1
|
Zhang S, Di L, Qi Y, Qian X, Wang S. Treatment of infections caused by carbapenem-resistant Acinetobacter baumannii. Front Cell Infect Microbiol 2024; 14:1395260. [PMID: 39081869 PMCID: PMC11287075 DOI: 10.3389/fcimb.2024.1395260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/24/2024] [Indexed: 08/02/2024] Open
Abstract
Patients with severe carbapenem-resistant Acinetobacter baumannii (CRAB) infections currently face significant treatment challenges. When patients display signs of infection and the clinical suspicion of CRAB infections is high, appropriate treatment should be immediately provided. However, current treatment plans and clinical data for CRAB are limited. Inherent and acquired resistance mechanisms, as well as host factors, significantly restrict options for empirical medication. Moreover, inappropriate drug coverage can have detrimental effects on patients. Most existing studies have limitations, such as a restricted sample size, and are predominantly observational or non-randomized, which report significant variability in patient infection severity and comorbidities. Therefore, a gold-standard therapy remains lacking. Current and future treatment options of infections due to CRAB were described in this review. The dose and considerable side effects restrict treatment options for polymyxins, and high doses of ampicillin-sulbactam or tigecycline appear to be the best option at the time of initial treatment. Moreover, new drugs such as durlobactam and cefiderocol have substantial therapeutic capabilities and may be effective salvage treatments. Bacteriophages and antimicrobial peptides may serve as alternative treatment options in the near future. The advantages of a combination antimicrobial regimen appear to predominate those of a single regimen. Despite its significant nephrotoxicity, colistin is considered a primary treatment and is often used in combination with antimicrobials, such as tigecycline, ampicillin-sulbactam, meropenem, or fosfomycin. The Infectious Diseases Society of America (IDSA) has deemed high-dose ampicillin-sulbactam, which is typically combined with high-dose tigecycline, polymyxin, and other antibacterial agents, the best option for treating serious CRAB infections. A rational combination of drug use and the exploration of new therapeutic drugs can alleviate or prevent the effects of CRAB infections, shorten hospital stays, and reduce patient mortality.
Collapse
Affiliation(s)
- Siqin Zhang
- Department of Clinical Laboratory, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Lingfang Di
- Department of Clinical Laboratory, Tongxiang First People’s Hospital, Tongxiang, Zhejiang, China
| | - Yan Qi
- Department of Clinical Laboratory, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiang Qian
- Department of Clinical Laboratory, Hangzhou Traditional Chinese Medicine Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Siwei Wang
- Panvascular Diseases Research Center, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People’s Hospital, Quzhou, China
| |
Collapse
|
2
|
Özkarakaş H, Özdemir Y, Tosun S, Tekgül ZT, Bilgin MU, Özmuk O, Çalık B. Risks of Polymyxin B Nephrotoxicity and Its Precursors in the Intensive Care Unit: A Retrospective Cohort Study. Cureus 2023; 15:e44301. [PMID: 37779820 PMCID: PMC10535720 DOI: 10.7759/cureus.44301] [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] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND AND AIM Polymyxin group antibiotics constitute a part of our limited arsenal in the treatment of multidrug-resistant gram-negative bacteria. However, their use is limited especially due to nephrotoxicity and other side effects. In this study, we primarily aimed to determine the effect of polymyxin B on the rate of nephrotoxicity in critically ill patients, and secondly to identify the factors that facilitate nephrotoxicity caused by polymyxin B. MATERIALS AND METHODS The study was designed as a retrospective cohort study and conducted by scanning patients aged 18 years or older who had been admitted to our intensive care unit (ICU) in 2022 and treated with polymyxin B for at least 72 hours. Patients without chronic renal failure and acute kidney injury (AKI) before starting polymyxin B therapy were included and AKI was examined after the use of polymyxin B. The patients were then divided into two groups, those with AKI and those without AKI. We tried to find factors that may facilitate AKI by comparing the two groups. RESULTS Of the patients, 26 were female and 34 were male. In 21 of the patients (35%), renal damage of varying degrees developed; these patients belonged to the nephrotoxicity (NT) group, while the rest belonged to the non-nephrotoxicity (non-NT) group. We found that advanced age (p=0.008), low baseline GFR (p=0.01), baseline creatinine (p=0.006), BMI (p=0.011), concomitant diseases (p<0.001), and days of use of polymyxin B (p=0.006) were statistically different between the two groups. In multivariate analysis of univariate analysis, we found that duration of polymyxin B use, BMI, and advanced age were independent risk factors for AKI development. CONCLUSION We found that 21 (35%) of 60 intensive care unit patients who had no previous history of kidney injury developed kidney injury after being treated with polymyxin B. We identified advanced age, high BMI, and duration of polymyxin B use as independent risk factors. Therefore, we recommend close monitoring of renal function and prompt intervention, particularly in patients with risk factors, during polymyxin B use.
Collapse
Affiliation(s)
- Hüseyin Özkarakaş
- Intensive Care Unit, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| | - Yeliz Özdemir
- Infectious Diseases and Clinical Microbiology, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| | - Selma Tosun
- Infectious Diseases and Clinical Microbiology, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| | - Zeki T Tekgül
- Anesthesiology and Reanimation, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| | - Mehmet U Bilgin
- Anesthesiology and Reanimation, Helios Klinikum Schleswig, Academic Teaching Hospital for the University of Kiel and Lubeck, Schleswig, DEU
| | - Ozkan Özmuk
- Critical Care Medicine, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| | - Bülent Çalık
- General Surgery, University of Health Sciences Izmir Bozyaka Training and Research Hospital, Izmir, TUR
| |
Collapse
|
3
|
Yusuf K, Sampath V, Umar S. Bacterial Infections and Cancer: Exploring This Association And Its Implications for Cancer Patients. Int J Mol Sci 2023; 24:3110. [PMID: 36834525 PMCID: PMC9958598 DOI: 10.3390/ijms24043110] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
Bacterial infections are common in the etiology of human diseases owing to the ubiquity of bacteria. Such infections promote the development of periodontal disease, bacterial pneumonia, typhoid, acute gastroenteritis, and diarrhea in susceptible hosts. These diseases may be resolved using antibiotics/antimicrobial therapy in some hosts. However, other hosts may be unable to eliminate the bacteria, allowing them to persist for long durations and significantly increasing the carrier's risk of developing cancer over time. Indeed, infectious pathogens are modifiable cancer risk factors, and through this comprehensive review, we highlight the complex relationship between bacterial infections and the development of several cancer types. For this review, searches were performed on the PubMed, Embase, and Web of Science databases encompassing the entirety of 2022. Based on our investigation, we found several critical associations, of which some are causative: Porphyromonas gingivalis and Fusobacterium nucleatum are associated with periodontal disease, Salmonella spp., Clostridium perfringens, Escherichia coli, Campylobacter spp., and Shigella are associated with gastroenteritis. Helicobacter pylori infection is implicated in the etiology of gastric cancer, and persistent Chlamydia infections present a risk factor for the development of cervical carcinoma, especially in patients with the human papillomavirus (HPV) coinfection. Salmonella typhi infections are linked with gallbladder cancer, and Chlamydia pneumoniae infection is implicated in lung cancer, etc. This knowledge helps identify the adaptation strategies used by bacteria to evade antibiotic/antimicrobial therapy. The article also sheds light on the role of antibiotics in cancer treatment, the consequences of their use, and strategies for limiting antibiotic resistance. Finally, the dual role of bacteria in cancer development as well as in cancer therapy is briefly discussed, as this is an area that may help to facilitate the development of novel microbe-based therapeutics as a means of securing improved outcomes.
Collapse
Affiliation(s)
- Kafayat Yusuf
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Venkatesh Sampath
- Department of Pediatrics and Gastroenterology, Children’s Mercy Hospital, Kansas City, KS 66160, USA
| | - Shahid Umar
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| |
Collapse
|
4
|
Gontijo AVL, Cavalieri AVG. Individualized optimization of colistin loading doses. J Pharmacokinet Pharmacodyn 2023; 50:11-20. [PMID: 36323974 DOI: 10.1007/s10928-022-09831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Colistin remains one of the few available options for the treatment of infections caused by resistant bacteria. Pharmacokinetic (PK) studies have been successful in estimating the appropriate colistin methanesulfonate (CMS) dose to achieve a target colistin concentration. Currently, there is a consensus that the dose of CMS should vary according to the patient renal function since CMS is mainly eliminated by renal route. For this same reason, the loading dose should vary according to the patient's renal capacity; however, this is not the current clinical practice. In this study we develop a framework to determine two key parameters for the loading dose regimen: (1) the optimal dose according to the characteristics (renal function and weight) of the patient; (2) the waiting time before the maintenance dose. Based on a previous PK model, our framework allows a fast parameter sweep so as to select optimal loading dose and waiting time minimizing the deviation between the plasma concentration and a target value. The results showed that patients presenting low creatinine clearance (CrCL) should receive a lower CMS loading dose with longer interval to start maintenance treatment to avoid nephrotoxic colistin concentrations. In cases of high CrCL, the dose should be higher and the interval to the next dose shorter to avoid subtherapeutic concentrations. Optimization of the loading dose should considerably improve colistin therapy, as the target concentration is reached more quickly, without reaching toxic values.
Collapse
Affiliation(s)
- Aline Vidal Lacerda Gontijo
- Department of Pharmacy, Anhanguera University, Av. Dr. João Batista de Souza Soares, 4009 - Cidade Morumbi, São José dos Campos, SP, 12236-660, Brazil.
| | - André V G Cavalieri
- Divisão de Engenharia Aeroespacial, Instituto Tecnológico de Aeronáutica, São José dos Campos, SP, Brazil
| |
Collapse
|
5
|
Gupta N, Angadi K, Jadhav S. Molecular Characterization of Carbapenem-Resistant Acinetobacter baumannii with Special Reference to Carbapenemases: A Systematic Review. Infect Drug Resist 2022; 15:7631-7650. [PMID: 36579124 PMCID: PMC9791997 DOI: 10.2147/idr.s386641] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
Carbapenemases are β-lactamase enzymes that hydrolyze a variety of β-lactams including carbapenem and belong to different Ambler classes (A, B, D). These enzymes can be encoded by plasmid or chromosomal-mediated genes. The major issues associated with carbapenemases-producing organisms are compromising the activity and increasing the resistance to carbapenems which are the last resort antibiotics used in treating serious infections. The global increase of pathogen, carbapenem-resistant A. baumannii has significantly threatened public health. Thus, there is a pressing need for a better understanding of this pathogen, to know the various carbapenem resistance encoding genes and dissemination of resistance genes from A. baumannii which help in developing strategies to overcome this problem. The horizontal transfer of resistant determinants through mobile genetic elements increases the incidence of multidrug, extensive drug, and Pan-drug resistant A. baumannii. Therefore, the current review aims to know the various mechanisms of carbapenem resistance, categorize and discuss carbapenemases encoding genes and various mobile genetic elements, and the prevalence of carbapenemase genes in recent years in A. baumannii from various geographical regions.
Collapse
Affiliation(s)
- Neetu Gupta
- Department of Microbiology, Symbiosis Medical College for Women (SMCW) & Symbiosis University Hospital and Research Centre (SUHRC), Symbiosis International (Deemed University), Lavale, Pune, India
| | - Kalpana Angadi
- Department of Microbiology, Symbiosis Medical College for Women (SMCW) & Symbiosis University Hospital and Research Centre (SUHRC), Symbiosis International (Deemed University), Lavale, Pune, India
| | - Savita Jadhav
- Department of Microbiology, Symbiosis Medical College for Women (SMCW) & Symbiosis University Hospital and Research Centre (SUHRC), Symbiosis International (Deemed University), Lavale, Pune, India,Correspondence: Savita Jadhav, Department of Microbiology, Symbiosis Medical College for Women (SMCW) & Symbiosis University Hospital and Research Centre (SUHRC), Symbiosis International (Deemed University), Lavale, Pune, India, Tel +919284434364, Email
| |
Collapse
|
6
|
Lee CM, Kim CJ, Kim SE, Park KH, Bae JY, Choi HJ, Jung Y, Lee SS, Choe PG, Park WB, Kim ES, Song JE, Kwak YG, Lee SH, Lee S, Cheon S, Kim YS, Kang YM, Bang JH, Jung SI, Song KH, Kim HB. Risk factors for early mortality in patients with carbapenem-resistant Acinetobacter baumannii bacteraemia. J Glob Antimicrob Resist 2022; 31:45-51. [PMID: 35981691 DOI: 10.1016/j.jgar.2022.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/18/2022] [Accepted: 08/12/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Although many deaths due to carbapenem-resistant Acinetobacter baumannii (CRAB) bacteraemia occur within a few days after the onset of bacteraemia, risk factors for early mortality (EM) have not been deeply investigated. We aimed to determine the risk factors for EM and the difference between risk factors associated with EM and late mortality (LM) in CRAB bacteraemia. METHODS Clinical information on all patients with CRAB bacteraemia in 10 hospitals during a 1-year period was collected. Among the cases with mortality within 30 days, EM and LM were defined as death within 3 and more than 5 calendar days from the first positive blood culture, respectively. RESULTS In total, 212 CRAB bacteraemia cases were included in the analysis. Of 122 (57.5%) patients with 30-day mortality, EM was observed in 75 (61.5%) patients and LM in 39 (32.0%) patients. The proportion of severe sepsis or septic shock, Pitt score, and Sequential Organ Failure Assessment (SOFA) score was significantly higher in patients with EM than those with LM. Although urinary tract infection as the site of infection and the severity of illness were independent predictors of LM, only factors representing the severity of illness were independent risk factors for EM. CONCLUSION Our results suggest that a large proportion of CRAB bacteraemia with high severity progresses to a rapidly fatal course, regardless of the underlying diseases or source of infection. Further studies might be needed to investigate the microbiological factors associated with CRAB and pathogen-host interaction in patients with EM.
Collapse
Affiliation(s)
- Chan Mi Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Chung-Jong Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Seong Eun Kim
- Department of Infectious diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ji Yun Bae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Hee Jung Choi
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Younghee Jung
- Graduate School of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Soon Lee
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Je Eun Song
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Yee Gyung Kwak
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Sun Hee Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Shinhye Cheon
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Yeon Sook Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Yu Min Kang
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Republic of Korea; Present address: Department of Internal Medicine, Myongji Hospital, Goyang, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul Metropolitan Boramae Hospital, Seoul, Republic of Korea
| | - Sook-In Jung
- Department of Infectious diseases, Chonnam National University Medical School, Gwangju, Republic of Korea.
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea.
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | | |
Collapse
|
7
|
Zheng G, Wang S, Lv H, Zhang G. Nomogram Analysis of Clinical Characteristics and Mortality Risk Factor of Non-Fermentative Gram-Negative Bacteria-Induced Post-Neurosurgical Meningitis. Infect Drug Resist 2022; 15:6379-6389. [PMID: 36345538 PMCID: PMC9636862 DOI: 10.2147/idr.s385502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/15/2022] [Indexed: 11/05/2022] Open
Abstract
Objective To explore the clinical characteristics of post-neurosurgical meningitis (PNM) patients infected with nonfermenting Gram-negative bacilli (NFGNB) and to evaluate the related mortality risk factors. Methods A cohort analysis of PNM patients infected with NFGNB in Beijing Tiantan Hospital and Capital Medical University from 2012.1 to 2020.12. The microbial distribution, antimicrobial sensitivity and genotypes were tested, and potential mortality risk factors were evaluated using Mann–Whitney U or chi-squared tests. Independent risk factors for mortality were established by constructing a logistic model. Results A total of 2940 PNM patients were enrolled in this study, of whom 207 (17.1%) were infected with NFGNB. Among these patients, 29 died of NFGNB meningitis, with an overall mortality rate of 14.0%. The top three NFGNBs were Acinetobacter baumannii (105 cases, 50.7%), Pseudomonas aeruginosa (29 cases, 14.0%) and Acinetobacter lwoffii (20 cases, 9.7%). Nomogram analysis revealed that hypertension (OR 4.551, 95% CI: 1.464–14.154, P = 0.009), external ventricular drainage (EVD) (OR 3.944, 95% CI: 1.286–12.095, P = 0.016), and assisted mechanical ventilator (AMV) (OR 6.192, 95% CI: 1.737–22.081, P = 0.005) were independent risk factors for mortality. In addition, antibiotic prophylaxis was shown to play a vital role in NFGNB-induced PNM therapy. Conclusion PNM patients infected with NFGNB have a high mortality rate. Hypertension, EVD and AMV were independent mortality risk factors, and clinical attention should be paid to their prevention and treatment.
Collapse
Affiliation(s)
- Guanghui Zheng
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
| | - Siqi Wang
- School of clinical laboratory diagnostics, Capital Medical University, Beijing, 100076, People’s Republic of China
| | - Hong Lv
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
| | - Guojun Zhang
- Laboratory of Beijing Tiantan Hospital, Capital Medical University, Beijing, 100076, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing, 100076, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing, 100076, People’s Republic of China
- Correspondence: Guojun Zhang, Laboratory of Beijing Tiantan Hospital, Capital Medical University, NO. 119 Nansihuan West Road, Fengtai District, Beijing, People’s Republic of China, Tel +86 15811219411, Email
| |
Collapse
|
8
|
Colistin Monotherapy versus Colistin plus Meropenem Combination Therapy for the Treatment of Multidrug-Resistant Acinetobacter baumannii Infection: A Meta-Analysis. J Clin Med 2022; 11:jcm11113239. [PMID: 35683622 PMCID: PMC9181109 DOI: 10.3390/jcm11113239] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
(1) Introduction: Colistin combination therapy with other antibiotics is a way to enhance colistin activity. The purpose of this meta-analysis was to compare the efficacy and safety of treatment with colistin monotherapy versus colistin plus meropenem combination therapy in patients with drug-resistant Acinetobacter baumannii infection. (2) Methods: All studies were included if they reported one or more of the following outcomes: clinical improvement, complete microbiological response, 14-day mortality, hospital mortality, or nephrotoxicity. (3) Results: Three randomized controlled trials and seven retrospective studies were included in the meta-analysis. Colistin monotherapy has similar rates of clinical improvement, 14-day mortality, hospital mortality, and nephrotoxicity as colistin plus meropenem combination therapy. Regarding complete microbiological response, the colistin plus meropenem combination was better than colistin monotherapy. (4) Discussion: Previous meta-analyses demonstrated heterogeneity in study quality and a lack of evidence supporting the use of colistin-based combination therapy. Our meta-analysis clearly showed that colistin combined with meropenem was not superior to colistin monotherapy for the treatment of Acinetobacter baumannii infection. (5) Conclusions: The efficacy and safety of treatment with colistin monotherapy and that of colistin plus meropenem combination therapy in patients with drug-resistant Acinetobacter baumannii infection were comparable. The majority of the evidence was obtained from nonrandomized studies, and high-quality randomized controlled trials are needed to confirm the role of colistin plus meropenem combination therapy in the treatment of multidrug-resistant Acinetobacter baumannii infection.
Collapse
|
9
|
Mirjalili M, Mirzaei E, Vazin A. Pharmacological agents for the prevention of colistin-induced nephrotoxicity. Eur J Med Res 2022; 27:64. [PMID: 35525994 PMCID: PMC9077985 DOI: 10.1186/s40001-022-00689-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 04/19/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Colistin is a polymyxin antibiotic which has been used for treatment of Gram-negative infections, but it was withdrawn due to its nephrotoxicity. However, colistin has gained its popularity in recent years due to the reemergence of multidrug resistant Gram-negative infections and drug-induced toxicity is considered as the main obstacle for using this valuable antibiotic. RESULTS In total, 30 articles, including 29 animal studies and one clinical trial were included in this study. These compounds, including aged black garlic extract, albumin fragments, alpha lipoic acid, astaxanthin, baicalein, chrysin, cilastatin, colchicine, curcumin, cytochrome c, dexmedetomidine, gelofusine, grape seed proanthocyanidin extract, hesperidin, luteolin, lycopene, melatonin, methionine, N-acetylcysteine, silymarin, taurine, vitamin C, and vitamin E exhibited beneficial effects in most of the published works. CONCLUSIONS In this review, the authors have attempted to review the available literature on the use of several compounds for prevention or attenuation of colistin-induced nephrotoxicity. Most of the studied compounds were potent antioxidants, and it seems that using antioxidants concomitantly can have a protective effect during the colistin exposure.
Collapse
Affiliation(s)
- Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ehsan Mirzaei
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
10
|
Wang SH, Yang KY, Sheu CC, Chen WC, Chan MC, Feng JY, Chen CM, Wu BR, Zheng ZR, Chou YC, Peng CK. The necessity of a loading dose when prescribing intravenous colistin in critically ill patients with CRGNB-associated pneumonia: a multi-center observational study. Crit Care 2022; 26:91. [PMID: 35379303 PMCID: PMC8981852 DOI: 10.1186/s13054-022-03947-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background The importance or necessity of a loading dose when prescribing intravenous colistin has not been well established in clinical practice, and approximate one-third to half of patients with carbapenem-resistant gram-negative bacteria (CRGNB) infection did not receive the administration of a loading dose. The aim of this study is to investigate the efficacy and risk of acute kidney injury when prescribing intravenous colistin for critically ill patients with nosocomial pneumonia caused by CRGNB. Methods This was a multicenter, retrospective study that recruited ICU-admitted patients who had CRGNB-associated nosocomial pneumonia and were treated with intravenous colistin. Then, we classified the patients into colistin loading dose (N = 85) and nonloading dose groups (N = 127). After propensity-score matching for important covariates, we compared the mortality rate, clinical outcome and microbiological eradication rates between the groups (N = 67). Results The loading group had higher percentages of patients with favorable clinical outcomes (55.2% and 35.8%, p = 0.037) and microbiological eradication rates (50% and 27.3%, p = 0.042) at day 14 than the nonloading group. The mortality rates at days 7, 14 and 28 and overall in-hospital mortality were not different between the two groups, but the Kaplan–Meier analysis showed that the loading group had a longer survival time than the nonloading group. Furthermore, the loading group had a shorter length of hospital stay than the nonloading group (52 and 60, p = 0.037). Regarding nephrotoxicity, there was no significant difference in the risk of developing acute kidney injury between the groups. Conclusions The administration of a loading dose is recommended when prescribing intravenous colistin for critically ill patients with nosocomial pneumonia caused by CRGNB. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03947-9.
Collapse
Affiliation(s)
- Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gong Rd, Neihu 114, Taipei, Taiwan.,Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Cheng Chen
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Education, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,National Chung Hsing University, Taichung, Taiwan
| | - Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Min Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Biing-Ru Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Zhe-Rong Zheng
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.,Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gong Rd, Neihu 114, Taipei, Taiwan.
| | | |
Collapse
|
11
|
Evaluation of the Efficacy of Colistin Therapy with or without Loading Dose in the Treatment of Multi Drug Resistant Gram-negative Bacterial Infections. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1058903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
12
|
Keski̇n AS, Seyman D, Önder KD, Kizilateş F, Keski̇n O. Investigation of Effect of the Colistin Loading Dosage on the clinical, Microbiological, and Laboratory Results in Acinetobacter baumannii Ventilator-Associated Pneumonia /Pneumonia. Int J Clin Pract 2022; 2022:5437850. [PMID: 36105785 PMCID: PMC9441370 DOI: 10.1155/2022/5437850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/13/2022] [Indexed: 11/21/2022] Open
Abstract
MATERIALS AND METHODS Adult patients administered colistin with and without LD for MDR Acinetobacter baumannii VAP/pneumonia in intensive care units (ICUs) in a tertiary teaching hospital between 1 January 2018 and 31 December 2019 were included in this retrospective cohort study. The primary endpoint was an assessment of clinical and microbiological success between treatment groups. Secondary endpoints included 14- and 30-day mortality and development of nephrotoxicity. RESULTS A total of 101 patients were included (colistin with LD, n = 57; colistin without LD, n = 44). No significant difference in clinical success was observed between groups (73.7% versus 77.3%; p=0.670). In patients receiving colistin with LD, the microbiological success rate increased from 65.9% to 71.9%, but there was no statistically significantly difference (p=0.510). In terms of using combination therapies with carbapeneme and/or tigecycline, there was no significant difference between treatment groups (p=0.30). The rates of 14- and 30-day mortality were similar between groups. The colistin with LD group had a higher rate of nephrotoxicity compared to the other group (52.6% versus 20.5% p=0.001). The clinical and microbiological response times were found significantly higher in the colistin with LD group (p=0.001; p=0.017). CONCLUSION Colistin with LD was associated with a higher risk of nephrotoxicity and was not related to clinical success, microbiological success, and prolonged survival. Randomized comparative studies are needed to confirm the efficacy of LD colistin regimen on MDR Acinetobacter infection.
Collapse
Affiliation(s)
- Ayşegül Seremet Keski̇n
- University of Health Sciences Antalya Training and Research Hospital, Infectious Disease and Clinical Microbiology, Antalya, Turkey
| | - Derya Seyman
- University of Health Sciences Antalya Training and Research Hospital, Infectious Disease and Clinical Microbiology, Antalya, Turkey
| | - Kübra Demir Önder
- University of Health Sciences Antalya Training and Research Hospital, Infectious Disease and Clinical Microbiology, Antalya, Turkey
| | - Filiz Kizilateş
- University of Health Sciences Antalya Training and Research Hospital, Infectious Disease and Clinical Microbiology, Antalya, Turkey
| | - Olgun Keski̇n
- University of Health Sciences Antalya Training and Research Hospital, Department of Pulmomology., Antalya, Turkey
| |
Collapse
|
13
|
Wen YX, Qu Q, Long WM, Luo Y, Zhuang HH, Teng XQ, Qu J. Nephrotoxicity and Efficacy Assessment of Polymyxin B Use in Renal Transplant Patients. Infect Drug Resist 2022; 15:275-283. [PMID: 35115795 PMCID: PMC8801393 DOI: 10.2147/idr.s348571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yu-Xin Wen
- Department of Pharmacy, The Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
- Department of Pharmacy, Lixian People’s Hospital in Hunan, Lixian, 415500, People’s Republic of China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410078, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410078, People’s Republic of China
| | - Wen-Ming Long
- Department of Pharmacy, Jingzhou District, Second People’s Hospital of Huaihua City, Huaihua, 418400, People’s Republic of China
| | - Yue Luo
- Department of Pharmacy, The People’s Hospital of Liuyang, Liuyang, 410300, People’s Republic of China
| | - Hai-Hui Zhuang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
| | - Xin-Qi Teng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
| | - Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, Changsha, 410011, People’s Republic of China
- Correspondence: Jian Qu, Department of Pharmacy, The Second Xiangya Hospital, Central South University; Institute of Clinical Pharmacy, Central South University, No. 139 Middle Renmin Road, Changsha, 410011, People’s Republic of China, Tel +86-15973190614, Fax +86-731-85292072, Email
| |
Collapse
|
14
|
Colistin-Induced Acute Kidney Injury and the Effect on Survival in Patients with Multidrug-Resistant Gram-Negative Infections: Significance of Drug Doses Adjusted to Ideal Body Weight. Int J Nephrol 2021; 2021:7795096. [PMID: 34966562 PMCID: PMC8712152 DOI: 10.1155/2021/7795096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/04/2021] [Indexed: 12/31/2022] Open
Abstract
Background Colistin is a lifesaving treatment for multidrug-resistant Gram-negative bacterial (MDR-GNB) infections along with its well-known nephrotoxicity. The controversy of colistin-induced acute kidney injury (AKI) on mortality is noted. This study aimed to determine the risk factors and impact of AKI on the survival and significance of colistin dosage. Methods A retrospective cohort study was performed in adult patients who received intravenous colistin for MDR-GNB treatment between June 2015 and June 2017. Factors influencing colistin-induced AKI and survival were evaluated by Cox regression analysis. Cut-off levels of the colistin dose per ideal body weight (IBW) that significantly affected clinical outcomes were assessed with linearity trends and receiver operating characteristic analyses. Results AKI occurred in 68.5% of 412 enrolled patients with an incidence rate of 10.6 per 100 patients-days and a median time was 6 (3–13) days. Stages I–III of AKI were 38.3, 24.5, and 37.2%. Factors associated with colistin-induced AKI were advanced age, high serum bilirubin, AKI presented before colistin administration, increased daily colistin doses per IBW, and concomitant use of nephrotoxic drugs. Colistin-induced AKI was related to mortality (HR 1.74, 95% CI 1.06–2.86, p=0.028). In the non-AKI before colistin usage subgroup, the total dose and total dose/IBW were >1,500–2,000 mg and 30–35 mg/kg to benefit mortality reduction but were <2,500–3,000 mg and 45–50 mg/kg for risk reduction of AKI. A daily colistin dose/IBW >4.5 mg/kg/day also increased the risk of AKI. In the AKI developed before colistin subgroup, the cut-off values of total colistin dose >1250–1350 mg and total dose/IBW >23.5–24 mg/kg demonstrated significant risks of AKI. Conclusion The incidence of AKI after colistin administration was high and impacted mortality. Prevention and early correction of these related factors are mandatory. Careful use of colistin was also both beneficial in mortality and AKI reductions.
Collapse
|
15
|
Katip W, Uitrakul S, Oberdorfer P. Clinical Efficacy and Nephrotoxicity of the Loading Dose Colistin for the Treatment of Carbapenem-Resistant Acinetobacter baumannii in Critically Ill Patients. Pharmaceutics 2021; 14:pharmaceutics14010031. [PMID: 35056926 PMCID: PMC8780224 DOI: 10.3390/pharmaceutics14010031] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/09/2021] [Accepted: 12/22/2021] [Indexed: 01/01/2023] Open
Abstract
Carbapenem-resistant Acinetobacter baumannii (CRAB) is one of the most common causes of nosocomial infections in critically ill patients. Colistin methanesulfonate (CMS), an inactive prodrug, has been considered as a last-resort treatment for CRAB infection in critically ill patients. The objective of this study was to assess 30-day survival and nephrotoxicity in critically ill patients who received non-loading dose (LD) versus LD of CMS for CRAB infection treatment. Between 2012 and 2017, this retrospective cohort analysis was performed at Chiang Mai University Hospital (CMUH), focusing on critically ill patients with CRAB infection who received either non-LD or LD of CMS. A total of 383 patients met the criteria for inclusion. At the 30th day of treatment, the survival rate of patients in the LD CMS group was 1.70 times (adjusted HR) of those in the non-LD group (95% CI = 1.17-2.50, p = 0.006). Clinical response was significantly higher in the LD CMS group than non-LD CMS group (aHR, 1.35, 95% CI, 1.01-1.82, p = 0.046). In addition, a microbiological response-eradication of pre-treatment isolated pathogens in post-treatment cultures-in patients with LD CMS was 1.57 times that of patients with non-LD CMS (95% CI, 1.15-2.15, p = 0.004). Additionally, there was a significant difference in nephrotoxicity between LD CMS and non-LD CMS (aHR, 1.57, 95% CI, 1.14-2.17, p = 0.006). Based on these results, LD CMS should be used to increase the opportunity of patients to achieve favourable outcomes. However, LD CMS was found associated with an increase in nephrotoxicity, so renal function should be closely monitored when LD colistin was administered.
Collapse
Affiliation(s)
- Wasan Katip
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
- Epidemiology Research Group of Infectious Disease (ERGID), Chiang Mai University, Chiang Mai 50200, Thailand;
- Correspondence: ; Tel.: +66-(53)-9443423; Fax: +66-(53)-222741
| | - Suriyon Uitrakul
- Department of Pharmaceutical Care, School of Pharmacy, Walailak University, Nakhon Si Thammarat 80160, Thailand;
| | - Peninnah Oberdorfer
- Epidemiology Research Group of Infectious Disease (ERGID), Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Pediatrics, Division of Infectious Diseases, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| |
Collapse
|
16
|
Gunay E, Kaya S, Baysal B, Yuksel E, Arac E. Evaluation of prognosis and nephrotoxicity in patients treated with colistin in intensive care unit. Ren Fail 2021; 42:704-709. [PMID: 32703065 PMCID: PMC7470093 DOI: 10.1080/0886022x.2020.1795878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Nephrotoxicity is the most important adverse effect of colistin therapy. We investigated the frequency of nephrotoxicity, risk factors related to nephrotoxicity, and its relationship with mortality in patients who received intravenous colistin in intensive care units (ICUs). Materials and methods We retrospectively reviewed the data of patients who received intravenous colistin in ICUs between 2011 and 2017. Acute kidney injury (AKI) diagnosis and staging were made based on the Kidney Disease Improving Global Outcome criteria. Results There were 149 patients included in the study with 61% being male. The mean age was 58.7 ± 20.3 years. AKI was detected in 96 (64.4%) patients. There were 25 patients with AKI stage 1 (16.8%) and 71 patients with AKI stage 2 or 3 (47.7%). Advanced age (65.0 vs. 47.4 years; p < .001), diabetes mellitus (p < .001), heart failure (p = .01), high APACHE II score (31.7 vs. 28.08, p = .019), and inotrope usage (p = .01) were found as risk factors for AKI. The 14-day mortality rate was higher in the AKI group (p = .027). Discussion Higher AKI and mortality rates are observed in patients with diabetes, heart failure, advanced age and the hemodynamically impaired. However, it is a fact that there are no alternative therapies other than colistin in the treatment of multidrug-resistant Gram-negative bacterial infections. Therefore, the development of AKI in this patient group should not be considered a sufficient reason for discontinuing colistin treatment. Understanding the risk factors in this potential nephrotoxic treatment can provide a more careful patient follow-up.
Collapse
Affiliation(s)
- Emrah Gunay
- Department of Nephrology, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Safak Kaya
- Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Birol Baysal
- Department of Gastroenterology, Memorial Sisli Hospital, Istanbul, Turkey
| | - Enver Yuksel
- Department of Nephrology, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Esref Arac
- Department of Internal Medicine, University of Health Sciences, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| |
Collapse
|
17
|
Truong CB, Durham SH, Qian J. Comparisons of adverse event reporting for colistin versus polymyxin B using the US Food and Drug Administration Adverse Event Reporting System (FAERS). Expert Opin Drug Saf 2021; 20:603-609. [PMID: 33573405 DOI: 10.1080/14740338.2021.1890024] [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] [Indexed: 10/22/2022]
Abstract
Background: The polymyxins (colistin and polymyxin B) have recently reemerged in clinical practice. With the same antimicrobial activities, colistin has been more frequently prescribed in most countries, although available evidence on their nephrotoxicity is conflicting.Methods: The US Food and Drug Administration Adverse Event Reporting System (FAERS) data from Q1-2004 to Q1-2020 were used to identify adverse events (AE) reports. We described the reporting patterns and compare the reporting rates of serious AEs, acute kidney diseases (AKD), and death between colistin and polymyxin B using reporting odds ratios (RORs).Results: The annual number of AE reports increased over time for both drugs. Heterogeneity in reporting characteristics was observed in age and reporter region. RORs of serious, AKD, and death AEs were significantly higher for both drugs versus other drugs. RORs of serious and AKD AEs were higher for colistin compared to polymyxin B (p = 0.0479 and p = 0.0306, respectively), but no difference in death RORs was detected (p = 0.2211).Conclusions: This study showed higher reporting rates of serious AEs and AKD for colistin than polymyxin B, but no difference in death. The findings support future research with stronger study design and larger sample size for the safety comparison between colistin and polymyxin B.
Collapse
Affiliation(s)
- Cong Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Spencer H Durham
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| |
Collapse
|
18
|
Wagenlehner F, Lucenteforte E, Pea F, Soriano A, Tavoschi L, Steele VR, Henriksen AS, Longshaw C, Manissero D, Pecini R, Pogue JM. Systematic review on estimated rates of nephrotoxicity and neurotoxicity in patients treated with polymyxins. Clin Microbiol Infect 2021; 27:S1198-743X(20)30764-3. [PMID: 33359542 DOI: 10.1016/j.cmi.2020.12.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/03/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Nephrotoxicity and neurotoxicity are commonly associated with polymyxin treatment; however, the emergence of multidrug-resistant Gram-negative bacteria with limited therapeutic options has resulted in increased use of polymyxins. OBJECTIVES To determine the rates of nephrotoxicity and neurotoxicity during polymyxin treatment and whether any factors influence these. DATA SOURCES Medline, Embase and Cochrane Library databases were searched on 2 January 2020. STUDY ELIGIBILITY CRITERIA Studies reporting nephrotoxicity and/or neurotoxicity rates in patients with infections treated with polymyxins were included. Reviews, meta-analyses and reports not in English were excluded. PARTICIPANTS Patients hospitalized with infections treated with systemic or inhaled polymyxins were included. For comparative analyses, patients treated with non-polymyxin-based regimens were also included. METHODS Meta-analyses were performed using a random-effects model; subgroup meta-analyses were conducted where data permitted using a mixed-effects model. RESULTS In total, 237 reports of randomized controlled trials, cohort and case-control studies were eligible for inclusion; most were single-arm observational studies. Nephrotoxic events in 35,569 patients receiving polymyxins were analysed. Overall nephrotoxicity rate was 0.282 (95% confidence interval (CI) 0.259-0.307). When excluding studies where >50% of patients received inhaled-only polymyxin treatment or nephrotoxicity assessment was by methods other than internationally recognized criteria (RIFLE, KDIGO or AKIN), the nephrotoxicity rate was 0.391 (95% CI 0.364-0.419). The odds of nephrotoxicity were greater with polymyxin therapies compared to non-polymyxin-based regimens (odds ratio 2.23 (95% CI 1.58-3.15); p < 0.001). Meta-analyses showed a significant effect of polymyxin type, dose, patient age, number of concomitant nephrotoxins and use of diuretics, glycopeptides or vasopressors on the rate of nephrotoxicity. Polymyxin therapies were not associated with a significantly different rate of neurotoxicity than non-polymyxin-based regimens (p 0.051). The overall rate of neurotoxicity during polymyxin therapy was 0.030 (95% CI 0.020-0.043). CONCLUSIONS Polymyxins are associated with a higher risk of nephrotoxicity than non-polymyxin-based regimens.
Collapse
Affiliation(s)
- Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Giessen, Germany
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Pea
- Department of Medicine, University of Udine and Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUIUD, Udine, Italy
| | - Alex Soriano
- Infectious Diseases Department, Hospital Clínic of Barcelona, University of Barcelona IDIBAPS, Barcelona, Spain
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | | | | | - Davide Manissero
- University College of London, Institute for Global Health, London, UK
| | | | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
| |
Collapse
|
19
|
Liu J, Shu Y, Zhu F, Feng B, Zhang Z, Liu L, Wang G. Comparative efficacy and safety of combination therapy with high-dose sulbactam or colistin with additional antibacterial agents for multiple drug-resistant and extensively drug-resistant Acinetobacter baumannii infections: A systematic review and network meta-analysis. J Glob Antimicrob Resist 2020; 24:136-147. [PMID: 32889142 DOI: 10.1016/j.jgar.2020.08.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/20/2020] [Accepted: 08/25/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This study aimed to compare the efficacy and safety of combination therapy with high-dose sulbactam or colistin with additional antibacterial agents for treating multidrug-resistant or extensively drug-resistant Acinetobacter baumannii (MDR-AB or XDR-AB) infections. METHODS We systematically searched PubMed, Embase, Cochrane, and Web of Science (through March 30, 2020) for studies that examined high-dose sulbactam or colistin with additional antibacterial agents as therapy for patients with infections with MDR-AB and XDR-AB. Through a network meta-analysis (NMA), using both direct and indirect evidence, we determined risk ratios and 95% confidence intervals. Primary outcomes included clinical improvement, clinical cure, microbiological eradication, and mortality from any cause. Secondary outcomes included nephrotoxicity. RESULTS The NMA included 18 studies and 1835 patients. We found that high-dose sulbactam (≥6 g per day), combined with another single antibacterial agent (levofloxacin or tigecycline), which were the highest ranking in clinical improvement and clinical cure. Still colistin-based combination in drug-resistant Acinetobacter baumannii therapy occupied the main position (the number of studies and patients) in most studies. Colistin combined with additional antibacterial agents was associated with a higher risk of nephrotoxicity. CONCLUSIONS Therapeutic regimens including high-dose sulbactam in combination with additional antibacterial agents (including colistin) might be one of the promising options for the treatment of MDR-AB or XDR-AB infections and high-quality study will be needed to confirm clinical efficacy.
Collapse
Affiliation(s)
- Jiating Liu
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, 1 Xianglin Road, Luzhou 646000, China; Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou 646000, China
| | - Yunfeng Shu
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, 1 Xianglin Road, Luzhou 646000, China; Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou 646000, China
| | - Feilong Zhu
- The Affiliated Xuzhou Rehabilitation Hospital of Xuzhou Medical University, Xuzhou 221009, China
| | - Bimin Feng
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, 1 Xianglin Road, Luzhou 646000, China
| | - Zhengjie Zhang
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, 1 Xianglin Road, Luzhou 646000, China; Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou 646000, China
| | - Liang Liu
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, 1 Xianglin Road, Luzhou 646000, China; Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou 646000, China
| | - Guojun Wang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou 646000, China.
| |
Collapse
|
20
|
Jiang AM, Shi X, Liu N, Gao H, Ren MD, Zheng XQ, Fu X, Liang X, Ruan ZP, Yao Y, Tian T. Nosocomial infections due to multidrug-resistant bacteria in cancer patients: a six-year retrospective study of an oncology Center in Western China. BMC Infect Dis 2020; 20:452. [PMID: 32600270 PMCID: PMC7324970 DOI: 10.1186/s12879-020-05181-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Bacterial infections are the most frequent complications in patients with malignancy, and the epidemiology of nosocomial infections among cancer patients has changed over time. This study aimed to evaluate the characteristics, antibiotic resistance patterns, and prognosis of nosocomial infections due to multidrug-resistant (MDR) bacteria in cancer patients. METHODS This retrospective observational study analyzed cancer patients with nosocomial infections caused by MDR from August 2013 to May 2019. The extracted clinical data were recorded in a standardized form and compared based on the survival status of the patients after infection and during hospitalization. The data were analyzed using independent samples t-test, Chi-square test, and binary logistic regression. P-values < 0.05 were considered significant. RESULTS One thousand eight patients developed nosocomial infections during hospitalization, with MDR strains detected in 257 patients. Urinary tract infection (38.1%), respiratory tract infection (26.8%), and bloodstream infection (BSI) (12.5%) were the most common infection types. Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-PE) (72.8%) members were the most frequently isolated MDR strains, followed by Acinetobacter baumannii (11.7%), and Stenotrophomonas maltophilia (6.2%). The results of multivariate regression analysis revealed that smoking history, intrapleural/abdominal infusion history within 30 days, the presence of an indwelling urinary catheter, length of hospitalization, and hemoglobin were independent factors for in-hospital mortality in the study population. The isolated MDR bacteria exhibited high rates of sensitivity to amikacin, meropenem, and imipenem. CONCLUSIONS The burden of nosocomial infections due to MDR bacteria is considerably high in oncological patients, with ESBL-PE being the most predominant causative pathogen. Our findings suggest that amikacin and carbapenems actively against more than 89.7% of MDR isolates. The precise management of MDR bacterial infections in cancer patients may improve the prognosis of these individuals.
Collapse
Affiliation(s)
- Ai-Min Jiang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xin Shi
- School of Public Health, Xi'an Jiaotong University Health Science Center, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Na Liu
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Huan Gao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Meng-Di Ren
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiao-Qiang Zheng
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xiao Fu
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Xuan Liang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Zhi-Ping Ruan
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Yu Yao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Tao Tian
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi, 710061, People's Republic of China.
| |
Collapse
|
21
|
Bellos I, Pergialiotis V, Frountzas M, Kontzoglou K, Daskalakis G, Perrea DN. Efficacy and safety of colistin loading dose: a meta-analysis. J Antimicrob Chemother 2020; 75:1689-1698. [DOI: 10.1093/jac/dkaa064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/22/2020] [Accepted: 02/04/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Colistin represents a polypeptide used for the treatment of MDR microorganisms, although the optimal dosing strategy is under investigation. The present meta-analysis aims to determine whether the administration of a colistin loading dose in patients receiving high-dose maintenance regimens changes the rates of treatment success and the risk of nephrotoxicity.
Methods
Medline, Scopus, CENTRAL, Clinicaltrials.gov and Google Scholar were systematically searched from inception to 18 November 2019. Studies were considered eligible if they reported clinical outcomes among patients receiving high-dose colistin therapy with and without the administration of a loading dose. Meta-analysis was performed by fitting a random-effects model.
Results
Eight (three prospective and five retrospective cohort) studies were included, comprising 1115 patients. The administration of a colistin loading dose was associated with significantly higher microbiological [risk ratio (RR) = 1.23, 95% CI = 1.10–1.39] but not clinical (RR = 1.04, 95% CI = 0.87–1.24) success. No significant associations were calculated for nephrotoxicity (RR = 1.31, 95% CI = 0.90–1.91) and mortality (RR = 1.03, 95% CI = 0.82–1.29) risk. The results remained stable after adjustments for small sample size, credibility ceilings, publication bias and risk of bias.
Conclusions
Observational evidence suggests that the administration of a colistin loading dose in patients receiving high maintenance dosage regimens is significantly associated with higher rates of microbiological response, but does not change clinical cure, mortality or nephrotoxicity risk. The dosing regimen that would provide the optimal balance between treatment efficacy and safety needs to be determined by future randomized controlled trials.
Collapse
Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kontzoglou
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Daskalakis
- First Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
22
|
Jung S, Chung EK, Jun MS, Son ES, Rhie SJ. Differences in Colistin Administration and Bacterial and Treatment Outcomes in Critically Ill Patients. Sci Rep 2019; 9:8781. [PMID: 31217523 PMCID: PMC6584744 DOI: 10.1038/s41598-019-44965-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 05/24/2019] [Indexed: 11/09/2022] Open
Abstract
The desired target steady-state average colistin concentration (Css,avg) to balance between therapeutic effectiveness and nephrotoxicity is largely unclear. The objective of this study was to evaluate the effect of the desired target colistin Css,avg on the effectiveness and safety of IV colistin therapy in critically ill patients. Overall, 153 critically ill patients (71% males) receiving IV colistin were retrospectively analyzed. The desired target colistin Css,avg was estimated based on the daily colistin dose and creatinine clearance of each patient. No significant predictor for clinical cure was identified. However, microbiological outcome was significantly associated with pneumonia compared to bacteremia (odds ratio [OR] 0.092, 95% confidence interval [CI] [0.033-0.251], P < 0.001) and the use of IV colistin loading dose (OR 2.783, 95% CI [1.126-6.880], P = 0.027). Colistin-associated nephrotoxicity was significantly less likely to occur in patients who received inhaled colistin close to the time of IV colistin therapy (OR 0.331, CI [0.119-0.925], P = 0.035). The desired target Css,avg of colistin was not associated with treatment outcomes or the risk of nephrotoxicity. Loading dose and inhaled colistin use near the time of IV colistin therapy may be considered to maximize therapeutic effectiveness and minimize the risk of colistin-associated nephrotoxicity, respectively.
Collapse
Affiliation(s)
- Sunmi Jung
- Graduate School of Clinical Health Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.,Division of Pharmacy, Yonsei University Health System, Seoul, 03722, Republic of Korea
| | - Eun Kyoung Chung
- College of Pharmacy, Kyung Hee University, Seoul, 02447, Republic of Korea.,Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Seoul, 05278, Republic of Korea
| | - Min Sun Jun
- Division of Life & Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Eun Sun Son
- Division of Pharmacy, Yonsei University Health System, Seoul, 03722, Republic of Korea
| | - Sandy Jeong Rhie
- Graduate School of Clinical Health Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea. .,College of Pharmacy, Ewha Womans University, Seoul, 03760, Republic of Korea. .,Division of Life & Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea. .,Department of Pharmacy, Ewha Womans University Mokdong Hospital, Seoul, 07985, Republic of Korea.
| |
Collapse
|
23
|
Polymyxin Acute Kidney Injury: Dosing and Other Strategies to Reduce Toxicity. Antibiotics (Basel) 2019; 8:antibiotics8010024. [PMID: 30875778 PMCID: PMC6466603 DOI: 10.3390/antibiotics8010024] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 12/20/2022] Open
Abstract
Polymyxins are valuable antimicrobials for the management of multidrug-resistant Gram-negative bacteria; however, nephrotoxicity associated with these drugs is a very common side effect that occurs during treatment. This article briefly reviews nephrotoxic mechanisms and risk factors for polymyxin-associated acute kidney injury (AKI) and discusses dosing strategies that may mitigate kidney damage without compromising antimicrobial activity. Polymyxins have a very narrow therapeutic window and patients requiring treatment with these drugs are frequently severely ill and have multiple comorbidities, which increases the risk of AKI. Notably, there is a significant overlap between therapeutic and toxic plasma polymyxin concentrations that substantially complicates dose selection. Recent dosing protocols for both colistin and polymyxin B have been developed and may help fine tune dose adjustment of these antibiotics. Minimizing exposure to modifiable risk factors, such as other nephrotoxic agents, is strongly recommended. The dose should be carefully selected, particularly in high-risk patients. The administration of oxidative stress-reducing drugs is a promising strategy to ameliorate polymyxin-associated AKI, but still requires support from clinical studies.
Collapse
|
24
|
Muntean D, Licker M, Horhat F, Dumitrașcu V, Săndesc D, Bedreag O, Dugăeșescu D, Coșniță DA, Krasta A, Bădițoiu L. Extensively drug-resistant Acinetobacter baumannii and Proteeae association in a Romanian intensive care unit: risk factors for acquisition. Infect Drug Resist 2018; 11:2187-2197. [PMID: 30519056 PMCID: PMC6233948 DOI: 10.2147/idr.s171288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to identify risk factors for extensively drug-resistant (XDR) Acinetobacter baumannii (AB) and XDR Proteeae association in the largest intensive care unit (ICU) in Western Romania. Materials and methods This retrospective case-controlled study was conducted between January 2016 and December 2016 in the ICU of the “Pius Brînzeu” County Emergency Clinical Hospital of Timi oara. Data were collected, in strict confidentiality, from the electronic database of the Microbiology Laboratory and the hospital’s electronic medical records. Risk factors were ș investigated by logistic regression. Independent variables with P≤0.05 and OR >1 (95% CI >1) in the univariate analysis were entered into multivariate sequenced analysis. Findings The incidence density of coinfection with XDR AB and XDR Proteeae was 5.31 cases per 1,000 patient-days. Independent risk factors for the association of XDR AB and XDR Proteeae were represented by the presence of tracheostomy and naso-/orogastric nutrition ≥ 8 days. In addition, pressure ulcers were independent predictive factors for infections with all three infection types. Previous antibiotic therapy was an independent risk factor for the acquisition of XDR-AB strains, alone or in association, while the prolonged hospitalization in the ICU, blood transfusion, and hemodialysis appear as independent risk factors for single infections. Conclusion This association of XDR AB and XDR Proteeae may well not be limited to our hospital or our geographical area.
Collapse
Affiliation(s)
- Delia Muntean
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania, .,Pius Brînzeu Emergency Clinical County Hospital, Timisoara, Romania,
| | - Monica Licker
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania, .,Pius Brînzeu Emergency Clinical County Hospital, Timisoara, Romania,
| | - Florin Horhat
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania,
| | - Victor Dumitrașcu
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania,
| | - Dorel Săndesc
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania, .,Pius Brînzeu Emergency Clinical County Hospital, Timisoara, Romania,
| | - Ovidiu Bedreag
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania, .,Pius Brînzeu Emergency Clinical County Hospital, Timisoara, Romania,
| | - Dorina Dugăeșescu
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania,
| | - Dan A Coșniță
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania,
| | - Anca Krasta
- Pius Brînzeu Emergency Clinical County Hospital, Timisoara, Romania,
| | - Luminița Bădițoiu
- Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania,
| |
Collapse
|