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Liabeuf S, Hafez G, Pešić V, Spasovski G, Bobot M, Mačiulaitis R, Bumblyte IA, Ferreira AC, Farinha A, Malyszko J, Pépin M, Massy ZA, Unwin R, Capasso G, Mani LY. Drugs with a negative impact on cognitive functions (part 3): antibacterial agents in patients with chronic kidney disease. Clin Kidney J 2024; 17:sfae174. [PMID: 39114495 PMCID: PMC11304602 DOI: 10.1093/ckj/sfae174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Indexed: 08/10/2024] Open
Abstract
The relationship between chronic kidney disease (CKD) and cognitive function has received increased attention in recent years. Antibacterial agents (ABs) represent a critical component of therapy regimens in patients with CKD due to increased susceptibility to infections. Following our reviewing work on the neurocognitive impact of long-term medications in patients with CKD, we propose to focus on AB-induced direct and indirect consequences on cognitive function. Patients with CKD are predisposed to adverse drug reactions (ADRs) due to altered drug pharmacokinetics, glomerular filtration decline, and the potential disruption of the blood-brain barrier. ABs have been identified as a major cause of ADRs in vulnerable patient populations. This review examines the direct neurotoxic effects of AB classes (e.g. beta-lactams, fluoroquinolones, aminoglycosides, and metronidazole) on the central nervous system (CNS) in patients with CKD. We will mainly focus on the acute effects on the CNS associated with AB since they are the most extensively studied effects in CKD patients. Moreover, the review describes the modulation of the gut microbiota by ABs, potentially influencing CNS symptoms. The intricate brain-gut-kidney axis emerges as a pivotal focus, revealing the interplay between microbiota alterations induced by ABs and CNS manifestations in patients with CKD. The prevalence of antibiotic-associated encephalopathy in patients with CKD undergoing intravenous AB therapy supports the use of therapeutic drug monitoring for ABs to reduce the number and seriousness of ADRs in this patient population. In conclusion, elucidating AB-induced cognitive effects in patients with CKD demands a comprehensive understanding and tailored therapeutic strategies that account for altered pharmacokinetics and the brain-gut-kidney axis.
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Affiliation(s)
- Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
| | - Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Vesna Pešić
- Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Goce Spasovski
- Department of Nephrology, Clinical Centre “Mother Theresa”, Saints Cyril and Methodius University, Skopje, North Macedonia
| | - Mickaël Bobot
- Aix-Marseille University, Department of Nephrology, AP-HM, La Conception Hospital, Marseille, France; C2VN Laboratory, Inserm 1263, INRAE 1260, Aix-Marseille University, Marseille, France
| | - Romaldas Mačiulaitis
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Faculty of Medicines, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Inga Arune Bumblyte
- Department of Nephrology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | - Ana Farinha
- Department of Nephrology, Hospital de Vila Franca de Xira, Lisbon, Portugal
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marion Pépin
- Department of Geriatrics, Ambroise Paré University Medical Center, APHP, Boulogne-Billancourt, France
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
| | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
| | - Robert Unwin
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Giovambattista Capasso
- Department of Translantional Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Biogem Research Institute, Ariano Irpino, Italy
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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3
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Kim JH, Kim T, Kim W, Kim SH, Hong YJ, Lim E, Bae DW, Noh SM, Lee J. The incidence and predictors of antibiotic-associated encephalopathy: a multicenter hospital-based study. Sci Rep 2024; 14:8747. [PMID: 38627483 PMCID: PMC11021399 DOI: 10.1038/s41598-024-59555-w] [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: 10/03/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
This study aimed to evaluate the incidence and likelihood of antibiotic-associated encephalopathy (AAE), comparing rates among the classes of antibiotics in monotherapy or in combination therapy. We also investigated the associations between the incidence of AAE and the glomerular filtration rate (GFR) and electroencephalogram features. Consecutive admissions that used any kind of antibiotics to treat infectious diseases were identified from six hospitals. We classified antibiotics according to three distinct pathophysiologic mechanisms and clinical subtypes. We searched for the incidence of AAE as the primary outcome. A total of 97,433 admission cases among 56,038 patients was identified. Cases that received type 1 antibiotics had significantly more frequent AAE compared to those that received type 2 antibiotics (adjusted odds ratio [OR], 2.62; 95% confidence interval [CI] 1.15-5.95; P = 0.021). Combined use of type 1 + 2 antibiotics was associated with a significantly higher incidence of AAE compared to the use of type 2 antibiotics alone (adjusted OR, 3.44; 95% CI 1.49-7.93; P = 0.004). Groups with GFR < 60 mL/min/1.73 m2 had significantly higher incidence rates of AAE compared to those with GFRs ≥ 90 mL/min/1.73 m2 among cases that received type 1 + 2 antibiotics. Detection of spike-and-wave or sharp-and-wave patterns on electroencephalogram was significantly more common in the combination therapy group. Combination use of antibiotics was associated with a higher incidence of AAE compared to monotherapy. The incidence of AAE significantly increased as renal function decreased, and epileptiform discharges were more likely to be detected in cases receiving combined antibiotics.
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Affiliation(s)
- Jean Hee Kim
- Department of Neurology, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taewon Kim
- Department of Neurology, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-Ro, Bupyeong-Gu, Incheon, 21431, South Korea.
| | - Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong-Hoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yun Jeong Hong
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eunyae Lim
- Department of Neurology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dae Woong Bae
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Mi Noh
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jieun Lee
- Department of Neurology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Sivarajan D, Ramachandran B. Antibiotics modulate frequency and early generation of epileptic seizures in zebrafish. Exp Brain Res 2023; 241:571-583. [PMID: 36625966 DOI: 10.1007/s00221-023-06546-4] [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: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
Antibiotics have been used for decades to treat various bacterial infections. Apart from bactericidal activities, their potential side effects have not been much studied or evaluated. Neurotoxicity is a major concern in the case of β-lactam and fluoroquinolone families, which can result in convulsions or seizures. Here, we proposed a hypothesis to check whether antibiotic treatment can conclusively enhance anxiety-like behaviours and how seizure behavioural profile gets modulated in pentylenetetrazole (PTZ)-treated zebrafish. Zebrafish were treated with selected antibiotics such as 25 mg/L Penicillin G (PG) and Ciprofloxacin (CPFX), for 7 days and thereafter exposed to PTZ (7.5 mM) for 20 min. The data indicate that PG and CPFX-treated groups exhibited anxiety-like or stressed behavioural phenotypes in the novel tank test (6 min), and also, they were found to promote hyperactivity. Early onset of PTZ-induced seizure-like behavioural scores, the heightened intensity of seizure and reduced latency in different scores were found in PG and CPFX-administered groups. This study substantiates that PG and CPFX as potential seizure modulators in zebrafish. The zebrafish is a well-established and still expanding model organism in many fields. Here, we again reinforce zebrafish as a prominent model to investigate seizure-like neuro-behavioural entities and confirm that chronic antibiotic use has negative consequences that can exacerbate the circumstances of vertebrate species exhibiting seizure-related reactions.
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Affiliation(s)
- Dhanusha Sivarajan
- Department of Zoology, Christ College (Autonomous), Irinjalakuda, Thrissur, Kerala, 680125, India
| | - Binu Ramachandran
- Neuronal Plasticity Group, Department of Zoology, University of Calicut, Thenhipalam, Malappuram, Kerala, 673635, India.
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5
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Huang Q, Li J, Huang N, Xia X, Qiu Y, Zhong Z, Lin Z, Huang X, Zhang D, Huang F. Clinical characteristics and outcomes of antibiotic-associated encephalopathy in patients with end-stage kidney disease. Ren Fail 2022; 44:1708-1716. [PMID: 36259485 PMCID: PMC9586608 DOI: 10.1080/0886022x.2022.2134025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective End-stage kidney disease (ESKD) patients have a higher risk of antibiotic-associated encephalopathy (AAE) than other patients. We aimed to evaluate the prevalence, risk factors and outcomes of AAE in ESKD patients. Method A retrospective study of ESKD patients treated with intravenous antibiotics in our hospital from Jan. 1, 2006, to Dec. 31, 2015 was performed. AAE was diagnosed by the modified Delphi method. Control individuals were randomly selected from the remaining patients who did not exhibit neurologic symptoms. Logistic regression analysis was used to identify risk factors for AAE as well as the association between AAE and outcome. Result A total of 2104 patients were included in the study. The prevalence of AAE in our study was 4.4% (92/2104). The multivariate logistic regression analysis revealed that anuria (OR = 8.04, 95% CI: 4.13–15.65, p < 0.001), history of central nervous system disorder (OR = 3.03, 95% CI: 1.21–7.56, p = 0.018) and hypoalbuminemia (OR= 1.87, 95% CI: 1.01–3.47, p = 0.046) were independent factors associated with AAE in ESKD patients. After adjustment for confounders, AAE was associated with composite outcomes of in-hospital mortality and treatment withdrawal (OR = 4.36, 95% CI: 2.09–9.10, p < 0.001). Conclusion The prevalence of AAE was 4.4% in ESKD patients and varied among different antibiotics. Anuria, history of central nervous system disorder and hypoalbuminemia were associated with AAE in ESKD patients. AAE is associated with worse outcomes in ESKD patients.
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Affiliation(s)
- Qingxiu Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China.,Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, China
| | - Jianbo Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Naya Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xi Xia
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Yagui Qiu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Zhong Zhong
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Zhenchuan Lin
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China.,Department of Nephrology, Kidney and Urology Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Xiaowen Huang
- Zhongshan Hospital of Traditional Chinese Medicine, Affiliated to Guangzhou University of Chinese Medicine, Zhongshan, China
| | - Dihua Zhang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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6
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Roger C, Louart B. Beta-Lactams Toxicity in the Intensive Care Unit: An Underestimated Collateral Damage? Microorganisms 2021; 9:microorganisms9071505. [PMID: 34361942 PMCID: PMC8306322 DOI: 10.3390/microorganisms9071505] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022] Open
Abstract
Beta-lactams are the most commonly prescribed antimicrobials in intensive care unit (ICU) settings and remain one of the safest antimicrobials prescribed. However, the misdiagnosis of beta-lactam-related adverse events may alter ICU patient management and impact clinical outcomes. To describe the clinical manifestations, risk factors and beta-lactam-induced neurological and renal adverse effects in the ICU setting, we performed a comprehensive literature review via an electronic search on PubMed up to April 2021 to provide updated clinical data. Beta-lactam neurotoxicity occurs in 10-15% of ICU patients and may be responsible for a large panel of clinical manifestations, ranging from confusion, encephalopathy and hallucinations to myoclonus, convulsions and non-convulsive status epilepticus. Renal impairment, underlying brain abnormalities and advanced age have been recognized as the main risk factors for neurotoxicity. In ICU patients, trough concentrations above 22 mg/L for cefepime, 64 mg/L for meropenem, 125 mg/L for flucloxacillin and 360 mg/L for piperacillin (used without tazobactam) are associated with neurotoxicity in 50% of patients. Even though renal complications (especially severe complications, such as acute interstitial nephritis, renal damage associated with drug induced hemolytic anemia and renal obstruction by crystallization) remain rare, there is compelling evidence of increased nephrotoxicity using well-known nephrotoxic drugs such as vancomycin combined with beta-lactams. Treatment mainly relies on the discontinuation of the offending drug but in the near future, antimicrobial optimal dosing regimens should be defined, not only based on pharmacokinetics/pharmacodynamic (PK/PD) targets associated with clinical and microbiological efficacy, but also on PK/toxicodynamic targets. The use of dosing software may help to achieve these goals.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
- Correspondence:
| | - Benjamin Louart
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
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Downes KJ, Goldman JL. Too Much of a Good Thing: Defining Antimicrobial Therapeutic Targets to Minimize Toxicity. Clin Pharmacol Ther 2021; 109:905-917. [PMID: 33539569 DOI: 10.1002/cpt.2190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/27/2021] [Indexed: 12/19/2022]
Abstract
Antimicrobials are a common cause of drug toxicity. Understanding the relationship between systemic antimicrobial exposure and toxicity is necessary to enable providers to take a proactive approach to prevent undesired drug effects. When an exposure threshold has been defined that predicts drug toxicity, therapeutic drug monitoring (TDM) can be performed to assure drug exposure does not exceed the defined threshold. Although some antimicrobials have well-defined dose-dependent toxicities, many other exposure-toxicity relationships have either not been well-defined or, in some cases, not been evaluated at all. In this review, we examine the relationship between exposures and toxicities for antibiotic, antifungal, and antiviral agents. Furthermore, we classify these relationships into four categories: known association between drug exposure and toxicity such that clinical implementation of a specific exposure threshold associated with toxicity for TDM is supported (category 1), known association between drug exposure and toxicity but the specific exposure threshold associated with toxicity is undefined (category 2), association between drug exposure and toxicity has been suggested but relationship is poorly defined (category 3), and no known association between drug exposure and toxicity (category 4). Further work to define exposure-toxicity thresholds and integrate effective TDM strategies has the potential to minimize many of the observed antimicrobial toxicities.
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Affiliation(s)
- Kevin J Downes
- The Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer L Goldman
- Divisions of Clinical Pharmacology, Toxicology and Therapeutic Innovation and Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri - Kansas City, Kansas City, Missouri, USA
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A Translational Pharmacokinetic Rat Model of Cerebral Spinal Fluid and Plasma Concentrations of Cefepime. mSphere 2019; 4:4/1/e00595-18. [PMID: 30700511 PMCID: PMC6354808 DOI: 10.1128/msphere.00595-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
This study defines the transit of cefepime between plasma and cerebral spinal fluid (CSF) in a rat model. Male Sprague-Dawley rats received cefepime intravenously. Plasma samples were obtained via a second dedicated intravenous catheter. CSF sampling occurred via an intracisternal catheter. Drug exposures and transfer from the plasma to the CSF during the first 24 h were calculated. The median CSF/blood percentage of penetration was 19%. Cefepime transit to the CSF is rapid and predictable in the rat model. This model will be highly useful for understanding the therapeutic window for cefepime and neurotoxicity. This study sought to define the transit of cefepime between plasma and cerebral spinal fluid (CSF) in a rat model. Male Sprague-Dawley rats received cefepime intravenously. A total daily dose of 150 mg/kg of body weight/day was administered as a single injection every 24 h for 4 days. Plasma samples were obtained via a second dedicated intravenous catheter. CSF sampling occurred via an intracisternal catheter. Cefepime levels in plasma and CSF were quantified via liquid chromatography-tandem mass spectrometry (LC-MS/MS). Pharmacokinetic (PK) analyses were conducted using Pmetrics for R. PK parameters and exposures during the first 24 h (i.e., area under the concentration-time curve from 0 to 24 h [AUC0–24] and maximum concentration of drug in serum from 0 to 24 h [Cmax 0–24]) were calculated from Bayesian posteriors. CSF penetration was estimated by comparing the exposure profiles between plasma and the CSF. Eleven rats contributed PK data. A four-compartmental model with a lag compartment for CSF fit the data well for both plasma (Bayesian [R2 = 0.956]) and CSF (Bayesian [R2 = 0.565]). Median parameter values (with the coefficient of variation percentage [CV%] in parentheses) for the rate constants to CSF from the lag compartment (K34), to the central compartment from the CSF compartment (K41), and to the lag compartment from the central compartment (K13) were 2.96 h−1 (116.27%), 0.47 h−1 (54.86%), and 0.13 h−1 (23.42%), respectively. The elimination rate constant (kel) was 3.15 h−1 (7.5%). Exposure estimation revealed a plasma median (with interquartile range [IQR] in parentheses) half-life, AUC0–24, and Cmax 0–24, of 1.7 (1.5 to 1.9) h, 111.3 (95.7 to 136.5) mg · 24 h/liter, and 177.8 (169.7 to 236.4) μg/ml, from the first dose, respectively. Exposure estimation of CSF demonstrated a median (with IQR in parentheses) AUC0–24 and Cmax 0–24 of 26.3 (16.6 to 43.1) mg · 24 h/liter and 6.8 (5.2 to 9.4) μg/ml, respectively. The median CSF/blood percentage of penetration was 19%. Cefepime transit to the CSF is rapid and predictable in the rat model. This model will be highly useful for understanding the therapeutic window for cefepime and neurotoxicity. IMPORTANCE This study defines the transit of cefepime between plasma and cerebral spinal fluid (CSF) in a rat model. Male Sprague-Dawley rats received cefepime intravenously. Plasma samples were obtained via a second dedicated intravenous catheter. CSF sampling occurred via an intracisternal catheter. Drug exposures and transfer from the plasma to the CSF during the first 24 h were calculated. The median CSF/blood percentage of penetration was 19%. Cefepime transit to the CSF is rapid and predictable in the rat model. This model will be highly useful for understanding the therapeutic window for cefepime and neurotoxicity.
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Imani S, Buscher H, Marriott D, Gentili S, Sandaradura I. Too much of a good thing: a retrospective study of β-lactam concentration-toxicity relationships. J Antimicrob Chemother 2018; 72:2891-2897. [PMID: 29091190 DOI: 10.1093/jac/dkx209] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/31/2017] [Indexed: 01/08/2023] Open
Abstract
Objectives To determine the existence of concentration-toxicity relationships for common β-lactam antibiotic adverse effects and define thresholds above which toxicity is more likely. Patients and methods Retrospective review of consecutive patients treated with piperacillin, meropenem or flucloxacillin who underwent therapeutic drug monitoring (TDM) at St Vincent's Hospital (Sydney, Australia) between January 2013 and December 2015. Adverse events investigated included neurotoxicity, nephrotoxicity, hepatotoxicity and opportunistic Clostridium difficile infection. Toxicity was measured using observational grading criteria, clinical assessment and relevant serum biomarkers. These findings were correlated with trough TDM measurements at the time of toxicity presentation. Results TDM results from 378 patients (piperacillin = 223, meropenem = 94 and flucloxacillin = 61) were investigated. There was no difference in baseline patient characteristics across antibiotic groups. A statistically significant elevation in mean serum trough concentrations (Cmin) was found in patients diagnosed with neurotoxicity (piperacillin, P < 0.01; meropenem, P = 0.04; flucloxacillin, P = 0.01) and those who developed nephrotoxicity whilst being treated with piperacillin (P < 0.01) or meropenem (P < 0.01). Incidence of hepatotoxicity and C. difficile was not related to Cmin. Threshold concentrations for which there is 50% risk of developing a neurotoxicity event (piperacillin, Cmin >361.4 mg/L; meropenem, Cmin >64.2 mg/L; flucloxacillin, Cmin >125.1 mg/L) or nephrotoxicity (piperacillin, Cmin >452.65 mg/L; meropenem, Cmin >44.45 mg/L) varied across antibiotics. Conclusions Our data reveal an association between toxic concentrations for a number of β-lactam agents and neurotoxic/nephrotoxic effects. We have defined threshold concentrations above which these toxicities become more likely. Clinicians should balance concerns for therapeutic efficacy with potential toxicity when considering aggressive therapy.
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Affiliation(s)
- Sahand Imani
- School of Medicine, University of Notre Dame Australia, Sydney, NSW, Australia.,Department of Clinical Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Debbie Marriott
- Department of Clinical Microbiology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sheridan Gentili
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Indy Sandaradura
- School of Medicine, University of New South Wales, Sydney, NSW, Australia.,Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
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Su BC, Huang HN, Lin TW, Hsiao CD, Chen JY. Epinecidin-1 protects mice from LPS-induced endotoxemia and cecal ligation and puncture-induced polymicrobial sepsis. Biochim Biophys Acta Mol Basis Dis 2017; 1863:3028-3037. [PMID: 28882626 DOI: 10.1016/j.bbadis.2017.08.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 01/07/2023]
Abstract
The antimicrobial peptide, epinecidin-1 (Epi), was identified from Epinephelus coioides and may have clinical application for treating sepsis. Epi has been shown to ameliorate antibiotic-resistant bacteria-induced sepsis in mice, but further evaluation in mixed-flora models and a description of the protective mechanisms are essential to establish this peptide as a potential therapeutic. Therefore, we first tested the protective effects of Epi against polymicrobial sepsis-induced bactericidal infection, inflammation and lung injury that result from cecal ligation and puncture in mice. Furthermore, since lipopolysaccharide (LPS) is a key inducer of inflammation during bacterial infection and sepsis, we also tested the LPS-antagonizing activity and related mechanisms of Epi-mediated protection in mice with LPS-induced endotoxemia and LPS-treated Raw264.7 mouse macrophage cells. Epi rescued mice from both polymicrobial sepsis and endotoxemia after delayed administration and suppressed both lung and systemic inflammatory responses, while attenuating lung injury and diminishing bacterial load. In vitro studies revealed that Epi suppressed LPS-induced inflammatory cytokine production. Mechanistically, Epi disrupted the interaction between LPS and LPS binding protein, competed with LPS for binding on the cell surface, and inhibited Toll-like receptor 4 endocytosis, resulting in inhibition of LPS-induced reactive oxygen species/p38/Akt/NF-κB signaling and subsequent cytokine production. Overall, our results demonstrate that Epi is a promising therapeutic agent for endotoxemia and polymicrobial sepsis.
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Affiliation(s)
- Bor-Chyuan Su
- Marine Research Station, Institute of Cellular and Organismic Biology, Academia Sinica, Jiaushi, Ilan, Taiwan
| | - Han-Ning Huang
- Marine Research Station, Institute of Cellular and Organismic Biology, Academia Sinica, Jiaushi, Ilan, Taiwan
| | - Tai-Wen Lin
- Institute of Molecular Biology, Academia Sinica, Taipei, Taiwan; Molecular Cell Biology, Taiwan International Graduate Program, Graduate Institute of Life Sciences, National Defense Medical Center and Academia Sinica, Taipei, Taiwan
| | | | - Jyh-Yih Chen
- Marine Research Station, Institute of Cellular and Organismic Biology, Academia Sinica, Jiaushi, Ilan, Taiwan.
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11
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Fernández-Delgado E, Egea-Guerrero JJ, Freire-Aragón MD, Rivera-Fernández V, Durán-Martínez P. [Severe respiratory failure and neuromuscular blockade after administration of colimycin]. Med Intensiva 2015; 39:448-9. [PMID: 25583045 DOI: 10.1016/j.medin.2014.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 10/22/2014] [Accepted: 10/29/2014] [Indexed: 11/16/2022]
Affiliation(s)
- E Fernández-Delgado
- Unidad de Neurocríticos, Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España.
| | - J J Egea-Guerrero
- Unidad de Neurocríticos, Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - M D Freire-Aragón
- Unidad de Neurocríticos, Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - V Rivera-Fernández
- Unidad de Neurocríticos, Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - P Durán-Martínez
- Unidad de Neurocríticos, Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España
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12
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Ma TKW, Chow KM, Choy ASM, Kwan BCH, Szeto CC, Li PKT. Clinical manifestation of macrolide antibiotic toxicity in CKD and dialysis patients. Clin Kidney J 2014; 7:507-12. [PMID: 25859365 PMCID: PMC4389137 DOI: 10.1093/ckj/sfu098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/21/2014] [Indexed: 11/15/2022] Open
Abstract
Macrolide antibiotics, erythromycin, clarithromycin and azithromycin are commonly prescribed for upper respiratory infection, and their use has recently been further linked to immunomodulatory effects. With the widespread and expanded use of macrolides, special attention should be paid to their potential adverse effects. We reported two cases of end-stage renal disease (ESRD) patients who developed hallucinations such as vivid images of worms after taking clarithromycin. Similar to previous case reports of clarithromycin neurotoxicity, the visual hallucination resolved upon cessation of clarithromycin. Furthermore, we discussed the pharmacokinetic properties and other toxicities of macrolide antibiotics in patients with chronic kidney disease and ESRD.
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Affiliation(s)
- Terry King-Wing Ma
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Kai-Ming Chow
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Agnes Shin Man Choy
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Bonnie Ching-Ha Kwan
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Cheuk-Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
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13
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Troidle L. The chronic kidney disease patient in the acute hospital environment. Adv Chronic Kidney Dis 2014; 21:355-9. [PMID: 24969387 DOI: 10.1053/j.ackd.2014.05.004] [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: 10/29/2013] [Revised: 05/21/2014] [Accepted: 05/21/2014] [Indexed: 11/11/2022]
Abstract
CKD is common, affecting more than 10% of the adult US population. Hospital admissions are common among these patients and present challenges for their caregivers. In the acute hospital setting, there is often a lack of awareness of the CKD patient and the best practices developed to help this population. This can place the CKD patient at risk for medication errors such as incorrect dosage or administration of a potentially harmful or unhelpful medication. CKD patients may need procedures during a hospital stay that increase their risk of adverse events. Also, common admission practices such as placing intravenous access needs to be thoughtfully considered in this population.
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