Conventional- versus high-dose vancomycin regimen in patients with acute bacterial meningitis: a randomized clinical trial

Systematic review of efficacy, safety and pharmacokinetics of intravenous and intraventricular vancomycin for central nervous system infections

Objective: The decision of vancomycin dosage for central nervous system (CNS) infections is still a challenge because its bactericidal nature in cerebrospinal fluid (CSF) has not been confirmed by human studies. This study systematically reviewed the literatures on vancomycin in patients with meningitis, ventriculitis, and CNS device-associated infections, to assess efficacy, safety, and pharmacokinetics to better serve as a practical reference. Methods: Medline, Embase, and Cochrane Library were searched using terms vancomycin, Glycopeptides, meningitis, and central nervous system infections. Data were extracted including characteristics of participants, causative organism(s), administration, dosage, etc., The clinical response, microbiological response, adverse events and pharmacokinetic parameters were analyzed. Results: Nineteen articles were included. Indications for vancomycin included meningitis, ventriculitis, and intracranial device infections. No serious adverse effects of intravenous (IV) and intraventricular (IVT) vancomycin have been reported. Dosages of IV and IVT vancomycin ranged from 1000-3000 mg/day and 2-20 mg/day. Duration of IV and IVT vancomycin therapy most commonly ranged from 3-27 days and 2-21 days. Therapeutic drug monitoring was conducted in 14 studies. Vancomycin levels in CSF in patients using IV and IVT vancomycin were varied widely from 0.06 to 22.3 mg/L and 2.5-292.9 mg/L. No clear relationships were found between vancomycin CSF levels and efficacy or toxicity. Conclusion: Using vancomycin to treat CNS infections appears effective and safe based on current evidence. However, the optimal regimens are still unclear. Higher quality clinical trials are required to explore the vancomycin disposition within CNS.

Pharmacokinetic variability of vancomycin in patients with nosocomial meningitis

WHAT IS KNOWN AND OBJECTIVE

High doses of vancomycin are required early in the treatment of nosocomial meningitis. However, the dosage is often reduced later during treatment, irrespective of renal function. This study was designed to investigate the pharmacokinetic variability of vancomycin and the associated factors throughout the treatment course for patients with nosocomial bacterial meningitis.

METHODS

This study included 17 patients who received vancomycin for nosocomial bacterial meningitis at the Tokyo Women's Medical University Yachiyo Medical Center from April 2013 to May 2020. All patients had their serum vancomycin concentrations and cerebrospinal fluid (CSF) parameters measured within 7 days of initiating treatment (early period) and after 8 days (later period) of treatment.

RESULTS AND DISCUSSION

The relative error between the predicted serum vancomycin concentration and the measured value was significantly higher in the later period than in the early period. In 13 patients who did not have their dosing interval shortened, the vancomycin dosage/serum vancomycin concentration/estimated glomerular filtration rate (D/C/eGFR) ratio significantly decreased in the later period. Moreover, the rate of change in the D/C/eGFR ratio significantly correlated with that in the CSF protein and C-reactive protein levels.

WHAT IS NEW AND CONCLUSION

This study suggests that the clinical condition and inflammatory response of a patient with meningitis influence the pharmacokinetics of vancomycin. Therefore, the vancomycin dosage for the treatment of nosocomial bacterial meningitis must be adjusted according to changes in the clinical condition and renal function of the patient, necessitating careful therapeutic drug monitoring.

Frequency Distribution of Antibiotic Therapy Intervention According to Lumbar Puncture Cerebrospinal Fluid Outcome in Hospitalized Children

Background: The aim of this study was to evaluate the frequency distribution of antibiotic therapy according to lumbar puncture outcome in hospitalized children. Methods:This study was conducted on 94 children undergoing lumbar puncture. All data were extracted from medical records. Administration of primary treatments and initial diagnosis including febrile convulsion, meningitis, and encephalitis in these patients were based on a physician's opinion. Results:The majority of subjects were diagnosed with febrile convulsion. Antibiotic treatment before lumbar puncture was taken by 58 children. After lumbar puncture, 35 children discontinued antibiotic therapy, two patients were switched to another antibiotic treatment and 21 subjects continued antibiotic medication. In addition, 36 children did not take antibiotics. Positive PCR was found in four cases from the encephalitis group. Conclusion: After lumbar puncture, antibiotic treatment was continued in 23 cases, whereas administration of antibiotics could be justified only in four cases based on positive PCR. Given that antibiotic treatment of our subjects was initiated prior to lumbar puncture but it was changed in two cases and continued in 21 cases after the medical procedure, conducting lumbar puncture seemed to be not very useful in these patients, assuming that laboratory signs or symptoms could justify an antibiotic treatment.

Cilastatin as a protective agent against drug-induced nephrotoxicity: a literature review

INTRODUCTION

Cilastatin, a dehydropeptidase I inhibitor, has been used alongside imipenem, a broad spectrum antibiotic, in order to reduce its renal metabolism, consequently increasing its urinary recovery and effectiveness for many years. However, this measure could be useful in preventing imipenem-induced renal damage and decreasing the number of nephrotoxicity reports with imipenem. In this review, the authors gathered all available studies focusing on cilastatin use as a nephroprotective agent, beside well-known nephrotoxic medications like vancomycin, cisplatin, cyclosporine, or tacrolimus.

AREAS COVERED

PubMed, Scopus, Google Scholar, and Medline databases were searched using key words like 'cilastatin,' 'nephroprotective,' 'nephroprotection,' 'vancomycin,' 'nephrotoxicity,' 'cisplatin,' 'cyclosporine,' 'tacrolimus,' and 'prevention' with varying combinations. All relevant animal and human studies up to the date of publication were included.

EXPERT OPINION

It seems that cilastatin could potentially be effective against drug-induced nephrotoxicity via mechanisms such as reducing reactive oxygen species (ROS) production, apoptosis, P-glycoprotein suppression, and morphological changes of renal cells. Nearly all the in vitro, in vivo and human studies have supported this hypothesis. Though since cilastatin protective effect has not extensively been researched in humans, its efficacy and widespread use with other nephrotoxic agents is yet to be defined in large well-designed human studies.

Comparative efficacy of antibiotic(s) alone or in combination of corticosteroids in adults with acute bacterial meningitis: A systematic review and network meta-analysis

OBJECTIVE

To compare relative efficacy of different antibiotic therapies either with or without the addition of corticosteroids among adult patients with acute bacterial meningitis on all-cause mortality, neurological complications and any hearing loss.

METHODS

We searched nine databases from inception to 8 February 2018 for randomized controlled trials evaluating pharmacological interventions and clinical outcomes in adult bacterial meningitis. An updated search from 9 February to 9 March 2020 was performed, and no new studies met the inclusion criteria. Study quality was assessed using the revised Cochrane Risk of Bias Tool. The Grading of Recommendations Assessment, Development and Evaluation system was used for quality of evidences evaluation. Meta-analyses were conducted to estimate the risk ratio with 95% confidence interval for both direct and indirect comparisons on the primary outcomes of all-cause mortality, neurologic sequelae and any hearing loss. The study was registered in PROSPERO (CRD42018108062).

RESULTS

Nine RCTs were included in systematic review, involving 1,002 participants with a mean age ranging between 25.3 to 50.56 years. Six RCTs were finally included in the network-meta analysis. No significant difference between treatment was noted in meta-analysis. Network meta-analysis suggests that corticosteroids in combination with antibiotic therapy was more effective in reducing the risk of any hearing loss compared to mono antibiotic therapy (RR 0.64; 95%CI, 0.45 to 0.91, 4 RCTs, moderate certainty of evidence). Numerical lower risk of mortality and neurological complications was also shown for adjunctive corticosteroids in combination with antibiotic therapy versus mono antibiotic therapy (RR 0.65; 95%CI, 0.42 to 1.02, 6 RCTs, moderate certainty of evidence; RR 0.75; 95%CI, 0.47 to 1.18, 6 RCTs, moderate certainty of evidence). No differences were noted in the adverse events between different therapies. The overall certainty of evidence was moderate to very low for all primary outcomes examined.

CONCLUSIONS

Results of this study suggest that corticosteroids therapy in combination with antibiotic is more effective than mono antibiotic therapy in reducing the risk of any hearing loss in adult patients with acute bacterial meningitis. More well-design RCTs to investigate relative effective treatments in acute bacterial meningitis particularly in adult population should be mandated to aid clinicians in treatment recommendations.