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Smith NM, Nguyen TD, Lodise TP, Chen L, Kaur JN, Klem JF, Boissonneault KR, Holden PN, Roach DR, Tsuji BT. Machine Learning-Led Optimization of Combination Therapy: Confronting the Public Health Threat of Extensively Drug Resistant Gram-Negative Bacteria. Clin Pharmacol Ther 2024; 115:896-905. [PMID: 38062797 DOI: 10.1002/cpt.3134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023]
Abstract
Developing optimized regimens for combination antibiotic therapy is challenging and often performed empirically over many clinical studies. Novel implementation of a hybrid machine-learning pharmacokinetic/pharmacodynamic/toxicodynamic (ML-PK/PD/TD) approach optimizes combination therapy using human PK/TD data along with in vitro PD data. This study utilized human population PK (PopPK) of aztreonam, ceftazidime/avibactam, and polymyxin B along with in vitro PDs from the Hollow Fiber Infection Model (HFIM) to derive optimal multi-drug regimens de novo through implementation of a genetic algorithm (GA). The mechanism-based PD model was constructed based on 7-day HFIM experiments across 4 clinical, extensively drug resistant Klebsiella pneumoniae isolates. GA-led optimization was performed using 13 different fitness functions to compare the effects of different efficacy (60%, 70%, 80%, or 90% of simulated subjects achieving bacterial counts of 102 CFU/mL) and toxicity (66% of simulated subjects having a target polymyxin B area under the concentration-time curve [AUC] of 100 mg·h/L and aztreonam AUC of 1,332 mg·h/L) on the optimized regimen. All regimens, except those most heavily weighted for toxicity prevention, were able to achieve the target efficacy threshold (102 CFU/mL). Overall, GA-based regimen optimization using preclinical data from animal-sparing in vitro studies and human PopPK produced clinically relevant dosage regimens similar to those developed empirically over many years for all three antibiotics. Taken together, these data provide significant insight into new therapeutic approaches incorporating ML to regimen design and treatment of resistant bacterial infections.
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Affiliation(s)
- Nicholas M Smith
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas D Nguyen
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Troy, New York, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack-Meridian Health, Nutley, New Jersey, USA
| | - Jan Naseer Kaur
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - John F Klem
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Patricia N Holden
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Brian T Tsuji
- School of Pharmacy & Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
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Zhou J, Qian Y, Lang Y, Zhang Y, Tao X, Moya B, Sayed ARM, Landersdorfer CB, Shin E, Werkman C, Smith NM, Kim TH, Kumaraswamy M, Shin BS, Tsuji BT, Bonomo RA, Lee RE, Bulitta JB. Comprehensive stability analysis of 13 β-lactams and β-lactamase inhibitors in in vitro media, and novel supplement dosing strategy to mitigate thermal drug degradation. Antimicrob Agents Chemother 2024; 68:e0139923. [PMID: 38329330 PMCID: PMC10916406 DOI: 10.1128/aac.01399-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Non-clinical antibiotic development relies on in vitro susceptibility and infection model studies. Validating the achievement of the targeted drug concentrations is essential to avoid under-estimation of drug effects and over-estimation of resistance emergence. While certain β-lactams (e.g., imipenem) and β-lactamase inhibitors (BLIs; clavulanic acid) are believed to be relatively unstable, limited tangible data on their stability in commonly used in vitro media are known. We aimed to determine the thermal stability of 10 β-lactams and 3 BLIs via LC-MS/MS in cation-adjusted Mueller Hinton broth at 25 and 36°C as well as agar at 4 and 37°C, and in water at -20, 4, and 25°C. Supplement dosing algorithms were developed to achieve broth concentrations close to their target over 24 h. During incubation in broth (pH 7.25)/agar, degradation half-lives were 16.9/21.8 h for imipenem, 20.7/31.6 h for biapenem, 29.0 h for clavulanic acid (studied in broth only), 23.1/71.6 h for cefsulodin, 40.6/57.9 h for doripenem, 46.5/64.6 h for meropenem, 50.8/97.7 h for cefepime, 61.5/99.5 h for piperacillin, and >120 h for all other compounds. Broth stability decreased at higher pH. All drugs were ≥90% stable for 72 h in agar at 4°C. Degradation half-lives in water at 25°C were >200 h for all drugs except imipenem (14.7 h, at 1,000 mg/L) and doripenem (59.5 h). One imipenem supplement dose allowed concentrations to stay within ±31% of their target concentration. This study provides comprehensive stability data on β-lactams and BLIs in relevant in vitro media using LC-MS/MS. Future studies are warranted applying these data to antimicrobial susceptibility testing and assessing the impact of β-lactamase-related degradation.
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Affiliation(s)
- Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Yuli Qian
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Yongzhen Zhang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Xun Tao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Bartolome Moya
- Servicio de Microbiología and Unidad de investigación, Hospital Universitario Son Espases, Instituto de investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Alaa R. M. Sayed
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Department of Chemistry, Faculty of Science, Fayoum University, Fayoum, Egypt
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Eunjeong Shin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Carolin Werkman
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Nicholas M. Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Tae Hwan Kim
- College of Pharmacy, Catholic University of Daegu, Gyeongsan, Gyeongbuk, South Korea
| | - Monika Kumaraswamy
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
- Infectious Diseases Section, VA San Diego Healthcare System, San Diego, California, USA
| | - Beom Soo Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Brian T. Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Robert A. Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, Cleveland, Ohio, USA
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Departments of Pharmacology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, and the CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio, USA
| | - Richard E. Lee
- Department of Chemical Biology and Therapeutics, St Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
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3
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Kaur JN, Singh N, Smith NM, Klem JF, Cha R, Lang Y, Chen L, Kreiswirth B, Holden PN, Bulitta JB, Tsuji BT. Next generation antibiotic combinations to combat pan-drug resistant Klebsiella pneumoniae. Sci Rep 2024; 14:3148. [PMID: 38326428 PMCID: PMC10850076 DOI: 10.1038/s41598-024-53130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Antimicrobial resistance has emerged as one of the leading public health threats of the twenty-first century. Gram-negative pathogens have been a major contributor to the declining efficacy of antibiotics through both acquired resistance and tolerance. In this study, a pan-drug resistant (PDR), NDM-1 and CTX-M-15 co-producing isolate of K. pneumoniae, CDC Nevada, (Kp Nevada) was exposed to the clinical combination of aztreonam + ceftazidime/avibactam (ATM/CAZ/AVI) to overcome metallo-β-lactamases. Unexpectedly, the β-lactam combination resulted in long filamentous cell formation induced by PBP3 inhibition over 168 h in the hollow fiber infection model experiments with eventual reversion of the total population upon drug removal. However, the addition of imipenem to the two drug β-lactam combination was highly synergistic with suppression of all drug resistant subpopulations over 5 days. Scanning electron microscopy and fluorescence microscopy for all imipenem combinations in time kill studies suggested a role for imipenem in suppression of long filamentous persisters, via the formation of metabolically active spheroplasts. To complement the imaging studies, salient transcriptomic changes were quantified using RT-PCR and novel cassette assay evaluated β-lactam permeability. This showed significant upregulation of both spheroplast protein Y (SPY), a periplasmic chaperone protein that has been shown to be related to spheroplast formation, and penicillin binding proteins (PBP1, PBP2, PBP3) for all combinations involving imipenem. However, with aztreonam alone, pbp1, pbp3 and spy remained unchanged while pbp2 levels were downregulated by > 25%. Imipenem displayed 207-fold higher permeability as compared with aztreonam (mean permeability coefficient of 17,200 nm/s). Although the clinical combination of aztreonam/avibactam and ceftazidime has been proposed as an important treatment of MBL Gram-negatives, we report the first occurrence of long filamentous persister formation. To our knowledge, this is the first study that defines novel β-lactam combinations involving imipenem via maximal suppression of filamentous persisters to combat PDR CDC Nevada K. pneumoniae.
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Affiliation(s)
- Jan Naseer Kaur
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA.
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Navaldeep Singh
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Nicholas M Smith
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jack F Klem
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Raymond Cha
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Liang Chen
- Center for Discovery and Innovation, Hackensack Meridian Health, Edison, NJ, USA
| | - Barry Kreiswirth
- Center for Discovery and Innovation, Hackensack Meridian Health, Edison, NJ, USA
| | - Patricia N Holden
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Brian T Tsuji
- Center for Infectious Diseases Next Generation Therapeutics, University at Buffalo, Buffalo, NY, USA.
- Division of Clinical and Translational Therapeutics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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Bulitta JB, Shin E, Bergen PJ, Lang Y, Forrest A, Tsuji BT, Moya B, Li J, Nation RL, Landersdorfer CB. Distinguishing Inducible and Non-Inducible Resistance to Colistin in Pseudomonas aeruginosa by Quantitative and Systems Pharmacology Modeling at Low and Standard Inocula. J Pharm Sci 2024; 113:202-213. [PMID: 37879409 DOI: 10.1016/j.xphs.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/20/2023] [Accepted: 10/20/2023] [Indexed: 10/27/2023]
Abstract
Colistin is a polymyxin and peptide antibiotic that can yield rapid bacterial killing, but also leads to resistance emergence. We aimed to develop a novel experimental and Quantitative and Systems Pharmacology approach to distinguish between inducible and non-inducible resistance. Viable count profiles for the total and less susceptible populations of Pseudomonas aeruginosa ATCC 27853 from static and dynamic in vitro infection models were simultaneously modeled. We studied low and normal initial inocula to distinguish between inducible and non-inducible resistance. A novel cutoff filter approach allowed us to describe the eradication and inter-conversion of bacterial populations. At all inocula, 4.84 mg/L of colistin (sulfate) yielded ≥4 log10 killing, followed by >4 log10 regrowth. A pre-existing, less susceptible population was present at standard but not at low inocula. Formation of a non-pre-existing, less susceptible population was most pronounced at intermediate colistin (sulfate) concentrations (0.9 to 5 mg/L). Both less susceptible populations inter-converted with the susceptible population. Simultaneously modeling of the total and less susceptible populations at low and standard inocula enabled us to identify the de novo formation of an inducible, less susceptible population. Inducible resistance at intermediate colistin concentrations highlights the importance of rapidly achieving efficacious polymyxin concentrations by front-loaded dosage regimens.
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Affiliation(s)
- Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA.
| | - Eunjeong Shin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Phillip J Bergen
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Australia
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Alan Forrest
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Bartolome Moya
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Australia; Biomedicine Discovery Institute, Infection Program, Department of Microbiology and Department of Pharmacology, Monash University, Melbourne, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Australia
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Australia
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Mahamad Maifiah MH, Zhu Y, Tsuji BT, Creek DJ, Velkov T, Li J. Integrated metabolomic and transcriptomic analyses of the synergistic effect of polymyxin-rifampicin combination against Pseudomonas aeruginosa. J Biomed Sci 2022; 29:89. [PMID: 36310165 PMCID: PMC9618192 DOI: 10.1186/s12929-022-00874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the mechanism of antimicrobial action is critical for improving antibiotic therapy. For the first time, we integrated correlative metabolomics and transcriptomics of Pseudomonas aeruginosa to elucidate the mechanism of synergistic killing of polymyxin-rifampicin combination. METHODS Liquid chromatography-mass spectrometry and RNA-seq analyses were conducted to identify the significant changes in the metabolome and transcriptome of P. aeruginosa PAO1 after exposure to polymyxin B (1 mg/L) and rifampicin (2 mg/L) alone, or in combination over 24 h. A genome-scale metabolic network was employed for integrative analysis. RESULTS In the first 4-h treatment, polymyxin B monotherapy induced significant lipid perturbations, predominantly to fatty acids and glycerophospholipids, indicating a substantial disorganization of the bacterial outer membrane. Expression of ParRS, a two-component regulatory system involved in polymyxin resistance, was increased by polymyxin B alone. Rifampicin alone caused marginal metabolic perturbations but significantly affected gene expression at 24 h. The combination decreased the gene expression of quorum sensing regulated virulence factors at 1 h (e.g. key genes involved in phenazine biosynthesis, secretion system and biofilm formation); and increased the expression of peptidoglycan biosynthesis genes at 4 h. Notably, the combination caused substantial accumulation of nucleotides and amino acids that last at least 4 h, indicating that bacterial cells were in a state of metabolic arrest. CONCLUSION This study underscores the substantial potential of integrative systems pharmacology to determine mechanisms of synergistic bacterial killing by antibiotic combinations, which will help optimize their use in patients.
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Affiliation(s)
- Mohd Hafidz Mahamad Maifiah
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
- International Institute for Halal Research and Training, International Islamic University Malaysia, 50728, Kuala Lumpur, Malaysia
| | - Yan Zhu
- Infection Program and Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, VIC, 3800, Australia
| | - Brian T Tsuji
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Darren J Creek
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Tony Velkov
- Department of Biochemistry and Pharmacology, University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Jian Li
- Infection Program and Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, VIC, 3800, Australia.
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Bulman ZP, Wicha SG, Nielsen EI, Lenhard JR, Nation RL, Theuretzbacher U, Derendorf H, Tängdén T, Zeitlinger M, Landersdorfer CB, Bulitta JB, Friberg LE, Li J, Tsuji BT. Research priorities towards precision antibiotic therapy to improve patient care. Lancet Microbe 2022; 3:e795-e802. [PMID: 35777386 DOI: 10.1016/s2666-5247(22)00121-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 04/04/2022] [Accepted: 04/28/2022] [Indexed: 12/24/2022]
Abstract
Antibiotic resistance presents an incessant threat to our drug armamentarium that necessitates novel approaches to therapy. Over the past several decades, investigation of pharmacokinetic and pharmacodynamic (PKPD) principles has substantially improved our understanding of the relationships between the antibiotic, pathogen, and infected patient. However, crucial gaps in our understanding of the pharmacology of antibacterials and their optimal use in the care of patients continue to exist; simply attaining antibiotic exposures that are considered adequate based on traditional targets can still result in treatment being unsuccessful and resistance proliferation for some infections. It is this salient paradox that points to key future directions for research in antibiotic therapeutics. This Personal View discusses six priority areas for antibiotic pharmacology research: (1) antibiotic-pathogen interactions, (2) antibiotic targets for combination therapy, (3) mechanistic models that describe the time-course of treatment response, (4) understanding and modelling of host response to infection, (5) personalised medicine through therapeutic drug management, and (6) application of these principles to support development of novel therapies. Innovative approaches that enhance our understanding of antibiotic pharmacology and facilitate more accurate predictions of treatment success, coupled with traditional pharmacology research, can be applied at the population level and to individual patients to improve outcomes.
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Affiliation(s)
- Zackery P Bulman
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA.
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | | | - Justin R Lenhard
- Department of Clinical and Administrative Sciences, California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | | | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Cornelia B Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Jian Li
- Monash Biomedicine Discovery Institute, Infection and Immunity Program and Department of Microbiology, Monash University, Melbourne, VIC, Australia
| | - Brian T Tsuji
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA
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Lodise TP, Smith NM, O'Donnell N, Eakin AE, Holden PN, Boissonneault KR, Zhou J, Tao X, Bulitta JB, Fowler VG, Chambers HF, Bonomo RA, Tsuji BT. Determining the optimal dosing of a novel combination regimen of ceftazidime/avibactam with aztreonam against NDM-1-producing Enterobacteriaceae using a hollow-fibre infection model. J Antimicrob Chemother 2021; 75:2622-2632. [PMID: 32464664 DOI: 10.1093/jac/dkaa197] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND MBL-producing strains of Enterobacteriaceae are a major public health concern. We sought to define optimal combination regimens of ceftazidime/avibactam with aztreonam in a hollow-fibre infection model (HFIM) of MBL-producing strains of Escherichia coli and Klebsiella pneumoniae. METHODS E. coli ARLG-1013 (blaNDM-1, blaCTX-M, blaCMY, blaTEM) and K. pneumoniae ARLG-1002 (blaNDM-1, blaCTXM-15, blaDHA, blaSHV, blaTEM) were studied in the HFIM using simulated human dosing regimens of ceftazidime/avibactam and aztreonam. Experiments were designed to evaluate the effect of staggered versus simultaneous administration, infusion duration and aztreonam daily dose (6 g/day versus 8 g/day) on bacterial killing and resistance suppression. Prospective validation experiments for the most active combination regimens were performed in triplicate to ensure reproducibility. RESULTS Staggered administration of the combination (ceftazidime/avibactam followed by aztreonam) was found to be inferior to simultaneous administration. Longer infusion durations (2 h and continuous infusion) also resulted in enhanced bacterial killing relative to 30 min infusions. The rate of killing was more pronounced with 8 g/day versus 6 g/day aztreonam combination regimens for both tested strains. In the prospective validation experiments, ceftazidime/avibactam with aztreonam dosed every 8 and 6 h, respectively (ceftazidime/avibactam 2/0.5 g every 8 h + aztreonam 2 g every 6 h), or ceftazidime/avibactam with aztreonam as continuous infusions resulted in maximal bacterial killing and resistance suppression over 7 days. CONCLUSIONS Simultaneous administration of aztreonam 8 g/day given as a continuous or 2 h infusion with ceftazidime/avibactam resulted in complete bacterial eradication and resistance suppression. Further study of this combination is needed with additional MBL-producing Gram-negative pathogens. The safety of this double β-lactam strategy also warrants further study in Phase 1 clinical trials.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Nicolas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | - Nick O'Donnell
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Ann E Eakin
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | | | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Xun Tao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Henry F Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, CA, USA
| | - Robert A Bonomo
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
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Lang Y, Shah NR, Tao X, Reeve SM, Zhou J, Moya B, Sayed ARM, Dharuman S, Oyer JL, Copik AJ, Fleischer BA, Shin E, Werkman C, Basso KB, Lucas DD, Sutaria DS, Mégroz M, Kim TH, Loudon-Hossler V, Wright A, Jimenez-Nieves RH, Wallace MJ, Cadet KC, Jiao Y, Boyce JD, LoVullo ED, Schweizer HP, Bonomo RA, Bharatham N, Tsuji BT, Landersdorfer CB, Norris MH, Shin BS, Louie A, Balasubramanian V, Lee RE, Drusano GL, Bulitta JB. Combating Multidrug-Resistant Bacteria by Integrating a Novel Target Site Penetration and Receptor Binding Assay Platform Into Translational Modeling. Clin Pharmacol Ther 2021; 109:1000-1020. [PMID: 33576025 PMCID: PMC10662281 DOI: 10.1002/cpt.2205] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 12/26/2022]
Abstract
Multidrug-resistant bacteria are causing a serious global health crisis. A dramatic decline in antibiotic discovery and development investment by pharmaceutical industry over the last decades has slowed the adoption of new technologies. It is imperative that we create new mechanistic insights based on latest technologies, and use translational strategies to optimize patient therapy. Although drug development has relied on minimal inhibitory concentration testing and established in vitro and mouse infection models, the limited understanding of outer membrane permeability in Gram-negative bacteria presents major challenges. Our team has developed a platform using the latest technologies to characterize target site penetration and receptor binding in intact bacteria that inform translational modeling and guide new discovery. Enhanced assays can quantify the outer membrane permeability of β-lactam antibiotics and β-lactamase inhibitors using multiplex liquid chromatography tandem mass spectrometry. While β-lactam antibiotics are known to bind to multiple different penicillin-binding proteins (PBPs), their binding profiles are almost always studied in lysed bacteria. Novel assays for PBP binding in the periplasm of intact bacteria were developed and proteins identified via proteomics. To characterize bacterial morphology changes in response to PBP binding, high-throughput flow cytometry and time-lapse confocal microscopy with fluorescent probes provide unprecedented mechanistic insights. Moreover, novel assays to quantify cytosolic receptor binding and intracellular drug concentrations inform target site occupancy. These mechanistic data are integrated by quantitative and systems pharmacology modeling to maximize bacterial killing and minimize resistance in in vitro and mouse infection models. This translational approach holds promise to identify antibiotic combination dosing strategies for patients with serious infections.
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Affiliation(s)
- Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Nirav R. Shah
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Present address: Jansen R&D, Johnson & Johnson, Spring House, Pennsylvania, USA
| | - Xun Tao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Present address: Genentech USA,Inc., South San Francisco, California, USA
| | - Stephanie M. Reeve
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Bartolome Moya
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Alaa R. M. Sayed
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Department of Chemistry, Faculty of Science, Fayoum University, Fayoum, Egypt
| | - Suresh Dharuman
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jeremiah L. Oyer
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Alicja J. Copik
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Brett A. Fleischer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Eunjeong Shin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Carolin Werkman
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Kari B. Basso
- Department of Chemistry, University of Florida, Gainesville, Florida, USA
| | - Deanna Deveson Lucas
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Dhruvitkumar S. Sutaria
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
- Present address: Genentech USA,Inc., South San Francisco, California, USA
| | - Marianne Mégroz
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Tae Hwan Kim
- College of Pharmacy, Catholic University of Daegu, Gyeongsan, Gyeongbuk, Korea
| | - Victoria Loudon-Hossler
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Amy Wright
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Rossie H. Jimenez-Nieves
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Miranda J. Wallace
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Keisha C. Cadet
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Yuanyuan Jiao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - John D. Boyce
- Infection and Immunity Program, Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Eric D. LoVullo
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, USA
| | - Herbert P. Schweizer
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, Arizona, USA
| | - Robert A. Bonomo
- Research Service and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Department of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio, USA
| | - Nagakumar Bharatham
- BUGWORKS Research India Pvt. Ltd., Centre for Cellular & Molecular Platforms, National Centre for Biological Sciences, Bengaluru, Karnataka, India
| | - Brian T. Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, New York, USA
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael H. Norris
- Spatial Epidemiology and Ecology Research Laboratory, Department of Geography and the Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Beom Soo Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, Korea
| | - Arnold Louie
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, Florida, USA
| | - Venkataraman Balasubramanian
- BUGWORKS Research India Pvt. Ltd., Centre for Cellular & Molecular Platforms, National Centre for Biological Sciences, Bengaluru, Karnataka, India
| | - Richard E. Lee
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - George L. Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, Florida, USA
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
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9
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Chua HC, Tse A, Smith NM, Mergenhagen KA, Cha R, Tsuji BT. Combatting the Rising Tide of Antimicrobial Resistance: Pharmacokinetic/Pharmacodynamic Dosing Strategies for Maximal Precision. Int J Antimicrob Agents 2021; 57:106269. [PMID: 33358761 DOI: 10.1016/j.ijantimicag.2020.106269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/09/2020] [Accepted: 12/13/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Antimicrobial pharmacokinetics/pharmacodynamics (PK/PD) principles and PK/PD models have been essential in characterizing the mechanism of antibiotic bacterial killing and determining the most optimal dosing regimen that maximizes clinical outcomes. This review summarized the fundamentals of antimicrobial PK/PD and the various types of PK/PD experiments that shaped the utilization and dosing strategies of antibiotics today. METHODS Multiple databases - including PubMed, Scopus, and EMBASE - were searched for published articles that involved PK/PD modelling and precision dosing. Data from in vitro, in vivo and mechanistic PK/PD models were reviewed as a basis for compiling studies that guide dosing regimens used in clinical trials. RESULTS Literature regarding the utilization of exposure-response analyses, mathematical modelling and simulations that were summarized are able to provide a better understanding of antibiotic pharmacodynamics that influence translational drug development. Optimal pharmacokinetic sampling of antibiotics from patients can lead to personalized dosing regimens that attain target concentrations while minimizing toxicity. Thus the development of a fully integrated mechanistic model based on systems pharmacology can continually adapt to data generated from clinical responses, which can provide the framework for individualized dosing regimens. CONCLUSIONS The promise of what PK/PD can provide through precision dosing for antibiotics has not been fully realized in the clinical setting. Antimicrobial resistance, which has emerged as a significant public health threat, has forced clinicians to empirically utilize therapies. Future research focused on implementation and translation of PK/PD-based approaches integrating novel approaches that combine knowledge of combination therapies, systems pharmacology and resistance mechanisms are necessary. To fully realize maximally precise therapeutics, optimal PK/PD strategies are critical to maximize antimicrobial efficacy against extremely-drug-resistant organisms, while minimizing toxicity.
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Affiliation(s)
- Hubert C Chua
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA; VA Western New York Healthcare System, Buffalo, NY, USA
| | - Andy Tse
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Nicholas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | | | - Raymond Cha
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA.
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10
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Smith NM, Chen L, Boissonneault KR, Lodise T, Holden PN, Bulitta JB, Bonomo RA, Kreiswirth BN, Tsuji BT. 1325. Things that go Bump in the Night: Combating Klebsiella pneumoniae co-producing New Delhi metallo-beta-lactamase (NDM) and Mobile Colistin Resistance (MCR). Open Forum Infect Dis 2020. [PMCID: PMC7777449 DOI: 10.1093/ofid/ofaa439.1507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background The scourge of MBLs among Gram negatives, such New Delhi Metallo-beta-lactamase-producing Klebsiella pneumoniae, has resulted in an overwhelming need for new treatmens. Worryingly, additional acquisition of plasmid-mediated polymyxin resistance through the mcr gene can produce strains resistant to all last line agents. The novel combination of aztreonam (ATM, which is not an MBL substrate) with avibactam (AVI, to inhibit extended spectrum beta-lactamases that inactivate ATM) has been proposed to restore ATM activity. Methods K. pneumoniae SZ04 harboring blaNDM-5, blaCTX-M-55, and mcr-1 (MICATM = 128 mg/L, MICPolymyxin B = 4 mg/L, MICAmikacin = 1 mg/L, MICceftazidime/avibactam > 16/4 mg/L) was studied at two initial inoculum (106 and 108 cfu/mL) over 24h in static time kills (SCTK). Concentration arrays of 2-, 3-, and 4-drug combinations of low- and package insert-dose polymyxin B (PMB) ± low- and package insert-dose amikacin (AMI) ± package insert dosing of ATM/AVI were simulated in > 200 individual arms of SCTK. Data were summarized using the Log Ratio Area (LRA) which is calculated by integrating the area under the bacterial killing curve, normalizing to the growth control, then log-transforming. A Hill-type function was fit to the data in order to determine the maximum effect (Emax) and drug concentration for 50% effect (EC50). Results When simulating the maximum free concentration of amikacin 15 mg/kg (52 mg/L) in combination with package insert concentrations of ATM/AVI, there was a marked reduction of 3.22 in the LRA compared to the growth control for the 108 cfu/mL starting inocula. Combining ATM with low amikacin (0.813 mg/L) and polymyxin B (0.125 mg/L) resulted in a reduction in LRA of 4.32 at 106 cfu/mL. Model fitting results showed a statistically significant difference in EC50 to amikacin between low and high inocula at 1.24 and 18.1 mg/L, respectively. Combination of AMI with low-concentration PMB (0.125 mg/L) resulted in an increase in the Emax of amikacin to -5.68. Conclusion The use of ATM/AVI combinations is a promising option against MBL and MCR co-producing K. pneumoniae. Low-dose strategies of polymyxin or amikacin dosing in combination with ATM/AVI is merits further testing for future translation to the clinical setting to improve efficacy and optimize treatment. Disclosures Thomas Lodise, PharmD, PhD, Paratek Pharmaceuticals, Inc. (Consultant) Robert A. Bonomo, MD, Entasis, Merck, Venatorx (Research Grant or Support)
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Affiliation(s)
- Nicholas M Smith
- University at Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, New York
| | - Liang Chen
- Hackensack-Meridian Health Center for Discovery and Innovation, Nutley, NJ, USA, Nutley, New Jersey
| | | | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY
| | - Patricia N Holden
- University at Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, New York
| | | | | | | | - Brian T Tsuji
- University at Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, New York
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11
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Hua X, Li C, Pogue JM, Sharma VS, Karaiskos I, Kaye KS, Tsuji BT, Bergen PJ, Zhu Y, Song J, Li J. Correction: ColistinDose, a Mobile App for Determining Intravenous Dosage Regimens of Colistimethate in Critically Ill Adult Patients: Clinician-Centered Design and Development Study. JMIR Mhealth Uhealth 2020; 8:e26593. [PMID: 33338026 PMCID: PMC7775816 DOI: 10.2196/26593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Xueliang Hua
- Independent ResearcherSanta Clara, CAUnited States
| | - Chen Li
- Department of Biochemistry and Molecular BiologyMonash UniversityMelbourneAustralia
- Infection and Immunity ProgramBiomedicine Discovery InstituteMonash UniversityMelbourneAustralia
- Institute of Molecular Systems BiologyDepartment of BiologyETH ZurichZurichSwitzerland
| | - Jason M Pogue
- Department of Clinical PharmacyUniversity of Michigan College of PharmacyAnn Arbor, MIUnited States
| | - Varun S Sharma
- Institute of Molecular Systems BiologyDepartment of BiologyETH ZurichZurichSwitzerland
| | - Ilias Karaiskos
- 1st Internal Medicine and Infectious Diseases DepartmentHygeia HospitalMarousiGreece
| | - Keith S Kaye
- Department of Internal MedicineUniversity of Michigan Medical SchoolAnn Arbor, MIUnited States
| | - Brian T Tsuji
- Laboratory for Antimicrobial DynamicsNYS Center of Excellence in Bioinformatics & Life SciencesBuffalo, NYUnited States
- School of Pharmacy and Pharmaceutical SciencesUniversity at BuffaloBuffalo, NYUnited States
| | - Phillip J Bergen
- Infection and Immunity ProgramBiomedicine Discovery InstituteMonash UniversityMelbourneAustralia
- Department of MicrobiologyMonash UniversityMelbourneAustralia
| | - Yan Zhu
- Infection and Immunity ProgramBiomedicine Discovery InstituteMonash UniversityMelbourneAustralia
- Department of MicrobiologyMonash UniversityMelbourneAustralia
| | - Jiangning Song
- Department of Biochemistry and Molecular BiologyMonash UniversityMelbourneAustralia
- Infection and Immunity ProgramBiomedicine Discovery InstituteMonash UniversityMelbourneAustralia
- Monash Centre for Data ScienceFaculty of Information TechnologyMonash UniversityMelbourneAustralia
| | - Jian Li
- Infection and Immunity ProgramBiomedicine Discovery InstituteMonash UniversityMelbourneAustralia
- Department of MicrobiologyMonash UniversityMelbourneAustralia
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12
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Hua X, Li C, Pogue JM, Sharma VS, Karaiskos I, Kaye KS, Tsuji BT, Bergen PJ, Zhu Y, Song J, Li J. ColistinDose, a Mobile App for Determining Intravenous Dosage Regimens of Colistimethate in Critically Ill Adult Patients: Clinician-Centered Design and Development Study. JMIR Mhealth Uhealth 2020; 8:e20525. [PMID: 33325835 PMCID: PMC7748388 DOI: 10.2196/20525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 10/28/2020] [Indexed: 01/01/2023] Open
Abstract
Background Determining a suitable dose of intravenous colistimethate is challenging because of complicated pharmacokinetics, confusing terminology, and the potential for renal toxicity. Only recently have reliable pharmacokinetic/pharmacodynamic data and dosing recommendations for intravenous colistimethate become available. Objective The aim of this work was to develop a clinician-friendly, easy-to-use mobile app incorporating up-to-date dosing recommendations for intravenous colistimethate in critically ill adult patients. Methods Swift programming language and common libraries were used for the development of an app, ColistinDose, on the iPhone operating system (iOS; Apple Inc). The compatibility among different iOS versions and mobile devices was validated. Dosing calculations were based on equations developed in our recent population pharmacokinetic study. Recommended doses generated by the app were validated by comparison against doses calculated manually using the appropriate equations. Results ColistinDose provides 3 major functionalities, namely (1) calculation of a loading dose, (2) calculation of a daily dose based on the renal function of the patient (including differing types of renal replacement therapies), and (3) retrieval of historical calculation results. It is freely available at the Apple App Store for iOS (version 9 and above). Calculated doses accurately reflected doses recommended in patients with varying degrees of renal function based on the published equations. ColistinDose performs calculations on a local mobile device (iPhone or iPad) without the need for an internet connection. Conclusions With its user-friendly interface, ColistinDose provides an accurate and easy-to-use tool for clinicians to calculate dosage regimens of intravenous colistimethate in critically ill patients with varying degrees of renal function. It has significant potential to avoid the prescribing errors and patient safety issues that currently confound the clinical use of colistimethate, thereby optimizing patient treatment.
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Affiliation(s)
- Xueliang Hua
- Independent Researcher, Santa Clara, CA, United States
| | - Chen Li
- Department of Biochemistry and Molecular Biology, Monash University, Melbourne, Australia.,Infection and Immunity Program, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, United States
| | - Varun S Sharma
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
| | - Ilias Karaiskos
- 1st Internal Medicine and Infectious Diseases Department, Hygeia Hospital, Marousi, Greece
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Brian T Tsuji
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, United States.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Phillip J Bergen
- Infection and Immunity Program, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Department of Microbiology, Monash University, Melbourne, Australia
| | - Yan Zhu
- Infection and Immunity Program, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Department of Microbiology, Monash University, Melbourne, Australia
| | - Jiangning Song
- Department of Biochemistry and Molecular Biology, Monash University, Melbourne, Australia.,Infection and Immunity Program, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Monash Centre for Data Science, Faculty of Information Technology, Monash University, Melbourne, Australia
| | - Jian Li
- Infection and Immunity Program, Biomedicine Discovery Institute, Monash University, Melbourne, Australia.,Department of Microbiology, Monash University, Melbourne, Australia
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13
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Aye SM, Galani I, Yu H, Wang J, Chen K, Wickremasinghe H, Karaiskos I, Bergen PJ, Zhao J, Velkov T, Giamarellou H, Lin YW, Tsuji BT, Li J. Polymyxin Triple Combinations against Polymyxin-Resistant, Multidrug-Resistant, KPC-Producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2020; 64:e00246-20. [PMID: 32393492 PMCID: PMC7526826 DOI: 10.1128/aac.00246-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023] Open
Abstract
Resistance to polymyxin antibiotics is increasing. Without new antibiotic classes, combination therapy is often required. We systematically investigated bacterial killing with polymyxin-based combinations against multidrug-resistant (including polymyxin-resistant), carbapenemase-producing Klebsiella pneumoniae Monotherapies and double- and triple-combination therapies were compared to identify the most efficacious treatment using static time-kill studies (24 h, six isolates), an in vitro pharmacokinetic/pharmacodynamic model (IVM; 48 h, two isolates), and the mouse thigh infection model (24 h, six isolates). In static time-kill studies, all monotherapies (polymyxin B, rifampin, amikacin, meropenem, or minocycline) were ineffective. Initial bacterial killing was enhanced with various polymyxin B-containing double combinations; however, substantial regrowth occurred in most cases by 24 h. Most polymyxin B-containing triple combinations provided greater and more sustained killing than double combinations. Standard dosage regimens of polymyxin B (2.5 mg/kg of body weight/day), rifampin (600 mg every 12 h), and amikacin (7.5 mg/kg every 12 h) were simulated in the IVM. Against isolate ATH 16, no viable bacteria were detected across 5 to 25 h with triple therapy, with regrowth to ∼2-log10 CFU/ml occurring at 48 h. Against isolate BD 32, rapid initial killing of ∼3.5-log10 CFU/ml at 5 h was followed by a slow decline to ∼2-log10 CFU/ml at 48 h. In infected mice, polymyxin B monotherapy (60 mg/kg/day) generally was ineffective. With triple therapy (polymyxin B at 60 mg/kg/day, rifampin at 120 mg/kg/day, and amikacin at 300 mg/kg/day), at 24 h there was an ∼1.7-log10 CFU/thigh reduction compared to the starting inoculum for all six isolates. Our results demonstrate that the polymyxin B-rifampin-amikacin combination significantly enhanced in vitro and in vivo bacterial killing, providing important information for the optimization of polymyxin-based combinations in patients.
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Affiliation(s)
- Su Mon Aye
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Irene Galani
- Fourth Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Heidi Yu
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Jiping Wang
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Ke Chen
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Hasini Wickremasinghe
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Ilias Karaiskos
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Phillip J Bergen
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Jinxin Zhao
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Tony Velkov
- Department of Pharmacology & Therapeutics, School of Biomedical Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Helen Giamarellou
- First Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Yu-Wei Lin
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, NYS Centre of Excellence in Bioinformatics & Life Sciences, Buffalo, New York, USA
| | - Jian Li
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
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14
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Onufrak NJ, Smith NM, Satlin MJ, Bulitta JB, Tan X, Holden PN, Nation RL, Li J, Forrest A, Tsuji BT, Bulman ZP. In pursuit of the triple crown: mechanism-based pharmacodynamic modelling for the optimization of three-drug combinations against KPC-producing Klebsiella pneumoniae. Clin Microbiol Infect 2020; 26:1256.e1-1256.e8. [PMID: 32387437 DOI: 10.1016/j.cmi.2020.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/30/2020] [Accepted: 04/19/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Optimal combination therapy for Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) is unknown. The present study sought to characterize the pharmacodynamics (PD) of polymyxin B (PMB), meropenem (MEM) and rifampin (RIF) alone and in combination using a hollow fibre infection model (HFIM) coupled with mechanism-based modelling (MBM). METHODS A 10-day HFIM was utilized to simulate human pharmacokinetics (PK) of various PMB, MEM and RIF dosing regimens against a clinical KPC-Kp isolate, with total and resistant subpopulations quantified to capture PD response. A MBM was developed to characterize bacterial subpopulations and synergy between agents. Simulations using the MBM and published population PK models were employed to forecast the bacterial time course and the extent of its variability in infected patients for three-drug regimens. RESULTS In the HFIM, a PMB single-dose ('burst') regimen of 5.53 mg/kg combined with MEM 8 g using a 3-hr prolonged infusion every 8 hr and RIF 600 mg every 24 hr resulted in bacterial counts below the quantitative limit within 24 hr and remained undetectable throughout the 10-day experiment. The final MBM consisted of two bacterial subpopulations of differing PMB and MEM joint susceptibility and the ability to form a non-replicating, tolerant subpopulation. Synergistic interactions between PMB, MEM and RIF were well quantified, with the MBM providing adequate capture of the observed data. DISCUSSION An in vitro-in silico approach answers questions related to PD optimization as well as overall feasibility of combination therapy against KPC-Kp, offering crucial insights in the absence of clinical trials.
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Affiliation(s)
- N J Onufrak
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Institute for Clinical Pharmacodynamics, Inc., Schenectady, NY, USA.
| | - N M Smith
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA
| | - M J Satlin
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - J B Bulitta
- Department of Pharmacotherapy & Translational Research, University of Florida, Gainesville, FL, USA
| | - X Tan
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - P N Holden
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA
| | - R L Nation
- Drug Delivery Disposition & Dynamics, Monash University, Melbourne, Victoria, Australia
| | - J Li
- Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - A Forrest
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - B T Tsuji
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA
| | - Z P Bulman
- Department of Pharmacy Practice, University at Buffalo, Buffalo, NY, USA; Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA.
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15
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Tsuji BT, Pogue JM, Zavascki AP, Paul M, Daikos GL, Forrest A, Giacobbe DR, Viscoli C, Giamarellou H, Karaiskos I, Kaye D, Mouton JW, Tam VH, Thamlikitkul V, Wunderink RG, Li J, Nation RL, Kaye KS. International Consensus Guidelines for the Optimal Use of the Polymyxins: Endorsed by the American College of Clinical Pharmacy (ACCP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), International Society for Anti-infective Pharmacology (ISAP), Society of Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). Pharmacotherapy 2020; 39:10-39. [PMID: 30710469 DOI: 10.1002/phar.2209] [Citation(s) in RCA: 488] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The polymyxin antibiotics colistin (polymyxin E) and polymyxin B became available in the 1950s and thus did not undergo contemporary drug development procedures. Their clinical use has recently resurged, assuming an important role as salvage therapy for otherwise untreatable gram-negative infections. Since their reintroduction into the clinic, significant confusion remains due to the existence of several different conventions used to describe doses of the polymyxins, differences in their formulations, outdated product information, and uncertainties about susceptibility testing that has led to lack of clarity on how to optimally utilize and dose colistin and polymyxin B. We report consensus therapeutic guidelines for agent selection and dosing of the polymyxin antibiotics for optimal use in adult patients, as endorsed by the American College of Clinical Pharmacy (ACCP), Infectious Diseases Society of America (IDSA), International Society of Anti-Infective Pharmacology (ISAP), Society for Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) endorses this document as a consensus statement. The overall conclusions in the document are endorsed by the European Committee on Antimicrobial Susceptibility Testing (EUCAST). We established a diverse international expert panel to make therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, polymyxin agent selection, dosing, dosage adjustment and monitoring of colistin and polymyxin B, use of polymyxin-based combination therapy, intrathecal therapy, inhalation therapy, toxicity, and prevention of renal failure. The treatment guidelines provide the first ever consensus recommendations for colistin and polymyxin B therapy that are intended to guide optimal clinical use.
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Affiliation(s)
- Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | | | - Alexandre P Zavascki
- Department of Internal Medicine, Medical School, Universidade Federal, do Rio Grande do Sul, Porto Alegre, Brazil.,Infectious Diseases Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - George L Daikos
- First Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Alan Forrest
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniele R Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, Ospedale Policlinico San Martino-Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia, Genoa, Italy.,Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Helen Giamarellou
- 1st Department of Internal Medicine, Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Ilias Karaiskos
- 1st Department of Internal Medicine, Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Donald Kaye
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Vincent H Tam
- University of Houston College of Pharmacy, Houston, Texas
| | - Visanu Thamlikitkul
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jian Li
- Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, Michigan
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16
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Landersdorfer CB, Wang J, Wirth V, Chen K, Kaye KS, Tsuji BT, Li J, Nation RL. Pharmacokinetics/pharmacodynamics of systemically administered polymyxin B against Klebsiella pneumoniae in mouse thigh and lung infection models. J Antimicrob Chemother 2019; 73:462-468. [PMID: 29149294 DOI: 10.1093/jac/dkx409] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/09/2017] [Indexed: 11/14/2022] Open
Abstract
Background The pharmacokinetic/pharmacodynamic (PK/PD) relationship for polymyxin B against Klebsiella pneumoniae infections is not known. Methods Dose-fractionation studies with subcutaneous polymyxin B were conducted in neutropenic mice in which infection with three strains of K. pneumoniae had been produced in thighs or lungs. Dosing (thigh infection 0.5-120 mg/kg/day; lung infection 5-120 mg/kg/day) commenced 2 h after inoculation, and bacterial burden was measured 24 h later. Plasma exposure measures for unbound polymyxin B were from population pharmacokinetic analysis of single doses and plasma protein binding by ultracentrifugation. The inhibitory sigmoid dose-effect model was employed to determine the relationship between exposure and efficacy. Antibacterial activities of polymyxin B and colistin against thigh infection were compared at equimolar doses generating exposures resulting in maximal antibacterial activity. Results The pharmacokinetics of polymyxin B were well described by a model comprising parallel linear and saturable pathways for absorption and elimination. Plasma binding of polymyxin B was constant (P > 0.05) over the range ∼0.9-37 mg/L; average (±SD) percentage bound was 91.4 ± 1.65. In thigh infection, antibacterial effect was well correlated with fAUC/MIC (R2 = 0.89). Target values of fAUC/MIC for stasis and 1 log10 kill were 1.22-13.5 and 3.72-28.0, respectively; 2 log10 kill was not achieved for any strain, even at the highest tolerated dose. There was no difference (P > 0.05) in antibacterial activity between polymyxin B and colistin with equimolar doses. It was not possible to achieve stasis in lung infection, even at the highest dose tolerated by mice. Conclusions The results will assist in the design of optimized dosage regimens of polymyxin B.
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Affiliation(s)
- Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo State University of New York, Buffalo, NY, USA
| | - Jiping Wang
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Veronika Wirth
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Ke Chen
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo State University of New York, Buffalo, NY, USA.,Laboratory for Antimicrobial Pharmacodynamics, NYS Centre of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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17
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Sumon ZE, Berenson CS, Sellick JA, Bulman ZP, Tsuji BT, Mergenhagen KA. Successful cure of daptomycin-non-susceptible, vancomycin-intermediate Staphylococcus aureus prosthetic aortic valve endocarditis directed by synergistic in vitro time-kill study. Infect Dis (Lond) 2019; 51:287-292. [PMID: 30760062 DOI: 10.1080/23744235.2018.1533646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Infectious complications following surgical valve replacements are extremely difficult to treat, often requiring prolonged antimicrobials therapy with or without surgery. Vancomycin-intermediate Staphylococcus aureus is an infrequent pathogen, with an estimated prevalence of less than 0.3%, but presents even greater challenges. We report a case of successful cure of daptomycin-non-susceptible and vancomycin-intermediate Staphylococcus aureus prosthetic valve endocarditis using an eight-week course of combination antimicrobial therapy. Using time-kill study, the combination of daptomycin plus ceftaroline and rifampin resulted in a greater than 4 log reduction of bacterial growth at 24 hours. This antimicrobial combination was used for a total of eight weeks with a successful outcome.
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Affiliation(s)
- Zarchi E Sumon
- a Department of Medicine, Infectious Diseases Division , University at Buffalo, Jacobs School of Medicine and Biomedical Sciences , Buffalo , NY , USA
| | - Charles S Berenson
- a Department of Medicine, Infectious Diseases Division , University at Buffalo, Jacobs School of Medicine and Biomedical Sciences , Buffalo , NY , USA.,b Department of Medicine, Infectious Diseases Division , Veterans Administration Western New York Healthcare System , Buffalo , NY , USA
| | - John A Sellick
- a Department of Medicine, Infectious Diseases Division , University at Buffalo, Jacobs School of Medicine and Biomedical Sciences , Buffalo , NY , USA.,b Department of Medicine, Infectious Diseases Division , Veterans Administration Western New York Healthcare System , Buffalo , NY , USA
| | - Zackery P Bulman
- c Laboratory for Antimicrobial Pharmacodynamics , University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Brian T Tsuji
- c Laboratory for Antimicrobial Pharmacodynamics , University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Kari A Mergenhagen
- d Department of Pharmacy , Veterans Administration Western New York Healthcare System , Buffalo , NY , USA
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18
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Abstract
Combinations of antimicrobial agents are often used in the management of infectious diseases. Antimicrobial agents used as part of combination therapy are often selected empirically. As regrowth and the emergence of polymyxin (either colistin or polymyxin B) resistance has been observed with polymyxin monotherapy, polymyxin combination therapy has been suggested as a possible means by which to increase antimicrobial activity and reduce the development of resistance. This chapter provides an overview of preclinical and clinical investigations of CMS/colistin and polymyxin B combination therapy. In vitro data and animal model data suggests a potential clinical benefit with many drug combinations containing clinically achievable concentrations of polymyxins, even when resistance to one or more of the drugs in combination is present and including antibiotics normally inactive against Gram-negative organisms. The growing body of data on the emergence of polymyxin resistance with monotherapy lends theoretical support to a benefit with combination therapy. Benefits include enhanced bacterial killing and a suppression of polymyxin resistant subpopulations. However, the complexity of the critically ill patient population, and high rates of treatment failure and death irrespective of infection-related outcome make demonstrating a potential benefit for polymyxin combinations extremely challenging. Polymyxin combination therapy in the clinic remains a heavily debated and controversial topic. When combinations are selected, optimizing the dosage regimens for the polymyxin and the combinatorial agent is critical to ensure that the benefits outweigh the risk of the development of toxicity. Importantly, patient characteristics, pharmacokinetics, the site of infection, pathogen and resistance mechanism must be taken into account to define optimal and rational polymyxin combination regimens in the clinic.
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Affiliation(s)
- Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Parkville Campus, Melbourne, VIC, Australia.
| | - Nicholas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Tyler B Bedard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Zackery P Bulman
- University of Illinois Chicago, College of Pharmacy, Chicago, IL, USA
| | - Raymond Cha
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
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19
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Lodise TP, Smith NM, Holden P, O’Donnell JN, Bedard T, Bonomo RA, Tsuji BT. 1385. Efficacy of Ceftazidime–Avibactam in Combination with Aztreonam (COMBINE): Solutions for Metallo-β-Lactamase Producing-Enterobacteriaceae (MBL). Open Forum Infect Dis 2018. [PMCID: PMC6252595 DOI: 10.1093/ofid/ofy210.1216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Novel antibiotics will not be available to combat the threat of MBLs until 2021. One strategy to overcome MBLs is to combine CAZ-AVI + ATM. ATM is not hydrolysed by MBLs and AVI offers protection for ATM and CAZ vs. ESBLs and AmpCs. The combination also offers a theoretical advantage to inactivating multiple PBPs by using dual β-lactam therapy. Our objective was to define optimal dosing profiles for clinical use of ATM to add to CAZ-AVI in the hollow fiber infection model (HFIM).
Methods
E. coli ARLG-1013 (blaNDM-1, blaCTX-M, blaCMY, blaTEM) and K. pneumoniae ARLG-1002 (blaNDM-1, blaCTXM-15, blaDHA, blaSHV, blaTEM) were studied at a 7.5 log10 CFU/mL in the HFIM. Human dosing regimens of CAZ-AVI 2 g/0.5 g q8h (2 hours infusion) and ATM 2 g q8h (2 hours infusion) were simulated in alone and in combination. Continuous infusion (CI) regimens of CAZ-AVI 6 g/1.5 g per day CI + ATM 6 g/day CI and q8h regimens were given simultaneously and sequentially (ATM given 2 hours after CAZ-AVI). Resistant subpopulations were profiled on single (ATM), double (CAZ/AVI) and triple (ATM/CAZ/AVI) drug plates containing 2/2/4, 8/8/4, or 32/32/4 mg/L over 7 days.
Results
Against E. coli ARLG-1013, ATM alone mirrored growth control (+3.14 at 168 hours) (All units Log10 CFU/mL change vs. baseline). CAZ-AVI alone showed some intrinsic activity (+1.19 at 168 hours). CAZ-AVI 2g/0.5g q8h (2 hours infusion) + ATM 2g q8h (2 hours infusion) given sequentially resulted regrowth and stasis (+0.34 at 168 hours) vs. the simultaneous combination resulted initial bactericidal activity (-3.53 killing within 28 hours) which regrew at (−0.90 at 168 hours). All CI regimens were effective. CAZ-AVI 6g/1.5g per day CI + ATM 6 g/day CI resulted in dramatic killing (up to -5.78 killing within 50 hours) which was sustained (up to -3.90 killing at 168 hours). Comparing the infusion time of CAZ/AVI + ATM on bacterial killing: CI + CI > 2 hours + 2 hours > 30 minutes + 30 minutes. CI + CI resulted in complete suppression of resistance over 7 days. Against K. pneumoniae ARLG-1002, CAZ/AVI (CI) + ATM (CI) resulted in early synergy (>5.0 log killing within 24 hours) and suppression of resistance for more than 168 hours.
Conclusion
The combination of CAZ-AVI + ATM was highly synergistic and suppressed resistance against MBL Enterobacteriaceae in HFIM. ATM efficacy in combination was driven by %T > MIC. A Phase I study will assess safety to provide patients a critically important solution against “untreatable” Gram negatives.
Disclosures
T. P. Lodise, paratek: Consultant and Scientific Advisor, Consulting fee. B. T. Tsuji, Nabriva: Consultant, Consulting fee. Achaogen: Grant Investigator, Educational grant. ARLG, DCRI: Grant Investigator, Grant recipient. NIH/NIAID: Grant Investigator, Grant recipient.
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20
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Bulman ZP, Zhao M, Satlin MJ, Chen L, Kreiswirth BN, Walsh TJ, Nation RL, Li J, Tsuji BT. Polymyxin B and fosfomycin thwart KPC-producing Klebsiella pneumoniae in the hollow-fibre infection model. Int J Antimicrob Agents 2018; 52:114-118. [PMID: 29486233 DOI: 10.1016/j.ijantimicag.2018.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 01/30/2023]
Abstract
Polymyxin B (PMB) and fosfomycin are two 'old' antibiotics that consistently maintain activity against Klebsiella pneumoniae carbapenemase (KPC)-producing organisms based on in vitro susceptibility testing. However, the use of each antibiotic in monotherapy has been associated with high rates of treatment failure. Therefore, the objective of this study was to investigate the combinatorial pharmacodynamics of PMB and fosfomycin against KPC-producing K. pneumoniae (KPC-Kp). PMB front-loading (3.33 mg/kg for one dose, followed by 1.43 mg/kg every 12 h starting 12 h later) and burst (5.53 mg/kg for one dose, with no subsequent doses) simulated dosing regimens were explored in combination with fosfomycin (4 g every 8 h) against KPC-2-producing K. pneumoniae ST258 in a hollow-fibre infection model over 120 h. Population analysis profiles were used to track the temporal PMB and fosfomycin resistance profiles. Against isolate KPC-Kp 9A (PMB MIC = 0.5 mg/L; fosfomycin MIC ≤ 8 mg/L), monotherapies resulted in >3 log10 CFU/mL killing within 3 h but re-growth and proliferation of resistant subpopulations within 48 h. PMB combinations with fosfomycin demonstrated rapid bacterial killing (>6 log10 CFU/mL reductions) while preventing propagation of PMB and fosfomycin resistance. Against isolate KPC-Kp 24A with a higher fosfomycin MIC (polymyxin B MIC = 0.5 mg/L; fosfomycin MIC = 32 mg/L), a PMB burst and fosfomycin combination caused a >6 log10 CFU/mL reduction within 1 h, although bacterial re-growth occurred with the amplification of fosfomycin-resistant subpopulations. PMB in combination with fosfomycin may provide a practicable treatment strategy against KPC-Kp and warrants further investigation.
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Affiliation(s)
- Zackery P Bulman
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
| | - Miao Zhao
- Institute of Antibiotics, Huashan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China
| | - Michael J Satlin
- Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Liang Chen
- Public Health Research Institute, New Jersey Medical School-Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Barry N Kreiswirth
- Public Health Research Institute, New Jersey Medical School-Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Thomas J Walsh
- Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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21
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Smith NM, Bulman ZP, Sieron AO, Bulitta JB, Holden PN, Nation RL, Li J, Wright GD, Tsuji BT. Pharmacodynamics of dose-escalated 'front-loading' polymyxin B regimens against polymyxin-resistant mcr-1-harbouring Escherichia coli. J Antimicrob Chemother 2018; 72:2297-2303. [PMID: 28505268 DOI: 10.1093/jac/dkx121] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/24/2017] [Indexed: 01/09/2023] Open
Abstract
Objectives Gram-negative bacteria harbouring the mcr-1 plasmid are resistant to the 'last-line' polymyxins and have been reported worldwide. Our objective was to define the impact of increasing the initial polymyxin B dose intensity against an mcr-1 -harbouring strain to delineate the impact of plasmid-mediated polymyxin resistance on the dynamics of bacterial killing and resistance. Methods A hollow fibre infection model (HFIM) was used to simulate polymyxin B regimens against an mcr-1 -harbouring Escherichia coli (MIC 8 mg/L) over 10 days. Four escalating polymyxin B 'front-loading' regimens (3.33, 6.66, 13.3 or 26.6 mg/kg for one dose followed by 1.43 mg/kg every 12 h starting 12 h later) simulating human pharmacokinetics were utilized in the HFIM. A mechanism-based, mathematical model was developed using S-ADAPT to characterize bacterial killing. Results The 3.33 mg/kg 'front-loading' regimen resulted in regrowth mirroring the growth control. The 6.66, 13.3 and 26.6 mg/kg 'front-loading' regimens resulted in maximal bacterial reductions of 1.91, 3.79 and 6.14 log 10 cfu/mL, respectively. Irrespective of the early polymyxin B exposure (24 h AUC), population analysis profiles showed similar growth of polymyxin B-resistant subpopulations. The HFIM data were well described by the mechanism-based model integrating three subpopulations (susceptible, intermediate and resistant). Compared with the susceptible subpopulation of mcr-1 -harbouring E. coli , the resistant subpopulation had an approximately 10-fold lower rate of killing due to polymyxin B treatment. Conclusions Manipulating initial dose intensity of polymyxin B was not able to overcome plasmid-mediated resistance due to mcr-1 in E. coli . This reinforces the need to develop new combinatorial strategies to combat these highly resistant Gram-negative bacteria.
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Affiliation(s)
- Nicholas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,New York State Center of Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Zackery P Bulman
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,New York State Center of Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Arthur O Sieron
- Michael G. DeGroote Institute for Infectious Disease Research and the Department of Biochemistry and Biomedical Sciences, McMaster University, Ontario, Canada
| | - Jürgen B Bulitta
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,New York State Center of Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Gerard D Wright
- Michael G. DeGroote Institute for Infectious Disease Research and the Department of Biochemistry and Biomedical Sciences, McMaster University, Ontario, Canada
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,New York State Center of Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
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22
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Lenhard JR, Thamlikitkul V, Silveira FP, Garonzik SM, Tao X, Forrest A, Soo Shin B, Kaye KS, Bulitta JB, Nation RL, Li J, Tsuji BT. Polymyxin-resistant, carbapenem-resistant Acinetobacter baumannii is eradicated by a triple combination of agents that lack individual activity. J Antimicrob Chemother 2018; 72:1415-1420. [PMID: 28333347 DOI: 10.1093/jac/dkx002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 12/29/2016] [Indexed: 12/13/2022] Open
Abstract
Objectives The emergence of polymyxin resistance threatens to leave clinicians with few options for combatting drug-resistant Acinetobacter baumannii . The objectives of the current investigation were to define the in vitro emergence of polymyxin resistance and identify a combination regimen capable of eradicating A. baumannii with no apparent drug susceptibilities. Methods Two clonally related, paired, A. baumannii isolates collected from a critically ill patient who developed colistin resistance while receiving colistin methanesulfonate in a clinical population pharmacokinetic study were evaluated: an A. baumannii isolate collected before (03-149.1, polymyxin-susceptible, MIC 0.5 mg/L) and an isolate collected after (03-149.2, polymyxin-resistant, MIC 32 mg/L, carbapenem-resistant, ampicillin/sulbactam-resistant). Using the patient's unique pharmacokinetics, the patient's actual regimen received in the clinic was recreated in a hollow-fibre infection model (HFIM) to track the emergence of polymyxin resistance against 03-149.1. A subsequent HFIM challenged the pan-resistant 03-149.2 isolate against polymyxin B, meropenem and ampicillin/sulbactam alone and in two-drug and three-drug combinations. Results Despite achieving colistin steady-state targets of an AUC 0-24 >60 mg·h/L and C avg of >2.5 mg/L, colistin population analysis profiles confirmed the clinical development of polymyxin resistance. During the simulation of the patient's colistin regimen in the HFIM, no killing was achieved in the HFIM and amplification of polymyxin resistance was observed by 96 h. Against the polymyxin-resistant isolate, the triple combination of polymyxin B, meropenem and ampicillin/sulbactam eradicated the A. baumannii by 96 h in the HFIM, whereas monotherapies and double combinations resulted in regrowth. Conclusions To combat polymyxin-resistant A. baumannii , the triple combination of polymyxin B, meropenem and ampicillin/sulbactam holds great promise.
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Affiliation(s)
- Justin R Lenhard
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences and School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Visanu Thamlikitkul
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fernanda P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samira M Garonzik
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences and School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | - Xun Tao
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Alan Forrest
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences and School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Beom Soo Shin
- School of Pharmacy, Sungkyunkwan University, Gyeonggi-do, Korea
| | - Keith S Kaye
- Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jürgen B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences and School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.,Veterans Administration Western New York Healthcare System, Buffalo, NY, USA
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Zhao M, Bulman ZP, Lenhard JR, Satlin MJ, Kreiswirth BN, Walsh TJ, Marrocco A, Bergen PJ, Nation RL, Li J, Zhang J, Tsuji BT. Pharmacodynamics of colistin and fosfomycin: a 'treasure trove' combination combats KPC-producing Klebsiella pneumoniae. J Antimicrob Chemother 2017; 72:1985-1990. [PMID: 28444224 PMCID: PMC5890748 DOI: 10.1093/jac/dkx070] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/25/2017] [Accepted: 02/12/2017] [Indexed: 12/26/2022] Open
Abstract
Objectives KPC-producing Klebsiella pneumoniae are an emerging public health problem around the globe. We defined the combinatorial pharmacodynamics and ability to suppress resistance of two 'old' antibiotics, fosfomycin and colistin, in time-kill experiments and hollow-fibre infection models (HFIM). Methods Two KPC-2-producing K. pneumoniae isolates were used: one susceptible to both colistin and fosfomycin (KPC 9A: MIC colistin 0.25 mg/L and MIC fosfomycin ≤8 mg/L) and the other resistant to colistin and susceptible to fosfomycin (KPC 5A: MIC colistin 64 mg/L and MIC fosfomycin 32 mg/L). Time-kill experiments assessed an array of colistin and fosfomycin concentrations against both isolates. Colistin and fosfomycin pharmacokinetics from critically ill patients were simulated in the HFIM to define the pharmacodynamic activity of humanized regimens over 5 days against KPC 9A. Results In time-kill experiments, synergy was demonstrated for all colistin/fosfomycin combinations containing >8 mg/L fosfomycin against the double-susceptible KPC strain, 9A. Synergy versus KPC strain 5A was only achieved at the highest concentrations of colistin (4 mg/L) and fosfomycin (512 mg/L) at 48 h. In the HFIM, colistin or fosfomycin monotherapies resulted in rapid proliferation of resistant subpopulations; KPC 9A regrew by 24 h. In contrast to the monotherapies, the colistin/fosfomycin combination resulted in a rapid 6.15 log 10 cfu/mL reduction of KPC 9A by 6 h and complete suppression of resistant subpopulations until 120 h. Conclusions Colistin and fosfomycin may represent an important treatment option for KPC-producing K. pneumoniae otherwise resistant to traditional antibiotics.
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Affiliation(s)
- Miao Zhao
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Institute of Antibiotics, Huashan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China
| | - Zackery P. Bulman
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Justin R. Lenhard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | | | | | - Thomas J. Walsh
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Amanda Marrocco
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Phillip J. Bergen
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Roger L. Nation
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jian Li
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China
| | - Brian T. Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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24
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Shafiq I, Bulman ZP, Spitznogle SL, Osorio JE, Reilly IS, Lesse AJ, Parameswaran GI, Mergenhagen KA, Tsuji BT. A combination of ceftaroline and daptomycin has synergistic and bactericidal activity in vitro against daptomycin nonsusceptible methicillin-resistant Staphylococcus aureus (MRSA). Infect Dis (Lond) 2017; 49:410-416. [PMID: 28116950 DOI: 10.1080/23744235.2016.1277587] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
There is an urgent need to optimize therapeutic options in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia who have failed conventional therapy. Two clinical isolates were obtained from a 68-year-old male with persistent MRSA bacteremia before and after the development of daptomycin nonsusceptibility. The pharmacodynamic activity of monotherapies and combinations of ceftaroline, daptomycin, cefoxitin, nafcillin and vancomycin were evaluated in time-kill experiments versus 108 CFU/mL of the pre- and post-daptomycin nonsusceptible MRSA isolates. Cefoxitin, nafcillin and vancomycin alone or in combination with ceftaroline failed to generate prolonged bactericidal activity against the post-daptomycin nonsusceptible isolate whereas a ceftaroline-daptomycin combination resulted in 6, 24 and 48 h log10(CFU/mL) reductions of 3.90, 4.40 and 6.32. Population analysis profiles revealed a daptomycin heteroresistant subpopulation of the pre-daptomycin nonsusceptible MRSA isolate that expanded by >10,000× on daptomycin agar containing 2-16 mg/L in the post-daptomycin nonsusceptible isolate. Daptomycin and ceftaroline combinations may be promising against persistent MRSA bacteremia.
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Affiliation(s)
- Iffat Shafiq
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Zackery P Bulman
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Sarah L Spitznogle
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Justin E Osorio
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Irene S Reilly
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
| | - Alan J Lesse
- b Infectious Diseases Department, Veterans Affairs Western New York Healthcare System , Buffalo , NY , USA
| | - Ganapathi I Parameswaran
- b Infectious Diseases Department, Veterans Affairs Western New York Healthcare System , Buffalo , NY , USA
| | - Kari A Mergenhagen
- b Infectious Diseases Department, Veterans Affairs Western New York Healthcare System , Buffalo , NY , USA
| | - Brian T Tsuji
- a Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences , Buffalo , NY , USA
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25
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Tängdén T, Ramos Martín V, Felton TW, Nielsen EI, Marchand S, Brüggemann RJ, Bulitta JB, Bassetti M, Theuretzbacher U, Tsuji BT, Wareham DW, Friberg LE, De Waele JJ, Tam VH, Roberts JA. The role of infection models and PK/PD modelling for optimising care of critically ill patients with severe infections. Intensive Care Med 2017; 43:1021-1032. [PMID: 28409203 DOI: 10.1007/s00134-017-4780-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/18/2017] [Indexed: 01/14/2023]
Abstract
Critically ill patients with severe infections are at high risk of suboptimal antimicrobial dosing. The pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in these patients differ significantly from the patient groups from whose data the conventional dosing regimens were developed. Use of such regimens often results in inadequate antimicrobial concentrations at the site of infection and is associated with poor patient outcomes. In this article, we describe the potential of in vitro and in vivo infection models, clinical pharmacokinetic data and pharmacokinetic/pharmacodynamic models to guide the design of more effective antimicrobial dosing regimens. Individualised dosing, based on population PK models and patient factors (e.g. renal function and weight) known to influence antimicrobial PK, increases the probability of achieving therapeutic drug exposures while at the same time avoiding toxic concentrations. When therapeutic drug monitoring (TDM) is applied, early dose adaptation to the needs of the individual patient is possible. TDM is likely to be of particular importance for infected critically ill patients, where profound PK changes are present and prompt appropriate antibiotic therapy is crucial. In the light of the continued high mortality rates in critically ill patients with severe infections, a paradigm shift to refined dosing strategies for antimicrobials is warranted to enhance the probability of achieving drug concentrations that increase the likelihood of clinical success.
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Affiliation(s)
- T Tängdén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - V Ramos Martín
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - T W Felton
- Intensive Care Unit, University Hospital of South Manchester, Manchester, UK
| | - E I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - S Marchand
- Inserm U1070, Pole Biologie Santé, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - R J Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, USA
| | - M Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital and University of Udine, Udine, Italy
| | | | - B T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, USA
| | - D W Wareham
- Antimicrobial Research Group, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - L E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - V H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, USA
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia. .,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, Brisbane, QLD, 4029, Australia.
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26
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Bulman Z, Satlin M, Kreiswirth BN, Chen L, Lenhard J, Smith N, Holden P, Tsuji BT. Ceftazidime-Avibactam Combats KPC-2 and KPC-3-Producing Klebsiella pneumoniae ST258: New Pharmacodynamic Insights into the Next Generation of β-Lactam/β-Lactamase Inhibitors. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Barry N. Kreiswirth
- Public Health Research Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - Liang Chen
- Public Health Research Institute, Rutgers University, Newark, NJ
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27
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Tsuji BT, Venuto C, Ma Q, Difrancesco R, Bednasz C, Smith N, Morse G, Talal A. Insights into the Exposure Response Relationship for Ribavirin in the Treatment of Chronic Hepatitis C Virus (HCV) infections. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Qing Ma
- University at Buffalo, Buffalo, NY
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28
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Bulman Z, Mergenhagen K, Lesse A, Parameswaran G, Tsuji BT. Optimizing Antimicrobial Strategies to Combat Invasive Staphylococcus epidermidis Displaying the Small Colony Variant (SCV) Phenotype. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Kari Mergenhagen
- Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY
| | - Alan Lesse
- Infectious Diseases, University at Buffalo/Buffalo Veterans Affairs Medical Center, Buffalo, NY
| | - Ganapathi Parameswaran
- Infectious Diseases, University at Buffalo/Buffalo Veterans Affairs Medical Center, Buffalo, NY
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29
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Brotzki CR, Mergenhagen KA, Bulman ZP, Tsuji BT, Berenson CS. Native valve Proteus mirabilis endocarditis: successful treatment of a rare entity formulated by in vitro synergy antibiotic testing. BMJ Case Rep 2016; 2016:bcr-2016-215956. [PMID: 27797858 DOI: 10.1136/bcr-2016-215956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Infective endocarditis caused by Proteus mirabilis is a rare and poorly reported disease, with no well-defined effective antibiotic regimen. Here, we present a case of P. mirabilis aortic valve endocarditis. We reviewed prior cases and treatment regimens, and devised effective treatment, which was guided by in vitro sensitivity and synergy testing on the pathogen. Our patient survived without complications or the need for a surgical intervention.
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Affiliation(s)
- Caroline R Brotzki
- Department of Medicine, University at Buffalo State University of New York, School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Kari A Mergenhagen
- Department of Pharmacy, Veterans Administration Western New York Healthcare System, Buffalo, New York, USA
| | - Zackery P Bulman
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York, USA
| | - Charles S Berenson
- State University of New York at Buffalo, Buffalo, New York, USA.,Veterans Administration Western New York Healthcare System, Buffalo, NY, USA
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30
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Lenhard JR, Bulitta JB, Connell TD, King-Lyons N, Landersdorfer CB, Cheah SE, Thamlikitkul V, Shin BS, Rao G, Holden PN, Walsh TJ, Forrest A, Nation RL, Li J, Tsuji BT. High-intensity meropenem combinations with polymyxin B: new strategies to overcome carbapenem resistance in Acinetobacter baumannii. J Antimicrob Chemother 2016; 72:153-165. [PMID: 27634916 DOI: 10.1093/jac/dkw355] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/07/2016] [Accepted: 07/26/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The pharmacodynamics of polymyxin/carbapenem combinations against carbapenem-resistant Acinetobacter baumannii (CRAB) are largely unknown. Our objective was to determine whether intensified meropenem regimens in combination with polymyxin B enhance killing and resistance suppression of CRAB. METHODS Time-kill experiments for meropenem and polymyxin B combinations were conducted against three polymyxin B-susceptible (MIC of polymyxin B = 0.5 mg/L) CRAB strains with varying meropenem MICs (ATCC 19606, N16870 and 03-149-1; MIC of meropenem = 4, 16 and 64 mg/L, respectively) at 108 cfu/mL. A hollow-fibre infection model was then used to simulate humanized regimens of polymyxin B and meropenem (2, 4, 6 and 8 g prolonged infusions every 8 h) versus N16870 at 108 cfu/mL over 14 days. New mathematical mechanism-based models were developed using S-ADAPT. RESULTS Time-kill experiments were well described by the mathematical mechanism-based models, with the presence of polymyxin B drastically decreasing the meropenem concentration needed for half-maximal activity against meropenem-resistant populations from 438 to 82.1 (ATCC 19606), 158 to 93.6 (N16870) and 433 to 76.0 mg/L (03-149-1). The maximum killing effect of combination treatment was similar among all three strains despite divergent meropenem MIC values (Emax = 2.13, 2.08 and 2.15; MIC of meropenem = 4, 16 and 64 mg/L, respectively). Escalating the dose of meropenem in hollow-fibre combination regimens from 2 g every 8 h to 8 g every 8 h resulted in killing that progressed from a >2.5 log10 cfu/mL reduction with regrowth by 72 h (2 g every 8 h) to complete eradication by 336 h (8 g every 8 h). CONCLUSION Intensified meropenem dosing in combination with polymyxin B may offer a unique strategy to kill CRAB irrespective of the meropenem MIC.
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Affiliation(s)
- Justin R Lenhard
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.,California Northstate College of Pharmacy, Elk Grove, CA, USA
| | - Jürgen B Bulitta
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA.,Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Terry D Connell
- Department of Microbiology and Immunology and The Witebsky Center for Microbial Pathogenesis and Immunology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Natalie King-Lyons
- Department of Microbiology and Immunology and The Witebsky Center for Microbial Pathogenesis and Immunology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Soon-Ee Cheah
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Visanu Thamlikitkul
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Gauri Rao
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA.,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Thomas J Walsh
- Departments of Pediatrics, Microbiology and Immunology Weill Cornell Medicine, New York, NY, USA
| | - Alan Forrest
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA.,School of Pharmacy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA .,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
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31
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Rees VE, Bulitta JB, Oliver A, Tsuji BT, Rayner CR, Nation RL, Landersdorfer CB. Resistance suppression by high-intensity, short-duration aminoglycoside exposure against hypermutable and non-hypermutable Pseudomonas aeruginosa. J Antimicrob Chemother 2016; 71:3157-3167. [PMID: 27521357 DOI: 10.1093/jac/dkw297] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Hypermutable bacteria are causing a drastic problem via their enhanced ability to become resistant. Our objectives were to compare bacterial killing and resistance emergence between differently shaped tobramycin concentration-time profiles at a given fAUC/MIC, and determine the tobramycin exposure durations that prevent resistance. METHODS Static concentration time-kill studies over 24 h used Pseudomonas aeruginosa WT strains (ATCC 27853 and PAO1) and hypermutable PAOΔmutS. fAUC/MIC values of 36, 72 and 168 were assessed at initial inocula of 106 and 104 cfu/mL (all strains) and 101.2 cfu/mL (PAOΔmutS only) in duplicate. Tobramycin was added at 0 h and removed at 1, 4, 10 or 24 h. Proportions of resistant bacteria and MICs were determined at 24 h. Mechanism-based modelling was conducted. RESULTS For all strains, high tobramycin concentrations over 1 and 4 h resulted in more rapid and extensive initial killing compared with 10 and 24 h exposures at a given fAUC/MIC. No resistance emerged for 1 and 4 h durations of exposure, although extensive regrowth of susceptible bacteria occurred. The 24 h duration of exposure revealed less regrowth, but tobramycin-resistant populations had completely replaced susceptible bacteria by 24 h for the 106 cfu/mL inoculum. The hypermutable PAOΔmutS showed the highest numbers of resistant bacteria. Total and resistant bacterial counts were described well by novel mechanism-based modelling. CONCLUSIONS Extensive resistance emerged for 10 and 24 h durations of exposure, but not for shorter durations. The tobramycin concentration-time profile shape is vital for resistance prevention and should aid the introduction of optimized combination regimens.
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Affiliation(s)
- Vanessa E Rees
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Victoria 3052, Australia
| | - Jürgen B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de Palma, Palma de Mallorca, Spain
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Craig R Rayner
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Victoria 3052, Australia.,d3 medicine LLC, Parsippany, NJ, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Victoria 3052, Australia
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Victoria 3052, Australia .,School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Rao GG, Ly NS, Bulitta JB, Soon RL, San Roman MD, Holden PN, Landersdorfer CB, Nation RL, Li J, Forrest A, Tsuji BT. Polymyxin B in combination with doripenem against heteroresistant Acinetobacter baumannii: pharmacodynamics of new dosing strategies. J Antimicrob Chemother 2016; 71:3148-3156. [PMID: 27494922 DOI: 10.1093/jac/dkw293] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Polymyxin B is being increasingly utilized as a last resort against resistant Gram-negative bacteria. We examined the pharmacodynamics of novel dosing strategies for polymyxin B combinations to maximize efficacy and minimize the emergence of resistance and drug exposure against Acinetobacter baumannii. METHODS The pharmacodynamics of polymyxin B together with doripenem were evaluated in time-kill experiments over 48 h against 108 cfu/mL of two polymyxin-heteroresistant A. baumannii isolates (ATCC 19606 and N16870). Pharmacokinetic/pharmacodynamic relationships were mathematically modelled using S-ADAPT. A hollow-fibre infection model (HFIM) was also used to simulate clinically relevant polymyxin B dosing strategies (traditional, augmented 'front-loaded' and 'burst' regimens), together with doripenem, against an initial inoculum of 109 cfu/mL of ATCC 19606. RESULTS In static time-kill studies, polymyxin B concentrations >4 mg/L in combination with doripenem 25 mg/L resulted in rapid bactericidal activity against both strains with undetectable bacterial counts by 24 h. The mathematical model described the rapid, concentration-dependent killing as subpopulation and mechanistic synergy. In the HFIM, the traditional polymyxin B combination regimen was synergistic, with a >7.5 log10 reduction by 48 h. The polymyxin B 'front-loaded' combination resulted in more rapid and extensive initial killing (>8 log10) within 24 h, which was sustained over 10 days. With only 25% of the cumulative drug exposure, the polymyxin B 'burst' combination demonstrated antibacterial activity similar to traditional and 'front-loaded' combination strategies. The polymyxin B 'front-loaded' and 'burst' combination regimens suppressed the emergence of resistance. CONCLUSIONS Early aggressive dosing regimens for polymyxin combinations demonstrate promise for treatment of heteroresistant A. baumannii infections.
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Affiliation(s)
- Gauri G Rao
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Neang S Ly
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Rachel L Soon
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Marie D San Roman
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Alan Forrest
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA.,Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, NC, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA .,The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
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Garonzik SM, Lenhard JR, Forrest A, Holden PN, Bulitta JB, Tsuji BT. Defining the Active Fraction of Daptomycin against Methicillin-Resistant Staphylococcus aureus (MRSA) Using a Pharmacokinetic and Pharmacodynamic Approach. PLoS One 2016; 11:e0156131. [PMID: 27284923 PMCID: PMC4902307 DOI: 10.1371/journal.pone.0156131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/11/2016] [Indexed: 11/30/2022] Open
Abstract
Our objective was to study the pharmacodynamics of daptomycin in the presence of varying concentrations of human serum (HS) in vitro to quantify the fraction of daptomycin that is ‘active’. Time kill experiments were performed with daptomycin (0 to 256 mg/L) against two MRSA strains at log-phase growth, in the presence of HS (0%, 10%, 30%, 50%, 70%) combined with Mueller-Hinton broth. Daptomycin ≥ 2 mg/L achieved 99.9% kill within 8 h at all HS concentrations; early killing activity was slightly attenuated at higher HS concentrations. After 1 h, bacterial reduction of USA300 upon exposure to daptomycin 4 mg/L ranged from -3.1 to -0.5 log10CFU/mL in the presence of 0% to 70% HS, respectively. Bactericidal activity was achieved against both strains at daptomycin ≥ 4 mg/L for all fractions of HS exposure. A mechanism-based mathematical model (MBM) was developed to estimate the active daptomycin fraction at each %HS, comprising 3 bacterial subpopulations differing in daptomycin susceptibility. Time-kill data were fit with this MBM with excellent precision (r2 >0.95). The active fraction of daptomycin was estimated to range from 34.6% to 25.2% at HS fractions of 10% to 70%, respectively. Despite the reported low unbound fraction of daptomycin, the impact of protein binding on the activity of daptomycin was modest. The active fraction approach can be utilized to design in vitro experiments and to optimize therapeutic regimens of daptomycin in humans.
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Affiliation(s)
- Samira M. Garonzik
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
| | - Justin R. Lenhard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
- New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Alan Forrest
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
- Department of Pharmacotherapy and Experimental Therapeutics, School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States of America
| | - Patricia N. Holden
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
- New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Jϋrgen B. Bulitta
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, United States of America
| | - Brian T. Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences Buffalo, Buffalo, NY, United States of America
- New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, Buffalo, NY, United States of America
- * E-mail:
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Soon RL, Lenhard JR, Reilly I, Brown T, Forrest A, Tsuji BT. Impact of Staphylococcus aureus accessory gene regulator (agr) system on linezolid efficacy by profiling pharmacodynamics and RNAIII expression. J Antibiot (Tokyo) 2016; 70:98-101. [DOI: 10.1038/ja.2016.59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/16/2016] [Accepted: 04/25/2016] [Indexed: 12/21/2022]
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Cheah SE, Johnson MD, Zhu Y, Tsuji BT, Forrest A, Bulitta JB, Boyce JD, Nation RL, Li J. Polymyxin Resistance in Acinetobacter baumannii: Genetic Mutations and Transcriptomic Changes in Response to Clinically Relevant Dosage Regimens. Sci Rep 2016; 6:26233. [PMID: 27195897 PMCID: PMC4872528 DOI: 10.1038/srep26233] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 04/29/2016] [Indexed: 12/11/2022] Open
Abstract
Polymyxins are often last-line therapeutic agents used to treat infections caused by multidrug-resistant A. baumannii. Recent reports of polymyxin-resistant A. baumannii highlight the urgent need for research into mechanisms of polymyxin resistance. This study employed genomic and transcriptomic analyses to investigate the mechanisms of polymyxin resistance in A. baumannii AB307-0294 using an in vitro dynamic model to mimic four different clinically relevant dosage regimens of polymyxin B and colistin over 96 h. Polymyxin B dosage regimens that achieved peak concentrations above 1 mg/L within 1 h caused significant bacterial killing (~5 log10CFU/mL), while the gradual accumulation of colistin resulted in no bacterial killing. Polymyxin resistance was observed across all dosage regimens; partial reversion to susceptibility was observed in 6 of 8 bacterial samples during drug-free passaging. Stable polymyxin-resistant samples contained a mutation in pmrB. The transcriptomes of stable and non-stable polymyxin-resistant samples were not substantially different and featured altered expression of genes associated with outer membrane structure and biogenesis. These findings were further supported via integrated analysis of previously published transcriptomics data from strain ATCC19606. Our results provide a foundation for understanding the mechanisms of polymyxin resistance following exposure to polymyxins and the need to explore effective combination therapies.
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Affiliation(s)
- Soon-Ee Cheah
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Matthew D Johnson
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Yan Zhu
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University of Buffalo, Kapoor Hall, Buffalo, NY 14214-8033, USA
| | - Alan Forrest
- Laboratory for Antimicrobial Pharmacodynamics, Department of Pharmacy Practice, University of Buffalo, Kapoor Hall, Buffalo, NY 14214-8033, USA.,Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Genetic Medicine Building, 120 Mason Farm Road, Chapel Hill NC 27599, USA
| | - Jurgen B Bulitta
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia.,Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, 6550 Sanger Road, Orloando FL 32827, USA
| | - John D Boyce
- Biomedicine Discovery Institute and Department of Microbiology, School of Biomedical Sciences, Monash University (Clayton campus), Wellington Road, Clayton, Victoria 3800, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), 381 Royal Parade, Parkville, Victoria 3052, Australia
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Bergen PJ, Bulman ZP, Landersdorfer CB, Smith N, Lenhard JR, Bulitta JB, Nation RL, Li J, Tsuji BT. Optimizing Polymyxin Combinations Against Resistant Gram-Negative Bacteria. Infect Dis Ther 2015; 4:391-415. [PMID: 26645096 PMCID: PMC4675771 DOI: 10.1007/s40121-015-0093-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Indexed: 01/01/2023] Open
Abstract
Polymyxin combination therapy is increasingly used clinically. However, systematic investigations of such combinations are a relatively recent phenomenon. The emerging pharmacodynamic (PD) and pharmacokinetic (PK) data on CMS/colistin and polymyxin B suggest that caution is required with monotherapy. Given this situation, polymyxin combination therapy has been suggested as a possible way to increase bacterial killing and reduce the development of resistance. Considerable in vitro data have been generated in support of this view, particularly recent studies utilizing dynamic models. However, most existing animal data are of poor quality with major shortcomings in study design, while clinical data are generally limited to retrospective analysis and small, low-power, prospective studies. This article provides an overview of clinical and preclinical investigations of CMS/colistin and polymyxin B combination therapy.
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Affiliation(s)
- Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Zackery P Bulman
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia.,Centre for Medicine Use and Safety, Monash University, Melbourne, Australia
| | - Nicholas Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Justin R Lenhard
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.
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Bergen PJ, Bulman ZP, Saju S, Bulitta JB, Landersdorfer C, Forrest A, Li J, Nation RL, Tsuji BT. Polymyxin combinations: pharmacokinetics and pharmacodynamics for rationale use. Pharmacotherapy 2015; 35:34-42. [PMID: 25630411 DOI: 10.1002/phar.1537] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Since their reintroduction into the clinic in the 1980s, the polymyxin antibiotics colistin-administered intravenously as an inactive prodrug, colistin methanesulfonate (CMS)-and polymyxin B have assumed an important role as salvage therapy for otherwise untreatable gram-negative infections. However, the emerging pharmacodynamic and pharmacokinetic data on CMS/colistin and polymyxin B indicate that polymyxin monotherapy is unlikely to generate plasma concentrations that are reliably efficacious. Additionally, regrowth and the emergence of resistance with monotherapy are commonly reported even when concentrations exceed those achieved clinically. Given this situation, polymyxin combination therapy, which is increasingly being used clinically, has been suggested as a possible means of increasing antimicrobial activity and reducing the development of resistance. Although considerable in vitro data support this view, investigations of polymyxin combination therapy in patients have only recently commenced. The currently available clinical data for polymyxin combinations are generally limited to retrospective analyses and small, low-powered, prospective studies using traditional dosage regimens that achieve low plasma concentrations. Considering the potential for rapid development of resistance to polymyxins, well-designed clinical trials that include higher-dose polymyxin regimens are urgently required to provide a more definitive answer regarding the role of polymyxin combination therapy compared with monotherapy. In this article, we provide an overview of key in vitro and clinical investigations examining CMS/colistin and polymyxin B combination therapy.
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Affiliation(s)
- Phillip J Bergen
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, New York
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Ly NS, Bulitta JB, Rao GG, Landersdorfer CB, Holden PN, Forrest A, Bergen PJ, Nation RL, Li J, Tsuji BT. Colistin and doripenem combinations against Pseudomonas aeruginosa: profiling the time course of synergistic killing and prevention of resistance. J Antimicrob Chemother 2015; 70:1434-42. [PMID: 25712313 DOI: 10.1093/jac/dku567] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/21/2014] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES Colistin is an 'old' drug, which is being increasingly utilized due to limited therapeutic options. However, resistance emergence during monotherapy is concerning. Here, our objective was to optimize colistin combinations against Pseudomonas aeruginosa by profiling the time course of synergistic killing and prevention of resistance. METHODS Hollow-fibre infection models over 10 days simulated clinically relevant dosage regimens of colistin and doripenem against two heteroresistant P. aeruginosa strains (MIC 1 mg/L) and one resistant (MIC 128 mg/L) strain (inoculum 10(9.3) cfu/mL). New mathematical mechanism-based models (MBMs) were developed using S-ADAPT. RESULTS Against heteroresistant P. aeruginosa strains, colistin monotherapy resulted in initial killing (up to 2.64 log10 cfu/mL) within 24 h followed by regrowth. High-intensity combinations involving free steady-state colistin concentrations of 5 mg/L achieved complete eradication (>9.3 log10 killing) within 48 h. These combinations achieved synergy with up to 9.38 log10 greater killing compared with the most active monotherapy. Against the colistin-resistant strain, the combination yielded marked initial synergy with up to 6.11 log10 cfu/mL bacterial reductions within 72 h followed by regrowth. The MBMs quantified total and resistant subpopulations and the proposed synergy between colistin and doripenem. CONCLUSIONS Our findings provide insight into optimal antibiotic treatment and may serve as a framework for new drug combinations and combination modelling.
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Affiliation(s)
- Neang S Ly
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Jürgen B Bulitta
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Gauri G Rao
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Cornelia B Landersdorfer
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Patricia N Holden
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Alan Forrest
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Phillip J Bergen
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Brian T Tsuji
- Laboratory for Antimicrobial and Bacterial Dynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA The New York State Center of Excellence in Bioinformatics & Life Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA
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Nation RL, Li J, Cars O, Couet W, Dudley MN, Kaye KS, Mouton JW, Paterson DL, Tam VH, Theuretzbacher U, Tsuji BT, Turnidge JD. Framework for optimisation of the clinical use of colistin and polymyxin B: the Prato polymyxin consensus. The Lancet Infectious Diseases 2015; 15:225-34. [DOI: 10.1016/s1473-3099(14)70850-3] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Rees VE, Bulitta JB, Nation RL, Tsuji BT, Sörgel F, Landersdorfer CB. Shape does matter: short high-concentration exposure minimizes resistance emergence for fluoroquinolones in Pseudomonas aeruginosa. J Antimicrob Chemother 2014; 70:818-26. [PMID: 25381167 DOI: 10.1093/jac/dku437] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES For fluoroquinolones, the area under the free plasma concentration-time curve divided by the MIC (fAUC/MIC) best predicts bacterial killing in mice and outcomes in patients. However, it is unknown whether the shape of the antibiotic concentration profile affects resistance emergence. Our objective was to compare killing and resistance between ciprofloxacin concentration profiles with different shapes at the same fAUC/MIC and identify the durations of ciprofloxacin exposure that minimize resistance emergence. METHODS Static time-kill studies over 24 h using Pseudomonas aeruginosa ATCC 27853 assessed fAUC/MIC of 44 and 132 of ciprofloxacin (MICCIP = 0.25 mg/L) and fAUC/MIC of 22, 44 and 132 of ciprofloxacin plus an efflux pump inhibitor (MICCIP+EPI = 0.031 mg/L) at initial inocula of 10(4), 10(5) and 10(6) cfu/mL. Ciprofloxacin was added at 0 h and rapidly removed at 1, 4, 10, 16 or 24 h. Mutant frequencies and MICs were determined at 24 h. RESULTS High ciprofloxacin concentrations over 1-10 h yielded more rapid and extensive initial killing compared with 16 and 24 h exposures at the same fAUC/MIC. No resistance emerged for 1-10 h exposures, although regrowth of susceptible bacteria was extensive. Ciprofloxacin exposure over 24 h yielded less regrowth, but ciprofloxacin-resistant bacteria at 5× MIC amplified by over 5 log10 and almost completely replaced the susceptible bacteria by 24 h; MICs increased 4- to 8-fold. Resistance also emerged on 3× MIC, but not 5× MIC, plates when efflux was inhibited. CONCLUSIONS Pre-existing resistant subpopulations amplified extensively with 24 and 16 h exposures, but not with shorter durations. The shape of the ciprofloxacin concentration profile was critical to minimize resistance emergence.
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Affiliation(s)
- Vanessa E Rees
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Victoria 3052, Australia
| | - Jürgen B Bulitta
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Victoria 3052, Australia School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Roger L Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Victoria 3052, Australia
| | - Brian T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Fritz Sörgel
- IBMP-Institute for Biomedical and Pharmaceutical Research, Paul-Ehrlich-Str. 19, Nürnberg-Heroldsberg, Germany Institute of Pharmacology, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville Campus), Parkville, Victoria 3052, Australia School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Rao GG, Ly NS, Haas CE, Garonzik S, Forrest A, Bulitta JB, Kelchlin PA, Holden PN, Nation RL, Li J, Tsuji BT. New dosing strategies for an old antibiotic: pharmacodynamics of front-loaded regimens of colistin at simulated pharmacokinetics in patients with kidney or liver disease. Antimicrob Agents Chemother 2013; 58:1381-8. [PMID: 24342636 PMCID: PMC3957851 DOI: 10.1128/aac.00327-13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 12/08/2013] [Indexed: 01/22/2023] Open
Abstract
Increasing evidence suggests that colistin monotherapy is suboptimal at currently recommended doses. We hypothesized that front-loading provides an improved dosing strategy for polymyxin antibiotics to maximize killing and minimize total exposure. Here, we utilized an in vitro pharmacodynamic model to examine the impact of front-loaded colistin regimens against a high bacterial density (10(8) CFU/ml) of Pseudomonas aeruginosa. The pharmacokinetics were simulated for patients with hepatic (half-life [t1/2] of 3.2 h) or renal (t1/2 of 14.8 h) disease. Front-loaded regimens (n=5) demonstrated improvement in bacterial killing, with reduced overall free drug areas under the concentration-time curve (fAUC) compared to those with traditional dosing regimens (n=14) with various dosing frequencies (every 12 h [q12h] and q24h). In the renal failure simulations, front-loaded regimens at lower exposures (fAUC of 143 mg · h/liter) obtained killing activity similar to that of traditional regimens (fAUC of 268 mg · h/liter), with an ∼97% reduction in the area under the viable count curve over 48 h. In hepatic failure simulations, front-loaded regimens yielded rapid initial killing by up to 7 log10 within 2 h, but considerable regrowth occurred for both front-loaded and traditional regimens. No regimen eradicated the high bacterial inoculum of P. aeruginosa. The current study, which utilizes an in vitro pharmacodynamic infection model, demonstrates the potential benefits of front-loading strategies for polymyxins simulating differential pharmacokinetics in patients with hepatic and renal failure at a range of doses. Our findings may have important clinical implications, as front-loading polymyxins as a part of a combination regimen may be a viable strategy for aggressive treatment of high-bacterial-burden infections.
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Affiliation(s)
- Gauri G. Rao
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- The New York State Center of Excellence in Bioinformatics & Life Sciences University at Buffalo, SUNY, Buffalo, New York, USA
| | - Neang S. Ly
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- The New York State Center of Excellence in Bioinformatics & Life Sciences University at Buffalo, SUNY, Buffalo, New York, USA
| | - Curtis E. Haas
- Department of Pharmacy and School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Samira Garonzik
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- Modeling and Simulation, Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | - Alan Forrest
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jurgen B. Bulitta
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Pamela A. Kelchlin
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- The New York State Center of Excellence in Bioinformatics & Life Sciences University at Buffalo, SUNY, Buffalo, New York, USA
| | - Patricia N. Holden
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- The New York State Center of Excellence in Bioinformatics & Life Sciences University at Buffalo, SUNY, Buffalo, New York, USA
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jian Li
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Brian T. Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
- The New York State Center of Excellence in Bioinformatics & Life Sciences University at Buffalo, SUNY, Buffalo, New York, USA
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Tsuji BT, Harigaya Y, Lesse AJ, Forrest A, Ngo D. Activity of AFN-1252, a novel FabI inhibitor, against Staphylococcus aureus in an in vitro pharmacodynamic model simulating human pharmacokinetics. J Chemother 2013; 25:32-5. [PMID: 23433442 PMCID: PMC3558987 DOI: 10.1179/1973947812y.0000000060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AFN-1252, a potent enoyl-ACP reductase (FabI) inhibitor, is under development for the treatment of Staphylococcus aureus infections. The activity of AFN-1252 against two isolates of S. aureus, MSSA 26213 and MRSA S186, was studied in an in vitro pharmacodynamic model simulating AFN-1252 pharmacokinetics in man. Reductions in bacterial viable count over the first 6 hours were generally 1–2 logs and maximal reductions in viable count were generally achieved at fAUC/MIC ratios of 100–200. Maximum reductions in viable count against MSSA 29213 and MRSA S186 were approximately 4 logs, achieved by 450 mg q12h (fAUC/MIC = 1875) dosing at 28 hours. Staphylococcal resistance to AFN-1252 did not develop throughout the 48-hour experiments. As multidrug resistance continues to increase, these studies support the continued investigation of AFN-1252 as a targeted therapeutic for staphylococcal infections.
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Affiliation(s)
- Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, The New York State Center of Excellence in Bioinformatics, University at Buffalo, State University of New York, NY14203, USA.
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Soon RL, Turner SJ, Forrest A, Tsuji BT, Brown J. Pharmacokinetic/pharmacodynamic evaluation of the efficacy and safety of daptomycin against Staphylococcus aureus. Int J Antimicrob Agents 2013; 42:53-8. [DOI: 10.1016/j.ijantimicag.2013.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 12/03/2012] [Accepted: 02/11/2013] [Indexed: 02/07/2023]
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He H, Li JC, Nation RL, Jacob J, Chen G, Lee HJ, Tsuji BT, Thompson PE, Roberts K, Velkov T, Li J. Pharmacokinetics of four different brands of colistimethate and formed colistin in rats. J Antimicrob Chemother 2013; 68:2311-7. [PMID: 23749953 DOI: 10.1093/jac/dkt207] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Very different labelling conventions are employed by different products of colistimethate (CMS), an inactive prodrug of colistin that is used as a last-line defence against Gram-negative 'superbugs'. This study examined the chemical composition and pharmacokinetics in rats of four commercial parenteral products of CMS. METHODS Contents per vial of four brands of CMS from three different continents were weighed (n = 3). Elemental analysis and HPLC examination were conducted. The pharmacokinetics of CMS and formed colistin were investigated for each product after intravenous administration in rats (28.1 mg/kg CMS; n = 4). Blood was collected over 180 min, and concentrations of CMS and colistin were measured followed by pharmacokinetic analysis. RESULTS X-GEN, Paddock and Atlantic products, labelled with 150 mg 'colistin base activity', contained 366.8 ± 0.80, 340.6 ± 0.08 and 380.0 ± 5.97 mg CMS (sodium) per vial, respectively; while the Forest product (labelled with 2 000 000 IU) contained 159.3 ± 1.75 mg CMS (sodium). The elemental compositions of the four products were similar; however, the HPLC profile of the Atlantic CMS was different from those of the other three products. The pharmacokinetics of CMS were generally comparable across brands; however, the molar ratios (%) of the AUC0-180min of colistin to CMS (1.68% ± 0.35% to 3.29% ± 0.43%) were significantly different (P = 0.0157). CONCLUSION This is the first study to demonstrate that although different brands of CMS from various parts of the world have similar elemental compositions, they lead to different exposures to the microbiologically active formed colistin. The study has significant implications for the interpretation of pharmacological studies of CMS conducted in different parts of the world.
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Affiliation(s)
- Hui He
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Takata T, Miyazaki M, Futo M, Hara S, Shiotsuka S, Kamimura H, Yoshimura H, Matsunaga A, Nishida T, Ishikura H, Ishikawa T, Tamura K, Tsuji BT. Presence of both heterogeneous vancomycin-intermediate resistance and β-lactam antibiotic-induced vancomycin resistance phenotypes is associated with the outcome in methicillin-resistant Staphylococcus aureus bloodstream infection. ACTA ACUST UNITED AC 2012; 45:203-12. [PMID: 23113753 DOI: 10.3109/00365548.2012.723221] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Although the individual expression of heterogeneous vancomycin-intermediate resistance (hVISA) and β-lactam antibiotic-induced vancomycin resistance (BIVR) phenotypes has been associated with treatment failure and recurrence in methicillin-resistant Staphylococcus aureus (MRSA) infections, the effect of the co-expression of these phenotypic profiles on clinical outcome has not been fully elucidated. The aim of this study was to determine the impact of the combination of hVISA and BIVR phenotypes on the clinical outcome in MRSA bacteremia. METHODS One hundred and sixty-two MRSA blood isolates from a 21-y period, 1987-2007, were randomly selected. Screening for hVISA was done by the macromethod Etest and confirmed by population analysis profiles. BIVR was identified using Mu3 agar containing 4 μg/ml of vancomycin. RESULTS Thirty (18.5%) and 39 (24.1%) of the 162 MRSA blood isolates were positive for the hVISA and BIVR phenotypes, respectively. Eighteen (11.1%) isolates possessed both hVISA and BIVR phenotypes (hVISA(+)/BIVR(+)). In a subset of patients who received initial treatment with glycopeptides, only the patients whose isolates were hVISA(+)/BIVR(+) displayed a significantly higher mortality rate in comparison to those with non-hVISA(+)/BIVR(+) (80.0% vs 31.3%, p = 0.004). The presence of both hVISA and BIVR phenotypes was a predictor of mortality using a logistic regression analysis (p = 0.025). CONCLUSIONS The combined phenotype of hVISA and BIVR was associated with a higher probability of mortality in patients with MRSA bacteremia. Further prospective studies are warranted to delineate the clinical significance of the combined phenotype of hVISA and BIVR.
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Affiliation(s)
- Tohru Takata
- Division of Oncology, Department of Medicine, Fukuoka University School of Medicine, Fukuoka University School ofMedicine, Fukuoka, Japan.
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Deris ZZ, Yu HH, Davis K, Soon RL, Jacob J, Ku CK, Poudyal A, Bergen PJ, Tsuji BT, Bulitta JB, Forrest A, Paterson DL, Velkov T, Li J, Nation RL. The combination of colistin and doripenem is synergistic against Klebsiella pneumoniae at multiple inocula and suppresses colistin resistance in an in vitro pharmacokinetic/pharmacodynamic model. Antimicrob Agents Chemother 2012; 56:5103-12. [PMID: 22802247 PMCID: PMC3457376 DOI: 10.1128/aac.01064-12] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 07/07/2012] [Indexed: 11/20/2022] Open
Abstract
Multidrug-resistant (MDR) Klebsiella pneumoniae may require combination therapy. We systematically investigated bacterial killing with colistin and doripenem mono- and combination therapy against MDR K. pneumoniae and emergence of colistin resistance. A one-compartment in vitro pharmacokinetic/pharmacodynamic model was employed over a 72-h period with two inocula (∼10(6) and ∼10(8) CFU/ml); a colistin-heteroresistant reference strain (ATCC 13883) and three clinical isolates (colistin-susceptible FADDI-KP032 [doripenem resistant], colistin-heteroresistant FADDI-KP033, and colistin-resistant FADDI-KP035) were included. Four combinations utilizing clinically achievable concentrations were investigated. Microbiological responses were examined by determining log changes and population analysis profiles (for emergence of colistin resistance) over 72 h. Against colistin-susceptible and -heteroresistant isolates, combinations of colistin (constant concentration regimens of 0.5 or 2 mg/liter) plus doripenem (steady-state peak concentration [C(max)] of 2.5 or 25 mg/liter over 8 h; half-life, 1.5 h) generally resulted in substantial improvements in bacterial killing at both inocula. Combinations were additive or synergistic against ATCC 13883, FADDI-KP032, and FADDI-KP033 in 9, 9, and 14 of 16 cases (4 combinations at 6, 24, 48, and 72 h) at the 10(6)-CFU/ml inoculum and 14, 11, and 12 of 16 cases at the 10(8)-CFU/ml inoculum, respectively. Combinations at the highest dosage regimens resulted in undetectable bacterial counts at 72 h in 5 of 8 cases (4 isolates at 2 inocula). Emergence of colistin-resistant subpopulations in colistin-susceptible and -heteroresistant isolates was virtually eliminated with combination therapy. Against the colistin-resistant isolate, colistin at 2 mg/liter plus doripenem (C(max), 25 mg/liter) at the low inoculum improved bacterial killing. This investigation provides important information for optimization of colistin-doripenem combinations.
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Affiliation(s)
- Zakuan Z Deris
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Australia
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Bulitta JB, Landersdorfer CB, Forrest A, Brown SV, Neely MN, Tsuji BT, Louie A. Relevance of pharmacokinetic and pharmacodynamic modeling to clinical care of critically ill patients. Curr Pharm Biotechnol 2012; 12:2044-61. [PMID: 21554212 DOI: 10.2174/138920111798808428] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 11/13/2010] [Indexed: 11/22/2022]
Abstract
Efficacious therapy is of utmost importance to save lives and prevent bacterial resistance in critically ill patients. This review summarizes pharmacokinetic (PK) and pharmacodynamic (PD) modeling methods to optimize clinical care of critically ill patients in empiric and individualized therapy. While these methods apply to all therapeutic areas, we focus on antibiotics to highlight important applications, as emergence of resistance is a significant problem. Nonparametric and parametric population PK modeling, multiple-model dosage design, Monte Carlo simulations, and Bayesian adaptive feedback control are the methods of choice to optimize therapy. Population PK can estimate between patient variability and account for potentially increased clearances and large volumes of distribution in critically ill patients. Once patient- specific PK data become available, target concentration intervention and adaptive feedback control algorithms can most precisely achieve target goals such as clinical cure of an infection or resistance prevention in stable and unstable patients with rapidly changing PK parameters. Many bacterial resistance mechanisms cause PK/PD targets for resistance prevention to be usually several-fold higher than targets for near-maximal killing. In vitro infection models such as the hollow fiber and one-compartment infection models allow one to study antibiotic-induced bacterial killing and emergence of resistance of mono- and combination therapies over clinically relevant treatment durations. Mechanism-based (and empirical) PK/PD modeling can incorporate effects of the immune system and allow one to design innovative dosage regimens and prospective validation studies. Mechanism-based modeling holds great promise to optimize mono- and combination therapy of anti-infectives and drugs from other therapeutic areas for critically ill patients.
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Harigaya Y, Ngo D, Lesse AJ, Huang V, Tsuji BT. Characterization of heterogeneous vancomycin-intermediate resistance, MIC and accessory gene regulator (agr) dysfunction among clinical bloodstream isolates of staphyloccocus aureus. BMC Infect Dis 2011; 11:287. [PMID: 22026752 PMCID: PMC3215976 DOI: 10.1186/1471-2334-11-287] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 10/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The development of hVISA has been associated with vancomycin clinical failures and is commonly misidentified in clinical microbiology laboratories. Therefore, the objectives of this present study was to improve the reliability of methodologies and criteria for identifying hVISA, evaluate the prevalence of hVISA among clinical bloodstream isolates of S. aureus and determine if there exists a relationship between accessory gene regulator (agr) dysfunction and the hVISA phenotype. METHODS The presence of hVISA in 220 clinical S. aureus isolates (121 MSSA, 99 MRSA) from bloodstream infections was examined by CLSI broth microdilution, Macro & Standard Etest. Isolates which were classified as hVISA by Macro Etest, were additionally evaluated using a modified PAP-AUC method using a modified starting inoculum of 10(10) CFU/mL, and growth on brain heart infusion agar with 4 mg/L vancomycin (BHIV4) at 10(8) and 10(10) CFU/mL, and agr function was assessed by delta-hemolysin production. RESULTS Broth microdilution MIC(50/90) of S.aureus and hVISA was 1.0/2.0 and 1.5/2.0 mg/L (p= 0.02), respectively. Macro Etest identified 12 (5.5%) hVISA isolates; higher among MRSA (9.1%) versus MSSA (2.5%) (p = 0.03). The mean modified PAP-AUC ratios (> 0.8) of 7 MRSA strains and 3 MSSA strains were significantly different (p = 0.001). 58% of hVISA strains were found to be agr dysfunctional when 21% of MRSA strains were agr dysfunctional. hVISA was detected among S. aureus bloodstream isolates, which were classified as susceptible among clinical microbiology laboratories. CONCLUSIONS Evaluating the correlation between Etest MICs and modified PAP-AUC ratio values will add further improvement of discriminating hVISA, and agr dysfunction may be predictive of strains which display a greater predilection to display the hVISA phenotype.
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Affiliation(s)
- Yoriko Harigaya
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, New York, USA
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Tsuji BT, Okusanya OO, Bulitta JB, Forrest A, Bhavnani SM, Fernandez PB, Ambrose PG. Application of Pharmacokinetic-Pharmacodynamic Modeling and the Justification of a Novel Fusidic Acid Dosing Regimen: Raising Lazarus From the Dead. Clin Infect Dis 2011; 52 Suppl 7:S513-9. [DOI: 10.1093/cid/cir166] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Tsuji BT, MacLean RD, Dresser LD, McGavin MJ, Simor AE. Impact of accessory gene regulator (agr) dysfunction on vancomycin pharmacodynamics among Canadian community and health-care associated methicillin-resistant Staphylococcus aureus. Ann Clin Microbiol Antimicrob 2011; 10:20. [PMID: 21599878 PMCID: PMC3120648 DOI: 10.1186/1476-0711-10-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 05/20/2011] [Indexed: 11/18/2022] Open
Abstract
Background The accessory gene regulator (agr) is a quorum sensing cluster of genes which control colonization and virulence in Staphylococcus aureus. We evaluated agr function in community- (CA) and healthcare-associated (HA) MRSA, to compare the pharmacodynamics and bactericidal activity of vancomycin against agr functional and dysfunctional HA-MRSA and CA-MRSA. Methods 40 clinical isolates of MRSA from the Canadian Nosocomial Infection Surveillance Program were evaluated for delta-haemolysin production, as a surrogate marker of agr function. Time kill experiments were performed for vancomycin at 0 to 64 times the MIC against an initial inoculum of 106 and 108 cfu/ml of agr functional and dysfunctional CA-MRSA and HA-MRSA and these data were fit to a hill-type pharmacodynamic model. Results 15% isolates were agr dysfunctional, which was higher among HA-MRSA (26.3%) versus CA-MRSA (4.76%). Against a low initial inoculum of 106 cfu/ml of CA-MRSA, vancomycin pharmacodynamics were similar among agr functional and dysfunctional strains. However, against a high initial inoculum of 108 cfu/ml, killing activity was notably attenuated against agr dysfunctional CA-MRSA (USA400) and HA-MRSA (USA100). CA-MRSA displayed a 20.0 fold decrease in the maximal reduction in bacterial counts (Emax) which was 3.71 log10 CFU/ml for agr functional vs. 2.41 log10 CFU/ml for agr dysfunctional MRSA (p = 0.0007). Conclusions Dysfunction in agr was less common among CA-MRSA vs. HA-MRSA. agr dysfunction demonstrated an impact on vancomycin bactericidal activity and pharmacodynamics against a high initial inoculum of CA-MRSA and HA-MRSA, which may have implications for optimal antimicrobial therapy against persistent, difficult to treat MRSA infections.
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Affiliation(s)
- Brian T Tsuji
- Laboratory Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, New York 14260, USA.
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