1
|
Bajaj JS, Fagan A, Gavis EA, Mousel T, Gallagher ML, Puri P, Fuchs M, Davis BC, Hylemon PB, Zhou H, Ahluwalia V, Cadrain R, Sikaroodi M, Gillevet PM. The RIVET RCT: Rifamycin SV MMX improves muscle mass, physical function, and ammonia in cirrhosis and minimal encephalopathy. Hepatol Commun 2024; 8:e0384. [PMID: 38315140 PMCID: PMC10843468 DOI: 10.1097/hc9.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Minimal hepatic encephalopathy (MHE) negatively affects the prognosis of cirrhosis, but treatment is not standard. Rifamycin SV MMX (RiVM) is a nonabsorbable rifampin derivative with colonic action. METHODS In a phase 2 placebo-controlled, double-blind randomized clinical trial patients with MHE were randomized to RiVM or placebo for 30 days with a 7-day follow-up. The primary endpoint was a change in stool cirrhosis dysbiosis ratio. Gut-brain (cognition, stool/salivary microbiome, ammonia, brain magnetic resonance spectroscopy), inflammation (stool calprotectin/serum cytokines), patient-reported outcomes (sickness impact profile: total/physical/psychosocial, high = worse), and sarcopenia (handgrip, bioelectric impedance) were secondary. Between/within groups and delta (post-pre) comparisons were performed. RESULTS Thirty patients (15/group) were randomized and completed the study without safety concerns. While cirrhosis dysbiosis ratio was statistically similar on repeated measures ANOVA (95% CI: -0.70 to 3.5), ammonia significantly reduced (95% CI: 4.4-29.6) in RiVM with changes in stool microbial α/β-diversity. MHE status was unchanged but only serial dotting (which tests motor strength) improved in RiVM-assigned patients. Delta physical sickness impact profile (95% CI: 0.33 = 8.5), lean mass (95% CI: -3.3 to -0.9), and handgrip strength (95% CI: -8.1 to -1.0) improved in RiVM versus placebo. Stool short-chain fatty acids (propionate, acetate, and butyrate) increased post-RiVM. Serum, urine, and stool bile acid profile changed to nontoxic bile acids (higher hyocholate/ursodeoxycholate and lower deoxycholate/lithocholate) post-RiVM. Serum IL-1β and stool calprotectin decreased while brain magnetic resonance spectroscopy showed higher glutathione concentrations in RiVM. CONCLUSIONS RiVM is well tolerated in patients with MHE with changes in stool microbial composition and function, ammonia, inflammation, brain oxidative stress, and sarcopenia-related parameters without improvement in cognition. RiVM modulates the gut-brain axis and gut-muscle axis in cirrhosis.
Collapse
Affiliation(s)
- Jasmohan S. Bajaj
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Edith A. Gavis
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Travis Mousel
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Mary L. Gallagher
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Puneet Puri
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Michael Fuchs
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Brian C. Davis
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Phillip B. Hylemon
- Department of Microbiology and Immunology, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Huiping Zhou
- Department of Microbiology and Immunology, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - Vishwadeep Ahluwalia
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
- Center for Advanced Brain Imaging, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Robert Cadrain
- Collaborative Advanced Research Imaging Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Patrick M. Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| |
Collapse
|
2
|
DuPont HL, Almenoff JS, Jamindar MS, Bortey E, Steffen R. Development of a new travellers' diarrhoea clinical severity classification and its utility in confirming rifamycin-SV efficacy. J Travel Med 2023; 30:taad043. [PMID: 37052453 PMCID: PMC10628770 DOI: 10.1093/jtm/taad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND travellers' diarrhoea (TD) is frequently reported with incidence up to 40% in high-risk destinations. Previous studies showed that the number of loose stools alone is inadequate to holistically predict the severity of TD. To improve the prediction of prognosis and to optimize treatments, a simple risk-based clinical severity classification has been developed. METHODS pooled baseline data of signs and symptoms and number of loose stools from 1098 subjects enrolled in two double-blind Phase 3 trials of rifamycin-SV were analyzed with correlation, multiple correspondence analyses, prognostic factor criteria, and Contal and O'Quigley method to generate a TD severity classification (mild, moderate and severe). The relative importance of this classification on resolution of TD was assessed by Cox proportional model hazard model on the time to last unformed stool (TLUS). RESULTS the analysis showed that TLUS were longer for the severe [hazard ratio (HR) 0.24; P < 0.001; n = 173] and moderate (HR 0.54; P = 0.0272; n = 912) vs mild. Additionally, when the treatment assigned in the studies was investigated in the severity classification, the results yielded that rifamycin-SV significantly shortened TLUS vs placebo for all subjects (HR 1.9; P = 0.0006), severe (HR 5.9; P = 0.0232) and moderate (HR 1.7; P = 0.0078) groups and was as equally efficacious as ciprofloxacin for all subjects, moderate and severe groups (HRs: 0.962, 0.9, 1.2; all P = NS, respectively). When reassessed by this classification, rifamycin-SV showed consistent efficacy with the Phase 3 studies. CONCLUSIONS this newly developed TD clinical severity classification demonstrated strong prognostic value and clinical utility by combining patients' multiple signs and symptoms of enteric infection and number of loose stools to provide a holistic assessment of TD. By expanding on the current classification by incorporating patient reported outcomes in addition to TLUS, a classification like the one developed, may help optimize patient selection for future clinical studies.
Collapse
Affiliation(s)
- Herbert L DuPont
- Internal Medicine, University of Texas School of Public Health, Houston, TX 77030, USA
| | - June S Almenoff
- Department of Medical Affairs, Redhill Biopharma Inc., Raleigh, NC 27617, USA
| | - Mansi S Jamindar
- Department of Medical Affairs, Redhill Biopharma Inc., Raleigh, NC 27617, USA
| | - Enoch Bortey
- Pharmaceutical Development Strategies LLC, Chapel Hill, NC 27517, USA
| | - Robert Steffen
- Department of Epidemiology, University of Zurich, 8001 Zurich, Switzerland
| |
Collapse
|
3
|
Grant TA, López-Pérez M, Haro-Moreno JM, Almagro-Moreno S. Allelic diversity uncovers protein domains contributing to the emergence of antimicrobial resistance. PLoS Genet 2023; 19:e1010490. [PMID: 36972246 PMCID: PMC10079234 DOI: 10.1371/journal.pgen.1010490] [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] [Received: 10/23/2022] [Revised: 04/06/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
Abstract
Antimicrobial resistance (AMR) remains a major threat to global health. To date, tractable approaches that decipher how AMR emerges within a bacterial population remain limited. Here, we developed a framework that exploits genetic diversity from environmental bacterial populations to decode emergent phenotypes such as AMR. OmpU is a porin that can make up to 60% of the outer membrane of Vibrio cholerae, the cholera pathogen. This porin is directly associated with the emergence of toxigenic clades and confers resistance to numerous host antimicrobials. In this study, we examined naturally occurring allelic variants of OmpU in environmental V. cholerae and established associations that connected genotypic variation with phenotypic outcome. We covered the landscape of gene variability and found that the porin forms two major phylogenetic clusters with striking genetic diversity. We generated 14 isogenic mutant strains, each encoding a unique ompU allele, and found that divergent genotypes lead to convergent antimicrobial resistance profiles. We identified and characterized functional domains in OmpU unique to variants conferring AMR-associated phenotypes. Specifically, we identified four conserved domains that are linked with resistance to bile and host-derived antimicrobial peptides. Mutant strains for these domains exhibit differential susceptibility patterns to these and other antimicrobials. Interestingly, a mutant strain in which we exchanged the four domains of the clinical allele for those of a sensitive strain exhibits a resistance profile closer to a porin deletion mutant. Finally, using phenotypic microarrays, we uncovered novel functions of OmpU and their connection with allelic variability. Our findings highlight the suitability of our approach towards dissecting the specific protein domains associated with the emergence of AMR and can be naturally extended to other bacterial pathogens and biological processes.
Collapse
Affiliation(s)
- Trudy-Ann Grant
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, Florida, United States of America
| | - Mario López-Pérez
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, Florida, United States of America
- Evolutionary Genomics Group, División de Microbiología, Universidad Miguel Hernández, San Juan, Alicante, Spain
| | - Jose Manuel Haro-Moreno
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, Florida, United States of America
- Evolutionary Genomics Group, División de Microbiología, Universidad Miguel Hernández, San Juan, Alicante, Spain
| | - Salvador Almagro-Moreno
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, Florida, United States of America
- * E-mail:
| |
Collapse
|
4
|
Kanazawa M, Tominaga K, Kanamori A, Tanaka T, Masuyama S, Watanabe S, Abe K, Yamamiya A, Goda K, Irisawa A. A Case of Stevens–Johnson Syndrome Complicated with Multimatrix System Mesalamine in Ulcerative Colitis. Medicina (B Aires) 2022; 58:medicina58020276. [PMID: 35208599 PMCID: PMC8876713 DOI: 10.3390/medicina58020276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/02/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022] Open
Abstract
A 41-year-old man was treated with prednisolone (PSL) and multimatrix (MMX) mesalamine for remission induction therapy of ulcerative colitis. PSL was tapered due to successful remission induction treatment. During the treatment course, ocular foreign body sensation, eyelid swelling, ocular conjunctiva hyperemia, facial redness and swelling, watery nasal discharge, stomatitis, anal pain, and reddish puffiness on the bilateral dorsum of the hands appeared, and he was diagnosed with Stevens–Johnson syndrome (SJS). SJS was improved by PSL treatment and intravenous immunoglobulin. MMX mesalamine was the causative agent by drug-induced lymphocyte stimulation test. This is the first reported case of SJS with MMX mesalamine.
Collapse
|
5
|
Sriram A, Tangirala S, Atmakuri S, Hoque S, Modani S, Srivastava S, Mahajan S, Maji I, Kumar R, Khatri D, Madan J, Singh PK. Budding Multi-matrix Technology-a Retrospective Approach, Deep Insights, and Future Perspectives. AAPS PharmSciTech 2021; 22:264. [PMID: 34734325 DOI: 10.1208/s12249-021-02133-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 08/30/2021] [Indexed: 11/30/2022] Open
Abstract
The human race is consistently striving for achieving good health and eliminate disease-causing factors. For the last few decades, scientists have been endeavoring to invent and innovate technologies that can substitute the conventional dosage forms and enable targeted and prolonged drug release at a particular site. The novel multi-matrix technology is a type of matrix formulation where the formulation is embraced to have a matrix system with multiple number of matrices. The MMX technology embraces with a combination of outer hydrophilic layer and amphiphilic/lipophilic core layer, within which drug is encapsulated followed by enteric coating for extended/targeted release at the required site. In comparison to conventional oral drug delivery systems and other drug delivery systems, multi-matrix (MMX) technology formulations afford many advantages. Additionally, it attributes for targeting strategy aimed at the colon and offers modified prolonged drug release. Thus, it has emerged rapidly as a potential alternative option in targeted oral drug delivery. However, the development of this MMX technology formulations is a exigent task and also has its own set of limitations. Due to its promising advantages and colon targeting strategy over the other colon targeted drug delivery systems, premier global companies are exploiting its potential. This article review deep insights into the formulation procedures, drug delivery mechanism, advantages, limitations, safety and efficacy studies of various marketed drug formulations of MMX technology including regulatory perspectives and future perspectives.
Collapse
|
6
|
Bacterial, viral and parasitic pathogens analysed by qPCR: Findings from a prospective study of travellers' diarrhoea. Travel Med Infect Dis 2020; 40:101957. [PMID: 33359433 DOI: 10.1016/j.tmaid.2020.101957] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The diagnostics of travellers' diarrhoea (TD) has been revolutionised by multiplex qPCR assays. While mostly of bacterial aetiology, viruses and parasites account for the disease among 10-20% of travellers. Despite this, prospective studies applying qPCR assays remain scarce that cover not only bacteria, such as the various diarrhoeagenic Escherichia coli (DEC), but also viral and parasitic pathogens. METHOD We analysed by qPCR pre- and post-travel stool samples of 146 Finnish travellers for bacterial, viral and parasitic pathogens: enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC), and enteroinvasive (EIEC) E. coli; Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae; norovirus G1 and G2, rotavirus, enteroviruses, and sapovirus; and Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Symptoms and medication data during travel were collected by questionnaires. RESULTS We detected bacterial pathogens in 102/146 samples (69.9%; EAEC, EPEC, ETEC most common), viral ones in 13 (8.9%; norovirus most common), and parasitic ones in one (0.7%; Giardia). Noroviruses were associated with severe symptoms (23.5% versus non-severe 4.9%). In the TD group, 41.7% (5/12) of those with viral pathogens (vs. 13.3%; 11/83 without) took antibiotics. CONCLUSION Viral pathogens, particularly noroviruses, prevail in severe TD. The symptoms of viral disease are often severe and lead to unwarranted use of antibiotics.
Collapse
|
7
|
Rimmer JE, Harro C, Sack DA, Talaat KR, Gutierrez RL, DeNearing B, Brubaker J, Laird RM, Poly F, Maue AC, Jaep K, Alcala A, Mochalova Y, Gariepy CL, Chakraborty S, Guerry P, Tribble DR, Porter CK, Riddle MS. Rifaximin Fails to Prevent Campylobacteriosis in the Human Challenge Model: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin Infect Dis 2019; 66:1435-1441. [PMID: 29145631 DOI: 10.1093/cid/cix1014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/13/2017] [Indexed: 12/15/2022] Open
Abstract
Background Campylobacter species are a leading cause of diarrheal disease globally with significant morbidity. Primary prevention efforts have yielded limited results. Rifaximin chemoprophylaxis decreases rates of travelers' diarrhea and may be suitable for high-risk persons. We assessed the efficacy of rifaximin in the controlled human infection model for Campylobacter jejuni. Methods Twenty-eight subjects were admitted to an inpatient facility and randomized to a twice-daily dose of 550 mg rifaximin or placebo. The following day, subjects ingested 1.7 × 105 colony-forming units of C. jejuni strain CG8421. Subjects continued prophylaxis for 3 additional days, were followed for campylobacteriosis for 144 hours, and were subsequently treated with azithromycin and ciprofloxacin. Samples were collected to assess immunologic responses to CG8421. Results There was no difference (P = 1.0) in the frequency of campylobacteriosis in those receiving rifaximin (86.7%) or placebo (84.6%). Additionally, there were no differences in the clinical signs and symptoms of C. jejuni infection to include abdominal pain/cramps (P = 1.0), nausea (P = 1.0), vomiting (P = .2), or fever (P = 1.0) across study groups. Immune responses to the CG8421 strain were comparable across treatment groups. Conclusions Rifaximin did not prevent campylobacteriosis in this controlled human infection model. Given the morbidity associated with Campylobacter infection, primary prevention efforts remain a significant need. Clinical Trials Registration NCT02280044.
Collapse
Affiliation(s)
- Joanna E Rimmer
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland.,School of Immunity and Infection, University of Birmingham.,Academic Department of Military Medicine, Royal Centre for Defence Medicine (Academia and Research), Medical Directorate, Joint Medical Command, Information and Communications Technology Centre, Birmingham Research Park, United Kingdom
| | - Clayton Harro
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - David A Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Kawsar R Talaat
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Ramiro L Gutierrez
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Barbara DeNearing
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Jessica Brubaker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Renee M Laird
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Frédéric Poly
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Alexander C Maue
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Kayla Jaep
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Ashley Alcala
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Yelizaveta Mochalova
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Christina L Gariepy
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Subhra Chakraborty
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Patricia Guerry
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Chad K Porter
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| | - Mark S Riddle
- Enteric Diseases Department, Naval Medical Research Center, Silver Spring, Maryland
| |
Collapse
|
8
|
Emerging concepts in the diagnosis, treatment, and prevention of travelers’ diarrhea. Curr Opin Infect Dis 2019; 32:468-474. [DOI: 10.1097/qco.0000000000000581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
9
|
Abstract
Rifamycin SV MMX® (Aemcolo™; Relafalk™) is a novel oral formulation of the antibacterial rifamycin SV that uses MultiMatrix (MMX®) technology to enable colonic delivery. Specifically, the active ingredient (rifamycin SV) is released throughout the colon, where it acts locally in the intestinal lumen; systemic absorption is minimal. Rifamycin SV MMX® exhibits antibacterial activity against a broad spectrum of clinically relevant enteropathogens and is available in the EU and the USA for the treatment of adults with traveller's diarrhoea. In two multinational, phase III studies, rifamycin SV MMX® (400 mg twice daily for 3 days) effectively shortened the duration of non-dysenteric traveller's diarrhoea in adults, being significantly more effective than placebo and noninferior to ciprofloxacin in reducing median time to last unformed stool. As expected (given its poor systemic absorption), rifamycin SV MMX® was well tolerated in this patient population, with the overall incidence of treatment-emergent adverse events generally similar to those of placebo and ciprofloxacin. Current evidence indicates that twice-daily rifamycin SV MMX® is an effective and well tolerated treatment option for shortening the duration of non-dysenteric traveller's diarrhoea in adults.
Collapse
|
10
|
Steffen R, DuPont HL. Rifamycin SV-MMX® as the recommended self-treatment for moderate to severe travellers' diarrhoea: reply. J Travel Med 2019; 26:5372335. [PMID: 30848824 PMCID: PMC6509471 DOI: 10.1093/jtm/taz014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/21/2019] [Accepted: 03/18/2019] [Indexed: 11/13/2022]
Affiliation(s)
- Robert Steffen
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Hirschengraben 84, Zurich, CH, Switzerland
| | - Herbert L DuPont
- The University of Texas-Houston School of Public Health and Medical School, Center for Infectious Diseases, 6720 Bertner MC1-164, Houston, TX, USA
| |
Collapse
|
11
|
Riddle MS, Connor P, Tribble DR. Antibiotics for Travellers' Diarrhoea on Trial-is there a potential role for Rifamycin SV? J Travel Med 2019; 26:5204459. [PMID: 30476231 DOI: 10.1093/jtm/tay137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 11/23/2018] [Indexed: 01/15/2023]
Affiliation(s)
- Mark S Riddle
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD, USA
| | - Patrick Connor
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
| | - David R Tribble
- Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, MD, USA
| |
Collapse
|
12
|
Lääveri T, Vilkman K, Pakkanen S, Kirveskari J, Kantele A. Despite antibiotic treatment of travellers' diarrhoea, pathogens are found in stools from half of travellers at return. Travel Med Infect Dis 2018; 23:49-55. [PMID: 29702254 DOI: 10.1016/j.tmaid.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/24/2018] [Accepted: 04/09/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Among visitors to the (sub)tropics, 20-50% contract travellers' diarrhoea (TD) and 5-30% take antibiotics. While shortening the duration of illness, antimicrobials predispose to acquisition of multi-drug resistant bacteria. Therefore, liberal use is no longer advocated. Although antibiotics kill pathogens, no data support the view that they could prevent post-infectious sequelae. We investigated how antibiotic use for TD abroad impacts the pathogen findings at return. MATERIALS AND METHODS We revisited 456 travellers' clinical data and stool pathogens examined by qPCR for Salmonella, Yersinia, Campylobacter, Shigella, Vibrio cholerae and enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC) Escherichia coli. RESULTS Among travellers with TD, antibiotic users had pathogen-positive samples less frequently than non-users (50% versus 83%). The difference was significant for EPEC (23% versus 47%) and EAEC (27% versus 54%), but not ETEC (17% versus 26%) or the other pathogens. Shigella/EIEC was found more often among antibiotic users than non-users (4% versus 1%). CONCLUSION Despite antibiotic treatment of TD, half of the users still had stool pathogens at return, reflecting either antibiotic resistance of pathogens or recolonisation/reinfection while abroad. Treatment of TD with antibiotics during travel should not be interpreted to indicate eradication of pathogens.
Collapse
Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Katri Vilkman
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland.
| | - Sari Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Helsinki, Finland, POB 21, FIN-00014 Helsinki, Finland.
| | - Juha Kirveskari
- Helsinki University Hospital Laboratory (HUSLAB), Department of Bacteriology, Helsinki, Finland, POB 720, FIN-00029 HUS, Finland; Mobidiag Ltd, Espoo, Finland, Keilaranta 16 A, FIN-02150 Espoo Finland.
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, POB 348, FIN-00029 HUS, Finland; Clinicum, University of Helsinki, Helsinki, Finland, POB 63, FI-00014 Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, Stockholm, Sweden, SE-17176 Stockholm, Sweden.
| |
Collapse
|
13
|
Lääveri T, Pakkanen SH, Kirveskari J, Kantele A. Travellers' diarrhoea: Impact of TD definition and control group design on study results. Travel Med Infect Dis 2018; 24:37-43. [PMID: 29409749 DOI: 10.1016/j.tmaid.2018.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is a common health problem among visitors to the (sub)tropics. Much research deals with aetiology, prevention, and post-infection sequalae, yet the data may not allow comparisons due to incompatible definitions of TD and No TD control groups. METHOD The impact of defining TD and No TD control groups was explored by revisiting our recent data. We set up two TD groups: classical TD i.e. ≥3 loose or liquid stools/day and WHO TD (diarrhoea as defined by the WHO) i.e. any diarrhoea, and four No TD groups by TD definition and timing (no classical/WHO TD during travel, no ongoing classical/WHO TD). RESULTS TD was recorded for 37% versus 65% of subjects when using classical versus WHO definitions, respectively; the proportions of the various pathogens proved similar. The strictest criterion for the No TD control group (no WHO TD during travel) yielded pathogens among 61% and the least strict (no ongoing classical TD) among 73% of the travellers; the differences were greatest for enteroaggregative Escherichia coli and Campylobacter. CONCLUSIONS Definition of TD and control group design substantially impact on TD study results. The WHO definition yields more cases, but the pathogen selection is similar by both definitions. Design of the No TD control group was found critical: only those remaining asymptomatic throughout the journey should be included.
Collapse
Affiliation(s)
- Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland
| | - Sari H Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, P.O. Box 21, FIN-00014 Helsinki, Finland
| | - Juha Kirveskari
- Helsinki University Hospital Laboratory (HUSLAB), Department of Bacteriology, POB 720, FIN-00029 HUS, Helsinki, Finland; Mobidiag Ltd, Keilaranta 16 A, FIN-02150 Espoo, Finland
| | - Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland; Clinicum, University of Helsinki, PO Box 63, FIN-00014, Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, SE-17176 Stockholm, Sweden.
| |
Collapse
|
14
|
Steffen R, Jiang ZD, Gracias Garcia ML, Araujo P, Stiess M, Nacak T, Greinwald R, DuPont HL. Rifamycin SV-MMX® for treatment of travellers' diarrhea: equally effective as ciprofloxacin and not associated with the acquisition of multi-drug resistant bacteria. J Travel Med 2018; 25:5193265. [PMID: 30462260 PMCID: PMC6331114 DOI: 10.1093/jtm/tay116] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 11/16/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The novel oral antibiotic formulation Rifamycin SV-MMX®, with a targeted delivery to the distal small bowel and colon, was superior to placebo in treating travellers' diarrhea (TD) in a previous study. Thus, a study was designed to compare this poorly absorbed antibiotic with the systemic agent ciprofloxacin. METHODS In a randomized double-blind phase 3 study (ERASE), the efficacy and safety of Rifamycin SV-MMX® 400 mg twice daily (RIF-MMX) was compared with ciprofloxacin 500 mg twice daily in the oral treatment of TD. Overall, 835 international visitors to India, Guatemala or Ecuador with acute TD were randomized to receive a 3-day treatment with RIF-MMX (n = 420) or ciprofloxacin (n = 415). Primary endpoint was time to last unformed stool (TLUS), after which clinical cure was declared. Stools samples for microbiological evaluation were collected at the baseline visit and the end of treatment visit. RESULTS Median TLUS in the RIF-MMX group was 42.8 h versus 36.8 h in the ciprofloxacin group indicating non-inferiority of RIF-MMX to ciprofloxacin (P = 0.0035). Secondary efficacy endpoint results including clinical cure rate, treatment failure rate, requirement of rescue therapy as well as microbiological eradication rate confirmed those of the primary analysis indicating equal efficacy for both compounds. While patients receiving ciprofloxacin showed a significant increase of Extended Spectrum Beta Lactamase Producing-Escherichia coli (ESBL-E. Coli) colonization rates after 3-days treatment (6.9%), rates did not increase in patients receiving RIF-MMX (-0.3%). Both drugs were well-tolerated and safe. CONCLUSION The novel multi-matrix formulation of the broad-spectrum, poorly absorbed antibiotic Rifamycin SV was found non-inferior to the systemic antibiotic ciprofloxacin in the oral treatment of non-dysenteric TD with the advantage of a lower risk of ESBL-E. Coli acquisition.
Collapse
Affiliation(s)
- Robert Steffen
- Department of Public Health, Epidemiology, Biostatistics and Prevention Institute, WHO Collaborating Centre for Travellers' Health, University of Zurich, Zurich, Switzerland.,Division of Epidemiology, Human Genetics & Environmental Sciences and Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
| | - Zhi-Dong Jiang
- Division of Epidemiology, Human Genetics & Environmental Sciences and Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
| | | | - Prithi Araujo
- Medical Department, NUSI Wockhardt Hospital, Cuncolim, Margao, Goa, India
| | - Michael Stiess
- Research and Development, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Tanju Nacak
- Research and Development, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Roland Greinwald
- Research and Development, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Herbert L DuPont
- Division of Epidemiology, Human Genetics & Environmental Sciences and Center for Infectious Diseases, University of Texas School of Public Health, Houston, TX, USA
| |
Collapse
|
15
|
Lääveri T, Vilkman K, Pakkanen SH, Kirveskari J, Kantele A. A prospective study of travellers' diarrhoea: analysis of pathogen findings by destination in various (sub)tropical regions. Clin Microbiol Infect 2017; 24:908.e9-908.e16. [PMID: 29133155 DOI: 10.1016/j.cmi.2017.10.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/12/2017] [Accepted: 10/24/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Eighty million travellers visiting (sub)tropical regions contract travellers' diarrhoea (TD) each year, yet prospective data comparing the prevalence of TD pathogens in various geographical regions are scarce. Our recent study using modern molecular methods found enteropathogenic (EPEC) and enteroaggregative (EAEC) Escherichia coli to be the most frequent pathogens, followed by enterotoxigenic E. coli (ETEC) and Campylobacter. We revisited our data to compare the findings by geographical region. METHODS A total of 459 prospectively recruited travellers provided stool samples and completed questionnaires before and after visiting destinations in various geographical regions. A multiplex quantitative real-time PCR assay was used to analyse Salmonella, Yersinia, Campylobacter jejuni/Campylobacter coli, Shigella, Vibrio cholerae, EPEC, EAEC, ETEC, enterohaemorrhagic E. coli and enteroinvasive E. coli. RESULTS TD was contracted by 69% (316/459) of the subjects; EPEC and EAEC outnumbered ETEC and Campylobacter in all regions. Multiple pathogens were detected in 42% (133/316) of the samples. The proportions of all pathogens varied by region. The greatest differences were seen for Campylobacter: while relatively frequent in South Asia (n = 11; 20% of the 55 with TD during travel) and Southeast Asia (15/84, 15%), it was less common in East and West Africa (5/71, 7% and 1/57, 2%) and absent in South America and the Caribbean (0/40). CONCLUSIONS EPEC and EAEC outnumbered ETEC and Campylobacter everywhere, yet the proportions of pathogen findings varied by region, with ETEC and Campylobacter rates showing the greatest differences. The high frequency of multibacterial findings in many regions indicates a need for further investigation of the clinical role of each pathogen.
Collapse
Affiliation(s)
- T Lääveri
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland
| | - K Vilkman
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland
| | - S H Pakkanen
- Department of Bacteriology and Immunology, University of Helsinki, Finland
| | - J Kirveskari
- Department of Bacteriology, Helsinki University Hospital Laboratory (HUSLAB), Finland
| | - A Kantele
- Inflammation Center, Division of Infectious Diseases, Helsinki University Hospital, Finland and University of Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Helsinki, Finland; Clinicum, University of Helsinki, Finland; Unit of Infectious Diseases, Department of Medicine/Solna, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
16
|
Lin SW, Lin CJ, Yang JC. Rifamycin SV MMX for the treatment of traveler’s diarrhea. Expert Opin Pharmacother 2017; 18:1269-1277. [DOI: 10.1080/14656566.2017.1353079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Shu-Wen Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Jung Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jyh-Chin Yang
- Department of Internal Medicine, Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
17
|
Nardelli S, Pisani LF, Tontini GE, Vecchi M, Pastorelli L. MMX ® technology and its applications in gastrointestinal diseases. Therap Adv Gastroenterol 2017; 10:545-552. [PMID: 28804515 PMCID: PMC5484438 DOI: 10.1177/1756283x17709974] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 04/18/2017] [Indexed: 02/04/2023] Open
Abstract
The Multimatrix® (MMX®) preparation MMX® is a recently obtained drug formulation developed to facilitate release of high concentrations of active drugs into the colon, with a homogeneous distribution along all colonic segments, particularly the most distal ones; the distal colonic tracts, indeed, are the most difficult to reach in significant amounts when a drug is given orally. The MMX® formulation is characterized by a lipophilic matrix dispersed in a hydrophilic structure. Indeed, in the last few years, MMX® technology has been widely used in the development of various drugs for the treatment of inflammatory and infectious gastrointestinal diseases localized in the colon. In particular, MMX® mesalamine, budesonide and parnaparin formulations have been investigated in patients with ulcerative colitis, and the first two have reached worldwide registration for the treatment of this disease. Moreover, MMX®-rifamycin is being positively tested in the treatment of colonic bacterial infections, including traveler's diarrhea. MMX® technology is, thus, proving to be a very effective formulation for the treatment of various colonic diseases. This effectiveness has been related not only to specific colonic delivery, but also to its ability to act in a once-daily dosage, thus favouring patients' adherence to prescribed schedules of treatment. The effective delivery of the active molecule to the site of need in the colon is also associated with very low systemic absorption and very low rates of adverse events (AEs). In this paper, we have reviewed all clinical trials performed with an MMX®-bound drug and all possible real-life reports, in order to give an overall evaluation of MMX®.
Collapse
Affiliation(s)
| | - Laura Francesca Pisani
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Maurizio Vecchi
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy Department of Biomedical Sciences for Health, Università di Milano, Milan, Italy
| | - Luca Pastorelli
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy Department of Biomedical Sciences for Health, Università di Milano, Milan, Italy
| |
Collapse
|
18
|
Riddle MS, Connor BA, Tribble DR. Targeted therapy in travelers' diarrhea: what is the role for the non-absorbable? J Travel Med 2014; 21:365-8. [PMID: 25345981 DOI: 10.1111/jtm.12162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 08/20/2014] [Accepted: 08/26/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Mark S Riddle
- Naval Medical Research Center, Silver Spring, MD, USA
| | | | | |
Collapse
|