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Lowe J, Gillespie D, Aboklaish A, Lau TMM, Consoli C, Babu M, Goddard M, Hood K, Klein N, Thomas-Jones E, Turner M, Hubbard M, Marchesi J, Berrington J, Kotecha S. Azithromycin therapy for prevention of chronic lung disease of prematurity (AZTEC): a multicentre, double-blind, randomised, placebo-controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:608-618. [PMID: 38679042 DOI: 10.1016/s2213-2600(24)00079-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Systematic reviews have reported conflicting evidence on whether macrolide antibiotics reduce rates of chronic lung disease of prematurity (CLD) in at-risk preterm infants born at less than 30 weeks' gestation, including in those colonised with pulmonary Ureaplasma spp. Since an adequately powered trial has been lacking, we aimed to assess if the macrolide azithromycin improved survival without the development of physiologically defined moderate or severe CLD in preterm infants. METHODS AZTEC was a multicentre, double-blind, randomised, placebo-controlled trial conducted in 28 tertiary neonatal intensive care units in the UK. Infants were eligible if they were born at less than 30 weeks' gestation and had received at least 2 h of either non-invasive (continuous positive airway pressure or humidified high flow nasal cannula therapy) or invasive respiratory support (via endotracheal tube) within 72 h of birth. Eligible infants were randomly allocated in a 1:1 ratio using random permuted blocks of four to receive either intravenous azithromycin at 20 mg/kg per day for 3 days followed by 10 mg/kg for 7 days, or to placebo. Allocation was stratified by centre and gestational age at birth (<28 weeks vs ≥28 weeks). Azithromycin and placebo vials were encased in tamper-evident custom cardboard cartons to ensure masking for clinicians, parents, and the research team. The primary outcome was survival without development of physiologically defined moderate or severe CLD at 36 weeks' postmenstrual age. Outcomes and safety were analysed on an intention-to-treat basis (all randomly allocated infants, regardless of any post-randomisation events). The study was registered with ISRCRN (11650227) and is closed. FINDINGS Infants were recruited between Oct 9, 2019, and March 22, 2022. 799 (53·1%) of 1505 eligible infants underwent random allocation; three infants were withdrawn, including consent to use their data, leaving 796 infants for analysis. Survival without moderate or severe CLD occurred in 166 (42%) of 394 infants in the intervention group and 179 (45%) of 402 in the placebo group (three-level adjusted OR [aOR] 0·84, 95% CI 0·55-1·29, p=0·43). Pulmonary Ureaplasma spp colonisation did not influence treatment effect. Overall, seven serious adverse events were reported for the azithromycin group (five graded as severe, two as moderate), and six serious adverse events were reported in the placebo group (two severe, two moderate, and two mild), as assessed by the local principal investigators. INTERPRETATION Since prophylactic use of azithromycin did not improve survival without development of physiologically-defined CLD, regardless of Ureaplasma spp colonisation, it cannot be recommended in clinical practice. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- John Lowe
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | | | - Ali Aboklaish
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK
| | | | - Claudia Consoli
- Central Biotechnology Services, Cardiff University, Cardiff, UK
| | - Malavika Babu
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Mark Goddard
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Nigel Klein
- Institute of Child Health, University College London, London, UK
| | | | - Mark Turner
- Women and Children's Health, University of Liverpool, Liverpool, UK
| | - Marie Hubbard
- Neonatal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Janet Berrington
- Neonatal Medicine, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, UK.
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Silwedel C, Laube M, Speer CP, Glaser K. The Role of Ureaplasma Species in Prenatal and Postnatal Morbidity of Preterm Infants: Current Concepts. Neonatology 2024; 121:627-635. [PMID: 38934167 DOI: 10.1159/000539613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Ureaplasma species are considered commensals of the adult urogenital tract. Yet, in pregnancy, Ureaplasma parvum and Ureaplasma urealyticum have been associated with chorioamnionitis and preterm birth. In preterm infants, Ureaplasma respiratory tract colonization has been correlated with the development of bronchopulmonary dysplasia and has been implicated in the pathogenesis of other complications of prematurity. Controversies on the impact of Ureaplasma exposure on neonatal morbidity, however, remain, and recommendations for screening practices and therapeutic management in preterm infants are missing. SUMMARY In this review, we outline clinical and experimental evidence of Ureaplasma-driven fetal and neonatal morbidity, critically examining inconsistencies across some of the existing studies. We explore underlying mechanisms of Ureaplasma-associated neonatal morbidity and discuss gaps in the current understanding including the interplay between Ureaplasma and the maternal urogenital tract and the preterm airway microbiome. Ultimately, we highlight the importance of adequate diagnostics and review the potential efficacy of anti-infective therapies. KEY MESSAGES There is strong evidence that perinatal Ureaplasma exposure is causally related to the development of bronchopulmonary dysplasia, and there are conclusive data of the role of Ureaplasma in the pathogenesis of neonatal central nervous system infection. Observational and experimental findings indicate immunomodulatory capacities that might promote an increased risk of secondary infections. The burden of Ureaplasma exposure is inversely related to gestational age - leaving the tiniest babies at highest risk. A better knowledge of contributing pathogen and host factors and modulating conditions remains paramount to define screening and treatment recommendations allowing early intervention in preterm infants at risk.
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Affiliation(s)
- Christine Silwedel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Mandy Laube
- Center for Pediatric Research Leipzig, Division of Neonatology, Department of Pediatrics, University of Leipzig, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Kirsten Glaser
- Center for Pediatric Research Leipzig, Division of Neonatology, Department of Pediatrics, University of Leipzig, Leipzig, Germany
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
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Zhang Y, Wang Y, Li J, Wang H, Hou M, Dong R, Li X. Population Pharmacokinetics and Individualized Medication of Azithromycin for Injection in Children Under 6 Years Old. J Pharm Sci 2024; 113:1351-1358. [PMID: 38253224 DOI: 10.1016/j.xphs.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
Pharmacokinetic data for injectable azithromycin in children remain limited. This study aims to develop and validate a population pharmacokinetic model of azithromycin for injection in children under 6 years old and optimize its dosage regimen in this population. We prospectively enrolled patients under 6 years old who received azithromycin for injection at Beijing Friendship Hospital, Capital Medical University. Demographic information, clinical characteristics, and venous blood samples were collected in accordance with the research protocol. Azithromycin concentrations were determined using a validated UPLC-MS/MS method. The population pharmacokinetic model was structured using Phoenix NLME. The adequacy and robustness of the model was evaluated using VPC and bootstrap. We optimized azithromycin's dosing regimen for injection through Monte Carlo simulations. We included 254 plasma concentration data from 148 patients to establish the model. The clearance and volume were 1.27 L/h/kg and 45.6 L/kg, respectively. The covariates included were weight and age. VPC plots and nonparametric bootstrap showed that the final PPK model was reliable and robust. Based on Monte Carlo simulation, we derived a simple and practical dosing scheme. The results provided reference for individualized dosing in this population. The individualized dosing scheme based on Monte Carlo simulation can optimize clinical decision-making and guide personalized therapy.
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Affiliation(s)
- Yuwen Zhang
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing China
| | - Yinghui Wang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China
| | - Jiangshuo Li
- Department of Research Ward, Beijing Friendship Hospital, Capital Medical University, 101100, Beijing, China
| | - Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, 545001, Liuzhou, Guangxi, China
| | - Mengyu Hou
- Department of Research Ward, Beijing Friendship Hospital, Capital Medical University, 101100, Beijing, China
| | - Ruihua Dong
- Department of Research Ward, Beijing Friendship Hospital, Capital Medical University, 101100, Beijing, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing China.
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Viscardi RM, Magder LS, Terrin ML, Davis NL. Predicting the likelihood of lower respiratory tract Ureaplasma infection in preterms. Arch Dis Child Fetal Neonatal Ed 2023; 108:250-255. [PMID: 36261143 PMCID: PMC10113605 DOI: 10.1136/archdischild-2022-324192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/06/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop predictive models of Ureaplasma spp lower airway tract infection in preterm infants. METHODS A dataset was assembled from five cohorts of infants born <33 weeks gestational age (GA) enrolled over 17 years (1999-2016) with culture and/or PCR-confirmed tracheal aspirate Ureaplasma status in the first week of life (n=415). Seventeen demographic, obstetric and neonatal factors were analysed including admission white blood cell (WBC) counts. Best subset regression was used to develop three risk scores for lower airway Ureaplasma infection: (1) including admission laboratory values, (2) excluding admission laboratory values and (3) using only data known prenatally. RESULTS GA and rupture of membranes >72 hours were significant predictors in all 3 models. When all variables including admission laboratory values were included in the regression, WBC count was also predictive in the resulting model. When laboratory values were excluded, delivery route was found to be an additional predictive factor. The area under the curve for the receiver operating characteristic indicated high predictive ability of each model to identify infants with lower airway Ureaplasma infection (range 0.73-0.77). CONCLUSION We developed predictive models based on clinical and limited laboratory information available in the perinatal period that can distinguish between low risk (<10%) and high risk (>40%) of lower airway Ureaplasma infection. These may be useful in the design of phase III trials of therapeutic interventions to prevent Ureaplasma-mediated lung disease in preterm infants and in clinical management of at-risk infants.
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Affiliation(s)
- Rose Marie Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael L Terrin
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Developmental Pharmacokinetics of Antibiotics Used in Neonatal ICU: Focus on Preterm Infants. Biomedicines 2023; 11:biomedicines11030940. [PMID: 36979919 PMCID: PMC10046592 DOI: 10.3390/biomedicines11030940] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023] Open
Abstract
Neonatal Infections are among the most common reasons for admission to the intensive care unit. Neonatal sepsis (NS) significantly contributes to mortality rates. Empiric antibiotic therapy of NS recommended by current international guidelines includes benzylpenicillin, ampicillin/amoxicillin, and aminoglycosides (gentamicin). The rise of antibacterial resistance precipitates the growth of the use of antibiotics of the Watch (second, third, and fourth generations of cephalosporines, carbapenems, macrolides, glycopeptides, rifamycins, fluoroquinolones) and Reserve groups (fifth generation of cephalosporines, oxazolidinones, lipoglycopeptides, fosfomycin), which are associated with a less clinical experience and higher risks of toxic reactions. A proper dosing regimen is essential for effective and safe antibiotic therapy, but its choice in neonates is complicated with high variability in the maturation of organ systems affecting drug absorption, distribution, metabolism, and excretion. Changes in antibiotic pharmacokinetic parameters result in altered efficacy and safety. Population pharmacokinetics can help to prognosis outcomes of antibiotic therapy, but it should be considered that the neonatal population is heterogeneous, and this heterogeneity is mainly determined by gestational and postnatal age. Preterm neonates are common in clinical practice, and due to the different physiology compared to the full terms, constitute a specific neonatal subpopulation. The objective of this review is to summarize the evidence about the developmental changes (specific for preterm and full-term infants, separately) of pharmacokinetic parameters of antibiotics used in neonatal intensive care units.
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Chang E, Ballard KE, Johnson PN, Nandyal R, Miller JL. Azithromycin for Eradication of Ureaplasma and Prevention of Bronchopulmonary Dysplasia in Preterm Neonates in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2023; 28:10-19. [PMID: 36777984 PMCID: PMC9901312 DOI: 10.5863/1551-6776-28.1.10] [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: 02/21/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023]
Abstract
Azithromycin has been explored as a treatment option for eradication of Ureaplasma and prevention of bronchopulmonary dysplasia (BPD) in preterm neonates. However, there is debate about the need for eradication of Ureaplasma and whether azithromycin is safe and efficacious for this indication. This literature review provides an overview of the evidence for use of azithromycin for eradication of Ureaplasma and prevention of BPD, including dosing and duration of azithromycin used in these studies. The literature search included articles published in the English language in Medline and PubMed from 1946 to January 2022. Relevant citations within identified articles were also reviewed. A total of 9 studies representing 388 neonates were included. The percentage of neonates that tested positive for Ureaplasma in these studies ranged from 18.6% to 57.1%. Azithromycin was initiated at <3 days of life in 8 studies (88.9%). Dosing was variable and ranged from 5 to 20 mg/kg/dose administered once daily, and the duration of treatment ranged from 1 to 35 days. Most studies used intravenous azithromycin. Overall, azithromycin was more efficacious than placebo at Ureaplasma eradication; however, most of these studies did not find a difference in the incidence of BPD between patients receiving azithromycin versus placebo. No adverse effects, specifically pyloric stenosis or QT interval prolongation, were noted in these studies.
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Affiliation(s)
- Eugenie Chang
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Kaci E Ballard
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Raja Nandyal
- Section of Neonatology (RN), Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Thangaraju P, Velmurugan H, N K. Current Status of Pharmacokinetic Research in Children: A Systematic Review of Clinical Trial Records. Curr Rev Clin Exp Pharmacol 2022; 19:CRCEP-EPUB-128427. [PMID: 36573054 DOI: 10.2174/2772432818666221223155455] [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: 06/04/2022] [Revised: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many medications have different pharmacokinetics in children than in adults. Knowledge about the safety and efficacy of medications in children requires research into the pharmacokinetic profiles of children's medicines. By analysing registered clinical trial records, this study determined how frequently pharmacokinetic data is gathered in paediatric drug trials. METHODS We searched for the pharmacokinetic data from clinical trial records for preterm infants and children up to the age of 16 from January 2011 to April 2022. The records of trials involving one or more drugs in preterm infants and children up to the age of 16 were examined for evidence that pharmacokinetic data would be collected. RESULTS In a total of 1483 records of interventional clinical trials, 136 (9.17%) pharmacokinetic data involved adults. Of those 136 records, 60 (44.1%) records were pharmacokinetics trials involving one or more medicines in children up to the age of 16. 20 (33.3 %) in America, followed by 19 (31.6 %) in Europe. Most trials researched medicines in the field of infection or parasitic diseases 20 (33.3%). 27 (48.2%) and 26 (46.4%) trials investigated medicines that were indicated as essential medicine. CONCLUSION The pharmacokinetic characteristics of children's drugs need to be better understood. The current state of pharmacokinetic research appears to address the knowledge gap in this area adequately. Despite slow progress, paediatric clinical trials have experienced a renaissance as the significance of paediatric trials has gained international attention. The outcome of paediatric trials will have an impact on children's health in the future. In recent years, the need for greater availability and access to safe child-size pharmaceuticals has received a lot of attention.
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Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Hemasri Velmurugan
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Krishnapriya N
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
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Barks JD, Liu Y, Dopp IA, Silverstein FS. Azithromycin reduces inflammation-amplified hypoxic-ischemic brain injury in neonatal rats. Pediatr Res 2022; 92:415-423. [PMID: 34625655 PMCID: PMC8989723 DOI: 10.1038/s41390-021-01747-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Systemic inflammation amplifies neonatal hypoxic-ischemic (HI) brain injury. Azithromycin (AZ), an antibiotic with anti-inflammatory properties, improves sensorimotor function and reduces tissue damage after neonatal rat HI brain injury. The objective of this study was to determine if AZ is neuroprotective in two neonatal rat models of inflammation-amplified HI brain injury. DESIGN/METHODS Seven-day-old (P7) rats received injections of toll-like receptor agonists lipopolysaccharide (LPS) or Pam3Cys-Ser-(Lys)4 (PAM) prior to right carotid ligation followed by 50 min (LPS + HI) or 60 min (PAM + HI) in 8% oxygen. Outcomes included contralateral forelimb function (forepaw placing; grip strength), survival, %Intact right hemisphere (brain damage), and a composite score incorporating these measures. We compared postnatal day 35 outcomes in controls and groups treated with three or five AZ doses. Then, we compared P21 outcomes when the first (of five) AZ doses were administered 1, 2, or 4 h after HI. RESULTS In both LPS + HI and PAM + HI models, AZ improved sensorimotor function, survival, brain tissue preservation, and composite scores. Benefits increased with five- vs. three-dose AZ and declined with longer initiation delay. CONCLUSIONS Perinatal systemic infection is a common comorbidity of neonatal asphyxia brain injury and contributes to adverse outcomes. These data support further evaluation of AZ as a candidate treatment for neonatal neuroprotection. IMPACT AZ treatment decreases sensorimotor impairment and severity of brain injury, and improves survival, after inflammation-amplified HI brain injury, and this can be achieved even with a 2 h delay in initiation. This neuroprotective benefit is seen in models of inflammation priming by both Gram-negative and Gram-positive infections. This extends our previous findings that AZ treatment is neuroprotective after HI brain injury in neonatal rats.
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Affiliation(s)
- John D.E. Barks
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Yiqing Liu
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Ian A. Dopp
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
| | - Faye S. Silverstein
- Department of Pediatrics, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI,Department of Neurology, University of Michigan Medical School, The University of Michigan, Ann Arbor, MI
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Randomized trial of azithromycin to eradicate Ureaplasma respiratory colonization in preterm infants: 2-year outcomes. Pediatr Res 2022; 91:178-187. [PMID: 33658655 PMCID: PMC8413397 DOI: 10.1038/s41390-021-01437-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND To assess the potential impact of azithromycin treatment in the first week following birth on 2-year outcomes in preterm infants with and without Ureaplasma respiratory colonization who participated in a double-blind, placebo-controlled randomized controlled trial. METHODS Respiratory morbidity was assessed at NICU discharge and at 6, 12, and 22-26 months corrected age using pulmonary questionnaires. Comprehensive neurodevelopmental assessments were completed between 22 and 26 months corrected age. The primary and secondary composite outcomes were death or severe respiratory morbidity and death or moderate-severe neurodevelopmental impairment, respectively, at 22-26 months corrected age. RESULTS One hundred and twenty-one randomized participants (azithromycin, N = 60; placebo, N = 61) were included in the intent-to-treat analysis. There were no significant differences in death or serious respiratory morbidity (34.8 vs 30.4%, p = 0.67) or death or moderate-severe neurodevelopmental impairment (47 vs 33%, p = 0.11) between the azithromycin and placebo groups. Among all trial participants, tracheal aspirate Ureaplasma-positive infants experienced a higher frequency of death or serious respiratory morbidity at 22-26 months corrected age (58%) than tracheal aspirate Ureaplasma-negative infants (34%) or non-intubated infants (21%) (p = 0.028). CONCLUSIONS We did not observe strong evidence of a difference in long-term pulmonary and neurodevelopment outcomes in preterm infants treated with azithromycin in the first week of life compared to placebo. IMPACT No strong evidence of a difference in long-term pulmonary and neurodevelopment outcomes was identified at 22-26 months corrected age in infants treated with azithromycin in the first week of life compared to placebo. The RCT is the first study of 2-year pulmonary and neurodevelopmental outcomes of azithromycin treatment in ELGANs. Provides evidence that ELGANs with lower respiratory tract Ureaplasma have the most frequent serious respiratory morbidity in the first 2 years of life, suggesting that a Phase III trial of azithromycin to prevent BPD targeting this population is warranted.
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Viscardi RM, Terrin ML, Magder LS, Davis NL, Dulkerian SJ, Waites KB, Ambalavanan N, Kaufman DA, Donohue P, Tuttle DJ, Weitkamp JH, Hassan HE, Eddington ND. Randomised trial of azithromycin to eradicate Ureaplasma in preterm infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:615-622. [PMID: 32170033 PMCID: PMC7592356 DOI: 10.1136/archdischild-2019-318122] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/26/2020] [Accepted: 02/25/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To test whether azithromycin eradicates Ureaplasma from the respiratory tract in preterm infants. DESIGN Prospective, phase IIb randomised, double-blind, placebo-controlled trial. SETTING Seven level III-IV US, academic, neonatal intensive care units (NICUs). PATIENTS Infants 240-286 weeks' gestation (stratified 240-266; 270-286 weeks) randomly assigned within 4 days following birth from July 2013 to August 2016. INTERVENTIONS Intravenous azithromycin 20 mg/kg or an equal volume of D5W (placebo) every 24 hours for 3 days. MAIN OUTCOME MEASURES The primary efficacy outcome was Ureaplasma-free survival. Secondary outcomes were all-cause mortality, Ureaplasma clearance, physiological bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age, comorbidities of prematurity and duration of respiratory support. RESULTS One hundred and twenty-one randomised participants (azithromycin: n=60; placebo: n=61) were included in the intent-to-treat analysis (mean gestational age 26.2±1.4 weeks). Forty-four of 121 participants (36%) were Ureaplasma positive (azithromycin: n=19; placebo: n=25). Ureaplasma-free survival was 55/60 (92% (95% CI 82% to 97%)) for azithromycin compared with 37/61 (61% (95% CI 48% to 73%)) for placebo. Mortality was similar comparing the two treatment groups (5/60 (8%) vs 6/61 (10%)). Azithromycin effectively eradicated Ureaplasma in all azithromycin-assigned colonised infants, but 21/25 (84%) Ureaplasma-colonised participants receiving placebo were culture positive at one or more follow-up timepoints. Most of the neonatal mortality and morbidity was concentrated in 21 infants with lower respiratory tract Ureaplasma colonisation. In a subgroup analysis, physiological BPD-free survival was 5/10 (50%) (95% CI 19% to 81%) among azithromycin-assigned infants with lower respiratory tract Ureaplasma colonisation versus 2/11 (18%) (95% CI 2% to 52%) in placebo-treated infants. CONCLUSION A 3-day azithromycin regimen effectively eradicated respiratory tract Ureaplasma colonisation in this study. TRIAL REGISTRATION NUMBER NCT01778634.
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Affiliation(s)
- Rose Marie Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael L Terrin
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Natalie L Davis
- Department of Pediatrics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Susan J Dulkerian
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ken B Waites
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - David A Kaufman
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Pamela Donohue
- Department of Pediatrics, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Deborah J Tuttle
- Department of Pediatrics, Christiana Care Health System, Newark, Delaware, USA
| | - Jorn-Hendrik Weitkamp
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hazem E Hassan
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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11
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Lowe J, Gillespie D, Hubbard M, Zhang L, Kirby N, Pickles T, Thomas-Jones E, Turner MA, Klein N, Marchesi JR, Hood K, Berrington J, Kotecha S. Study protocol: azithromycin therapy for chronic lung disease of prematurity (AZTEC) - a randomised, placebo-controlled trial of azithromycin for the prevention of chronic lung disease of prematurity in preterm infants. BMJ Open 2020; 10:e041528. [PMID: 33028566 PMCID: PMC7539578 DOI: 10.1136/bmjopen-2020-041528] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Chronic lung disease of prematurity (CLD), also known as bronchopulmonary dysplasia (BPD), is a cause of significant respiratory morbidity in childhood and beyond. Coupled with lung immaturity, infections (especially by Ureaplasma spp) are implicated in the pathogenesis of CLD through promotion of pulmonary inflammation. Azithromycin, which is a highly effective against Ureaplasma spp also has potent anti-inflammatory properties. Thus, azithromycin therapy may improve respiratory outcomes by targeting infective and inflammatory pathways. Previous trials using macrolides have not been sufficiently powered to definitively assess CLD rates. To address this, the azithromycin therapy for chronic lung disease of prematurity (AZTEC) trial aims to determine if a 10-day early course of intravenous azithromycin improves rates of survival without CLD when compared with placebo with an appropriately powered study. METHODS AND ANALYSIS 796 infants born at less than 30 weeks' gestational age who require at least 2 hours of continuous respiratory support within the first 72 hours following birth are being enrolled by neonatal units in the UK. They are being randomised to receive a double-blind, once daily dose of intravenous azithromycin (20 mg/kg for 3 days, followed by 10 mg/kg for a further 7 days), or placebo. CLD is being assessed at 36 weeks' PMA. Whether colonisation with Ureaplasma spp prior to randomisation modifies the treatment effect of azithromycin compared with placebo will also be investigated. Secondary outcomes include necrotising enterocolitis, intraventricular/cerebral haemorrhage, retinopathy of prematurity and nosocomial infections, development of antibiotic resistance and adverse reactions will be monitored. ETHICS AND DISSEMINATION Ethics permission has been granted by Wales Research Ethics Committee 2 (Ref 18/WA/0199), and regulatory permission by the Medicines and Healthcare Products Regulatory Agency (Clinical Trials Authorisation reference 21323/0050/001-0001). The study is registered on ISRCTN (ISRCTN11650227). The study is overseen by an independent Data Monitoring Committee and an independent Trial Steering Committee. We shall disseminate our findings via national and international peer-reviewed journals, and conferences. A summary of the findings will also be posted on the trial website.
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Affiliation(s)
- John Lowe
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - David Gillespie
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Marie Hubbard
- Neonatal Intensive Care Unit, University Hospitals of Leicester NHS Trust, Leicester, Leicester, UK
| | - Lei Zhang
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Nigel Kirby
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Timothy Pickles
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Nigel Klein
- GOS Institute of Child Health, University College London, London, London, UK
| | | | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Janet Berrington
- Neonatal Intensive Care Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, United Kingdom
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Zhou KQ, Davidson JO, Bennet L, Gunn AJ. Combination treatments with therapeutic hypothermia for hypoxic-ischemic neuroprotection. Dev Med Child Neurol 2020; 62:1131-1137. [PMID: 32614467 DOI: 10.1111/dmcn.14610] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 12/12/2022]
Abstract
Therapeutic hypothermia is now proven to reduce death or disability in term and near-term born infants with moderate to severe hypoxic-ischemic encephalopathy. Nevertheless, many infants still survive with disability, despite treatment with hypothermia. Recent preclinical and clinical studies suggest that current protocols for therapeutic hypothermia are near-optimal. The obvious strategy, in addition to improving early initiation of therapeutic hypothermia after birth, is to combine hypothermia with other neuroprotective agents. We review evidence that the mechanisms of action of many promising agents overlap with the anti-excitotoxic, anti-apoptotic, and anti-inflammatory mechanisms of hypothermia, leading to a lack of benefit from combination treatment. Moreover, even apparently beneficial combinations have failed to translate in clinical trials. These considerations highlight the need for preclinical studies to test clinically realistic protocols of timing and duration of treatment, before committing to large randomized controlled trials.
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Affiliation(s)
- Kelly Q Zhou
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, The University of Auckland, Auckland, New Zealand
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Abstract
Mycoplasma species (spp.) can be commensals or opportunistic pathogens of the urogenital tract, and they can be commonly isolated from amniotic fluid, placenta, and fetal/neonatal tissue or blood in mothers delivering prematurely or their preterm infants. Although the presence of Mycoplasma spp. has been associated with adverse maternal-fetal outcomes such as preterm birth and maternal chorioamnionitis, it is less clear whether vertical transmission to the neonate results in colonization or active infection/inflammation. Moreover, the presence of Mycoplasma spp. in neonatal blood, cerebrospinal fluid, or tissue has been variably associated with increased risk of neonatal comorbidities, especially bronchopulmonary dysplasia (BPD). Although the treatment of the mother or neonate with antibiotics is effective in eradicating ureaplasma, it is not clear that the treatment is effective in reducing the incidence of major morbidities of the preterm neonate (eg, BPD). In this article, we review the animal and clinical data for ureaplasma-related complications and treatment strategies. [Pediatr Ann. 2020;49(7):e305-e312.].
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Kong M, Zhang WW, Sewell K, Gorman G, Kuo HC, Aban I, Ambalavanan N, Whitley RJ. Azithromycin Treatment vs Placebo in Children With Respiratory Syncytial Virus-Induced Respiratory Failure: A Phase 2 Randomized Clinical Trial. JAMA Netw Open 2020; 3:e203482. [PMID: 32324238 PMCID: PMC7180420 DOI: 10.1001/jamanetworkopen.2020.3482] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Despite a high disease burden, there is no effective treatment for respiratory syncytial virus (RSV) infection. OBJECTIVES To determine whether administration of azithromycin (AZM) to children with RSV-induced respiratory failure is safe and to define the effect of AZM therapy on nasal matrix metalloproteinase 9 (MMP-9) levels. DESIGN, SETTING, AND PARTICIPANTS This randomized, double-blind, placebo-controlled phase 2 trial was conducted at a single tertiary pediatric intensive care unit from February 2016 to February 2019. The study included children with RSV infection who were admitted to the pediatric intensive care unit and required respiratory support via positive pressure ventilation (invasive and noninvasive). A total of 147 children were screened; 90 were excluded for not meeting inclusion criteria, having an absent legal guardian, lacking pharmacy support, or having a language barrier and 9 declined participation, resulting in 48 patients enrolled in the study. INTERVENTION Receipt of standard dose AZM (10 mg/kg/d), high-dose AZM (20 mg/kg/d), or a matching placebo of normal saline intravenously for 3 days. MAIN OUTCOMES AND MEASURES Nasal and endotracheal samples were collected at baseline as well as at 24 hours and 48 hours after start of treatment. The secondary outcome was to determine treatment effect on clinical outcome measures, including days of positive pressure ventilation and length of hospital stay. RESULTS A total of 48 patients were enrolled in the trial, with a median (range) age at randomization of 12 (1 to 125) months; 36 participants (75.0%) were younger than 2 years. Overall, 26 participants (54.2%) were boys, and 29 (60.4%) had a comorbidity. A total of 16 patients were randomized into each trial group (ie, placebo, standard-dose AZM, and high-dose AZM). Baseline demographic characteristics were comparable among the 3 groups. Both doses of AZM were safe, with no adverse events observed. No difference in nasal MMP-9 levels were observed between treatment groups. Among those who required mechanical ventilation and received high-dose AZM, endotracheal active and total MMP-9 levels were lower on day 3. Compared with baseline, active and total MMP-9 levels in endotracheal aspirates were 1.0 log lower in the high-dose AZM group (active MMP-9: 99.8% CI, -1.28 to -0.64; P < .001; total MMP-9: 99.8% CI, -1.37 to -0.57; P < .001). Patients who received high-dose AZM had fewer median (interquartile range) hospital days compared with those receiving the placebo (8 [6-14] days vs 11 [8-20] days; mean ratio estimate, 0.57; 95% CI, 0.38-0.87; P = .01). CONCLUSIONS AND RELEVANCE In this phase 2 randomized clinical trial, both doses of AZM were safe. While nasal MMP-9 levels were unchanged among treatment groups, endotracheal MMP-9 levels were lower among those who received high-dose AZM. The positive secondary clinical outcome, while exploratory, provides insight for end points in a multicenter randomized trial. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02707523.
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Affiliation(s)
- Michele Kong
- Department of Pediatrics, University of Alabama at Birmingham
| | - Wei Wei Zhang
- Department of Pediatrics, University of Alabama at Birmingham
| | - Kate Sewell
- Department of Pediatrics, University of Alabama at Birmingham
| | - Gregory Gorman
- McWhorter School of Pharmacy, Samford University, Birmingham, Alabama
| | - Hui-Chien Kuo
- Department of Pediatrics, University of Alabama at Birmingham
| | - Inmaculada Aban
- Department of Pediatrics, University of Alabama at Birmingham
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Nunes CR, Procianoy RS, Corso AL, Silveira RC. Use of Azithromycin for the Prevention of Lung Injury in Mechanically Ventilated Preterm Neonates: A Randomized Controlled Trial. Neonatology 2020; 117:522-528. [PMID: 32894857 DOI: 10.1159/000509462] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Macrolides have anti-inflammatory and immunomodulatory properties that give this class of antibiotics a role that differs from its classical use as an antibiotic, which opens new therapeutic possibilities. OBJECTIVE The aim of this study was to evaluate the anti-inflammatory effect of azithromycin in preventing mechanical ventilation (MV)-induced lung injury in very-low-birth-weight preterm neonates. METHODS This is a randomized, double-blind, placebo-controlled trial of preterm neonates who received invasive MV within 72 h of birth. Patients were randomized to receive intravenous azithromycin (at a dose of 10/mg/kg/day for 5 days) or placebo (0.9% saline) within 12 h of the start of MV. Two blood samples were collected (before and after intervention) for measurement of interleukins (ILs) and PCR for Ureaplasma. Patients were followed up throughout the hospital stay for the outcomes of death and broncho-pulmonary dysplasia defined as need for oxygen for a period of ≥28 days of life (registered at ClinicalTrials.gov, No. NCT03485703). RESULTS Forty patients were analyzed in the azithromycin group and 40 in the placebo group. Five days after the last dose, serum IL-2 and IL-8 levels dropped significantly in the azithromycin group. There was a significant reduction in the incidence of death and O2 dependency at 28 days/death in azithromycin-treated patients regardless of the detection of Ureaplasma in blood. CONCLUSIONS Azithromycin has anti-inflammatory effects, with a decrease in cytokines after 5 days of use and a reduction in death and O2 dependency at 28 days/death in mechanically ventilated preterm neonates.
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Affiliation(s)
- Cristiane R Nunes
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Renato S Procianoy
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Andréa L Corso
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Rita C Silveira
- Graduate Program in Child and Adolescent Health, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Neonatology Section, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil, .,Department of Pediatrics, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil,
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Repurposing azithromycin for neonatal neuroprotection. Pediatr Res 2019; 86:444-451. [PMID: 31100754 PMCID: PMC6764891 DOI: 10.1038/s41390-019-0408-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Inflammation contributes to neonatal hypoxic-ischemic brain injury pathogenesis. We evaluated the neuroprotective efficacy of azithromycin, a safe, widely available antibiotic with anti-inflammatory properties, in a neonatal rodent hypoxic-ischemic brain injury model. METHODS Seven-day-old rats underwent right carotid artery ligation followed by 90-min 8% oxygen exposure; this procedure elicits quantifiable left forepaw functional impairment and right cerebral hemisphere damage. Sensorimotor function (vibrissae-stimulated forepaw placing, grip strength) and brain damage were compared in azithromycin- and saline-treated littermates 2-4 weeks later. Multiple treatment protocols were evaluated (variables included doses ranging from 15 to 45 mg/kg; treatment onset 15 min to 4 h post-hypoxia, and comparison of 1 vs. 3 injections). RESULTS All azithromycin doses improved function and reduced brain damage; efficacy was dose dependent, and declined with increasing treatment delay. Three azithromycin injections, administered over 48 h, improved performance on both function measures and reduced brain damage more than a single dose. CONCLUSION In this neonatal rodent model, azithromycin improved functional and neuropathology outcomes. If supported by confirmatory studies in complementary neonatal brain injury models, azithromycin could be an attractive candidate drug for repurposing and evaluation for neonatal neuroprotection in clinical trials.
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McPherson C. Pharmacotherapy for the Prevention of Bronchopulmonary Dysplasia: Can Anything Compete with Caffeine and Corticosteroids? Neonatal Netw 2019; 38:242-249. [PMID: 31470395 DOI: 10.1891/0730-0832.38.4.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a morbidity of prematurity with implications for respiratory and neurologic health into adulthood. Multiple risk factors contribute to the development of BPD leading to examination of various prevention strategies. The roles of systemic corticosteroids and caffeine have been addressed by the American Academy of Pediatrics. The place in therapy of other agents commonly utilized in clinical practice remains unclear. Inhaled nitric oxide has been the subject of numerous large, randomized controlled trials in preterm infants. Despite sound rationale, these trials have largely failed to document benefit, suggesting a limited role for inhaled nitric oxide therapy in the preterm population. In contrast, intramuscular vitamin A has been documented to reduce the incidence of BPD in randomized trials. However, the invasiveness and the sporadic availability of this therapy have led to decreased utilization. All macrolide antibiotics do not appear to have a similar impact on the incidence of BPD; however, azithromycin administered to infants colonized with Ureaplasma may have impact. Questions remain about the optimal dosing approach and long-term safety of this intervention. Finally, diuretic therapy is widely used in clinical practice despite significant toxicities and limited data supporting a role in BPD prevention. Taken together, available data suggest that caffeine and selective use of corticosteroids remain the mainstays of pharmacologic BPD prevention.
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18
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Population Pharmacokinetics and Dosing Optimization of Azithromycin in Children with Community-Acquired Pneumonia. Antimicrob Agents Chemother 2018; 62:AAC.00686-18. [PMID: 29941652 DOI: 10.1128/aac.00686-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/20/2018] [Indexed: 12/30/2022] Open
Abstract
Azithromycin is extensively used in children with community-acquired pneumonia (CAP). Currently, the intravenous azithromycin is used off-label in children partly due to lacking of pharmacokinetic data. Our objective was to evaluate the population pharmacokinetics (PPK) and optimize dose strategy in order to improve treatment in this distinctive population. This was a prospective, multicenter, open-labeled pharmacokinetic study. Blood samples were collected from hospitalized pediatric patients and concentrations were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). PPK analysis was conducted using NONMEM software. The pharmacokinetic data from 95 pediatric patients (age range, 2.1 to 11.7 years) were available for analysis. The PPK was best fitted by a two-compartment model with linear elimination. Covariate analysis verified that body weight and alanine aminotransferase (ALT) had significant effects on azithromycin pharmacokinetics, yielding a 24% decrease of clearance in patients with ALT of >40. Monte Carlo simulation showed that for children with normal liver function, a loading-dose strategy (a loading dose of 15 mg/kg of body weight followed by maintenance doses of 10 mg/kg) would achieve the ratio of the area under free drug plasma concentration-time curve over 24 h (fAUC) to MIC90 (fAUC/MIC) target of 3 h in 53.2% of hypothetical patients, using a normative MIC susceptibility breakpoint of 2 mg/liter. For children with ALT of >40, the proposed dose needed to decrease by 15% to achieve comparable exposure. The corresponding risk of overdose for the recommended dosing regimen was less than 5.8%. In conclusion, the PPK of azithromycin was evaluated in children with CAP and an optimal dosing regimen was constructed based on developmental pharmacokinetic-pharmacodynamic modeling and simulation.
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Speer EM, Dowling DJ, Xu J, Ozog LS, Mathew JA, Chander A, Yin D, Levy O. Pentoxifylline, dexamethasone and azithromycin demonstrate distinct age-dependent and synergistic inhibition of TLR- and inflammasome-mediated cytokine production in human newborn and adult blood in vitro. PLoS One 2018; 13:e0196352. [PMID: 29715306 PMCID: PMC5929513 DOI: 10.1371/journal.pone.0196352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/11/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Neonatal inflammation, mediated in part through Toll-like receptor (TLR) and inflammasome signaling, contributes to adverse outcomes including organ injury. Pentoxifylline (PTX), a phosphodiesterase inhibitor which potently suppresses cytokine production in newborn cord blood, is a candidate neonatal anti-inflammatory agent. We hypothesized that combinations of PTX with other anti-inflammatory agents, the steroid dexamethasone (DEX) or the macrolide azithromycin (AZI), may exert broader, more profound and/or synergistic anti-inflammatory activity towards neonatal TLR- and inflammasome-mediated cytokine production. Methods Whole newborn and adult blood was treated with PTX (50–200 μM), DEX (10−10–10−7 M), or AZI (2.5–20 μM), alone or combined, and cultured with lipopolysaccharide (LPS) (TLR4 agonist), R848 (TLR7/8 agonist) or LPS/adenosine triphosphate (ATP) (inflammasome induction). Supernatant and intracellular cytokines, signaling molecules and mRNA were measured by multiplex assay, flow cytometry and real-time PCR. Drug interactions were assessed based on Loewe's additivity. Results PTX, DEX and AZI inhibited TLR- and/or inflammasome-mediated cytokine production in newborn and adult blood, whether added before, simultaneously or after TLR stimulation. PTX preferentially inhibited pro-inflammatory cytokines especially TNF. DEX inhibited IL-10 in newborn, and TNF, IL-1β, IL-6 and interferon-α in newborn and adult blood. AZI inhibited R848-induced TNF, IL-1β, IL-6 and IL-10, and LPS-induced IL-1β and IL-10. (PTX+DEX) synergistically decreased LPS- and LPS/ATP-induced TNF, IL-1β, and IL-6, and R848-induced IL-1β and interferon-α, while (PTX+AZI) synergistically decreased induction of TNF, IL-1β, and IL-6. Synergistic inhibition of TNF production by (PTX+DEX) was especially pronounced in newborn vs. adult blood and was accompanied by reduction of TNF mRNA and enhancement of IL10 mRNA. Conclusions Age, agent, and specific drug-drug combinations exert distinct anti-inflammatory effects towards TLR- and/or inflammasome-mediated cytokine production in human newborn blood in vitro. Synergistic combinations of PTX, DEX and AZI may offer benefit for prevention and/or treatment of neonatal inflammatory conditions while potentially limiting drug exposure and toxicity.
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Affiliation(s)
- Esther M. Speer
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
- * E-mail:
| | - David J. Dowling
- Department of Medicine, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jianjin Xu
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York, United States of America
| | - Lukasz S. Ozog
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Jaime A. Mathew
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Avinash Chander
- Department of Pediatrics, Division of Neonatology, Stony Brook University School of Medicine, Stony Brook, New York, United States of America
| | - Donglei Yin
- Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, New York, United States of America
| | - Ofer Levy
- Department of Medicine, Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Precision Vaccine Program, Boston Children’s Hospital, Boston, Massachusetts, United States of America
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Poets CF, Lorenz L. Prevention of bronchopulmonary dysplasia in extremely low gestational age neonates: current evidence. Arch Dis Child Fetal Neonatal Ed 2018; 103:F285-F291. [PMID: 29363502 DOI: 10.1136/archdischild-2017-314264] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/08/2018] [Accepted: 01/08/2018] [Indexed: 12/16/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the most frequent complications in extremely low gestational age neonates, but has remained largely unchanged in rate. We reviewed data on BPD prevention focusing on recent meta-analyses. Interventions with proven effectiveness in reducing BPD include the primary use of non-invasive respiratory support, the application of surfactant without endotracheal ventilation and the use of volume-targeted ventilation in infants requiring endotracheal intubation. Following extubation, synchronised nasal ventilation is more effective than continuous positive airway pressure in reducing BPD. Pharmacologically, commencing caffeine citrate on postnatal day 1 or 2 seems more effective than a later start. Applying intramuscular vitamin A for the first 4 weeks reduces BPD, but is expensive and painful and thus not widely used. Low-dose hydrocortisone for the first 10 days prevents BPD, but was associated with almost twice as many cases of late-onset sepsis in infants born at 24-25 weeks' gestation. Inhaled corticosteroids, despite reducing BPD, were associated with a higher mortality rate. Administering dexamethasone to infants still requiring mechanical ventilation around postnatal weeks 2-3 may represent the best trade-off between restricting steroids to infants at risk of BPD while still affording high efficacy. Finally, identifying infants colonised with ureaplasma and treating those requiring intubation and mechanical ventilation with azithromycin is another promising approach to BPD prevention. Further interventions yet only backed by cohort studies include exclusive breastmilk feeding and a better prevention of nosocomial infections.
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Affiliation(s)
- Christian F Poets
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
| | - Laila Lorenz
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
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Silwedel C, Speer CP, Glaser K. Ureaplasma-associated prenatal, perinatal, and neonatal morbidities. Expert Rev Clin Immunol 2017; 13:1073-1087. [DOI: 10.1080/1744666x.2017.1381559] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Christine Silwedel
- University Children’s Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Christian P. Speer
- University Children’s Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Kirsten Glaser
- University Children’s Hospital, University of Wuerzburg, Wuerzburg, Germany
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Donders GGG, Ruban K, Bellen G, Petricevic L. Mycoplasma/Ureaplasma infection in pregnancy: to screen or not to screen. J Perinat Med 2017; 45:505-515. [PMID: 28099135 DOI: 10.1515/jpm-2016-0111] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/01/2016] [Indexed: 11/15/2022]
Abstract
Mycoplasmata have been linked to pregnancy complications and neonatal risk. While formerly a limited number of species could be discovered by cultures, molecular biology nowadays discovers both lower quantities and more diverse species, making us realize that mycoplasmata are ubiquitous in the vaginal milieu and do not always pose a danger for pregnant women. As the meaning of mycoplasmata in pregnancy is not clear to many clinicians, we summarized the current knowledge about the meaning of different kinds of mycoplasmata in pregnancy and discuss the potential benefits and disadvantages of treatment. Currently, there is no general rule to screen and treat for mycoplasmata in pregnancy. New techniques seem to indicate that Ureaplasma parvum (Up), which now can be distinguished from U. urealyticum (Uu), may pose an increased risk for preterm birth and bronchopulmonary disease in the preterm neonate. Mycoplasma hominis (Mh) is related to early miscarriages and midtrimester abortions, especially in the presence of abnormal vaginal flora. Mycoplasma genitalium (Mg) is now recognized as a sexually transmitted infection (STI) that is involved in the causation of cervicitis, pelvic inflammatory disease (PID) in non-pregnant, and preterm birth and miscarriages in pregnant women, irrespective of the presence of concurrent other STIs, like Chlamydia or gonorrhoea. Proper studies to test for efficacy and improved pregnancy outcome are scarce and inconclusive. Azythromycin is the standard treatment now, although, for Mg, this may not be sufficient. The role of clarithromycin in clinical practice still has to be established. There is a stringent need for new studies based on molecular diagnostic techniques and randomized treatment protocols with promising and safe antimicrobials.
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Pea F. Intracellular Pharmacokinetics of Antibacterials and Their Clinical Implications. Clin Pharmacokinet 2017. [DOI: 10.1007/s40262-017-0572-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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de la Haye N, Hütten MC, Kunzmann S, Kramer BW. Bronchopulmonary Dysplasia and Ureaplasma: What Do We Know So Far? NEONATAL MEDICINE 2017. [DOI: 10.5385/nm.2017.24.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nicole de la Haye
- Department of Pediatrics, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Matthias C. Hütten
- Department of Pediatrics, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
- School of Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
- Division of Neonatology, Department of Pediatrics, Würzburg University Hospital, Würzburg, Germany
| | - Steffen Kunzmann
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Boris W. Kramer
- Department of Pediatrics, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
- School of Oncology and Developmental Biology (GROW), Maastricht, The Netherlands
- Department of Neonatology and Pediatric Intensive Care Medicine, Bürgerhospital Frankfurt am Main, Germany
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25
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Pharmacokinetics of Transfer of Azithromycin into the Breast Milk of African Mothers. Antimicrob Agents Chemother 2015; 60:1592-9. [PMID: 26711756 DOI: 10.1128/aac.02668-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/13/2015] [Indexed: 01/26/2023] Open
Abstract
Azithromycin (AZI) is used for its antibiotic and antimalarial properties in pregnancy. Reported estimates of AZI breast milk transfer, based on concentrations in mostly single samples from small numbers of women, have suggested that infant intake is safe. To better characterize infant intake and the associated potential benefits and risks, AZI was measured by liquid chromatography-mass spectrometry in four breast milk samples taken over 28 days postpartum from each of 20 Gambian women given 2 g AZI during labor. A population pharmacokinetic model utilizing published parameters for AZI disposition in pregnancy, the present breast milk concentrations, and increasing/decreasing sigmoid maximum-effect (Emax) functions adequately described temporal changes in the milk/plasma ratio. The median estimated absolute and relative cumulative infant doses were 4.5 mg/kg of body weight (95% prediction interval, 0.6 to 7.0 mg/kg) and 15.7% (95% prediction interval, 2.0 to 27.8%) of the maternal dose, respectively; the latter exceeded the recommended 10% safety limit. Although some infants with bacterial infections may benefit from AZI in breast milk, there is a risk of hypertrophic pyloric stenosis with a worst-case number needed to harm of 60 based on the present and available epidemiologic data. (This study has been registered at ClinicalTrials.gov under registration no. NCT01800942.).
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26
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Viscardi RM, Kallapur SG. Role of Ureaplasma Respiratory Tract Colonization in Bronchopulmonary Dysplasia Pathogenesis: Current Concepts and Update. Clin Perinatol 2015; 42:719-38. [PMID: 26593075 PMCID: PMC4662049 DOI: 10.1016/j.clp.2015.08.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Respiratory tract colonization with the genital mycoplasma species Ureaplasma parvum and Ureaplasma urealyticum in preterm infants is a significant risk factor for bronchopulmonary dysplasia (BPD). Recent studies of the ureaplasmal genome, animal infection models, and human infants have provided a better understanding of specific virulence factors, pathogen-host interactions, and variability in genetic susceptibility that contribute to chronic infection, inflammation, and altered lung development. This review provides an update on the current evidence supporting a causal role of ureaplasma infection in BPD pathogenesis. The current status of antibiotic trials to prevent BPD in Ureaplasma-infected preterm infants is also reviewed.
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Affiliation(s)
- Rose Marie Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca Street, 8th Floor, Baltimore, MD 21093, USA.
| | - Suhas G Kallapur
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333, Burnet Avenue, Cincinnati, OH 45229, USA
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