepted: 05/20/2022] [Indexed: 11/03/2022]
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28
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Ye Q, Wang Q, Chen Z, Chen W, Zhan Q, Wang C. Effectiveness, nephrotoxicity, and therapeutic drug monitoring of polymyxin B in nosocomial pneumonia among critically ill patients. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:402-412. [PMID: 35586931 PMCID: PMC9366561 DOI: 10.1111/crj.13493] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We aimed to assess the effectiveness and nephrotoxicity of polymyxin B in critically ill patients with nosocomial pneumonia and to evaluate the utility of its therapeutic drug monitoring (TDM). METHODS We retrospectively analyzed patients who received polymyxin B treatment for ≥48 h since the establishment of polymyxin B TDM in a 26-bed tertiary referral intensive care unit. Univariate and multivariate analyses were conducted to assess the variables associated with polymyxin B effectiveness and nephrotoxicity. RESULTS A total of 62 patients were enrolled. Most (56.5%) of the patients performed TDM, 54.3% of them reached the therapeutic target of area under curve across 24 h at steady state (AUCss,24h ) of 50-100 mg h L-1 , and 10 patients had an AUCss,24h value of <50 mg h L-1 . Thirty-six (58.1) and 31 (50.0%) patients had favorable clinical and microbiological responses, respectively. Reaching the therapeutic target of AUCss,24h (odds ratio [OR] = 13.15, p = 0.015), a favorable microbiological response (OR = 40.80, p = 0.00), and complicated with septic shock (OR = 0.12, p = 0.021) were independently associated with favorable clinical outcomes of polymyxin B treatment. The incidence of acute kidney injury (AKI) was 45.2%. A lower creatinine clearance (OR = 0.96, p = 0.008) and concomitant treatment with loop diuretics (OR = 5.93, p = 0.046) were predictive of nephrotoxicity. CONCLUSION Our findings show that TDM of polymyxin B is a valuable intervention, and the achievement of its optimal pharmacodynamic target can improve treatment outcome. Renal insufficiency and concomitant treatment with loop diuretics were found to be associated with the risk of nephrotoxicity.
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Affiliation(s)
- Qinghua Ye
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Qianlin Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ziying Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chen Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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29
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Chauzy A, Akrong G, Aranzana-Climent V, Moreau J, Prouvensier L, Mirfendereski H, Buyck JM, Couet W, Marchand S. PKPD Modeling of the Inoculum Effect of Acinetobacter baumannii on Polymyxin B in vivo. Front Pharmacol 2022; 13:842921. [PMID: 35370719 PMCID: PMC8966651 DOI: 10.3389/fphar.2022.842921] [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] [Received: 12/24/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
The reduction in antimicrobial activity at high bacterial counts is a microbiological phenomenon known as the inoculum effect (IE). In a previous in vitro study, a significant IE was observed for polymyxin B (PMB) against a clinical isolate of Acinetobacter baumannii, and well described by a new pharmacokinetic-pharmacodynamic model. Few in vivo studies have investigated the impact of inoculum size on survival or antibiotic efficacy. Therefore, our objective was to confirm the influence of inoculum size of this A. baumannii clinical isolate on PMB in vivo effect over time. Pharmacokinetics and pharmacodynamics of PMB after a single subcutaneous administration (1, 15 and 40 mg/kg) were studied in a neutropenic murine thigh infection model. The impact of A. baumannii inoculum size (105, 106 and 107 CFU/thigh) on PMB efficacy was also evaluated. In vivo PMB PK was well described by a two-compartment model including saturable absorption from the subcutaneous injection site and linear elimination. The previous in vitro PD model was modified to adequately describe the decrease of PMB efficacy with increased inoculum size in infected mice. The IE was modeled as a decrease of 32% in the in vivo PMB bactericidal effect when the starting inoculum increases from 105 to 107 CFU/thigh. Although not as important as previously characterized in vitro an IE was confirmed in vivo.
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Affiliation(s)
- Alexia Chauzy
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Grace Akrong
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Vincent Aranzana-Climent
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Jérémy Moreau
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - Laure Prouvensier
- INSERM U1070, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Hélène Mirfendereski
- INSERM U1070, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Julien M Buyck
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - William Couet
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
| | - Sandrine Marchand
- INSERM U1070, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France.,Département de Toxicologie et de Pharmacocinétique, CHU de Poitiers, Poitiers, France
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30
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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31
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A synthetic lipopeptide targeting top-priority multidrug-resistant Gram-negative pathogens. Nat Commun 2022; 13:1625. [PMID: 35338128 PMCID: PMC8956739 DOI: 10.1038/s41467-022-29234-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/07/2022] [Indexed: 11/08/2022] Open
Abstract
The emergence of multidrug-resistant (MDR) Gram-negative pathogens is an urgent global medical challenge. The old polymyxin lipopeptide antibiotics (polymyxin B and colistin) are often the only therapeutic option due to resistance to all other classes of antibiotics and the lean antibiotic drug development pipeline. However, polymyxin B and colistin suffer from major issues in safety (dose-limiting nephrotoxicity, acute toxicity), pharmacokinetics (poor exposure in the lungs) and efficacy (negligible activity against pulmonary infections) that have severely limited their clinical utility. Here we employ chemical biology to systematically optimize multiple non-conserved positions in the polymyxin scaffold, and successfully disconnect the therapeutic efficacy from the toxicity to develop a new synthetic lipopeptide, structurally and pharmacologically distinct from polymyxin B and colistin. This resulted in the clinical candidate F365 (QPX9003) with superior safety and efficacy against lung infections caused by top-priority MDR pathogens Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae. Polymyxins are often the last therapeutic option for multidrug-resistant (MDR) bacteria, but have suboptimal safety and efficacy. Here the authors report the discovery and development of a synthetic lipopeptide with an improved safety and efficacy against top-priority MDR Gram-negative pathogens.
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32
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Emelianova AG, Petrova NV, Fremez C, Fontanié M, Tarasov SА, Epstein ОI. Therapeutic potential of highly diluted antibodies in antibiotic-resistant infection. Eur J Pharm Sci 2022; 173:106161. [DOI: 10.1016/j.ejps.2022.106161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/02/2021] [Accepted: 03/02/2022] [Indexed: 12/31/2022]
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Koch BCP, Muller AE, Hunfeld NGM, de Winter BCM, Ewoldt TMJ, Abdulla A, Endeman H. Therapeutic Drug Monitoring of Antibiotics in Critically Ill Patients: Current Practice and Future Perspectives With a Focus on Clinical Outcome. Ther Drug Monit 2022; 44:11-18. [PMID: 34772892 DOI: 10.1097/ftd.0000000000000942] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Early initiation of antibiotics is essential for ameliorating infections in critically ill patients. The correct dosage of antibiotics is imperative to ensure their adequate exposure. Critically ill patients have altered pharmacokinetic parameters and are often infected by less susceptible microorganisms. Differences in drug disposition are not considered with standard doses of antibiotics. This can lead to suboptimal antibiotic exposure in critically ill patients. To overcome this problem of suboptimal dosing, therapeutic drug monitoring (TDM) is a strategy commonly used to support individualized dosing of antibiotics. It is routinely used for vancomycin and aminoglycosides in clinical practice. In recent years, it has become apparent that TDM may also be used in other antibiotics. METHODS This review summarizes the evidence for TDM of antibiotics in critically ill patients, focuses on clinical outcomes, and summarizes possibilities for optimized TDM in the future. RESULTS AND CONCLUSION After reviewing the literature, we can conclude that general TDM implementation is advised for glycopeptides and aminoglycosides, as evidence of the relationship between TDM and clinical outcome is present. For antibiotics, such as beta-lactams, fluoroquinolones, and linezolid, it seems rational to perform TDM in specific patient cases. TDM involving other antibiotics is supported by individual cases, specifically to decrease toxicity. When focusing on future possibilities to improve TDM of antibiotics in critically ill patients, implementation of model-informed precision dosing should be investigated because it can potentially streamline the TDM process. The logistics of TDM, such as turnaround time and available equipment, are challenging but may be overcome by rapid bioanalytical techniques or real-time monitoring of drug concentrations through biosensors in the future. Education, clinical information on targets, and clinical outcome studies are other important factors that facilitate TDM implementation.
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Affiliation(s)
- Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, the Netherlands; and
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
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Bian X, Liu X, Hu F, Feng M, Chen Y, Bergen PJ, Li J, Li X, Guo Y, Zhang J. Pharmacokinetic/Pharmacodynamic Based Breakpoints of Polymyxin B for Bloodstream Infections Caused by Multidrug-Resistant Gram-Negative Pathogens. Front Pharmacol 2022; 12:785893. [PMID: 35058776 PMCID: PMC8763792 DOI: 10.3389/fphar.2021.785893] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 12/02/2022] Open
Abstract
The latest PK/PD findings have demonstrated negligible efficacy of intravenous polymyxins against pulmonary infections. We investigated pharmacokinetic/pharmacodynamic (PK/PD)-based breakpoints of polymyxin B for bloodstream infections and the rationality of the recent withdrawal of polymyxin susceptibility breakpoints by the CLSI. Polymyxin B pharmacokinetic data were obtained from a phase I clinical trial in healthy Chinese subjects and population pharmacokinetic parameters were employed to determine the exposure of polymyxin B at steady state. MICs of 1,431 recent clinical isolates of Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae collected from across China were determined. Monte-Carlo simulations were performed for various dosing regimens (0.42–1.5 mg/kg/12 h via 1 or 2-h infusion). The probability of target attainment, PK/PD breakpoints and cumulative fraction of response were determined for each bacterial species. MIC90 of polymyxin B was 1 mg/L for P. aeruginosa and 0.5 mg/L for A. baumannii and K. pneumoniae. With the recommended polymyxin B dose of 1.5–2.5 mg/kg/day, the PK/PD susceptible breakpoints for P. aeruginosa, A. baumannii and K. pneumoniae were 2, 1 and 1 mg/L respectively for bloodstream infection. For Chinese patients, polymyxin B dosing regimens of 0.75–1.5 mg/kg/12 h for P. aeruginosa and 1–1.5 mg/kg/12 h for A. baumannii and K. pneumoniae were appropriate. Breakpoint determination should consider the antimicrobial PK/PD at infection site and delivery route. The recent withdrawal of polymyxin susceptible breakpoint by CLSI primarily based on poor efficacy against lung infections needs to be reconsidered for bloodstream infections.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China.,National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, School of Pharmacy, Fudan University, Shanghai, China
| | - Xiaofen Liu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China.,National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Fupin Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Meiqing Feng
- Department of Biological Medicines & Shanghai Engineering Research Center of Immunotherapeutics, School of Pharmacy, Fudan University, Shanghai, China
| | - Yuancheng Chen
- Phase I Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Xin Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China.,National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China.,National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Phase I Unit, Huashan Hospital, Fudan University, Shanghai, China
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Tamma PD, Aitken SL, Bonomo RA, Mathers AJ, van Duin D, Clancy CJ. Infectious Diseases Society of America Guidance on the Treatment of AmpC β-lactamase-Producing Enterobacterales, Carbapenem-Resistant Acinetobacter baumannii, and Stenotrophomonas maltophilia Infections. Clin Infect Dis 2021; 74:2089-2114. [PMID: 34864936 DOI: 10.1093/cid/ciab1013] [Citation(s) in RCA: 235] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. A previous guidance document focused on infections caused by extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa). Here, guidance is provided for treating AmpC β-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia infections. METHODS A panel of six infectious diseases specialists with expertise in managing antimicrobial-resistant infections formulated questions about the treatment of AmpC-E, CRAB, and S. maltophilia infections. Answers are presented as suggestions and corresponding rationales. In contrast to guidance in the previous document, published data on optimal treatment of AmpC-E, CRAB, and S. maltophilia infections are limited. As such, guidance in this document is provided as "suggested approaches" based on clinical experience, expert opinion, and a review of the available literature. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS Preferred and alternative treatment suggestions are provided, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Suggestions apply for both adult and pediatric populations. CONCLUSIONS The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of September 17, 2021 and will be updated annually. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance-2.0/.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samuel L Aitken
- Department of Pharmacy, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, University Hospitals Cleveland Medical Center and Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Amy J Mathers
- Departments of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - David van Duin
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Hanafin PO, Nation RL, Scheetz MH, Zavascki AP, Sandri AM, Kwa AL, Cherng BPZ, Kubin CJ, Yin MT, Wang J, Li J, Kaye KS, Rao GG. Assessing the predictive performance of population pharmacokinetic models for intravenous polymyxin B in critically ill patients. CPT Pharmacometrics Syst Pharmacol 2021; 10:1525-1537. [PMID: 34811968 PMCID: PMC8674003 DOI: 10.1002/psp4.12720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 12/23/2022] Open
Abstract
Polymyxin B (PMB) has reemerged as a last‐line therapy for infections caused by multidrug‐resistant gram‐negative pathogens, but dosing is challenging because of its narrow therapeutic window and pharmacokinetic (PK) variability. Population PK (POPPK) models based on suitably powered clinical studies with appropriate sampling strategies that take variability into consideration can inform PMB dosing to maximize efficacy and minimize toxicity and resistance. Here we reviewed published PMB POPPK models and evaluated them using an external validation data set (EVD) of patients who are critically ill and enrolled in an ongoing clinical study to assess their utility. Seven published POPPK models were employed using the reported model equations, parameter values, covariate relationships, interpatient variability, parameter covariance, and unexplained residual variability in NONMEM (Version 7.4.3). The predictive ability of the models was assessed using prediction‐based and simulation‐based diagnostics. Patient characteristics and treatment information were comparable across studies and with the EVD (n = 40), but the sampling strategy was a main source of PK variability across studies. All models visually and statistically underpredicted EVD plasma concentrations, but the two‐compartment models more accurately described the external data set. As current POPPK models were inadequately predictive of the EVD, creation of a new POPPK model based on an appropriately powered clinical study with an informed PK sampling strategy would be expected to improve characterization of PMB PK and identify covariates to explain interpatient variability. Such a model would support model‐informed precision dosing frameworks, which are urgently needed to improve PMB treatment efficacy, limit resistance, and reduce toxicity in patients who are critically ill.
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Affiliation(s)
- Patrick O Hanafin
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Marc H Scheetz
- Department of Pharmacy Practice and Pharmacometric Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Alexandre P Zavascki
- Department of Internal Medicine, Medical School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Infectious Diseases Service, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Ana M Sandri
- Infectious Diseases Service, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea L Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Emerging Infectious Diseases, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Benjamin P Z Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Christine J Kubin
- New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Michael T Yin
- Division of Infectious Diseases, Department of Internal Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Gauri G Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections such as ventriculitis and meningitis are associated with significant morbidity and mortality. In part, this may be due to increased difficulties in achieving a therapeutic antibiotic concentration at the site of infection due to both the pharmacokinetic (PK) changes observed during critical illness and the reduced antibiotic penetration through the blood brain barrier. This paper reviews the pharmacodynamics (PD) and CNS PKs of antibiotics used for Gram-negative bacterial CNS infections to provide clinicians with practical dosing advice. RECENT FINDINGS Recent PK studies have shown that currently used intravenous antibiotic dosing regimens may not achieve a therapeutic exposure within the CNS, even for reportedly 'susceptible' bacteria per the current clinical meningitis breakpoints. Limited data exist for new β-lactam antibiotic/β-lactamase inhibitor combinations, which may be required for multidrug resistant infections. Intraventricular antibiotic administration, although not a new concept, has further evidence demonstrating improved patient outcomes compared with intravenous therapy alone, despite the ongoing paucity of PK studies guiding dosing recommendations. SUMMARY Clinicians should obtain the bacterial minimum inhibitory concentration when treating patients with CNS Gram-negative bacterial infections and consider the underlying PK/PD principles when prescribing antibiotics. Therapeutic drug monitoring, where available, should be considered to guide dosing. Intraventricular therapy should also be considered for patients with ventricular drains to optimise clinical outcomes.
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The Susceptibility of MDR- K. Pneumoniae To Polymyxin B Plus Its Nebulised Form Versus Polymyxin B Alone in Critically Ill South Asian Patients. J Crit Care Med (Targu Mures) 2021; 7:28-36. [PMID: 34722901 PMCID: PMC8519379 DOI: 10.2478/jccm-2020-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/23/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Critically ill patients in intensive care units are at high risk of dying not only from the severity of their illness but also from secondary causes such as hospital-acquired infections. USA national medical record-data show that approximately 10% of patients on mechanical ventilation in an intensive care unit developed ventilator-associated pneumonia. Polymyxin B has been used intravenously in the treatment of multi-drug resistant gram-negative infections, either as a monotherapy or with other potentially effective antibiotics, and the recent international guidelines have emphasised the use of nebulised polymyxin B together with intravenous polymyxin B to gain the optimum clinical outcome in ventilator-associated pneumonia cases caused by multi-drug resistant gram-negative infections. Methods One hundred and seventy-eight patients with ventilator-associated pneumonia due to multi-drug resistant K. pneumoniae were identified during the study period. Following the inclusion and exclusion criteria, 121 patients were enrolled in the study and randomly allocated to two study groups. Group 1 patients were treated with intravenous Polymyxin B plus nebulised polymyxin B (n=64) and Group 2 patients with intravenous Polymyxin B alone (n=57). The study aimed to compare the use of Polymyxin B plus its nebulised form to polymyxin B alone, in the treatment of MDR-K. pneumoniae associated ventilator-associated pneumonia in critically ill patients. Results In Group 1, a complete clearance of K. pneumoniae was found in fifty-nine patients (92.1%; n=64) compared to forty patients (70.1%, n=57) in the Group 2 (P<0.003). The average time till extubation was significantly higher in Group 2 compared to Group 1 (P<0.05). The total length-of-stay in the ICU was significantly higher in Group 2 compared to Group 1. (P<0.05). These results support the view that the Polymyxin B dual-route regime may be considered as an appropriate antibiotic therapy, in critically ill South Asian patients with ventilator-associated pneumonia.
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Maynard M, Drusano GL, Vicchiarelli M, Liu W, Myrick J, Nole J, Duncanson B, Brown D, Louie A. Polymyxin B Pharmacodynamics in the Hollow-Fiber Infection Model: What You See May Not Be What You Get. Antimicrob Agents Chemother 2021; 65:e0185320. [PMID: 34097487 PMCID: PMC8284464 DOI: 10.1128/aac.01853-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Dose range studies for polymyxin B (PMB) regimens of 0.75 to 12 mg/kg given every 12 h (q12h) were evaluated for bacterial killing and resistance prevention against an AmpC-overexpressing Pseudomonas aeruginosa and a blaKPC-3-harboring Klebsiella pneumoniae in 10-day in vitro hollow-fiber models. An exposure-response was observed. But all regimens failed due to regrowth. Lower-dose regimens amplified isolates that expressed transient, lower-level adaptive resistance to PMB (MICs ≤ 4 mg/liter). Higher PMB dosages amplified isolates that expressed this resistance mechanism, a higher-MIC "moderately stable" adaptive resistance, and a higher-MIC stable resistance to PMB. Failure of the highest dose regimens was solely due to subpopulations that expressed the two higher-level resistances. Total and bioactive PMB concentrations in broth declined below targeted PK profiles within hours of treatment initiation and prior to bacterial regrowth. With treatment failure, the total PMB measured in bacteria was substantially higher than in broth. But the bioactive PMB in broth and bacteria were low to nondetectable. Together, these findings suggest a sequence of events for treatment failure of the clinical regimen. First, PMB concentrations in broth are diluted as PMB binds to bacteria, resulting in total and bioactive PMB in broth that is lower than targeted. Bacterial regrowth and treatment failure follow, with emergence of subpopulations that express transient lower-level adaptive resistance to PMB and possibly higher-level adaptive and stable resistances. Higher-dose PMB regimens can prevent the emergence of transient lower-level adaptive resistance, but they do not prevent treatment failure due to isolates that express higher-level resistance mechanisms.
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Affiliation(s)
- Michael Maynard
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - G. L. Drusano
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Michael Vicchiarelli
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Weiguo Liu
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Jenny Myrick
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Jocelyn Nole
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Brandon Duncanson
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - David Brown
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
| | - Arnold Louie
- Institute for Therapeutic Innovation, University of Florida, Orlando, Florida, USA
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McCreary EK, Heil EL, Tamma PD. New Perspectives on Antimicrobial Agents: Cefiderocol. Antimicrob Agents Chemother 2021; 65:e0217120. [PMID: 34031052 PMCID: PMC8373209 DOI: 10.1128/aac.02171-20] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bacterial resistance to carbapenem agents has reached alarming levels. Accordingly, collaborative efforts between national and international organizations and the pharmaceutical industry have led to an impressive expansion of commercially available β-lactam agents in recent years. No available agent comes close to the broad range of activity afforded by cefiderocol, a novel siderophore-cephalosporin conjugate. The novelty of and need for cefiderocol are clear, but available clinical data are conflicting, leaving infectious diseases specialists puzzled as to when to prescribe this agent in clinical practice. After a brief overview of cefiderocol pharmacokinetics and pharmacodynamics, safety data, cefiderocol susceptibility testing, and putative mechanisms of cefiderocol resistance, this review focuses on determining cefiderocol's role in the management of specific pathogens, including carbapenem-resistant Acinetobacter baumannii complex, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacterales, and less commonly identified glucose-nonfermenting organisms such as Stenotrophomonas maltophilia, Burkholderia species, and Achromobacter species. Available preclinical, clinical trial, and postmarketing data are summarized for each organism, and each section concludes with our opinions on where to position cefiderocol as a clinical therapeutic.
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Affiliation(s)
- Erin K. McCreary
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Pranita D. Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Baltimore, Maryland, USA
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Pharmacodynamic evaluation of suppression of in vitro resistance in Acinetobacter baumannii strains using polymyxin B-based combination therapy. Sci Rep 2021; 11:11339. [PMID: 34059725 PMCID: PMC8167102 DOI: 10.1038/s41598-021-90709-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/13/2021] [Indexed: 02/04/2023] Open
Abstract
The emergence of polymyxin resistance in Gram-negative bacteria infections has motivated the use of combination therapy. This study determined the mutant selection window (MSW) of polymyxin B alone and in combination with meropenem and fosfomycin against A. baumannii strains belonging to clonal lineages I and III. To evaluate the inhibition of in vitro drug resistance, we investigate the MSW-derived pharmacodynamic indices associated with resistance to polymyxin B administrated regimens as monotherapy and combination therapy, such as the percentage of each dosage interval that free plasma concentration was within the MSW (%TMSW) and the percentage of each dosage interval that free plasma concentration exceeded the mutant prevention concentration (%T>MPC). The MSW of polymyxin B varied between 1 and 16 µg/mL for polymyxin B-susceptible strains. The triple combination of polymyxin B with meropenem and fosfomycin inhibited the polymyxin B-resistant subpopulation in meropenem-resistant isolates and polymyxin B plus meropenem as a double combination sufficiently inhibited meropenem-intermediate, and susceptible strains. T>MPC 90% was reached for polymyxin B in these combinations, while %TMSW was 0 against all strains. TMSW for meropenem and fosfomycin were also reduced. Effective antimicrobial combinations significantly reduced MSW. The MSW-derived pharmacodynamic indices can be used for the selection of effective combination regimen to combat the polymyxin B-resistant strain.
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Rao GG, Landersdorfer CB. Antibiotic pharmacokinetic/pharmacodynamic modelling: MIC, pharmacodynamic indices and beyond. Int J Antimicrob Agents 2021; 58:106368. [PMID: 34058336 DOI: 10.1016/j.ijantimicag.2021.106368] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/09/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Abstract
The dramatic increase in antimicrobial resistance and the limited pharmacological treatment options highlight the urgent need to optimize therapeutic regimens of new and available anti-infectives. Several in-vitro and in-vivo infection models are employed to understand the relationship between drug exposure profiles in plasma or at the site of infection (pharmacokinetics) and the time course of therapeutic response (pharmacodynamics) to select and optimize dosage regimens for new and approved drugs. Well-designed preclinical studies, combined with mathematical-model-based pharmacokinetic/pharmacodynamic analysis and in-silico simulations, are critical for the effective translation of preclinical data and design of appropriate and successful clinical trials. Integration with population pharmacokinetic modelling and simulations allows for the incorporation of interindividual variability that occurs in both pharmacokinetics and pharmacodynamics, and helps to predict the probability of target attainment and treatment outcome in patients. This article reviews the role of pharmacokinetic/pharmacodynamic approaches in the optimization of dosage regimens to maximize antibacterial efficacy while minimizing toxicity and emergence of resistance, and to achieve a high likelihood of therapeutic success. Polymyxin B, an approved drug with a narrow therapeutic window, serves as an illustrative example to highlight the importance of pharmacokinetic/pharmacodynamic modelling in conjunction with experimentation, employing static time-kill studies followed by dynamic in-vitro or in-vivo models, or both, to learn and confirm mechanistic insights necessary for translation to the bedside.
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Affiliation(s)
- Gauri G Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Cornelia B Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
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Shi Y, Peng Y, Zhang Y, Chen Y, Zhang C, Luo X, Chen Y, Yuan Z, Chen J, Gong Y. Safety and Efficacy of a Phage, kpssk3, in an in vivo Model of Carbapenem-Resistant Hypermucoviscous Klebsiella pneumoniae Bacteremia. Front Microbiol 2021; 12:613356. [PMID: 34093455 PMCID: PMC8175031 DOI: 10.3389/fmicb.2021.613356] [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: 10/02/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Antimicrobial resistance (AMR) is one of the most significant threats to global public health. As antibiotic failure is increasing, phages are gradually becoming important agents in the post-antibiotic era. In this study, the therapeutic effects and safety of kpssk3, a previously isolated phage infecting carbapenem-resistant hypermucoviscous Klebsiella pneumoniae (CR-HMKP), were evaluated in a mouse model of systemic CR-HMKP infection. The therapeutic efficacy experiment showed that intraperitoneal injection with a single dose of phage kpssk3 (1 × 107 PFU/mouse) 3 h post infection protected 100% of BALB/c mice against bacteremia induced by intraperitoneal challenge with a 2 × LD100 dose of NY03, a CR-HMKP clinical isolate. In addition, mice were treated with antibiotics from three classes (polymyxin B, tigecycline, and ceftazidime/avibactam plus aztreonam), and the 7 days survival rates of the treated mice were 20, 20, and 90%, respectively. The safety test consisted of 2 parts: determining the cytotoxicity of kpssk3 and evaluating the short- and long-term impacts of phage therapy on the mouse gut microbiota. Phage kpssk3 was shown to not be cytotoxic to mammalian cells in vitro or in vivo. Fecal samples were collected from the phage-treated mice at 3 time points before (0 day) and after (3 and 10 days) phage therapy to study the change in the gut microbiome via high-throughput 16S rDNA sequence analysis, which revealed no notable alterations in the gut microbiota except for decreases in the Chao1 and ACE indexes.
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Affiliation(s)
- Yunlong Shi
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yuan Peng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Cheng Zhang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiaoqiang Luo
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yajie Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zhiqiang Yuan
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jing Chen
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yali Gong
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burn Research, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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Satlin MJ. Languid Uptake of Ceftazidime-Avibactam for Carbapenem-Resistant Gram-Negative Infections and Continued Reliance on Polymyxins. Clin Infect Dis 2021; 72:622-625. [PMID: 32107528 DOI: 10.1093/cid/ciaa065] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/03/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael J Satlin
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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45
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Satlin MJ, Lewis JS, Weinstein MP, Patel J, Humphries RM, Kahlmeter G, Giske CG, Turnidge J. Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing Position Statements on Polymyxin B and Colistin Clinical Breakpoints. Clin Infect Dis 2021; 71:e523-e529. [PMID: 32052041 DOI: 10.1093/cid/ciaa121] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Abstract
Recent data on polymyxin pharmacokinetics, pharmacodynamics, toxicity, and clinical outcomes suggest these agents have limited clinical utility. Pharmacokinetics-pharmacodynamics data show a steady-state concentration of 2 μg/mL is required for killing bacteria with colistin minimum inhibitory concentrations of 2 μg/mL. Less than 50% of patients with normal renal function achieve this exposure, and it is associated with high risk of nephrotoxicity. This exposure does not achieve bacterial stasis in pneumonia models. Randomized and observational studies consistently demonstrate increased mortality for polymyxins compared with alternative agents. The Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) are 2 global organizations that establish interpretive criteria for in vitro susceptibility data. CLSI has recently taken the step to eliminate the "susceptible" interpretive category for the polymyxins, whereas EUCAST maintains this interpretive category. This viewpoint describes the opinions of these organizations and the data that were used to inform their perspectives.
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Affiliation(s)
- Michael J Satlin
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Melvin P Weinstein
- Departments of Medicine and Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Jean Patel
- Beckman Coulter, Sacramento, California, USA
| | - Romney M Humphries
- Accelerate Diagnostics, Tucson, Arizona, USA.,Department of Pathology, University of Arizona, Tucson, Arizona, USA
| | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Växjö Central Hospital, Växjö, Sweden
| | - Christian G Giske
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - John Turnidge
- Adelaide Medical School, University of Adelaide, South Australia, Australia
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Synchrotron-based X-ray fluorescence microscopy reveals accumulation of polymyxins in single human alveolar epithelial cells. Antimicrob Agents Chemother 2021; 65:AAC.02314-20. [PMID: 33649114 PMCID: PMC8092916 DOI: 10.1128/aac.02314-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Intravenous administration of the last-line polymyxins results in poor drug exposure in the lungs and potential nephrotoxicity; while inhalation therapy offers better pharmacokinetics/pharmacodynamics for pulmonary infections by delivering the antibiotic to the infection site directly. However, polymyxin inhalation therapy has not been optimized and adverse effects can occur. This study aimed to quantitatively determine the intracellular accumulation and distribution of polymyxins in single human alveolar epithelial A549 cells. Cells were treated with an iodine-labeled polymyxin probe FADDI-096 (5.0 and 10.0 μM) for 1, 4, and 24 h. Concentrations of FADDI-096 in single A549 cells were determined by synchrotron-based X-ray fluorescence microscopy. Concentration- and time-dependent accumulation of FADDI-096 within A549 cells was observed. The intracellular concentrations (mean ± SEM, n ≥ 189) of FADDI-096 were 1.58 ± 0.11, 2.25 ± 0.10, and 2.46 ± 0.07 mM following 1, 4 and 24 h of treatment at 10 μM, respectively. The corresponding intracellular concentrations following the treatment at 5 μM were 0.05 ± 0.01, 0.24 ± 0.04, and 0.25 ± 0.02 mM (n ≥ 189). FADDI-096 was mainly localized throughout the cytoplasm and nuclear region over 24 h. The intracellular zinc concentration increased in a concentration- and time-dependent manner. This is the first study to quantitatively map the accumulation of polymyxins in human alveolar epithelial cells and provides crucial insights for deciphering the mechanisms of their pulmonary toxicity. Importantly, our results may shed light on the optimization of inhaled polymyxins in patients and the development of new-generation safer polymyxins.
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Abstract
Antibiotic resistance is a major global health challenge and, worryingly, several key Gram negative pathogens can become resistant to most currently available antibiotics. Polymyxins have been revived as a last-line therapeutic option for the treatment of infections caused by multidrug-resistant Gram negative bacteria, in particular Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacterales. Polymyxins were first discovered in the late 1940s but were abandoned soon after their approval in the late 1950s as a result of toxicities (e.g., nephrotoxicity) and the availability of "safer" antibiotics approved at that time. Therefore, knowledge on polymyxins had been scarce until recently, when enormous efforts have been made by several research teams around the world to elucidate the chemical, microbiological, pharmacokinetic/pharmacodynamic, and toxicological properties of polymyxins. One of the major achievements is the development of the first scientifically based dosage regimens for colistin that are crucial to ensure its safe and effective use in patients. Although the guideline has not been developed for polymyxin B, a large clinical trial is currently being conducted to optimize its clinical use. Importantly, several novel, safer polymyxin-like lipopeptides are developed to overcome the nephrotoxicity, poor efficacy against pulmonary infections, and narrow therapeutic windows of the currently used polymyxin B and colistin. This review discusses the latest achievements on polymyxins and highlights the major challenges ahead in optimizing their clinical use and discovering new-generation polymyxins. To save lives from the deadly infections caused by Gram negative "superbugs," every effort must be made to improve the clinical utility of the last-line polymyxins. SIGNIFICANCE STATEMENT: Antimicrobial resistance poses a significant threat to global health. The increasing prevalence of multidrug-resistant (MDR) bacterial infections has been highlighted by leading global health organizations and authorities. Polymyxins are a last-line defense against difficult-to-treat MDR Gram negative pathogens. Unfortunately, the pharmacological information on polymyxins was very limited until recently. This review provides a comprehensive overview on the major achievements and challenges in polymyxin pharmacology and clinical use and how the recent findings have been employed to improve clinical practice worldwide.
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Affiliation(s)
- Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Mohammad A K Azad
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Tony Velkov
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Qi Tony Zhou
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Victoria, Australia (S.C.N., M.A.K.A., J.L.); Department of Pharmacology and Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia (T.V.); and Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana (Q.T.Z.)
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48
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Zeng H, Zeng Z, Kong X, Zhang H, Chen P, Luo H, Chen Y. Effectiveness and Nephrotoxicity of Intravenous Polymyxin B in Chinese Patients With MDR and XDR Nosocomial Pneumonia. Front Pharmacol 2021; 11:579069. [PMID: 33613276 PMCID: PMC7892461 DOI: 10.3389/fphar.2020.579069] [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: 07/01/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Nosocomial pneumonia is a major health and economic burden globally. Multidrug-resistant (MDR) or extensively drug-resistant (XDR) Gram-negative bacteria are the most common causative pathogens in critically-ill patients. Polymyxin B is a salvage therapy for MDR Gram-negative pathogens; however, the current literature on its effectiveness and nephrotoxicity is limited, including in Chinese patients. Methods: We retrospectively analyzed 107 patients with nosocomial pneumonia caused by MDR or XDR Gram-negative bacteria treated with intravenous polymyxin B (2–3 mg/kg/day). Renal function was evaluated on the day before commencement of polymyxin B therapy and on the third and 7 days of treatment. Univariate and multivariate analyses were conducted to determine risk factors for the effectiveness and nephrotoxicity of polymyxin B. Sixty-seven (62.6%) and sixty-five (60.7%) patients had favorable clinical and microbiological responses, respectively. Acute physiology and chronic health evaluation II (APACHE II) scores, cardio-pulmonary resuscitation (CPR) history, numbers of pathogens per patient and a favorable microbiological response were independently associated with favorable clinical outcomes of polymyxin B treatment in Chinese patients with MDR or XDR nosocomial pneumonia. Initial renal dysfunction was not associated with late nephrotoxicity (on day 7), although early nephrotoxicity (on day 3) was independently associated with late nephrotoxicity (OR = 39.43, 95% CI 7.64–203.62, p = 0.00). Conclusion: Our findings support polymyxin B treatment for MDR and XDR pneumonia, with the severity of disease and polymicrobial infection being risk factors for a poor clinical outcome. Nephrotoxicity following 3 days of polymyxin B treatment was found to be a reliable risk factor for later nephrotoxicity.
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Affiliation(s)
- Huihui Zeng
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Unit of Respiratory Diseases, Central South University, Changsha, China.,Hunan Centre for Evidence-based Medicine, Changsha, China
| | - Zihang Zeng
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Unit of Respiratory Diseases, Central South University, Changsha, China.,Hunan Centre for Evidence-based Medicine, Changsha, China
| | - Xianglong Kong
- Department of Respiratory Medicine, The First Hospital of Changsha, Changsha, China
| | - Hongliang Zhang
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ping Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Unit of Respiratory Diseases, Central South University, Changsha, China.,Hunan Centre for Evidence-based Medicine, Changsha, China
| | - Hong Luo
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Unit of Respiratory Diseases, Central South University, Changsha, China.,Hunan Centre for Evidence-based Medicine, Changsha, China
| | - Yan Chen
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, China.,Research Unit of Respiratory Diseases, Central South University, Changsha, China.,Hunan Centre for Evidence-based Medicine, Changsha, China
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49
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Comparing the Population Pharmacokinetics of and Acute Kidney Injury Due to Polymyxin B in Chinese Patients with or without Renal Insufficiency. Antimicrob Agents Chemother 2021; 65:AAC.01900-20. [PMID: 33168613 DOI: 10.1128/aac.01900-20] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/29/2020] [Indexed: 12/24/2022] Open
Abstract
Despite excellent bactericidal effect, dosing adjustment of polymyxin B for patients with renal insufficiency and polymyxin B-related nephrotoxicity is still a major concern to clinicians. The aim of this study was to compare the population pharmacokinetics (PK) properties of polymyxin B in Chinese patients with different renal functions and to investigate the relationship between PK parameters and polymyxin B-related acute kidney injury (AKI). A total of 37 patients with normal renal function (creatinine clearance ≥ 80 ml/min) and 33 with renal insufficiency (creatinine clearance < 80 ml/min) were included. In the two-compartment population PK models, the central compartment clearance (CL) (2.19 liters/h versus 1.58 liters/h; P < 0.001) and intercompartmental clearance (Q) (13.83 liters/h versus 10.28 liters/h; P < 0.001) values were significantly different between the two groups. The simulated values for AUC across 24 h at steady state (AUCss,24h) for patients with normal renal function were higher than those for patients with renal insufficiency. However, renal dosing adjustment of polymyxin B seemed not to be necessary. In addition, during the treatment, AKI occurred in 23 (32.86%) patients. The polymyxin B AUCss,24h in patients with AKI was significantly higher than that in patients without AKI (108.66 ± 70.10 mg · h/liter versus 66.18 ± 34.79 mg · h/liter; P = 0.001). Both the receiver operating characteristic (ROC) curve and logistic regression analysis showed that an AUCss,24h of >100 mg · h/liter was a good predictor for the probability of nephrotoxicity.
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50
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Liu X, Chen Y, Yang H, Li J, Yu J, Yu Z, Cao G, Wu X, Wang Y, Wu H, Fan Y, Wang J, Wu J, Jin Y, Guo B, Hu J, Bian X, Li X, Zhang J. Acute toxicity is a dose-limiting factor for intravenous polymyxin B: A safety and pharmacokinetic study in healthy Chinese subjects. J Infect 2021; 82:207-215. [PMID: 33453286 DOI: 10.1016/j.jinf.2021.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/21/2020] [Accepted: 01/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Polymyxin B is a last-line antibiotic for multidrug-resistant gram-negative bacterial infections. However, limited safety and pharmacokinetic information is available. We investigated the safety and pharmacokinetics of intravenous polymyxin B in healthy subjects. METHODS An open-label, single-dose clinical trial was conducted in healthy Chinese subjects. Polymyxin B (sulphate) was administered intravenously at 0.75 or 1.5 mg/kg (n = 10 per dose, 5 males and 5 females) to examine the safety and pharmacokinetics. RESULTS One female subject in the 1.5-mg/kg group discontinued due to abdominal pain during administration. The most frequently reported adverse events were perioral paraesthesia, dizziness, and numbness of extremities (7/10 subjects in the 0.75-mg/kg group, all subjects in the 1.5-mg/kg group). All neurotoxicity-related events dissipated without treatment within a maximum of 23 h. Notably, abdominal pain (3/5) and vulvar pruritus (2/5), colpitis (2/5) or abnormal uterine bleeding (1/5) were reported in female subjects receiving the 1.5-mg/kg dose. In the 0.75-mg/kg group, the total clearance, volume of distribution and half-life of polymyxin B were 0.028±0.002 L/h/kg, 0.219±0.023 L/kg and 5.44±0.741 h, respectively; similar values were observed in the 1.5-mg/kg group. Urinary recovery was 3.7 ± 1.1% and 8.1 ± 1.3% in the 0.75- and 1.5-mg/kg groups, respectively. Population pharmacokinetics of polymyxin B was consistent with a three-compartment model. The clearance and distribution of the central compartment were 0.027 L/h/kg and 0.071 L/kg, respectively. CONCLUSIONS This study is the first to examine the safety and pharmacokinetics of polymyxin B in healthy subjects. Our results highlight that acute toxicity is a dose-limiting factor for intravenous polymyxin B.
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Affiliation(s)
- Xiaofen Liu
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Haijing Yang
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, 19 Innovation Walk, Victoria 3800, Melbourne, Australia
| | - Jicheng Yu
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhenwei Yu
- Sir Run Shaw Hospital, College of Medicine, Zhenjiang University, 3rd East Qingchun Road, Hangzhou 310016, China
| | - Guoying Cao
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaojie Wu
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yu Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Hailan Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jingjing Wang
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jufang Wu
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yi Jin
- National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Beining Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jiali Hu
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xin Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200040, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission of the People's Republic of China, Shanghai 200040, China; National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China.
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