1
|
Southern KW, Solis-Moya A, Kurz D, Smith S. Macrolide antibiotics (including azithromycin) for cystic fibrosis. Cochrane Database Syst Rev 2024; 2:CD002203. [PMID: 38411248 PMCID: PMC10897949 DOI: 10.1002/14651858.cd002203.pub5] [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] [Indexed: 02/28/2024]
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-limiting genetic condition, affecting over 90,000 people worldwide. CF affects several organs in the body, but airway damage has the most profound impact on quality of life (QoL) and survival. Causes of lower airway infection in people with CF are, most notably, Staphylococcus aureus in the early course of the disease and Pseudomonas aeruginosa at a later stage. Macrolide antibiotics, e.g. azithromycin and clarithromycin, are usually taken orally, have a broad spectrum of action against gram-positive (e.g. S aureus) and some gram-negative bacteria (e.g. Haemophilus influenzae), and may have a modifying role in diseases involving airway infection and inflammation such as CF. They are well-tolerated and relatively inexpensive, but widespread use has resulted in the emergence of resistant bacteria. This is an updated review. OBJECTIVES To assess the potential effects of macrolide antibiotics on clinical status in terms of benefit and harm in people with CF. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals, and abstract books of conference proceedings. We last searched the Group's Cystic Fibrosis Trials Register on 2 November 2022. We last searched the trial registries WHO ICTRP and clinicaltrials.gov on 9 November 2022. We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data, where possible. SELECTION CRITERIA We included randomised controlled trials of macrolide antibiotics in adults and children with CF. We compared them to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose or type of administration. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 14 studies (1467 participants) lasting 28 days to 36 months. All the studies assessed azithromycin: 11 compared oral azithromycin to placebo (1167 participants); one compared a high dose to a low dose (47 participants); one compared nebulised to oral azithromycin (45 participants); and one looked at weekly versus daily dose (208 participants). Oral azithromycin versus placebo There is a slight improvement in forced expiratory volume (FEV1 % predicted) in one second in the azithromycin group at up to six months compared to placebo (mean difference (MD) 3.97, 95% confidence interval (CI) 1.74 to 6.19; high-certainty evidence), although there is probably no difference at three months, (MD 2.70%, 95% CI -0.12 to 5.52), or 12 months (MD -0.13, 95% CI -4.96 to 4.70). Participants in the azithromycin group are probably at a decreased risk of pulmonary exacerbation with a longer time to exacerbation (hazard ratio (HR) 0.61, 95% CI 0.50 to 0.75; moderate-certainty evidence). Mild side effects were common, but there was no difference between groups (moderate-certainty evidence). There is no difference in hospital admissions at six months (odds ratio (OR) 0.61, 95% CI 0.36 to 1.04; high-certainty evidence), or in new acquisition of P aeruginosa at 12 months (HR 1.00, 95% CI 0.64 to 1.55; moderate-certainty evidence). High-dose versus low-dose azithromycin We are uncertain whether there is any difference in FEV1 % predicted at six months between the two groups (no data available) or in the rate of exacerbations per child per month (MD -0.05 (95% CI -0.20 to 0.10)); very low-certainty evidence for both outcomes. Only children were included in the study and the study did not report on any of our other clinically important outcomes. Nebulised azithromycin versus oral azithromycin We were unable to include any of the data into our analyses and have reported findings directly from the paper; we graded all evidence as being of very low certainty. The authors reported that there was a greater mean change in FEV1 % predicted at one month in the nebulised azithromycin group (P < 0.001). We are uncertain whether there was a change in P aeruginosa count. Weekly azithromycin versus daily azithromycin There is probably a lower mean change in FEV1 % predicted at six months in the weekly group compared to the daily group (MD -0.70, 95% CI -0.95 to -0.45) and probably also a longer period of time until first exacerbation in the weekly group (MD 17.30 days, 95% CI 4.32 days to 30.28 days). Gastrointestinal side effects are probably more common in the weekly group and there is likely no difference in admissions to hospital or QoL. We graded all evidence as moderate certainty. AUTHORS' CONCLUSIONS Azithromycin therapy is associated with a small but consistent improvement in respiratory function, a decreased risk of exacerbation and longer time to exacerbation at six months; but evidence for treatment efficacy beyond six months remains limited. Azithromycin appears to have a good safety profile (although a weekly dose was associated with more gastrointestinal side effects, which makes it less acceptable for long-term therapy), with a relatively minimal treatment burden for people with CF, and it is inexpensive. A wider concern may be the emergence of macrolide resistance reported in the most recent study which, combined with the lack of long-term data, means we do not feel that the current evidence is strong enough to support azithromycin therapy for all people with CF. Future research should report over longer time frames using validated tools and consistent reporting, to allow for easier synthesis of data. In particular, future trials should report important adverse events such as hearing impairment or liver disease. More data on the effects of azithromycin given in different ways and reporting on our primary outcomes would benefit decision-making on whether and how to give macrolide antibiotics. Finally, it is important to assess azithromycin therapy for people with CF who are established on the relatively new cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies which correct the underlying molecular defect associated with CF (none of the trials included in the review are relevant to this population).
Collapse
Affiliation(s)
- Kevin W Southern
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Arturo Solis-Moya
- Servicio de Neumología, Hospital Nacional de Niños, San José, Costa Rica
| | | | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
| |
Collapse
|
2
|
Avvari SK, Cusumano JA, Jogiraju VK, Manchandani P, Taft DR. PBPK Modeling of Azithromycin Systemic Exposure in a Roux-en-Y Gastric Bypass Surgery Patient Population. Pharmaceutics 2023; 15:2520. [PMID: 38004500 PMCID: PMC10674169 DOI: 10.3390/pharmaceutics15112520] [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: 09/26/2023] [Revised: 10/13/2023] [Accepted: 10/20/2023] [Indexed: 11/26/2023] Open
Abstract
In this investigation, PBPK modeling using the Simcyp® Simulator was performed to evaluate whether Roux-en-Y gastric bypass (RYGB) surgery impacts the oral absorption and bioavailability of azithromycin. An RYGB surgery patient population was adapted from the published literature and verified using the same probe medications, atorvastatin and midazolam. Next, a PBPK model of azithromycin was constructed to simulate changes in systemic drug exposure after the administration of different oral formulations (tablet, suspension) to patients pre- and post-RYGB surgery using the developed and verified population model. Clinically observed changes in azithromycin systemic exposure post-surgery following oral administration (single-dose tablet formulation) were captured using PBPK modeling based on the comparison of model-predicted exposure metrics (Cmax, AUC) to published clinical data. Model simulations predicted a 30% reduction in steady-state AUC after surgery for three- and five-day multiple dose regimens of an azithromycin tablet formulation. The relative bioavailability of a suspension formulation was 1.5-fold higher than the tablet formulation after multiple dosing. The changes in systemic exposure observed after surgery were used to evaluate the clinical efficacy of azithromycin against two of the most common pathogens causing community acquired pneumonia based on the corresponding AUC24/MIC pharmacodynamic endpoint. The results suggest lower bioavailability of the tablet formulation post-surgery may impact clinical efficacy. Overall, the research demonstrates the potential of a PBPK modeling approach as a framework to optimize oral drug therapy in patients post-RYGB surgery.
Collapse
Affiliation(s)
- Suvarchala Kiranmai Avvari
- Samuel J. and Joan B. Williamson Institute for Pharmacometrics, Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
| | - Jaclyn A. Cusumano
- Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
| | | | | | - David R. Taft
- Samuel J. and Joan B. Williamson Institute for Pharmacometrics, Division of Pharmaceutical Sciences, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY 11201, USA;
| |
Collapse
|
3
|
Swarup P, Agrawal GP. A Review on Delivery and Bioavailability Enhancement Strategies of Azithromycin. Assay Drug Dev Technol 2022; 20:251-257. [DOI: 10.1089/adt.2022.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pallavi Swarup
- Department of Pharmacy, Agra Public Pharmacy College, Heera Lal Ki Pyau, Artoni, Agra, India
| | | |
Collapse
|
4
|
Nichols DP, Singh PK, Baines A, Caverly LJ, Chmiel JF, GIbson RL, Lascano J, Morgan SJ, Retsch-Bogart G, Saiman L, Sadeghi H, Billings JL, Heltshe SL, Kirby S, Kong A, Nick JA, Mayer-Hamblett N. Testing the effects of combining azithromycin with inhaled tobramycin for P. aeruginosa in cystic fibrosis: a randomised, controlled clinical trial. Thorax 2022; 77:581-588. [PMID: 34706982 PMCID: PMC9043040 DOI: 10.1136/thoraxjnl-2021-217782] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/30/2021] [Indexed: 11/03/2022]
Abstract
RATIONALE Inhaled tobramycin and oral azithromycin are common chronic therapies in people with cystic fibrosis and Pseudomonas aeruginosa airway infection. Some studies have shown that azithromycin can reduce the ability of tobramycin to kill P. aeruginosa. This trial was done to test the effects of combining azithromycin with inhaled tobramycin on clinical and microbiological outcomes in people already using inhaled tobramycin. We theorised that those randomised to placebo (no azithromycin) would have greater improvement in forced expiratory volume in one second (FEV1) and greater reduction in P. aeruginosa sputum in response to tobramycin. METHODS A 6-week prospective, randomised, placebo-controlled, double-blind trial testing oral azithromycin versus placebo combined with clinically prescribed inhaled tobramycin in individuals with cystic fibrosis and P. aeruginosa airway infection. RESULTS Over a 6-week period, including 4 weeks of inhaled tobramycin, the relative change in FEV1 did not statistically significantly differ between groups (azithromycin (n=56) minus placebo (n=52) difference: 3.44%; 95% CI: -0.48 to 7.35; p=0.085). Differences in secondary clinical outcomes, including patient-reported symptom scores, weight and need for additional antibiotics, did not significantly differ. Among the 29 azithromycin and 35 placebo participants providing paired sputum samples, the 6-week change in P. aeruginosa density differed in favour of the placebo group (difference: 0.75 log10 CFU/mL; 95% CI: 0.03 to 1.47; p=0.043). CONCLUSIONS Despite having greater reduction in P. aeruginosa density in participants able to provide sputum samples, participants randomised to placebo with inhaled tobramycin did not experience significantly greater improvements in lung function or other clinical outcomes compared with those randomised to azithromycin with tobramycin.
Collapse
Affiliation(s)
- David P Nichols
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Pradeep K Singh
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Arthur Baines
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Chmiel
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L GIbson
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Sarah J Morgan
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Hossein Sadeghi
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Joanne L Billings
- Department of Medicine, Pulmonary, Allergy and Critical Care Division, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| | - Shannon Kirby
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Ada Kong
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jerry A Nick
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Centre, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington, USA
| |
Collapse
|
5
|
Grant JJ, McDade EJ, Zobell JT, Young DC. The indispensable role of pharmacy services and medication therapy management in cystic fibrosis. Pediatr Pulmonol 2022; 57 Suppl 1:S17-S39. [PMID: 34347382 DOI: 10.1002/ppul.25613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
Care for people with cystic fibrosis (PWCF) is highly complex and requires a multidisciplinary approach where the pharmacist plays a vital role. The purpose of this manuscript is to serve as a guideline for pharmacists and pharmacy technicians who provide care for PWCF by providing background and current recommendations for the use of cystic fibrosis (CF)-specific medications in both the acute and ambulatory care settings. The article explores current literature surrounding the role of pharmacists and pharmacy technicians, proven pharmacy models to emulate, and pharmacokinetic idiosyncrasies unique to the CF population while also identifying areas of future research. Clinical recommendations for the use of CF-specific medications are broken down by organ system including mechanism of action, adverse events, dosages, and monitoring parameters. The article also includes quick reference tables essential to the acute and chronic medication therapy management of PWCF.
Collapse
Affiliation(s)
- Jonathan J Grant
- Department of Outpatient Pharmacy-Specialty Services, The John's Hopkins Hospital, Baltimore, Maryland, USA
| | - Erin J McDade
- Pharmacy Department, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffery T Zobell
- Pharmacy Department, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - David C Young
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| |
Collapse
|
6
|
CFTR Modulators: Does One Dose Fit All? J Pers Med 2021; 11:jpm11060458. [PMID: 34073663 PMCID: PMC8224731 DOI: 10.3390/jpm11060458] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/11/2022] Open
Abstract
For many people with cystic fibrosis (pwCF), CFTR modulators will be the cornerstone of their treatment. These modulators show robust treatment effects at group level in pwCF with specific mutations. The individual effect however, is variable. In this review we will explain reasons for reconsideration of dosing regimens of CFTR modulating therapy in order to improve treatment response and prevent side effects. Since the effect of a drug depends on pharmacodynamics and pharmacokinetics, pharmacodynamics and pharmacokinetic properties of CFTR modulators will be discussed. Pharmacokinetic-pharmacodynamic relationships will be used to gain insight in dosage response and exposure response relationships. To understand the cause of variation in drug exposure, pharmacokinetic properties that may change due to CF disease will be explained. We show that with current insight, there are conceivable situations that give reason for reconsideration of dosing regimens, however many questions need to be unravelled.
Collapse
|
7
|
Martiniano SL, Wagner BD, Brennan L, Wempe MF, Anderson PL, Daley CL, Anthony M, Nick JA, Sagel SD. Pharmacokinetics of oral antimycobacterials and dosing guidance for Mycobacterium avium complex treatment in cystic fibrosis. J Cyst Fibros 2021; 20:772-778. [PMID: 34030986 DOI: 10.1016/j.jcf.2021.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Treatment failure of Mycobacterium avium complex (MAC) pulmonary disease occurs in about 30% of people with cystic fibrosis (CF) and may be a result of abnormal drug concentrations. METHODS Prospective, cross-over, single-dose PK study of 20 pancreatic insufficient individuals with CF and 10 healthy controls (HC). CF subjects received simultaneous doses of oral azithromycin, ethambutol, and rifampin in the fasting state and with food and pancreatic enzymes, separated by two weeks. HC received fasting doses only. A non-compartmental model was used to estimate PK parameters of drugs and metabolites. RESULTS Azithromycin maximum concentration (Cmax ) was higher and rifampin Cmax was lower in fasting CF subjects compared to HC, while other PK measures, including those for ethambutol, were similar. Addition of food and enzymes did not improve the Cmax of the antimycobacterial drugs. Nineteen of 20 CF subjects had one or more abnormal Cmax z-scores in either the fasting or fed state (or both), when compared to HC. CONCLUSION PK profiles of azithromycin and ethambutol were similar between CF and HC, except azithromycin Cmax was slightly higher in people with CF after a single dose. Rifampin PK parameters were altered in persons with CF. Addition of food and enzymes in CF subjects did not improve PK parameters. Standard dosing guidelines should be used as a starting point for people with CF initiating MAC therapy and therapeutic drug monitoring should be routinely performed to prevent the possibility of treatment failure due to abnormal drug concentrations. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02372383 Prior abstract publication: 1. Martiniano S, Wagner B, Brennan L, Wempe M, Anderson P, Nick J, Sagel S. Pharmacokinetics of oral MAC antibiotics in cystic fibrosis. Am J Resp Crit Care Med A4842-A4842, 2017. 2. Martiniano SL, Wagner BD, Brennan L, Wempe MF, Anderson PL, Nick JA, Sagel SD. Pharmacokinetics of oral MAC antibiotics in cystic fibrosis. J Cyst Fibros 16: S52-53, 2017.
Collapse
Affiliation(s)
- Stacey L Martiniano
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E. 16th Ave. B-395 Aurora, CO 80045, United States.
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO 80045, United States
| | - Laney Brennan
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Michael F Wempe
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO 80045, United States
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO 80045, United States
| | - Charles L Daley
- Department of Medicine, National Jewish Health, Denver, CO and University of Colorado School of Medicine, Aurora, CO 80206, United States
| | - Meg Anthony
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO 80045, United States
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO and University of Colorado School of Medicine, Aurora, CO 80206, United States
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E. 16th Ave. B-395 Aurora, CO 80045, United States
| |
Collapse
|
8
|
Burke A, Smith D, Coulter C, Bell SC, Thomson R, Roberts JA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Drug Treatment of Non-Tuberculous Mycobacteria in Cystic Fibrosis. Clin Pharmacokinet 2021; 60:1081-1102. [PMID: 33982266 DOI: 10.1007/s40262-021-01010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
Non-tuberculous mycobacteria (NTM) are an emerging group of pulmonary infectious pathogens of increasing importance to the management of patients with cystic fibrosis (CF). NTM include slow-growing mycobacteria such as Mycobacterium avium complex (MAC) and rapidly growing mycobacteria such as Mycobacterium abscessus. The incidence of NTM in the CF population is increasing and infection contributes to significant morbidity to the patient and costs to the health system. Treating M. abscessus requires the combination of multiple costly antibiotics for months, with potentially significant toxicity associated with treatment. Although international guidelines for the treatment of NTM infection in CF are available, there are a lack of robust pharmacokinetic studies in CF patients to inform dosing and drug choice. This paper aims to outline the pharmacokinetic and pharmacodynamic factors informing the optimal treatment of NTM infections in CF.
Collapse
Affiliation(s)
- Andrew Burke
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Daniel Smith
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Chris Coulter
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Rachel Thomson
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,Immunology Department, Gallipoli Medical Research Institute, Brisbane, QLD, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia. .,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| |
Collapse
|
9
|
Kumar M, Rao M, Mathur T, Barman TK, Joshi V, Chaira T, Singhal S, Pandya M, Al Khodor S, Upadhyay DJ, Masuda N. Azithromycin Exhibits Activity Against Pseudomonas aeruginosa in Chronic Rat Lung Infection Model. Front Microbiol 2021; 12:603151. [PMID: 33967970 PMCID: PMC8102702 DOI: 10.3389/fmicb.2021.603151] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 03/15/2021] [Indexed: 12/19/2022] Open
Abstract
Pseudomonas aeruginosa forms biofilms in the lungs of chronically infected cystic fibrosis patients, which are tolerant to both the treatment of antibiotics and the host immune system. Normally, antibiotics are less effective against bacteria growing in biofilms; azithromycin has shown a potent efficacy in cystic fibrosis patients chronically infected with P. aeruginosa and improved their lung function. The present study was conducted to evaluate the effect of azithromycin on P. aeruginosa biofilm. We show that azithromycin exhibited a potent activity against P. aeruginosa biofilm, and microscopic observation revealed that azithromycin substantially inhibited the formation of solid surface biofilms. Interestingly, we observed that azithromycin restricted P. aeruginosa biofilm formation by inhibiting the expression of pel genes, which has been previously shown to play an essential role in bacterial attachment to solid-surface biofilm. In a rat model of chronic P. aeruginosa lung infection, we show that azithromycin treatment resulted in the suppression of quorum sensing-regulated virulence factors, significantly improving the clearance of P. aeruginosa biofilms compared to that in the placebo control. We conclude that azithromycin attenuates P. aeruginosa biofilm formation, impairs its ability to produce extracellular biofilm matrix, and increases its sensitivity to the immune system, which may explain the clinical efficacy of azithromycin in cystic fibrosis patients.
Collapse
Affiliation(s)
- Manoj Kumar
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India.,Research Department, Sidra Medicine, Doha, Qatar
| | - Madhvi Rao
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Tarun Mathur
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Tarani Kanta Barman
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Vattan Joshi
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Tridib Chaira
- Department of Pharmacokinetics and Metabolism, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Smita Singhal
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Manisha Pandya
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | | | - Dilip J Upadhyay
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| | - Nobuhisa Masuda
- Department of Microbiology, Daiichi Sankyo India Pharma Private Limited, Gurgaon, India
| |
Collapse
|
10
|
Pharmacokinetic and Pharmacodynamic Optimization of Antibiotic Therapy in Cystic Fibrosis Patients: Current Evidences, Gaps in Knowledge and Future Directions. Clin Pharmacokinet 2021; 60:409-445. [PMID: 33486720 DOI: 10.1007/s40262-020-00981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Antibiotic therapy is one of the main treatments for cystic fibrosis (CF). It aims to eradicate bacteria during early infection, calms down the inflammatory process, and leads to symptom resolution of pulmonary exacerbations. CF can modify both the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of antibiotics, therefore specific PK/PD endpoints should be determined in the context of CF. Currently available data suggest that optimal PK/PD targets cannot be attained in sputum with intravenous aminoglycosides. Continuous infusion appears preferable for β-lactam antibiotics, but optimal concentrations in sputum are unlikely to be reached, with some possible exceptions such as meropenem and ceftolozane. Usual doses are likely suboptimal for fluoroquinolones and linezolid, whereas daily doses of 45-60 mg/kg and 200 mg could be convenient for vancomycin and doxycycline, respectively. Weekly azithromycin doses of 22-30 mg/kg could also be appropriate for its anti-inflammatory effect. The difficulty with achieving optimal concentrations supports the use of combined treatments and the inhaled administration route, as very high local concentrations, concomitantly with low systemic exposure, can be obtained with the inhaled route for aminoglycosides, colistin, and fluoroquinolones, thus minimizing the risk of toxicity.
Collapse
|
11
|
Akkerman-Nijland AM, Akkerman OW, Grasmeijer F, Hagedoorn P, Frijlink HW, Rottier BL, Koppelman GH, Touw DJ. The pharmacokinetics of antibiotics in cystic fibrosis. Expert Opin Drug Metab Toxicol 2020; 17:53-68. [PMID: 33213220 DOI: 10.1080/17425255.2021.1836157] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Dosing of antibiotics in people with cystic fibrosis (CF) is challenging, due to altered pharmacokinetics, difficulty of lung tissue penetration, and increasing presence of antimicrobial resistance. AREAS COVERED The purpose of this work is to critically review original data as well as previous reviews and guidelines on pharmacokinetics of systemic and inhaled antibiotics in CF, with the aim to propose strategies for optimization of antibacterial therapy in both children and adults with CF. EXPERT OPINION For systemic antibiotics, absorption is comparable in CF patients and non-CF controls. The volume of distribution (Vd) of most antibiotics is similar between people with CF with normal body composition and healthy individuals. However, there are a few exceptions, like cefotiam and tobramycin. Many antibiotic class-dependent changes in drug metabolism and excretion are reported, with an increased total body clearance for ß-lactam antibiotics, aminoglycosides, fluoroquinolones, and trimethoprim. We, therefore, recommend following class-specific guidelines for CF, mostly resulting in higher dosages per kg bodyweight in CF compared to non-CF controls. Higher local antibiotic concentrations in the airways can be obtained by inhalation therapy, with which eradication of bacteria may be achieved while minimizing systemic exposure and risk of toxicity.
Collapse
Affiliation(s)
- Anne M Akkerman-Nijland
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Onno W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Floris Grasmeijer
- Department of Pharmacy, PureIMS B.V , Roden, The Netherlands.,Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Paul Hagedoorn
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Henderik W Frijlink
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen , Groningen, The Netherlands
| | - Bart L Rottier
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Gerard H Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Daniel J Touw
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| |
Collapse
|
12
|
De Sutter PJ, Gasthuys E, Van Braeckel E, Schelstraete P, Van Biervliet S, Van Bocxlaer J, Vermeulen A. Pharmacokinetics in Patients with Cystic Fibrosis: A Systematic Review of Data Published Between 1999 and 2019. Clin Pharmacokinet 2020; 59:1551-1573. [DOI: 10.1007/s40262-020-00932-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
13
|
Oral Azithromycin Use and the Recovery of Lung Function from Pulmonary Exacerbations Treated with Intravenous Tobramycin or Colistimethate in Adults with Cystic Fibrosis. Ann Am Thorac Soc 2020; 16:853-860. [PMID: 30840835 DOI: 10.1513/annalsats.201811-773oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: The potential of azithromycin to alter the antimicrobial and clinical benefits of inhaled tobramycin in patients with cystic fibrosis (CF) has been previously reported. The potential interaction between azithromycin and intravenous antibiotics in the treatment of pulmonary exacerbations is unknown. Objectives: To determine if chronic azithromycin use as a concomitant therapy is associated with change in lung function after receiving intravenous antibiotic regimens including tobramycin or colistimethate. Methods: This was a retrospective cohort study evaluating the association of azithromycin with intravenous tobramycin or colistimethate in adult patients with CF treated for a pulmonary exacerbation. The primary outcome was relative lung function recovery (forced expiratory volume in 1 s [FEV1]) after exacerbation treatment. Generalized estimating equations were applied to account for repeated events with independent correlation structures and robust standard errors, incorporating several confounders. Results: A total of 220 exacerbation events occurred in 121 patients in the tobramycin group (47% using azithromycin), and 207 exacerbation events occurred in 86 patients in the colistimethate group (59% using azithromycin). Azithromycin use was associated with less FEV1% recovery in patients treated with tobramycin (-3% relative FEV1% recovery [95% confidence interval (CI), -7 to 0.2] and -2.64% absolute FEV1% change [95% CI, -4.52 to -0.76]). Azithromycin use was associated with greater recovery of FEV1% when treated with colistimethate (+3% relative FEV1% recovery [95% CI, -0.1 to 7] and 2.00% absolute improvement in FEV1% [95% CI, 0.13 to 3.87]). The odds of 90% or 100% recovery to baseline FEV1% were lower with azithromycin use in the tobramycin cohort and higher with azithromycin use in the colistimethate cohort but were not statistically significant. Conclusions: Azithromycin use was associated with a more favorable response in adult patients with CF treated with intravenous colistimethate but a less favorable response in those treated with intravenous tobramycin.
Collapse
|
14
|
Andrew EC, Connell T, Robinson P, Curtis N, Massie J, Robertson C, Harrison J, Shanthikumar S, Bryant PA, Starr M, Steer A, Ranganathan S, Gwee A. Pulmonary Mycobacterium abscessus complex in children with cystic fibrosis: A practical management guideline. J Paediatr Child Health 2019; 55:502-511. [PMID: 30884016 DOI: 10.1111/jpc.14427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/05/2019] [Accepted: 02/10/2019] [Indexed: 11/28/2022]
Abstract
The treatment of Mycobacterium abscessus complex (MABSC) pulmonary infections is an emerging challenge in patients with cystic fibrosis (CF). Multidrug therapy for prolonged durations is required and carries the significant burden of drug-related toxicity, cost and selective pressure for multiresistant bacteria. International guidelines acknowledge that clinical and in vitro data to support treatment regimens are limited, particularly in children. As part of a collaboration between the infectious diseases and respiratory units at our institution, we have developed a modified treatment guideline that aims to balance the aims of MABSC eradication and slowing disease progression with minimising drug toxicity and resistance. The outcomes of this treatment approach will be monitored and reported. In this manuscript, we discuss the available evidence for treatment choices and present our treatment guideline for paediatric patients with CF and MABSC infection.
Collapse
Affiliation(s)
- Eden C Andrew
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Tom Connell
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Infectious Diseases Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Phil Robinson
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Infectious Diseases Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John Massie
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Colin Robertson
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Joanne Harrison
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Shivanthan Shanthikumar
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Infectious Diseases Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mike Starr
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Steer
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Group A Streptococcal Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Sarath Ranganathan
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Respiratory Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Infectious Diseases Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
15
|
Roesch EA, Nichols DP, Chmiel JF. Inflammation in cystic fibrosis: An update. Pediatr Pulmonol 2018; 53:S30-S50. [PMID: 29999593 DOI: 10.1002/ppul.24129] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
Inflammation plays a critical role in cystic fibrosis (CF) lung pathology and disease progression making it an active area of research and important therapeutic target. In this review, we explore the most recent research on the major contributors to the exuberant inflammatory response seen in CF as well as potential therapeutics to combat this response. Absence of functional cystic fibrosis transmembrane conductance regulator (CFTR) alters anion transport across CF airway epithelial cells and ultimately results in dehydration of the airway surface liquid. The dehydrated airway surface liquid in combination with abnormal mucin secretion contributes to airway obstruction and subsequent infection that may serve as a trigger point for inflammation. There is also evidence to suggest that airway inflammation may be excessive and sustained relative to the infectious stimuli. Studies have shown dysregulation of both pro-inflammatory mediators such as IL-17 and pro-resolution mediators including metabolites of the eicosanoid pathway. Recently, CFTR potentiators and correctors have garnered much attention in the CF community. Although these modulators address the underlying defect in CF, their impact on downstream consequences such as inflammation are not known. Here, we review pre-clinical and clinical data on the impact of CFTR modulators on inflammation. In addition, we examine other cell types including neutrophils, macrophages, and T-lymphocytes that express CFTR and contribute to the CF inflammatory response. Finally, we address challenges in developing anti-inflammatory therapies and highlight some of the most promising anti-inflammatory drugs under development for CF.
Collapse
Affiliation(s)
- Erica A Roesch
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - David P Nichols
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - James F Chmiel
- Department of Pediatrics, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| |
Collapse
|
16
|
Chang WK, Chen CH, Chen YA, Tang MC, Ju SY, Huang SW, Wu KM. Unique Pharmacokinetic Parameters with Prolonged Elimination Half-life of Oral Azithromycin and Analysis of Pharmacokinetic Phenotype in Young Taiwanese Population. INT J PHARMACOL 2018. [DOI: 10.3923/ijp.2018.981.991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
17
|
Evaluation of the Microbiological Efficacy of a Single 2-Gram Dose of Extended-Release Azithromycin by Population Pharmacokinetics and Simulation in Japanese Patients with Gonococcal Urethritis. Antimicrob Agents Chemother 2017; 62:AAC.01409-17. [PMID: 29038284 DOI: 10.1128/aac.01409-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/05/2017] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to analyze the relationship between the pharmacokinetic (PK)/pharmacodynamic (PD) parameters of a single 2-g dose of extended-release formulation of azithromycin (AZM-SR) and its microbiological efficacy against gonococcal urethritis. Fifty male patients with gonococcal urethritis were enrolled in this study. In 36 patients, the plasma AZM concentrations were measured using liquid chromatography-tandem mass spectrometry, the AZM MIC values for the Neisseria gonorrhoeae isolates were determined, and the microbiological outcomes were assessed. AZM-SR monotherapy eradicated N. gonorrhoeae in 30 (83%) of the 36 patients. AZM MICs ranged from 0.03 to 2 mg/liter. The mean value of the area under the concentration-time curve (AUC), estimated by population PK analysis using a two-compartment model, was 20.8 mg · h/liter. Logistic regression analysis showed that the PK/PD target value required to predict an N. gonorrhoeae eradication rate of ≥95% was a calculated AUC/MIC of ≥59.5. The AUC/MIC value was significantly higher in patients who achieved microbiological cure than in patients who achieved microbiological failure. Monte Carlo simulation using this MIC distribution revealed that the probability that AZM-SR monotherapy would produce an AUC/MIC exceeding the AUC/MIC target of 59.5 was 47%. Furthermore, the MIC distribution for strains isolated in this study was mostly consistent with that for strains currently circulating in Japan. In conclusion, in Japan, AZM-SR monotherapy may not be effective against gonococcal urethritis. Therefore, use of a single 2-g dose of AZM-SR either with or without other antibiotics could be an option to treat gonococcal urethritis if patients are allergic to ceftriaxone and spectinomycin or are diagnosed to be infected with an AZM-sensitive strain.
Collapse
|
18
|
Nichols DP, Happoldt CL, Bratcher PE, Caceres SM, Chmiel JF, Malcolm KC, Saavedra MT, Saiman L, Taylor-Cousar JL, Nick JA. Impact of azithromycin on the clinical and antimicrobial effectiveness of tobramycin in the treatment of cystic fibrosis. J Cyst Fibros 2016; 16:358-366. [PMID: 28025037 DOI: 10.1016/j.jcf.2016.12.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Concomitant use of oral azithromycin and inhaled tobramycin occurs in approximately half of US cystic fibrosis (CF) patients. Recent data suggest that this combination may be antagonistic. METHODS Test the hypothesis that azithromycin reduces the clinical benefits of tobramycin by analyses of clinical trial data, in vitro modeling of P. aeruginosa antibiotic killing, and regulation of the MexXY efflux pump. RESULTS Ongoing administration of azithromycin associates with reduced ability of inhaled tobramycin, as compared with aztreonam, to improve lung function and quality of life in a completed clinical trial. In users of azithromycin FEV1 (L) increased 0.8% during a 4-week period of inhaled tobramycin and an additional 6.4% during a subsequent 4-week period of inhaled aztreonam (P<0.005). CFQ-R respiratory symptom score decreased 1.8 points during inhaled tobramycin and increased 8.3 points during subsequent inhaled aztreonam (P<0.001). A smaller number of trial participants not using azithromycin had similar improvement in lung function and quality of life scores during inhaled tobramycin and inhaled aztreonam. In vitro, azithromycin selectively reduced the bactericidal effects tobramycin in cultures of clinical strains of P. aeruginosa, while up regulating antibiotic resistance through MexXY efflux. CONCLUSIONS Azithromycin appears capable of reducing the antimicrobial benefits of tobramycin by inducing adaptive bacterial stress responses in P. aeruginosa, suggesting that these medications together may not be optimal chronic therapy for at least some patients.
Collapse
Affiliation(s)
- Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.
| | - Carrie L Happoldt
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Preston E Bratcher
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Silvia M Caceres
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - James F Chmiel
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Kenneth C Malcolm
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Milene T Saavedra
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Jennifer L Taylor-Cousar
- Department of Pediatrics, National Jewish Health, Denver, CO, United States; Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| |
Collapse
|
19
|
Elofson KA, Forbes RC, Gerlach AT. Can enteral antibiotics be used to treat pneumonia in the surgical intensive care unit? A clinical outcomes and cost comparison. Int J Crit Illn Inj Sci 2015; 5:149-54. [PMID: 26557484 PMCID: PMC4613413 DOI: 10.4103/2229-5151.164922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Controlling healthcare costs without compromising patient care is a focus given recent healthcare changes in the United States. The purpose of this study was to assess clinical improvement in surgical intensive care unit (SICU) patients initiated on or transitioned to enteral antibiotics compared to those who solely receive intravenous (IV) antibiotic therapy for treatment of bacterial pneumonia. Materials and Methods: This retrospective cohort study included patients with a positive quantitative respiratory culture being treated for bacterial pneumonia in a SICU from 1/1/09 to 3/31/11. Two distinct patient groups were identified: Those treated with IV antibiotics exclusively (IV) and those either initiated on or transitioned to enteral antibiotics within 4 days of antibiotic initiation (PO). The primary endpoint of clinical improvement was assessed on day of antibiotic discontinuation. Results: A total of 647 patients were evaluated; 124 met inclusion criteria (30 patients PO group and 94 IV group). There was no difference in clinical improvement (86.7 PO vs 72.3% IV, P = 0.14) or recurrence (10 PO vs. 12.8% IV, P > 0.99) between groups. Secondary outcomes of duration of mechanical ventilation, ICU and hospital length of stay, and all-cause mortality were also similar. Antibiotic and infection-related costs were significantly decreased in the PO group ($1,042 vs $697, P = 0.04; $20,776 vs $17,381, P = 0.012, respectively). Conclusions: SICU patients initiated on or transitioned to PO antibiotics for pneumonia had similar clinical outcomes, but significantly less infection-related and antibiotic costs compared to those receiving IV therapy. Further, prospective studies are warranted.
Collapse
Affiliation(s)
- Kathryn A Elofson
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, United States
| | - Rachel C Forbes
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony T Gerlach
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| |
Collapse
|
20
|
Abstract
Azithromycin is a broad-spectrum macrolide antibiotic with a long half-life and excellent tissue penetration. It is primarily used for the treatment of respiratory, enteric and genitourinary infections and may be used in preference to other macrolides for some sexually transmitted and enteric infections. Azithromycin has additional immunomodulatory effects and has been used in chronic respiratory inflammatory diseases for this purpose. Potential major adverse effects include cardiovascular arrhythmias and hearing loss. Macrolide resistance is also a problem, as are interactions with commonly prescribed drugs.
Collapse
|
21
|
Beigelman A, Isaacson-Schmid M, Sajol G, Baty J, Rodriguez OM, Leege E, Lyons K, Schweiger TL, Zheng J, Schechtman KB, Castro M, Bacharier LB. Randomized trial to evaluate azithromycin's effects on serum and upper airway IL-8 levels and recurrent wheezing in infants with respiratory syncytial virus bronchiolitis. J Allergy Clin Immunol 2015; 135:1171-8.e1. [PMID: 25458910 PMCID: PMC4426225 DOI: 10.1016/j.jaci.2014.10.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/26/2014] [Accepted: 10/02/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) bronchiolitis in infancy is a major risk factor for recurrent wheezing and asthma. Because azithromycin attenuated neutrophilic airway inflammation in a murine viral bronchiolitis model, demonstration of similar effects in human subjects might provide a strategy for the prevention of postbronchiolitis recurrent wheezing. OBJECTIVES We sought to investigate whether azithromycin treatment during RSV bronchiolitis reduces serum and nasal lavage IL-8 levels and the occurrence of postbronchiolitis recurrent wheezing. METHOD We performed a randomized, double-masked, placebo-controlled proof-of-concept trial in 40 otherwise healthy infants hospitalized with RSV bronchiolitis who were treated with azithromycin or placebo for 14 days. IL-8 levels were measured in nasal lavage fluid and serum on randomization, day 8, and day 15 (nasal lavage only). The occurrence of wheezing episodes was assessed monthly over the ensuing 50 weeks. RESULTS Compared with placebo, azithromycin treatment did not reduce serum IL-8 levels at day 8 (P = .6) but resulted in a greater decrease in nasal lavage fluid IL-8 levels by day 15 (P = .03). Twenty-two percent of azithromycin-treated participants experienced at least 3 wheezing episodes compared with 50% of participants in the placebo group (P = .07). Azithromycin treatment resulted in prolonged time to the third wheezing episode (P = .048) and in fewer days with respiratory symptoms over the subsequent year in comparison with placebo (36.7 vs 70.1 days, P = .01). CONCLUSION In this proof-of-concept study azithromycin treatment during RSV bronchiolitis reduced upper airway IL-8 levels, prolonged the time to the third wheezing episode, and reduced overall respiratory morbidity over the subsequent year.
Collapse
Affiliation(s)
- Avraham Beigelman
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo.
| | - Megan Isaacson-Schmid
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Geneline Sajol
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Oscar M Rodriguez
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Erin Leege
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Kevin Lyons
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Toni L Schweiger
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Jie Zheng
- Division of Biostatistics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Kenneth B Schechtman
- Division of Biostatistics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| |
Collapse
|
22
|
An optimal LC-MS/MS method for determination of azithromycin in white blood cells: application to pediatric samples. Bioanalysis 2014; 6:2317-28. [DOI: 10.4155/bio.14.81] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Studies suggest that particular antimicrobial and anti-inflammatory properties of azithromycin (AZM) can be related to its extensive accumulation in white blood cells (WBCs). However, available methods for determination of AZM in WBCs require large blood volumes unsuited to a pediatric context. Therefore, an LC-MS/MS method was developed for determination of AZM in WBCs. Results: WBCs were isolated from 500 µl of whole blood by lysing red blood cells. Then, lysis of WBCs was performed with methanol/buffer containing AZM-d3-13C as internal standard. After reversed phase LC, detection was performed under multiple reaction monitoring conditions in positive electrospray mode. Linearity ranged from 0.5 to 200 ng per WBC sample. Within-run and overall accuracy and precision ranged from 95.3 to 101.1% and from 1.6 to 4.7%, respectively. All validation parameters fulfilled international requirements. Conclusions: This method can be easily performed on small samples and provides reliable data, including in children and neonates.
Collapse
|
23
|
Sampson MR, Dumitrescu TP, Brouwer KLR, Schmith VD. Population pharmacokinetics of azithromycin in whole blood, peripheral blood mononuclear cells, and polymorphonuclear cells in healthy adults. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2014; 3:e103. [PMID: 24599342 PMCID: PMC4039392 DOI: 10.1038/psp.2013.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 12/26/2013] [Indexed: 01/13/2023]
Abstract
Azithromycin's extensive distribution to proinflammatory cells, including peripheral blood mononuclear cells (PBMCs) and polymorphonuclear cells (PMNs), may be important to its antimicrobial and anti-inflammatory properties. The need to simultaneously predict azithromycin concentrations in whole blood ("blood"), PBMCs, and PMNs motivated this investigation. A single-dose study in 20 healthy adults was conducted, and nonlinear mixed effects modeling was used to simultaneously describe azithromycin concentrations in blood, PBMCs, and PMNs (simultaneous PK model). Data were well described by a four-compartment mamillary model. Apparent central clearance and volume of distribution estimates were 67.3 l/hour and 336 l (interindividual variability of 114 and 122%, respectively). Bootstrapping and visual predictive checks showed adequate model performance. Azithromycin concentrations in blood, PBMCs, and PMNs from external studies of healthy adults and cystic fibrosis patients were within the 5th and 95th percentiles of model simulations. This novel empirical model can be used to predict azithromycin concentrations in blood, PBMCs, and PMNs with different dosing regimens.
Collapse
Affiliation(s)
- M R Sampson
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - T P Dumitrescu
- 1] Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA [2] Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | - K L R Brouwer
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - V D Schmith
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| |
Collapse
|
24
|
Dalbøge C, Nielsen X, Dalhoff K, Alffenaar J, Duno M, Buchard A, Uges D, Jensen A, Jürgens G, Pressler T, Johansen H, Høiby N. Pharmacokinetic variability of clarithromycin and differences in CYP3A4 activity in patients with cystic fibrosis. J Cyst Fibros 2014; 13:179-85. [DOI: 10.1016/j.jcf.2013.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 07/08/2013] [Accepted: 08/20/2013] [Indexed: 01/02/2023]
|
25
|
|
26
|
Kolumbic Lakos A, Skerk V, Malekovic G, Dujnic Spoljarevic T, Kovacic D, Pasini M, Markotic A, Magri V, Perletti G. A Switch Therapy Protocol with Intravenous Azithromycin and Ciprofloxacin Combination for Severe, Relapsing Chronic Bacterial Prostatitis: a Prospective Non-Comparative Pilot Study. J Chemother 2013; 23:350-3. [DOI: 10.1179/joc.2011.23.6.350] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
27
|
Development of a population pharmacokinetic model to describe azithromycin whole-blood and plasma concentrations over time in healthy subjects. Antimicrob Agents Chemother 2013; 57:3194-201. [PMID: 23629714 DOI: 10.1128/aac.02430-12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Azithromycin (AZI), a broad-spectrum antibiotic, accumulates in polymorphonuclear cells and peripheral blood mononuclear cells. The distribution of AZI in proinflammatory cells may be important to the anti-inflammatory properties. Previous studies have described plasma AZI pharmacokinetics. The objective of this study was to describe the pharmacokinetics of AZI in whole blood (concentration in whole blood [Cb]) and plasma (concentration in plasma [Cp]) of healthy subjects. In this study, 12 subjects received AZI (500 mg once a day for 3 days). AZI Cb and Cp were quantified in serial samples collected up to 3 weeks after the last dose and analyzed using noncompartmental and compartmental methods. After the last dose, Cb was greater than Cp. Importantly, Cb, but not Cp, was quantifiable in all but one subject at 3 weeks. The blood area under the curve during a 24-h dosing interval (AUC24) was ∼2-fold greater than the plasma AUC24, but simulations suggested that Cb was not at steady state by day 3. Upon exploration of numerous models, an empirical 3-compartment model adequately described Cp and Cb, but Cp was somewhat underestimated. Intercompartmental clearance (CL; likely representing cells) was lower than apparent oral CL (18 versus 118 liters/h). Plasma, peripheral, and cell compartmental volumes were 439 liters, 2,980 liters, and 3,084 liters, respectively. Interindividual variability in CL was low (26.2%), while the volume of distribution variability was high (107%). This is the first report to describe AZI Cb in healthy subjects, the distribution parameters between Cp and Cb, and AZI retention in blood for up to 3 weeks following 3 daily doses. The model can be used to predict Cb from Cp for AZI under various dosing regimens. (This study has been registered at ClinicalTrials.gov under registration no. NCT01026064.).
Collapse
|
28
|
Abstract
BACKGROUND Macrolide antibiotics may have a modifying role in diseases which involve airway infection and inflammation, like cystic fibrosis. OBJECTIVES To test the hypotheses that, in people with cystic fibrosis, macrolide antibiotics: 1. improve clinical status compared to placebo or another antibiotic; 2. do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings.We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data (May 2010).Latest search of the Group's Cystic Fibrosis Trials Register: 29 February 2012. SELECTION CRITERIA Randomised controlled trials of macrolide antibiotics compared to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Seven groups were contacted and provided additional data which were incorporated into the review. MAIN RESULTS Ten of 31 studies identified were included (959 patients). Five studies with a low risk of bias examined azithromycin versus placebo and demonstrated consistent improvement in forced expiratory volume in one second over six months (mean difference at six months 3.97% (95% confidence interval 1.74% to 6.19%; n = 549, from four studies)). Patients treated with azithromycin were approximately twice as likely to be free of pulmonary exacerbation at six months, odds ratio 1.96 (95% confidence interval 1.15 to 3.33). With respect to secondary outcomes, there was a significant reduction in need for oral antibiotics and greater weight gain in those taking azithromycin. Adverse events were uncommon and not obviously associated with azithromycin, although a once-weekly high dose regimen was associated with more frequent gastrointestinal adverse events. Treatment with azithromycin was associated with reduced identification of Staphylococcus aureus on respiratory culture, but also a significant increase in macrolide resistance. AUTHORS' CONCLUSIONS This review provides evidence of improved respiratory function after six months of azithromycin. Data beyond six months were less clear, although reduction in pulmonary exacerbation was sustained. Treatment appeared safe over a six-month period; however, emergence of macrolide resistance was a concern. A multi-centre trial examining long-term effects of this antibiotic treatment is needed, especially for infants recognised through newborn screening.
Collapse
Affiliation(s)
- Kevin W Southern
- Institute of ChildHealth, University of Liverpool, Liverpool, UK.
| | | | | | | |
Collapse
|
29
|
Wilms EB, Touw DJ, Heijerman HGM, van der Ent CK. Azithromycin maintenance therapy in patients with cystic fibrosis: a dose advice based on a review of pharmacokinetics, efficacy, and side effects. Pediatr Pulmonol 2012; 47:658-65. [PMID: 22684985 DOI: 10.1002/ppul.21620] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/27/2011] [Indexed: 01/31/2023]
Abstract
Azithromycin maintenance therapy results in improvement of respiratory function in patients with cystic fibrosis (CF). In azithromycin maintenance therapy, several dosing schemes are applied. In this review, we combine current knowledge about azithromycin pharmacokinetics with the dosing schedules used in clinical trials in order to come to a dosing advise which could be generally applicable. We used data from a recently updated Cochrane meta analysis (2011), the reports of clinical trials and pharmacokinetic studies. Based on these data, it was concluded that a dose level of 22-30 mg/kg/week is the lowest dose level with proven efficacy. Due to the extended half-life in patients with CF, the weekly dose of azithromycin can be divided in one to seven dosing moments, depending on patient preference and gastro-intestinal tolerance. No important side effects or interactions with other CF-related drugs have been documented so far.
Collapse
Affiliation(s)
- Erik B Wilms
- Central Hospital Pharmacy, The Hague, The Netherlands.
| | | | | | | |
Collapse
|
30
|
Abstract
BACKGROUND Macrolide antibiotics may have a modifying role in diseases which involve airway infection and inflammation, like cystic fibrosis. OBJECTIVES To test the hypotheses that, in people with cystic fibrosis, macrolide antibiotics: 1. improve clinical status compared to placebo or another antibiotic; 2. do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings.We contacted investigators known to work in the field, previous authors and pharmaceutical companies manufacturing macrolide antibiotics for unpublished or follow-up data (May 2010).Latest search of the Group's Cystic Fibrosis Trials Register: 09 February 2011. SELECTION CRITERIA Randomised controlled trials of macrolide antibiotics compared to: placebo; another class of antibiotic; another macrolide antibiotic; or the same macrolide antibiotic at a different dose. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Seven groups were contacted and provided additional data which were incorporated into the review. MAIN RESULTS Ten of 31 studies identified were included (959 patients). Five studies with a low risk of bias examined azithromycin versus placebo and demonstrated consistent improvement in forced expiratory volume in one second over six months (mean difference at six months 3.97% (95% confidence interval 1.74% to 6.19%; n = 549, from four studies)). Patients treated with azithromycin were approximately twice as likely to be free of pulmonary exacerbation at six months, odds ratio 1.96 (95% confidence interval 1.15 to 3.33). With respect to secondary outcomes, there was a significant reduction in need for oral antibiotics and greater weight gain in those taking azithromycin. Adverse events were uncommon and not obviously associated with azithromycin, although a once-weekly high dose regimen was associated with more frequent gastrointestinal adverse events. Treatment with azithromycin was associated with reduced identification of Staphylococcus aureus on respiratory culture, but also a significant increase in macrolide resistance. AUTHORS' CONCLUSIONS This review provides evidence of improved respiratory function after six months of azithromycin. Data beyond six months were less clear, although reduction in pulmonary exacerbation was sustained. Treatment appeared safe over a six-month period; however, emergence of macrolide resistance was a concern. A multi-centre trial examining long-term effects of this antibiotic treatment is needed, especially for infants recognised through newborn screening.
Collapse
Affiliation(s)
- Kevin W Southern
- Institute of Child Health, University of Liverpool, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, Merseyside, UK, L12 2AP
| | | | | | | |
Collapse
|
31
|
Zarogoulidis P, Papanas N, Kioumis I, Chatzaki E, Maltezos E, Zarogoulidis K. Macrolides: from in vitro anti-inflammatory and immunomodulatory properties to clinical practice in respiratory diseases. Eur J Clin Pharmacol 2011; 68:479-503. [PMID: 22105373 DOI: 10.1007/s00228-011-1161-x] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 10/25/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrolides have long been recognised to exert immunomodulary and anti-inflammatory actions. They are able to suppress the "cytokine storm" of inflammation and to confer an additional clinical benefit through their immunomodulatory properties. METHODS A search of electronic journal articles was performed using combinations of the following keywords: macrolides, COPD, asthma, bronchitis, bronchiolitis obliterans, cystic fibrosis, immunomodulation, anti-inflammatory effect, diabetes, side effects and systemic diseases. RESULTS Macrolide effects are time- and dose-dependent, and the mechanisms underlying these effects remain incompletely understood. Both in vitro and in vivo studies have provided ample evidence of their immunomodulary and anti-inflammatory actions. Importantly, this class of antibiotics is efficacious with respect to controlling exacerbations of underlying respiratory problems, such as cystic fibrosis, asthma, bronchiectasis, panbrochiolitis and cryptogenic organising pneumonia. Macrolides have also been reported to reduce airway hyper-responsiveness and improve pulmonary function. CONCLUSION This review provides an overview on the properties of macrolides (erythromycin, clarithromycin, roxithromycin, azithromycin), their efficacy in various respiratory diseases and their adverse effects.
Collapse
Affiliation(s)
- P Zarogoulidis
- Pulmonary Department, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.
| | | | | | | | | | | |
Collapse
|
32
|
Concentration of the macrolide antibiotic tulathromycin in broncho-alveolar cells is influenced by comedication of rifampicin in foals. Naunyn Schmiedebergs Arch Pharmacol 2009; 381:161-9. [DOI: 10.1007/s00210-009-0481-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 11/25/2009] [Indexed: 11/26/2022]
|
33
|
Sevilla-Sánchez D, Soy-Muner D, Soler-Porcar N. [Usefulness of macrolides as anti-inflammatories in respiratory diseases]. Arch Bronconeumol 2009; 46:244-54. [PMID: 19962815 DOI: 10.1016/j.arbres.2009.10.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 10/05/2009] [Accepted: 10/10/2009] [Indexed: 01/18/2023]
Abstract
The macrolides are antibiotics that, besides their anti-bacterial action, have an anti-inflammatory effect, by decreasing the activity of the immune cells and bacteria cell changes. An increase the survival of patients suffering from diffuse panbronchiolitis was already seen in the 1980s, after being treated with erythromycin. Currently, the use of macrolides in various chronic inflammatory diseases has increased significantly. Clinical improvements associated to the administration of macrolides have been observed in diseases such as, cystic fibrosis, asthma, and bronchiectasis. However, despite the apparent clinical benefit they seem to provide, the published results up until now are controversial and conclusive results are unable to be obtained. This means that further clinical trials are necessary to confirm or refute the long-term use of these drugs, which are not free of adverse effects, mainly the appearance of resistant bacteria.
Collapse
|
34
|
Christiansen SR, Broniscer A, Panetta JC, Stewart CF. Pharmacokinetics of erlotinib for the treatment of high-grade glioma in a pediatric patient with cystic fibrosis: case report and review of the literature. Pharmacotherapy 2009; 29:858-66. [PMID: 19558260 DOI: 10.1592/phco.29.7.858] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A 12-year-old girl with cystic fibrosis was diagnosed with a high-grade glioma after radiographic and biopsy results confirmed the primary intracranial lesion. She was treated with single-agent erlotinib during and after daily localized radiation therapy. Pharmacokinetic studies were conducted to assess the effect of pancreatic enzyme deficiency and intestinal malabsorption secondary to cystic fibrosis on the bioavailability of orally administered erlotinib, a lipophilic drug. Pharmacokinetic analysis of plasma samples from days 1 and 8 demonstrated that absorption of oral erlotinib was not affected by the patient's cystic fibrosis when the drug was given concomitantly with pancreatic enzyme replacement. When pediatric patients with cystic fibrosis are receiving erlotinib or other lipophilic oral drugs, continued supplementation of pancreatic enzymes is recommended, with therapeutic drug monitoring of plasma drug concentrations when feasible, and close observation for therapeutic responses and adverse effects.
Collapse
Affiliation(s)
- Shannon R Christiansen
- Department of Pharmaceutical Services, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
| | | | | | | |
Collapse
|
35
|
Chavanet P. [Presumptive bacterial meningitis in adults: initial antimicrobial therapy]. Med Mal Infect 2009; 39:499-512. [PMID: 19428207 DOI: 10.1016/j.medmal.2009.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 02/20/2009] [Indexed: 11/28/2022]
Abstract
CSF sterilization should be obtained very rapidly to reduce both mortality and morbidity due to bacterial meningitis. Thus, antibiotic treatment should be adapted to the suspected bacterium and administered as early as possible at high dosage with - if necessary - a loading dose and continuous perfusion. The rates of abnormal susceptibility to penicillin of Streptococcus pneumoniae, Neisseria meningitis and Haemophilus influenzae are 37%, 30% and 12% respectively. Thus, ceftriaxone or cefotaxim must be used as empirical treatment. Listeria monocytogenes remains fully susceptible to aminopenicillin, so, the combination aminopenicillin and aminoglycoside is the first-line treatment. Antibiotic resistance, allergy or contra-indications, are in fact rare but in these cases, antibiotic combinations are often needed. The latter are more or less complex and clinically validated; they include molecules such as vancomycine, fosfomycin, fluoroquinolone or linezolid.
Collapse
Affiliation(s)
- P Chavanet
- Département d'infectiologie, CHU de Dijon, BP 77908, 21000 Dijon, France.
| |
Collapse
|
36
|
Beringer PM, Kriengkauykiat J, Zhang X, Hidayat L, Liu S, Louie S, Synold T, Burckart GJ, Rao PA, Shapiro B, Gill M. Lack of Effect of P-glycoprotein Inhibition on Renal Clearance of Dicloxacillin in Patients with Cystic Fibrosis. Pharmacotherapy 2008; 28:883-94. [DOI: 10.1592/phco.28.7.883] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
37
|
Liu S, Beringer PM, Hidayat L, Rao AP, Louie S, Burckart GJ, Shapiro B. Probenecid, but not cystic fibrosis, alters the total and renal clearance of fexofenadine. J Clin Pharmacol 2008; 48:957-65. [PMID: 18511651 DOI: 10.1177/0091270008319707] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study aims to evaluate renal P-glycoprotein (P-gp) activity in patients with cystic fibrosis. P-gp efflux activity in peripheral T cells was measured by flow cytometry in 10 cystic fibrosis and 15 healthy volunteers. Eight cystic fibrosis patients and 8 healthy volunteers were recruited into a crossover pharmacokinetic study in which participants received 180 mg fexofenadine with or without 1 g probenecid twice a day. Genotyping was performed for ABCB1 C1236T, G2677T, and C3435T. P-gp efflux activity in peripheral T cells was not significantly different between cystic fibrosis patients and healthy volunteers. No difference in fexofenadine pharmacokinetic parameters was observed between cystic fibrosis patients and healthy volunteers when fexofenadine was administered with or without probenecid. Coadministration of probenecid significantly increased fexofenadine AUC and decreased the cumulative urinary excretion, total body clearance, and renal clearance. ABCB1 3435 C/T carriers showed increased basal P-gp activity in CD4+ and CD8+ T cells, increased R123-induced efflux activity in CD4+ T cell, and decreased fexofenadine AUC. Fexofenadine disposition and P-gp efflux activity in peripheral T cells was similar between cystic fibrosis patients and healthy volunteers. Probenecid administration significantly reduced the total body and renal clearance of fexofenadine. ABCB1 3435 C/T was associated with an elevated efflux activity compared with C/C subjects.
Collapse
Affiliation(s)
- Shanshan Liu
- Department of Pharmacy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | |
Collapse
|
38
|
Bergman SJ, Speil C, Short M, Koirala J. Pharmacokinetic and Pharmacodynamic Aspects of Antibiotic Use in High-Risk Populations. Infect Dis Clin North Am 2007; 21:821-46, x. [PMID: 17826625 DOI: 10.1016/j.idc.2007.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The study of pharmacokinetics includes the absorption, distribution, metabolism, and elimination of drugs. The pharmacologic effect that a medication has on the body is known as pharmacodynamics. With antimicrobials, pharmacokinetic and pharmacodynamic parameters become especially important because of the association between host drug concentrations, microorganism eradication, and resistance. This article focuses on the pharmacokinetic changes that can occur with antimicrobials when they are used in patients at high risk of infections and how they influence pharmacodynamic effects. The populations described here include patients with obesity and diabetes mellitus, renal or hepatic failure, chronic lung disease, severe burns, and long-term prosthetic devices and the elderly.
Collapse
Affiliation(s)
- Scott J Bergman
- Department of Pharmacy Practice, Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL, USA.
| | | | | | | |
Collapse
|
39
|
Abstract
Cystic fibrosis (CF) results in chronic pulmonary disease in the majority of patients resulting from the production of viscous secretions and impairment of mucociliary clearance due to alterations in airway surface liquid. Chronic infection results, and the combination of tissue damage by pathogenic organisms and a robust host inflammatory response leads to the development of bronchiectasis and progressive lung disease. Macrolide antibiotics have demonstrated efficacy in diffuse panbronchiolitis, a disease that shares many similarities to CF, and this has generated interest in the use of these agents in patients who have CF. The authors review the data that demonstrate clinical benefits of long-term azithromycin administration in patients who have CF and discuss potential host- and pathogen-related explanations for the positive therapeutic effect.
Collapse
Affiliation(s)
- John R McArdle
- Adult Cystic Fibrosis Program, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA.
| | | |
Collapse
|
40
|
Legssyer R, Huaux F, Lebacq J, Delos M, Marbaix E, Lebecque P, Lison D, Scholte BJ, Wallemacq P, Leal T. Azithromycin reduces spontaneous and induced inflammation in DeltaF508 cystic fibrosis mice. Respir Res 2006; 7:134. [PMID: 17064416 PMCID: PMC1637104 DOI: 10.1186/1465-9921-7-134] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Accepted: 10/25/2006] [Indexed: 12/05/2022] Open
Abstract
Background Inflammation plays a critical role in lung disease development and progression in cystic fibrosis. Azithromycin is used for the treatment of cystic fibrosis lung disease, although its mechanisms of action are poorly understood. We tested the hypothesis that azithromycin modulates lung inflammation in cystic fibrosis mice. Methods We monitored cellular and molecular inflammatory markers in lungs of cystic fibrosis mutant mice homozygous for the ΔF508 mutation and their littermate controls, either in baseline conditions or after induction of acute inflammation by intratracheal instillation of lipopolysaccharide from Pseudomonas aeruginosa, which would be independent of interactions of bacteria with epithelial cells. The effect of azithromycin pretreatment (10 mg/kg/day) given by oral administration for 4 weeks was evaluated. Results In naive cystic fibrosis mice, a spontaneous lung inflammation was observed, characterized by macrophage and neutrophil infiltration, and increased intra-luminal content of the pro-inflammatory cytokine macrophage inflammatory protein-2. After induced inflammation, cystic fibrosis mice combined exaggerated cellular infiltration and lower anti-inflammatory interleukin-10 production. In cystic fibrosis mice, azithromycin attenuated cellular infiltration in both baseline and induced inflammatory condition, and inhibited cytokine (tumor necrosis factor-α and macrophage inflammatory protein-2) release in lipopolysaccharide-induced inflammation. Conclusion Our findings further support the concept that inflammatory responses are upregulated in cystic fibrosis. Azithromycin reduces some lung inflammation outcome measures in cystic fibrosis mice. We postulate that some of the benefits of azithromycin treatment in cystic fibrosis patients are due to modulation of lung inflammation.
Collapse
Affiliation(s)
- Rachida Legssyer
- Clinical Chemistry, Université Catholique de Louvain, Ave Hippocrate 10, Brussels, Belgium
| | - François Huaux
- Industrial Toxicology and Occupational Medicine, Université Catholique de Louvain, Clos Chapelle aux Champs 30.54, Brussels, Belgium
| | - Jean Lebacq
- Cell Physiology, Université Catholique de Louvain, Ave Hippocrate 55, Brussels, Belgium
| | - Monique Delos
- Pathology, Louvain University Hospital at Mont-Godinne, Yvoir, Belgium
| | - Etienne Marbaix
- Pathology, Université Catholique de Louvain, Ave Hippocrate 10, Brussels, Belgium
| | - Patrick Lebecque
- Pneumology, Université Catholique de Louvain, Ave Hippocrate 10, Brussels, Belgium
| | - Dominique Lison
- Industrial Toxicology and Occupational Medicine, Université Catholique de Louvain, Clos Chapelle aux Champs 30.54, Brussels, Belgium
| | - Bob J Scholte
- Erasmus University Medical Center, Cell Biology, Rotterdam, The Netherlands
| | - Pierre Wallemacq
- Clinical Chemistry, Université Catholique de Louvain, Ave Hippocrate 10, Brussels, Belgium
| | - Teresinha Leal
- Clinical Chemistry, Université Catholique de Louvain, Ave Hippocrate 10, Brussels, Belgium
| |
Collapse
|
41
|
Abstract
BACKGROUND Chronic severe infection with Pseudomonas aeruginosa, affects many people with cystic fibrosis (CF). There is evidence from the laboratory and from other disease processes that macrolide antibiotics, whilst not directly active against Pseudomonas aeruginosa, may have indirect actions against this organism. OBJECTIVES We aimed to test the hypotheses that, in people with CF, macrolide antibiotics:(1) improve clinical status compared to placebo or another antibiotic;(2) do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH STRATEGY We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture macrolide antibiotics for unpublished or follow-up data (December 2003). Most recent search of the Group's register: January 2004 SELECTION CRITERIA Published or unpublished randomised controlled trials of macrolide antibiotics compared to placebo, another class of antibiotic or another macrolide antibiotic. Studies comparing regimens of the same macrolide antibiotic at different doses will also be included. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. Three groups were contacted for missing data and we hope to include these in future reviews. MAIN RESULTS Searches identified 14 studies, four were included in this review (296 participants). Two studies enrolled adults, one children (a significant number of whom were not colonised with Pseudomonas aeruginosa) and one both adults and children. All the clinical studies reported small but significant improvements in respiratory function with azithromycin versus placebo. Meta-analysis at the one-month and six-month time points demonstrates a significant benefit with respect to relative change in FEV1 (at six months, for n = 104, azithromycin and n = 114, placebo; WMD 5.82% (95% CI 2.45 to 9.20)). The largest study reported a significant increase in mild adverse events (nausea, diarrhoea and wheezing). REVIEWERS' CONCLUSIONS There is clear evidence from these studies of a small but significant improvement in respiratory function following treatment with azithromycin. The largest study employed a three times a week dose and, in this study, treatment with azithromycin was associated with a significant increase in mild adverse events. Further studies are needed to clarify the precise role of azithromycin in the treatment of CF lung disease.
Collapse
Affiliation(s)
- K W Southern
- Child Health, University of Liverpool, Alder Hey Children's Hospital, Eaton Road, Liverpool, Merseyside, UK, L12 2AP
| | | | | |
Collapse
|