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Rouphael N, Winokur P, Keefer MC, Traenkner J, Drobeniuc A, Doi Y, Munsiff S, Fowler VG, Evans S, Oler RE, Tuyishimire B, Lee M, Ghazaryan V, Chambers HF. Daily fosfomycin versus levofloxacin for complicated urinary tract infections. mBio 2023; 14:e0167723. [PMID: 37698412 PMCID: PMC10783529 DOI: 10.1128/mbio.01677-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 09/13/2023] Open
Abstract
IMPORTANCE Concerns over resistance and safety have been identified in the current treatment regimen for complicated urinary tract infections. Fosfomycin is a drug that is routinely used for the treatment of uncomplicated cystitis. This study shows that fosfomycin could be an oral alternative as step-down therapy for the treatment of complicated urinary tract infections, with a clinical cure rate comparable to levofloxacin but a lower microbiological success rate 3 weeks from start of antibiotics.
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Affiliation(s)
| | - Patricia Winokur
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Michael C. Keefer
- Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | - Ana Drobeniuc
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yohei Doi
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Antibacterial Resistance Leadership Group, Duke University Medical Center, Durham, North Carolina, USA
| | - Sonal Munsiff
- Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Vance G. Fowler
- Antibacterial Resistance Leadership Group, Duke University Medical Center, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott Evans
- Antibacterial Resistance Leadership Group, Duke University Medical Center, Durham, North Carolina, USA
- George Washington University, Rockville, Maryland, USA
| | | | | | - Marina Lee
- Division of Microbiology and Infectious Diseases, NIAID, NIH, Rockville, Maryland, USA
| | - Varduhi Ghazaryan
- Division of Microbiology and Infectious Diseases, NIAID, NIH, Rockville, Maryland, USA
| | - Henry F. Chambers
- Antibacterial Resistance Leadership Group, Duke University Medical Center, Durham, North Carolina, USA
- University of California at San Francisco, San Francisco, California, USA
| | - DMID 15-0045 study group
EsperAnnette1RebolledoPaulina A.1WileyZanthia1JacobJesse T.1MehtaAneesh1KraftColleen S1WangYun F1Bou ChaayaRody G.1FayadDanielle1BechnakAmer1MacenczakHollie1DretlerAlexandra1McCulloughMichele Paine1JohnsonSara Jo1BeydounNour1SaklawiYoussef1MulliganMark1AlaaeddineGhina1BunceCatherine2HardyDwight2AntenozziSusan2MoranAndrew2Almuntazar-HarrisMalcolm3WallAlison3SumerelJohn3KrederKarl4TakacsElizabeth B.4AdlerDavid5MuellerMargaret6Emory University School of Medicine, Atlanta, Georgia, USADivision of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USAThe EMMES Company, LLC, Rockville, Maryland, USAUniversity of Iowa College of Medicine, Iowa City, Iowa, USADepartment of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USADivision of Female Pelvic Medicine & Reconstructive Surgery, Depart of OB/GYN and Urology, Northwestern Medicine, Chicago, Illinois, USA
- Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, Iowa, USA
- Division of Infectious Diseases, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Antibacterial Resistance Leadership Group, Duke University Medical Center, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- George Washington University, Rockville, Maryland, USA
- The Emmes Company, LLC, Rockville, Maryland, USA
- Division of Microbiology and Infectious Diseases, NIAID, NIH, Rockville, Maryland, USA
- University of California at San Francisco, San Francisco, California, USA
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Shi HJ, Wee JH, Eom JS. Challenges to Early Discharge of Patients with Upper Urinary Tract Infections by ESBL Producers: TMP/SMX as a Step-Down Therapy for Shorter Hospitalization and Lower Costs. Infect Drug Resist 2021; 14:3589-3597. [PMID: 34511950 PMCID: PMC8422030 DOI: 10.2147/idr.s321888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/30/2021] [Indexed: 12/25/2022] Open
Abstract
Background Urinary tract infections (UTIs) caused by extended spectrum beta-lactamase (ESBL) producing pathogens have increased and are treated with carbapenem in general. Carbapenem use is associated with prolonged hospitalization or daily outpatient visit. The aim of this study was to investigate patients with UTIs by ESBL-producing pathogens for early discharge using an old oral antibiotic, trimethoprim-sulfamethoxazole (TMP-SMX), which is susceptible to ESBL-producing pathogens. Methods Data on UTIs caused by ESBL-producing pathogens from a single tertiary hospital were collected retrospectively. Patients who had been treated with intravenous carbapenems or oral TMP/SMX were included. Patients’ clinical and microbiological outcomes were compared between oral TMP/SMX and ertapenem treatment groups. Results A total of 103 patients were included, 21 of whom had been treated with TMP/SMX, whereas 82 with ertapenem. Clinical outcomes between the two groups were not significantly different (TMP/SMX: 90.5%; ertapenem: 84.1%, p = 0.73). The microbiological cure rate was higher in the TMP/SMX group than in the ertapenem group (90.5% vs 58.5%, respectively, p = 0.01). The mean duration of hospitalization was significantly shorter in the TMP/SMX group than in the ertapenem group (8.00 ± 10.50 days vs 14.00 ± 37.00 days, p = 0.07). The mean duration of antibiotic treatment was longer in the ertapenem group than in the TMP/SMX group (16.45 ± 4.77 vs 12.76 ± 5.37 days, p = 0.006). Conclusion For susceptible pathogens, TMP/SMX may enable early discharge as an effective oral antibiotic treatment option for UTIs caused by ESBL-positive pathogens. Additionally, use of oral antibiotics can shorten hospital stays and reduce medical costs.
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Affiliation(s)
- Hye Jin Shi
- Division of Infectious Diseases, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jae Hee Wee
- Division of Infectious Diseases, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Joong Sik Eom
- Division of Infectious Diseases, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Ahn ST, Han DE, Lee DH, Kim JW, Park HS, Moon DG, Oh MM. Single-dose amikacin plus 7 days of amoxicillin/clavulanate to treat acute cystitis caused by extended-spectrum beta-lactamase-producing Escherichia coli: A retrospective cohort study. Investig Clin Urol 2021; 62:310-316. [PMID: 33943052 PMCID: PMC8100019 DOI: 10.4111/icu.20200240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/09/2020] [Accepted: 01/21/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Treatment options for urinary tract infection (UTI) caused by extended-spectrum beta-lactamase (ESBL)-producing organisms are limited other than carbapenem. Accordingly, clinicians should investigate alternative antimicrobial options for limited infection. This study was performed to assess the efficacy of single-dose amikacin and a 7-day oral regimen of amoxicillin/clavulanate for the treatment of acute cystitis caused by ESBL-producing Escherichia coli and Klebsiella pneumoniae. MATERIALS AND METHODS A single-dose amikacin and 7-day oral amoxicillin/clavulanate regimen was given to all patients with acute cystitis or recurrent cystitis between May 2016 and October 2018. We conducted a retrospective cohort study assessing the efficacy of this regimen for the treatment of UTI due to ESBL-producing organisms. Both clinical and laboratory efficacy were assessed a minimum of 7 days and a maximum of 14 days after the completion of treatment. RESULTS A total of 47 patients were enrolled in this study. E. coli and K. pneumoniae were isolated in 44 patients (93.6%) and 3 patients (6.4%), respectively. Of the 47 enrolled, 39 patients (83.0%) showed sterile culture results on follow-up. Thirty-seven patients (78.7%) showed improvement of symptoms. Of 8 patients who showed bacterial persistence, 4 patients showed ESBL-producing E. coli, whereas 4 patients showed non-ESBL E. coli on follow-up cultures. During follow-up, 12 patients experienced the recurrence of acute cystitis with a median recurrence period of 2.5 months. CONCLUSIONS The combination of amoxicillin/clavulanate and amikacin may be an alternative to carbapenem treatment in patients with acute cystitis caused by ESBL-producing Enterobacteriaceae.
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Affiliation(s)
- Sun Tae Ahn
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Da Eun Han
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Dong Hyun Lee
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Jong Wook Kim
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Hong Seok Park
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Du Geon Moon
- Department of Urology, Korea University Guro Hospital, Seoul, Korea
| | - Mi Mi Oh
- Department of Urology, Korea University Guro Hospital, Seoul, Korea.
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Abbott IJ, Roberts JA, Meletiadis J, Peleg AY. Antimicrobial pharmacokinetics and preclinical in vitro models to support optimized treatment approaches for uncomplicated lower urinary tract infections. Expert Rev Anti Infect Ther 2020; 19:271-295. [PMID: 32820686 DOI: 10.1080/14787210.2020.1813567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Urinary tract infections (UTIs) are extremely common. Millions of people, particularly healthy women, are affected worldwide every year. One-in-two women will have a recurrence within 12-months of an initial UTI. Inadequate treatment risks worsening infection leading to acute pyelonephritis, bacteremia and sepsis. In an era of increasing antimicrobial resistance, it is critical to provide optimized antimicrobial treatment. AREAS COVERED Literature was searched using PubMed and Google Scholar (up to 06/2020), examining the etiology, diagnosis and oral antimicrobial therapy for uncomplicated UTIs, with emphasis on urinary antimicrobial pharmacokinetics (PK) and the application of dynamic in vitro models for the pharmacodynamic (PD) profiling of pathogen response. EXPERT OPINION The majority of antimicrobial agents included in international guidelines were developed decades ago without well-described dose-response relationships. Microbiology laboratories still apply standard diagnostic methodology that has essentially remained unchanged for decades. Furthermore, it is uncertain how relevant standard in vitro susceptibility is for predicting antimicrobial efficacy in urine. In order to optimize UTI treatments, clinicians must exploit the urine-specific PK of antimicrobial agents. Dynamic in vitro models are valuable tools to examine the PK/PD and urodynamic variables associated with UTIs, while informing uropathogen susceptibility reporting, optimized dosing schedules, clinical trials and treatment guidelines.
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Affiliation(s)
- Iain J Abbott
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Haidari, Greece
| | - Anton Y Peleg
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Australia.,Infection and Immunity Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Australia
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Oral Fosfomycin Efficacy with Variable Urinary Exposures following Single and Multiple Doses against Enterobacterales: the Importance of Heteroresistance for Growth Outcome. Antimicrob Agents Chemother 2020; 64:AAC.01982-19. [PMID: 31907184 DOI: 10.1128/aac.01982-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/24/2019] [Indexed: 12/20/2022] Open
Abstract
Oral fosfomycin trometamol is licensed as a single oral dose for the treatment of uncomplicated urinary tract infections, with activity against multidrug-resistant uropathogens. The impact of interindividual variability in urinary concentrations on antimicrobial efficacy, and any benefit of giving multiple doses, is uncertain. We therefore performed pharmacodynamic profiling of oral fosfomycin, using a dynamic bladder infection in vitro model, to assess high and low urinary exposures following a single oral dose and three repeat doses given every 72 h, 48 h, and 24 h against 16 clinical isolates with various MICs of fosfomycin (8 Escherichia coli, 4 Enterobacter cloacae, and 4 Klebsiella pneumoniae isolates). Baseline fosfomycin high-level-resistant (HLR) subpopulations were detected prior to drug exposure in half of the isolates (2 E. coli, 2 E. cloacae, and 4 K. pneumoniae isolates; proportion, 1 × 10-5 to 5 × 10-4% of the total population). Fosfomycin exposures were accurately reproduced compared to mathematical modeling (linear regression slope, 1.1; R 2, 0.99), with a bias of 3.8% ± 5.7%. All 5/5 isolates with MICs of ≤1 μg/ml had no HLR and were killed, whereas 8/11 isolates with higher MICs regrew regardless of exposure to high or low urinary concentrations. A disk diffusion zone of <24 mm was a better predictor for baseline HLR and regrowth. Administering 3 doses with average exposures provided very limited additional kill. These results suggest that baseline heteroresistance is important for treatment response, while increased drug exposure and administering multiple doses may not be better than standard single-dose fosfomycin therapy.
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Ex Vivo Urinary Bactericidal Activity and Urinary Pharmacodynamics of Fosfomycin after Two Repeated Dosing Regimens of Oral Fosfomycin Tromethamine in Healthy Adult Subjects. Antimicrob Agents Chemother 2020; 64:AAC.02102-19. [PMID: 31767717 DOI: 10.1128/aac.02102-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/14/2019] [Indexed: 11/20/2022] Open
Abstract
The ex vivo bactericidal activity and pharmacodynamics of fosfomycin in urine were evaluated in 18 healthy subjects. Subjects received 3 g every other day (QOD) for 3 doses and then every day (QD) for 7 doses or vice versa. Serial urine samples were collected before and up to 24 h after dosing on days 1 and 5. Eight bacterial strains with various genotypic and phenotypic susceptibilities to fosfomycin were used for all experiments (5 Escherichia coli, 2 Klebsiella pneumoniae, and 1 Proteus mirabilis). MICs were performed via agar dilution. Urinary bactericidal titers (UBTs) were performed via modified Schlichter test using participant's drug-free urine as the diluent. Urinary time-kill analyses were performed on pooled 24-h urine aliquots from days 1 and 5. All experiments were performed in triplicate with and without the addition of 25 mg/liter of glucose-6-phosphate (G6P). Mean 24-h urine concentrations of fosfomycin ranged from 324.7 to 434.6 mg/liter regardless of study day or dosing regimen. The urinary antibacterial activity of fosfomycin was also similar across study days and dosing regimens. UBT values did not correlate with MICs determined in the presence of G6P. Fosfomycin was reliably bactericidal in urine only against the 5 E. coli strains, regardless of genotype or MIC value. Together, these data do not support the use of oral fosfomycin tromethamine for pathogens other than E. coli or at a dosing frequency higher than QOD. Fosfomycin MICs determined in the presence of G6P may not accurately reflect the in vivo activity given the lack of G6P in human urine. (This study has been registered at ClinicalTrials.gov under identifier NCT02570074.).
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