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Zelenitsky SA. Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics. Antibiotics (Basel) 2023; 12:1738. [PMID: 38136772 PMCID: PMC10741006 DOI: 10.3390/antibiotics12121738] [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: 11/19/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.
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Affiliation(s)
- Sheryl A. Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0T5, Canada;
- Department of Pharmacy, St. Boniface Hospital, Winnipeg, MB R2H 2A6, Canada
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2
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MacDougall C. A Cloudy Crystal Ball: Critically Assessing and Rethinking the Antibiogram. Clin Infect Dis 2023; 77:1501-1503. [PMID: 37658904 DOI: 10.1093/cid/ciad468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Affiliation(s)
- Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, California, USA
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Rai S, Dash D, Agarwal N. Introducing the new face of CLSI M100 in 2023: An explanatory review. Indian J Med Microbiol 2023; 46:100432. [PMID: 37945125 DOI: 10.1016/j.ijmmb.2023.100432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The CLSI annual update of its M100 document is eagerly awaited every year. This year's update, the M100-Ed33, was published in February, and will significantly affect clinical practices. OBJECTIVE To highlight and explain the rationale of the changes and their clinical impact. CONTENT The major changes this year are mostly focused on PK/PD data, selective and cascade reporting of the antibiotics and therapy related comments. The CLSI has moved away from its classical grouping of antibiotics (A, B, U, O) to a tier-based approach (Tier 1, 2, 3, 4) which will aid in cascade reporting during an antibiotic susceptibility testing (AST). Rather than non-fastidious, fastidious and anaerobe grouping, the tables have been made organism specific. The aminoglycosides breakpoints have been changed for both Enterobacterales and Pseudomonas aeruginosa while for P. aeruginosa, the breakpoints of piperacillin - tazobactam (TZP) are also updated. These updates are mostly based on attainment of drug plasma level for bacterial stasis rather than bactericidal effect of the antibiotics. It is noteworthy, that these breakpoint changes are made, keeping in view that the aminoglycosides for all organisms should be used in combination therapy. For P. aeruginosa, gentamicin has been removed, while amikacin has been restricted for urinary isolates only.
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Affiliation(s)
- Sumit Rai
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
| | - Debabrata Dash
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
| | - Nidhima Agarwal
- Department of Clinical Microbiology, AIIMS Mangalagiri, Guntur, India.
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Lepak AJ, Trang M, Hammel JP, Sader HS, Bhavnani SM, VanScoy BD, Pogue JM, Ambrose PG, Andes DR. Development of Modernized Acinetobacter baumannii Susceptibility Test Interpretive Criteria for Recommended Antimicrobial Agents Using Pharmacometric Approaches. Antimicrob Agents Chemother 2023; 67:e0145222. [PMID: 36946729 PMCID: PMC10112158 DOI: 10.1128/aac.01452-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 02/13/2023] [Indexed: 03/23/2023] Open
Abstract
Acinetobacter baumannii-Acinetobacter calcoaceticus complex (referred to herein as A. baumannii) treatment guidelines contain numerous older antimicrobial agents with susceptibility test interpretive criteria (STIC, also known as susceptibility breakpoints) set using only epidemiological data. We utilized a combination of in vitro surveillance data, preclinical murine thigh and lung infection models, population pharmacokinetics, simulation, and pharmacokinetic/pharmacodynamic (PK/PD) target attainment analyses to evaluate A. baumannii STIC for four commonly recommended antimicrobials from different classes (amikacin, ceftazidime, ciprofloxacin, and minocycline). Antimicrobial in vitro surveillance data were based on 1,647 clinical A. baumannii isolates obtained from 109 centers in the United States and Europe. Among these isolates, 5 were selected for evaluation in murine infection models based on fitness and MIC variability. PK and dose-ranging studies were conducted using neutropenic murine thigh and lung infection models The MIC ranges for the 5 isolates evaluated were as follows: amikacin, 2 to 32 μg/mL; ceftazidime, 4 to 16 μg/mL; ciprofloxacin, 0.12 to 2 μg/mL; minocycline, 0.25 to 4 μg/mL. All organisms grew ≥1.5 log10 CFU in both models in untreated controls. Plasma and epithelial lining fluid (ELF) pharmacokinetics for all drugs were determined in mice using liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods. For each isolate, 5 dose levels of each drug were tested individually in the thigh and lung infection model. The inoculum ranged from 7.9 to 8.4 and 6.8 to 7.7 log10 CFU/mL for the lung and thigh models, respectively. PK/PD targets associated with net bacterial stasis and 1- and 2-log10 CFU reductions from baseline were identified for each organism/infection model using Hill-type models. Population pharmacokinetic models for each agent were identified from the literature. Using demographic variables for simulated patients with hospital-acquired or ventilator-associated bacterial pneumonia or urinary tract infections (including acute pyelonephritis) who were administered maximal dosing regimens of each agent, estimates of protein binding, and ELF penetration ratios based on data from the literature, free-drug plasma and total-drug concentration-time profiles were generated, and PK/PD indices by MIC were calculated. Percent probabilities of attaining median and randomly assigned PK/PD targets associated with the above-described endpoints were determined. Recommended susceptible breakpoints for each agent were those representing the highest MIC at which the percent probabilities of achieving PK/PD targets associated with a 1-log10 CFU reduction from baseline approached or were ≥90%. The following susceptible breakpoints for A. baumannii were identified: amikacin, ≤8 μg/mL for pneumonia; ceftazidime, ≤32 and ≤8 μg/mL for pneumonia; ciprofloxacin, ≤1 μg/mL; and minocycline, ≤0.5/≤1 μg/mL which correspond to the standard and high minocycline dosing regimens of 200 mg per day and 200 mg every 12 h, respectively. Implementation of appropriate STIC will help clinicians optimally use the above-described agents and improve the likelihood of successful patient outcomes.
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Affiliation(s)
- A. J. Lepak
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
| | - M. Trang
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - J. P. Hammel
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | | | - S. M. Bhavnani
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - B. D. VanScoy
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - J. M. Pogue
- University of Michigan, Ann Arbor, Michigan, USA
| | - P. G. Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - D. R. Andes
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
| | - United States Committee on Antimicrobial Susceptibility Testing
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
- JMI Laboratories, North Liberty, Iowa, USA
- University of Michigan, Ann Arbor, Michigan, USA
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Asempa TE, Kois AK, Gill CM, Nicolau DP. Phenotypes, genotypes and breakpoints: an assessment of β-lactam/β-lactamase inhibitor combinations against OXA-48. J Antimicrob Chemother 2023; 78:636-645. [PMID: 36626311 DOI: 10.1093/jac/dkac425] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 09/21/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Two of the three recently approved β-lactam agent (BL)/β-lactamase inhibitor (BLI) combinations have higher CLSI susceptibility breakpoints (ceftazidime/avibactam 8 mg/L; meropenem/vaborbactam 4 mg/L) compared with the BL alone (ceftazidime 4 mg/L; meropenem 1 mg/L). This can lead to a therapeutic grey area on susceptibility reports depending on resistance mechanism. For instance, a meropenem-resistant OXA-48 isolate (MIC 4 mg/L) may appear as meropenem/vaborbactam-susceptible (MIC 4 mg/L) despite vaborbactam's lack of OXA-48 inhibitory activity. METHODS OXA-48-positive (n = 51) and OXA-48-negative (KPC, n = 5; Klebsiella pneumoniae wild-type, n = 1) Enterobacterales were utilized. Susceptibility tests (broth microdilution) were conducted with ceftazidime/avibactam, imipenem/relebactam and meropenem/vaborbactam, as well as their respective BL partner. Antimicrobial activity of all six agents was evaluated in the murine neutropenic thigh model using clinically relevant exposures. Efficacy was assessed as the change in bacterial growth at 24 h, compared with 0 h controls. RESULTS On average, the three BL/BLI agents resulted in robust bacteria killing among OXA-48-negative isolates. Among OXA-48-positive isolates, poor in vivo activity with imipenem/relebactam was concordant with its resistant phenotypic profile. Variable meropenem/vaborbactam activity was observed among isolates with a 'susceptible' MIC of 4 mg/L. Only 30% (7/23) of isolates at meropenem/vaborbactam MICs of 2 and 4 mg/L met the ≥1-log bacterial reduction threshold predictive of clinical efficacy in serious infections. In contrast, ceftazidime/avibactam resulted in marked bacterial density reduction across the range of MICs, and 96% (49/51) of isolates exceeded the ≥1-log bacterial reduction threshold. CONCLUSIONS Data demonstrate that current imipenem/relebactam and ceftazidime/avibactam CLSI breakpoints are appropriate. Data also suggest that higher meropenem/vaborbactam breakpoints relative to meropenem can translate to potentially poor clinical outcomes in patients infected with OXA-48-harbouring isolates.
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Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Abigail K Kois
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Christian M Gill
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Johnson WM, Clark JA, Olney K, Burgess DR, Burgess DS. Changing times: The impact of gram-negative breakpoint changes over the previous decade. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e165. [PMID: 36483380 PMCID: PMC9726557 DOI: 10.1017/ash.2022.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 06/17/2023]
Abstract
We assessed breakpoint changes of 13,101 Enterobacterales and Pseudomonas aeruginosa isolates from the past decade. All β-lactams and fluoroquinolones demonstrated decreased susceptibilities following breakpoint changes. Enterobacter cloacae experienced the largest average decrease in susceptibility amongst the Enterobacterales at 5.3% and P. aeruginosa experienced an average decrease in susceptibility of 9.3%.
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Affiliation(s)
- Wes M. Johnson
- University of Kentucky Chandler Medical Center, Lexington, Kentucky
| | - Justin A. Clark
- University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Katherine Olney
- University of Kentucky Chandler Medical Center, Lexington, Kentucky
| | - Donna R. Burgess
- University of Kentucky Chandler Medical Center, Lexington, Kentucky
- University of Kentucky College of Pharmacy, Lexington, Kentucky
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Asempa TE, Kois AK, Gill CM, Nicolau DP. Phenotypes, genotypes and breakpoints: an assessment of β-lactam/ β-lactamase inhibitor combinations against OXA-48. J Antimicrob Chemother 2022; 77:2622-2631. [PMID: 35325165 DOI: 10.1093/jac/dkac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/10/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Two out of the three recently approved β-lactam (BL)/β-lactamase inhibitors (BLIs) have higher CLSI susceptibility breakpoints (ceftazidime/avibactam 8 mg/L; meropenem/vaborbactam 4 mg/L) compared with the BL alone (ceftazidime 4 mg/L; meropenem 1 mg/L). This can lead to a therapeutic grey area on susceptibility reports depending on resistance mechanism. For instance, a meropenem-resistant OXA-48 isolate (MIC 4 mg/L) may appear as meropenem/vaborbactam-susceptible (MIC 4 mg/L) despite vaborbactam's lack of OXA-48 inhibitory activity. METHODS OXA-48-positive (n = 51) and OXA-48-negative (KPC, n = 5; Klebsiella pneumoniae WT, n = 1) Enterobacterales were utilized. Susceptibility tests (broth microdilution) were conducted with ceftazidime/avibactam, imipenem/relebactam and meropenem/vaborbactam, as well as their respective BL partner. Antimicrobial activity of all six agents was evaluated in the murine neutropenic thigh model using clinically relevant exposures. Efficacy was assessed as the change in bacterial growth at 24 h, compared with 0 h controls. RESULTS On average, the three BL/BLI agents resulted in robust bacteria killing among OXA-48-negative isolates. Among OXA-48-positive isolates, poor in vivo activity with imipenem/relebactam was concordant with its resistant phenotypic profile. Variable meropenem/vaborbactam activity was observed among isolates with a 'susceptible' MIC of 4 mg/L. Only 30% (7/23) of isolates at meropenem/vaborbactam MICs of 2 and 4 mg/L met the ≥1 log bacterial reduction threshold predictive of clinical efficacy in serious infections. In contrast, ceftazidime/avibactam resulted in marked bacterial density reduction across the range of MICs and 73% (37/51) of isolates exceeded the ≥1 log bacterial reduction threshold. CONCLUSIONS Data demonstrate that current imipenem/relebactam and ceftazidime/avibactam CLSI breakpoints are appropriate. Data also suggest that higher meropenem/vaborbactam breakpoints relative to meropenem can translate to potentially poor clinical outcomes in patients infected with OXA-48-harbouring isolates.
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Affiliation(s)
- Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Abigail K Kois
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Christian M Gill
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Bhavnani SM, Krause KM, Ambrose PG. A Broken Antibiotic Market: Review of Strategies to Incentivize Drug Development. Open Forum Infect Dis 2020; 7:ofaa083. [PMID: 32667365 PMCID: PMC7336557 DOI: 10.1093/ofid/ofaa083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/11/2020] [Indexed: 11/12/2022] Open
Abstract
The threat posed by infections arising from antimicrobial-resistant bacteria is a global concern. Despite this trend, the future development of new antimicrobial agents is currently very uncertain. The lack of commercial success for newly launched antimicrobial agents provides little incentive to invest in the development of new agents. To address this crisis, a number of push and pull incentives have been constructed to support antimicrobial drug development. Push incentives, which are designed to lower the cost of developing new antimicrobial agents, include grants, contracts, public-private partnerships, tax credits, and clinical trial networks. Pull incentives, which are designed to facilitate higher financial returns for a newly launched antimicrobial agent, include those that decrease the time for a regulatory review, extend patent exclusivity, or provide premium pricing. Such incentives may also include direct, advanced, or milestone payments or they may be insurance-based whereby healthcare systems pay for the right to access an antimicrobial agent rather than the number of units administered. Another strategy involves the re-evaluation of interpretive criteria for in vitro susceptibility testing (susceptibility breakpoints) of old antimicrobial agents using the same standards applied to that of new agents, which will allow for an accurate determination of antimicrobial resistance. Although each of the above-described strategies will be important to ensure that antimicrobial agents are developed in the decades to come, the update of susceptibility breakpoints for old agents is a strategy that could be implemented quickly and one that could be the most effective for incentivizing drug developers and financiers to reconsider the development of antimicrobial agents.
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Affiliation(s)
| | | | - Paul G Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
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