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Li Y, Zhu D, Sun S, Chang X, Cao Z, Yang Y, Fu X, Li X, Xu J, Zhu Y, Hui F, Xu X, Chen Z, Peng L, Ma Z, Mo B, Li C, Lv Y, Zhao L, Zhu G, He Y, Liu H, Chen J, Wang Y, Liang Y, Lu Y, Qin Z, Yang H, Zhang M, Wu S, Tong Z, Ye F, Xiao Z, Wang X, Qiu C, Kuang J, Huang H, Wang K, Ying K, Jin F, Lv X, Huang Y, Liu D, Wang W, Zhang Y. A multicentre, randomised, double-blind, double-dummy, parallel-controlled, phase 3 clinical trial assessing the efficacy and safety of intravenous nemonoxacin malate vs. levofloxacin for community-acquired pneumonia in adult patients. Int J Antimicrob Agents 2024; 64:107235. [PMID: 38851462 DOI: 10.1016/j.ijantimicag.2024.107235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/09/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Nemonoxacin malate is a novel non-fluorinated quinolone for oral and intravenous (IV) administration. This phase 3, multicentre, randomised, double-blind, double-dummy, parallel-controlled clinical trial (NCT02205112) evaluated the efficacy and safety of IV nemonoxacin vs. levofloxacin for the treatment of community-acquired pneumonia (CAP) in adult patients. METHODS Eligible patients were randomised to receive 500 mg nemonoxacin or levofloxacin via IV infusion, once daily for 7-14 days. The primary endpoint was the clinical cure rate at the test-of-cure (TOC) visit in the modified intent-to-treat (mITT) population. Secondary efficacy and safety were also compared between nemonoxacin and levofloxacin. RESULTS Overall, 525 patients were randomised and treated with nemonoxacin (n = 349) or levofloxacin (n = 176). The clinical cure rate was 91.8% (279/304) for nemonoxacin and 85.7% (138/161) for levofloxacin in the mITT population (P > 0.05). The clinical efficacy of nemonoxacin was non-inferior to levofloxacin for treatment of CAP. Microbiological success rate with nemonoxacin was 88.8% (95/107) and with levofloxacin was 87.8% (43/49) (P > 0.05) at the TOC visit in the bacteriological mITT population. The incidence of drug-related adverse events (AEs) was 37.1% in the nemonoxacin group and 22.2% in the levofloxacin group. These AEs were mostly local reactions at the infusion site, nausea, elevated alanine aminotransferase/aspartate aminotransferase (ALT/AST), and QT interval prolongation. The nemonoxacin-related AEs were mostly mild and resolved after discontinuation of nemonoxacin. CONCLUSIONS Nemonoxacin 500 mg IV once daily for 7-14 days is effective and safe and non-inferior to levofloxacin for treating CAP in adult patients.
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Affiliation(s)
- Ying Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Demei Zhu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shenghua Sun
- The Third Xiangya Hospital of Central South University, Changsha, China
| | | | - Zhaolong Cao
- Peking University People's Hospital, Beijing, China
| | | | - Xiuhua Fu
- The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiangyang Li
- Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Jinfu Xu
- Shanghai Pulmonary Hospital, Shanghai, China
| | - Yingqun Zhu
- The Third Hospital of Changsha, Changsha, China
| | | | - Xingxiang Xu
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Zhang Chen
- General Hospital of PLA Western Theatre Command, Chengdu, China
| | - Liping Peng
- The First Hospital of Jilin University, Changchun, China
| | - Zhuang Ma
- General Hospital of PLA Northern Theatre Command, Shenyang, China
| | - Biwen Mo
- Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Chen Li
- The Fourth Hospital of Jilin University Jilin Province (FAW General Hospital), Changchun, China
| | - Yuan Lv
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, China
| | - Li Zhao
- Shengjing Hospital of China Medical University, Shenyang, China
| | - Guangfa Zhu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yong He
- The Third Affiliated Hospital (Daping Hospital) of the Third Military Medical University, Chongqing, China
| | - Hua Liu
- Gansu Provincial Hospital, Lanzhou, China
| | | | - Ying Wang
- PLA Rocket General Hospital, Beijing, China
| | - Yongjie Liang
- Shanghai East Hospital Affiliated to Tongji University, Shanghai, China
| | - Youjin Lu
- The Second Hospital of Anhui Medical University
| | - Zhiqiang Qin
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | | | - Min Zhang
- Shenzhen Second People's Hospital, Shenzhen, China
| | - Shiman Wu
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhaohui Tong
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Feng Ye
- The First Affiliated Hospital of Guangzhou Medical University (National Centre for Respiratory Medicine), Guangzhou, China
| | - Zuke Xiao
- Jiangxi Provincial Hospital, Nanchang, China
| | - Xuefen Wang
- The First Affiliated Hospital, Zhejiang University School of Medicine (The First Hospital of Zhejiang Province), Hangzhou, China
| | - Chen Qiu
- Shenzhen People's Hospital (The Second Clinical Medical School of Jinan University), Shenzhen, China
| | - Jiulong Kuang
- The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaping Huang
- The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Kai Wang
- The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Kejing Ying
- Sir Run Run Shaw Hospital affiliated to Zhejiang University School of Medicine, Hangzhou, China
| | - Faguang Jin
- Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaoju Lv
- West China Hospital, Sichuan University, Chengdu, China
| | | | - Deling Liu
- The 900(th) Hospital of PLA Joint Logistics Support Force, Fuzhou, China
| | - Wei Wang
- The Second Hospital of Shandong University, Jinan, China
| | - Yingyuan Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.
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Tang F, Hou XF, Cheng Y, Liu Y, Sun J, Liu HY, Lv LP, Fu L. Longitudinal associations between serum IL-34 with severity and prognosis in community-acquired pneumonia patients. Respir Investig 2024; 62:223-230. [PMID: 38218098 DOI: 10.1016/j.resinv.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/13/2023] [Accepted: 12/22/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Interleukin-34 (IL-34) is a hematopoietic cytokine and a ligand of colony-stimulating factor 1 receptor (CSF-1R). Numerous studies have demonstrated that IL-34 is involved in several inflammatory diseases. Nevertheless, the role of IL-34 is obscure in community-acquired pneumonia (CAP) patients. This research aimed to assess the associations of serum IL-34 with severity and prognosis in CAP patients through a longitudinal study. METHODS CAP patients and healthy volunteers were recruited. Peripheral blood samples were collected. Serum IL-34 and inflammatory cytokines were tested by enzyme linked immunosorbent assay (ELISA). Demographic characteristics and clinical information were acquired through electronic medical records. RESULTS Serum IL-34 was elevated in CAP patients compared with healthy volunteers. The content of serum IL-34 was gradually upregulated with increased CAP severity scores. Mixed logistic and linear regression models suggested that serum IL-34 elevation was associated with increased PSI and SMART-COP scores. Correlative analysis found that serum IL-34 was positively correlated with inflammatory cytokines among CAP patients. A longitudinal study indicated that higher serum IL-34 at admission elevated the risks of mechanical ventilation and death during hospitalization. Serum IL-34 had a higher predictive capacity for death than CAP severity scores. CONCLUSION There are prominently positive dose-response associations between serum IL-34 at admission with the severity and poor prognosis, suggesting that IL-34 is implicated in the occurrence and development of CAP. Serum IL-34 may serve as a biomarker to forecast disease progression and poor prognosis in CAP patients.
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Affiliation(s)
- Fei Tang
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, Anhui, 230022, China
| | - Xue-Feng Hou
- School of Pharmacy, Drug Research & Development Center, Wannan Medical College, Wuhu, Anhui, 241002, China
| | - Yu Cheng
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, Anhui, 230022, China
| | - Ying Liu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China
| | - Jing Sun
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China
| | - Hong-Yan Liu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China; Institute of Respiratory Diseases, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China.
| | - Li-Ping Lv
- Department of Interventional Pulmonology and Endoscopic Diagnosis and Treatment Center, Anhui Chest Hospital, Hefei, Anhui, 230022, China.
| | - Lin Fu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China; Institute of Respiratory Diseases, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, China.
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Cortegiani A, Antonelli M, Falcone M, Giarratano A, Girardis M, Leone M, Pea F, Stefani S, Viaggi B, Viale P. Rationale and clinical application of antimicrobial stewardship principles in the intensive care unit: a multidisciplinary statement. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:11. [PMID: 37386615 PMCID: PMC10245548 DOI: 10.1186/s44158-023-00095-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/21/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Antimicrobial resistance represents a major critical issue for the management of the critically ill patients hospitalized in the intensive care unit (ICU), since infections by multidrug-resistant bacteria are characterized by high morbidity and mortality, high rates of treatment failure, and increased healthcare costs worldwide. It is also well known that antimicrobial resistance can emerge as a result of inadequate antimicrobial therapy, in terms of drug selection and/or treatment duration. The application of antimicrobial stewardship principles in ICUs improves the quality of antimicrobial therapy management. However, it needs specific considerations related to the critical setting. METHODS The aim of this consensus document gathering a multidisciplinary panel of experts was to discuss principles of antimicrobial stewardship in ICU and to produce statements that facilitate their clinical application and optimize their effectiveness. The methodology used was a modified nominal group discussion. CONCLUSION The final set of statements underlined the importance of the specific interpretation of antimicrobial stewardship's principles in critically ill patient management, quasi-targeted therapy, the use of rapid diagnostic methods, the personalization of antimicrobial therapies' duration, obtaining microbiological surveillance data, the use of PK/PD targets, and the use of specific indicators in antimicrobial stewardship programs.
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy.
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy.
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, Aix-Marseille University, AP-HM, North Hospital, Marseille, France
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138, Bologna, Italy
| | - Stefania Stefani
- Microbiology Section, Dept of Biomedical and Biotechnological Science, University of Catania, Catania, Italy
- Unità Operativa Complessa (UOC) Laboratory Analysis, University Hospital Policlinico-San Marco, Catania, Italy
| | - Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
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Hurtado IC, Valencia S, Pinzon EM, Lesmes MC, Sanchez M, Rodriguez J, Ochoa B, Shewade HD, Edwards JK, Hann K, Khogali M. Antibiotic resistance and consumption before and during the COVID-19 pandemic in Valle del Cauca, Colombia. Rev Panam Salud Publica 2023; 47:e10. [PMID: 37082532 PMCID: PMC10105594 DOI: 10.26633/rpsp.2023.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/26/2022] [Indexed: 04/22/2023] Open
Abstract
Objective To assess changes in antibiotic resistance of eight of the World Health Organization priority bug-drug combinations and consumption of six antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ciprofloxacin, vancomycin) before (March 2018 to July 2019) and during (March 2020 to July 2021) the COVID-19 pandemic in 31 hospitals in Valle del Cauca, Colombia. Methods This was a before/after study using routinely collected data. For antibiotic consumption, daily defined doses (DDD) per 100 bed-days were compared. Results There were 23 405 priority bacterial isolates with data on antibiotic resistance. The total number of isolates increased from 9 774 to 13 631 in the periods before and during the pandemic, respectively. While resistance significantly decreased for four selected bug-drug combinations (Klebsiella pneumoniae, extended spectrum beta lactamase [ESBL]-producing, 32% to 24%; K. pneumoniae, carbapenem-resistant, 4% to 2%; Pseudomonas aeruginosa, carbapenem-resistant, 12% to 8%; Acinetobacter baumannii, carbapenem-resistant, 23% to 9%), the level of resistance for Enterococcus faecium to vancomycin significantly increased (42% to 57%). There was no change in resistance for the remaining three combinations (Staphylococcus aureus, methicillin-resistant; Escherichia coli, ESBL-producing; E. coli, carbapenem-resistant). Consumption of all antibiotics increased. However, meropenem consumption decreased in intensive care unit settings (8.2 to 7.1 DDD per 100 bed-days). Conclusions While the consumption of antibiotics increased, a decrease in antibiotic resistance of four bug-drug combinations was observed during the pandemic. This was possibly due to an increase in community-acquired infections. Increasing resistance of E. faecium to vancomycin must be monitored. The findings of this study are essential to inform stewardship programs in hospital settings of Colombia and similar contexts elsewhere.
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Affiliation(s)
- Isabel Cristina Hurtado
- Valle del Cauca Secretariat of HealthCaliColombiaValle del Cauca Secretariat of Health, Cali, Colombia
- Universidad del ValleCaliColombiaUniversidad del Valle, Cali, Colombia
| | - Sandra Valencia
- Valle del Cauca Secretariat of HealthCaliColombiaValle del Cauca Secretariat of Health, Cali, Colombia
| | - Elisa Maria Pinzon
- Valle del Cauca Secretariat of HealthCaliColombiaValle del Cauca Secretariat of Health, Cali, Colombia
- Fundacion Universitaria San MartinCaliColombiaFundacion Universitaria San Martin, Cali, Colombia
| | - Maria Cristina Lesmes
- Valle del Cauca Secretariat of HealthCaliColombiaValle del Cauca Secretariat of Health, Cali, Colombia
| | - Mauro Sanchez
- University of BrasíliaBrasíliaBrazilUniversity of Brasília, Brasília, Brazil
| | - Jaime Rodriguez
- Universidad Pedagógica y Tecnológica de ColombiaTunjaColombiaUniversidad Pedagógica y Tecnológica de Colombia, Tunja, Colombia
| | - Brindis Ochoa
- Pan American Health OrganizationWashington, D.C.United States of AmericaPan American Health Organization, Washington, D.C., United States of America
| | - Hemant Deepak Shewade
- ICMR–National Institute of EpidemiologyChennaiIndiaICMR–National Institute of Epidemiology, Chennai, India
| | - Jeffrey K. Edwards
- University of WashingtonSeattleUnited States of AmericaUniversity of Washington, Seattle, United States of America
| | - Katrina Hann
- Sustainable Health SystemsFreetownSierra LeoneSustainable Health Systems, Freetown, Sierra Leone
| | - Mohammed Khogali
- World Health OrganizationGenevaSwitzerlandWorld Health Organization, Geneva, Switzerland
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5
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Yao MX, Cheng JY, Liu Y, Sun J, Hua DX, He QY, Liu HY, Fu L, Zhao H. Cross-sectional and longitudinal associations of serum Cysteine-rich 61 with severity and prognosis among community-acquired pneumonia patients in China. Front Med (Lausanne) 2022; 9:939002. [PMID: 36035395 PMCID: PMC9403795 DOI: 10.3389/fmed.2022.939002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCysteine-rich 61 (CYR61) is implicated in many pulmonary diseases. However, the relationship between CYR61 and community-acquired pneumonia (CAP) patients was unknown. This research aimed to estimate the correlations of serum CYR61 with severity and prognosis in CAP patients through a prospective cohort study.MethodsAll 541 CAP patients were enrolled in this study. Fasting venous blood was collected. Clinical characteristics and demographic information were obtained. CYR61 and inflammatory cytokines were detected in serum using ELISA.ResultsSerum CYR61 was gradually increased in parallel with severity scores in CAP patients. Correlative analysis indicated that serum CYR61 was strongly associated with many clinical parameters in CAP patients. Moreover, mixed logistic and linear regression models found that there were positive correlations between serum CYR61 and CAP severity scores after adjusted for age, BMI, and respiratory rate. Stratified analyses suggested that age affected the associations between serum CYR61 and severity scores. On admission, higher serum CYR61 levels elevated the risks of mechanical ventilation, vasoactive agent, ICU admission, death, and longer hospital stays during hospitalization. Moreover, serum CYR61 in combination with severity scores upregulated the predictive capacities for severity and death than single serum CYR61 or severity scores in CAP patients.ConclusionThere are significantly positive dose-response associations of serum CYR61 on admission with the severity and adverse prognostic outcomes, demonstrating that CYR61 is involved in the pathophysiology of CAP. Serum CYR61 may be used as a potential biomarker for the diagnosis and prognosis in CAP patients.
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Affiliation(s)
- Meng-Xing Yao
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jia-Yi Cheng
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ying Liu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Sun
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dong-Xu Hua
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qi-Yuan He
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hong-Yan Liu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lin Fu
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of Toxicology, Anhui Medical University, Hefei, China
- *Correspondence: Lin Fu, ;
| | - Hui Zhao
- Department of Respiratory and Critical Care Medicine, Second Affiliated Hospital of Anhui Medical University, Hefei, China
- Hui Zhao,
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Cao LF, Cheng JY, Xu Z, Feng CM, Zhao H, Wang XM, Fu L. Serum 8-Hydroxydeoxyguanosine Is a Potential Indicator for the Severity and Prognosis in Patients with Community-Acquired Pneumonia: A Prospective Cohort Study. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2022; 208:321-327. [PMID: 34911771 DOI: 10.4049/jimmunol.2100711] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/02/2021] [Indexed: 12/23/2022]
Abstract
Previous studies have demonstrated that 8-hydroxydeoxyguanosine (8-OHdG) exerted key roles in various pulmonary diseases, but the evidence for its role in community-acquired pneumonia (CAP) was lacking. The goal of this research was to evaluate the correlations of serum 8-OHdG with the severity and prognosis among patients with CAP through a prospective cohort study. A total of 239 patients with CAP and 239 healthy participants were enrolled. Fasting blood samples were collected. 8-OHdG and inflammatory cytokines were measured by ELISA. On admission, serum 8-OHdG was significantly increased in patients with CAP compared with control subjects. Besides, serum 8-OHdG was incrementally increased in line with CAP severity scores. Pearson correlative analysis found that serum 8-OHdG was correlated with clinical characteristics and inflammatory cytokines in patients with CAP. Linear and logistic regression analysis showed that serum 8-OHdG was positively associated with CAP severity scores. Furthermore, the prognostic outcomes were tracked. Higher serum 8-OHdG on admission increased the risks for intensive care unit admission, mechanical ventilation, vasoactive agent usage, death, and longer hospital stay among patients with CAP. Serum 8-OHdG combination with confusion, respiratory rate, blood pressure, and age ≥65 y or pneumonia severity index had stronger predictive powers for death than single 8-OHdG, CAP severity scores, or several inflammatory cytokines in patients with CAP. These results indicated that serum 8-OHdG is positively associated with the severity and poor prognosis in patients with CAP, demonstrating that 8-OHdG may be involved in the pathophysiology process of CAP.
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Affiliation(s)
- Lin-Feng Cao
- Department of Respiratory Medicine, The First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Jia-Yi Cheng
- Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; and
| | - Zheng Xu
- Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; and
| | - Chun-Mei Feng
- Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; and
| | - Hui Zhao
- Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; and
| | - Xin-Ming Wang
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Lin Fu
- Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; and
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7
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Advances in Bacteriophage Therapy against Relevant MultiDrug-Resistant Pathogens. Antibiotics (Basel) 2021; 10:antibiotics10060672. [PMID: 34199889 PMCID: PMC8226639 DOI: 10.3390/antibiotics10060672] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023] Open
Abstract
The increase of multiresistance in bacteria and the shortage of new antibiotics in the market is becoming a major public health concern. The World Health Organization (WHO) has declared critical priority to develop new antimicrobials against three types of bacteria: carbapenem-resistant A. baumannii, carbapenem-resistant P. aeruginosa and carbapenem-resistant and ESBL-producing Enterobacteriaceae. Phage therapy is a promising alternative therapy with renewed research in Western countries. This field includes studies in vitro, in vivo, clinical trials and clinical cases of patients receiving phages as the last resource after failure of standard treatments due to multidrug resistance. Importantly, this alternative treatment has been shown to be more effective when administered in combination with antibiotics, including infections with biofilm formation. This review summarizes the most recent studies of this strategy in animal models, case reports and clinical trials to deal with infections caused by resistant A. baumannii, K. pneumoniae, E. coli, and P. aeruginosa strains, as well as discusses the main limitations of phage therapy.
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8
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Self WH, Wunderink RG, DiNubile MJ, Stossel TP, Levinson SL, Williams DJ, Anderson EJ, Bramley AM, Jain S, Edwards KM, Grijalva CG. Low Admission Plasma Gelsolin Concentrations Identify Community-acquired Pneumonia Patients at High Risk for Severe Outcomes. Clin Infect Dis 2020; 69:1218-1225. [PMID: 30561561 DOI: 10.1093/cid/ciy1049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Plasma gelsolin (pGSN) is an abundant circulating protein that neutralizes actin exposed by damaged cells, modulates inflammatory responses, and enhances alveolar macrophage antimicrobial activity. We investigated whether adults with low pGSN at hospital admission for community-acquired pneumonia (CAP) were at high risk for severe outcomes. METHODS Admission pGSN concentrations in 455 adults hospitalized with CAP were measured using enzyme-linked immunosorbent assay. Patients were grouped into the following 4 hierarchical, mutually exclusive categories based on maximum clinical severity experienced during their hospitalization: general floor care without intensive care unit (ICU) admission, invasive respiratory or vasopressor support (IRVS), or death; ICU care without IRVS or death; IRVS without death; or death. Admission pGSN concentrations were compared across these discrete outcome categories. Additionally, outcomes among patients in the lowest quartile of pGSN concentration were compared to those in the upper 3 quartiles. RESULTS Overall, median (interquartile range) pGSN concentration was 38.1 (32.1, 45.7) μg/mL. Patients with more severe outcomes had lower pGSN concentrations (P = .0001); median values were 40.3 μg/mL for floor patients, 36.7 μg/mL for ICU patients, 36.5 μg/mL for patients receiving IRVS, and 25.7 μg/mL for patients who died. Compared to patients with higher pGSN concentrations, patients in the lowest quartile (pGSN ≤ 32.1 μg/mL) more often required IRVS (21.2% vs 11.7%, P = .0114) and died (8.8% vs 0.9%, P < .0001). CONCLUSIONS Among adults hospitalized with CAP, lower pGSN concentrations were associated with more severe clinical outcomes. Future studies are planned to investigate possible therapeutic benefits of recombinant human pGSN in this population.
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Affiliation(s)
- Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard G Wunderink
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Derek J Williams
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan J Anderson
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Anna M Bramley
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Seema Jain
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Liu S, Tong X, Ma Y, Wang D, Huang J, Zhang L, Wu M, Wang L, Liu T, Fan H. Respiratory Fluoroquinolones Monotherapy vs. β-Lactams With or Without Macrolides for Hospitalized Community-Acquired Pneumonia Patients: A Meta-Analysis. Front Pharmacol 2019; 10:489. [PMID: 31139081 PMCID: PMC6517694 DOI: 10.3389/fphar.2019.00489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/17/2019] [Indexed: 02/05/2023] Open
Abstract
Background: The choice of empirical antibiotic treatment for patients with community-acquired pneumonia (CAP) who are admitted to non-intensive care unit (ICU) hospital wards is complicated by the limited availability of evidence. We systematically reviewed the efficacy and safety of strategies of empirical treatment with respiratory fluoroquinolone monotherapy and β-lactam with or without macrolide for non-ICU hospitalized CAP patients. Methods: We searched databases including PubMed, the Cochrane Library (Issue11, 2018), EMbase, China National Knowledge Internet (CNKI), WanFang Data, VIP, and China Biology Medicine disc (CBMdisc) to identify randomized controlled trials (RCTs) involving the comparison of respiratory fluoroquinolone monotherapy and β-lactam with or without macrolide for the non-ICU hospitalized patients with CAP up to November 2018. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data, and assessed the risk of bias of the included studies. A meta-analysis was performed with the outcomes. Results: A total of 22 studies involving 6,235 patients were included. The results of the meta-analysis showed a non-significant trend toward an advantage to the respiratory fluoroquinolone in overall mortality (RR 0.82, 95% CI 0.65-1.02). No significant difference was found between the two strategies in clinical success (the intention-to-treat population: RR 1.03, 95% CI 0.99-1.08; the clinically evaluable population: RR 1.03, 95% CI 0.999-1.055; the population in which it was unclear whether intention-to-treat or per-protocol analysis was used: RR 1.04, 95% CI 0.99-1.09), microbiological treatment success (RR 1.04, 95% CI 0.997-1.092), and length of stay (SMD -0.06, 95% CI -0.16 to 0.04). The advantage of respiratory fluoroquinolone was statistically significant on the drug-related adverse events (RR 0.87, 95% CI 0.77-0.97). Conclusions: Current evidence shows that fluoroquinolone monotherapy has similar efficacy and favorable safety compared with β-lactam with or without macrolide for non-ICU hospitalized CAP patients. Since the limitation of region, quantity and quality of included studies, more RCTs with large scale and high quality are needed to verify the above conclusion.
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Affiliation(s)
- Sitong Liu
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiang Tong
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Yao Ma
- The Center of Gerontology and Geriatrics, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Dongguang Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Jizhen Huang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Man Wu
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Lei Wang
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Liu
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory Medicine and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
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Liang R, Zou X, Wu Y, Ma Z, Deng M, Deng C. WITHDRAWN: Pneumonia: A Case Report on Largely Emerging and Severe Infectious Disease from Southeast China and Literature Review. Respir Med Case Rep 2019. [DOI: 10.1016/j.rmcr.2019.100841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Yuan J, Mo B, Ma Z, Lv Y, Cheng SL, Yang Y, Tong Z, Wu R, Sun S, Cao Z, Wu J, Zhu D, Chang L, Zhang Y, Zhao L, Wang X, Wang X, Wang D, Li X, Peng Y, Liang Y, Liu H, Xiao Z, Lv X, Wu S, Dai Y, Huang Y, Hu Z, Qiu C, Li X, Zhang S, Li W, Liu S, Shi Y, Xiong C, Kuang J, Xiu Q, Cui S, Li J, Lin Q, Huang W, Wan Y, Qimanguli, Shen C, Xiao Y, Wu X, Chuang YC, Perng WC, Tsao SM, Hsu JY, Wang CC, Wang JH, Yeh PF, Lin HH, Kuo P, Lin MS, Su WJ. Safety and efficacy of oral nemonoxacin versus levofloxacin in treatment of community-acquired pneumonia: A phase 3, multicenter, randomized, double-blind, double-dummy, active-controlled, non-inferiority trial. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:35-44. [DOI: 10.1016/j.jmii.2017.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/08/2017] [Accepted: 07/14/2017] [Indexed: 11/30/2022]
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Lewies A, Du Plessis LH, Wentzel JF. Antimicrobial Peptides: the Achilles’ Heel of Antibiotic Resistance? Probiotics Antimicrob Proteins 2018; 11:370-381. [DOI: 10.1007/s12602-018-9465-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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13
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Mohd R, Nesam T, Kamaruzaman L, Cader RA, Mustafar R, Kong WY. Community acquired multi drug resistant (MDR) Acinetobacter baumannii pneumonia in Malaysia - A case report. Respir Med Case Rep 2018; 24:147-149. [PMID: 29977783 PMCID: PMC6010644 DOI: 10.1016/j.rmcr.2018.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/23/2022] Open
Abstract
Acinetobacter baumannii is an aerobic Gram-negative coccobacillus that is associated with hospital acquired pneumonia. There is increased reporting of emergent cases of community acquired multidrug resistance (MDR) acinetobacter associated with a higher mortality due to antibiotic resistance. Community acquired MDR acinetobacter pneumonia has not been reported in Malaysia. Here we report a case of a 19-year-old army officer who presented with fever and respiratory symptoms for 5 days. He had no known medical illness before and no history of hospitalization. Upon arrival, he was in septicaemic shock, requiring invasive ventilator support and renal replacement therapy in intensive care unit. Chest radiograph showed bilateral lung consolidations and bronchoscopy revealed haemoserous and greenish bronchiole secretion. He was treated with broad spectrum antibiotics and oseltamivir. Unfortunately he died on day 3 of hospital admission. His bronchial lavage culture came back positive for MDR Acinetobacter baumannii. This case illustrates that clinicians need to be aware that MDR Acinetobacter baumannii can cause severe community acquired pneumonia. We may need to consider this diagnosis in patients who do not respond to standard therapy.
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Affiliation(s)
| | | | - Lydia Kamaruzaman
- Corresponding author. Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, 56000 Kuala Lumpur, Malaysia.
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Govindan S, Hyzy RC. The 2016 Guidelines for Hospital-acquired and Ventilator-associated Pneumonia. A Selection Correction? Am J Respir Crit Care Med 2017; 194:658-60. [PMID: 27463241 DOI: 10.1164/rccm.201607-1447ed] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sushant Govindan
- 1 Department of Internal Medicine University of Michigan Ann Arbor, Michigan
| | - Robert C Hyzy
- 1 Department of Internal Medicine University of Michigan Ann Arbor, Michigan
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15
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Mansour H, Chahine EB, Karaoui LR, El-Lababidi RM. Cethromycin: A New Ketolide Antibiotic. Ann Pharmacother 2016; 47:368-79. [DOI: 10.1345/aph.1r435] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the pharmacology, chemistry, microbiology, in vitro susceptibility, mechanism of resistance, pharmacokinetics, pharmacodynamics, clinical efficacy, safety, drug interactions, dosage, and administration of cethromycin, a new ketolide antibiotic. DATA SOURCES Literature was obtained through searching PubMed (1950-October 2012), International Pharmaceutical Abstracts (1970-October 2012), and a bibliographic review of published articles. Search terms included cethromycin, ABT-773, ketolide antibiotic, and community-acquired pneumonia. STUDY SELECTION AND DATA EXTRACTION All available in vitro and preclinical studies, as well as Phase 1, 2, and 3 clinical studies published in English were evaluated to summarize the pharmacology, chemistry, microbiology, efficacy, and safety of cethromycin in the treatment of respiratory tract infections. DATA SYNTHESIS Cethromycin, a new ketolide, has a similar mechanism of action to telithromycin with an apparently better safety profile. Cethromycin displays in vitro activity against selected gram-positive, gram-negative, and atypical bacteria. The proposed indication of cethromycin is treatment of mild to moderate community-acquired bacterial pneumonia in patients aged 18 years or older. Based on clinical studies, the recommended dose is 300 mg orally once a day without regard to meals. Cethromycin has an orphan drug designation for tularemia, plague, and anthrax prophylaxis. The Food and Drug Administration denied approval for the treatment of community-acquired pneumonia in 2009; a recent noninferiority trial showed comparable efficacy between cethromycin and clarithromycin. Preliminary data on adverse effects suggest that cethromycin is safe and gastrointestinal adverse effects appear to be dose-related. CONCLUSIONS Cethromycin appears to be a promising ketolide for the treatment of mild to moderate community-acquired pneumonia. It was denied approval by the FDA in 2009 pending more evidence to show its efficacy, with more recent studies showing its noninferiority to antibiotics for the same indication.
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Affiliation(s)
- Hanine Mansour
- Hanine Mansour PharmD BCPS, at the time of writing, College of Pharmacy, University of Florida; now, Clinical Assistant Professor, Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
| | - Elias B Chahine
- Elias B Chahine PharmD BCPS (AQ-ID), Assistant Professor of Pharmacy Practice, Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL
| | - Lamis R Karaoui
- Lamis R Karaoui PharmD BCPS, Clinical Assistant Professor, Director of Experiential Education, Department of Pharmacy Practice, School of Pharmacy, Lebanese American University
| | - Rania M El-Lababidi
- Rania M El-Lababidi PharmD BCPS (AQ-ID) AAHIVP, at time of writing, Assistant Director, Clinical Services Department of Pharmacy, Florida Hospital, Orlando; now, Training Manager, Cleveland Clinic Abu Dhabi, Department of Pharmacy Services, Abu Dhabi, United Arab Emirates
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Stanley D, Mason LJ, Mackin KE, Srikhanta YN, Lyras D, Prakash MD, Nurgali K, Venegas A, Hill MD, Moore RJ, Wong CHY. Translocation and dissemination of commensal bacteria in post-stroke infection. Nat Med 2016; 22:1277-1284. [DOI: 10.1038/nm.4194] [Citation(s) in RCA: 215] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 09/01/2016] [Indexed: 12/13/2022]
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Host-directed therapies for antimicrobial resistant respiratory tract infections. Curr Opin Pulm Med 2016; 22:203-11. [DOI: 10.1097/mcp.0000000000000271] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Abstract
There is an ongoing race between bacterial evolution and medical advances. Pathogens have the advantages of short generation times and horizontal gene transfer that enable rapid adaptation to new host environments and therapeutics that currently outpaces clinical research. Antibiotic resistance, the growing impact of nosocomial infections, cancer-causing bacteria, the risk of zoonosis, and the possibility of biowarfare all emphasize the increasingly urgent need for medical research focussed on bacterial pathogens. Bacterial glycoproteins are promising targets for alternative therapeutic intervention since they are often surface exposed, involved in host-pathogen interactions, required for virulence, and contain distinctive glycan structures. The potential exists to exploit these unique structures to improve clinical prevention, diagnosis, and treatment strategies. Translation of the potential in this field to actual clinical impact is an exciting prospect for fighting infectious diseases.
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Affiliation(s)
- Kelly M Fulton
- a Human Health Therapeutics Portfolio , National Research Council Canada , Ottawa , Canada
| | - Jeffrey C Smith
- b Department of Chemistry and Institute of Biochemistry , Carleton University , Ottawa , Canada
| | - Susan M Twine
- a Human Health Therapeutics Portfolio , National Research Council Canada , Ottawa , Canada
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19
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Cheng VCC, Wong SCY, Ho PL, Yuen KY. Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China. Emerg Microbes Infect 2015; 4:e8. [PMID: 26038766 PMCID: PMC4345289 DOI: 10.1038/emi.2015.8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/30/2014] [Accepted: 12/30/2014] [Indexed: 01/23/2023]
Abstract
Antimicrobial-resistant bacteria are either highly prevalent or increasing rapidly in Hong Kong and China. Treatment options for these bacteria are generally limited, less effective and more expensive. The emergence and dynamics of antimicrobial resistance genes in bacteria circulating between animals, the environment and humans are not entirely known. Nonetheless, selective pressure by antibiotics on the microbiomes of animal and human, and their associated environments (especially farms and healthcare institutions), sewage systems and soil are likely to confer survival advantages upon bacteria with antimicrobial-resistance genes, which may be further disseminated through plasmids or transposons with integrons. Therefore, antibiotic use must be tightly regulated to eliminate such selective pressure, including the illegalization of antibiotics as growth promoters in animal feed and regulation of antibiotic use in veterinary practice and human medicine. Heightened awareness of infection control measures to reduce the risk of acquiring resistant bacteria is essential, especially during antimicrobial use or institutionalization in healthcare facilities. The transmission cycle must be interrupted by proper hand hygiene, environmental cleaning, avoidance of undercooked or raw food and compliance with infection control measures by healthcare workers, visitors and patients, especially during treatment with antibiotics. In addition to these routine measures, proactive microbiological screening of hospitalized patients with risk factors for carrying resistant bacteria, including history of travel to endemic countries, transfer from other hospitals, and prolonged hospitalization; directly observed hand hygiene before oral intake of drugs, food and drinks; and targeted disinfection of high-touch or mutual-touch items, such as bed rails and bed curtains, are important. Transparency of surveillance data from each institute for public scrutiny provides an incentive for controlling antimicrobial resistance in healthcare settings at an administrative level.
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Affiliation(s)
- Vincent C C Cheng
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China ; Infection Control Team, Queen Mary Hospital , Hong Kong, China
| | - Sally C Y Wong
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China
| | - Pak-Leung Ho
- Department of Microbiology, Queen Mary Hospital , Hong Kong, China
| | - Kwok-Yung Yuen
- Department of Microbiology, Queen Mary Hospital, Hong Kong, China ; Department of Clinical Microbiology and Infection Control, Hong Kong University-Shenzhen Hospital , Shenzhen 518053, Guangdong province, China
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García-Quintanilla M, Pulido MR, Pachón J, McConnell MJ. Immunization with lipopolysaccharide-deficient whole cells provides protective immunity in an experimental mouse model of Acinetobacter baumannii infection. PLoS One 2014; 9:e114410. [PMID: 25485716 PMCID: PMC4259314 DOI: 10.1371/journal.pone.0114410] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 11/09/2014] [Indexed: 11/18/2022] Open
Abstract
The increasing clinical importance of infections caused by multidrug resistant Acinetobacter baumannii warrants the development of novel approaches for prevention and treatment. In this context, vaccination of certain patient populations may contribute to reducing the morbidity and mortality caused by this pathogen. Vaccines against Gram-negative bacteria based on inactivated bacterial cells are highly immunogenic and have been shown to produce protective immunity against a number of bacterial species. However, the high endotoxin levels present in these vaccines due to the presence of lipopolysaccharide complicates their use in human vaccination. In the present study, we used a laboratory-derived strain of A. baumannii that completely lacks lipopolysaccharide due to a mutation in the lpxD gene (IB010), one of the genes involved in the first steps of lipopolysaccharide biosynthesis, for vaccination. We demonstrate that IB010 has greatly reduced endotoxin content (<1.0 endotoxin unit/106 cells) compared to wild type cells. Immunization with formalin inactivated IB010 produced a robust antibody response consisting of both IgG1 and IgG2c subtypes. Mice immunized with IB010 had significantly lower post-infection tissue bacterial loads and significantly lower serum levels of the pro-inflammatory cytokines IL-1β, TNF-α and IL-6 compared to control mice in a mouse model of disseminated A. baumannii infection. Importantly, immunized mice were protected from infection with the ATCC 19606 strain and an A. baumannii clinical isolate. These data suggest that immunization with inactivated A. baumannii whole cells deficient in lipopolysaccharide could serve as the basis for a vaccine for the prevention of infection caused by A. baumannii.
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Affiliation(s)
- Meritxell García-Quintanilla
- Institute of Biomedicine of Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain
| | - Marina R. Pulido
- Institute of Biomedicine of Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain
| | - Jerónimo Pachón
- Institute of Biomedicine of Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain
| | - Michael J. McConnell
- Institute of Biomedicine of Sevilla (IBiS), University Hospital Virgen del Rocío/CSIC/University of Sevilla, Sevilla, Spain
- * E-mail:
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Disruption of biofilm formation by the human pathogen Acinetobacter baumannii using engineered quorum-quenching lactonases. Antimicrob Agents Chemother 2013; 58:1802-5. [PMID: 24379199 DOI: 10.1128/aac.02410-13] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acinetobacter baumannii is a major human pathogen associated with multidrug-resistant nosocomial infections; its virulence is attributed to quorum-sensing-mediated biofilm formation, and disruption of biofilm formation is an attractive antivirulence strategy. Here, we report the first successful demonstration of biofilm disruption in a clinical isolate of A. baumannii S1, using a quorum-quenching lactonase obtained by directed evolution; this engineered lactonase significantly reduced the biomass of A. baumannii-associated biofilms, demonstrating the utility of this antivirulence strategy.
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Cullen M, Fogg T, Delaney A. Timing of appropriate antibiotics in patients with septic shock: A retrospective cohort study. Emerg Med Australas 2013; 25:308-15. [DOI: 10.1111/1742-6723.12100] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 01/04/2023]
Affiliation(s)
- Martin Cullen
- Intensive Care Unit; Westmead Hospital; Sydney; New South Wales; Australia
| | - Toby Fogg
- Emergency Department; Royal North Shore Hospital; Sydney; New South Wales; Australia
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Oh YJ, Song SH, Baik SH, Lee HH, Han IM, Oh DH. A case of fulminant community-acquired Acinetobacter baumannii pneumonia in Korea. Korean J Intern Med 2013; 28:486-90. [PMID: 23864808 PMCID: PMC3712158 DOI: 10.3904/kjim.2013.28.4.486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/18/2012] [Accepted: 05/04/2012] [Indexed: 11/27/2022] Open
Abstract
Acinetobacter baumannii (AB) is a common pathogen found in patients with hospital-acquired pneumonia all over the world. Community-acquired AB pneumonia, however, is very rare and has seldom been reported in Asia-Pacific countries. Community-acquired AB pneumonia has a fulminant course and is associated with a higher mortality than hospital-acquired AB pneumonia. In Korea, no case of fatal community-acquired AB pneumonia has been reported to date. Here, we describe the first fatal case of fulminant community-acquired AB pneumonia in Korea.
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Affiliation(s)
- Yoon Jung Oh
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Sung Heon Song
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Seung Hee Baik
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - Hak Hyun Lee
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
| | - In Mee Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hyun Oh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Draft Genome Sequences of Two Multidrug-Resistant Acinetobacter baumannii Strains of Sequence Type ST92 and ST96. GENOME ANNOUNCEMENTS 2013; 1:1/3/e00296-13. [PMID: 23723398 PMCID: PMC3668006 DOI: 10.1128/genomea.00296-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The global epidemiology of multidrug-resistant Acinetobacter baumannii is dominated by a limited number of clones. Here, we announce the draft genome sequences of two multidrug-resistant A. baumannii strains, 1H8 and 4A3, representing the major epidemic clones, sequence type 92 (ST92) and ST96, respectively.
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Antibiotics nonadherence and knowledge in a community with the world's leading prevalence of antibiotics resistance: implications for public health intervention. Am J Infect Control 2012; 40:113-7. [PMID: 21741119 PMCID: PMC7115258 DOI: 10.1016/j.ajic.2011.03.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 03/05/2011] [Accepted: 03/07/2011] [Indexed: 01/02/2023]
Abstract
Background Community determinants of antibiotics nonadherence, an important contributor of antibiotics resistance, remained unclear. Objectives Our objective was to investigate whether deficient antibiotics knowledge could contribute to nonadherence in a community with high prevalence of antibiotics resistance. Methods We recruited 465 people by random sampling from 5 urban areas in Hong Kong. A structured questionnaire was used to assess antibiotics knowledge and adherence. Adherence was defined as completing the most recent course of antibiotics entirely according to physicians’ instructions. An antibiotics knowledge score ranging from 0 to 3 (highest) was composed based on the number of correctly answered questions. Results Of the 465 participants interviewed, 96.3% had heard of the term “antibiotics,” and 80.6% recalled having previously received antibiotics prescription. Among the eligible 369 subjects, 32.9% showed nonadherence. Percentages of participants with antibiotics knowledge scores of 0, 1, 2, and 3 were 11%, 27%, 33%, and 29%, respectively. There was a higher prevalence of nonadherence among people with lower antibiotics knowledge score (P < .001). Furthermore, people with nonadherence had a significantly lower mean antibiotics knowledge score (1.3 ± 1.0 versus 2.0 ± 0.9, P < .001), with no interaction with education (P < .05). Adjusted for potential confounders, antibiotics knowledge scores of 2, 1, and 0 independently predicted increased risk of nonadherence by 1-fold (odds ratio [OR], 2.00; 95% confidence interval [CI]: 1.01-3.94; P = .047), 4-fold (OR, 4.77; 95% CI: 2.30-9.92; P < .001), and 17-fold (OR, 18.41; 95% CI: 6.92-48.97; P < .001) respectively, compared with the maximum score of 3. Conclusion Lack of antibiotics knowledge is a critical determinant of nonadherence independent of education in the community.
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Tiwari V, Nagpal I, Subbarao N, Moganty RR. In-silico modeling of a novel OXA-51 from β-lactam-resistant Acinetobacter baumannii and its interaction with various antibiotics. J Mol Model 2012; 18:3351-61. [PMID: 22271096 DOI: 10.1007/s00894-011-1346-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 12/20/2011] [Indexed: 01/09/2023]
Abstract
Acinetobacter baumannii, one of the major Gram negative bacteria, causes nosocomial infections such as pneumonia, urinary tract infection, meningitis, etc. β-lactam-based antibiotics like penicillin are used conventionally to treat infections of A. baumannii; however, they are becoming progressively less effective as the bacterium produces diverse types of β-lactamases to inactivate the antibiotics. We have recently identified a novel β-lactamase, OXA-51 from clinical strains of A. baumannii from our hospital. In the present study, we generated the structure of OXA-51 using MODELLER9v7 and studied the interaction of OXA-51 with a number of β-lactams (penicillin, oxacillin, ceftazidime, aztreonam and imipenem) using two independent programs: GLIDE and GOLD. Based on the results of different binding parameters and number of hydrogen bonds, interaction of OXA-51 was found to be maximum with ceftazidime and lowest with imipenem. Further, molecular dynamics simulation results also support this fact. The lowest binding affinity of imipenem to OXA-51 indicates clearly that it is not efficiently cleaved by OXA-51, thus explaining its high potency against resistant A. baumannii. This finding is supported by experimental results from minimum inhibitory concentration analysis and transmission electron microscopy. It can be concluded that carbapenems (imipenem) are presently effective β-lactam antibiotics against resistant strains of A. baumannii harbouring OXA-51. The results presented here could be useful in designing more effective derivatives of carbapenem.
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Affiliation(s)
- Vishvanath Tiwari
- Department of Biochemistry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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[Emerging Acinetobacter baumannii infections and factors favouring their occurrence]. ACTA ACUST UNITED AC 2011; 60:314-9. [PMID: 21963271 DOI: 10.1016/j.patbio.2011.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 08/31/2011] [Indexed: 01/31/2023]
Abstract
During the last decade, Acinetobacter baumannii (AB) has been increasingly responsible for infections occurring in three particular contexts (in terms of patients and environment). Community AB pneumonia is severe infections, mainly described around the Indian Ocean, and which mainly concern patients with major co-morbidities. AB is also responsible for infections occurring among soldiers wounded in action during operations conducted in Iraq or Afghanistan. Lastly, this bacterium is responsible for infections occurring among casualties from natural disasters like earthquakes and tsunamis. Those infections are often due to multidrug-resistant strains, which can be implicated in nosocomial outbreaks when patients are hospitalized in a local casualty department or during their repatriation thereafter. The source of the contaminations which lead to AB infections following injuries (warfare or natural disasters) is still poorly known. Three hypotheses are usually considered: a contamination of wounds with environmental bacteria, a wound contamination from a previous cutaneous or oropharyngeal endogenous reservoir, or hospital acquisition. The implication of telluric or agricultural primary reservoirs in human AB infections is a common hypothesis which remains to be demonstrated by further specifically designed studies.
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Outer membrane vesicles as an acellular vaccine against Acinetobacter baumannii. Vaccine 2011; 29:5705-10. [PMID: 21679737 DOI: 10.1016/j.vaccine.2011.06.001] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 05/27/2011] [Accepted: 06/01/2011] [Indexed: 11/20/2022]
Abstract
Acinetobacter baumannii produces different types of infections including pneumonia, meningitis, and bloodstream infections. The optimal treatment of these infections has been complicated by the global emergence of multidrug resistant strains, requiring the development of novel approaches for treatment and prevention. Outer membrane vesicles are outpouchings of the bacterial outer membrane that are secreted from numerous pathogenic Gram-negative bacteria. In the present study, we describe the isolation of outer membrane vesicles from A. baumannii and their use as a vaccine in a mouse model of disseminated sepsis. Immunization produced a robust antibody response against multiple bacterial antigens which consisted of antigen-specific IgG and IgM. In addition, both IgG1 and IgG2c subtypes were produced by immunization. Immunized mice had lower tissue bacterial loads and lower serum levels of the pro-inflammatory cytokines IL-6 and IL-1β post-infection compared to control mice. Importantly, vaccination protected mice from challenge with the ATCC 19606 strain and provided protection against two clinical isolates, including a pan-resistant strain. These results indicate that vaccination with outer membrane vesicles may be a viable strategy for preventing A. baumannii infection.
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Peterson LR. Molecular laboratory tests for the diagnosis of respiratory tract infection due to Staphylococcus aureus. Clin Infect Dis 2011; 52 Suppl 4:S361-6. [PMID: 21460297 DOI: 10.1093/cid/cir052] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
When Staphylococcus aureus is the cause of ventilator-associated pneumonia or a bacterial infection following influenza, the infections are devastating if not treated promptly. Disease due to methicillin-resistant S. aureus (MRSA) continues to be of concern throughout most of the United States. Currently, the U.S. Food and Drug Administration (FDA) has cleared polymerase chain reaction tests for detection of MRSA in nasal swab specimens; however, there are no FDA-cleared tests for identifying S. aureus in purulent respiratory secretions. The real-time polymerase chain reaction tests for S. aureus (primarily MRSA) in nares provide results in <2 h and have sensitivities ranging from 95% to 100%, with specificities of 96%-99%; these results are comparable to that of standard cultures, which can take up to 3-4 days for final results. The FDA is encouraged to work closely with industry providers to expedite the evaluation and clearance process for molecular diagnostic devices detecting S. aureus (including MRSA) in the diagnosis of respiratory tract infection.
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Affiliation(s)
- Lance R Peterson
- Department of Pathology and Laboratory Medicine, NorthShore University HealthSystem (NorthShore) and University of Chicago, Evanston, Illinois v, USA.
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Ulldemolins M, Nuvials X, Palomar M, Masclans JR, Rello J. Appropriateness is critical. Crit Care Clin 2011; 27:35-51. [PMID: 21144985 DOI: 10.1016/j.ccc.2010.09.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Inappropriate empirical antibiotic therapy for severe infections in the intensive care unit is a modifiable prognostic factor that has a great effect on patient outcome and health care resources. Inappropriate treatment is usually associated with microorganisms resistant to the common antibiotics, which must be empirically targeted when risk factors are present. Previous antibiotic exposure, prolonged length of hospital stay, admission category, local susceptibilities, colonization pressure, and the presence of invasive devices increase the likelihood of infection by resistant pathogens. Consideration of issues beyond in vitro susceptibility, such as antibiotic physicochemistry, tissue penetration, and pharmacokinetic/pharmacodynamic-driven dosing, is mandatory for the optimization of antibiotic use.
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Affiliation(s)
- Marta Ulldemolins
- Critical Care Department, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
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Hoogendijk AJ, Diks SH, van der Poll T, Peppelenbosch MP, Wieland CW. Kinase activity profiling of pneumococcal pneumonia. PLoS One 2011; 6:e18519. [PMID: 21483672 PMCID: PMC3071703 DOI: 10.1371/journal.pone.0018519] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 03/10/2011] [Indexed: 01/10/2023] Open
Abstract
Background Pneumonia represents a major health burden. Previous work demonstrated that although the induction of inflammation is important for adequate host defense against pneumonia, an inability to regulate the host's inflammatory response within the lung later during infection can be detrimental. Intracellular signaling pathways commonly rely on activation of kinases, and kinases play an essential role in the regulation of the inflammatory response of immune cells. Methodology/Principal Findings Pneumonia was induced in mice via intranasal instillation of Streptococcus (S.) pneumoniae. Kinomics peptide arrays, exhibiting 1024 specific consensus sequences for protein kinases, were used to produce a systems biology analysis of cellular kinase activity during the course of pneumonia. Several differences in kinase activity revealed by the arrays were validated in lung homogenates of individual mice using western blot. We identified cascades of activated kinases showing that chemotoxic stress and a T helper 1 response were induced during the course of pneumococcal pneumonia. In addition, our data point to a reduction in WNT activity in lungs of S. pneumoniae infected mice. Moreover, this study demonstrated a reduction in overall CDK activity implying alterations in cell cycle biology. Conclusions/Significance This study utilizes systems biology to provide insight into the signaling events occurring during lung infection with the common cause of community acquired pneumonia, and may assist in identifying novel therapeutic targets in the treatment of bacterial pneumonia.
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Affiliation(s)
- Arie J Hoogendijk
- Center for Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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McConnell MJ, Pachón J. Active and passive immunization against Acinetobacter baumannii using an inactivated whole cell vaccine. Vaccine 2010; 29:1-5. [DOI: 10.1016/j.vaccine.2010.10.052] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 09/28/2010] [Accepted: 10/20/2010] [Indexed: 09/30/2022]
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Vaccination with outer membrane complexes elicits rapid protective immunity to multidrug-resistant Acinetobacter baumannii. Infect Immun 2010; 79:518-26. [PMID: 20974823 DOI: 10.1128/iai.00741-10] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acinetobacter baumannii causes pneumonias, bacteremias, and skin and soft tissue infections, primarily in the hospitalized setting. The incidence of infections caused by A. baumannii has increased dramatically over the last 30 years, while at the same time the treatment of these infections has been complicated by the emergence of antibiotic-resistant strains. Despite these trends, no vaccines or antibody-based therapies have been developed for the prevention of A. baumannii infection. In this study, an outer membrane complex vaccine consisting of multiple surface antigens from the bacterial membrane of A. baumannii was developed and tested in a murine sepsis model. Immunization elicited humoral and cellular responses that were able to reduce postinfection bacterial loads, reduce postinfection proinflammatory cytokine levels in serum, and protect mice from infection with human clinical isolates of A. baumannii. A single administration of the vaccine was able to elicit protective immunity in as few as 6 days postimmunization. In addition, vaccine antiserum was used successfully to therapeutically rescue naïve mice with established infection. These results indicate that prophylactic vaccination and antibody-based therapies based on an outer membrane complex vaccine may be viable approaches to preventing the morbidity and mortality caused by this pathogen.
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van Rensburg DJJ, Perng RP, Mitha IH, Bester AJ, Kasumba J, Wu RG, Ho ML, Chang LW, Chung DT, Chang YT, King CHR, Hsu MC. Efficacy and safety of nemonoxacin versus levofloxacin for community-acquired pneumonia. Antimicrob Agents Chemother 2010; 54:4098-106. [PMID: 20660689 PMCID: PMC2944601 DOI: 10.1128/aac.00295-10] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 05/10/2010] [Accepted: 07/17/2010] [Indexed: 01/12/2023] Open
Abstract
Nemonoxacin, a novel nonfluorinated quinolone, exhibits potent in vitro and in vivo activities against community-acquired pneumonia (CAP) pathogens, including multidrug-resistant Streptococcus pneumoniae. Patients with mild to moderate CAP (n = 265) were randomized to receive oral nemonoxacin (750 mg or 500 mg) or levofloxacin (500 mg) once daily for 7 days. Clinical responses were determined at the test-of-cure visit in intent-to-treat (ITT), clinical per protocol (PPc), evaluable-ITT, and evaluable-PPc populations. The clinical cure rates for 750 mg nemonoxacin, 500 mg nemonoxacin, and levofloxacin were 89.9%, 87.0%, and 91.1%, respectively, in the evaluable-ITT population; 91.7%, 87.7%, and 90.3%, respectively, in the evaluable-PPc population; 82.6%, 75.3%, and 80.0%, respectively, in the ITT population; and 83.5%, 78.0%, and 82.3%, respectively, in the PPc population. Noninferiority to levofloxacin was demonstrated in both the 750-mg and 500-mg nemonoxacin groups for the evaluable-ITT and evaluable-PPc populations, and also in the 750 mg nemonoxacin group for the ITT and PPc populations. Overall bacteriological success rates were high for all treatment groups in the evaluable-bacteriological ITT population (90.2% in the 750 mg nemonoxacin group, 84.8% in the 500 mg nemonoxacin group, and 92.0% in the levofloxacin group). All three treatments were well tolerated, and no drug-related serious adverse events were observed. Overall, oral nemonoxacin (both 750 mg and 500 mg) administered for 7 days resulted in high clinical and bacteriological success rates in CAP patients. Further, good tolerability and excellent activity against common causative pathogens were demonstrated. Nemonoxacin (750 mg and 500 mg) once daily is as effective and safe as levofloxacin (500 mg) once daily for the treatment of CAP.
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Affiliation(s)
- Dirkie J. J. van Rensburg
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Reury-Perng Perng
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Ismail H. Mitha
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Andrè J. Bester
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Joseph Kasumba
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Ren-Guang Wu
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Ming-Lin Ho
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Li-Wen Chang
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - David T. Chung
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Yu-Ting Chang
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Chi-Hsin R. King
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
| | - Ming-Chu Hsu
- Park Medical Center, Witbank, Mpumalanga, South Africa, Taipei Veterans General Hospital, Taipei, Taiwan, Benmed/Pentagon Hospital, Benoni, South Africa, Jubilee Hospital, Temba, South Africa, Josha Research, Bloemfontien, South Africa, Cheng Ching Hospital, Taichung, Taiwan, Changhua Christian Hospital, Changhua, Taiwan, TaiGen Biotechnology Co. Ltd., Taipei, Taiwan
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