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Larrosa-Garcia M, Terradas Campanario S, Fernández Polo A, Cañete Ramírez C, Parra AP, Campany Herrero D. Characterization and real-live results of nebulized voriconazole: A single-center observational study. FARMACIA HOSPITALARIA 2024; 48:T29-T33. [PMID: 37858518 DOI: 10.1016/j.farma.2023.09.006] [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: 03/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVE Pulmonary administration of voriconazole involves advantages, including optimization of lung penetration and reduction of adverse effects and interactions. However, there is scarce evidence about its use and there are no commercial presentations for nebulization. We aim to characterize a compounded voriconazole solution for nebulization and describe its use in our center. METHOD This is a retrospective observational study including patients who received nebulized voriconazole to treat fungal lung diseases (infection or colonization). Voriconazole solution was prepared from commercial vials for intravenous administration. RESULTS The pH and osmolarity of voriconazole solutions were adequate for nebulization. Ten patients were included, nine adults and a child. The dosage was 40 mg in adults and 10 mg in the pediatric patient, diluted to a final concentration of 10 mg/ml, administered every 12-24 hours. The median duration of treatment was 139 (range: 26-911) days. There were no reported adverse effects and the drug was not detected in plasma when nebulized only. CONCLUSION Voriconazole nebulization is well tolerated and it is not absorbed into the systemic circulation; further research is needed to assess its efficacy.
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Affiliation(s)
- Maria Larrosa-Garcia
- Departamento de Farmacia, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | | | | | - Carme Cañete Ramírez
- Departamento de Farmacia, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Alba Pau Parra
- Departamento de Farmacia, Hospital Universitario Vall d'Hebron, Barcelona, España
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2
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Larrosa-Garcia M, Campanario ST, Polo AF, Ramírez CC, Parra AP, Herrero DC. Characterization and real-live results of nebulized voriconazole: A single-center observational study. FARMACIA HOSPITALARIA 2024; 48:29-33. [PMID: 37612182 DOI: 10.1016/j.farma.2023.07.010] [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: 03/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE Pulmonary administration of voriconazole involves advantages, including optimization of lung penetration and reduction of adverse effects and interactions. However, there is scarce evidence about its use and there are no commercial presentations for nebulization. We aim to characterize a compounded voriconazole solution for nebulization and describe its use in our center. METHOD This is a retrospective observational study including patients who received nebulized voriconazole to treat fungal lung diseases (infection or colonization). Voriconazole solution was prepared from commercial vials for intravenous administration. RESULTS The pH and osmolarity of voriconazole solutions were adequate for nebulization. Ten patients were included, 9 adults and a child. The dosage was 40 mg in adults and 10 mg in the pediatric patient, diluted to a final concentration of 10 mg/ml, administered every 12-24 h. The median duration of treatment was 139 (range: 26-911) days. There were no reported adverse effects and the drug was not detected in plasma when nebulized only. CONCLUSION Voriconazole nebulization is well-tolerated and it is not absorbed into the systemic circulation; further research is needed to assess its efficacy.
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Affiliation(s)
| | | | | | | | - Alba Pau Parra
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
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3
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Zha S, Niu J, He Z, Fu W, Huang Q, Guan L, Zhou L, Chen R. Prophylactic antibiotics for preventing ventilator-associated pneumonia: a pairwise and Bayesian network meta-analysis. Eur J Med Res 2023; 28:348. [PMID: 37715208 PMCID: PMC10503075 DOI: 10.1186/s40001-023-01323-z] [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: 12/22/2022] [Accepted: 08/27/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The role of prophylactic antibiotics in preventing ventilator-associated pneumonia (VAP) in patients undergoing invasive mechanical ventilation (IMV) remains unclear. This network meta-analysis compared the efficacy and safety of antibiotic prophylaxis in preventing VAP in an IMV population in intensive-care units (ICUs). METHODS We searched the PubMed, Web of Science, Embase, and Cochrane Library databases from inception to December 2021, to identify relevant studies assessing the impact of prophylactic antibiotics on the incidence of VAP, the mortality, and the duration of ICU stays and hospitalization to perform a meta-analysis. RESULTS Thirteen studies (2144 patients) were included, 12 of which were selected for the primary analysis, which revealed that treatment with prophylactic antibiotics resulted in a lower VAP rate compared with control groups [risk ratio (RR) = 0.62]. Bayesian network meta-analysis indicated that aerosolized tobramycin and intravenous ampicillin-sulbactam presented the greatest likelihood being the most efficient regimen for reducing VAP. CONCLUSIONS Antibiotic prophylaxis may reduce the incidence of VAP, but not the mortality, for adult patients undergoing IMV in ICUs. Tobramycin via nebulization and ampicillin-sulbactam via intravenous administration presented the greatest likelihood of being the most efficient regimen for preventing VAP. However, well-designed randomized studies are warranted before definite recommendations can be made.
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Affiliation(s)
- Shanshan Zha
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianyi Niu
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhenfeng He
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wei Fu
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiaoyun Huang
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lili Guan
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China.
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Luqian Zhou
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China.
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
| | - Rongchang Chen
- Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510120, Guangdong, China.
- Respiratory Mechanics Laboratory, Guangzhou Institute of Respiratory Health, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
- Department of Respiratory and Critical Care Medicine, Shenzhen Institute of Respiratory Diseases, Shenzhen People's Hospital, First Affiliated Hospital of Southern University of Science and Technology, Second Clinical Medical College of Jinan University, Shenzhen, 518020, Guangdong, China.
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4
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Schultheis JM, Durham ME, Kram SJ, Kuhrt M, Gilstrap DL, Parish A, Green CL, Kram BL. Incidence and associated risk factors for systemic drug levels with inhaled aminoglycoside therapy. J Antimicrob Chemother 2023; 78:450-456. [PMID: 36512376 PMCID: PMC10169422 DOI: 10.1093/jac/dkac412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/11/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To characterize the incidence of and risk factors for a detectable drug level (DDL) in patients that received inhaled aminoglycoside therapy. METHODS This retrospective, single-centre study included adult patients who received at least one dose of an inhaled aminoglycoside with a drug level during inpatient hospitalization. Patients were excluded if they received an aminoglycoside intravenously within 7 days or if the drug level was not drawn within 4 h of the next dose. A repeated measures logistic regression model evaluated the association between potential risk factors and a DDL. RESULTS Among 286 drug levels, 88 (30.8%) drug levels were detectable. In multivariable analysis, cystic fibrosis (CF) (OR: 3.03; 95% CI: 1.10-8.35), chronic kidney disease (CKD) (OR: 4.25; 95% CI: 1.84-9.83), lung transplant recipient (OR: 3.08; 95% CI: 1.09-8.73), mechanical ventilation (OR: 2.99; 95% CI: 1.25-7.15) and tobramycin (OR: 5.26; 95% CI: 2.35-11.78) were associated with higher odds of a DDL. Among those with a DDL, inhaled aminoglycoside type and drug level concentration were not associated with acute kidney injury (P = 0.161). CONCLUSIONS Among 286 drug levels identified among inpatients receiving inhaled aminoglycoside therapy, 88 (30.8%) unique drug levels were detectable. Based on the results of this study, periodic trough concentrations should be considered for patients receiving inhaled aminoglycoside therapy with CF, CKD, lung transplantation, mechanical ventilation or tobramycin.
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Affiliation(s)
| | - Mary E Durham
- Department of Pharmacy, Premier Inc., Charlotte, NC, USA
| | - Shawn J Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Michelle Kuhrt
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
| | - Daniel L Gilstrap
- Department of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia L Green
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Bridgette L Kram
- Department of Pharmacy, Duke University Hospital, Durham, NC, USA
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de Carvalho Patricio BF, da Silva Lopes Pereira JO, Sarcinelli MA, de Moraes BPT, Rocha HVA, Gonçalves-de-Albuquerque CF. Could the Lung Be a Gateway for Amphotericin B to Attack the Army of Fungi? Pharmaceutics 2022; 14:2707. [PMID: 36559201 PMCID: PMC9784761 DOI: 10.3390/pharmaceutics14122707] [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: 10/31/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/07/2022] Open
Abstract
Fungal diseases are a significant cause of morbidity and mortality worldwide, primarily affecting immunocompromised patients. Aspergillus, Pneumocystis, and Cryptococcus are opportunistic fungi and may cause severe lung disease. They can develop mechanisms to evade the host immune system and colonize or cause lung disease. Current fungal infection treatments constitute a few classes of antifungal drugs with significant fungi resistance development. Amphotericin B (AmB) has a broad-spectrum antifungal effect with a low incidence of resistance. However, AmB is a highly lipophilic antifungal with low solubility and permeability and is unstable in light, heat, and oxygen. Due to the difficulty of achieving adequate concentrations of AmB in the lung by intravenous administration and seeking to minimize adverse effects, nebulized AmB has been used. The pulmonary pathway has advantages such as its rapid onset of action, low metabolic activity at the site of action, ability to avoid first-pass hepatic metabolism, lower risk of adverse effects, and thin thickness of the alveolar epithelium. This paper presented different strategies for pulmonary AmB delivery, detailing the potential of nanoformulation and hoping to foster research in the field. Our finds indicate that despite an optimistic scenario for the pulmonary formulation of AmB based on the encouraging results discussed here, there is still no product registration on the FDA nor any clinical trial undergoing ClinicalTrial.gov.
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Affiliation(s)
- Beatriz Ferreira de Carvalho Patricio
- Pharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | | | - Michelle Alvares Sarcinelli
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Bianca Portugal Tavares de Moraes
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
| | - Helvécio Vinicius Antunes Rocha
- Laboratory of Micro and Nanotechnology, Institute of Technology of Drugs, Oswaldo Cruz Foundation, Brazil Av., 4036, Rio de Janeiro 213040-361, Brazil
| | - Cassiano Felippe Gonçalves-de-Albuquerque
- Postgraduate Program in Molecular and Cell Biology, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
- Postgraduate Program in Biotechnology, Biology Institute, Federal Fluminense University, Rua Prof. Marcos Waldemar de Freitas Reis, Niterói 24210-201, Brazil
- Immunopharmacology Laboratory, Biomedical Institute, Federal University of State of Rio de Janeiro, 94 Frei Caneca Street, Rio de Janeiro 20211-010, Brazil
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Messika J, Bunel V, Weisenburger G, Godet C, Mal H. Pseudomonas aeruginosa eradication after lung transplantation: is it the tip of the iceberg? Eur Respir J 2021; 58:58/1/2004380. [PMID: 34326172 DOI: 10.1183/13993003.04380-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Jonathan Messika
- APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France .,Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France.,Paris Transplant Group, Paris, France
| | - Vincent Bunel
- APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France.,Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France
| | - Gaelle Weisenburger
- APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France.,Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France
| | - Cendrine Godet
- APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France.,Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France
| | - Hervé Mal
- APHP.Nord-Université de Paris, Hôpital Bichat-Claude Bernard, Service de Pneumologie B et Transplantation Pulmonaire, Paris, France.,Physiopathology and Epidemiology of Respiratory Diseases, UMR1152 INSERM and Université de Paris, Paris, France
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7
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Chalmers JD, van Ingen J, van der Laan R, Herrmann JL. Liposomal drug delivery to manage nontuberculous mycobacterial pulmonary disease and other chronic lung infections. Eur Respir Rev 2021; 30:30/161/210010. [PMID: 34289985 PMCID: PMC9488898 DOI: 10.1183/16000617.0010-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/01/2021] [Indexed: 12/20/2022] Open
Abstract
Nontuberculous mycobacterial (NTM) pulmonary disease is a chronic respiratory infection associated with declining lung function, radiological deterioration and significantly increased morbidity and mortality. Patients often have underlying lung conditions, particularly bronchiectasis and COPD. NTM pulmonary disease is difficult to treat because mycobacteria can evade host defences and antimicrobial therapy through extracellular persistence in biofilms and sequestration into macrophages. Management of NTM pulmonary disease remains challenging and outcomes are often poor, partly due to limited penetration of antibiotics into intracellular spaces and biofilms. Efficient drug delivery to the site of infection is therefore a key objective of treatment, but there is high variability in lung penetration by antibiotics. Inhalation is the most direct route of delivery and has demonstrated increased efficacy of antibiotics like amikacin compared with systemic administration. Liposomes are small, artificial, enclosed spherical vesicles, in which drug molecules can be encapsulated to provide controlled release, with potentially improved pharmacokinetics and reduced toxicity. They are especially useful for drugs where penetration of cell membranes is essential. Inhaled delivery of liposomal drug solutions can therefore facilitate direct access to macrophages in the lung where the infecting NTM may reside. A range of liposomal drugs are currently being evaluated in respiratory diseases. Liposome-encapsulated antibiotics can optimise respiratory disease treatment. Amikacin liposomal inhalation suspension is effective in nontuberculous mycobacterial pulmonary disease that has failed to convert following oral guideline-based therapy.https://bit.ly/3f3ixIu
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Affiliation(s)
- James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Jakko van Ingen
- Dept of Medical Microbiology, Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jean-Louis Herrmann
- Université Paris-Saclay, UVSQ, INSERM, Infection and Inflammation, Montigny-le-Bretonneux, France.,APHP, Groupe Hospitalo-Universitaire Paris-Saclay, Hôpital Raymond Poincaré, Garches, France
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8
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Liao Q, Lam JKW. Inhaled Antifungal Agents for the Treatment and Prophylaxis of Pulmonary Mycoses. Curr Pharm Des 2021; 27:1453-1468. [PMID: 33388013 DOI: 10.2174/1381612826666210101153547] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/31/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022]
Abstract
Pulmonary mycoses are associated with high morbidity and mortality. The current standard treatment by systemic administration is limited by inadequate local bioavailability and systemic toxic effects. Aerosolisation of antifungals is an attractive approach to overcome these problems, but no inhaled antifungal formulation is currently available for the treatment of pulmonary mycoses. Hence, the development of respirable antifungals formulations is of interest and in high demand. In this review, the recent advances in the development of antifungal formulations for pulmonary delivery are discussed, including both nebulised and dry powder formulations. Although the clinical practices of nebulised parenteral amphotericin B and voriconazole formulations (off-label use) are reported to show promising therapeutic effects with few adverse effects, there is no consensus about the dosage regimen (e.g. the dose, frequency, and whether they are used as single or combination therapy). To maximise the benefits of nebulised antifungal therapy, it is important to establish standardised protocol that clearly defines the dose and specifies the device and the administration conditions. Dry powder formulations of antifungal agents such as itraconazole and voriconazole with favourable physicochemical and aerosol properties are developed using various powder engineering technologies, but it is important to consider their suitability for use in patients with compromised lung functions. In addition, more biological studies on the therapeutic efficacy and pharmacokinetic profile are needed to demonstrate their clinical potential.
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Affiliation(s)
- Qiuying Liao
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong SAR, Hong Kong
| | - Jenny K W Lam
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong SAR, Hong Kong
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Chiron E, Varache M, Stokniene J, Thomas DW, Ferguson EL. A physicochemical assessment of the thermal stability of dextrin-colistin conjugates. Sci Rep 2021; 11:10600. [PMID: 34011987 PMCID: PMC8134461 DOI: 10.1038/s41598-021-89946-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/04/2021] [Indexed: 11/25/2022] Open
Abstract
Attachment of polysaccharide carriers is increasingly being used to achieve precision delivery and improved effectiveness of protein and peptide drugs. Although it is clear that their clinical effectiveness relies on the purity and integrity of the conjugate in storage, as well as following administration, instability of polysaccharide-based conjugates can reduce the protective efficacy of the polymer, which may adversely affect the bioactive's potency. As a model, these studies used dextrin-colistin conjugates, with varying degrees of polymer modification (1, 2.5 and 7.5 mol% succinoylation) to assess the effect of storage temperature (- 20, 4, 21 and 37 °C) and duration (up to 12 months) on saccharide and colistin release and antimicrobial activity. Estimation of the proportion of saccharide release (by comparison of area under the curve from size exclusion chromatograms) was more pronounced at higher temperatures (up to 3 and 35% at - 20 °C and 37 °C, respectively after 12 months), however, repeated freeze-thaw did not produce any measurable release of saccharides, while addition of amylase (20, 100, 500 IU/L) caused rapid release of saccharides (> 70% total within 24 h). At all temperatures, conjugates containing the lowest degree of succinoylation released the highest proportion of free colistin, which increased with storage temperature, however no trend in saccharide release was observed. Despite the clear physical effects of prolonged storage, antimicrobial activity of all samples was only altered after storage at 37 °C for 12 months (> threefold decreased activity). These results demonstrate significant release of saccharides from dextrin-colistin conjugates during prolonged storage in buffered solution, especially at elevated temperature, which, in most cases, did not affect antimicrobial activity. These findings provide vital information about the structure-activity relationship of dextrin-colistin conjugates, prior to full-scale commercial development, which can subsequently be applied to other polysaccharide-protein and -peptide conjugates.
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Affiliation(s)
- Emilie Chiron
- Advanced Therapies Group, Oral and Biomedical Sciences, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK
| | - Mathieu Varache
- Advanced Therapies Group, Oral and Biomedical Sciences, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK
- CNRS, Ingénierie Des Matériaux Polymères, IMP UMR CNRS 5223, Université de Lyon, Université Claude Bernard Lyon 1, 15 bd A. Latarjet, 69622, Villeurbanne, France
| | - Joana Stokniene
- Advanced Therapies Group, Oral and Biomedical Sciences, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK
| | - David W Thomas
- Advanced Therapies Group, Oral and Biomedical Sciences, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK
| | - Elaine L Ferguson
- Advanced Therapies Group, Oral and Biomedical Sciences, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK.
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10
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Almangour TA, Garcia E, Zhou Q, Forrest A, Kaye KS, Li J, Velkov T, Rao GG. Polymyxins for the treatment of lower respiratory tract infections: lessons learned from the integration of clinical pharmacokinetic studies and clinical outcomes. Int J Antimicrob Agents 2021; 57:106328. [PMID: 33785362 DOI: 10.1016/j.ijantimicag.2021.106328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/18/2021] [Accepted: 03/20/2021] [Indexed: 11/26/2022]
Abstract
The global rise in nosocomial pneumonia caused by multidrug-resistant (MDR) Gram-negative pathogens and the increasingly limited antibiotic treatment options are growing threats to modern medicine. As a result, older antibiotics such as polymyxins are being used as last-resort drugs for MDR nosocomial pneumonia. Polymyxins are bactericidal against most aerobic Gram-negative bacilli. High-dose intravenous (IV) adminsitration of polymyxins, however, results in subtherapeutic concentrations at the site of infection making treatment challenging. Alternative forms of polymyxin delivery have been considered in order to better achieve the necessary concentrations at the site of infection. Several studies have evaluated the effectiveness of aerosolised polymyxins in patients with nosocomial pneumonia caused by MDR Gram-negative pathogens such as Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae. Here we evaluated the pharmacokinetic data supporting the use of inhaled polymyxins in nosocomial pneumonia and provide insight into the limitations and challenges that future studies should address. We have also reviewed the literature published between 2006 and 2020 on the use of aerosolised polymyxins for the treatment of nosocomial pneumonia, including ventilator-associated pneumonia, in patients without cystic fibrosis to evaluate their safety and efficacy as monotherapy or as an adjunct to IV antimicrobials. This review highlights the need for well-designed multicentre studies with standardised methodologies to further evaluate the effectiveness of inhaled polymyxins and to provide reliable pharmacokinetic/pharmacodynamic data in order to redefine appropriate dosing strategies.
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Affiliation(s)
- Thamer A Almangour
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA; Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Estefany Garcia
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Qi Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | - Alan Forrest
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Tony Velkov
- Department of Pharmacology and Therapeutics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gauri G Rao
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.
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11
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Speck PG, Warner MS, Bihari S, Bersten AD, Mitchell JG, Tucci J, Gordon DL. Potential for bacteriophage therapy for Staphylococcus aureus pneumonia with influenza A coinfection. Future Microbiol 2021; 16:135-142. [PMID: 33538181 DOI: 10.2217/fmb-2020-0163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The ability of influenza A virus to evolve, coupled with increasing antimicrobial resistance, could trigger an influenza pandemic with great morbidity and mortality. Much of the 1918 influenza pandemic mortality was likely due to bacterial coinfection, including Staphylococcus aureus pneumonia. S. aureus resists many antibiotics. The lack of new antibiotics suggests alternative antimicrobials, such as bacteriophages, are needed. Potential delivery routes for bacteriophage therapy (BT) include inhalation and intravenous injection. BT has recently been used successfully in compassionate access pulmonary infection cases. Phage lysins, enzymes that hydrolyze bacterial cell walls and which are bactericidal, are efficacious in animal pneumonia models. Clinical trials will be needed to determine whether BT can ameliorate disease in influenza and S. aureus coinfection.
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Affiliation(s)
- Peter G Speck
- Flinders University of South Australia, College of Science and Engineering, Bedford Park, SA, 5042, Australia
| | - Morgyn S Warner
- The Queen Elizabeth Hospital, Infectious Diseases Unit, Woodville, SA, 5011, Australia.,Microbiology & Infectious Diseases Directorate, SA Pathology, Adelaide, SA, 5000, Australia.,University of Adelaide, Faculty of Health & Medical Sciences, Adelaide, SA, 5006, Australia
| | - Shailesh Bihari
- Flinders Medical Centre, Intensive & Critical Care Unit, Bedford Park, SA, 5042, Australia.,Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia
| | - Andrew D Bersten
- Flinders Medical Centre, Intensive & Critical Care Unit, Bedford Park, SA, 5042, Australia.,Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia
| | - James G Mitchell
- Flinders University of South Australia, College of Science and Engineering, Bedford Park, SA, 5042, Australia
| | - Joseph Tucci
- Department of Pharmacy & Biomedical Science, LaTrobe University, La Trobe Institute for Molecular Science, Bendigo, Victoria, 3552, Australia
| | - David L Gordon
- Flinders University of South Australia, College of Medicine and Public Health, Bedford Park, SA, 5042, Australia.,Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, SA, 5042, Australia
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12
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Kaur R, Dennison SR, Burrow AJ, Rudramurthy SM, Swami R, Gorki V, Katare OP, Kaushik A, Singh B, Singh KK. Nebulised surface-active hybrid nanoparticles of voriconazole for pulmonary Aspergillosis demonstrate clathrin-mediated cellular uptake, improved antifungal efficacy and lung retention. J Nanobiotechnology 2021; 19:19. [PMID: 33430888 PMCID: PMC7798018 DOI: 10.1186/s12951-020-00731-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/07/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Incidence of pulmonary aspergillosis is rising worldwide, owing to an increased population of immunocompromised patients. Notable potential of the pulmonary route has been witnessed in antifungal delivery due to distinct advantages of direct lung targeting and first-pass evasion. The current research reports biomimetic surface-active lipid-polymer hybrid (LPH) nanoparticles (NPs) of voriconazole, employing lung-specific lipid, i.e., dipalmitoylphosphatidylcholine and natural biodegradable polymer, i.e., chitosan, to augment its pulmonary deposition and retention, following nebulization. RESULTS The developed nanosystem exhibited a particle size in the range of 228-255 nm and drug entrapment of 45-54.8%. Nebulized microdroplet characterization of NPs dispersion revealed a mean diameter of ≤ 5 μm, corroborating its deep lung deposition potential as determined by next-generation impactor studies. Biophysical interaction of LPH NPs with lipid-monolayers indicated their surface-active potential and ease of intercalation into the pulmonary surfactant membrane at the air-lung interface. Cellular viability and uptake studies demonstrated their cytocompatibility and time-and concentration-dependent uptake in lung-epithelial A549 and Calu-3 cells with clathrin-mediated internalization. Transepithelial electrical resistance experiments established their ability to penetrate tight airway Calu-3 monolayers. Antifungal studies on laboratory strains and clinical isolates depicted their superior efficacy against Aspergillus species. Pharmacokinetic studies revealed nearly 5-, 4- and threefolds enhancement in lung AUC, Tmax, and MRT values, construing significant drug access and retention in lungs. CONCLUSIONS Nebulized LPH NPs were observed as a promising solution to provide effective and safe therapy for the management of pulmonary aspergillosis infection with improved patient compliance and avoidance of systemic side-effects.
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Affiliation(s)
- Ranjot Kaur
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Sarah R Dennison
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Andrea J Burrow
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK
| | | | - Rajan Swami
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Varun Gorki
- Department of Zoology, Panjab University, Chandigarh, India, 160 014
| | - O P Katare
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India
| | - Anupama Kaushik
- Dr SSB University Institute Chem Engineering and Technology, Panjab University, Chandigarh, India, 160 014
| | - Bhupinder Singh
- University Institute of Pharmaceutical Sciences, UGC Centre of Advanced Studies, Panjab University, Chandigarh, 160 014, India.
- UGC Centre for Excellence in Nano-Biomedical Applications, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, 160 014, India.
| | - Kamalinder K Singh
- School of Pharmacy and Biomedical Sciences, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE, UK.
- UCLan Research Centre for Smarts Materials, University of Central Lancashire, Preston, PR1 2HE, UK.
- UCLan Research Centre for Drug Design and Development, University of Central Lancashire, Preston, PR1 2HE, UK.
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13
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Thanukrishnan H, Corcoran TE, Iasella CJ, Moore CA, Nero JA, Morrell MR, McDyer JF, Hussain S, Nguyen MH, Venkataramanan R, Ensor CR. Aerosolization of Second-generation Triazoles: In Vitro Evaluation and Application in Therapy of Invasive Airway Aspergillosis. Transplantation 2020; 103:2608-2613. [PMID: 31343565 DOI: 10.1097/tp.0000000000002697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND A lung transplant patient with invasive aspergillosis (IA) manifested symptoms of voriconazole-induced transaminitis with systemic voriconazole and progression of IA after switching to oral posaconazole. With limited options for standard triazole therapy, aerosolized delivery with one of the second-generation triazoles was considered. METHODS Feasibility for aerosolized delivery was evaluated using cascade impactor and analysis of physicochemical characteristics of voriconazole (10 mg/mL) and posaconazole (6, 12 mg/mL) solutions. RESULTS Both triazoles showed favorable characteristics for aerosol delivery with mass median aerodynamic diameter, geometric standard deviation, respirable fraction (<5.4 µm) of 2.8 µm, 2.0, 86%; 3.4 µm, 2.4, 78%; and 3.0 µm, 2.3, 79% for voriconazole and 6, 12 mg/mL of posaconazole, respectively. Aspergillus fumigatus isolate from the patient was more susceptible to voriconazole, and hence aerosolized voriconazole was introduced around the third month posttransplant at 40 mg TID for 1 week, 40 mg BID for 1 week, followed by 40 mg daily thereafter, along with IV caspofungin (50 mg/d) and liposomal amphotericin B (300 mg/d). The aerosol regimen was well tolerated by the patient with undetectable trough plasma levels of voriconazole. Bronchoscopy at the fourth month revealed improvement in anastomotic plaques with reduction in bronchoalveolar lavage galactomannan values (7.48-2.15 ng/mL). This consolidated aerosolized and intravenous regimen was maintained until 2.97 years posttransplant. CONCLUSIONS The intravenous solutions of both second-generation triazoles showed characteristics that were suitable for aerosol delivery. Our report further adds to the therapeutic experience with the use of aerosolized voriconazole for IA in a lung transplant patient.
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Affiliation(s)
- Harisudhan Thanukrishnan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Timothy E Corcoran
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Carlo J Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Cody A Moore
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Joseph A Nero
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Matthew R Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Shahid Hussain
- Multi-Organ Transplant Program, Division of Infectious Diseases, Transplant Infectious Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON
| | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA.,Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher R Ensor
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
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Gaurav A, Kothari A, Omar BJ, Pathania R. Assessment of polymyxin B-doxycycline in combination against Pseudomonas aeruginosa in vitro and in a mouse model of acute pneumonia. Int J Antimicrob Agents 2020; 56:106022. [PMID: 32439481 DOI: 10.1016/j.ijantimicag.2020.106022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 12/18/2022]
Abstract
The increasing prevalence of antibiotic resistance in Pseudomonas aeruginosa has created an urgent need for suitable therapy. This study explored the pairing of doxycycline with other antipseudomonal antibiotics, and found that polymyxin B in combination with doxycycline had a synergistic effect against clinical strains of P. aeruginosa. This synergistic combination was studied by checkerboard assays and time-kill curve analysis. Further, in-vitro biofilm disruption, pyoverdine inhibition assays were performed. The efficacy of polymyxin B-doxycycline in combination, administered by inhalation, was evaluated using a mouse model of acute pneumonia. The combination was found to have a synergistic effect in both in-vitro and in-vivo studies. The combination decreased biofilms of P. aeruginosa and reduced the level of pyoverdine, an important siderophore of P. aeruginosa. In addition, the combination decreased the P. aeruginosa population by 3 log10 (P<0.01) in the mouse model of acute pneumonia, and showed an improvement in lung function by inhalation. To the best of the authors' knowledge, this is the first in-vivo study to evaluate the efficacy of polymyxin B in combination with doxycycline against P. aeruginosa, showing a possible promising option for acute pneumonia due to multi-drug-resistant P. aeruginosa.
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Affiliation(s)
- Amit Gaurav
- Department of Biotechnology, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India
| | - Ashish Kothari
- Department of Microbiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
| | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
| | - Ranjana Pathania
- Department of Biotechnology, Indian Institute of Technology Roorkee, Roorkee, Uttarakhand, India.
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15
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Niederman MS, Alder J, Bassetti M, Boateng F, Cao B, Corkery K, Dhand R, Kaye KS, Lawatscheck R, McLeroth P, Nicolau DP, Wang C, Wood GC, Wunderink RG, Chastre J. Inhaled amikacin adjunctive to intravenous standard-of-care antibiotics in mechanically ventilated patients with Gram-negative pneumonia (INHALE): a double-blind, randomised, placebo-controlled, phase 3, superiority trial. THE LANCET. INFECTIOUS DISEASES 2019; 20:330-340. [PMID: 31866328 DOI: 10.1016/s1473-3099(19)30574-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/31/2019] [Accepted: 09/26/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Treatment of ventilated pneumonia is often unsuccessful, even when patients are treated according to established guidelines. Therefore, we aimed to investigate the efficacy of the combination drug device Amikacin Inhale as an adjunctive therapy to intravenous standard-of-care antibiotics for pneumonia caused by Gram-negative pathogens in intubated and mechanically ventilated patients. METHODS INHALE was a prospective, double-blind, randomised, placebo-controlled, phase 3 study comprising two trials (INHALE 1 and INHALE 2) done in 153 hospital intensive-care units in 25 countries. Eligible patients were aged 18 years or older; had pneumonia that had been diagnosed by chest radiography and that was documented as being caused by or showing two risk factors for a Gram-negative, multidrug-resistant pathogen; were intubated and mechanically ventilated; had impaired oxygenation within 48 h before screening; and had a modified Clinical Pulmonary Infection Score of at least 6. Patients were stratified by region and disease severity (according to their Acute Physiology and Chronic Health Evaluation [APACHE] II score) and randomly assigned (1:1) via an interactive voice-recognition system to receive 400 mg amikacin (Amikacin Inhale) or saline placebo, both of which were aerosolised, administered every 12 h for 10 days via the same synchronised inhalation system, and given alongside standard-of-care intravenous antibiotics. All patients and all staff involved in administering devices and monitoring outcomes were masked to treatment assignment. The primary endpoint, survival at days 28-32, was analysed in all patients who received at least one dose of study drug, were infected with a Gram-negative pathogen, and had an APACHE II score of at least 10 at diagnosis. Safety analyses were done in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, numbers NCT01799993 and NCT00805168. FINDINGS Between April 13, 2013, and April 7, 2017, 807 patients were assessed for eligibility and 725 were randomly assigned to Amikacin Inhale (362 patients) or aerosolised placebo (363 patients). 712 patients received at least one dose of study drug (354 in the Amikacin Inhale group and 358 in the placebo group), although one patient assigned to Amikacin Inhale received placebo in error and was included in the placebo group for safety analyses. 508 patients (255 in the Amikacin Inhale group and 253 in the placebo group) were assessed for the primary endpoint. We found no between-group difference in survival: 191 (75%) patients in the Amikacin Inhale group versus 196 (77%) patients in the placebo group survived until days 28-32 (odds ratio 0·841, 95% CI 0·554-1·277; p=0·43). Similar proportions of patients in the two treatment groups had a treatment-emergent adverse event (295 [84%] of 353 patients in the Amikacin Inhale group vs 303 [84%] of 359 patients in the placebo group) or a serious treatment-emergent adverse event (101 [29%] patients vs 97 [27%] patients). INTERPRETATION Our findings do not support use of inhaled amikacin adjunctive to standard-of-care intravenous therapy in mechanically ventilated patients with Gram-negative pneumonia. FUNDING Bayer AG.
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Affiliation(s)
- Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA.
| | - Jeff Alder
- Anti-Infective Consulting, Margaretville, NY, USA
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Policlinico San Martino Hospital, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - G Christopher Wood
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, University of Tennessee, Memphis, TN, USA
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jean Chastre
- Intensive Care Unit, Sorbonne University Hospitals, Paris, France
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16
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Cotner SE, Dawson KL. New Options in Antifungal Therapy: New Drugs, Inhaled Antifungals, and Management of Resistant Pathogens. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00208-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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17
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Abstract
PURPOSE OF REVIEW In the absence of randomized clinical trial data, questions remain regarding the optimal treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections. CRE have historically been susceptible to polymyxins, tigecycline or aminoglycosides (mostly gentamicin), and these antibiotics have long been considered the drugs of choice for CRE infections, although varying rates of resistance to all have been reported. This review looks at data from clinical studies assessing the outcomes of CRE infections treated with different antibiotic regimens. RECENT FINDINGS The recently approved fixed-dose combination agent, ceftazidime-avibactam (CAZ-AVI), is active against KPC and OXA-48-producing Enterobacteriaceae. The limited clinical data available on CAZ-AVI indicate that it is associated with survival benefits relative to other commonly used regimens, although development of resistance is a concern. New drugs active against CRE isolates (including the recently approved meropenem-vaborbactam) are in different stages of development. SUMMARY CAZ-AVI and meropenem-vaborbactam seem destined to become the backbone of target therapy for high-risk patients with severe infections caused by susceptible CRE strains. However, empirical therapy should be based on risk factors to be defined in the near future, whereas the necessity of combinations with CAZ-AVI requires further studies. Polymyxins are still important options for low-risk patients with susceptible CRE infections, but also for high-risk patients in regions where metallo-β-lactamase-producing CRE predominate because CAZ-AVI and meropenem-vaborbactam are both ineffective against these strains.
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18
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A Breath of Fresh Air in the Fog of Antimicrobial Resistance: Inhaled Polymyxins for Gram-Negative Pneumonia. Antibiotics (Basel) 2019; 8:antibiotics8010027. [PMID: 30884839 PMCID: PMC6466860 DOI: 10.3390/antibiotics8010027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 01/08/2023] Open
Abstract
Despite advancements in therapy, pneumonia remains the leading cause of death due to infectious diseases. Novel treatment strategies are desperately needed to optimize the antimicrobial therapy of patients suffering from this disease. One such strategy that has recently garnered significant attention is the use of inhaled antibiotics to rapidly achieve therapeutic concentrations directly at the site of infection. In particular, there is significant interest in the role of inhaled polymyxins for the treatment of nosocomial pneumonia, including ventilator-associated pneumonia, due to their retained activity against multi-drug resistant Gram-negative pathogens, including Acinetobacter baumannii and Pseudomonas aeruginosa. This review will provide a comprehensive overview of the pharmacokinetic/pharmacodynamic profile, clinical outcomes, safety, and potential role of inhaled polymyxins in clinical practice.
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19
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Gibson BH, Sharpe JP, Lewis RH, Newell JS, Swanson JM, Wood GC, Fabian TC, Croce MA, Magnotti LJ. Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients. Am Surg 2018. [DOI: 10.1177/000313481808401236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.
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Affiliation(s)
- Brian H. Gibson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - John P. Sharpe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Richard H. Lewis
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joshua S. Newell
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joseph M. Swanson
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - G. Christopher Wood
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Timothy C. Fabian
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Martin A. Croce
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Louis J. Magnotti
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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20
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Ajimura CM, Jagan N, Morrow LE, Malesker MA. Drug Interactions With Oral Inhaled Medications. J Pharm Technol 2018; 34:273-280. [PMID: 34861014 DOI: 10.1177/8755122518788809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To evaluate the potential for drug interactions with oral inhaled medications (OIMs). OIMs include bronchodilators (β-agonists and antimuscarinics), corticosteroids, combination products (2 or more agents combined within a single inhalation device), antibiotics, prostacyclins, anesthetics, acetylcysteine, mucolytics, insulin, antivirals, nitric oxide, and nicotine replacement. Data Sources: A systemic literature search (1980 to May 2018) was performed using PubMed and EBSCO to locate relevant articles. The MESH terms used included each specific medication available as an OIM as well as "drug interactions." DAILYMED was used for product-specific drug interactions. Study Selection and Data Extraction: The search was conducted to identify drug interactions with OIMs. The search was limited to those articles studying human applications with OIMs and publications using the English language. Case reports, clinical trials, review articles, treatment guidelines, and package labeling were selected for inclusion. Data Synthesis: Primary literature and package labeling indicate that OIMs are subject to pharmacokinetic and pharmacodynamics interactions. The most frequently identified clinically significant drug interaction is an inhaled corticosteroid when combined with a potent CYP 450 inhibitor such as a protease inhibitor or antifungal. Conclusions: The available literature indicates that OIMs are associated with clinically significant drug interactions and subsequent adverse reactions. Clinicians in all practice settings should be mindful of this potential to minimize adverse effects and optimize therapy.
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Affiliation(s)
- Chanelle M Ajimura
- PPGY1 Pharmacy Practice Resident Providence Portland, Medical Center, Portland, OR, USA
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21
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Poulakou G, Matthaiou DK, Nicolau DP, Siakallis G, Dimopoulos G. Inhaled Antimicrobials for Ventilator-Associated Pneumonia: Practical Aspects. Drugs 2018; 77:1399-1412. [PMID: 28741229 DOI: 10.1007/s40265-017-0787-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Positive experience with inhaled antibiotics in pulmonary infections of patients with cystic fibrosis has paved the way for their utilization in mechanically ventilated, critically ill patients with lower respiratory tract infections. A successful antibiotic delivery depends upon the size of the generated particle and the elimination of drug impaction in the large airways and the ventilator circuit. Generated droplet size is mainly affected by the type of the nebulizer employed. Currently, jet, ultrasonic, and vibrating mesh nebulizers are marketed; the latter can deliver optimal antibiotic particle size. Promising novel drug-device combinations are able to release drug concentrations of 25- to 300-fold the minimum inhibitory concentration of the targeted pathogens into the pulmonary alveoli. The most important practical steps of nebulization include pre-assessment and preparation of the patient (suctioning, sedation, possible bronchodilation, adjustment of necessary ventilator settings); adherence to the procedure (drug preparation, avoidance of unnecessary tubing connections, interruption of heated humidification, removal of heat-moisture exchanger); inspection of the procedure (check for residual in drug chamber, change of expiratory filter, return sedation, and ventilator settings to previous status); and surveillance of the patient for adverse events (close monitoring of the patient and particularly of peak airway pressure and bronchoconstriction). Practical aspects of nebulization are very important to ensure optimal drug delivery and safe procedure for the patient. Therefore, the development of an operational checklist is a priority for every department adopting this modality.
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Affiliation(s)
- Garyphallia Poulakou
- Fourth Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, 1 Rimini St, 12462, Athens, Greece.
| | - Dimitrios K Matthaiou
- Department of Critical Care, University Hospital Attikon, Faculty of Medicine, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Georgios Siakallis
- Fourth Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, 1 Rimini St, 12462, Athens, Greece
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Faculty of Medicine, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece
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22
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Porreca AM, Sullivan KV, Gallagher JC. The Epidemiology, Evolution, and Treatment of KPC-Producing Organisms. Curr Infect Dis Rep 2018; 20:13. [PMID: 29730830 DOI: 10.1007/s11908-018-0617-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to investigate the evolution and epidemiology of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms and the current and future treatment options for infections caused by KPC-producing isolates. RECENT FINDINGS The emergence of resistance in Enterobacteriaceae producing carbapenemases globally has increased the challenges in treating infections caused by these organisms. One of the prominent mechanisms of resistance is the production of KPC enzymes. Infections caused by organisms producing KPCs have limited treatment options and are associated with poor clinical outcomes. The rapid rise of KPC-producing organisms necessitated the use of drugs with pharmacokinetic and toxicity limitations, including polymyxins, tigecycline, fosfomycin, and aminoglycosides. The availability of new beta-lactamase inhibitor combinations that are effective against KPC-producing organisms represent an advance in safety and efficacy. Several agents are currently being studied that have activity against KPC-producing organisms and appear to represent promising additions to our armamentarium. KPC-producing organisms cause infections with high morbidity and mortality. Limited treatment options are available, though new therapies have been developed. Pipeline agents are likely to have a place in therapy for the treatment of infections caused by KPC-producing isolates.
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Affiliation(s)
- Ann Marie Porreca
- Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, PA, USA
| | - Kaede V Sullivan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Jason C Gallagher
- Temple University School of Pharmacy, 3307 North Broad Street, Philadelphia, PA, USA.
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Solé A, García-Robles AA, Jordá C, Cases Viedma E, Mancheño N, Poveda-Andrés JL, Reig Mezquida JP, Pemán J. Salvage therapy with topical posaconazole in lung transplant recipients with invasive Scedosporium infection. Am J Transplant 2018; 18:504-509. [PMID: 29116676 DOI: 10.1111/ajt.14580] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/06/2017] [Accepted: 10/25/2017] [Indexed: 01/25/2023]
Abstract
Scedosporium is an important pathogen in cystic fibrosis (CF) and post-transplantation, but it rarely causes invasive infection. Treatment remains challenging, particularly due to the inherent resistance to multiple antifungal agents. We present 3 complicated invasive tracheobronchial and lung Scedosporium apiospermum infections following lung transplantation. In 2 of 3 cases, the infection was clinically and radiologically cured with frequent cleansing bronchoscopies, combining triazole with terbinafine therapy and nebulized posaconazole. These cases highlight the importance of adjunctive nebulized therapy in addition to prolonged triazole treatment to manage complex invasive Scedosporium infections in immunosuppressed patients. Posaconazole (PSZ) was delivered during the bronchoscopy procedure through intrabronchial administration, whereas an eFlow rapid® device was used for nebulized therapy. Topical posaconazole was well tolerated in 2 patients, with only a slight cough during administrations; the third patient had local irritation with poor tolerance, which led to its withdrawal. This is the first report on compassionate use of topical PSZ as salvage therapy for resistant mold infections in lung transplant recipients. These 3 cases represent the entire experience using this approach; no additional patients have received this therapy due to there not having been any additional cases of Scedosporium tracheobronchitis presented.
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Affiliation(s)
- Amparo Solé
- Lung Transplant and Cystic Fibrosis Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Carlos Jordá
- Lung Transplant and Cystic Fibrosis Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Enrique Cases Viedma
- Respiratory Endoscopy Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Nuria Mancheño
- Pathology Service, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Juan Pablo Reig Mezquida
- Lung Transplant and Cystic Fibrosis Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Javier Pemán
- Microbiology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
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Detectable Concentrations of Inhaled Tobramycin in Critically Ill Children Without Cystic Fibrosis: Should Routine Monitoring Be Recommended? Pediatr Crit Care Med 2017; 18:e615-e620. [PMID: 29206744 DOI: 10.1097/pcc.0000000000001362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the percentage of detectable tobramycin troughs and acute kidney injury in critically ill children without cystic fibrosis on inhaled therapy. DESIGN Historic cohort. SETTING Academic hospital. PATIENTS Forty children less than 18 years receiving inhaled tobramycin across 6.5 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary objective was to determine the percentage of detectable tobramycin troughs greater than or equal to 0.5 µg/mL. Secondary objectives included a comparison of acute kidney injury in children with and without detectable troughs. Twenty-two (55%) had trough concentrations obtained. Ten of these (45.5%) had detectable concentrations, with a median of 0.85 µg/mL (interquartile range, 0.5-2.0). There was no statistical significance between the detectable and nondetectable groups in age, gender, and method of administration. However, patients in the detectable group tended to be younger than nondetectable group and more likely to have a tracheotomy. There was a clinically significant decrease in estimated glomerular filtration rate in the detectable trough group. CONCLUSIONS Detectable troughs were noted in almost half of patients with concentrations obtained. A clinically significant decrease in estimated glomerular filtration rate was noted in patients with detectable concentrations. Continued work should be directed to better understand outcomes and monitoring in children requiring inhaled tobramycin.
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Mulanovich V, Kontoyiannis DP. Acute myeloid leukemia and the infectious diseases consultant. Leuk Lymphoma 2017; 59:1284-1291. [PMID: 28914100 DOI: 10.1080/10428194.2017.1365861] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Infectious complications following treatment of acute myeloid leukemia (AML) are important causes of morbidity and mortality. The spectrum and complexity of these infections is reflected by the severe net state of immunosuppression of AML patients, that is dynamic and continuously changing, the polypharmacy, including the widespread use of anti-infectives and the complex epidemiology of severe and frequently resistant pathogens afflicting these patients. Infectious diseases (ID) consultants having a critical mass of expertise and intimate knowledge of the intricacies of leukemia care, add considerable value in improving outcomes of patients with AML who develop infections. Furthermore, pharmaco-economic considerations such as length of stay, choice of cost-effective anti-infective program, infection control and antibiotic stewardship strategies create a delicate interplay of the ID consultant and the ecosystem of care of AML patients. This is an increasingly recognized area of cross collaboration and a productive direction for future collaborative practice models and research.
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Affiliation(s)
- Victor Mulanovich
- a Department of Infectious Diseases, Infection Control and Employee Health , University of Texas, MD Anderson Cancer Center , Houston , TX , USA
| | - Dimitrios P Kontoyiannis
- a Department of Infectious Diseases, Infection Control and Employee Health , University of Texas, MD Anderson Cancer Center , Houston , TX , USA
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Wood GC, Swanson JM. An Update on Aerosolized Antibiotics for Treating Hospital-Acquired and Ventilator-Associated Pneumonia in Adults. Ann Pharmacother 2017; 51:1112-1121. [PMID: 28778127 DOI: 10.1177/1060028017723934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE A significant percentage of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) have poor outcomes with intravenous antibiotics. It is not clear if adding aerosolized antibiotics improves treatment. This review is an update on using aerosolized antibiotics for treating HAP/VAP in adults. DATA SOURCES PubMed search using the terms "aerosolized antibiotics pneumonia," "nebulized antibiotics pneumonia," and "inhaled antibiotics pneumonia." Reference lists from identified articles were also searched. STUDY SELECTION AND DATA EXTRACTION Clinical studies of aerosolized antibiotics for treating HAP/VAP in adults from July 2010 to March 2017. This article updates a previous review on this topic written in mid-2010. DATA SYNTHESIS The size and quality of studies have improved dramatically in the recent time period compared to previous studies. However, there still are not large randomized controlled trials available. Colistin and aminoglycosides were the most commonly studied agents, and the most common pathogens were Pseudomonas and Acinetobacter. The clinical efficacy of adding aerosolized antibiotics was mixed. Approximately half of the studies showed better outcomes, and none showed worse outcomes. Aerosolized antibiotics appear to be relatively safe, though pulmonary adverse events can occur. Attention to proper administration technique in mechanically ventilated patients is required, including the use of vibrating plate nebulizers. CONCLUSIONS Adding aerosolized antibiotics to intravenous antibiotics may improve the outcomes of adult patients with HAP/VAP in some settings. It seems reasonable to add aerosolized antibiotics in patients with multidrug-resistant organisms or who appear to be failing therapy. Clinicians should pay attention to potential adverse events and proper administration technique.
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Affiliation(s)
| | - Joseph M Swanson
- 1 University of Tennessee Health Science Center, Memphis, TN, USA
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Neuner EA, Gallagher JC. Pharmacodynamic and pharmacokinetic considerations in the treatment of critically Ill patients infected with carbapenem-resistant Enterobacteriaceae. Virulence 2017; 8:440-452. [PMID: 27589330 PMCID: PMC5477717 DOI: 10.1080/21505594.2016.1221021] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/26/2016] [Accepted: 08/02/2016] [Indexed: 01/20/2023] Open
Abstract
Carbapenem-Resistant Enterobacteriaceae (CRE) are an emerging healthcare crisis. Infections due to CRE are associated with high morbidity and mortality, especially in critically ill patients. Due to the multi-drug resistant nature of these infections only limited treatment options are available. Antimicrobials that have been described for the treatment of CRE infections include carbapenems, polymyxins, fosfomycin, tigecycline, aminoglycosides, and ceftazidime-avibactam. Given the limited treatment options it is imperative the pharmacokinetic and pharmacodynamics (PK-PD) characteristics of these agents are considered to optimize treatment regimens. This review will focus on the PK-PD challenges of the current treatment options for CRE infections.
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Affiliation(s)
| | - Jason C. Gallagher
- Department of Pharmacy Practice, Infectious Diseases, Temple University, Philadelphia, PA, USA
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Rello J, Solé-Lleonart C, Rouby JJ, Chastre J, Blot S, Poulakou G, Luyt CE, Riera J, Palmer LB, Pereira JM, Felton T, Dhanani J, Bassetti M, Welte T, Roberts JA. Use of nebulized antimicrobials for the treatment of respiratory infections in invasively mechanically ventilated adults: a position paper from the European Society of Clinical Microbiology and Infectious Diseases. Clin Microbiol Infect 2017; 23:629-639. [PMID: 28412382 DOI: 10.1016/j.cmi.2017.04.011] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
Abstract
With an established role in cystic fibrosis and bronchiectasis, nebulized antibiotics are increasingly being used to treat respiratory infections in critically ill invasively mechanically ventilated adult patients. Although there is limited evidence describing their efficacy and safety, in an era when there is a need for new strategies to enhance antibiotic effectiveness because of a shortage of new agents and increases in antibiotic resistance, the potential of nebulization of antibiotics to optimize therapy is considered of high interest, particularly in patients infected with multidrug-resistant pathogens. This Position Paper of the European Society of Clinical Microbiology and Infectious Diseases provides recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology regarding the use of nebulized antibiotics in invasively mechanically ventilated adults, based on a systematic review and meta-analysis of the existing literature (last search July 2016). Overall, the panel recommends avoiding the use of nebulized antibiotics in clinical practice, due to a weak level of evidence of their efficacy and the high potential for underestimated risks of adverse events (particularly, respiratory complications). Higher-quality evidence is urgently needed to inform clinical practice. Priorities of future research are detailed in the second part of the Position Paper as guidance for researchers in this field. In particular, the panel identified an urgent need for randomized clinical trials of nebulized antibiotic therapy as part of a substitution approach to treatment of pneumonia due to multidrug-resistant pathogens.
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Affiliation(s)
- J Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients, Barcelona, Spain.
| | - C Solé-Lleonart
- Service de Médecine Intensive Adulte, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - J-J Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie of Paris 6, Paris, France
| | - J Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie of Paris, Paris, France
| | - S Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, Ghent, Belgium
| | - G Poulakou
- 4th Department of Internal Medicine, Athens University School of Medicine, Attikon University General Hospital, Athens, Greece
| | - C-E Luyt
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie of Paris 6, Paris, France
| | - J Riera
- Clinical Research & Innovation in Pneumonia and Sepsis, Vall d'Hebron Institute of Research, CIBERES, Barcelona, Spain
| | - L B Palmer
- Pulmonary, Critical Care and Sleep Division, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - J M Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - T Felton
- Acute Intensive Care Unit, University Hospital of South Manchester, Manchester, United Kingdom
| | - J Dhanani
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Butterfield Street, Herston, Brisbane, Australia
| | - M Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - T Welte
- German Centre for Lung Research (DZL), Department of Respiratory Medicine, Medizinische Hochschule, Hannover, Germany
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Butterfield Street, Herston, Brisbane, Australia
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Poulakou G, Siakallis G, Tsiodras S, Arfaras-Melainis A, Dimopoulos G. Nebulized antibiotics in mechanically ventilated patients: roadmap and challenges. Expert Rev Anti Infect Ther 2017; 15:211-229. [DOI: 10.1080/14787210.2017.1268052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Poulakou
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Siakallis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - S Tsiodras
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - A Arfaras-Melainis
- 4th Department of Internal Medicine and Infectious Diseases Unit, Athens National and Kapodistrian University, Medical School, Attikon University General Hospital of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital ATTIKON, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Chen JK, Martin-McNew BL, Lubsch LM. Nebulized Gentamicin as an Alternative to Nebulized Tobramycin for Tracheitis in Pediatric Patients. J Pediatr Pharmacol Ther 2017; 22:9-14. [PMID: 28337076 PMCID: PMC5341539 DOI: 10.5863/1551-6776-22.1.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Tracheitis is an infection of the lower respiratory tract and is defined by the US Centers for Disease Control and Prevention (CDC) based on signs and symptoms with no radiographic evidence of pneumonia. One method of treatment involves the use of tobramycin given by nebulizer. The purpose of this study was to compare the safety and efficacy of nebulized gentamicin with nebulized tobramycin. METHODS This study was conducted in patients under 21 years of age who received greater than or equal to 1 day of gentamicin, 80 mg, or tobramycin, 300 mg, given twice a day by nebulization within the 14-month study period. The primary endpoint was amount of time until the patient no longer met the CDC definition of tracheitis. RESULTS There were 19 patients who presented with 60 separate encounters. The average age of the patients within the gentamicin group was 7.2 and 5 years old within the tobramycin group. The average duration of time for the gentamicin treatment encounters to be free of the CDC definition of tracheitis was 3.36 days compared to 3.17 days with tobramycin. No adverse effects were observed that were attributable to aminoglycoside nebulization. CONCLUSIONS No differences were detected between the safety and efficacy of intravenous gentamicin administered twice a day by nebulizer and that of tobramycin inhalation solution given twice daily in children without cystic fibrosis.
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Yu Y, Zhu C, Liu C, Gao Y. Amphotericin B nebulisation for invasive pulmonary aspergillosis prophylaxis: the conflict of ideality and reality. Int J Antimicrob Agents 2016; 49:263-264. [PMID: 27979501 DOI: 10.1016/j.ijantimicag.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/29/2016] [Accepted: 11/12/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China
| | - Cheng Zhu
- Department of Emergency Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chunyan Liu
- Department of Emergency Medicine, Min Hang Central Hospital, School of Medicine, Fu Dan University, Shanghai, China
| | - Yuan Gao
- Department of Critical Care Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 145 Middle Shandong Road, Shanghai 200001, China.
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Kollef MH. COUNTERPOINT: Should Inhaled Antibiotic Therapy Be Used Routinely for the Treatment of Bacterial Lower Respiratory Tract Infections in the ICU Setting? No. Chest 2016; 151:740-743. [PMID: 27916619 DOI: 10.1016/j.chest.2016.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/18/2022] Open
Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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Daniels LM, Juliano J, Marx A, Weber DJ. Inhaled Antibiotics for Hospital-Acquired and Ventilator-Associated Pneumonia. Clin Infect Dis 2016; 64:386-387. [PMID: 27803096 DOI: 10.1093/cid/ciw726] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Lindsay M Daniels
- Department of Pharmacy, University of North Carolina Medical Center,
| | | | - Ashley Marx
- Department of Pharmacy, University of North Carolina Medical Center
| | - David J Weber
- Department of Medicine, University of North Carolina Medical Center, Chapel Hill, North Carolina
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Abstract
OBJECTIVE To provide a systematic review of the current role of nebulized fentanyl in acute pain and potentially other conditions. DATA SOURCES A MEDLINE literature search inclusive of the dates 1946 to May 2016 was performed using the following search terms: fentanyl and administration, inhaled Excerpta Medica was searched from 1980 to May 2016 using the following search terms: exp fentanyl/inhalation drug administration Additionally, Web of Science was searched using the terms fentanyl and pain inclusive of 1945 to May 2016. STUDY SELECTION AND DATA EXTRACTION We utilized the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to select English language, human primary literature, review articles, and supporting data assessing the efficacy of nebulized fentanyl in acute pain. DATA SYNTHESIS Seven clinical trials have demonstrated no difference in efficacy between nebulized fentanyl and intravenous (IV) opioids. Few adverse effects were reported; however, the trials were of short duration. Nebulized fentanyl appeared to be a rapid-acting analgesic that does not require IV access. CONCLUSION Evidence suggests that nebulized fentanyl is as effective as IV opioids in the treatment of acute pain, with relatively few adverse effects. However, questions remain about the extemporaneous preparation of fentanyl nebulized solution, the variability in nebulization devices, and ensuring consistent drug delivery to distal airways in the clinical setting. The abuse potential of nebulized fentanyl should also be considered.
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Wenzler E, Fraidenburg DR, Scardina T, Danziger LH. Inhaled Antibiotics for Gram-Negative Respiratory Infections. Clin Microbiol Rev 2016; 29:581-632. [PMID: 27226088 PMCID: PMC4978611 DOI: 10.1128/cmr.00101-15] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Gram-negative organisms comprise a large portion of the pathogens responsible for lower respiratory tract infections, especially those that are nosocomially acquired, and the rate of antibiotic resistance among these organisms continues to rise. Systemically administered antibiotics used to treat these infections often have poor penetration into the lung parenchyma and narrow therapeutic windows between efficacy and toxicity. The use of inhaled antibiotics allows for maximization of target site concentrations and optimization of pharmacokinetic/pharmacodynamic indices while minimizing systemic exposure and toxicity. This review is a comprehensive discussion of formulation and drug delivery aspects, in vitro and microbiological considerations, pharmacokinetics, and clinical outcomes with inhaled antibiotics as they apply to disease states other than cystic fibrosis. In reviewing the literature surrounding the use of inhaled antibiotics, we also highlight the complexities related to this route of administration and the shortcomings in the available evidence. The lack of novel anti-Gram-negative antibiotics in the developmental pipeline will encourage the innovative use of our existing agents, and the inhaled route is one that deserves to be further studied and adopted in the clinical arena.
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Affiliation(s)
- Eric Wenzler
- University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois, USA
| | - Dustin R Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Tonya Scardina
- Loyola University Medical Center, Chicago, Illinois, USA
| | - Larry H Danziger
- University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois, USA University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
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Nicolau DP, Dimopoulos G, Welte T, Luyt CE. Can we improve clinical outcomes in patients with pneumonia treated with antibiotics in the intensive care unit? Expert Rev Respir Med 2016; 10:907-18. [PMID: 27181707 DOI: 10.1080/17476348.2016.1190277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pneumonia in the intensive care unit (ICU) is associated with high morbidity, mortality and healthcare costs. However, treatment outcomes with conventional intravenous (IV) antibiotics remain suboptimal, and there is an urgent need for improved therapy options. AREAS COVERED We review how clinical outcomes in patients with pneumonia treated in the ICU could be improved; we discuss the importance of choosing appropriate outcome measures in clinical trials, highlight the current suboptimal outcomes in patients with pneumonia, and outline potential solutions. We have included key studies and papers based on our clinical expertise, therefore a systematic literature review was not conducted. Expert commentary: Reasons for poor outcomes in patients with nosocomial pneumonia in the ICU include inappropriate initial therapy, increasing bacterial resistance and the complexities of IV dosing in critically ill patients. Robust clinical trial endpoints are needed to enable an accurate assessment of the success of new treatment approaches, but progress in this field has been slow. In addition, only very few new antimicrobials are currently in development for nosocomial pneumonia; two potential alternative solutions to improve outcomes could therefore include the optimization of pharmacokinetic/pharmacodynamics (PK/PD) and dosing of existing therapies, and the refinement of antimicrobial delivery by inhalation.
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Affiliation(s)
- David P Nicolau
- a Center for Anti-infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - George Dimopoulos
- b Department of Critical Care Medicine, Medical School , University of Athens , Athens , Greece
| | - Tobias Welte
- c Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany
| | - Charles-Edouard Luyt
- d Service de Réanimation, Institut de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris , Paris , France.,e UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition , Sorbonne Universités , Paris , France
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Bassetti M, Luyt CE, Nicolau DP, Pugin J. Characteristics of an ideal nebulized antibiotic for the treatment of pneumonia in the intubated patient. Ann Intensive Care 2016; 6:35. [PMID: 27090532 PMCID: PMC4835402 DOI: 10.1186/s13613-016-0140-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023] Open
Abstract
Gram-negative pneumonia in patients who are intubated and mechanically ventilated is associated with increased morbidity and mortality as well as higher healthcare costs compared with those who do not have the disease. Intravenous antibiotics are currently the standard of care for pneumonia; however, increasing rates of multidrug resistance and limited penetration of some classes of antimicrobials into the lungs reduce the effectiveness of this treatment option, and current clinical cure rates are variable, while recurrence rates remain high. Inhaled antibiotics may have the potential to improve outcomes in this patient population, but their use is currently restricted by a lack of specifically formulated solutions for inhalation and a limited number of devices designed for the nebulization of antibiotics. In this article, we review the challenges clinicians face in the treatment of pneumonia and discuss the characteristics that would constitute an ideal inhaled drug/device combination. We also review inhaled antibiotic options currently in development for the treatment of pneumonia in patients who are intubated and mechanically ventilated.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Santa Maria Misericordia University Hospital, Udine, Italy.
| | - Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, USA
| | - Jérôme Pugin
- Service des Soins Intensifs, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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Nijdam LC, Assink MDM, Kuijvenhoven JC, de Saegher MEA, van der Valk PDLPM, van der Palen J, Brusse-Keizer MGJ, Movig KLL. Safety and Tolerability of Nebulized Amoxicillin-Clavulanic Acid in Patients with COPD (STONAC 1 and STONAC 2). COPD 2016; 13:448-54. [PMID: 26744171 DOI: 10.3109/15412555.2015.1107893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The safety and tolerability of nebulized amoxicillin clavulanic acid were determined in patients with stable COPD and during severe exacerbations of COPD. Nine stable COPD patients received doses ranging from 50:10 mg up to 300:60 mg amoxicillin clavulanic acid and eight patients hospitalised for a COPD exacerbation received fixed doses 200/40 mg twice daily. Safety was evaluated by spirometry before and after inhalation. Tolerability was evaluated by questionnaire. Plasma and expectorated sputum samples were assayed for amoxicillin content. Seventeen patients underwent in total 100 nebulizations with amoxicillin clavulanic acid. In this safety and tolerability study no clinically relevant deteriorations in FEV1 were observed. Nebulized amoxicillin clavulanic acid produces sputum concentrations well above the Minimal Inhibiting Concentration of 90% for potential pathogenic micro-organisms, with low concentrations in the central compartment (low systemic exposure). Based on spirometry and reported side effects, inhalation of nebulized amoxicillin clavulanic acid seems to be safe and well tolerated, both in stable patients with COPD as in those experiencing a severe exacerbation. Levels of amoxicillin were adequate.
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Affiliation(s)
- L C Nijdam
- a Department of Clinical Pharmacy , Medisch Spectrum Twente , Enschede , the Netherlands
| | - M D M Assink
- b Department of Clinical Pharmacy , Ziekenhuisgroep Twente , Hengelo/Almelo, Enschede , the Netherlands
| | - J C Kuijvenhoven
- c Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands
| | - M E A de Saegher
- c Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands
| | - P D L P M van der Valk
- c Department of Pulmonary Medicine , Medisch Spectrum Twente , Enschede , the Netherlands
| | - J van der Palen
- d Department of Research Methodology , Measurement, and Data Analysis, University of Twente , Enschede , the Netherlands.,e Medical School Twente, Medisch Spectrum Twente , Enschede , the Netherlands
| | - M G J Brusse-Keizer
- e Medical School Twente, Medisch Spectrum Twente , Enschede , the Netherlands
| | - K L L Movig
- a Department of Clinical Pharmacy , Medisch Spectrum Twente , Enschede , the Netherlands
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Gauthier TP, Wasko J, Unger NR, Abbo LM, Fernandez M, Aragon L. Cost Reduction of Inhaled Tobramycin by Use of Preservative-Free Intravenous Tobramycin Given via Inhalation. Antibiotics (Basel) 2015; 5:antibiotics5010002. [PMID: 27025517 PMCID: PMC4810404 DOI: 10.3390/antibiotics5010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/04/2015] [Accepted: 12/23/2015] [Indexed: 11/29/2022] Open
Abstract
This study evaluates drug cost outcomes related to automatic therapeutic substitution of branded tobramycin solution for inhalation (TOBI®) with inhaled generic preservative-free intravenous tobramycin (PFIT). A retrospective single-center evaluation of inhaled tobramycin use from 2008 through 2012 was performed. Number of doses dispensed and acquisition costs were obtained. Hourly wage data was acquired, pharmacy production costs were estimated and total cost-savings calculated. Days of therapy (DOTs) were determined for each year. Quality assurance and safety data was collected. In 2008, TOBI® drug costs and doses dispensed were $118,665 and 1769, respectively. Following implementation of the interchange in May 2009, TOBI® utilization ceased. PFIT costs in 2010 through 2012 averaged $34,775 annually and TOBI® cost-avoidance exceeded $94,000 annually when accounting for pharmacy production costs, which were determined to be at most $5.28 per dose. The maximum estimated pharmacy production cost ranged from $8812 to $11,299 annually. PFIT doses dispensed exceeded 1650 each year and annual DOTs ranged from 815 to 1069. The 40-month savings were calculated to be $374,706. Quality assurance and safety data identified one patient who refused PFIT due to odor complaints and one patient who was inappropriately administered a dose orally. Therapeutic substitution of TOBI® with PFIT can produce immediate and sustained savings with an acceptable safety profile.
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Affiliation(s)
- Timothy P Gauthier
- Department of Pharmacy, Miami Veterans Affairs Healthcare System, 1201 NW 16th Street, Miami, FL 33125, USA.
| | - Justin Wasko
- Department of Pharmacy, University of Minnesota Medical Center, 420 Delaware Street, Minneapolis, MN 55455, USA.
| | - Nathan R Unger
- College of Pharmacy, Nova Southeastern University, 11501 North Military Trail, Palm Beach Gardens, FL 33410, USA.
| | - Lilian M Abbo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, 2101 NW 117th Avenue, Miami, FL 33172, USA.
| | - Margaret Fernandez
- Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33125, USA.
| | - Laura Aragon
- Department of Pharmacy, Jackson Memorial Hospital, 1611 NW 12th Avenue, Miami, FL 33125, USA.
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Mukker JK, Singh RSP, Derendorf H. Pharmacokinetic and pharmacodynamic implications in inhalable antimicrobial therapy. Adv Drug Deliv Rev 2015; 85:57-64. [PMID: 25770775 DOI: 10.1016/j.addr.2015.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/14/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Inhaled antimicrobials provide a promising alternative to the systemically delivered drugs for the treatment of acute and chronic lung infections. The delivery of antimicrobials via inhalation route decreases the systemic exposure while increasing the local concentration in the lungs, enabling the use of antimicrobials with severe systemic side effects. The inhalation route of administration has several challenges in pharmacokinetic (PK) and pharmacodynamic (PD) assessments. This review discusses various issues that need to be considered during study, data analysis, and interpretation of PK and PD of inhaled antimicrobials. Advancements overcoming the challenges are also discussed.
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Effect of nebulized colistin on the ventilator circuit: a prospective pilot case- control study from a single cancer center. Mediterr J Hematol Infect Dis 2015; 7:e2015032. [PMID: 25960860 PMCID: PMC4418373 DOI: 10.4084/mjhid.2015.032] [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: 01/28/2015] [Accepted: 03/23/2015] [Indexed: 11/25/2022] Open
Abstract
Nebulized colistin (NC) is used for the treatment of pneumonia due to multidrug- resistant Gram-negative bacteria. In this one-year case-control study, our objective was to evaluate the effect of NC on the ventilator circuit (VC) components. The case group consisted of 25 mechanically-ventilated patients who received NC for the treatment of nosocomial pneumonia while the control group was 25 mechanically-ventilated patients who did not receive NC. Respiratory therapists inspected the VC every 4 hrs and whenever a ventilator alarm was reported. The VC component was changed if the alarm did not subside after necessary measures were performed. Patients from both groups were treated at the adult medical/surgical intensive care unit at King Hussein Cancer Center. In the case group, 22 (88%) patients required changing at least one of the circuit components (flow sensor, exhalation membrane, or nebulizer kit). The median number of changes (range) per patient of the flow sensor, exhalation membrane, and nebulizer kit were: 2 (1–3), 2 (1–6), and 1 (1–2), respectively. Large amounts of white crystals, which resembled the colistin powder, were reported on the replaced VC components. The flow sensor was changed in 2 control patients, but white crystals were absent. Crystals obtained from one case subject were confirmed to be colistin by chromatographic mass spectroscopy. Further studies are needed to evaluate the effect of crystal formation on the efficacy of NC and clinical outcomes.
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Vendrell M, Muñoz G, de Gracia J. Evidence of inhaled tobramycin in non-cystic fibrosis bronchiectasis. Open Respir Med J 2015; 9:30-6. [PMID: 25893022 PMCID: PMC4397829 DOI: 10.2174/1874306401509010030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 03/03/2015] [Accepted: 03/03/2015] [Indexed: 12/24/2022] Open
Abstract
There is currently less experience with inhaled tobramycin in non-cystic fibrosis bronchiectasis than in cystic fibrosis (CF). Intravenous formulation and solution for inhalation (TSI) have been studied in non-CF bronchiectasis patients with chronic P. aeruginosa bronchial infection. An improvement in clinical parameters and a reduction in bacterial density have been shown with both inhaled solutions in these patients. However, further trials are needed to determine the most effective dose and administration protocol in these patients. Based on the current evidence, recommendations cannot be made regarding the use of TSI to treat exacerbations. Although no systemic toxicity has been reported in studies specifically investigating this treatment, patients with known kidney disease or ear disorders should be treated with caution. Adverse respiratory effects are reported to be more common in non-CF patients than in CF patients, who tend to be non-smokers and younger. Research is being conducted into the possibility of combining tobramycin with other antibiotics to increase its antibacterial activity. In this review we will present and discuss the published evidence regarding the use of inhaled tobramycin in non-CF bronchiectasis.
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Affiliation(s)
- Montserrat Vendrell
- Bronchiectasis Group. [Girona Biomedical Research Institute] IDIBGI, Dr Trueta University Hospital, Girona, Spain ; CIBER de Enfermedades Respiratorias (Ciberes CB06/06/0030), Instituto de Salud Carlos III, Spain
| | - Gerard Muñoz
- Bronchiectasis Group. [Girona Biomedical Research Institute] IDIBGI, Dr Trueta University Hospital, Girona, Spain
| | - Javier de Gracia
- CIBER de Enfermedades Respiratorias (Ciberes CB06/06/0030), Instituto de Salud Carlos III, Spain ; Department of Pulmonology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona
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Antibióticos nebulizados. ¿Una opción adecuada para el tratamiento de la infección respiratoria relacionada con la ventilación mecánica? Med Intensiva 2015; 39:97-100. [DOI: 10.1016/j.medin.2014.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 11/21/2022]
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Loo CY, Lee WH, Young PM, Cavaliere R, Whitchurch CB, Rohanizadeh R. Implications and emerging control strategies for ventilator-associated infections. Expert Rev Anti Infect Ther 2015; 13:379-93. [DOI: 10.1586/14787210.2015.1007045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Dalhoff A. Pharmacokinetics and pharmacodynamics of aerosolized antibacterial agents in chronically infected cystic fibrosis patients. Clin Microbiol Rev 2014; 27:753-82. [PMID: 25278574 PMCID: PMC4187638 DOI: 10.1128/cmr.00022-14] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Bacteria adapt to growth in lungs of patients with cystic fibrosis (CF) by selection of heterogeneously resistant variants that are not detected by conventional susceptibility testing but are selected for rapidly during antibacterial treatment. Therefore, total bacterial counts and antibiotic susceptibilities are misleading indicators of infection and are not helpful as guides for therapy decisions or efficacy endpoints. High drug concentrations delivered by aerosol may maximize efficacy, as decreased drug susceptibilities of the pathogens are compensated for by high target site concentrations. However, reductions of the bacterial load in sputum and improvements in lung function were within the same ranges following aerosolized and conventional therapies. Furthermore, the use of conventional pharmacokinetic/pharmacodynamic (PK/PD) surrogates correlating pharmacokinetics in serum with clinical cure and presumed or proven eradication of the pathogen as a basis for PK/PD investigations in CF patients is irrelevant, as minimization of systemic exposure is one of the main objectives of aerosolized therapy; in addition, bacterial pathogens cannot be eradicated, and chronic infection cannot be cured. Consequently, conventional PK/PD surrogates are not applicable to CF patients. It is nonetheless obvious that systemic exposure of patients, with all its sequelae, is minimized and that the burden of oral treatment for CF patients suffering from chronic infections is reduced.
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Affiliation(s)
- Axel Dalhoff
- University Medical Center Schleswig-Holstein, Institute for Infection Medicine, Kiel, Germany
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Gorman T, Dropkin J, Kamen J, Nimbalkar S, Zuckerman N, Lowe T, Szeinuk J, Milek D, Piligian G, Freund A. Controlling health hazards to hospital workers. New Solut 2014; 23 Suppl:1-167. [PMID: 24252641 DOI: 10.2190/ns.23.suppl] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Wood GC. Aerosolized antibiotics for treating hospital-acquired and ventilator-associated pneumonia. Expert Rev Anti Infect Ther 2014; 9:993-1000. [DOI: 10.1586/eri.11.126] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Zhu Z, Zheng J, Wu Z, Xie Y, Gao Y, Zhong L, Jiang M. Clinical practice of nebulized therapy in China: a national questionnaire survey. J Aerosol Med Pulm Drug Deliv 2014; 27:386-91. [PMID: 24383963 DOI: 10.1089/jamp.2013.1053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite having been used in the clinical practice of respiratory diseases for decades in China, the overall description of nebulized therapy has not been reported to date. The purpose of this study was to investigate the basic characteristics and information on the application of nebulized therapy in the clinical practice of respiratory diseases in China. METHODS A questionnaire survey with 17 questions relating to nebulized therapy was carried out in three levels (tertiary, secondary, and primary) of hospitals throughout mainland China. The perspectives of various professional degrees of the medical staffs from different levels of hospitals were further studied. RESULTS A total of 6,449 effective questionnaires were collected from 1,328 hospitals or clinics located in 27 provinces or autonomous regions of mainland China. Nebulized therapy was applied in 91.1% of the hospitals, significantly more in tertiary and secondary levels of hospitals than in the primary level of hospitals. Jet and ultrasonic nebulizers were used in 53.3% and 47.7% of the hospitals, respectively. Only 50.8% of the responders identified the brands of the devices. 82.5 Percent of the responders had prescribed nebulized therapy. 68.8 Percent and 41.5% of responders agreed that nebulized therapy can be used for the treatment of asthma and COPD, respectively. 86.5 Percent of responders agreed that nebulized therapy can be used for patients with acute exacerbation, whereas 27.5% stated that it can be used for stable patients. The most commonly used medicines were short-acting bronchodilators, followed by corticosteroids, mucolytics, and antibiotics. 17.2 Percent of the responders reported adverse events of nebulized therapy experienced by the patients. Continuous medical education and training on nebulized therapy were required by 72.1% of responders. CONCLUSIONS The present national survey, firstly, provided the basic characteristics and information on the application of nebulizer therapy in the clinical practice of respiratory diseases in China. Certainly, this will help facilitate nebulized therapy, especially in the community hospitals. Continuous medical education and technical training are essential to improve the clinical application of nebulized therapy.
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Affiliation(s)
- Zheng Zhu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University , Guangzhou 510120, China
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50
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Doshi NM, Cook CH, Mount KL, Stawicki SP, Frazee EN, Personett HA, Schramm GE, Arnold HM, Murphy CV. Adjunctive aerosolized colistin for multi-drug resistant gram-negative pneumonia in the critically ill: a retrospective study. BMC Anesthesiol 2013; 13:45. [PMID: 24274315 PMCID: PMC4175116 DOI: 10.1186/1471-2253-13-45] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 11/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of multi-drug resistant (MDR) gram-negative (GN) organisms including Pseudomonas and Acinetobacter spp has increased in the last decade, prompting re-evaluation of colistin for the management of these infections. Aerosolized colistin as an adjunct to intravenous therapy is a current option for the management of MDR-GN pneumonia, although data supporting this practice is limited. This study evaluates the efficacy of adjunctive aerosolized colistin in combination with intravenous colistin in critically ill patients with MDR-GN pneumonia. METHODS A retrospective multi-center cohort analysis comparing critically ill patients with MDR-GN pneumonia who received intravenous colistin (IV) alone or in combination with adjunctive aerosolized colistin (IV/AER) with a primary endpoint of clinical cure at the end of colistin therapy. Secondary endpoints included microbiologic cure, duration of mechanical ventilation, length of stay, and hospital mortality. A post-hoc subgroup analysis was performed for patients with high quality cultures used for diagnosis of MDR-GN pneumonia. Dichotomous data were compared using Fisher's exact test while the student's t-test or Mann-Whitney U test were used for continuous variables. RESULTS Ninety-five patients met criteria for evaluation with 51 patients receiving IV and 44 receiving IV/AER. Baseline characteristics were similar between the two groups. Twenty patients (39.2%) receiving IV and 24 (54.5%) receiving IV/AER achieved clinical cure (p = 0.135). There was no difference in microbiologic cure rates between the IV and IV/AER colistin groups (40.7vs. 44.4%, p = 0.805). The IV group demonstrated a trend towards higher pneumonia attributable mortality (70.4 vs. 40%, p = 0.055). In the subgroup analysis of patients with high quality respiratory cultures, there was a significantly lower clinical cure rate for those in the IV group as compared to the IV/AER group (31.3 vs. 57.1%, p = 0.033). CONCLUSIONS Addition of aerosolized colistin to IV colistin may improve clinical cure and mortality for patients with MDR-GN pneumonia. Larger, prospective trials are warranted to confirm the benefit of adjunctive aerosolized colistin in critically ill patients with MDR-GN pneumonia.
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Affiliation(s)
- Neha M Doshi
- Department of Pharmacy, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Charles H Cook
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kari L Mount
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stanislaw P Stawicki
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | | | - Heather M Arnold
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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