Rifaximin in the treatment of irritable bowel syndrome: is there a high risk for development of antimicrobial resistance?

In Vitro Inhibition of Growth, Biofilm Formation, and Persisters of Staphylococcus aureus by Pinaverium Bromide

Biofilm or persister cells formed by Staphylococcus aureus are closely related to pathogenicity. However, no antimicrobials exist to inhibit biofilm formation or persister cells induced by S. aureus in clinical practice. This study found that pinaverium bromide had antibacterial activity against S. aureus, with the MIC₅₀/MIC₉₀ at 12.5/25 μM, respectively. Pinaverium bromide (at 4 × MIC) showed a rapid bactericidal effect on S. aureus planktonic cells, and it was more effective (at least 1-log₁₀ cfu/mL) than linezolid, vancomycin, and ampicillin at 4 h of the time-killing test. Pinaverium bromide (at 10 × MIC) significantly inhibited the formation of S. aureus persister cells (at least 3-log₁₀ cfu/mL) than linezolid, vancomycin, and ampicillin at 24, 48, 72, 96, and 120 h of the time-killing test. Biofilm formation and adherent cells of S. aureus isolates were significantly inhibited by pinaverium bromide (at 1/2 or 1/4 × MICs). The fluorescence intensity of the membrane polarity of S. aureus increased with the treatment of pinaverium bromide (≥1 × MIC), and the MICs of pinaverium bromide increased by 4 times with the addition of cell membrane phospholipids, phosphatidyl glycerol and cardiolipin. The cell viabilities of human hepatocellular carcinoma cells HepG2 and Huh7, mouse monocyte-macrophage cells J774, and human hepatic stellate cells LX-2 were slightly inhibited by pinaverium bromide (<50 μM). There were 54 different abundance proteins detected in the pinaverium bromide-treated S. aureus isolate by proteomics analysis, of which 33 proteins increased, whereas 21 proteins decreased. The abundance of superoxide dismutase sodM and ica locus proteins icaA and icaB decreased. While the abundance of global transcriptional regulator spxA and Gamma-hemolysin component B increased. In conclusion, pinaverium bromide had an antibacterial effect on S. aureus and significantly inhibited the formation of biofilm and persister cells of S. aureus.

Impact of Antibiotic Resistance Genes in Gut Microbiome of Patients With Cirrhosis

BACKGROUND AND AIMS

Cirrhosis is associated with changes in intestinal microbiota that can lead to hepatic encephalopathy (HE) and infections, especially with antibiotic-resistant organisms. However, the impact of gut microbial antibiotic resistance gene (ARG) burden on clinical outcomes is unclear. The aims of the study were to determine the impact of ARGs in cirrhosis-related gut metagenome on outcomes and disease progression, study the effect of rifaximin on ARG burden, and compare ARGs in cirrhosis with chronic kidney disease (CKD) and diabetes.

METHODS

In outpatients with cirrhosis who underwent metagenomics, we evaluated change in ARG abundances with progression and their multivariable impact on 90-day hospitalizations and deaths over 1 year. We also studied ARGs pre- and 8 weeks post-rifaximin in patients with compensated cirrhosis in an open-label trial. Finally, ARGs from CKD and diabetes studies were compared with cirrhosis on machine learning.

RESULTS

A total of 163 patients with cirrhosis (43 compensated, 20 ascites-only, 30 HE-only, 70 both) and 40 controls were included. ARG abundances were higher in cirrhosis versus controls and worsened with advancing cirrhosis severity; 44 patients were hospitalized and 14 died. ARG abundances were associated with hospitalizations and mortality while controlling for cirrhosis complications, medications, and demographics. Rifaximin trial: ARG abundance patterns were minimally affected in 19 patients post-rifaximin. CKD/diabetes comparison: ARG abundance patterns in cirrhosis are distinguishable on machine learning and include more gram-positive ARGs.

CONCLUSIONS

Cirrhosis is associated with high gut microbial ARG gene burden compared with controls, which worsens with disease progression and may be different from CKD and diabetes. ARGs are not affected by rifaximin and are associated with hospitalizations and death.

Targeting the pregnane X receptor using microbial metabolite mimicry

The human PXR (pregnane X receptor), a master regulator of drug metabolism, has essential roles in intestinal homeostasis and abrogating inflammation. Existing PXR ligands have substantial off-target toxicity. Based on prior work that established microbial (indole) metabolites as PXR ligands, we proposed microbial metabolite mimicry as a novel strategy for drug discovery that allows exploiting previously unexplored parts of chemical space. Here, we report functionalized indole derivatives as first-in-class non-cytotoxic PXR agonists as a proof of concept for microbial metabolite mimicry. The lead compound, FKK6 (Felix Kopp Kortagere 6), binds directly to PXR protein in solution, induces PXR-specific target gene expression in cells, human organoids, and mice. FKK6 significantly represses pro-inflammatory cytokine production cells and abrogates inflammation in mice expressing the human PXR gene. The development of FKK6 demonstrates for the first time that microbial metabolite mimicry is a viable strategy for drug discovery and opens the door to underexploited regions of chemical space.

Evaluation of lactulose, lactose, and fructose breath testing in clinical practice: A focus on methane

Background and Aim

Breath testing (BT) is used to identify carbohydrate malabsorption and small intestine bacterial overgrowth. Measuring methane alongside hydrogen is advocated to reduce false-negative studies, but the variability of methane production is unknown. The aim of this study is to examine the effect of high methane production on hydrogen excretion after ingesting lactulose, fructose, or lactose.

Methods

A retrospective audit was performed of patients with gastrointestinal symptoms who underwent BT. Following a low fermentable carbohydrate diet for 24-h, a fasting BT before consuming 35 ml lactulose, 35 g fructose, or lactose in 200 ml water, followed by BT every 10-15 min for up to 3-h, was performed. A positive test was defined as a ≥20 ppm rise of hydrogen or methane from baseline. A high methane producer had an initial reading of ≥5 ppm. Breath hydrogen and methane production were measured as area under the curve. Chi-squared tests were used to compare proportions of those meeting the cut-off criteria.

Results

Of patients, 26% (28/106) were high methane producers at their initial lactulose test. The test-retest repeatability of methane production was high, with the same methane production status before ingesting lactose in all (70/70) and before ingesting fructose in most (71/73). Methane production was highly variable during testing, with 38% (10/26) having ≥1 reading lower than baseline. Hydrogen produced by high or low methane producers did not differ (1528 [960-3645] ppm min vs 2375 [1810-3195] ppm min [P = 0.11]). Symptoms and breath test results were not positively related.

Conclusion

The validity of including an increase of ≥20 ppm methane to identify carbohydrate malabsorption or small intestine bacterial overgrowth should be questioned due to the variability of readings during testing.

Berberine prevents stress-induced gut inflammation and visceral hypersensitivity and reduces intestinal motility in rats

BACKGROUND

Irritable bowel syndrome (IBS) is a common chronic non-organic disease of the digestive system. Berberine (BBR) has been used to treat patients with IBS, but the underlying therapeutic mechanism is little understood. We believe that BBR achieves its therapeutic effect on IBS by preventing stress intestinal inflammation and visceral hypersensitivity and reducing bowel motility.

AIM

To test the hypothesis that BBR achieves its therapeutic effect on IBS by preventing subclinical inflammation of the intestinal mucosa and reducing visceral hypersensitivity and intestinal motility.

METHODS

IBS was induced in rats via water avoidance stress (WAS). qRT-PCR and histological analyses were used to evaluate the levels of cytokines and mucosal inflammation, respectively. Modified ELISA and qRT-PCR were used to evaluate the nuclear factor kappa-B (NF-κB) signal transduction pathway. Colorectal distention test, gastrointestinal transit measurement, Western blot, and qRT-PCR were used to analyze visceral sensitivity, intestinal motility, the expression of C-kit (marker of Cajal mesenchymal cells), and the expression of brain derived neurotrophic factor (BDNF) and its receptor TrkB.

RESULTS

WAS led to mucosal inflammation, visceral hyperalgesia, and high intestinal motility. Oral administration of BBR inhibited the NF-κB signal transduction pathway, reduced the expression of pro-inflammatory cytokines [interleukin (IL)-1β, IL-6, interferon-γ, and tumor necrosis factor-α], promoted the expression of anti-inflammatory cytokines (IL-10 and transforming growth factor-β), and improved the terminal ileum tissue inflammation. BBR inhibited the expression of BDNF, TrkB, and C-kit in IBS rats, leading to the reduction of intestinal motility and visceral hypersensitivity. The therapeutic effect of BBR at a high dose (100 mg/kg) was superior to than that of the low-dose (25 mg/kg) group.

CONCLUSION

BBR reduces intestinal mucosal inflammation by inhibiting the intestinal NF-κB signal pathway in the IBS rats. BBR reduces the expression of BDNF, its receptor TrkB, and C-kit. BBR also reduces intestinal motility and visceral sensitivity to achieve its therapeutic effect on IBS.

Emergence of rifampin-resistant staphylococci after rifaximin administration in cirrhotic patients

Objectives

Rifaximin, a poorly absorbed antibiotics, has gut-specific therapeutic effects. Although frequently prescribed to manipulate intestinal luminal bacterial population in various diseases, the possible induction of antibacterial cross-resistance to a target pathogen is a major concern in long-term rifaximin administration. We aimed to evaluate whether rifampin-resistant staphylococci could evolve after rifaximin treatment in cirrhotic patients.

Method

A total of 25 cirrhotic patients who were administered rifaximin for the prevention of hepatic encephalopathy were enrolled. Swabs from both hands and the perianal skin were acquired on day 0 (before rifaximin treatment), period 1 (1–7 weeks after treatment), and period 2 (8–16 weeks after treatment) the staphylococcal strain identification and rifampin-resistance testing.

Results

A total of 198 staphylococcal isolates from 15 species were identified. Staphylococcus epidermidis was isolated most frequently, and Staphylococcus haemolyticus was the most common resistant species both from hands and perianal skin. Eleven patients (44.0%) developed rifampin-resistant staphylococcal isolates in period 1. Among these patients, only six (54.5%) were found to have rifampin-resistant isolates in period 2, with no significant infectious events. Rifampin-resistant staphylococcal isolates were more frequently found in perianal skin than from the hands. No patients acquired a newly resistant strain in period 2.

Conclusions

About one-half of cirrhotic patients in this study developed rifampin-resistant staphylococcal isolates after rifaximin treatment. Although the resistant strains were no longer detected in about half of the patients in the short-term, the long-term influence of this drug treatment should be determined.

Recent advances in the treatment of hyperammonemia

Ammonia is a neurotoxic agent that is primarily generated in the intestine and detoxified in the liver. Toxic increases in systemic ammonia levels predominantly result from an inherited or acquired impairment in hepatic detoxification and lead to potentially life-threatening neuropsychiatric symptoms. Inborn deficiencies in ammonia detoxification mainly affect the urea cycle, an endogenous metabolic removal system in the liver. Hepatic encephalopathy, on the other hand, is a hyperammonemia-related complication secondary to acquired liver function impairment. A range of therapeutic options is available to target either ammonia generation and absorption or ammonia removal. Therapies for hepatic encephalopathy decrease intestinal ammonia production and uptake. Treatments for urea cycle disorders eliminate ammoniagenic amino acids through metabolic transformation, preventing ammonia generation. Therapeutic approaches removing ammonia activate the urea cycle or the second essential endogenous ammonia detoxification system, glutamine synthesis. Recent advances in treating hyperammonemia include using synergistic combination treatments, broadening the indication of orphan drugs, and developing novel approaches to regenerate functional liver tissue. This manuscript reviews the various pharmacological treatments of hyperammonemia and focuses on biopharmaceutical and drug delivery issues.

Rifaximin: Irritable Bowel Syndrome

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu .

Emerging role of probiotics and antimicrobials in the management of irritable bowel syndrome

OBJECTIVE

To review the potential role of probiotics and antimicrobials for management of functional bowel disorders (FBDs), with a focus on irritable bowel syndrome (IBS).

RESEARCH DESIGN AND METHODS

Relevant adult data were identified via PubMed, with additional references obtained by reviewing bibliographies from selected articles.

RESULTS

Probiotic treatment involves colonizing the intestines with beneficial microorganisms, whereas antimicrobial therapy involves modulation of the bacterial load and/or host response. A meta-analysis reported that all probiotic species evaluated improved flatulence compared with placebo; some, but not all, species improved abdominal pain and abdominal bloating/distension; and no species evaluated improved stool frequency or consistency, straining during stool evacuation, sense of incomplete evacuation, or fecal urgency. Two additional meta-analyses reported that probiotics significantly improved overall IBS symptoms. Individual studies have demonstrated potential benefits of probiotics for functional constipation symptoms. The nonsystemic antimicrobials neomycin and rifaximin have been evaluated in patients with IBS and other FBDs. Neomycin may improve global IBS symptoms and provide bowel normalization versus placebo, but the risk of ototoxicity and the development of clinically relevant bacterial resistance may limit its use for recurrent symptoms. In phase 3 randomized studies, rifaximin-treated patients were significantly more likely than placebo-treated patients to achieve adequate relief of global IBS symptoms and abdominal bloating. Although preliminary data suggest that development of clinically relevant bacterial resistance is unlikely with rifaximin, prospective data are needed, and a phase 3 study is ongoing. Limitations of evidence for probiotics include small populations analyzed and lack of clarity in optimal dosing regimen; antimicrobial evidence would benefit from better understanding of the effects of repeated treatment in patients with IBS.

CONCLUSIONS

Probiotics and nonsystemic antibiotics have a place in IBS management. Additional studies are needed to establish optimal regimens and identify subgroups of patients most likely to benefit from these therapies.