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Barbier F, Hraiech S, Kernéis S, Veluppillai N, Pajot O, Poissy J, Roux D, Zahar JR. Rationale and evidence for the use of new beta-lactam/beta-lactamase inhibitor combinations and cefiderocol in critically ill patients. Ann Intensive Care 2023; 13:65. [PMID: 37462830 DOI: 10.1186/s13613-023-01153-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Healthcare-associated infections involving Gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) phenotype are associated with impaired patient-centered outcomes and poses daily therapeutic challenges in most of intensive care units worldwide. Over the recent years, four innovative β-lactam/β-lactamase inhibitor (BL/BLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, imipenem-relebactam and meropenem-vaborbactam) and a new siderophore cephalosporin (cefiderocol) have been approved for the treatment of certain DTR-GNB infections. The literature addressing their microbiological spectrum, pharmacokinetics, clinical efficacy and safety was exhaustively audited by our group to support the recent guidelines of the French Intensive Care Society on their utilization in critically ill patients. This narrative review summarizes the available evidence and unanswered questions on these issues. METHODS A systematic search for English-language publications in PUBMED and the Cochrane Library database from inception to November 15, 2022. RESULTS These drugs have demonstrated relevant clinical success rates and a reduced renal risk in most of severe infections for whom polymyxin- and/or aminoglycoside-based regimen were historically used as last-resort strategies-namely, ceftazidime-avibactam for infections due to Klebsiella pneumoniae carbapenemase (KPC)- or OXA-48-like-producing Enterobacterales, meropenem-vaborbactam for KPC-producing Enterobacterales, ceftazidime-avibactam/aztreonam combination or cefiderocol for metallo-β-lactamase (MBL)-producing Enterobacterales, and ceftolozane-tazobactam, ceftazidime-avibactam and imipenem-relebactam for non-MBL-producing DTR Pseudomonas aeruginosa. However, limited clinical evidence exists in critically ill patients. Extended-infusion scheme (except for imipenem-relebactam) may be indicated for DTR-GNB with high minimal inhibitory concentrations and/or in case of augmented renal clearance. The potential benefit of combining these agents with other antimicrobials remains under-investigated, notably for the most severe presentations. Other important knowledge gaps include pharmacokinetic information in particular situations (e.g., pneumonia, other deep-seated infections, and renal replacement therapy), the hazard of treatment-emergent resistance and possible preventive measures, the safety of high-dose regimen, the potential usefulness of rapid molecular diagnostic tools to rationalize their empirical utilization, and optimal treatment durations. Comparative clinical, ecological, and medico-economic data are needed for infections in whom two or more of these agents exhibit in vitro activity against the causative pathogen. CONCLUSIONS New BL/BLI combinations and cefiderocol represent long-awaited options for improving the management of DTR-GNB infections. Several research axes must be explored to better define the positioning and appropriate administration scheme of these drugs in critically ill patients.
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Affiliation(s)
- François Barbier
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de l'Hôpital, 45000, Orléans, France.
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France.
| | - Sami Hraiech
- Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, and Centre d'Études et de Recherche sur les Services de Santé et la Qualité de Vie, Université Aix-Marseille, Marseille, France
| | - Solen Kernéis
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Nathanaël Veluppillai
- Équipe de Prévention du Risque Infectieux, Hôpital Bichat-Claude Bernard, Assistance Publique - Hôpitaux de Paris, and INSERM/IAME, Université Paris Cité, Paris, France
| | - Olivier Pajot
- Réanimation Polyvalente, Hôpital Victor Dupouy, Argenteuil, France
| | - Julien Poissy
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Lille, Inserm U1285, Université de Lille, and CNRS/UMR 8576 - UGSF - Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Damien Roux
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- DMU ESPRIT, Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique - Hôpitaux de Paris, Colombes, and INSERM/CNRS, Institut Necker Enfants Malades, Université Paris Cité, Paris, France
| | - Jean-Ralph Zahar
- Institut Maurice Rapin, Hôpital Henri Mondor, Créteil, France
- Département de Microbiologie Clinique, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Bobigny and INSERM/IAME, Université de Paris, Paris, France
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Sękowska A, Grabowska M, Bogiel T. Satisfactory In Vitro Activity of Ceftolozane–Tazobactam against Carbapenem-Resistant Pseudomonas aeruginosa But Not against Klebsiella pneumoniae Isolates. Medicina (B Aires) 2023; 59:medicina59030518. [PMID: 36984519 PMCID: PMC10057464 DOI: 10.3390/medicina59030518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
Background: Gram-negative rods are one of the most commonly isolated bacteria within human infections. These microorganisms are typically opportunistic pathogens that pose a serious threat to public health due to the possibility of transmission in the human population. Resistance to carbapenems is one of the most important antimicrobial resistance mechanisms amongst them. The aim of this study was to evaluate ceftolozane–tazobactam in vitro activity against carbapenem-resistant Pseudomonas aeruginosa and Klebsiella pneumoniae clinical strains. Information on the antimicrobial activity of this antimicrobial against Gram-negative rods was also supplemented with a brief review of the relevant literature. Methods: The research involved 316 strains of Gram-negative rods: P. aeruginosa—206 and K. pneumoniae—110. Results: Of the tested strains, 86.0% P. aeruginosa and 30.0% K. pneumoniae remained susceptible to ceftolozane–tazobactam. Conclusions: Therefore, ceftolozane–tazobactam might be a good option in the treatment of infections caused by carbapenem-resistant P. aeruginosa strains, including those in ICU patients. Meanwhile, due to dissemination of ESBLs among K. pneumoniae strains, infections with this etiology should not be treated with the ceftolozane–tazobactam combination.
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Affiliation(s)
- Alicja Sękowska
- Microbiology Department, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, 85-094 Bydgoszcz, Poland
- Clinical Microbiology Department, Dr Antoni Jurasz University Hospital No 1 in Bydgoszcz, 85-094 Bydgoszcz, Poland
- Correspondence: (A.S.); (T.B.); Tel.: +48-52-585-44-80 (T.B.)
| | - Marta Grabowska
- Microbiology Department, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, 85-094 Bydgoszcz, Poland
- Dr Jan Biziel University Hospital No 2 in Bydgoszcz, 85-168 Bydgoszcz, Poland
| | - Tomasz Bogiel
- Microbiology Department, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, 85-094 Bydgoszcz, Poland
- Clinical Microbiology Department, Dr Antoni Jurasz University Hospital No 1 in Bydgoszcz, 85-094 Bydgoszcz, Poland
- Correspondence: (A.S.); (T.B.); Tel.: +48-52-585-44-80 (T.B.)
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In Vitro Activity of Imipenem-Relebactam, Meropenem-Vaborbactam, Ceftazidime-Avibactam and Comparators on Carbapenem-Resistant Non-Carbapenemase-Producing Enterobacterales. Antibiotics (Basel) 2023; 12:antibiotics12010102. [PMID: 36671303 PMCID: PMC9854925 DOI: 10.3390/antibiotics12010102] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
Background: Avibactam, relebactam and vaborbactam are β-lactamase inhibitors that proved their efficiency against KPC-producing Enterobacterales. Regarding their inhibitor activity towards Ambler’s class A extended spectrum β-lactamases (ESBL) and Ambler’s class C cephalosporinase (AmpC), they should be active on most of the carbapenem-resistant non-carbapenemase-producing Enterobacterales (CR non-CPE). Objectives: Determine the in vitro activity of ceftazidime-avibactam, imipenem-relebactam and meropenem-vaborbactam and comparators against CR non-CPE. Methods: MICs to ceftazidime/avibactam, imipenem/relebactam, meropenem/vaborbactam, but also temocillin, ceftolozane/tazobactam, ertapenem, colistin, eravacycline and tigecycline were determined by broth microdilution (ThermoFisher) on a collection of 284 CR non-CPE (inhibition zone diameter < 22 mm to meropenem). Whole genome sequencing was performed on 90 isolates to assess the genetic diversity as well as resistome. Results: According to EUCAST breakpoints, susceptibility rates of ceftazidime, imipenem, meropenem and ertapenem used at standard dose were 0.7%, 45.1%, 14.8% and 2.5%, respectively. Increased exposure of ceftazidime, imipenem and meropenem led to reach 3.5%, 68.3% and 67.7% susceptibility, respectively. Using the EUCAST clinical breakpoints, susceptibility rates of ceftazidime/avibactam, imipenem/relebactam and meropenem/vaborbactam were 88.4%, 81.0% and 80.6%, respectively. Susceptibility rates of temocillin, ceftolozane/tazobactam, tigecycline, eravacycline, and colistin were 0%, 4.6%, 27.8%, 54.9% and 90.1%. MICs distributions with and without the presence of the inhibitor demonstrated a better ability of avibactam and relebactam compared to vaborbactam to restore susceptibility to the associated β-lactam. Conclusions: This study demonstrated the in vitro efficacy of ceftazidime/avibactam, imipenem/relebactam and to a lesser extent meropenem/vaborbactam against CR non-CPE. Moreover, to test all β-lactams/β-lactamases inhibitors combinations without a priori for CRE, non-CPE is crucial since resistance to one of the β-lactam/β-lactamase inhibitor combinations does not predict resistance to another molecule, depending on the resistance mechanisms involved.
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Pharmacokinetics, Pharmacodynamics, and Dosing Considerations of Novel β-Lactams and β-Lactam/β-Lactamase Inhibitors in Critically Ill Adult Patients: Focus on Obesity, Augmented Renal Clearance, Renal Replacement Therapies, and Extracorporeal Membrane Oxygenation. J Clin Med 2022; 11:jcm11236898. [PMID: 36498473 PMCID: PMC9738279 DOI: 10.3390/jcm11236898] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Dose optimization of novel β-lactam antibiotics (NBLA) has become necessary given the increased prevalence of multidrug-resistant infections in intensive care units coupled with the limited number of available treatment options. Unfortunately, recommended dose regimens of NBLA based on PK/PD indices are not well-defined for critically ill patients presenting with special situations (i.e., obesity, extracorporeal membrane oxygenation (ECMO), augmented renal clearance (ARC), and renal replacement therapies (RRT)). This review aimed to discuss and summarize the available literature on the PK/PD attained indices of NBLA among critically ill patients with special circumstances. DATA SOURCES PubMed, MEDLINE, Scopus, Google Scholar, and Embase databases were searched for studies published between January 2011 and May 2022. STUDY SELECTION AND DATA EXTRACTION Articles relevant to NBLA (i.e., ceftolozane/tazobactam, ceftazidime/avibactam, cefiderocol, ceftobiprole, imipenem/relebactam, and meropenem/vaborbactam) were selected. The MeSH terms of "obesity", "augmented renal clearance", "renal replacement therapy", "extracorporeal membrane oxygenation", "pharmacokinetic", "pharmacodynamic" "critically ill", and "intensive care" were used for identification of articles. The search was limited to adult humans' studies that were published in English. A narrative synthesis of included studies was then conducted accordingly. DATA SYNTHESIS Available evidence surrounding the use of NBLA among critically ill patients presenting with special situations was limited by the small sample size of the included studies coupled with high heterogeneity. The PK/PD target attainments of NBLA were reported to be minimally affected by obesity and/or ECMO, whereas the effect of renal functionality (in the form of either ARC or RRT) was more substantial. CONCLUSION Critically ill patients presenting with special circumstances might be at risk of altered NBLA pharmacokinetics, particularly in the settings of ARC and RRT. More robust, well-designed trials are still required to define effective dose regimens able to attain therapeutic PK/PD indices of NBLA when utilized in those special scenarios, and thus aid in improving the patients' outcomes.
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Díaz Santos E, Mora Jiménez C, Del Río-Carbajo L, Vidal-Cortés P. Treatment of severe multi-drug resistant Pseudomonas aeruginosa infections. Med Intensiva 2022; 46:508-520. [PMID: 35840495 DOI: 10.1016/j.medine.2022.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 06/15/2023]
Abstract
Pseudomonas aeruginosa is the microorganism most frequently involved in the main ICU-acquired infections, with special importance in ventilator associated pneumonia. Its importance lies, in addition to its high incidence in critically ill patients, in the severity of the infections it causes and in the difficulty of its antimicrobial treatment, directly related to the high percentage of resistance to antibiotics classically considered first-line. New active antibiotics have recently been developed against Pseudomonas aeruginosa, even against multi-drug resistant strains. This review analyzes both the differential characteristics of Pseudomonas aeruginosa infections and the new therapeutic options, focusing on multi-drug resistant Pseudomonas aeruginosa.
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Affiliation(s)
- E Díaz Santos
- Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - C Mora Jiménez
- Medicina Intensiva, Consorci Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - L Del Río-Carbajo
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - P Vidal-Cortés
- Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain.
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Zhou Y, Zhang J, Chen Y, Wu J, Guo B, Wu X, Zhang Y, Wang M, Ya R, Huang H. Combined PK/PD Index May Be a More Appropriate PK/PD Index for Cefoperazone/Sulbactam against Acinetobacter baumannii in Patients with Hospital-Acquired Pneumonia. Antibiotics (Basel) 2022; 11:antibiotics11050703. [PMID: 35625347 PMCID: PMC9138011 DOI: 10.3390/antibiotics11050703] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 05/18/2022] [Accepted: 05/21/2022] [Indexed: 02/06/2023] Open
Abstract
Cefoperazone/sulbactam (CPZ/SUL) is a β-lactam and β-lactamase inhibitor combination therapy for the treatment of respiratory tract infections. Using data from a prospective, multiple-center, open-label clinical trial in 54 patients with hospital-acquired pneumonia or ventilator-associated pneumonia caused by multidrug-resistant Acinetobacter baumannii (Ab), we showed that a combined PK/PD index %(T > MICcpz*T > MICsul) is a more appropriate PK/PD index against Ab, compared to the PK/PD index (%T > MIC) for a single drug. For a 2 h infusion, the PK/PD cutoff of CPZ/SUL (2 g/1 g, q8h) for clinical and microbiological efficacy was 4/2 and 1/0.5 mg/L, respectively. The corresponding cumulative fraction of response was 46.5% and 25.3%, respectively. Results based on the combined PK/PD index were quite similar to that based on the joint probability of target attainment. The two drugs have interaction from the viewpoint of PK/PD. When the dose of one drug was too high, the PK/PD cutoff was often determined by another drug in which the dose was maintained. In most cases, sulbactam exerted the main effect against infection by Ab in the complex CPZ/SUL, which was similar to the literature reports. When the MIC of CPZ was 8, 16, or 32 mg/L, a CPZ/SUL 2 g/1 g (q8h), 2 g/2 g (q8h), or 2 g/2 g (q6h) (infusion was all 3 h) was recommended, respectively. A clinical efficacy and safety study to confirm simulation results is warranted.
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Affiliation(s)
- Yingjie Zhou
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
- Correspondence: ; Tel.: +86-021-54602085
| | - Jufang Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Beining Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Xiaojie Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
- Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yingyuan Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (Y.Z.); (J.Z.); (J.W.); (B.G.); (X.W.); (Y.Z.); (M.W.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Ru Ya
- Yonghe Branch of Huashan Hospital, Fudan University, Shanghai 200436, China; (R.Y.); (H.H.)
| | - Hao Huang
- Yonghe Branch of Huashan Hospital, Fudan University, Shanghai 200436, China; (R.Y.); (H.H.)
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Tratamiento de las infecciones graves por Pseudomonas aeruginosa multirresistente. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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