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Landmesser KB, Autry EB, Gardner BM, Bosko KA, Schadler A, Kuhn RJ. Comparison of the predictive value of area under the curve versus maximum serum concentration of intravenous tobramycin in cystic fibrosis patients treated for an acute pulmonary exacerbation. Pediatr Pulmonol 2021; 56:3209-3216. [PMID: 34241975 DOI: 10.1002/ppul.25569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/19/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The primary objective of this study was to compare the therapeutic predictive value of area under the curve (AUC24 ) versus maximum concentration (Cmax ) in cystic fibrosis (CF) patients receiving intravenous (IV) tobramycin for a Pseudomonas aeruginosa (PsA) acute pulmonary exacerbation (APE). Acute kidney injury (AKI) incidence and the relationship between time undetectable and efficacy were also assessed. METHODS A retrospective review was conducted in patients aged at least 1 month with a diagnosis of CF receiving IV tobramycin for treatment of a PsA APE and admitted to the University of Kentucky between August 2015 and August 2019. Patients were excluded if they had no growth of PsA on sputum culture or if two postdose tobramycin levels were not obtained following a dose adjustment of ≥20%. RESULTS A total of 44 pediatric and 107 adult patient encounters met inclusion criteria. In patients with therapeutic success (n = 91), 75.8% had an AUC24 ≥80% and 80.3% had a Cmax ≥8 times the highest PsA minimal inhibitory concentration. There was a significant correlation between AUC24 and Cmax (r[149] = 0.727; p < 0.001). AKI incidence was significantly higher in patients receiving IV tobramycin dosed multiple times daily versus at least every 24 h (χ2 [1, 151] = 3.9; p = 0.047). CONCLUSIONS The results of this study indicate that both AUC24 and Cmax serve as relatively accurate predictors of tobramycin efficacy. Additionally, given the significant increase in incidence of AKI, multidaily dosing of IV tobramycin should be avoided in pediatric and adult patients with CF.
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Affiliation(s)
| | - Elizabeth B Autry
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Brian M Gardner
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katherine A Bosko
- Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Aric Schadler
- Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Pediatrics, Kentucky Children's Hospital, Lexington, Kentucky, USA
| | - Robert J Kuhn
- Department of Pharmacy, Kentucky Children's Hospital, Lexington, Kentucky, USA.,Department of Pharmacy, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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2
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Miller T, Pastuch C, Garavaglia L, Gannon K, Parravani A. Unknown Renal Impairment: A Rare Case of Inhaled Tobramycin Induced Acute Kidney Injury in a Cystic Fibrosis Patient. Antibiotics (Basel) 2021; 10:antibiotics10040424. [PMID: 33921466 PMCID: PMC8070657 DOI: 10.3390/antibiotics10040424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/16/2022] Open
Abstract
Acute kidney injury is a reversible medical condition commonly caused by nephrotoxic agents. The infrequency that a nebulized medication elicits a renal insult presents a rare diagnostic challenge. Within this case, we report a 57-year-old cystic fibrosis patient with chronic kidney disease (CKD) Stage G3b (baseline 1.5–1.6 mg/dL) who developed an acute kidney injury (AKI) with a serum creatinine elevation to 4.08 mg/dL and associated worsening vestibular dysfunction related to twice-daily nebulized tobramycin inhalation solution (TIS). The patient was found to have a tobramycin serum level of 4.2 μg/mL 2.5 h after TIS dosing, with elevation remaining present at 1.1 μg/mL 24 h after discontinuation of therapy. Laboratory values at one month continued to show elevated creatinine levels at 2.1 mg/dL, suggesting progression of his baseline CKD. This case supports the benefit of obtaining tobramycin serum levels and vestibular/audiology function testing when evaluating patients on chronic nebulized TIS who present with acute or chronic renal dysfunction. From these serum levels, adjustments to daily dosing, regular monitoring of tobramycin serum levels, or discontinuation of treatment should be made to prevent permanent renal damage in patients with CKD. Calculated Naranjo ADR Probability Scale: 9; Definite.
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Affiliation(s)
- Tyler Miller
- Department of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Correspondence:
| | - Cristina Pastuch
- Department of Pediatrics and Medicine, West Virginia University, Morgantown, WV 26506, USA;
- Adult Cystic Fibrosis, Mountain State Cystic Fibrosis Center, West Virginia University, Morgantown, WV 26506, USA
| | - Lisa Garavaglia
- Department of Pharmaceutical Services, West Virginia University, Morgantown, WV 26506, USA;
| | - Kelley Gannon
- Section of General Internal Medicine, Department of Medicine, West Virginia University, Morgantown, WV 26506, USA;
| | - Anthony Parravani
- Section of Nephrology, Department of Medicine, West Virginia University, Morgantown, WV 26506, USA;
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3
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Homa M, Sándor A, Tóth E, Szebenyi C, Nagy G, Vágvölgyi C, Papp T. In vitro Interactions of Pseudomonas aeruginosa With Scedosporium Species Frequently Associated With Cystic Fibrosis. Front Microbiol 2019; 10:441. [PMID: 30894846 PMCID: PMC6414507 DOI: 10.3389/fmicb.2019.00441] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/20/2019] [Indexed: 11/13/2022] Open
Abstract
Members of the Scedosporium apiospermum species complex are the second most frequently isolated pathogens after Aspergillus fumigatus from cystic fibrosis (CF) patients with fungal pulmonary infections. Even so, the main risk factors for the infection are unrevealed. According to previous studies, bacterial infections might reduce the risk of a fungal infection, but an antibacterial therapy may contribute to the airway colonization by several fungal pathogens. Furthermore, corticosteroids, which are often used to reduce lung inflammation in children and adults with CF, are also proved to enhance the growth of A. fumigatus in vitro. Considering all the above discussed points, we aimed to test how Pseudomonas aeruginosa influences the growth of scedosporia and to investigate the potential effect of commonly applied antibacterial agents and corticosteroids on Scedosporium species. Direct interactions between fungal and bacterial strains were tested using the disk inhibition method. Indirect interactions via volatile compounds were investigated by the plate-in-plate method, while the effect of bacterial media-soluble molecules was tested using a modified cellophane assay and also in liquid culture media conditioned by P. aeruginosa. To test the effect of bacterial signal molecules, antibacterial agents and corticosteroids on the fungal growth, the broth microdilution method was used. We also investigated the germination ability of Scedosporium conidia in the presence of pyocyanin and diffusible signal factor by microscopy. According to our results, P. aeruginosa either inhibited or enhanced the growth of scedosporia depending on the culture conditions and the mode of interactions. When the two pathogens were cultured physically separately from each other in the plate-in-plate tests, the presence of the bacteria was able to stimulate the growth of several fungal isolates. While in direct physical contact, bacterial strains inhibited the fungal growth. This effect might be attributed to bacterial signal molecules, which also proved to inhibit the germination and growth of scedosporia. In addition, antibacterial agents showed growth-promoting, while corticosteroids exhibited growth inhibitory effect on several Scedosporium isolates. These data raise the possibility that a P. aeruginosa infection or a previously administered antibacterial therapy might be able to increase the chance of a Scedosporium colonization in a CF lung.
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Affiliation(s)
- Mónika Homa
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Alexandra Sándor
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Eszter Tóth
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Interdisciplinary Excellence Centre, Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Csilla Szebenyi
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary.,Interdisciplinary Excellence Centre, Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Gábor Nagy
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Interdisciplinary Excellence Centre, Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Csaba Vágvölgyi
- Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary.,Interdisciplinary Excellence Centre, Department of Microbiology, University of Szeged, Szeged, Hungary
| | - Tamás Papp
- MTA-SZTE "Lendület" Fungal Pathogenicity Mechanisms Research Group, Szeged, Hungary.,Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary.,Interdisciplinary Excellence Centre, Department of Microbiology, University of Szeged, Szeged, Hungary
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4
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Glomerular and Tubular Renal Function after Repeated Once-Daily Tobramycin Courses in Cystic Fibrosis Patients. Pulm Med 2017; 2017:2602653. [PMID: 28133546 PMCID: PMC5241496 DOI: 10.1155/2017/2602653] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/14/2016] [Indexed: 11/24/2022] Open
Abstract
Introduction. Antibiotic treatment regimens against Pseudomonas aeruginosa lung infection in cystic fibrosis (CF) patients often include aminoglycoside antibiotics that may cause chronic renal failure after repeated courses. Aminoaciduria is an early marker of acute aminoglycoside-induced renal tubular dysfunction. We hypothesized that urinary amino acid reabsorption is decreased after repeated once-daily tobramycin therapies. Methods. In this prospective cross-sectional study creatinine clearance was estimated by the Schwartz and the Cockcroft-Gault formula. Tubular amino acid reabsorption was determined by ion exchange chromatography in 46 patients with CF who received multiple tobramycin courses (6.3 ± 10.1 (1–57)) in a once-daily dosing regimen and 10 who did not. Results. Estimated creatinine clearance employing the Cockcroft-Gault was mildly reduced in 17/46 (37%) of the patients who received tobramycin and 5/10 (50%) of the patients who did not but in none using the Schwartz formula. No association with lifetime tobramycin courses was found. Tubular amino acid reabsorption was not influenced by the amount of once-daily tobramycin courses. Conclusion. Clinically not significant reduction of eCCL occurred in a minority of CF patients. However, chronic tubular dysfunction was not present in patients with CF repeatedly treated with tobramycin in the once-daily dosing scheme.
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Meylan S, Porter CBM, Yang JH, Belenky P, Gutierrez A, Lobritz MA, Park J, Kim SH, Moskowitz SM, Collins JJ. Carbon Sources Tune Antibiotic Susceptibility in Pseudomonas aeruginosa via Tricarboxylic Acid Cycle Control. Cell Chem Biol 2017; 24:195-206. [PMID: 28111098 DOI: 10.1016/j.chembiol.2016.12.015] [Citation(s) in RCA: 236] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/21/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
Abstract
Metabolically dormant bacteria present a critical challenge to effective antimicrobial therapy because these bacteria are genetically susceptible to antibiotic treatment but phenotypically tolerant. Such tolerance has been attributed to impaired drug uptake, which can be reversed by metabolic stimulation. Here, we evaluate the effects of central carbon metabolite stimulations on aminoglycoside sensitivity in the pathogen Pseudomonas aeruginosa. We identify fumarate as a tobramycin potentiator that activates cellular respiration and generates a proton motive force by stimulating the tricarboxylic acid (TCA) cycle. In contrast, we find that glyoxylate induces phenotypic tolerance by inhibiting cellular respiration with acetyl-coenzyme A diversion through the glyoxylate shunt, despite drug import. Collectively, this work demonstrates that TCA cycle activity is important for both aminoglycoside uptake and downstream lethality and identifies a potential strategy for potentiating aminoglycoside treatment of P. aeruginosa infections.
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Affiliation(s)
- Sylvain Meylan
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA; Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Caroline B M Porter
- Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Jason H Yang
- Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Peter Belenky
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Arnaud Gutierrez
- Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Michael A Lobritz
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA; Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jihye Park
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Sun H Kim
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Samuel M Moskowitz
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - James J Collins
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA; Department of Biological Engineering, Institute for Medical Engineering & Science, Synthetic Biology Center, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Harvard-MIT Program, Health Sciences and Technology, Cambridge, MA 02139, USA.
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6
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Safi KH, Damiani JM, Sturza J, Nasr SZ. Extended-Interval Aminoglycoside Use in Cystic Fibrosis Exacerbation in Children and Young Adults: A Prospective Quality Improvement Project. Glob Pediatr Health 2016; 3:2333794X16635464. [PMID: 27336007 PMCID: PMC4905153 DOI: 10.1177/2333794x16635464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/21/2022] Open
Abstract
This is a prospective quality improvement project for patients with cystic fibrosis who are 5 years of age and older who were admitted for intravenous antibiotic administration as part of treatment of cystic fibrosis exacerbation. The goal of this project was to compare the pharmacokinetics of once-daily versus thrice-daily aminoglycoside use when treating cystic fibrosis exacerbation in different age groups. Of the total of 119 patient encounters, 82.4% were started on once-daily dosing, and the remainder were started on thrice-daily dosing. Patients with pharmacokinetics allowing the continuation of once-daily dosing differed from patients who required a switch to thrice-daily dosing in terms of baseline forced expiratory volume in 1 second, forced expiratory flow from 25% to 75% of vital capacity, age, and body mass index (BMI) but were similar in BMI percentiles. The once-daily dosing group had higher mean 18-hour level, higher mean half-life, higher mean area under the curve, and lower mean elimination constant. This study showed that aminoglycoside clearance is higher in younger children.
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