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Zhang LL, Liu Y, Huang QY, Zhang HW, Xie LJ, Chen J, Ding L, Zhou C, Sun LN, Wang YQ. Safety, pharmacokinetics, and food-effect of pivmecillinam after single- and multiple-dose in healthy Chinese subjects: a phase I study. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:7639-7647. [PMID: 38691150 DOI: 10.1007/s00210-024-03118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/24/2024] [Indexed: 05/03/2024]
Abstract
Urinary tract infection (UTI) is one of the most prevalent bacterial infectious diseases worldwide. However, the resistance of urinary pathogens to other UTI antibiotics such as trimethoprim and trimethoprim/sulphamethoxazole increased. Pivmecillinam is a prodrug of mecillinam, which is effective for the treatment of urinary tract infections. The purpose of this study was to assess the safety, and pharmacokinetics of pivmecillinam and mecillinam after single- and multiple-dose oral administration of pivmecillinam tablets in healthy Chinese subjects. The study also investigated the profile of urinary excretion of mecillinam, as well as the effect of food and gender on the pharmacokinetics of pivmecillinam and mecillinam. This study was a single-center, open-label phase I study carried out in three groups. In total, 34 subjects were included in the study: group 1-food effect study with pivmecillinam 200 mg (n = 12); group 2-single- and multiple-dose study with pivmecillinam 400 mg (n = 12); group 3-single dose study with pivmecillinam 600 mg (n = 10). The plasma and urine concentrations of pivmecillinam and mecillinam were measured, and their pharmacokinetics were calculated. Treatment-emergent adverse events were evaluated and recorded in safety assessments for three groups. No severe adverse events were found in this study. After a single dose of pivmecillinam was taken orally, the maximum plasma concentration (Cmax) and the area under the concentration-time curve (AUC) of pivmecillinam increased in a dose-proportional manner, nor did mecillinam. Food had significant effects on Cmax and AUC0-t of pivmecillinam and Cmax of mecillinam. The mean cumulative percentage of urine excretion of mecillinam at 0 to 24 h ranged from 35.5 to 44.0%. Urinary cumulative excretion is relative to the drug dose, but the diet and multiple-dose administration did not affect the urinary cumulative excretion rate. The safety and pharmacokinetics of pivmecillinam and mecillinam after single- (200/400/600 mg) or multiple-dose (400 mg) administration were demonstrated in healthy Chinese subjects. Food affected the pharmacokinetics of pivmecillinam and mecillinam.
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Affiliation(s)
- Lu-Lu Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China
| | - Yi Liu
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qiong-Ye Huang
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hong-Wen Zhang
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Li-Jun Xie
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Juan Chen
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Li Ding
- Department of Pharmaceutical Analytical, China Pharmaceutical University, Nanjing, 210009, China
| | - Chen Zhou
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lu-Ning Sun
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Yong-Qing Wang
- School of Pharmacy, Nanjing Medical University, Nanjing, 211166, China.
- Research Division of Clinical Pharmacology, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Hawser S, Morrissey I, Kothari N, Monti F, Henriksen AS. Activity of mecillinam against USA urinary tract clinical isolates from 2017 to 2020 including isolates resistant to comparator antibiotics. J Glob Antimicrob Resist 2024; 39:137-143. [PMID: 39278462 DOI: 10.1016/j.jgar.2024.08.013] [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: 05/08/2024] [Revised: 08/07/2024] [Accepted: 08/31/2024] [Indexed: 09/18/2024] Open
Abstract
OBJECTIVES To support the clinical development of mecillinam and pivmecillinam in the United States for the treatment of complicated and uncomplicated urinary tract infections (UTIs), this study investigated the activity of mecillinam compared with other antibiotics against Enterobacterales isolates from patients with UTIs in the United States during 2017 to 2020. Mecillinam is a first-in-class amidinopenicillin antibiotic, being the only β-lactam to exert its antibacterial activity through exclusive binding to penicillin-binding protein 2. Pivmecillinam is the oral prodrug of mecillinam and is recommended as a first-line therapy by the Infectious Disease Society of America guidelines for uncomplicated UTIs and is approved for the treatment of uncomplicated UTIs in Europe, Canada, and the United States. METHODS A total of 3303 isolates were collected and antimicrobial susceptibility determined according to Clinical Laboratory and Standards Institute (CLSI) guidelines. RESULTS Susceptibility was highest for fosfomycin (97.1% susceptible) and mecillinam (94.9% susceptible). Against extended-spectrum beta-lactamase (ESBL)-positive bacteria susceptibilities were highest for mecillinam (98.2% susceptible) and fosfomycin (97.3% susceptible) and against ESBL-positive K. pneumoniae only mecillinam and fosfomycin had > 80% susceptibility. Resistance to comparator antibiotics was highest for trimethoprim-sulfamethoxazole (27.1%), followed by ciprofloxacin (19.3%), ceftriaxone (19.2%), and nitrofurantoin (12.1%). Multi-drug-resistant isolates were most susceptible to mecillinam and fosfomycin. CONCLUSION The data further support the clinical development and clinical utility of mecillinam. © 2024 The Author(s). Published by Elsevier Ltd on behalf of International Society for Antimicrobial Chemotherapy.
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Affiliation(s)
| | - Ian Morrissey
- Antimicrobial Focus Ltd., Sawbridgeworth, Hertfordshire, UK
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Lodise TP, Kaye KS, Santerre Henriksen A, Kahlmeter G. Review of the In Vitro Microbiological Activity of Mecillinam Against Common Uropathogens in Uncomplicated Urinary Tract Infection: Focus on Resistant Pathogens. Open Forum Infect Dis 2024; 11:ofae296. [PMID: 38868308 PMCID: PMC11167674 DOI: 10.1093/ofid/ofae296] [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] [Received: 02/28/2024] [Accepted: 05/22/2024] [Indexed: 06/14/2024] Open
Abstract
Antimicrobial resistance in uropathogens commonly causing urinary tract infections (UTIs) is a growing problem internationally. Pivmecillinam, the oral prodrug of mecillinam, has been used for over 40 years, primarily in Northern Europe and Canada. It is recommended in several countries as a first-line agent for the treatment of uncomplicated UTIs (uUTIs) and is now approved in the United States. We performed a structured literature search to review the available evidence on susceptibility of common uUTI-causing uropathogens to mecillinam. Among 38 studies included in this literature review, susceptibility rates for Escherichia coli to mecillinam-including resistant phenotypes such as extended-spectrum β-lactamase-producing E. coli-exceed 90% in most studies. High rates of susceptibility were also reported among many other uropathogens including Klebsiella spp., Enterobacter spp., and Citrobacter spp. In the current prescribing climate within the United States, pivmecillinam represents a viable first-line treatment option for patients with uUTI.
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Affiliation(s)
- Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Keith S Kaye
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Central Hospital, Växjö, Sweden
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Beaurain C, Thibon P, Fiaux E, Piednoir E, Magnani C, Caron F, Verdon R. General practitioners' clinical practice on the management of cystitis in Normandy, France: A clinical vignettes-based study. J Eval Clin Pract 2021; 27:421-428. [PMID: 32929837 DOI: 10.1111/jep.13464] [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: 02/10/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The objective was to measure the quality of clinical practice for the management of cystitis in adult women in general practice by collaborating with quality circles and the regional centre for antibiotic counsel. METHOD This descriptive cross-sectional study was performed in 2018 in Normandy, France. A questionnaire composed of clinical vignettes was used to evaluate practices of general practitioners (GPs) with regard to cystitis classified into four categories: simple, at risk of complication, recurrent, and caused by multidrug-resistant bacteria. The 2017 French Infectious Diseases Society's guidelines were used as a reference. RESULTS A total of 142 GPs participated in the study (45.5% of the solicited). Fosfomycin-trometamol and pivmecillinam were cited as first-line treatments for simple cystitis by 134 (94%) and 38 (27%) participants, respectively. For at risk of complication cystitis, the treatments cited were cefixime by 64 participants (45%), ofloxacin by 50 (35%), pivmecillinam by 49 (35%), fosfomycin-trometamol by 38 (27%), nitrofurantoin by 36 (25%), and amoxicillin-clavulanic acid by 28 (20%). Mean compliance rates were 85% for simple cystitis, 39% for at risk of complication cystitis, 60% for recurrent cystitis and 14% for cystitis caused by multidrug-resistant bacteria. Two criteria had less than 10% of the compliant answers: comprehensive knowledge of cystitis complication risk factors (9%) and positivity thresholds of urine cultures (10%). CONCLUSIONS In this study, diagnostic means, follow-up testing, and simple cystitis treatment (with fosfomycin predominantly mentioned) were broadly compliant. The use of critical antibiotics was too frequent for at risk of complication cystitis. There may be a need to improve the knowledge of professionals on antibiotic resistance and appropriate antibiotic use.
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Affiliation(s)
- Claire Beaurain
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France.,Université de Caen Normandie, Medical school, Caen, France
| | - Pascal Thibon
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Elise Fiaux
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Emmanuel Piednoir
- Centre Régional de Conseil en Antibiothérapie NormAntibio, Caen-Rouen, France
| | - Claude Magnani
- Union Régionale des Médecins Libéraux de Normandie, Caen, France
| | - François Caron
- Université de Rouen Normandie, Medical school, Rouen, France.,CHU de Rouen, Service Maladies infectieuses et tropicales, Rouen, France.,Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) Université de Normandie, UNIROUEN, UNICAEN, GRAM 2.0, Rouen, France
| | - Renaud Verdon
- Université de Caen Normandie, Medical school, Caen, France.,CHU de Caen, Service Maladies infectieuses et tropicales, Caen, France.,Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0) Université de Normandie, UNICAEN, UNIROUEN, GRAM 2.0, Caen, France
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Syre H, Hetland MAK, Bernhoff E, Bollestad M, Grude N, Simonsen GS, Löhr IH. Microbial risk factors for treatment failure of pivmecillinam in community-acquired urinary tract infections caused by ESBL-producing Escherichia coli. APMIS 2019; 128:232-241. [PMID: 31755584 DOI: 10.1111/apm.13013] [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] [Received: 05/31/2019] [Accepted: 11/14/2019] [Indexed: 11/30/2022]
Abstract
The aim of this study was to identify microbial risk factors for treatment failure of pivmecillinam in community-acquired urinary tract infections (ca-UTIs) caused by ESBL-producing Escherichia coli. Eighty-nine ESBL-producing E. coli isolated from women suffering from ca-UTIs were included. The susceptibilities to mecillinam were determined using MIC gradient strip. Whole genome sequencing was performed on a MiSeq platform, and genome assembly was performed using SPAdes v3.11.0. Neither mecillinam MICs nor ESBL genotypes were associated with treatment outcome of patients treated with pivmecillinam. Specific STs, however, showed significant differences in treatment outcome. Patients infected with ST131 were more likely to experience treatment failure compared to patients infected with non-ST131 (p 0.02) when adjusted for pivmecillinam dose, mecillinam MIC and severity of infection. Patients infected with ST69 were more often successfully treated compared to patients infected with non-ST69 (p 0.04). Patients infected with blaCTX-M-15 ST131 strains were more likely to experience treatment failure than those infected with non-blaCTX-M-15 ST131 strains (p 0.02). The results suggest that specific STs are associated with the clinical efficacy of pivmecillinam. Further studies with a larger number of strains, including a larger number of mecillinam resistant strains, are needed to confirm these results.
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Affiliation(s)
- Heidi Syre
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | | | - Eva Bernhoff
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | - Marianne Bollestad
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway.,Antibiotic Centre of Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Nils Grude
- Department of Medical Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.,Faculty of Health Science, The Arctic University of Norway, Tromsø, Norway
| | - Iren Høyland Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
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Raja NS. Emerging clinical role of pivmecillinam in the treatment of urinary tract infections caused by Extended Spectrum βeta-lactamase (ESBL) producing Enterobacteriaceae. Int J Clin Pract 2019; 73:1-5. [PMID: 31243859 DOI: 10.1111/ijcp.13387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/07/2019] [Accepted: 06/23/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Extended Spectrum βeta-lactamase (ESBL)-producing Enterobacteriaceae causing urinary tract infections (UTIs) appear resistant to many common oral agents. There is a growing need to discover new antibiotics to combat with emerging antibiotic resistance problem. Until the discovery of new antimicrobials, we can bring back forgotten antibiotics to our clinical formulary. Pivmecillinam (prodrug of mecillinam), an oral antimicrobial agent is effective against ESBL producing organisms. We analysed the sensitivity rates of ESBL-producing Enterobacteriaceae from urine samples to mecillinam and to document if pivmecillinam is a suitable alternative option in the treatment of UTI. MATERIALS/METHODS This retrospective study was conducted from September 2015 to September 2017. Data were collected from the pathology information system. Antimicrobial sensitivity testing on ESBL-producing Enterobacteriaceae isolates was carried out by disc diffusion method in accordance with The European Committee on Antimicrobial Susceptibility Testing. RESULTS A total of 986 ESBL-producing Enterobacteriaceae were tested for mecillinam during the study period. Of 986 organisms, Escherichia coli was the most common organism (889); followed by Klebsiella species (71) and others Enterobacteriaceae (26). Mecillinam sensitivity was found in 96% Escherichia coli (855/889 isolates), 83% Klebsiella species (59/71 isolates) and 88% other Enterobacteriaceae (23/26 isolates). Overall 95% (935/986 isolates) of ESBL-producing urinary isolates were sensitive to mecillinam. CONCLUSIONS Pivmecillinam appears to be suitable option to treat ESBL-producing Enterobacteriaceae causing uncomplicated UTI. Our results showed low resistance rate to mecillinam. We recommend the use of pivmecillinam in uncomplicated UTIs because of ESBL-producing Enterobacteriaceae. More studies on in vitro activity of mecillinam against ESBL producing organism and its use and clinical outcome should be tried in future.
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Affiliation(s)
- Nadeem S Raja
- Department of Clinical Microbiology, The Conquest Hospital, East Sussex Healthcare Trust, Hastings, UK
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Bollestad M, Grude N, Solhaug S, Raffelsberger N, Handal N, Nilsen HJS, Romstad MR, Emmert A, Tveten Y, Søraas A, Jenum PA, Jenum S, Møller-Stray J, Weme ET, Lindbaek M, Simonsen GS. Clinical and bacteriological efficacy of pivmecillinam treatment for uncomplicated urinary tract infections caused by ESBL-producing Escherichia coli: a prospective, multicentre, observational cohort study. J Antimicrob Chemother 2018; 73:2503-2509. [DOI: 10.1093/jac/dky230] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/22/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marianne Bollestad
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nils Grude
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medical Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Sigrid Solhaug
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Niclas Raffelsberger
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Nina Handal
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Norway
| | | | - Monica Regine Romstad
- Department of Medical Microbiology, Stavanger University Hospital, Stavanger, Norway
| | - Andreas Emmert
- Department of Medical Microbiology, Unilabs Telelab AS, Skien, Norway
| | - Yngvar Tveten
- Department of Medical Biochemistry, Telemark Hospital, Skien, Norway
| | - Arne Søraas
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Pål A Jenum
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Synne Jenum
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Janne Møller-Stray
- Department of Laboratory Medicine, Vestre Viken Hospital Trust, Drammen, Norway
| | | | - Morten Lindbaek
- The Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, and Research Group for Host-Microbe Interaction, Faculty of Health Sciences, UiT – The Arctic University of Norway, Tromsø, Norway
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Jansåker F, Frimodt-Møller N, Benfield TL, Knudsen JD. Mecillinam for the treatment of acute pyelonephritis and bacteremia caused by Enterobacteriaceae: a literature review. Infect Drug Resist 2018; 11:761-771. [PMID: 29872326 PMCID: PMC5973435 DOI: 10.2147/idr.s163280] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The pharmacokinetic properties of mecillinam (MEC) for urinary tract infections are excellent, and the resistance rate in Enterobacteriaceae is low compared to other recommended antibiotics. The oral prodrug pivmecillinam (P-MEC) has been used successfully as first choice for cystitis in the Nordic countries for many years. Norwegian and Danish guidelines also recommend P-MEC for acute uncomplicated pyelonephritis (AUP) and intravenous (IV) MEC for suspected urosepsis (only in Denmark). Here, we wish to present an updated investigation on the clinical data behind these recommendations together with sparse but more current clinical data. Methods Prospective clinical trials evaluating MEC as monotherapy or in polytherapy with one other beta-lactam (mostly ampicillin [AMP]) for pyelonephritis or bacteremia were reviewed. Outcomes of primary interest were clinical and bacteriological success and relapse, respectively. Search databases used were PubMed, Cochrane Library, and Embase. Results Twelve clinical studies (1979-2015) were included in this integrated literature review. Clinical success was seen in 38/51 (75%) patients treated with MEC as monotherapy and in 152/164 (93%) patients treated with MEC and one other beta-lactam. Bacteriological success was seen in 35/47 (74%) and 117/167 (70%) patients treated with MEC alone and with one other beta-lactam, respectively. In complicated infections, bacteriological success was much lower. Clinical relapse rate was not well described. Several uropathogenic bacteremia cases were treated successfully with MEC alone (ie, 10/15 [67%] and 13/15 [87%] for clinical and bacteriological success, respectively) or with one other beta-lactam (ie, 57/65 [88%] and 53/63 [84%] for clinical and bacteriological success, respectively). However, data on bacteremia are very sparse. Adverse reactions were few and mild (73/406 [18%]) and primarily seen when AMP was co-administered (69/73 [95%]). No serious adverse reactions were reported. Conclusion IV MEC or oral P-MEC for 14 days may be suitable for the treatment of AUP and pediatric pyelonephritis. Randomized controlled trials using a single standardized dose of P-MEC compared to other current recommendations are warranted. Similarly, more evidence is required before MEC should be recommended for bacteremia or sepsis due to Enterobacteriaceae.
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Affiliation(s)
- Filip Jansåker
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas L Benfield
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Jenny Dahl Knudsen
- Department of Clinical Microbiology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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