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Wangchinda W, Pogue JM, Thamlikitkul V, Leelawattanachai P, Koomanachai P, Pai MP. Population pharmacokinetic/pharmacodynamic target attainment analysis of IV fosfomycin for the treatment of MDR Gram-negative bacterial infections. J Antimicrob Chemother 2024; 79:1372-1379. [PMID: 38597137 DOI: 10.1093/jac/dkae111] [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: 01/30/2024] [Accepted: 03/22/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND IV fosfomycin is used against MDR Gram-negative bacilli (GNB) but has dose-limiting side effects, especially in patients with impaired kidney function. OBJECTIVES To determine the optimal dosage of IV fosfomycin for patients with varying degrees of kidney function. METHODS Adult patients receiving IV fosfomycin for treatment of GNB were eligible. Five serial blood samples were collected after at least three doses of fosfomycin; plasma was assayed by LC-MS/MS and modelled by population pharmacokinetic analysis. The PTA for AUC24/MIC of 98.9 for Escherichia coli and Klebsiella pneumoniae, and 40.8 for Pseudomonas aeruginosa were computed by Monte Carlo simulations. Cumulative fractions of response (CFR) were analysed for each pathogen using EUCAST MIC distributions. RESULTS A total of 24 patients were included. Creatinine clearance (CLCR) and gender significantly influenced fosfomycin clearance. The kidney function-adjusted dosing regimens are proposed by using the lowest dose that can achieve ≥90% PTA for AUC24/MIC of 98.9 at an MIC of ≤32 mg/L (EUCAST v.13 susceptibility breakpoint for Enterobacterales). For patients with normal kidney function (CLCR 91-120 mL/min), a dosage of 15 g/day is suggested. This regimen achieved 97.1% CFR against E. coli, whereas CFR was 72.9% for K. pneumoniae and 76.7% for P. aeruginosa. CONCLUSIONS A fosfomycin dosage of 15 g/day with adjustment according to kidney function provided high PTA and CFR when treating E. coli. This dosage is lower than that used in current practice and may improve tolerability. Higher dosages may be needed for P. aeruginosa; however, safety data are limited.
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Affiliation(s)
- Walaiporn Wangchinda
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jason M Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
| | | | - Pannee Leelawattanachai
- Department of Pharmacy, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48108, USA
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2
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Castro-Balado A, Varela-Rey I, Mejuto B, Mondelo-García C, Zarra-Ferro I, Rodríguez-Jato T, Fernández-Ferreiro A. Updated antimicrobial dosing recommendations for obese patients. Antimicrob Agents Chemother 2024; 68:e0171923. [PMID: 38526051 PMCID: PMC11064535 DOI: 10.1128/aac.01719-23] [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: 03/26/2024] Open
Abstract
The prevalence of obesity has increased considerably in the last few decades. Pathophysiological changes in obese patients lead to pharmacokinetic (PK) and pharmacodynamic (PD) alterations that can condition the correct exposure to antimicrobials if standard dosages are used. Inadequate dosing in obese patients can lead to toxicity or therapeutic failure. In recent years, additional antimicrobial PK/PD data, extended infusion strategies, and studies in critically ill patients have made it possible to obtain data to provide a better dosage in obese patients. Despite this, it is usually difficult to find information on drug dosing in this population, which is sometimes contradictory. This is a comprehensive review of the dosing of different types of antimicrobials (antibiotics, antifungals, antivirals, and antituberculosis drugs) in obese patients, where the literature on PK and possible dosing strategies in obese adults was critically assessed.
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Affiliation(s)
- Ana Castro-Balado
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Iria Varela-Rey
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Beatriz Mejuto
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
| | - Cristina Mondelo-García
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Irene Zarra-Ferro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Teresa Rodríguez-Jato
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Anxo Fernández-Ferreiro
- Pharmacy Department, University Clinical Hospital of Santiago de Compostela (SERGAS), Santiago de Compostela, Spain
- Clinical Pharmacology Group, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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3
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Darlow CA, Parrott N, Peck RW, Hope W. Development and application of neonatal physiology-based pharmacokinetic models of amikacin and fosfomycin to assess pharmacodynamic target attainment. CPT Pharmacometrics Syst Pharmacol 2024; 13:464-475. [PMID: 38108548 PMCID: PMC10941605 DOI: 10.1002/psp4.13097] [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: 09/18/2023] [Revised: 11/14/2023] [Accepted: 11/22/2023] [Indexed: 12/19/2023] Open
Abstract
Antimicrobial resistance increasingly complicates neonatal sepsis in a global context. Fosfomycin and amikacin are two agents being tested in an ongoing multicenter neonatal sepsis trial. Although neonatal pharmacokinetics (PKs) have been described for these drugs, the physiological variability within neonatal populations makes population PKs in this group uncertain. Physiologically-based pharmacokinetic (PBPK) models were developed in Simcyp for fosfomycin and amikacin sequentially for adult, pediatric, and neonatal populations, with visual and quantitative validation compared to observed data at each stage. Simulations were performed using the final validated neonatal models to determine drug exposures for each drug across a demographic range, with probability of target attainment (PTA) assessments. Successfully validated neonatal PBPK models were developed for both fosfomycin and amikacin. PTA analysis demonstrated high probability of target attainment for amikacin 15 mg/kg i.v. q24h and fosfomycin 100 mg/kg (in neonates aged 0-7 days) or 150 mg/kg (in neonates aged 7-28 days) i.v. q12h for Enterobacterales with fosfomycin and amikacin minimum inhibitory concentrations at the adult breakpoints. Repeat analysis in premature populations demonstrated the same result. PTA analysis for a proposed combination fosfomycin-amikacin target was also performed. The simulated regimens, tested in a neonatal sepsis trial, are likely to be adequate for neonates across different postnatal ages and gestational age. This work demonstrates a template for determining target attainment for antimicrobials (alone or in combination) in special populations without sufficient available PK data to otherwise assess with traditional pharmacometric methods.
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Affiliation(s)
- Christopher A. Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Department of PharmacologyUniversity of LiverpoolLiverpoolUK
| | - Neil Parrott
- Pharmaceutical Sciences, Roche Pharma Research and Early Development, Roche Innovation Centre BaselBaselSwitzerland
| | - Richard W. Peck
- Antimicrobial Pharmacodynamics and Therapeutics, Department of PharmacologyUniversity of LiverpoolLiverpoolUK
- Pharmaceutical Sciences, Roche Pharma Research and Early Development, Roche Innovation Centre BaselBaselSwitzerland
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of PharmacologyUniversity of LiverpoolLiverpoolUK
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4
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Farrington N, Dubey V, Johnson A, Horner I, Stevenson A, Unsworth J, Jimenez-Valverde A, Schwartz J, Das S, Hope W, Darlow CA. Molecular pharmacodynamics of meropenem for nosocomial pneumonia caused by Pseudomonas aeruginosa. mBio 2024; 15:e0316523. [PMID: 38236031 PMCID: PMC10865990 DOI: 10.1128/mbio.03165-23] [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: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
Hospital-acquired pneumonia (HAP) is a leading cause of morbidity and mortality, commonly caused by Pseudomonas aeruginosa. Meropenem is a commonly used therapeutic agent, although emergent resistance occurs during treatment. We used a rabbit HAP infection model to assess the bacterial kill and resistance pharmacodynamics of meropenem. Meropenem 5 mg/kg administered subcutaneously (s.c.) q8h (±amikacin 3.33-5 mg/kg q8h administered intravenously[i.v.]) or meropenem 30 mg/kg s.c. q8h regimens were assessed in a rabbit lung infection model infected with P. aeruginosa, with bacterial quantification and phenotypic/genotypic characterization of emergent resistant isolates. The pharmacokinetic/pharmacodynamic output was fitted to a mathematical model, and human-like regimens were simulated to predict outcomes in a clinical context. Increasing meropenem monotherapy demonstrated a dose-response effect to bacterial kill and an inverted U relationship with emergent resistance. The addition of amikacin to meropenem suppressed the emergence of resistance. A network of porin loss, efflux upregulation, and increased expression of AmpC was identified as the mechanism of this emergent resistance. A bridging simulation using human pharmacokinetics identified meropenem 2 g i.v. q8h as the licensed clinical regimen most likely to suppress resistance. We demonstrate an innovative experimental platform to phenotypically and genotypically characterize bacterial emergent resistance pharmacodynamics in HAP. For meropenem, we have demonstrated the risk of resistance emergence during therapy and identified two mitigating strategies: (i) regimen intensification and (ii) use of combination therapy. This platform will allow pre-clinical assessment of emergent resistance risk during treatment of HAP for other antimicrobials, to allow construction of clinical regimens that mitigate this risk.IMPORTANCEThe emergence of antimicrobial resistance (AMR) during antimicrobial treatment for hospital-acquired pneumonia (HAP) is a well-documented problem (particularly in pneumonia caused by Pseudomonas aeruginosa) that contributes to the wider global antimicrobial resistance crisis. During drug development, regimens are typically determined by their sufficiency to achieve bactericidal effect. Prevention of the emergence of resistance pharmacodynamics is usually not characterized or used to determine the regimen. The innovative experimental platform described here allows characterization of the emergence of AMR during the treatment of HAP and the development of strategies to mitigate this. We have demonstrated this specifically for meropenem-a broad-spectrum antibiotic commonly used to treat HAP. We have characterized the antimicrobial resistance pharmacodynamics of meropenem when used to treat HAP, caused by initially meropenem-susceptible P. aeruginosa, phenotypically and genotypically. We have also shown that intensifying the regimen and using combination therapy are both strategies that can both treat HAP and suppress the emergence of resistance.
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Affiliation(s)
- Nicola Farrington
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Vineet Dubey
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Iona Horner
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Adam Stevenson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Jennifer Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | | | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - Christopher A. Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
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5
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Pipitone G, Di Bella S, Maraolo AE, Granata G, Gatti M, Principe L, Russo A, Gizzi A, Pallone R, Cascio A, Iaria C. Intravenous Fosfomycin for Systemic Multidrug-Resistant Pseudomonas aeruginosa Infections. Antibiotics (Basel) 2023; 12:1653. [PMID: 38136687 PMCID: PMC10741068 DOI: 10.3390/antibiotics12121653] [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: 10/03/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Human Pseudomonas infections have high morbidity and mortality rates. Pseudomonas bacteria can cause sepsis or septic shock; they produce biofilm and commonly exhibit a multidrug-resistant phenotype. The choice of antimicrobial therapy in many cases is challenging, and deep knowledge of clinical, microbiological, and pharmacological issues is required. Intravenous fosfomycin is being repurposed in a combination given its favorable pharmacokinetic/pharmacodynamic properties (a small molecule with favorable kinetic both in bloodstream infection and in deep-seated infections), antibiofilm activity, and its interesting synergistic effects with other antimicrobials. Recent literature on epidemiological, microbiological, pharmacological, and clinical data on intravenous fosfomycin therapy against Pseudomonas is herein reviewed and discussed.
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Affiliation(s)
- Giuseppe Pipitone
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, 90127 Palermo, Italy; (G.P.)
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy
| | - Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, 80131 Naples, Italy
| | - Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, 00149 Rome, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Clinical Pharmacology Unit, IRCCS University Hospital of Bologna, 40138 Bologna, Italy
| | - Luigi Principe
- Microbiology and Virology Unit, Great Metropolitan Hospital “Bianchi-Melacrino-Morelli”, 89133 Reggio Calabria, Italy
| | - Alessandro Russo
- Infectious and Tropical Diseases Unit, Department of Medical and Surgical Sciences, ‘Magna Graecia’ University of Catanzaro, 88100 Catanzaro, Italy
| | - Andrea Gizzi
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, 90127 Palermo, Italy; (G.P.)
- Infectious Diseases Unit, University Hospital P. Giaccone, 90127 Palermo, Italy
| | - Rita Pallone
- Infectious and Tropical Diseases Unit, University Hospital “Renato Dulbecco”, 88100 Catanzaro, Italy
| | - Antonio Cascio
- Infectious Diseases Unit, University Hospital P. Giaccone, 90127 Palermo, Italy
| | - Chiara Iaria
- Infectious Diseases Unit, ARNAS Civico-Di Cristina Hospital, 90127 Palermo, Italy; (G.P.)
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6
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Aubry R, Buyck J, Prouvensier L, Decousser JW, Nordmann P, Wicha SG, Marchand S, Grégoire N. An improved PKPD modeling approach to characterize the pharmacodynamic interaction over time between ceftazidime/avibactam and colistin from in vitro time-kill experiments against multidrug-resistant Klebsiella pneumoniae isolates. Antimicrob Agents Chemother 2023; 67:e0030123. [PMID: 37681977 PMCID: PMC10583682 DOI: 10.1128/aac.00301-23] [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: 03/07/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023] Open
Abstract
In contrast to the checkerboard method, bactericidal experiments [time-kill curves (TKCs)] allow an assessment of pharmacodynamic (PD) interactions over time. However, TKCs in combination pose interpretation problems. The objective of this study was to characterize the PD interaction over time between ceftazidime/avibactam (CZA) and colistin (CST) using TKC against four multidrug-resistant Klebsiella pneumoniae susceptible to both antibiotics and expressing a widespread carbapenemase determinant KPC-3. In vitro TKCs were performed and analyzed using pharmacokinetic/pharmacodynamic (PKPD) modeling. The general pharmacodynamic interaction model was used to characterize PD interactions between drugs. The 95% confidence intervals (95%CIs) of the expected additivity and of the observed interaction were built using parametric bootstraps and compared to evaluate the in vitro PD interaction over time. Further simulations were conducted to investigate the effect of the combination at varying concentrations typically observed in patients. Regrowth was observed in TKCs at high concentrations of drugs alone [from 4 to 32× minimum inhibitory concentrations (MIC)], while the combination systematically prevented the regrowth at concentrations close to the MIC. Significant synergy or antagonism were observed under specific conditions but overall 95%CIs overlapped widely over time indicating an additive interaction between antibiotics. Moreover, simulations of typical PK profile at standard dosages indicated that the interaction should be additive in clinical conditions. The nature of the PD interaction varied with time and concentration in TKC. Against the four K. pneumoniae isolates, the bactericidal effect of CZA + CST combination was predicted to be additive and to prevent the emergence of resistance at clinical concentrations.
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Affiliation(s)
- Romain Aubry
- Université de Poitiers, PHAR2, Inserm U1070, Poitiers, France
| | - Julien Buyck
- Université de Poitiers, PHAR2, Inserm U1070, Poitiers, France
| | - Laure Prouvensier
- Université de Poitiers, PHAR2, Inserm U1070, Poitiers, France
- Laboratoire de Toxicologie-Pharmacologie, CHU de Poitiers, Poitiers, France
| | - Jean-Winoc Decousser
- Department of Bacteriology and Infection Control, University Hospital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
- Faculté de Médecine de Créteil, Ecole nationale vétérinaire d'Alfort (EnvA), EA 7380 Dynamyc Université Paris - Est Créteil (UPEC), Créteil, France
| | - Patrice Nordmann
- Medical and Molecular Microbiology Unit, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
- Swiss National Reference Center for Emerging Antibiotic Resistance (NARA), University of Fribourg, Fribourg, Switzerland
- Institute for Microbiology, University of Lausanne and University Hospital Centre, Lausanne, Switzerland
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sandrine Marchand
- Université de Poitiers, PHAR2, Inserm U1070, Poitiers, France
- Laboratoire de Toxicologie-Pharmacologie, CHU de Poitiers, Poitiers, France
| | - Nicolas Grégoire
- Université de Poitiers, PHAR2, Inserm U1070, Poitiers, France
- Laboratoire de Toxicologie-Pharmacologie, CHU de Poitiers, Poitiers, France
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Anastasia A, Bonura S, Rubino R, Giammanco GM, Miccichè I, Di Pace MR, Colomba C, Cascio A. The Use of Intravenous Fosfomycin in Clinical Practice: A 5-Year Retrospective Study in a Tertiary Hospital in Italy. Antibiotics (Basel) 2023; 12:971. [PMID: 37370290 DOI: 10.3390/antibiotics12060971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Fosfomycin in intravenous (IV) formulation has re-emerged as a valuable tool in the treatment of multi-drug resistant (MDR) and extensively drug-resistant (XDR) infections because of its broad spectrum of antibacterial action and pharmacokinetic characteristics. This retrospective study aimed to evaluate how fosfomycin was used in patients admitted to the Polyclinic of Palermo between January 2017 and July 2022. Clinical indications, therapeutic associations, clinical outcomes, and any side effects were analyzed. Intravenous fosfomycin was used in 343 patients, 63% male, with a mean age of 68 years (range 15-95). Urinary tract infections (UTIs) and hospital-acquired pneumonia (HAP) were the main indications for treatment (19% and 18% of the total cases, respectively), followed by skin and soft tissue infections and sepsis. IV fosfomycin was administered in combination with other antibacterial agents, the most common of which were ceftazidime/avibactam (35%), meropenem (17%), and colistin (14%). Nineteen patients received it as monotherapy for UTIs. About 66% had resolution of the infectious process with clinical remission (cure or discharge). Electrolyte disturbances occurred in 2.6% and gastrointestinal symptoms occurred in 2.9%. The data showed that IV fosfomycin is a safe and effective therapeutic option in the treatment of infections with multidrug-resistant microorganisms.
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Affiliation(s)
- Antonio Anastasia
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G D'Alessandro", University of Palermo, 90127 Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Silvia Bonura
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Raffaella Rubino
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Giovanni Maurizio Giammanco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G D'Alessandro", University of Palermo, 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Microbiology and Virology Unit, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Irene Miccichè
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- UOC Farmacia, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
| | - Maria Rita Di Pace
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Claudia Colomba
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G D'Alessandro", University of Palermo, 90127 Palermo, Italy
| | - Antonio Cascio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G D'Alessandro", University of Palermo, 90127 Palermo, Italy
- Infectious and Tropical Disease Unit and Sicilian Regional Reference Center for the Fight against AIDS, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
- Antimicrobial Stewardship Team, AOU Policlinico "P. Giaccone", 90127 Palermo, Italy
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8
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Edwina AE, Koch BCP, Muller AE, Al Jalali V, Matzneller P, Zeitlinger M, Sassen SDT. Population plasma and urine pharmacokinetics and the probability of target attainment of fosfomycin in healthy male volunteers. Eur J Clin Pharmacol 2023; 79:775-787. [PMID: 37060459 DOI: 10.1007/s00228-023-03477-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/13/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE A population pharmacokinetic model of fosfomycin was developed in healthy volunteers after intravenous administration, and different dosing regimens were evaluated in terms of the probability of target attainment for Escherichia coli using both plasma and urinary pharmacokinetic/pharmacodynamic targets. METHODS Eight healthy men received fosfomycin as both intermittent 8 g q8h and continuous infusion 1 g/h with a loading dose of 8 g in a crossover study design. Dense sampling was conducted during both regimens. Population pharmacokinetic modelling was performed using NONMEM. Monte Carlo simulations were conducted to evaluate the Probability of Target Attainment (PTA) of different dosing regimens using bactericidal (AUC24h/MIC of 83 and 75%T>MIC) and bacteriostatic (AUC24h/MIC of 25) plasma targets and bacteriostatic (AUC24h/MIC of 3994) urine target. RESULTS A total of 176 plasma and 86 urine samples were available for PK analysis. A two-compartment model with a urine compartment best described the data. Glomerular filtration rate (GFR) showed a significant correlation with renal clearance and was implemented in the final model. Simulation results show that the dose of 4 g q8h reached 100% of PTA using bactericidal and bacteriostatic targets for MIC up to 16 mg/L. CONCLUSION For the clinical breakpoint of 32 mg/L, the standard dosing regimen (4 g q8h) might not be sufficient to reach the bactericidal target. Higher dosing of 8 g q8h as an intermittent infusion or 0.75 g/h as a continuous infusion might be required. Continuous infusion resulted in better attainment of the %T>MIC target than intermittent infusion.
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Affiliation(s)
- Angela Elma Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
- Gerontology and Geriatrics Unit, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Valentin Al Jalali
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Matzneller
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- Service of Rheumatology, Hospital of Merano, South Tyrol Health System ASDAA-SABES, South Tyrol, Italy
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Sebastiaan D T Sassen
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.
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9
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Ruiz-Ramos J, Gras-Martín L, Ramírez P. Antimicrobial Pharmacokinetics and Pharmacodynamics in Critical Care: Adjusting the Dose in Extracorporeal Circulation and to Prevent the Genesis of Multiresistant Bacteria. Antibiotics (Basel) 2023; 12:antibiotics12030475. [PMID: 36978342 PMCID: PMC10044431 DOI: 10.3390/antibiotics12030475] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/21/2023] [Accepted: 02/24/2023] [Indexed: 03/02/2023] Open
Abstract
Critically ill patients suffering from severe infections are prone to pathophysiological pharmacokinetic changes that are frequently associated with inadequate antibiotic serum concentrations. Minimum inhibitory concentrations (MICs) of the causative pathogens tend to be higher in intensive care units. Both pharmacokinetic changes and high antibiotic resistance likely jeopardize the efficacy of treatment. The use of extracorporeal circulation devices to support hemodynamic, respiratory, or renal failure enables pharmacokinetic changes and makes it even more difficult to achieve an adequate antibiotic dose. Besides a clinical response, antibiotic pharmacokinetic optimization is important to reduce the selection of strains resistant to common antibiotics. In this review, we summarize the present knowledge regarding pharmacokinetic changes in critically ill patients and we discuss the effects of extra-corporeal devices on antibiotic treatment together with potential solutions.
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Affiliation(s)
- Jesus Ruiz-Ramos
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Laura Gras-Martín
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Paula Ramírez
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
- Correspondence:
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10
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Chavan R, Naphade B, Waykar B, Bhagwat S. Investigations on In Vivo Pharmacokinetic/Pharmacodynamic Determinants of Fosfomycin in Murine Thigh and Kidney Infection Models. Microb Drug Resist 2023; 29:18-27. [PMID: 36346323 DOI: 10.1089/mdr.2022.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Amidst the era of widespread resistance, there has been a renewed interest in older antibiotics such as fosfomycin, owing to its activity against certain resistant Gram-negative pathogens, including multidrug-resistant variants expressing extended spectrum β-lactamases or carbapenemases. The goal of the study was to investigate pharmacokinetic/pharmacodynamic (PK/PD) index and PK/PD targets of fosfomycin in murine thigh and kidney infection models, employing clinical isolates of Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae). Methods: Seven isolates of E. coli (one wild-type and six clinical isolates) and five isolates of K. pneumoniae (one wild-type and four clinical isolates) were utilized for in vivo PK/PD studies. Single-dose plasma PK studies were conducted in infected mice by subcutaneous route. PD index was determined from exposure-response analysis employing 24-hr dose fractionation studies in neutropenic murine thigh infection model, while pharmacodynamic targets (PDTs) were derived from both thigh and kidney infection models. Results: Dose fractionation studies demonstrated that in vivo efficacy of fosfomycin best correlated with AUC/MIC for E. coli (R2 = 0.9227) and K. pneumoniae (R2 = 0.8693). The median AUC/MIC linked to 1 log10 kill effects were 346.2 and 745.2 in thigh infection model and 244.1 and 425.4 in kidney infection model for E. coli and K. pneumoniae, respectively. The mice plasma protein binding of fosfomycin was estimated to be 5.4%. Conclusions: The in vivo efficacy of fosfomycin against Enterobacterales was best described by AUC/MIC. The PDTs derived from this study may help define the coverage potential of fosfomycin at the clinical doses approved.
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Affiliation(s)
- Rajesh Chavan
- Department of Microbiology, Badrinarayan Barwale College, Jalna, India
| | - Bhushan Naphade
- Department of Microbiology, Badrinarayan Barwale College, Jalna, India
| | - Bhalchandra Waykar
- Department of Zoology, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad, India
| | - Sachin Bhagwat
- Department of Microbiology, Wockhardt Research Centre, Aurangabad, India
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11
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Ortiz-Padilla M, Portillo-Calderón I, Velázquez-Escudero A, Rodríguez-Baño J, Pascual Á, Rodríguez-Martínez JM, Docobo-Pérez F. Effect of Glycerol on Fosfomycin Activity against Escherichia coli. Antibiotics (Basel) 2022; 11:antibiotics11111612. [PMID: 36421256 PMCID: PMC9686493 DOI: 10.3390/antibiotics11111612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Fosfomycin is an antimicrobial that inhibits the biosynthesis of peptidoglycan by entering the bacteria through two channels (UhpT and GlpT). Glycerol is clinically used as a treatment for elevated intracranial pressure and induces the expression of glpT in Escherichia coli. Glycerol might offer synergistic activity by increasing fosfomycin uptake. The present study evaluates the use of glycerol at physiological concentrations in combination with fosfomycin against a collection of isogenic mutants of fosfomycin-related genes in E. coli strains. Induction of fosfomycin transporters, susceptibility tests, interaction assays, and time-kill assays were performed. Our results support the notion that glycerol allows activation of the GlpT transporter, but this induction is delayed over time and is not homogeneous across the bacterial population, leading to contradictory results regarding the enhancement of fosfomycin activity. The susceptibility assays showed an increase in fosfomycin activity with glycerol in the disk diffusion assay but not in the agar dilution or broth microdilution assays. Similarly, in the time-kill assays, the effect of glycerol was absent by the emergence of fosfomycin-resistant subpopulations. In conclusion, glycerol may not be a good candidate for use as an adjuvant with fosfomycin.
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Affiliation(s)
- Miriam Ortiz-Padilla
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
- Departamento de Microbiología, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
| | - Inés Portillo-Calderón
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Ana Velázquez-Escudero
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
| | - Álvaro Pascual
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
- Departamento de Microbiología, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - José Manuel Rodríguez-Martínez
- Departamento de Microbiología, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
- Correspondence: (J.M.R.-M.); (F.D.-P.); Tel.: +34-95-455-6100 (J.M.R.-M. & F.D.-P.)
| | - Fernando Docobo-Pérez
- Departamento de Microbiología, Facultad de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41009 Sevilla, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
- Correspondence: (J.M.R.-M.); (F.D.-P.); Tel.: +34-95-455-6100 (J.M.R.-M. & F.D.-P.)
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12
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Mohd Sazlly Lim S, Heffernan A, Naicker S, Wallis S, Roberts JA, Sime FB. Evaluation of Fosfomycin-Sulbactam Combination Therapy against Carbapenem-Resistant Acinetobacter baumannii Isolates in a Hollow-Fibre Infection Model. Antibiotics (Basel) 2022; 11:1578. [PMID: 36358238 PMCID: PMC9686642 DOI: 10.3390/antibiotics11111578] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 12/17/2023] Open
Abstract
Static concentration in vitro studies have demonstrated that fosfomycin- or sulbactam-based combinations may be efficacious against carbapenem-resistant Acinetobacter baumannii (CRAB). In the present study, we aimed to evaluate the bacterial killing and resistance suppression potential of fosfomycin-sulbactam combination therapies against CRAB isolates in a dynamic infection model. We simulated clinically relevant dosing regimens of fosfomycin (8 g every 8 h, 1 h infusion) and sulbactam (12 g continuous infusion or 4 g every 8 h, 4 h infusion) alone and in combination for 7 days in a hollow-fibre infection model (HFIM) against three clinical isolates of CRAB. The simulated pharmacokinetic profiles in the HFIM were based on fosfomycin and sulbactam data from critically ill patients. Fosfomycin monotherapy resulted in limited bacterial killing. Sulbactam monotherapies resulted in ~ 3 to 4 log10 kill within the first 8 to 32 h followed by regrowth of up to 8 to 10 log10 CFU/mL. A combination of fosfomycin and continuous infusion of sulbactam led to a ~2 to 4 log10 reduction in bacterial burden within the first 24 h, which was sustained throughout the duration of the experiments. A combination of fosfomycin and extended infusion of sulbactam produced a ~4 log10 reduction in colony count within 24 h. This study demonstrated that fosfomycin in combination with sulbactam is a promising option for the treatment of MDR A. baumannii. Further studies are needed to further assess the potential clinical utility of this combination.
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Affiliation(s)
- Sazlyna Mohd Sazlly Lim
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang 43400, Malaysia
| | - Aaron Heffernan
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
- School of Medicine, Griffith University, Southport, QLD 4222, Australia
| | - Saiyuri Naicker
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
| | - Steven Wallis
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
| | - Jason A. Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
| | - Fekade Bruck Sime
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD 4029, Australia
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13
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Obiero CW, Williams P, Murunga S, Thitiri J, Omollo R, Walker AS, Egondi T, Nyaoke B, Correia E, Kane Z, Gastine S, Kipper K, Standing JF, Ellis S, Sharland M, Berkley JA. Randomised controlled trial of fosfomycin in neonatal sepsis: pharmacokinetics and safety in relation to sodium overload. Arch Dis Child 2022; 107:802-810. [PMID: 35078765 PMCID: PMC9411916 DOI: 10.1136/archdischild-2021-322483] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/24/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess pharmacokinetics and changes to sodium levels in addition to adverse events (AEs) associated with fosfomycin among neonates with clinical sepsis. DESIGN A single-centre open-label randomised controlled trial. SETTING Kilifi County Hospital, Kenya. PATIENTS 120 neonates aged ≤28 days admitted being treated with standard-of-care (SOC) antibiotics for sepsis: ampicillin and gentamicin between March 2018 and February 2019. INTERVENTION We randomly assigned half the participants to receive additional intravenous then oral fosfomycin at 100 mg/kg two times per day for up to 7 days (SOC-F) and followed up for 28 days. MAIN OUTCOMES AND MEASURES Serum sodium, AEs and fosfomycin pharmacokinetics. RESULTS 61 and 59 infants aged 0-23 days were assigned to SOC-F and SOC, respectively. There was no evidence of impact of fosfomycin on serum sodium or gastrointestinal side effects. We observed 35 AEs among 25 SOC-F participants and 50 AEs among 34 SOC participants during 1560 and 1565 infant-days observation, respectively (2.2 vs 3.2 events/100 infant-days; incidence rate difference -0.95 events/100 infant-days (95% CI -2.1 to 0.20)). Four SOC-F and 3 SOC participants died. From 238 pharmacokinetic samples, modelling suggests an intravenous dose of 150 mg/kg two times per day is required for pharmacodynamic target attainment in most children, reduced to 100 mg/kg two times per day in neonates aged <7 days or weighing <1500 g. CONCLUSION AND RELEVANCE Fosfomycin offers potential as an affordable regimen with a simple dosing schedule for neonatal sepsis. Further research on its safety is needed in larger cohorts of hospitalised neonates, including very preterm neonates or those critically ill. Resistance suppression would only be achieved for the most sensitive of organisms so fosfomycin is recommended to be used in combination with another antimicrobial. TRIAL REGISTRATION NUMBER NCT03453177.
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Affiliation(s)
- Christina W Obiero
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Phoebe Williams
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sheila Murunga
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Raymond Omollo
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | | | - Thaddaeus Egondi
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Borna Nyaoke
- Global Antibiotic Research and Development Partnership, Nairobi, Kenya
| | - Erika Correia
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Zoe Kane
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International (ASI) Ltd, St George's - University of London, London, UK
| | - Joseph F Standing
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, University of London, London, UK
| | - James Alexander Berkley
- Clinical Research Deptartment, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya .,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
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14
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Zarakolu P, Eser ÖK, Otlu B, Gürpınar Ö, Özakın C, Akalın H, Köksal İ, Ünal S. In-vitro activity of fosfomycin against Escherichia coli and Klebsiella pneumoniae bloodstream isolates and frequency of OXA-48, NDM, KPC, VIM, IMP types of carbapenemases in the carbapenem-resistant groups. J Chemother 2022; 34:235-240. [PMID: 34495816 DOI: 10.1080/1120009x.2021.1963618] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim of this study was to determine the in-vitro activity of fosfomycin against Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae) isolates and the frequency of OXA-48, NDM, KPC, VIM, IMP types of carbapenemases in the carbapenem-resistant (CR) groups. A total of 346 isolates (126 E. coli and 220 K. pneumoniae) from nosocomial bloodstream infections were included. Carbapenem and fosfomycin susceptibility were tested by Etest (bioMerieux, France) and agar dilution methods, respectively and evaluated in accordance with EUCAST criteria. The presence of OXA-48, NDM, KPC, VIM, IMP types of carbapenemases were conducted by using PCR method. Of the total 346 isolates, 185 (41 E. coli, 144 K. pneumoniae) were CR. Fosfomycin susceptibility of E. coli was higher than 95% and was not statistically significant between the CR and carbapenem-susceptible (CS) groups. Fosfomycin susceptibility of CS and CR K. pneumoniae was 90.7% and 69.4%, respectively, and statistically significantly lower in CR group. Of the total 185 CR isolates, 163 (32 E. coli, 131 K. pneumoniae) were producing carbapenemases. OXA-48 was the prominent carbapenemase type produced by E. coli (96.8%) and K. pneumoniae (70.9%). The frequency of NDM and KPC types produced by K. pneumoniae was 20.6% and 15.2%, respectively. Fosfomycin has substantial in-vitro activity against nosocomial CS and CR E. coli and CS K. pneumoniae bloodstream isolates. However, due to the risk of emerging resistance with fosfomycin monotherapy, combination therapy should be considered to obtain the possible additive or synergistic activity. Emerging fosfomycin resistance of CR K. pneumoniae isolates is alarming and OXA-48 is still the prominent carbapenemase type in Turkey.
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Affiliation(s)
- Pınar Zarakolu
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Özgen Köseoğlu Eser
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Barış Otlu
- Department of Medical Microbiology, Faculty of Medicine, Inönü University, Malatya, Turkey
| | - Öznur Gürpınar
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Cüneyt Özakın
- Department of Medical Microbiology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Halis Akalın
- Department of Medical Microbiology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - İftihar Köksal
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Serhat Ünal
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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15
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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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16
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Assessment of In-Vitro Synergy of Fosfomycin with Meropenem, Amikacin and Tigecycline in Whole Genome Sequenced Extended and Pan Drug Resistant Klebsiella Pneumoniae: Exploring A Colistin Sparing Protocol. Antibiotics (Basel) 2022; 11:antibiotics11020153. [PMID: 35203756 PMCID: PMC8868363 DOI: 10.3390/antibiotics11020153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 12/10/2022] Open
Abstract
Fosfomycin has emerged as a very useful antimicrobial in management of extremely drug resistant (XDR) and pan drug resistant (PDR) Klebsiella pneumoniae. In this study, we assessed in-vitro synergy of colistin sparing combinations of fosfomycin (FOS) with meropenem (MEM), tigecycline (TGC) and amikacin (AK) against XDR and PDR Klebsiella pneumoniae. Method: Non-replicate fully characterised 18 clinical isolates of K. pneumoniae (15 XDR and 3 PDR strains) were subjected to in-vitro synergy testing by checkerboard and time kill assay. Combinations tested were FOS-MEM, FOS-TGC and FOS-AK with glucose-6-phosphate being incorporated in all runs.WGS was carried out on the Illumina next-generation sequencing platform. Results: FOS-MEM and FOS-AK both demonstrated excellent synergy against all PDRs and all but one XDR. Synergy led to lowering of MICs to susceptible breakpoints. FOS-TGC demonstrated antagonism. MLST-231 K. pneumoniae predominated (14), followed by ST-395 (3) and ST147 (1). Majority harboured OXA-232 (n = 15), while n = 2 carried NDM-1 type and n = 1 co-carried NDM-5 + OXA-232. Mortality was high in both ST-231 (57.1%) and ST-395 (66.6%). Synergy was observed despite widespread presence of resistance markers against aminoglycosides [aph(3′)-Ic, aacA4, and rmtf], beta-lactams [blaSHV-11, blaTEM-1b, blaCTX-M-15, and blaOXA-232], fosfomycin [fosA6 and fosA5] and presence of porin proteins OmpK37, OmpA and K. pneumoniae antibiotic efflux pumps Kpn F, H, G, and E. Conclusion: FOS + MEM and FOS + AK are excellent colistin sparing combinations against ST 231, ST-395 and ST-147 XDR and PDR K. pneumoniae. FOS with fewer side effects than colistin, excellent tissue distribution and minimal side effects may be recommended in combination with meropenem.
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17
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Sojo-Dorado J, López-Hernández I, Rosso-Fernandez C, Morales IM, Palacios-Baena ZR, Hernández-Torres A, Merino de Lucas E, Escolà-Vergé L, Bereciartua E, García-Vázquez E, Pintado V, Boix-Palop L, Natera-Kindelán C, Sorlí L, Borrell N, Giner-Oncina L, Amador-Prous C, Shaw E, Jover-Saenz A, Molina J, Martínez-Alvarez RM, Dueñas CJ, Calvo-Montes J, Silva JT, Cárdenes MA, Lecuona M, Pomar V, Valiente de Santis L, Yagüe-Guirao G, Lobo-Acosta MA, Merino-Bohórquez V, Pascual A, Rodríguez-Baño J. Effectiveness of Fosfomycin for the Treatment of Multidrug-Resistant Escherichia coli Bacteremic Urinary Tract Infections: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2137277. [PMID: 35024838 PMCID: PMC8759008 DOI: 10.1001/jamanetworkopen.2021.37277] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE The consumption of broad-spectrum drugs has increased as a consequence of the spread of multidrug-resistant (MDR) Escherichia coli. Finding alternatives for these infections is critical, for which some neglected drugs may be an option. OBJECTIVE To determine whether fosfomycin is noninferior to ceftriaxone or meropenem in the targeted treatment of bacteremic urinary tract infections (bUTIs) due to MDR E coli. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized, pragmatic, open clinical trial was conducted at 22 Spanish hospitals from June 2014 to December 2018. Eligible participants were adult patients with bacteremic urinary tract infections due to MDR E coli; 161 of 1578 screened patients were randomized and followed up for 60 days. Data were analyzed in May 2021. INTERVENTIONS Patients were randomized 1 to 1 to receive intravenous fosfomycin disodium at 4 g every 6 hours (70 participants) or a comparator (ceftriaxone or meropenem if resistant; 73 participants) with the option to switch to oral fosfomycin trometamol for the fosfomycin group or an active oral drug or parenteral ertapenem for the comparator group after 4 days. MAIN OUTCOMES AND MEASURES The primary outcome was clinical and microbiological cure (CMC) 5 to 7 days after finalization of treatment; a noninferiority margin of 7% was considered. RESULTS Among 143 patients in the modified intention-to-treat population (median [IQR] age, 72 [62-81] years; 73 [51.0%] women), 48 of 70 patients (68.6%) treated with fosfomycin and 57 of 73 patients (78.1%) treated with comparators reached CMC (risk difference, -9.4 percentage points; 1-sided 95% CI, -21.5 to ∞ percentage points; P = .10). While clinical or microbiological failure occurred among 10 patients (14.3%) treated with fosfomycin and 14 patients (19.7%) treated with comparators (risk difference, -5.4 percentage points; 1-sided 95% CI, -∞ to 4.9; percentage points; P = .19), an increased rate of adverse event-related discontinuations occurred with fosfomycin vs comparators (6 discontinuations [8.5%] vs 0 discontinuations; P = .006). In an exploratory analysis among a subset of 38 patients who underwent rectal colonization studies, patients treated with fosfomycin acquired a new ceftriaxone-resistant or meropenem-resistant gram-negative bacteria at a decreased rate compared with patients treated with comparators (0 of 21 patients vs 4 of 17 patients [23.5%]; 1-sided P = .01). CONCLUSIONS AND RELEVANCE This study found that fosfomycin did not demonstrate noninferiority to comparators as targeted treatment of bUTI from MDR E coli; this was due to an increased rate of adverse event-related discontinuations. This finding suggests that fosfomycin may be considered for selected patients with these infections. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02142751.
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Affiliation(s)
- Jesús Sojo-Dorado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Inmaculada López-Hernández
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Clara Rosso-Fernandez
- Unidad de Investigación Clínica y Ensayos Clínicos, Hospital Universitario Virgen del Rocío-Macarena, Sevilla, Spain
| | - Isabel M. Morales
- Unidad Clínica de Urgencias, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Zaira R. Palacios-Baena
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Alicia Hernández-Torres
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Esperanza Merino de Lucas
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Instituto Investigación Biomédica de Alicante, Alicante, Spain
| | - Laura Escolà-Vergé
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d’Hebrón, Barcelona, Spain
| | - Elena Bereciartua
- Unidad de Enfermedades Infecciosas, Hospital Universitario Cruces, Instituto de Investigación Biocruces, Baracaldo, Vizcaya, Spain
| | - Elisa García-Vázquez
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Vicente Pintado
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Lucía Boix-Palop
- Unidad de Enfermedades Infecciosas, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Clara Natera-Kindelán
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Luisa Sorlí
- Servicio de Enfermedades Infecciosas, Hospital del Mar, and Grupo de Investigación en Patología Infecciosa y Antibioterapia, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Pompeu Fabra, Barcelona, Spain
| | - Nuria Borrell
- Servicio de Microbiología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Livia Giner-Oncina
- Unidad de Enfermedades Infecciosas, Hospital General Universitario de Alicante, Instituto Investigación Biomédica de Alicante, Alicante, Spain
| | - Concha Amador-Prous
- Unidad de Enfermedades Infecciosas, Hospital Marina Baixa, Villajoyosa, Alicante, Spain
| | - Evelyn Shaw
- Servei de Malalties Infeccioses, Hospital Universitari de Bellvitge, Epidemiologia de les Infeccions Bacterianes, Patologia Infecciosa i Transplantament, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
| | - Alfredo Jover-Saenz
- Unidad Territorial Infección Nosocomial, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Lleida, Spain
| | - Jose Molina
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Rosa M. Martínez-Alvarez
- Unidad de Enfermedades Infecciosas, Hospital Royo Villanova, Zaragoza, Spain
- Now with Unidad de Enfermedades Infecciosas, Hospital Miguel Servet, Zaragoza, Spain
| | - Carlos J. Dueñas
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Burgos, Burgos, Spain
- Presently with Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Jorge Calvo-Montes
- Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria Valdecilla, Santander, Spain
| | - Jose T. Silva
- Unidad de Enfermedades Infecciosas, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Miguel A. Cárdenes
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Gran Canaria Dr Negrín, Las Palmas de Gran Canaria, Spain
| | - María Lecuona
- Servicio de Microbiología y Control de la Infección, Hospital Universitario de Canarias, La Laguna, Spain
| | - Virginia Pomar
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lucía Valiente de Santis
- Servicio de Enfermedades Infecciosas, UGC de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - Genoveva Yagüe-Guirao
- Servicio de Microbiología, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - María Angeles Lobo-Acosta
- Unidad de Investigación Clínica y Ensayos Clínicos, Hospital Universitario Virgen del Rocío-Macarena, Sevilla, Spain
| | - Vicente Merino-Bohórquez
- Unidad Clínica de Farmacia, Hospital Universitario Virgen Macarena and Departamento de Farmacología, Universidad de Sevilla, Sevilla, Spain
| | - Alvaro Pascual
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Consejo Superior de Investigaciones Científicas, Departamentos de Medicina y Microbiología, Universidad de Sevilla, Sevilla, Spain
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Liu L, Wang J, Zhang H, Chen M, Cai Y. Model-Informed Precision Dosing of Antibiotics in Osteoarticular Infections. Infect Drug Resist 2022; 15:99-110. [PMID: 35046675 PMCID: PMC8760971 DOI: 10.2147/idr.s332366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/11/2021] [Indexed: 11/23/2022] Open
Abstract
As a heterogeneous and wide inflammation, osteoarticular infection (OAI) shows an increasing incidence in recent years. Staphylococcus aureus is the most important pathogen causing OAI. The antibiotic treatment will affect the outcomes of OAI patients, and the drug selection and dosage regimen highly rely on patients’ variability, pathogen susceptibility, and drug property like bone permeability. Model-informed precision dosing (MIPD) provides options to describe and quantify the pharmacokinetic (PK) variability of the OAI population using different models, such as the population pharmacokinetic (PPK) model and physiological-based pharmacokinetic (PB/PK) model. In the present review, we highlighted that the MIPD of antibiotics played a critical role in OAI and listed the dose regimen recommended by the model. Collectively, our current study provided a valuable reference for the treatment of patients and improved the safety and efficiency of drug use.
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Affiliation(s)
- Lingling Liu
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, People’s Republic of China
| | - Jin Wang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, People’s Republic of China
| | - Huan Zhang
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, People’s Republic of China
| | - Mengli Chen
- Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, People’s Republic of China
- Mengli Chen Department of Pharmacy, Medical Supplies Center, PLA General Hospital, 28 Fu Xing Road, Beijing, 100853, People’s Republic of ChinaTel +86-10-6693-9610 Email
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, Beijing, People’s Republic of China
- Correspondence: Yun Cai Center of Medicine Clinical Research, Department of Pharmacy, Medical Supplies Center, PLA General Hospital, 28 Fu Xing Road, Beijing, 100853, People’s Republic of ChinaTel +86-10-6693-7166 Email
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19
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Zirpe KG, Mehta Y, Pandit R, Pande R, Deshmukh AM, Patil S, Bhagat S, Barkate H. A Real-world Study on Prescription Pattern of Fosfomycin in Critical Care Patients. Indian J Crit Care Med 2021; 25:1055-1058. [PMID: 34963727 PMCID: PMC8664030 DOI: 10.5005/jp-journals-10071-23958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study presents a real-world scenario for prescription pattern, efficacy, and safety data on the current clinical use of intravenous fosfomycin in critically ill patients in Indian settings. Patients and methods This was a retrospective cohort study conducted for a period of 10 months among critically ill patients admitted to hospital's critical care unit. The primary objective of the study was to analyze the prescription pattern of intravenous fosfomycin, and the secondary objective was to evaluate the safety profile and patient outcomes. Results A total of 309 patients were enrolled, and they were diagnosed with bacteremia (45.3%), pneumonia (15.85%), septic shock (14.24%), and urinary tract infections (UTI) (13.91%). The average dose of fosfomycin given was 11.7 ± 4.06 gm/day. The average duration of the therapy was 4.85 ± 3.59 days with a median duration of 4 days. Fosfomycin was given at 8 hourly dosing frequency to maximum (45.6%) cases. Hypokalemia was the most observed adverse event. The overall survival was seen in 55% of patients. Conclusion Our data suggest that UTI, infection caused by Escherichia coli, and a daily dose of >12 g were associated with better clinical outcomes. The overall survival of critically ill patients receiving fosfomycin was 55%. How to cite this article Zirpe KG, Mehta Y, Pandit R, Pande R, Deshmukh AM, Patil S, et al. A Real-world Study on Prescription Pattern of Fosfomycin in Critical Care Patients. Indian J Crit Care Med 2021;25(9):1055–1058.
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Affiliation(s)
- Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Yatin Mehta
- Institute of Critical Care and Anesthesia, Medanta-The Medicity, Gurugram, Haryana, India
| | - Rahul Pandit
- Department of Intensive Care, Fortis, Mumbai, Maharashtra, India
| | - Rajesh Pande
- Department of Critical Care Medicine, BLK Super Speciality Hospital, Delhi, India
| | - Abhijit M Deshmukh
- Department of Neuro Trauma Stroke Unit, Grant Medical Foundation's Ruby Hall Clinic, Pune, Maharashtra, India
| | - Saiprasad Patil
- Department of Global Medical Affairs, Glenmark Pharmaceutical Ltd, Mumbai, Maharashtra, India
| | - Sagar Bhagat
- Glenmark Pharmaceutical Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Department of Global Medical Affairs, Glenmark Pharmaceutical Ltd, Mumbai, Maharashtra, India
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20
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Dose Optimization of Combined Linezolid and Fosfomycin against Enterococcus by Using an In Vitro Pharmacokinetic/Pharmacodynamic Model. Microbiol Spectr 2021; 9:e0087121. [PMID: 34851157 PMCID: PMC8635129 DOI: 10.1128/spectrum.00871-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The rapid spread of antibiotic resistance among Enterococcus has prompted considerable interest in determining the dosage regimen of linezolid combined with fosfomycin. A checkerboard assay was employed to evaluate whether linezolid combined with fosfomycin had a synergistic effect on Enterococcus isolates from the hospital, including three drug-resistant strains (MIC of linezolid [MICLZD], ≥8 mg/L; MIC of fosfomycin [MICFOF], ≥256 mg/L). The in vitro static time-kill assay, dynamic pharmacokinetic (PK)/pharmacodynamic (PD) model, and semimechanistic PK/PD model were used to explore and predict effective combined dosage regimens. The checkerboard assay and in vitro static time-kill assay demonstrated that linezolid combined with fosfomycin has a synergistic effect on drug-resistant and sensitive Enterococcus. In the in vitro PK/PD model, the dosage regimen of linezolid (8 mg/L or 12 mg/L, steady-state concentration) combined with fosfomycin (6 g or 8 g) via a 0.5-h infusion every 8 h effectively suppressed bacterial growth at 24 h with a 3 log10 CFU/mL decrease compared with the initial inocula against two resistant and one sensitive Enterococcus isolates. The semimechanistic PK/PD model predicted that linezolid (more than 16 mg/L) combined with fosfomycin (6 g or 10 g) via a 0.5-h infusion every 8 h was required to achieve a 4 log10 CFU/mL decrease at 24 h against Enterococcus isolates (MICLZD ≥ 8 mg/L and MICFOF ≥ 256 mg/L). According to the prediction of the semimechanical PK/PD model, the effect of the combination was driven by linezolid, with fosfomycin enhancing the effect. Our study is the first to explore the synergistic effects of these two drugs from a qualitative and quantitative perspective and provides a simulation tool for future studies. IMPORTANCE In this study, we found that linezolid combined with fosfomycin could kill Enterococcus in vitro and that the administered dose was significantly lower after the combination treatment, which could reduce adverse effects and the development of drug resistance. The potential mechanism of the two-drug combination against Enterococcus was revealed from a quantitative perspective, which is an important step toward dose optimization in simulated humans. We hope that our research will help build a better relationship between clinicians and patients as we work together to address the challenges of antibiotic resistance in the 21st century.
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21
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Darlow CA, da Costa RMA, Ellis S, Franceschi F, Sharland M, Piddock L, Das S, Hope W. Potential Antibiotics for the Treatment of Neonatal Sepsis Caused by Multidrug-Resistant Bacteria. Paediatr Drugs 2021; 23:465-484. [PMID: 34435316 PMCID: PMC8418595 DOI: 10.1007/s40272-021-00465-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 01/26/2023]
Abstract
Neonatal sepsis causes up to an estimated 680,000 deaths annually worldwide, predominantly in low- and middle-income countries (LMICs). A significant and growing proportion of bacteria causing neonatal sepsis are resistant to multiple antibiotics, including the World Health Organization-recommended empiric neonatal sepsis regimen of ampicillin/gentamicin. The Global Antibiotic Research and Development Partnership is aiming to develop alternative empiric antibiotic regimens that fulfil several criteria: (1) affordable in LMIC settings; (2) activity against neonatal bacterial pathogens, including extended-spectrum β-lactamase producers, gentamicin-resistant Gram-negative bacteria, and methicillin-resistant Staphylococcus aureus (MRSA); (3) a licence for neonatal use or extensive experience of use in neonates; and (4) minimal toxicities. In this review, we identify five antibiotics that fulfil these criteria: amikacin, tobramycin, fosfomycin, flomoxef, and cefepime. We describe the available characteristics of each in terms of mechanism of action, resistance mechanisms, clinical pharmacokinetics, pharmacodynamics, and toxicity profile. We also identify some knowledge gaps: (1) the neonatal pharmacokinetics of cefepime is reliant on relatively small and limited datasets, and the pharmacokinetics of flomoxef are also reliant on data from a limited demographic range and (2) for all reviewed agents, the pharmacodynamic index and target has not been definitively established for both bactericidal effect and emergence of resistance, with many assumed to have an identical index/target to similar class molecules. These five agents have the potential to be used in novel combination empiric regimens for neonatal sepsis. However, the data gaps need addressing by pharmacokinetic trials and pharmacodynamic characterisation.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | | | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Laura Piddock
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
- Antimicrobials Research Group, Institute for Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
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22
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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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23
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Kuiper SG, Dijkmans AC, Wilms EB, Kamerling IMC, Burggraaf J, Stevens J, van Nieuwkoop C. Pharmacokinetics of fosfomycin in patients with prophylactic treatment for recurrent Escherichia coli urinary tract infection. J Antimicrob Chemother 2021; 75:3278-3285. [PMID: 32712666 PMCID: PMC9297308 DOI: 10.1093/jac/dkaa294] [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: 03/10/2020] [Accepted: 05/25/2020] [Indexed: 01/16/2023] Open
Abstract
Objectives To evaluate the pharmacokinetics and clinical effectiveness of IV and oral fosfomycin treatment in patients with recurrent urinary tract infection (rUTI) with Escherichia coli. Patients and methods Patients with rUTI treated with 3 g of oral fosfomycin every 72 h for at least 14 days were included in a prospective open-label single-centre study. Serum samples were taken after oral and IV administration of fosfomycin. Urine was collected for 24 h on 3 consecutive days. Fosfomycin concentrations in serum and urine were analysed using validated LC–MS/MS. Pharmacokinetics were evaluated using a population model. EudraCT number 2018-000616-25. Results Twelve patients were included, of whom nine were also administered IV fosfomycin. Data were best described by a two-compartment model with linear elimination and a transit-absorption compartment. Median values for absolute bioavailability and serum half-life were 18% and 2.13 h, respectively. Geometric mean urine concentrations on Days 1, 2 and 3 were above an MIC of 8 mg/L after both oral and IV administration. Quality of life reported on a scale of 1–10 increased from 5.1 to 7.4 (P = 0.001). The average score of UTI symptoms decreased after fosfomycin dosing (by 3.1 points, 95% CI = −0.7 to 7.0, P = 0.10). Conclusions Oral fosfomycin at 3 g every 72 h provides plasma and urine concentrations of fosfomycin above the MIC for E. coli. This pharmacokinetic model can be used to develop optimal dosing regimens of fosfomycin in patients with UTI.
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Affiliation(s)
- Sander G Kuiper
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Anneke C Dijkmans
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Erik B Wilms
- Department of Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands
| | - Ingrid M C Kamerling
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobus Burggraaf
- Centre for Human Drug Research (CHDR), Leiden, The Netherlands.,Leiden University Medical Center, Leiden, The Netherlands
| | - Jasper Stevens
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
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24
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Kane Z, Gastine S, Obiero C, Williams P, Murunga S, Thitiri J, Ellis S, Correia E, Nyaoke B, Kipper K, van den Anker J, Sharland M, Berkley JA, Standing JF. IV and oral fosfomycin pharmacokinetics in neonates with suspected clinical sepsis. J Antimicrob Chemother 2021; 76:1855-1864. [PMID: 33855449 PMCID: PMC8212774 DOI: 10.1093/jac/dkab083] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/20/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fosfomycin has the potential to be re-purposed as part of a combination therapy to treat neonatal sepsis where resistance to current standard of care (SOC) is common. Limited data exist on neonatal fosfomycin pharmacokinetics and estimates of bioavailability and CSF/plasma ratio in this vulnerable population are lacking. OBJECTIVES To generate data informing the appropriate dosing of IV and oral fosfomycin in neonates using a population pharmacokinetic analysis of plasma and CSF data. METHODS The NeoFosfo study (NCT03453177) was a randomized trial that examined the safety and pharmacokinetics of fosfomycin comparing SOC versus SOC plus fosfomycin. Sixty-one neonates received fosfomycin (100 mg/kg IV q12h for 48 h) and then they converted to oral therapy at the same dose. Two plasma pharmacokinetic samples were taken following the first IV and oral doses, sample times were randomized to cover the whole pharmacokinetic profile and opportunistic CSF pharmacokinetic samples were collected. A population pharmacokinetic model was developed in NONMEM and simulations were performed. RESULTS In total, 238 plasma and 15 CSF concentrations were collected. A two-compartment disposition model, with an additional CSF compartment and first-order absorption, best described the data. Bioavailability was estimated as 0.48 (95% CI = 0.347-0.775) and the CSF/plasma ratio as 0.32 (95% CI = 0.272-0.409). Allometric weight and postmenstrual age (PMA) scaling was applied; additional covariates included postnatal age (PNA) on clearance and CSF protein on CSF/plasma ratio. CONCLUSIONS Through this analysis a population pharmacokinetic model has been developed that can be used alongside currently available pharmacodynamic targets to select a neonatal fosfomycin dose based on an infant's PMA, PNA and weight.
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Affiliation(s)
- Zoe Kane
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Quotient Sciences, Mere Way, Ruddington, Nottingham, UK
| | - Silke Gastine
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Phoebe Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Sally Ellis
- GARDP-Global Antibiotic Research & Development Partnership, Genève, Switzerland
| | - Erika Correia
- GARDP-Global Antibiotic Research & Development Partnership, Genève, Switzerland
| | - Borna Nyaoke
- DNDi-Drugs for Neglected Diseases initiative, Nairobi, Kenya
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Joseph F Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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25
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Amikacin Combined with Fosfomycin for Treatment of Neonatal Sepsis in the Setting of Highly Prevalent Antimicrobial Resistance. Antimicrob Agents Chemother 2021; 65:e0029321. [PMID: 33972238 PMCID: PMC8373250 DOI: 10.1128/aac.00293-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial resistance (particularly through extended-spectrum β-lactamase and aminoglycoside-modifying enzyme production) in neonatal sepsis is a global problem, particularly in low- and middle-income countries, with significant mortality rates. High rates of resistance are reported for the current WHO-recommended first-line antibiotic regimen for neonatal sepsis, i.e., ampicillin and gentamicin. We assessed the utility of fosfomycin and amikacin as a potential alternative regimen to be used in settings of increasingly prevalent antimicrobial resistance. The combination was studied in a 16-arm dose-ranged hollow-fiber infection model (HFIM) experiment. The combination of amikacin and fosfomycin enhanced bactericidal activity and prevented the emergence of resistance, compared to monotherapy with either antibiotic. Modeling of the experimental quantitative outputs and data from checkerboard assays indicated synergy. We further assessed the combination regimen at clinically relevant doses in the HFIM with nine Enterobacterales strains with high fosfomycin and amikacin MICs and demonstrated successful kill to sterilization for 6/9 strains. From these data, we propose a novel combination breakpoint threshold for microbiological success for this antimicrobial combination against Enterobacterales strains, i.e., MICF × MICA < 256 (where MICF and MICA are the fosfomycin and amikacin MICs, respectively). Monte Carlo simulations predict that a standard fosfomycin-amikacin neonatal regimen would achieve >99% probability of pharmacodynamic success for strains with MICs below this threshold. We conclude that the combination of fosfomycin with amikacin is a viable regimen for the empirical treatment of neonatal sepsis and is suitable for further clinical assessment in a randomized controlled trial.
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Antonello RM, Di Bella S, Maraolo AE, Luzzati R. Fosfomycin in continuous or prolonged infusion for systemic bacterial infections: a systematic review of its dosing regimen proposal from in vitro, in vivo and clinical studies. Eur J Clin Microbiol Infect Dis 2021; 40:1117-1126. [PMID: 33604721 PMCID: PMC8139892 DOI: 10.1007/s10096-021-04181-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
Fosfomycin (FOS) administered intravenously has been recently rediscovered for the treatment of systemic infections due to multidrug-resistant bacteria. Its pharmacokinetic properties suggest a time-dependent dosing schedule with more clinical benefits from prolonged (PI) or continuous infusion (CI) than from intermittent infusion. We revised literature concerning PI and CI FOS to identify the best dosing regimen based on current evidence. We performed a MEDLINE/PubMed search. Ninety-one studies and their pertinent references were screened. Seventeen studies were included in the present review. The activity of FOS against Gram-negative and Gram-positive bacteria was evaluated in fourteen and five studies, respectively. Six studies evaluated FOS activity in combination with another antibiotic. Daily dosing of 12, 16, 18 or 24 g, administered with different schedules, were investigated. These regimens resulted active against the tested isolates in most cases. Emergence of resistant isolates has been shown to be preventable through the coadministration of another active antibiotic. FOS is a promising option to treat systemic infections caused by multidrug-resistant bacteria. Coadministration with another active molecule is required to prevent the emergence of resistant bacterial strains. The results of our review suggest that a therapeutic regimen including a loading dose of FOS 8 g followed by a daily dose of 16 g or 24 g CI could be the best therapeutic approach for patients with normal renal function. The dosing regimens in patients with renal insufficiency and CI or PI superiority compared with intermittent infusion in clinical settings should be further investigated.
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Affiliation(s)
- Roberta Maria Antonello
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy
| | - Stefano Di Bella
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy
| | - Alberto Enrico Maraolo
- First Division of Infectious Diseases, Cotugno Hospital, AORN dei Colli, 80131 Naples, Italy
| | - Roberto Luzzati
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy
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Population pharmacokinetics and Monte Carlo simulation for dosage optimization of fosfomycin in the treatment of osteoarticular infections in patients without renal dysfunction. Antimicrob Agents Chemother 2021; 65:AAC.02038-20. [PMID: 33619055 PMCID: PMC8092888 DOI: 10.1128/aac.02038-20] [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: 12/28/2022] Open
Abstract
Background: Fosfomycin is gaining interest in the treatment of complex osteoarticular infections (OI) due to MDR pathogens.Objective: The aims were to conduct population pharmacokinetics of fosfomycin in a cohort of OI patients receiving 16g/daily by intermittent (II) or continuous infusion (CI), and to carry out Monte Carlo simulations for dosage optimization in the treatment of these infections.Methods: Patients underwent blood sampling on day 5 of therapy (2-3 serial samples). Population pharmacokinetics and Monte Carlo simulations were performed to define the probability of target attainment (PTA) of 70% T>MIC, and the cumulative fraction of response (CFR) against common OI pathogens with dosages of 8, 12, 16, and 20g/day administered by II, extended-infusion (EI) or CI.Results: Forty-eight patients were recruited. A two-compartment open model with infusion input and first-order elimination was developed. Estimated creatinine clearance (CLCR) was included as covariate in the final model. Monte Carlo simulations showed that optimal PTAs and CFRs (≥90%) may be achieved in three different classes of renal function by administering a daily dosage of: 2g q6h by II against S. aureus, E. coli, ESBL-producing E. Coli and MRSA; 8g by CI against CoNS, K. pneumoniae and ESBL-producing K. pneumoniae; 12g by CI against P. aeruginosa, and 16g by CI against KPC-producing K. pneumoniae Conclusion: Our study provides a strong rationale for considering fosfomycin dosages of 8-16 g daily by CI in several clinical scenarios for OI patients. Feasibility of administration by CI in an elastomeric pump makes fosfomycin a candidate for OPAT programs.
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Activity of fosfomycin and amikacin against fosfomycin-heteroresistant Escherichia coli strains in a hollow-fiber infection model. Antimicrob Agents Chemother 2021; 65:AAC.02213-20. [PMID: 33685903 PMCID: PMC8092889 DOI: 10.1128/aac.02213-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives:To evaluate human-like intravenous doses of fosfomycin (8g/Q8h) and amikacin (15mg/kg/Q24h) efficacy in monotherapy and in combination against six fosfomycin-heteroresistant Escherichia coli isolates using a hollow-fiber infection model (HFIM).Materials and methods:Six fosfomycin-heteroresistant E. coli isolates (4 with strong mutator phenotype) and the control strain E. coli ATCC 25922 were used. Mutant frequencies for rifampin (100mg/L), fosfomycin (50 and 200mg/L) and amikacin (32mg/L) were determined. Fosfomycin and amikacin MICs were assessed by agar dilution (AD), gradient strip (GSA) and broth microdilution (BMD) assays. Fosfomycin and amikacin synergies were studied by checkerboard and time-kill assays at different concentrations. Fosfomycin (8g/Q8h) and amikacin (15mg/kg/Q24h) efficacy alone and in combination were assessed using a HFIM.Results:Five isolates were resistant to fosfomycin by AD and BMD, but all susceptible by GSA. All isolates were considered susceptible to amikacin. Antibiotic combinations were synergistic in two isolates and no antagonism was detected. In time-kill assays, all isolates survived under fosfomycin at 64mg/L, although, at 307mg/L, only the normomutators and two hypermutators survived. Four isolates survived under 16mg/L amikacin and none at 45mg/L. No growth was detected under combination conditions. In HFIM, fosfomycin and amikacin monotherapies failed to sterilise bacterial cultures, however, fosfomycin and amikacin combination showed a rapid eradication.Conclusions.There may be a risk of treatment failure of fosfomycin-heteroresistant E. coli isolates using either amikacin or fosfomycin in monotherapy. These results support that the combination amikacin-fosfomycin can rapidly decrease bacterial burden and prevent the emergence of resistant subpopulations against fosfomycin-heteroresistant strains.
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Wang G, Yu W, Cui Y, Shi Q, Huang C, Xiao Y. Optimal empiric treatment for KPC-2-producing Klebsiella pneumoniae infections in critically ill patients with normal or decreased renal function using Monte Carlo simulation. BMC Infect Dis 2021; 21:307. [PMID: 33771113 PMCID: PMC8004468 DOI: 10.1186/s12879-021-06000-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Limited clinical studies describe the pharmacodynamics of fosfomycin (FOS), tigecycline (TGC) and colistin methanesulfonate (CMS) in combination against KPC-producing Klebsiella pneumoniae (KPC-Kp). Population pharmacokinetic models were used in our study. Monte Carlo simulation was conducted to calculate probability of target attainment (PTA) and cumulative fraction of response (CFR) of each agent alone and in combination against KPC-Kp in patients with normal or decreased renal function. RESULTS The simulated regimen of FOS 6 g q8h reached ≥90% PTA against a MIC of 64 mg/L in patients with normal renal function. For patients with renal impairment, FOS 4 g q8h could provide sufficient antimicrobial coverage against a MIC of 128 mg/L. And increasing the daily dose could result to the cut-off value to 256 mg/L in decreased renal function. For TGC, conventional dosing regimens failed to reach 90% PTA against a MIC of 2 mg/L. Higher loading and daily doses (TGC 200/400 mg loading doses followed by 100 mg q12h/200 mg q24h) were needed. For CMS, none achieved 90% PTA against a MIC of 2 mg/L in normal renal function. Against KPC-Kp, the regimens of 200/400 mg loading dose followed by 100 q12h /200 mg q24h achieved > 80% CFRs regardless of renal function, followed by CMS 9 million IU loading dose followed by 4.5/3 million IU q12h in combination with FOS 8 g q8h (CFR 75-91%). CONCLUSIONS The use of a loading dose and high daily dose of TGC and CMS in combination with FOS can provide sufficient antimicrobial coverage against critically ill patients infected with KPC-Kp.
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Affiliation(s)
- Guoan Wang
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, 315000, China
| | - Wei Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yushan Cui
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, 315000, China
| | - Qingyi Shi
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, 315000, China
| | - Chen Huang
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, 315000, China.
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310003, China.
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Interplay among Different Fosfomycin Resistance Mechanisms in Klebsiella pneumoniae. Antimicrob Agents Chemother 2021; 65:AAC.01911-20. [PMID: 33361305 DOI: 10.1128/aac.01911-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/18/2020] [Indexed: 12/26/2022] Open
Abstract
The objectives of this study were to characterize the role of the uhpT, glpT, and fosA genes in fosfomycin resistance in Klebsiella pneumoniae and evaluate the use of sodium phosphonoformate (PPF) in combination with fosfomycin. Seven clinical isolates of K. pneumoniae and the reference strain (ATCC 700721) were used, and their genomes were sequenced. ΔuhpT, ΔglpT, and ΔfosA mutants were constructed from two isolates and K. pneumoniae ATCC 700721. Fosfomycin susceptibility testing was done by the gradient strip method. Synergy between fosfomycin and PPF was studied by checkerboard assay and analyzed using SynergyFinder. Spontaneous fosfomycin mutant frequencies at 64 and 512 mg/liter, in vitro activity using growth curves with fosfomycin gradient concentrations (0 to 256mg/liter), and time-kill assays at 64 and 307 mg/liter were evaluated with and without PPF (0.623 mM). The MICs of fosfomycin against the clinical isolates ranged from 16 to ≥1,024 mg/liter. The addition of 0.623 mM PPF reduced fosfomycin MIC between 2- and 8-fold. Deletion of fosA led to a 32-fold decrease. Synergistic activities were observed with the combination of fosfomycin and PPF (most synergistic area at 0.623 mM). The lowest fosfomycin-resistant mutant frequencies were found in ΔfosA mutants, with decreases in frequency from 1.69 × 10-1 to 1.60 × 10-5 for 64 mg/liter of fosfomycin. In the final growth monitoring and time-kill assays, fosfomycin showed a bactericidal effect only with the deletion of fosA and not with the addition of PPF. We conclude that fosA gene inactivation leads to a decrease in fosfomycin resistance in K. pneumoniae The pharmacological approach using PPF did not achieve enough activity, and the effect decreased with the presence of fosfomycin-resistant mutations.
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Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
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Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
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Clinical Pharmacokinetics of Fosfomycin after Continuous Infusion Compared with Intermittent Infusion: a Randomized Crossover Study in Healthy Volunteers. Antimicrob Agents Chemother 2020; 65:AAC.01375-20. [PMID: 33106259 DOI: 10.1128/aac.01375-20] [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: 07/03/2020] [Accepted: 10/15/2020] [Indexed: 01/28/2023] Open
Abstract
Continuous infusion (CON) of fosfomycin has been proposed as potentially advantageous in certain clinical scenarios. However, no clinical data on the pharmacokinetics (PK) of fosfomycin after CON are available to date. This study aimed to investigate the PK of fosfomycin after CON and compare it with intermittent infusion (INT) of fosfomycin. A randomized two-way crossover study including 8 healthy male volunteers was performed. Each subject received fosfomycin as INT of 8 g over 30 min every 8 h and, separated by a washout period, as CON of 1 g/h preceded by a loading dose of 8 g over 30 min. PK sampling was performed for 18 and 24 h in the CON and INT groups, respectively. Fosfomycin was generally well tolerated. However, 2 out of 8 subjects (25%) developed thrombophlebitis at the infusion site following CON, which was prevented in the following subjects with a simultaneous coinfusion of Ringer's lactate. The steady-state maximum concentration of drug in serum (C max) and area under the concentration-time curve from 0 to 24 h at steady state (AUCSS,0-24) of fosfomycin after INT were 551.5 ± 67.8 mg/liter and 3,678.5 ± 601.9 h · mg/liter, respectively. CON led to an average steady-state concentration of 183.8 ± 35.9 mg/liter, resulting in a calculated AUCSS,0-24 of 4,411.2 ± 862.4 h · mg/liter, which was 1.2-fold higher than that with INT. CON resulted in a 100% T >MIC (time during which the drug concentration exceeds the MIC) for MICs of ≤128 mg/liter, whereas the %T >MIC for INT was only 44% for an MIC of 128 mg/liter. CON of fosfomycin led to improved PK and PK/pharmacodynamic (PD) determinants in plasma of healthy volunteers. The clinical relevance of these findings remains to be investigated in patients.
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Kanchanasurakit S, Santimaleeworagun W, McPherson CE, Piriyachananusorn N, Boonsong B, Katwilat P, Saokaew S. Fosfomycin Dosing Regimens based on Monte Carlo Simulation for Treated Carbapenem-Resistant Enterobacteriaceae Infection. Infect Chemother 2020; 52:516-529. [PMID: 33124216 PMCID: PMC7779995 DOI: 10.3947/ic.2020.52.4.516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/20/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Infections by Carbapenem-Resistant Enterobacteriaceae (CRE) remain a leading cause of death in critically ill patients. Fosfomycin has been regarded as an alternative therapy for treatment of infections caused by CRE organisms. The purpose of this study is to evaluate clinical outcomes amongst patients with CRE infection who are receiving a fosfomycin dosing regimen using a Monte Carlo simulation and fosfomycin minimum inhibitory concentration (MIC). MATERIALS AND METHODS Fosfomycin MIC was defined by the E-test method. We used Fosfomycin pharmacokinetic parameters from a previously published study. The percent of the time period in which the drug concentration exceeded the MIC, or %T>MIC, used in this study were determined to be 70% of T>MIC and 100% of T>MIC, respectively. All dosing regimens were estimated for the probability of target attainment using a Monte Carlo simulation. RESULTS In this study, we found the MIC's of fosfomycin against CRE isolates ranged from 8 mg/L to 96 mg/L. The total daily dose of fosfomycin ranged from 16 - 24 g and was administered utilizing various fosfomycin dosing regimens to achieve the pharmacokinetic/pharmacodynamic (PK/PD) target in pathogens with a MIC of 32 mg/L for 70%T>MIC and a MIC of 12 mg/L for 100%T>MIC, respectively. For the twelve patients who received the recommended fosfomycin dosing regimen, eleven achieved bacterial eradication for a microbiological cure rate of 91%; and of those patients achieving eradication, two died despite having negative cultures for CRE; the one remaining patient had bacterial persistence. The most commonly observed adverse drug reactions were hypernatremia (3 cases) and hypokalemia (3 cases) and acute kidney injury (3 cases). CONCLUSION Our findings suggest fosfomycin has tended to good efficacy when using dosing regimens that achieve the PK/PD target. Nonetheless, further validation of these regimens in larger populations is needed.
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Affiliation(s)
- Sukrit Kanchanasurakit
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Division of Pharmaceutical care, Department of Pharmacy, Phrae Hospital, Phrae, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Wichai Santimaleeworagun
- Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group (PIRBIG), Nakorn Pathom, Thailand
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakorn Pathom, Thailand
| | - Charles E McPherson
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Benjawan Boonsong
- Division of Pharmaceutical care, Department of Pharmacy, Phrae Hospital, Phrae, Thailand
| | - Papanin Katwilat
- Division of Infectious Disease, Department of Medicine, Phrae Hospital, Phrae, Thailand
| | - Surasak Saokaew
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence on Herbal Medicine, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Biofunctional Molecule Exploratory Research Group, Biomedicine Research Advancement Centre, School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.
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Some Suggestions from PK/PD Principles to Contain Resistance in the Clinical Setting-Focus on ICU Patients and Gram-Negative Strains. Antibiotics (Basel) 2020; 9:antibiotics9100676. [PMID: 33036190 PMCID: PMC7601871 DOI: 10.3390/antibiotics9100676] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022] Open
Abstract
The containment of the phenomenon of resistance towards antimicrobials is a priority, especially in preserving molecules acting against Gram-negative pathogens, which represent the isolates more frequently found in the fragile population of patients admitted to Intensive Care Units. Antimicrobial therapy aims to prevent resistance through several actions, which are collectively known as “antimicrobial stewardship”, to be taken together, including the application of pharmacokinetic/pharmacodynamic (PK/PD) principles. PK/PD application has been shown to prevent the emergence of resistance in numerous experimental studies, although a straight translation to the clinical setting is not possible. Individualized antibiotic dosing and duration should be pursued in all patients, and even more especially when treating intensive care unit (ICU) septic patients in whom optimal exposure is both difficult to achieve and necessary. In this review, we report on the available data that support the application of PK/PD parameters to contain the development of resistance and we give some practical suggestions that can help to translate the benefit of PK/PD application to the bedside.
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In Vitro Pharmacodynamics of Fosfomycin against Carbapenem-Resistant Enterobacter cloacae and Klebsiella aerogenes. Antimicrob Agents Chemother 2020; 64:AAC.00536-20. [PMID: 32571821 DOI: 10.1128/aac.00536-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/15/2020] [Indexed: 11/20/2022] Open
Abstract
The increase of carbapenem-resistant Enterobacterales (CRE) and lack of therapeutic options due to the scarcity of new antibiotics has sparked interest toward the use of intravenous fosfomycin against systemic CRE infections. We aimed to investigate the in vitro pharmacodynamics of fosfomycin against carbapenem-resistant Enterobacter cloacae and Klebsiella aerogenes Time-kill studies and population analysis profiles were performed with eight clinical CRE isolates, which were exposed to fosfomycin concentrations ranging from 0.25 to 2,048 mg/liter. The 24-h mean killing effect was characterized by an inhibitory sigmoid maximum effect (E max) model. Whole-genome sequencing was performed to elucidate known fosfomycin resistance mechanisms. Fosfomycin MICs ranged from 0.5 to 64 mg/liter. The isolates harbored a variety of carbapenemase genes including bla IMP, bla KPC, and bla NDM Five out of eight isolates harbored the fosA gene, while none harbored the recently discovered fosL-like gene. Heteroresistant subpopulations were detected in all isolates, with two out of eight isolates harboring heteroresistant subpopulations at up to 2,048 mg/liter. In time-kill studies, fosfomycin exhibited bactericidal activity at 2 to 4 h at several fosfomycin concentrations (one isolate at ≥16 mg/liter, two at ≥32 mg/liter, two at ≥64 mg/liter, two at ≥128 mg/liter, and one at ≥512 mg/liter). At 24 h, bactericidal activity was only observed in two isolates (MICs, 0.5 and 4 mg/liter) at 2,048 mg/liter. From the E max model, no significant bacterial killing was observed beyond 500 mg/liter. Our findings suggest that the use of fosfomycin monotherapy may be limited against CRE due to heteroresistance and rapid bacterial regrowth. Further optimization of intravenous fosfomycin dosing regimens is required to increase efficacy against such infections.
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Abstract
PURPOSE OF REVIEW In the last decade, an increasing interest in using fosfomycin for the treatment of multidrug-resistant gram-negative (MDR-GNB) infections have been registered, especially when none or only a few other active alternatives remained available. RECENT FINDINGS Fosfomycin may remain active against a considerable proportion of MDR-GNB. In observational studies, a possible curative effect of oral fosfomycin monotherapy has been described for uncomplicated urinary tract infections (UTI) and bacterial prostatitis caused by MDR-GNB, whereas intravenous fosfomycin has been mostly used in combination with other agents for various type of severe MDR-GNB infections. The ZEUS randomized controlled trial (RCT) has started to provide high-level evidence about the possible use of fosfomycin for complicated UTI caused by extended-spectrum β-lactamase-producing GNB, but no results of large RCT are currently available to firmly guide the use of fosfomycin for carbapenem-resistant GNB. SUMMARY Fosfomycin is an important therapeutic option for MDR-GNB infections. Further pharmacokinetic/pharmacodynamic and clinical research is needed to optimize its use.
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The Clinical Significance of High Antimicrobial Resistance in Community-Acquired Urinary Tract Infections. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2020; 2020:2967260. [PMID: 32566057 PMCID: PMC7293720 DOI: 10.1155/2020/2967260] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 04/21/2020] [Accepted: 05/13/2020] [Indexed: 12/25/2022]
Abstract
Background Urinary tract infections (UTIs) affect up to 150 million individuals annually worldwide, mainly due to Escherichia coli (E. coli) and Klebsiella. The emergence and spread of multidrug-resistant (MDR) bacteria are increasing, representing one of the biggest threats for human health. The objective of our study was to describe antimicrobial patterns of resistance and identify risk factors associated with MDR uropathogens. Methods We conducted a cross-sectional study in 296 patients with community-acquired UTI who underwent clinical and microbiologic analysis, and clinical associations to MDR uropathogens were investigated. Findings. Microbiological analysis included E. coli (55%), ESBL-E. coli (26%), Enterococcus (6%), Klebsiella (5%), and others (8%). Higher frequencies of MDR bacteria were found among ESBL-E. coli, with resistance to ampicillin (100%), ceftriaxone (96%), gentamicin (57%), ciprofloxacin (89%), and TMP/SMX (53%). However, they were sensitive to fosfomycin (6.6%), nitrofurantoin (1.3%), and carbapenems (0%). Fosfomycin MIC90 for ESBL-E. coli was 5.78 μg/mL. The only clinical variable with significant association to ESBL producers was the presence of comorbidities: hypertension and type 2 diabetes mellitus with an OR (95%CI) of 2.5(1.3 − 4.9)(p < 0.01) and 2.8(1.2 − 6.7)(p < 0.05), respectively. Conclusions In the majority of cases, resistance rates to commonly prescribed antimicrobials in UTIs were high, except for fosfomycin, nitrofurantoin, and carbapenems. To provide appropriate treatment, both the identification of risk factors and the uropathogen would be important. An active surveillance in UTIs in the community is required since the proportion of ESBL producers is increasing.
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Erturk Sengel B, Altinkanat Gelmez G, Soyletir G, Korten V. In vitro synergistic activity of fosfomycin in combination with meropenem, amikacin and colistin against OXA-48 and/or NDM-producing Klebsiella pneumoniae. J Chemother 2020; 32:237-243. [PMID: 32228228 DOI: 10.1080/1120009x.2020.1745501] [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] [Indexed: 02/02/2023]
Abstract
Objective: Carbapenemase-producing Klebsiella pneumoniae (CPKp) infections are increasing worldwide. We investigated the in vitro synergistic activity of fosfomycin (FOS) with meropenem (MRP), amikacin (AMK) and colistin (COL) against OXA-48 and/or New Delhi metallo-beta-lactamase (NDM)-producing Kp blood isolates. Materials and Methods: Seventeen CPKp blood isolates were studied. The broth microdilution method was used for COL, MRP and AMK susceptibilities, while agar dilution for FOS. Synergy was tested by agar dilution chequerboard technique and also was confirmed by a time-kill assay for FOS/MRP and FOS/COL using three representative isolates that were found to be synergistic. Results: FOS in combination with MRP was found to be the most synergistic (15/17 strains, 88%), while 29% and 41% with AMK and COL, respectively. Antagonism was only determined in 2 isolates with the COL/FOS. Conclusions: The MRP/FOS combination demonstrated synergistic activity against CRKp, especially against the two common enzyme-producing isolates in Turkey (OXA-48 and NDM).
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Affiliation(s)
- Buket Erturk Sengel
- Department of Infectious Diseases, Marmara University School of Medicine, Istanbul, Turkey
| | | | - Guner Soyletir
- Department of Medical Microbiology, Marmara University School of Medicine, Istanbul, Turkey
| | - Volkan Korten
- Department of Infectious Diseases, Marmara University School of Medicine, Istanbul, Turkey
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39
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Grabein B, Ebenhoch M, Kühnen E, Thalhammer F. Calculated parenteral initial treatment of bacterial infections: Infections with multi-resistant Gram-negative rods - ESBL producers, carbapenemase-producing Enterobacteriaceae, carbapenem-resistant Acinetobacter baumannii. GMS INFECTIOUS DISEASES 2020; 8:Doc04. [PMID: 32373429 PMCID: PMC7186793 DOI: 10.3205/id000048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This is the sixteenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Infections due to multiresistant Gram-negative rods are challenging. In this chapter recommendations for targeted therapy for infections caused by ESBL-producing Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii are given, based on the limited available evidence.
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Affiliation(s)
- Béatrice Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Munich, Germany
| | - Michael Ebenhoch
- Stabsstelle Hygiene, Klinische Infektiologie und Mikrobiologie, BG-Unfallklinik Murnau, Germany
| | - Ernst Kühnen
- Mikrobiologie & Hygiene, MVZ Synlab Trier, Germany
| | - Florian Thalhammer
- Klinische Abteilung für Infektiologie und Tropenmedizin, Medizinische Universität Wien, Vienna, Austria
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40
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Garimella N, Zere T, Hartman N, Gandhi A, Bekele A, Li X, Stone H, Sacks L, Weaver JL. Effect of drug combinations on the kinetics of antibiotic resistance emergence in Escherichia coli CFT073 using an in vitro hollow-fibre infection model. Int J Antimicrob Agents 2019; 55:105861. [PMID: 31838036 DOI: 10.1016/j.ijantimicag.2019.105861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/04/2019] [Accepted: 12/08/2019] [Indexed: 11/30/2022]
Abstract
Antibiotic resistance is one of the major threats to public health today. To address this problem requires an urgent comprehensive approach. Strategic and multitargeted combination therapy has been increasingly used clinically to treat bacterial infections. The hollow-fibre infection model (HFIM) is a well-controlled in vitro bioreactor system that is increasingly being used in the assessment of resistance emergence with monotherapies and combination antibiotic therapies. In this study, the HFIM was evaluated as a reliable in vitro method to quantitatively and reproducibly analyse the emergence of antibiotic resistance using ampicillin, fosfomycin and ciprofloxacin and their simultaneous combinations against Escherichia coli CFT073, a clinical uropathogenic strain. Bacteria were exposed to clinically relevant pharmacokinetic (PK) concentrations of the drugs for 10 days. Drug and bacterial samples were collected at different time points for PK analysis and to enumerate total and resistant bacterial populations, respectively. The results demonstrated that double or triple combinations significantly delayed the emergence of resistant E. coli CFT073 subpopulations. These findings suggest that strategic combinations of antimicrobials may play a role in controlling the emergence of resistance during treatment. Further animal and human trials will be needed to confirm this and to ensure that there is no adverse impact on the host microbiome or unexpected toxicity. The HFIM system could potentially be used to identify clinically relevant combination dosing regimens for use in a clinical trial evaluating the appearance of resistance to antibacterial drugs.
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Affiliation(s)
- Narayana Garimella
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Tesfalem Zere
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Neil Hartman
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Adarsh Gandhi
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Aschalew Bekele
- Division of Microbiology Assessment, Office of Product Quality, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Xianbin Li
- Division of Biometrics IV, Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Heather Stone
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - Leonard Sacks
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, USA
| | - James L Weaver
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, US Food and Drug Administration, USA.
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41
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Petrosillo N, Granata G, Boyle B, Doyle MM, Pinchera B, Taglietti F. Preventing sepsis development in complicated urinary tract infections. Expert Rev Anti Infect Ther 2019; 18:47-61. [PMID: 31795788 DOI: 10.1080/14787210.2020.1700794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Urinary tract infections (UTIs) are the most prevalent infections in the community and the most common reason for antimicrobial prescribing in ambulatory care. A UTI is defined as complicated when urinary tract anatomical abnormalities or urinary devices are present, when it is recurrent and when associated with immunodeficiency. Complicated UTIs (cUTIs) have a higher risk of treatment failure and often require longer antimicrobial treatment courses. cUTIs, especially those which are healthcare-associated, are often due to multidrug resistant organisms (MDROs).Areas covered: This article will review the available evidence in relation to prevention of sepsis in cUTI, evaluating the risk factors associated with sepsis development. Published articles from January 2005 to September 2019 on UTIs and sepsis prevention in complicated UTIs were identified by using MEDLINE (National Library of Medicine Bethesda MD) and by reviewing the references of retrieved articles.Expert opinion: Prevention of sepsis relies on prompt and timely diagnosis of cUTI, early identification of the causative organism, removal of obstructions and source control, proper and adequate empirical/targeted antimicrobial treatment. In particular, source control, i.e. removal of urinary obstructions, infected stents, urinary catheters, nephrostomies, and drainage of hydronephrosis/abscess, is essential for preventing the development and progression of sepsis.
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Affiliation(s)
- Nicola Petrosillo
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Guido Granata
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
| | - Breida Boyle
- Department of Clinical Microbiology, St. James Hospital, Dublin, Ireland and Trinity College Dublin, Ireland
| | - Maeve M Doyle
- Consultant Microbiologist, University Hospital Waterford, Waterford, Ireland.,Ireland and Royal College of Surgeons, University College Cork, Cork, Ireland
| | - Biagio Pinchera
- Clinic of Infectious Diseases, University "Federico II", Naples, Italy
| | - Fabrizio Taglietti
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS, Rome, Italy
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42
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Trinh TD, Smith JR, Rybak MJ. Parenteral Fosfomycin for the Treatment of Multidrug Resistant Bacterial Infections: The Rise of the Epoxide. Pharmacotherapy 2019; 39:1077-1094. [PMID: 31487056 DOI: 10.1002/phar.2326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Fosfomycin was initially discovered in 1969 but has recently gained renewed interest for the treatment of multidrug-resistant (MDR) bacterial infections, particularly in the United States. Its unique mechanism of action, bactericidal activity, broad spectrum of activity, and relatively safe and tolerable adverse effect profile make it a great addition to the dwindling antibiotic armamentarium. Fosfomycin contains a three-membered epoxide ring with a direct carbon to phosphorous bond that bypasses the intermediate oxygen bond commonly present in other organophosphorous compounds; this structure makes the agent unique from other antibiotics. Despite nearly 50 years of parenteral fosfomycin use in Europe, fosfomycin has retained stable activity against most pathogens. Furthermore, fosfomycin demonstrated in vitro synergy in combination with other cell wall-active antibiotics (e.g., β-lactams, daptomycin). These combinations may offer respite for severe infections due to MDR gram-positive and gram-negative bacteria. The intravenous (IV) formulation is currently under review in the United States, and apropos, this review collates more contemporary evidence (i.e., studies published between 2000 and early 2019) in anticipation of this development. The approval of IV fosfomycin provides another option for consideration in the management of MDR infections. Its unique structure will give rise to a promising epoxide epoch in the battle against MDR bacteria.
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Affiliation(s)
- Trang D Trinh
- Medication Outcomes Center, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, California
| | - Jordan R Smith
- Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, High Point, North Carolina
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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43
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Bilal H, Peleg AY, McIntosh MP, Styles IK, Hirsch EB, Landersdorfer CB, Bergen PJ. Elucidation of the pharmacokinetic/pharmacodynamic determinants of fosfomycin activity against Pseudomonas aeruginosa using a dynamic in vitro model. J Antimicrob Chemother 2019; 73:1570-1578. [PMID: 29506207 DOI: 10.1093/jac/dky045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/24/2018] [Indexed: 01/09/2023] Open
Abstract
Objectives To identify the fosfomycin pharmacokinetic (PK)/pharmacodynamic (PD) index (fT>MIC, fAUC/MIC or fCmax/MIC) most closely correlated with activity against Pseudomonas aeruginosa and determine the PK/PD target associated with various extents of bacterial killing and the prevention of emergence of resistance. Methods Dose fractionation was conducted over 24 h in a dynamic one-compartment in vitro PK/PD model utilizing P. aeruginosa ATCC 27853 and two MDR clinical isolates (CR 1005 and CW 7). In total, 35 different dosing regimens were examined across the three strains. Microbiological response was examined by log changes and population analysis profiles. A Hill-type Emax model was fitted to the killing effect data (expressed as the log10 ratio of the area under the cfu/mL curve for treated regimens versus controls). Results Bacterial killing of no more than ∼3 log10 cfu/mL was achieved irrespective of regimen. The fAUC/MIC was the PK/PD index most closely correlated with efficacy (R2 = 0.80). The fAUC/MIC targets required to achieve 1 and 2 log10 reductions in the area under the cfu/mL curve relative to growth control were 489 and 1024, respectively. No regimen was able to suppress the emergence of resistance, and near-complete replacement of susceptible with resistant subpopulations occurred with virtually all regimens. Conclusions Bacterial killing for fosfomycin against P. aeruginosa was most closely associated with the fAUC/MIC. Suppression of fosfomycin-resistant subpopulations could not be achieved even with fosfomycin exposures well above those that can be safely achieved clinically.
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Affiliation(s)
- Hajira Bilal
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Infection and Immunity Program, Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Michelle P McIntosh
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Ian K Styles
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Elizabeth B Hirsch
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | | | - Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
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44
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Soman R, Veeraraghavan B, Hegde A, Jiandani P, Mehta Y, Nagavekar V, Rodrigues C, Singh RK, Swaminathan S, Todi S, Varma S, Patil S, Barkate H. Indian consensus on the management of CRE infection in critically ill patients (ICONIC) - India. Expert Rev Anti Infect Ther 2019; 17:647-660. [PMID: 31375039 DOI: 10.1080/14787210.2019.1647103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: The increasing burden of carbapenem-resistant Enterobacteriaceae (CRE) carriage and infection in different patient settings in India has created an acute need for guidance for clinicians regarding optimal strategies for the management of CRE infection in critically ill patients. Research design and methods: A multidisciplinary panel of 11 Indian experts in CRE infection assembled for comprehensive discussion and consensus development. The experts developed clinical statements through a systematic review of key literature. Main outcome measures: The panel voted anonymously on 60 clinically relevant questions, through a modified Delphi process. Results: Forty-six key clinical consensus statements (CCS) were proposed. The panel reached a consensus on several important issues, providing recommendations on surveillance, diagnosis, prevention, pharmacokinetic challenges, combination therapy, and cornerstone molecules in CRE infections. The panel also proposed a treatment algorithm for NDM-prevalent settings. Conclusion: These consensus statements may offer clinicians expert guidance on the management of CRE infections. There is a dearth of high-/moderate-level evidence on managing CRE infections; the recommendations presented herein are based on expert opinion.
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Affiliation(s)
- Rajeev Soman
- a Infectious Diseases, Jupiter Hospital , Pune , India
| | - Balaji Veeraraghavan
- b Department of Clinical Microbiology, Christian Medical College , Vellore , India
| | - Ashit Hegde
- c Critical Care, Hinduja Hospital , Mumbai , India
| | | | - Yatin Mehta
- e Institute of Critical Care and Anesthesiology, Medanta, The Medicity , Gurugram , India
| | | | | | - R K Singh
- h Department of Emergency Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences , Lucknow , India
| | | | - Subhash Todi
- j Critical Care, Critical Care AMRI Hospitals , Kolkata , India
| | - Subhash Varma
- k Internal Medicine/Hematology, Fortis Hospital , Mohali , India
| | - Saiprasad Patil
- l Medical Services, IF, Glenmark Pharmaceuticals Ltd ., Mumbai , India
| | - Hanmant Barkate
- m Medical Services, IF & MEA, Glenmark Pharmaceuticals Ltd ., Mumbai , India
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45
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Sumi CD, Heffernan AJ, Lipman J, Roberts JA, Sime FB. What Antibiotic Exposures Are Required to Suppress the Emergence of Resistance for Gram-Negative Bacteria? A Systematic Review. Clin Pharmacokinet 2019; 58:1407-1443. [DOI: 10.1007/s40262-019-00791-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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46
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Petrosillo N, Taglietti F, Granata G. Treatment Options for Colistin Resistant Klebsiella pneumoniae: Present and Future. J Clin Med 2019; 8:E934. [PMID: 31261755 PMCID: PMC6678465 DOI: 10.3390/jcm8070934] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/01/2019] [Accepted: 06/25/2019] [Indexed: 01/17/2023] Open
Abstract
Multidrug-resistant (MDR) Klebsiella pneumoniae represents an increasing threat to human health, causing difficult-to-treat infections with a high mortality rate. Since colistin is one of the few treatment options for carbapenem-resistant K. pneumoniae infections, colistin resistance represents a challenge due to the limited range of potentially available effective antimicrobials, including tigecycline, gentamicin, fosfomycin and ceftazidime/avibactam. Moreover, the choice of these antimicrobials depends on their pharmacokinetics/pharmacodynamics properties, the site of infection and the susceptibility profile of the isolated strain, and is sometimes hampered by side effects. This review describes the features of colistin resistance in K. pneumoniae and the characteristics of the currently available antimicrobials for colistin-resistant MDR K. pneumoniae, as well as the characteristics of novel antimicrobial options, such as the soon-to-be commercially available plazomicin and cefiderocol. Finally, we consider the future use of innovative therapeutic strategies in development, including bacteriophages therapy and monoclonal antibodies.
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Affiliation(s)
- Nicola Petrosillo
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS-Via Portuense, 292 00149 Rome, Italy.
| | - Fabrizio Taglietti
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS-Via Portuense, 292 00149 Rome, Italy.
| | - Guido Granata
- Systemic and Immunocompromised Host Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", IRCCS-Via Portuense, 292 00149 Rome, Italy.
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47
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Fosfomycin for treatment of multidrug-resistant pathogens causing urinary tract infection: A real-world perspective and review of the literature. Diagn Microbiol Infect Dis 2019; 95:114856. [PMID: 31307867 DOI: 10.1016/j.diagmicrobio.2019.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/16/2019] [Accepted: 06/18/2019] [Indexed: 11/23/2022]
Abstract
Among 47 patients with urinary tract infections (UTIs) due to multidrug-resistant (MDR) bacteria, treatment with fosfomycin resulted in clinical cure rates of 87% and 94% at 48 hours and 14 days, respectively. Response rates did not vary across pathogens. Our retrospective, observational findings support fosfomycin treatment against MDR pathogens causing UTIs.
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48
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Plasma and tissue pharmacokinetics of fosfomycin in morbidly obese and non-obese surgical patients: a controlled clinical trial. J Antimicrob Chemother 2019; 74:2335-2340. [DOI: 10.1093/jac/dkz203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/04/2019] [Accepted: 04/09/2019] [Indexed: 01/10/2023] Open
Abstract
Abstract
Objectives
To assess the pharmacokinetics and tissue penetration of fosfomycin in obese and non-obese surgical patients.
Methods
Fifteen obese patients undergoing bariatric surgery and 15 non-obese patients undergoing major intra-abdominal surgery received an intravenous single short infusion of 8 g of fosfomycin. Fosfomycin concentrations were determined by LC-MS/MS in plasma and microdialysate from subcutaneous tissue up to 8 h after dosing. The pharmacokinetic analysis was performed in plasma and interstitial fluid (ISF) by non-compartmental methods.
Results
Thirteen obese patients (BMI 38–50 kg/m2) and 14 non-obese patients (BMI 0–29 kg/m2) were evaluable. The pharmacokinetics of fosfomycin in obese versus non-obese patients were characterized by lower peak plasma concentrations (468 ± 139 versus 594 ± 149 mg/L, P = 0.040) and higher V (24.4 ± 6.4 versus 19.0 ± 3.1 L, P = 0.010). The differences in AUC∞ were not significant (1275 ± 477 versus 1515 ± 352 mg·h/L, P = 0.16). The peak concentrations in subcutaneous tissue were reached rapidly and declined in parallel with the plasma concentrations. The drug exposure in tissue was nearly halved in obese compared with non-obese patients (AUC∞ 1052 ± 394 versus 1929 ± 725 mg·h/L, P = 0.0010). The tissue/plasma ratio (AUCISF/AUCplasma) was 0.86 ± 0.32 versus 1.27 ± 0.34 (P = 0.0047).
Conclusions
Whereas the pharmacokinetics of fosfomycin in plasma of surgical patients were only marginally different between obese and non-obese patients, the drug exposure in subcutaneous tissue was significantly lower in the obese patients.
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Candel FJ, David MM, López JB. New perspectives for reassessing fosfomycin: applicability in current clinical practice. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32 Suppl 1:1-7. [PMID: 31131586 PMCID: PMC6555164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Fosfomycin is a bactericidal antibiotic that interferes with cell wall synthesis. The drug therefore has a broad spectrum of activity against a wide range of Gram-positive and Gram-negative bacteria. Both the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) have started review processes of the accumulated information on the use of fosfomycin and on information from new clinical trials. The intent is to establish usage terms in Europe and to authorize the sale of fosfomycin in the US. This monograph reviews the most current aspects of the compound. From the microbiological point of view, fosfomycin's single mechanism of action can provide a synergistic effect to other classes of antibiotics, including β-lactams, aminoglycosides, lipopeptides and fluoroquinolones. The resistance mechanisms include the reduced intracellular transport of the antibiotic, the change in target and the direct inactivation of the antibiotic by metalloenzymes and kinases; however, the clinical impact of some of these mechanisms has not yet been elucidated. The lack of agreement in determining the sensitivity cutoffs between the Clinical and Laboratory Standards Institute (CLSI) (≤64 mg/L) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) (≤32 mg/L), the fact that a number of microorganisms require a higher MIC (Klebsiella spp., Enterobacter spp., Serratia spp., Pseudomonas aeruginosa) and the drug's different effective concentrations against Gram-positive and Gram-negative bacteria have resulted in recommended dosages for treating multiresistant microorganism infections that vary between 8 and 12 g/day for Gram-positive bacteria and 16 and 24 g/day for Gram-negative bacteria. Fosfomycin has 3 presentations (intravenous with disodium salt, oral with calcium salt and combined with tromethamine),has good distribution in tissues and abscesses and is well tolerated. The pharmacodynamic ratio of dosage production for fosfomycin is AUC/MIC. However, the pharmacokinetics/pharmacodynamic ratio could be optimized in daily practice based on the pathogen, the patient's clinical profile or the infection model. Fosfomycin is the treatment of choice for cystitis in immunocompetent patients, patients with transplants, pregnant women and in pediatric settings. The drug is especially useful due to its microbiological activity and oral posology in cystitis caused by ESBL bacteria. Administer intravenously at high doses and combined with other antimicrobial agents. Fosfomycin has been useful in treating infections by multiresistant Gram-negative bacteria, such as Enterobacteriaceae, carbapenemase carriers and P. aeruginosa, extensively resistant or panresistant in urinary infections and in skin and soft tissue. Fosfomycin has also been shown active in combination with daptomycin or imipenem in osteoarticular infections by methicillin-resistant Staphylococcus aureus. Fosfomycin is an old antibiotic that still has much to reveal.
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Affiliation(s)
- Francisco Javier Candel
- Enfermedades Infecciosas. Microbiología Clínica. Instituto de Investigación sanitaria San Carlos (IdIISC). Hospital Clínico San Carlos. Universidad Complutense. Madrid
| | | | - José Barberán López
- Medicina Interna y Enfermedades Infecciosas. Hospital Universitario HM Montepríncipe. Universidad San Pablo CEU. Madrid
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50
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Rodríguez-Gascón A, Canut-Blasco A. Deciphering pharmacokinetics and pharmacodynamics of fosfomycin. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2019; 32 Suppl 1:19-24. [PMID: 31131588 PMCID: PMC6555163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fosfomycin, a low molecular weight and hydrophilic drug with negligible protein binding, is eliminated almost exclusively by glomerular filtration, whose clearance is subject to patient renal function. The volume of distribution approximates to the extracellular body water (about 0.3 L/Kg) in healthy volunteers, but it is increased in critically ill patients with bacterial infections. Fosfomycin presents a high ability to distribute into many tissues, including inflamed tissues and abscess fluids. Based on PK/PD analysis and Monte Carlo simulations, we have evaluated different fosfomycin dosing regimen to optimize the treatment of septic patients due to Enterobacterales and Pseudomonas aeruginosa. As PK/PD targets, we selected %T>MIC > 70% for all pathogens, and AUC24/MIC > 24 and AUC24/MIC > 15 for net stasis of Enterobacterales and P. aeruginosa, respectively. Pharmacokinetic parameters in critically ill patients were obtained from the literature. Several dosing regimens were studied in patients with normal renal function: fosfomycin 2-8 g given every 6-12 hours, infused over 30 minutes- 24 hours. At the susceptibility EUCAST breakpoint for Enterobacterales and Staphylococcus spp. (MIC ≤ 32 mg/L), fosfomycin 4 g/8h or higher infused over 30 minutes achieved a probability of target attainment (PTA) > 90%, based in both %T>MIC and AUC24/MIC. For MIC of 64 mg/L, fosfomycin 6 g/6h in 30-minute infusion and 8 g/ 8h in 30-minute and 6 hours infusions also achieved PTA values higher than 90%. No fosfomycin monotherapy regimen was able to achieve PK/PD targets related to antimicrobial efficacy for P. aeruginosa with MICs of 256-512 mg/L.
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Affiliation(s)
- Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, España,Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, España
| | - Andrés Canut-Blasco
- Microbiology Service, Hospital Universitario de Álava, Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, España,Instituto de Investigación Biosanitaria (BIOARABA), Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, España
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