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Bintang MAKM, Nopparat J, Srichana T. In vivo evaluation of nephrotoxicity and neurotoxicity of colistin formulated with sodium deoxycholate sulfate in a mice model. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3243-3252. [PMID: 37249614 DOI: 10.1007/s00210-023-02531-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
Neurotoxicity and nephrotoxicity are the major dose-limiting factors for the clinical use of colistin against multidrug-resistant (MDR) Gram-negative bacteria. This study aimed to investigate the neurotoxic and nephrotoxic effects of colistin formulated with in-house synthesized sodium deoxycholate sulfate (SDCS) in a mouse model. Male mice C57BL/6 were randomly divided into four groups: control (saline solution), colistin (15 mg/kg/day), colistin:SDCS 1:1, and colistin:SDCS 1:2. In the colistin:SDCS treatment groups, the dosage was 15 mg/kg/day colistin equivalent; all mice were treated for 7 successive days. The thermal tolerance, body weight gain and organ weights were measured. The levels of serum blood urea nitrogen (BUN), creatinine (Cr), superoxide dismutase (SOD), and catalase (CAT) were assessed. Histopathological damages were assessed on mice organ. The colistin:SDCS formulations significantly improved thermal pain response of the mice comparable to the control group. The administration did not impair kidney function as evidence from BUN and Cr results; however, the oxidative stress biomarkers decreased in the colistin and colistin-SDCS treated mice. Several abnormalities were observed in the kidney, liver, spleen, and sciatic nerve tissues following colistin treatment, which indicated evidence of toxicity. The colistin-SDCS formulations were associated with less acute toxicity and fewer nephrotoxic and neurotoxic changes compared with the colistin alone group which indicated that SDCS attenuated colistin nephrotoxicity and neurotoxicity. This study highlights the potential application of colistin formulated with SDCS for safer clinical use against MDR Gram-negative bacteria.
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Affiliation(s)
- Muhammad Ali Khumaini Mudhar Bintang
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand
| | - Jongdee Nopparat
- Division of Health and Applied Sciences, Faculty of Science, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand
- Center of Excellence for Trace Analysis and Biosensor, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Teerapol Srichana
- Drug Delivery System Excellence Center, Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand.
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Zhang J, Song C, Wu M, Yue J, Zhu S, Zhu P, Oo C, Schlender JF, Lv Z, Zhu Y, Sy SKB, Yu M. Physiologically-based pharmacokinetic modeling to inform dosing regimens and routes of administration of rifampicin and colistin combination against Acinetobacter baumannii. Eur J Pharm Sci 2023; 185:106443. [PMID: 37044198 DOI: 10.1016/j.ejps.2023.106443] [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: 09/14/2022] [Revised: 02/28/2023] [Accepted: 04/09/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Carbapenem-resistant Acinetobacter baumannii (CRAB) is resistant to major antibiotics such as penicillin, cephalosporin, fluoroquinolone and aminoglycoside, and has become a significant nosocomial pathogen. The efficacy of rifampicin and colistin combination against CRAB could be dependent on the administration routes and drug concentrations at the site of infection. OBJECTIVE The objective is to predict drug disposition in biological tissues. Treatment efficacy is extrapolated by assessing respective pharmacodynamic (PD) indices, as well as parameters associated with the emergence of resistance. METHODS Physiologically-based pharmacokinetic models of rifampicin and colistin were utilized to predict tissue exposures. Dosing regimens and administration routes for combination therapy were evaluated in terms of in vitro antimicrobial susceptibility of A. baumannii associated with targeted PD indices and resistance parameters. RESULTS Simulated exposures in blood, heart, lung, skin and brain were consistent with reported penetration rates. The results demonstrated that a combination of colistin and rifampicin using conventional intravenous (i.v.) doses could achieve effective exposures in the blood and skin. However, for lung infections, colistin by inhalation would be required due to low lung penetration from intravenous route. Inhaled colistin alone provided good PD coverage but this practice could encourage the emergence of additional resistance which may be overcome by a combination regimen that includes inhaled colistin. CONCLUSION This in silico extrapolation provides valuable information on dosing regimens and routes of administration against CRAB infections in specific tissues. The PBPK modeling approach could be a non-invasive way to inform therapeutic benefits of combination antimicrobial therapy.
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Affiliation(s)
- Jiayuan Zhang
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Chu Song
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Mengyuan Wu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Jiali Yue
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Shixing Zhu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Peijuan Zhu
- Department of Pharmacology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles Oo
- SunLife Biopharma, Morris Plains, New Jersey, USA
| | | | - Zhihua Lv
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao, People's Republic of China.
| | - Yuanqi Zhu
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Sherwin K B Sy
- Department of Statistics, State University of Maringá, Maringá, Paraná, Brazil.
| | - Mingming Yu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao, People's Republic of China.
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Surovoy YA, Burkin MA, Galvidis IA, Sobolev MA, Rende OC, Tsarenko SV. Comparative polymyxin B pharmacokinetics in critically ill patients with renal insufficiency and in continuous veno-venous hemodialysis. Eur J Clin Pharmacol 2023; 79:79-87. [PMID: 36378296 DOI: 10.1007/s00228-022-03415-x] [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: 08/02/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to assess polymyxin B pharmacokinetics (PK) in patients with varying degrees of renal dysfunction and in patients who require continuous veno-venous hemodialysis (CVVHD). METHODS The study enrolled 37 patients with sepsis, including 13 patients with glomerular filtration rate (GFR) below 80 mL/min and 11 patients on CVVHD. Each patient received a loading dose of polymyxin B (200-300 mg) and at least 3 subsequent doses of 100-150 mg every 12 h. For every patient, 6-8 blood samples were collected between doses. Polymyxin B (PMB) serum concentration was determined using enzyme-linked immunosorbent assay. RESULTS In sepsis, patients with preserved renal function mean area under the curve over 24 h (AUC0-24 h) value reached 67.8 ± 9.8 mg*h/L, while in patients with GFR below 80 mL/min, mean AUC0-24 h was 87 ± 5.8 mg*h/L. PMB PK in patients with renal insufficiency was characterized by significantly lower clearance (CL) compared to the normal renal function group (2.1 ± 0.1 L/h vs 3.9 ± 0.4 L/h respectively). In patients on CVVHD, mean AUC0-24 h was 110.4 ± 10.3 mg*h/L, while CL reached 2 ± 0.23 L/h. The median recovery rate from dialysate constituted 22%. Simulation of different dosage regimens that indicate a fixed maintenance dose of 100 mg q12h with a loading dose of 200 mg is optimal for patients on CVVHD, and no dosage increase is required. CONCLUSION This study demonstrates decreased clearance of PMB in patients with renal insufficiency, which puts them at risk of toxicity. Therefore, patients with extremes of renal function might benefit from therapeutic drug monitoring. For patients with anuria, who require CVVHD, we suggest a fixed dose of 100 mg q12h.
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Affiliation(s)
- Yury A Surovoy
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia. .,Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia.
| | - Maksim A Burkin
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia
| | - Inna A Galvidis
- I.I. Mechnikov Research Institute for Vaccines and Sera, Moscow, 105064, Russia
| | | | - Onur Can Rende
- Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia
| | - Sergei V Tsarenko
- Faculty of Medicine, M.V. Lomonosov Moscow State University, Moscow, 119991, Russia.,Moscow City Clinical Hospital #52, Moscow, 123182, Russia
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Zhu S, Zhang J, Lv Z, Zhu P, Oo C, Yu M, Sy SKB. Prediction of Tissue Exposures of Meropenem, Colistin, and Sulbactam in Pediatrics Using Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2022; 61:1427-1441. [PMID: 35947360 DOI: 10.1007/s40262-022-01161-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND The combination of polymyxins, meropenem, and sulbactam demonstrated efficacy against multi-drug-resistant bacillus Acinetobacter baumannii. These three antibiotics are commonly used against major blood, skin, lung, and heart muscle infections. OBJECTIVE The objective of this study was to predict drug disposition and extrapolate the efficacy in these tissues using a physiologically based pharmacokinetic modeling approach that linked drug exposures to their target pharmacodynamic indices associated with antimicrobial activities against A. baumannii. METHODS An adult physiologically based pharmacokinetic model was developed for meropenem, colistin, and sulbactam and scaled to pediatrics accounting for both renal and non-renal clearances. The model reliability was evaluated by comparing simulated plasma and tissue drug exposures to observed data. Target pharmacodynamic indices were used to evaluate whether pediatric and adult dosing regimens provided sufficient coverage. RESULTS The modeled plasma drug exposures in adults and pediatric patients were consistent with reported literature data. The mean fold errors for meropenem, colistin, and sulbactam were in the range of 0.710-1.37, 0.981-1.47, and 0.647-1.39, respectively. Simulated exposures in the blood, skin, lung, and heart were consistent with reported penetration rates. In a virtual pediatric population aged from 2 to < 18 years, the interpretive breakpoints were achieved in 85-90% of subjects for their targeted pharmacodynamic indices after administration of pediatric dosing regimens consisting of 30 mg/kg of meropenem, and 40 mg/kg of sulbactam three times daily as a 3-h or continuous infusion and 5 mg/kg/day of colistin base activity. CONCLUSIONS The physiologically based pharmacokinetic modeling supports pediatric dosing regimens of meropenem/colistin/sulbactam in a co-administration setting against infections in the blood, lung, skin, and heart tissues due to A. baumannii.
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Affiliation(s)
- Shixing Zhu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Jiayuan Zhang
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China
| | - Zhihua Lv
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China.,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao, People's Republic of China
| | - Peijuan Zhu
- Department of Pharmacology, University of Pennsylvania, Philadelphia, PA, USA
| | - Charles Oo
- SunLife Biopharma, Morris Plains, NJ, USA
| | - Mingming Yu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, People's Republic of China. .,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao, People's Republic of China.
| | - Sherwin K B Sy
- Department of Statistics, State University of Maringá, Maringá, Paraná, Brazil.
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Extensive Therapeutic Drug Monitoring of Colistin in Critically Ill Patients Reveals Undetected Risks. Microorganisms 2020; 8:microorganisms8030415. [PMID: 32183443 PMCID: PMC7143967 DOI: 10.3390/microorganisms8030415] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 01/16/2023] Open
Abstract
(1) Background: With the rise of multi-/pan-drug resistant (MDR/PDR) pathogens, the less utilized antibiotic Colistin has made a comeback. Colistin fell out of favor due to its small therapeutic range and high potential for toxicity. Today, it is used again as a last resort substance in treating MDR/PDR pathogens. Although new guidelines with detailed recommendations for Colistin dosing are available, finding the right dose in critically ill patients with renal failure remains difficult. Here, we evaluate the efficiency of the current guidelines' recommendations by using high resolution therapeutic drug monitoring of Colistin. (2) Methods: We analyzed plasma levels of Colistin and its prodrug colisthimethate sodium (CMS) in 779 samples, drawn from eight PDR-infected ICU patients, using a HPLC-MS/MS approach. The impact of renal function on proper Colistin target levels was assessed. (3) Results: CMS levels did not correlate with Colistin levels. Over-/Underdosing occurred regardless of renal function and mode of renal replacement therapy. Colistin elimination half-time appeared to be longer than previously reported. (4) Conclusion: Following dose recommendations from the most current guidelines does not necessarily lead to adequate Colistin plasma levels. Use of Colistin without therapeutic drug monitoring might be unsafe and guideline adherence does not warrant efficient target levels in critically ill patients.
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Pharmacokinetics and Pharmacodynamics of Anti-infective Agents during Continuous Veno-venous Hemofiltration in Critically Ill Patients: Lessons Learned from an Ancillary Study of the IVOIRE Trial. J Transl Int Med 2019; 7:155-169. [PMID: 32010602 PMCID: PMC6985915 DOI: 10.2478/jtim-2019-0031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Hemofiltration rate, changes in blood and ultrafiltration flow, and discrepancies between the prescribed and administered doses strongly influence pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobial agents during continuous veno-venous hemofiltration (CVVH) in critically ill patients. Methods Ancillary data were from the prospective multicenter IVOIRE (hIgh VOlume in Intensive caRE) study. High volume (HV, 70 mL/kg/h) was at random compared with standard volume (SV, 35 mL/kg/h) CVVH in septic shock patients with acute kidney injury (AKI). PK/PD parameters for all antimicrobial agents used in each patient were studied during five days. Results Antimicrobial treatment met efficacy targets for both percentage of time above the minimal inhibitory concentration and inhibitory quotient. A significant correlation was observed between the ultrafiltration flow and total systemic clearance (Spearman test: P < 0.005) and between CVVH clearance and drug elimination half-life (Spearman test: P < 0.005). All agents were easily filtered. Mean sieving coefficient ranged from 38.7% to 96.7%. Mean elimination half-life of all agents was significantly shorter during HV-CVVH (from 1.29 to 28.54 h) than during SV-CVVH (from 1.51 to 33.85 h) (P < 0.05). Conclusions This study confirms that CVVH influences the PK/PD behavior of most antimicrobial agents. Antimicrobial elimination was directly correlated with convection rate. Current antimicrobial dose recommendations will expose patients to underdosing and increase the risk for treatment failure and development of resistance. Dose recommendations are proposed for some major antibiotic and antifungal treatments in patients receiving at least 25 mL/kg/h CVVH.
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Treatment of Ventilator-associated Pneumonia with High-dose Colistin Under Continuous Veno-venous Hemofiltration. J Transl Int Med 2019; 7:100-105. [PMID: 31637180 PMCID: PMC6795054 DOI: 10.2478/jtim-2019-0022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background and Objectives High-dose colistin (COL) ensures adequate treatment of pneumonia caused by multidrug resistant gram-negative bacteria (MDR-GNB) but must be weighed against a higher risk of nephrotoxicity. Continuous veno-venous hemofiltration (CVVH) clears COL by filtering and membrane adsorption that permits to avoid dose accumulation and excessively high peak concentrations. We evaluated clinical/microbiological efficacy of the high-dose COL treatment under CVVH in patients with newly diagnosed MDR-GNB ventilator-associated pneumonia (VAP). Methods Observational cohort study in critically ill adult patients with MDR-GNB VAP. Colistimethate sodium (CMS) was administered as a 9 million international units (MIU) of loading dose followed by 3 × 4.5 MIU daily. CVVH was performed over a highly adsorptive membrane. Clinical and microbiological efficacies were assessed at the end of therapy. In survivors, serum creatinine level was evaluated before and at the end of therapy. Results Fourteen patients (8 male patients, aged 57 ± 14 years) were consecutively included. Isolated pathogens were Pseudomonas aeruginosa in 7, Klebsiella pneumoniae in 5, and other Enterobacteriaceae in 2 patients. A favorable clinical response was observed in 9 patients (64%). Full and presumed microbiological eradication was observed in 12 patients (86%). Two patients were diagnosed with Stage 1 acute kidney injury. Conclusions In patients with MDR-GNB VAP, CVVH may represent an interesting option to enable effective high-dose COL treatment.
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Korucu B, Unal I, Pekcan M, Inkaya AC, Yeter H, Cetinkaya MA, Kaymaz FF, Unal S, Akova M, Erdem Y. Ultrastructural evaluation of urine alkalinization versus hydration on colistin-induced nephrotoxicity. Hum Exp Toxicol 2019; 38:1366-1377. [PMID: 31280613 DOI: 10.1177/0960327119862339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Colistin is a vital antibiotic used in multidrug-resistant infections. Its most important side effect is nephrotoxicity. Colistin is a weak acid. This study aims to evaluate whether urine alkalinization is protective in the nephrotoxicity of colistin. METHODS Twenty-eight male Sprague-Dawley rats were divided into groups. Group I (n = 4) was injected with intramuscular distilled water twice a day for 7 days. Group II (n = 8) was injected with 750,000 IU/kg/day colistin for 7 days. Group III (n = 8) was injected with the same dose of colistin after their urinary pH was ≥7 through the addition of bicarbonate in their drinking water. Group IV (n = 8) was injected with the same dose of colistin after their urine density fell below 1010 through the addition of NaCl molds in their food and 12.6 mg/L NaCl in their drinking water. RESULTS According to tubular degenerations (scored 0-5), group I scored 0, group II scored 4.25, group III scored 2, and group IV scored 1.5. In groups III and IV, protection was achieved (p = 0.001). The bicarbonate group was not superior to the NaCl group (p = 0.789). In transmission electron microscopy, group III had more microvilli integrity and autophagic vacuoles compared to group IV. Group IV had mitochondrial swelling and cristae lysis. A lower urine density was related to lower tubular scores (p = 0.001). CONCLUSIONS Colistin was highly nephrotoxic without protection. Light microscopy findings revealed that urinary alkalinization and NaCl hydration were similarly protective. Urine alkalinization further prevents ultrastructural changes as revealed by electron microscopy.
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Affiliation(s)
- B Korucu
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - I Unal
- Department of Histology and Embryology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M Pekcan
- Department of Biochemistry, Ankara University Faculty of Veterinary Medicine, Ankara, Turkey
| | - A C Inkaya
- Department of Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - H Yeter
- Department of Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - M A Cetinkaya
- Department of Histology and Embryology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - F F Kaymaz
- Department of Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - S Unal
- Department of Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M Akova
- Department of Infectious Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Y Erdem
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Narayanaswamy VP, Keagy LL, Duris K, Wiesmann W, Loughran AJ, Townsend SM, Baker S. Novel Glycopolymer Eradicates Antibiotic- and CCCP-Induced Persister Cells in Pseudomonas aeruginosa. Front Microbiol 2018; 9:1724. [PMID: 30123191 PMCID: PMC6085434 DOI: 10.3389/fmicb.2018.01724] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 07/11/2018] [Indexed: 11/13/2022] Open
Abstract
Antibiotic treatments often fail to completely eradicate a bacterial infection, leaving behind an antibiotic-tolerant subpopulation of intact bacterial cells called persisters. Persisters are considered a major cause for treatment failure and are thought to greatly contribute to the recalcitrance of chronic infections. Pseudomonas aeruginosa infections are commonly associated with elevated levels of drug-tolerant persister cells, posing a serious threat to human health. This study represents the first time a novel large molecule polycationic glycopolymer, poly (acetyl, arginyl) glucosamine (PAAG), has been evaluated against antibiotic and carbonyl cyanide m-chlorophenylhydrazone induced P. aeruginosa persisters. PAAG eliminated eliminated persisters at concentrations that show no significant cytotoxicity on human lung epithelial cells. PAAG demonstrated rapid bactericidal activity against both forms of induced P. aeruginosa persister cells resulting in complete eradication of the in vitro persister cells within 24 h of treatment. PAAG demonstrated greater efficacy against persisters in vitro than antibiotics currently being used to treat persistent chronic infections such as tobramycin, colistin, azithromycin, aztreonam, and clarithromycin. PAAG caused rapid permeabilization of the cell membrane and caused significant membrane depolarization in persister cells. PAAG efficacy against these bacterial subpopulations suggests it may have substantial therapeutic potential for eliminating recurrent P. aeruginosa infections.
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Chronic kidney disease after acute kidney injury associated with intravenous colistin use in survivors of severe infections: A comparative cohort study. J Crit Care 2018; 44:244-248. [DOI: 10.1016/j.jcrc.2017.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 10/29/2017] [Accepted: 11/15/2017] [Indexed: 11/22/2022]
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Honore PM, Spapen HD. Eravacycline for treatment of complicated intra-abdominal infections: the fire is not ignited! ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:425. [PMID: 29201877 DOI: 10.21037/atm.2017.08.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick M Honore
- Intensive Care Medicine, ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- Intensive Care Medicine, ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Nebulization of Antiinfective Agents in Invasively Mechanically Ventilated Adults: A Systematic Review and Meta-analysis. Anesthesiology 2017; 126:890-908. [PMID: 28248714 DOI: 10.1097/aln.0000000000001570] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nebulization of antiinfective agents is a common but unstandardized practice in critically ill patients. METHODS A systematic review of 1,435 studies was performed in adults receiving invasive mechanical ventilation. Two different administration strategies (adjunctive and substitute) were considered clinically relevant. Inclusion was restricted to studies using jet, ultrasonic, and vibrating-mesh nebulizers. Studies involving children, colonized-but-not-infected adults, and cystic fibrosis patients were excluded. RESULTS Five of the 11 studies included had a small sample size (fewer than 50 patients), and only 6 were randomized. Diversity of case-mix, dosage, and devices are sources of bias. Only a few patients had severe hypoxemia. Aminoglycosides and colistin were the most common antibiotics, being safe regarding nephrotoxicity and neurotoxicity, but increased respiratory complications in 9% (95% CI, 0.01 to 0.18; I = 52%), particularly when administered to hypoxemic patients. For tracheobronchitis, a significant decrease in emergence of resistance was evidenced (risk ratio, 0.18; 95% CI, 0.05 to 0.64; I = 0%). Similar findings were observed in pneumonia by susceptible pathogens, without improvement in mortality or ventilation duration. In pneumonia caused by resistant pathogens, higher clinical resolution (odds ratio, 1.96; 95% CI, 1.30 to 2.96; I = 0%) was evidenced. These findings were not consistently evidenced in the assessment of efficacy against pneumonia caused by susceptible pathogens. CONCLUSIONS Performance of randomized trials evaluating the impact of nebulized antibiotics with more homogeneous populations, standardized drug delivery, predetermined clinical efficacy, and safety outcomes is urgently required. Infections by resistant pathogens might potentially have higher benefit from nebulized antiinfective agents. Nebulization, without concomitant systemic administration of the drug, may reduce nephrotoxicity but may also be associated with higher risk of respiratory complications.
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Karaiskos I, Souli M, Galani I, Giamarellou H. Colistin: still a lifesaver for the 21st century? Expert Opin Drug Metab Toxicol 2016; 13:59-71. [DOI: 10.1080/17425255.2017.1230200] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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A Hydrogel‐Based Localized Release of Colistin for Antimicrobial Treatment of Burn Wound Infection. Macromol Biosci 2016; 17. [DOI: 10.1002/mabi.201600320] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/15/2016] [Indexed: 11/07/2022]
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16
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Karaiskos I, Friberg LE, Galani L, Ioannidis K, Katsouda E, Athanassa Z, Paskalis H, Giamarellou H. Challenge for higher colistin dosage in critically ill patients receiving continuous venovenous haemodiafiltration. Int J Antimicrob Agents 2016; 48:337-41. [PMID: 27474468 DOI: 10.1016/j.ijantimicag.2016.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/06/2016] [Accepted: 06/10/2016] [Indexed: 11/15/2022]
Abstract
Traditionally, reduced daily doses of colistin methanesulphonate (CMS) in critically ill patients receiving continuous venovenous haemodiafiltration (CVVHDF) have resulted in suboptimal colistin concentrations. The necessity of a loading dose (LD) at treatment initiation has been proposed. A LD of 9 million IU (MU) [ca. 270 mg of colistin base activity (CBA)] was administrated with a maintenance dose of 4.5 MU (ca. 140 mg CBA) every 12 h (q12h) to eight critically ill patients receiving renal replacement therapy. Blood samples were collected immediately before and at different time intervals after the LD and the fourth dose, whilst pre-filter and post-filter blood samples were also collected. CMS and colistin concentrations were determined using an LC-MS/MS assay. Median maximum observed concentrations after the LD were 22.1 mg/L for CMS and 1.55 mg/L for colistin, whereas during maintenance dosing the corresponding values were 12.6 mg/L and 1.72 mg/L, respectively. CVVHDF clearance was determined as 2.98 L/h for colistin, equivalent to 62% of total apparent colistin clearance in CVVHDF patients. Both CMS and colistin were cleared by CVVHDF. Application of a LD of 9 MU CMS resulted in more rapid achievement of the target colistin concentration. Following implementation of a predicted pharmacokinetic model on plasma CMS/colistin concentrations, a LD of 12 MU CMS appears more appropriate, whilst a CMS maintenance dosage of at least 6.5-7.5 MU q12h is suggested in patients undergoing CVVHDF. However, further clinical studies are warranted to assess the safety of a LD of 12 MU CMS in patients receiving CVVHDF.
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Affiliation(s)
- Ilias Karaiskos
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece.
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lambrini Galani
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | | | | | - Zoe Athanassa
- Intensive Care Unit, Hygeia General Hospital, Athens, Greece
| | - Harris Paskalis
- Intensive Care Unit, Hygeia General Hospital, Athens, Greece
| | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
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Luo J. Clinical study on acute renal failure treated with continuous blood purification. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Fiaccadori E, Antonucci E, Morabito S, d'Avolio A, Maggiore U, Regolisti G. Colistin Use in Patients With Reduced Kidney Function. Am J Kidney Dis 2016; 68:296-306. [PMID: 27160031 DOI: 10.1053/j.ajkd.2016.03.421] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/21/2016] [Indexed: 11/11/2022]
Abstract
Colistin (polymyxin E) is a mainly concentration-dependent bactericidal antimicrobial active against multidrug-resistant Gram-negative bacteria. After being abandoned over the past 30 years due to its neuro- and nephrotoxicity, colistin has been reintroduced recently as a last-resort drug for the treatment of multidrug-resistant Gram-negative bacteria infections in combination with other antimicrobials. Unfortunately, although renal toxicity is a well-known dose-related adverse effect of colistin, relatively few studies are currently available on its peculiar pharmacodynamic/pharmacokinetic properties in clinical settings at high risk for drug accumulation, such as acute or chronic kidney disease. In these specific contexts, the risk for underdosing is also substantial because colistin can be easily removed by dialysis/hemofiltration, especially when the most efficient modalities of renal replacement therapy (RRT) are used in critically ill patients. For this reason, recent recommendations in patients undergoing RRT have shifted toward higher dosing regimens, and therapeutic drug monitoring is advised. This review aims to summarize the main issues related to chemical structure, pharmacodynamics/pharmacokinetics, and renal toxicity of colistin. Moreover, recent data and current recommendations concerning colistin dosing in patients with reduced kidney function, with special regard to those receiving RRT such as dialysis or hemofiltration, are also discussed.
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Affiliation(s)
- Enrico Fiaccadori
- Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Santo Morabito
- Hemodialysis Unit, Department of Nephrology and Urology, University of Rome "Sapienza," Rome, Italy
| | - Antonio d'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Infectious Disease Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Umberto Maggiore
- Kidney-Pancreas Transplantation Unit, Parma University Hospital, Parma, Italy
| | - Giuseppe Regolisti
- Renal Failure Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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Trifi A, Abdellatif S, Daly F, Mahjoub K, Nasri R, Oueslati M, Mannai R, Bouzidi M, Ben Lakhal S. Efficacy and Toxicity of High-Dose Colistin in Multidrug-Resistant Gram-Negative Bacilli Infections: A Comparative Study of a Matched Series. Chemotherapy 2016; 61:190-6. [PMID: 26863534 DOI: 10.1159/000442786] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 11/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Colistimethate sodium (CMS) is the commercialized form of colistin that is effective against multiresistant Gram-negative bacilli. Its main side effects are nephrotoxicity and neurotoxicity. Pharmacodynamic dosages showed that they were infratherapeutic. Therefore, strategies with higher doses were proposed. The aim of this study was to assess the efficiency and toxicity of higher-dose CMS by comparing two treatment strategies: high-dose CMS versus standard-dose CMS. METHODS A prospective and comparative study of two matched groups was conducted. Fourty-six patients in each group were matched for age, severity and nature of infection. In the high-dose colistin group, CMS was administered at a loading dose of 9 MIU followed by a maintenance dose of 4.5 MIU/12 h. In the second group, retrospectively analyzed, colistin was administered at 6 MIU/day. For each group, clinical results, bacteriological eradication and daily creatinine clearance were recorded. Primary outcome measures were clinical cure defined as disappearance of infectious signs and eradication of microorganisms in all the follow-up cultures. Secondary outcome measures were incidence of acute renal failure and mortality. RESULTS Ninety-two patients were analyzed by matching. There was a higher cure rate in the high-dose group (63 vs. 41.3%, p = 0.04). No higher risk of nephrotoxicity was found by increasing daily doses of colistin (32.2 versus 26%, p = 0.64). Similarly, there was no significant difference in the time to onset of renal failure (8.32 vs. 11 days, p = 1) or in the requirement of hemodialysis (26.6 vs. 41%, p = 1). CONCLUSION The high-dose colistin regimen is more efficient, without significant renal or neurological toxicity.
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Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Prevention and treatment of sepsis-induced acute kidney injury: an update. Ann Intensive Care 2015; 5:51. [PMID: 26690796 PMCID: PMC4686459 DOI: 10.1186/s13613-015-0095-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive “kidney afterload” are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients’ refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rita Jacobs
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Inne Hendrickx
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Olivier Joannes-Boyau
- Haut Leveque University Hospital of Bordeaux, University of Bordeaux 2, Pessac, France.
| | - Willem Boer
- Department of Anaesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Elisabeth De Waele
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Viola Van Gorp
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Herbert D Spapen
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Shahbazi F, Dashti-Khavidaki S. Colistin: efficacy and safety in different populations. Expert Rev Clin Pharmacol 2015; 8:423-48. [DOI: 10.1586/17512433.2015.1053390] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Ordooei Javan A, Shokouhi S, Sahraei Z. A review on colistin nephrotoxicity. Eur J Clin Pharmacol 2015; 71:801-10. [DOI: 10.1007/s00228-015-1865-4] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
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How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy? Diagn Microbiol Infect Dis 2015; 82:92-103. [PMID: 25698632 DOI: 10.1016/j.diagmicrobio.2015.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 12/28/2014] [Accepted: 01/25/2015] [Indexed: 12/30/2022]
Abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
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Abstract
Increasing incidence of resistance of gram-negative bacteria against even newer antibiotic including carbapenem has generated interest in the old antibiotic colistin, which are being used as salvage therapy in the treatment of multidrug resistant infection. Colistin has excellent bactericidal activity against most gram-negative bacilli. It has shown persist level in the liver, kidney, heart, and muscle; while it is poorly distributed to the bones, cerebrospinal fluid, lung parenchyma, and pleural cavity. Being an old drug, colistin was never gone through the drug development process needed for compliance with competent regulatory authorities that resulted in very much limited understanding of pharmacokinetic (PK) and pharmacodynamic (PD) parameters, such as Cmax/MIC ratio, AUC/MIC and T > MIC that could predict the efficacy of colistin. In available PK/PD studies of colistin, mean maximum serum concentration (Cmax) of colistin were found just above the MIC breakpoint at steady states that would most probably lead to suboptimal for killing the bacteria, even at dosages of 3.0 million international units (MIU) i.e., 240 mg of colistimethate sodium (CMS) intravenously every 8 h. These finding stresses to use high loading as well as high maintenance dose of intravenous colistin. It is not only suboptimal plasma concentration of colistin but also poor lung tissue concentration, which has been demonstrated in recent studies, poses major concern in using intravenous colistin. Combination therapy mainly with carbapenems shows synergistic effect. In recent studies, inhaled colistin has been found promising in treatment of lung infection due to MDR gram-negative bacteria. New evidence shows less toxicity than previously reported.
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Affiliation(s)
- Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, UP India
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Honore PM, Jacobs R, Waele ED, Gorp VV, Spapen HD. Colistin pharmacokinetics/pharmacodynamics and acute kidney injury: A difficult but reasonable marriage. Indian J Crit Care Med 2014; 18:415-6. [PMID: 25097350 PMCID: PMC4118503 DOI: 10.4103/0972-5229.136065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Patrick M Honore
- Department of ICU, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rita Jacobs
- Department of ICU, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elisabeth De Waele
- Department of ICU, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Viola Van Gorp
- Department of ICU, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- Department of ICU, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium
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