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Maranchick NF, Peloquin CA. Role of therapeutic drug monitoring in the treatment of multi-drug resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2024; 36:100444. [PMID: 38708036 PMCID: PMC11067344 DOI: 10.1016/j.jctube.2024.100444] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Tuberculosis (TB) is a leading cause of mortality worldwide, and resistance to anti-tuberculosis drugs is a challenge to effective treatment. Multi-drug resistant TB (MDR-TB) can be difficult to treat, requiring long durations of therapy and the use of second line drugs, increasing a patient's risk for toxicities and treatment failure. Given the challenges treating MDR-TB, clinicians can improve the likelihood of successful outcomes by utilizing therapeutic drug monitoring (TDM). TDM is a clinical technique that utilizes measured drug concentrations from the patient to adjust therapy, increasing likelihood of therapeutic drug concentrations while minimizing the risk of toxic drug concentrations. This review paper provides an overview of the TDM process, pharmacokinetic parameters for MDR-TB drugs, and recommendations for dose adjustments following TDM.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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Peloquin CA. Therapeutic drug monitoring for isoniazid and rifampicin exposure. Int J Tuberc Lung Dis 2024; 28:168-169. [PMID: 38454183 DOI: 10.5588/ijtld.23.0495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
- C A Peloquin
- College of Pharmacy, University of Florida, Gainesville, FL, USA
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Maranchick NF, Kwara A, Peloquin CA. Clinical considerations and pharmacokinetic interactions between HIV and tuberculosis therapeutics. Expert Rev Clin Pharmacol 2024. [PMID: 38339997 DOI: 10.1080/17512433.2024.2317954] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Tuberculosis(TB) is a leading infectious diseases cause of mortality worldwide,especially for people living with human immunodeficiency virus(PLWH). Treating TB in PLWH can be challenging due to numerous druginteractions. AREASCOVERED Thisreview discusses drug interactions between antitubercular andantiretroviral drugs. Due to its clinical importance, initiation ofantiretroviral therapy in patients requiring TB treatment isdiscussed. Special focus is placed on the rifamycin class, as itaccounts for the majority of interactions. Clinically relevantguidance is provided on how to manage these interactions. Anadditional section on utilizing therapeutic drug monitoring (TDM) tooptimize drug exposure and minimize toxicities is included. EXPERTOPINION Antitubercularand antiretroviral coadministration can be successfully managed. TDMcan be used to optimize drug exposure and minimize toxicity risk. Asnew TB and HIV drugs are discovered, additional research will beneeded to assess for clinically relevant drug interactions.
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Affiliation(s)
- Nicole F Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Awewura Kwara
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
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Maranchick NF, Trillo-Alvarez C, Kariyawasam V, Venugopalan V, Kwara A, Rand K, Peloquin CA, Alshaer MH. A Randomized Clinical Trial of Bayesian-Guided Beta-Lactam Infusion Strategy and Associated Bacterial Resistance and Clinical Outcomes in Patients With Severe Pneumonia. Ther Drug Monit 2024; 46:95-101. [PMID: 38018847 PMCID: PMC10769161 DOI: 10.1097/ftd.0000000000001144] [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: 06/12/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Antimicrobial resistance is a growing health concern worldwide. The objective of this study was to evaluate the effect of beta-lactam infusion on the emergence of bacterial resistance in patients with severe pneumonia in the intensive care unit. METHODS Adult intensive care patients receiving cefepime, meropenem, or piperacillin-tazobactam for severe pneumonia caused by Gram-negative bacteria were randomized to receive beta-lactams as an intermittent (30 minutes) or continuous (24 hours) infusion. Respiratory samples for culture and susceptibility testing, with minimum inhibitory concentrations (MIC), were collected once a week for up to 4 weeks. Beta-lactam plasma concentrations were measured and therapeutic drug monitoring was performed using Bayesian software as the standard of care. RESULTS The study was terminated early owing to slow enrollment. Thirty-five patients were enrolled in this study. Cefepime (n = 22) was the most commonly prescribed drug at randomization, followed by piperacillin (n = 8) and meropenem (n = 5). Nineteen patients were randomized into the continuous infusion arm and 16 into the intermittent infusion arm. Pseudomonas aeruginosa was the most common respiratory isolate (n = 19). Eighteen patients were included in the final analyses. No differences in bacterial resistance were observed between arms ( P = 0.67). No significant differences in superinfection ( P = 1), microbiological cure ( P = 0.85), clinical cure at day 7 ( P = 0.1), clinical cure at end of therapy ( P = 0.56), mortality ( P = 1), intensive care unit length of stay ( P = 0.37), or hospital length of stay ( P = 0.83) were observed. Achieving 100% ƒT > MIC ( P = 0.04) and ƒT > 4 × MIC ( P = 0.02) increased likelihood of clinical cure at day 7 of therapy. CONCLUSIONS No differences in the emergence of bacterial resistance or clinical outcomes were observed between intermittent and continuous infusions. Pharmacokinetic/pharmacodynamic target attainment may be associated with a clinical cure on day 7.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Cesar Trillo-Alvarez
- Division of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Vidhu Kariyawasam
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida; and
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, Florida
| | - Awewura Kwara
- Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, Florida; and
| | - Kenneth Rand
- College of Medicine, University of Florida, Gainesville, Florida
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, Florida
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
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Rao PS, Reed K, Modi N, Handler D, de Guex KP, Yu S, Kagan L, Reiss R, Narayanan N, Peloquin CA, Lardizabal A, Vinnard C, Thomas TA, Xie YL, Heysell SK. Isoniazid urine spectrophotometry for prediction of serum pharmacokinetics in adults with TB. IJTLD Open 2024; 1:90-95. [PMID: 38655375 PMCID: PMC11037464 DOI: 10.5588/ijtldopen.23.0361] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Isoniazid (INH) is an important drug in many TB regimens, and unfavorable treatment outcomes can be caused by suboptimal pharmacokinetics. Dose adjustment can be personalized by measuring peak serum concentrations; however, the process involves cold-chain preservation and laboratory techniques such as liquid chromatography (LC)/mass spectrometry (MS), which are unavailable in many high-burden settings. Urine spectrophotometry could provide a low-cost alternative with simple sampling and quantification methods. METHODS We enrolled 56 adult patients on treatment for active TB. Serum was collected at 0, 1, 2, 4, 6, and 8 h for measurement of INH concentrations using validated LC-MS/MS methods. Urine was collected at 0-4, 4-8, and 8-24 h intervals, with INH concentrations measured using colorimetric methods. RESULTS The median peak serum concentration and total serum exposure over 24 h were 4.8 mg/L and 16.4 mg*hour/L, respectively. Area under the receiver operator characteristic curves for urine values predicting a subtherapeutic serum concentration (peak <3.0 mg/L) were as follows: 0-4 h interval (AUC 0.85, 95% CI 0.7-0.96), 0-8 h interval (AUC 0.85, 95% CI 0.71-0.96), and 0-24 h urine collection interval (AUC 0.84, 95% CI 0.68-0.96). CONCLUSION Urine spectrophotometry may improve feasibility of personalized dosing in high TB burden regions but requires further study of target attainment following dose adjustment based on a urine threshold.
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Affiliation(s)
- P S Rao
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA
| | - K Reed
- School of Arts and Sciences, University of Virginia, Charlottesville, VA
| | - N Modi
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - D Handler
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - K Petros de Guex
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA
| | - S Yu
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers State University of New Jersey, Newark, NJ
| | - L Kagan
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers State University of New Jersey, Newark, NJ
| | - R Reiss
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - N Narayanan
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers State University of New Jersey, Newark, NJ
| | - C A Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - A Lardizabal
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - C Vinnard
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA
| | - Y L Xie
- Public Health Research Institute and Global Tuberculosis Institute, Rutgers New Jersey Medical School, Newark, NJ
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA
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Tucker EW, Ruiz-Bedoya CA, Mota F, Erice C, Kim J, de Jesus P, Jahdav R, Bahr M, Flavahan K, Chen X, Peloquin CA, Freundlich JS, Jain SK. Linezolid does not improve bactericidal activity of rifampin-containing first-line regimens in animal models of TB meningitis. Int J Antimicrob Agents 2024; 63:107048. [PMID: 38061419 PMCID: PMC10841818 DOI: 10.1016/j.ijantimicag.2023.107048] [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: 08/24/2023] [Revised: 11/15/2023] [Accepted: 11/28/2023] [Indexed: 01/02/2024]
Abstract
Tuberculous meningitis (TB meningitis) is the most devastating form of tuberculosis (TB) and there is a critical need to optimize treatment. Linezolid is approved for multidrug resistant TB and has shown encouraging results in retrospective TB meningitis studies, with several clinical trials underway assessing its additive effects on high-dose (35 mg/kg/day) or standard-dose (10 mg/kg/day) rifampin-containing regimens. However, the efficacy of adjunctive linezolid to rifampin-containing first-line TB meningitis regimens and the tissue pharmacokinetics (PK) in the central nervous system (CNS) are not known. We therefore conducted cross-species studies in two mammalian (rabbits and mice) models of TB meningitis to test the efficacy of linezolid when added to the first-line TB regimen and measure detailed tissue PK (multicompartmental positron emission tomography [PET] imaging and mass spectrometry). Addition of linezolid did not improve the bactericidal activity of the high-dose rifampin-containing regimen in either animal model. Moreover, the addition of linezolid to standard-dose rifampin in mice also did not improve its efficacy. Linezolid penetration (tissue/plasma) into the CNS was compartmentalized with lower than previously reported brain and cerebrospinal fluid (CSF) penetration, which decreased further two weeks after initiation of treatment. These results provide important data regarding the addition of linezolid for the treatment of TB meningitis.
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Affiliation(s)
- Elizabeth W Tucker
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Camilo A Ruiz-Bedoya
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Filipa Mota
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clara Erice
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John Kim
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Patricia de Jesus
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ravindra Jahdav
- Department of Pharmacology, Physiology and Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Melissa Bahr
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Flavahan
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xueyi Chen
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Joel S Freundlich
- Department of Pharmacology, Physiology and Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Brooks KM, Pau AK, Swaim D, Bunn HT, Adeojo L, Peloquin CA, Kumar P, Kovacs JA, George JM. Pharmacokinetics, Safety, and Tolerability of Once-Daily Darunavir With Cobicistat and Weekly Isoniazid/Rifapentine. J Acquir Immune Defic Syndr 2023; 94:468-473. [PMID: 37955446 PMCID: PMC10651166 DOI: 10.1097/qai.0000000000003301] [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: 04/18/2023] [Accepted: 08/21/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Once-weekly isoniazid with rifapentine (HP) for 3 months is a recommended treatment for latent tuberculosis infection in persons with HIV. HP reduces exposures of certain antiretroviral medications, resulting in limited options for the concomitant use of these therapies. Here, we examined the pharmacokinetics (PK), safety, and tolerability of darunavir/cobicistat with HP. METHODS This was an open-label, fixed sequence, two-period crossover study in persons without HIV. Participants received darunavir 800 mg/cobicistat 150 mg once-daily alone for 4 days, then continued darunavir/cobicistat once-daily for days 5-19 with HP coadministration on days 5, 12, and 19. Intensive PK assessments were performed on days 4, 14, and 19. PK parameters were determined using noncompartmental methods. Geometric mean ratios with 90% confidence intervals (CIs) were calculated and compared between phases using mixed-effects models. RESULTS Thirteen participants were enrolled. Two withdrew after day 4, and one withdrew after day 14. Of the 3 withdrawals, 2 were attributed to drug-related adverse events. Darunavir area under the concentration-time curve, maximum concentrations (Cmax), and concentrations at 24 hours postdose (C24h) were reduced by 71%, 41%, and 96% ∼48-72 hours after HP administration (day 14), respectively, and 36%, 17%, and 89% with simultaneous HP administration (day 19), respectively. On day 14, 45% of the predose and 73% of C24h concentrations were below the darunavir EC50 (0.055 µg/mL). CONCLUSIONS Darunavir exposures were significantly decreased with HP coadministration. Temporal relationships between HP coadministration and the extent of induction or mixed inhibition/induction of darunavir metabolism were apparent. Coadministration of darunavir/cobicistat with 3HP should be avoided.
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Affiliation(s)
- Kristina M Brooks
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Alice K Pau
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Doris Swaim
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Haden T Bunn
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Pumas-AI, Inc., Centreville, VA
| | - Lilian Adeojo
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Arcus Biosciences, Hayward, CA
| | - Charles A Peloquin
- University of Florida College of Pharmacy and Emerging Pathogens Institute, Gainesville, FL
| | - Parag Kumar
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Gilead Sciences, Inc., Foster City, CA
| | - Joseph A Kovacs
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD; and
| | - Jomy M George
- Clinical Pharmacokinetic Research Laboratory, Clinical Center Pharmacy Department, NIH Clinical Center, Bethesda, MD, USA
- Currently, Office of Regulatory Affairs, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, NIH, Rockville, MD
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Maranchick NF, Webber J, Alshaer MH, Felton TW, Peloquin CA. Impact of Beta-Lactam Target Attainment on Resistance Development in Patients with Gram-Negative Infections. Antibiotics (Basel) 2023; 12:1696. [PMID: 38136730 PMCID: PMC10740680 DOI: 10.3390/antibiotics12121696] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The objective was to identify associations between beta-lactam pharmacokinetic/pharmacodynamic (PK/PD) targets and Gram-negative bacteria resistance emergence in patients. METHODS Retrospective data were collected between 2016 to 2019 at the University of Florida Health-Shands Hospital in Gainesville, FL. Adult patients with two Gram-negative isolates receiving cefepime, meropenem, or piperacillin-tazobactam and who had plasma beta-lactam concentrations were included. Beta-lactam exposures and time free drug concentrations that exceeded minimum inhibitory concentrations (ƒT > MIC), four multiples of MIC (ƒT > 4× MIC), and free area under the time concentration curve to MIC (ƒAUC/MIC) were generated. Resistance emergence was defined as any increase in MIC or two-fold increase in MIC. Multiple regression analysis assessed the PK/PD parameter impact on resistance emergence. RESULTS Two hundred fifty-six patients with 628 isolates were included. The median age was 58 years, and 59% were males. Cefepime was the most common beta-lactam (65%) and Pseudomonas aeruginosa the most common isolate (43%). The mean daily ƒAUC/MIC ≥ 494 was associated with any increase in MIC (p = 0.002) and two-fold increase in MIC (p = 0.004). The daily ƒAUC/MIC ≥ 494 was associated with decreased time on antibiotics (p = 0.008). P. aeruginosa was associated with any increase in MIC (OR: 6.41, 95% CI [3.34-12.28]) or 2× increase in MIC (7.08, 95% CI [3.56-14.07]). CONCLUSIONS ƒAUC/MIC ≥ 494 may be associated with decreased Gram-negative resistance emergence.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
| | - Jessica Webber
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
| | - Timothy W. Felton
- North West Ventilation Unit, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
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Yang H, Antwi S, Maranchick N, Dompreh A, Amissah AK, Sly-Moore E, Martyn-Dickens C, Opoku T, Enimil A, Bosomtwe D, Ojewale O, Sarfo AD, Appiah AF, Kusi-Amponsah I, Dong SK, Osei Kuffour B, Morgan R, Alshaer MH, Peloquin CA, Kwara A. Effect of HIV infection on plasma exposure to first-line TB drugs and target attainment in children. Int J Tuberc Lung Dis 2023; 27:931-937. [PMID: 38042977 DOI: 10.5588/ijtld.23.0184] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND: Whether HIV infection adversely affects exposure to first-line TB drugs in children is debatable. It is also not known whether HIV infection increases the risk of plasma underexposure or overexposure to TB drugs. This study sought to address these questions.DESIGN/METHODS: Children on TB treatment were enrolled. After 4 weeks on therapy, blood samples were collected at pre-dose, 1, 2, 4, 8, and 12 h post-dose for pharmacokinetic analysis. Plasma drug exposure below and above the lower and upper bounds of the 95% confidence intervals of the reference mean for children were considered underexposure and overexposure, respectively. The effect of HIV infection on drugs exposure and risk of underexposure were examined using multivariate analysis.RESULTS: Of 86 participants (median age: 4.9 years), 45 had HIV coinfection. HIV coinfection was associated with lower pyrazinamide (PZA) and ethambutol exposures in adjusted analysis. Patients with TB-HIV coinfection were three times more likely to have PZA underexposure than those with TB only. Underexposure of rifampin was common irrespective of HIV coinfection status.CONCLUSIONS: HIV coinfection was associated with a higher risk for PZA underexposure in children. This effect should be accounted for in models and simulations to determine optimal PZA dose for children.
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Affiliation(s)
- H Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - S Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - N Maranchick
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - A Dompreh
- Department of Clinical Microbiology, Komfo Anokye Teaching Hospital, Kumasi, Department of Medical Diagnostics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - A K Amissah
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - E Sly-Moore
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - C Martyn-Dickens
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - T Opoku
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - A Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - D Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - O Ojewale
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - A D Sarfo
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - A F Appiah
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi
| | - I Kusi-Amponsah
- Department of Clinical Microbiology, Komfo Anokye Teaching Hospital, Kumasi
| | - S K Dong
- Department of Pharmacy, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - B Osei Kuffour
- Department of Pharmacy, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - R Morgan
- Department of Pharmacy, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - M H Alshaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - A Kwara
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA, Medical Service, North Florida South Georgia Veterans Health System, Gainesville, FL, USA
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10
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Xie YL, Modi N, Handler D, Yu S, Rao P, Kagan L, Petros de Guex K, Reiss R, Siemiątkowska A, Narang A, Narayanan N, Hearn J, Khalil A, Woods P, Young L, Lardizabal A, Subbian S, Peloquin CA, Vinnard C, Thomas TA, Heysell SK. Simplified urine-based method to detect rifampin underexposure in adults with tuberculosis: a prospective diagnostic accuracy study. Antimicrob Agents Chemother 2023; 67:e0093223. [PMID: 37877727 PMCID: PMC10648923 DOI: 10.1128/aac.00932-23] [Citation(s) in RCA: 1] [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: 07/19/2023] [Accepted: 08/28/2023] [Indexed: 10/26/2023] Open
Abstract
Variable pharmacokinetics of rifampin in tuberculosis (TB) treatment can lead to poor outcomes. Urine spectrophotometry is simpler and more accessible than recommended serum-based drug monitoring, but its optimal efficacy in predicting serum rifampin underexposure in adults with TB remains uncertain. Adult TB patients in New Jersey and Virginia receiving rifampin-containing regimens were enrolled. Serum and urine samples were collected over 24 h. Rifampin serum concentrations were measured using validated liquid chromatography-tandem mass spectrometry, and total exposure (area under the concentration-time curve) over 24 h (AUC0-24) was determined through noncompartmental analysis. The Sunahara method was used to extract total rifamycins, and rifampin urine excretion was measured by spectrophotometry. An analysis of 58 eligible participants, including 15 (26%) with type 2 diabetes mellitus, demonstrated that urine spectrophotometry accurately identified subtarget rifampin AUC0-24 at 0-4, 0-8, and 0-24 h. The area under the receiver operator characteristic curve (AUC ROC) values were 0.80 (95% CI 0.67-0.90), 0.84 (95% CI 0.72-0.94), and 0.83 (95% CI 0.72-0.93), respectively. These values were comparable to the AUC ROC of 2 h serum concentrations commonly used for therapeutic monitoring (0.82 [95% CI 0.71-0.92], P = 0.6). Diabetes status did not significantly affect the AUC ROCs for urine in predicting subtarget rifampin serum exposure (P = 0.67-0.92). Spectrophotometric measurement of urine rifampin excretion within the first 4 or 8 h after dosing is a simple and cost-effective test that accurately predicts rifampin underexposure. This test provides critical information for optimizing tuberculosis treatment outcomes by facilitating appropriate dose adjustments.
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Affiliation(s)
- Yingda L. Xie
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Nisha Modi
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Deborah Handler
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sijia Yu
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, State University of New Jersey, Piscataway, New Jersey, USA
| | - Prakruti Rao
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | - Leonid Kagan
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, State University of New Jersey, Piscataway, New Jersey, USA
| | - Kristen Petros de Guex
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | - Robert Reiss
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Anna Siemiątkowska
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, State University of New Jersey, Piscataway, New Jersey, USA
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Anshika Narang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Navaneeth Narayanan
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, State University of New Jersey, Piscataway, New Jersey, USA
| | - Jasie Hearn
- Virginia Department of Health, Richmond, USA
| | | | | | - Laura Young
- Virginia Department of Health, Richmond, USA
| | - Alfred Lardizabal
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Selvakumar Subbian
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | | | - Tania A. Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | - Scott K. Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
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11
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Séraphin MN, Bellot J, Klann E, Ukhanova M, Saulsberry FG, Peloquin CA, Mai V. Gut microbiota composition and diversity before, during, and two months after rifamycin-based tuberculosis preventive therapy. Sci Rep 2023; 13:18933. [PMID: 37919333 PMCID: PMC10622450 DOI: 10.1038/s41598-023-44854-5] [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: 11/25/2022] [Accepted: 10/12/2023] [Indexed: 11/04/2023] Open
Abstract
Tuberculosis (TB) preventive therapy (TPT) is an effective strategy to eliminate TB in low-incidence settings. Shorter TPT regimens incorporating the antimicrobial class of rifamycins are designed to improve adherence and completion rates but carry the risk of modifications to the gut microbiota. We enrolled six subjects diagnosed with latent TB infection (LTBI) who accepted to initiate TPT. We also enrolled six healthy volunteers unexposed to the rifamycins. We profiled the gut microbiota using 16S rRNA amplicon sequencing (V1-V2 region) to document the immediate effect of rifamycin-based TPT on the gut microbiota composition and tracked recovery to baseline two months after TPT. Overall, TPT accounted for 17% of the variance in gut microbial community dissimilarity. This rifamycin-based TPT induced dysbiosis was characterized by a depletion of butyrate-producing taxa (Clostridium-XIVa and Roseburia) and expansion of potentially pathogenic taxa within the Firmicutes and Proteobacteria phyla. Recovery of the gut microbial composition was incomplete two months after TPT. Robust clinical studies are necessary to comprehensively catalogue TPT-induced gut microbiota dysbiosis to inform strategies to mitigate potential long-term sequelae of this important TB control intervention.
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Affiliation(s)
- Marie Nancy Séraphin
- Department of Medicine, Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA.
| | - Julia Bellot
- Department of Medicine, Division of Infectious Diseases and Global Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Klann
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Maria Ukhanova
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Florence G Saulsberry
- Florida Department of Health in Alachua County, Disease Control Unit, Alachua County Health Department, Gainesville, FL, USA
| | - Charles A Peloquin
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Volker Mai
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
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12
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Alshaer MH, Williams R, Mousa MJ, Alexander KM, Maguigan KL, Manigaba K, Maranchick N, Shoulders BR, Felton TW, Mathew SK, Peloquin CA. Cefepime Daily Exposure and the Associated Impact on the Change in Sequential Organ Failure Assessment Scores and Vasopressors Requirement in Critically Ill Patients Using Repeated-Measures Mixed-Effect Modeling. Crit Care Explor 2023; 5:e0993. [PMID: 38304706 PMCID: PMC10833631 DOI: 10.1097/cce.0000000000000993] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
IMPORTANCE Sepsis and septic shock are major healthcare problems that need early and appropriate management. OBJECTIVES To evaluate the association of daily cefepime pharmacokinetic/pharmacodynamic (PK/PD) parameters with change in Sequential Organ Failure Assessment (SOFA) score and vasopressors requirement. DESIGN SETTING AND PARTICIPANTS This is a retrospective study. Adult ICU patients who received cefepime for Gram-negative pneumonia or bloodstream infection (BSI) and had cefepime concentrations measured were included. Daily cefepime exposure was generated and PK/PD parameters calculated for patients. Repeated-measures mixed-effect modeling was used to evaluate the impact of PK/PD on the outcomes. MAIN OUTCOMES AND MEASURES Change in daily SOFA score and vasopressors requirement. RESULTS A total of 394 and 207 patients were included in the SOFA and vasopressors analyses, respectively. The mean (±sd) age was 55 years (19) and weight 81 kg (29). For the change in SOFA score, daily SOFA score, mechanical ventilation, renal replacement therapy, and number of vasopressors were included. In the vasopressors analysis, daily SOFA score, day of therapy, and hydrocortisone dose were significant covariates in the final model. Achieving cefepime concentrations above the minimum inhibitory concentration (MIC) (T>MIC) for 100% of the dosing interval was associated with 0.006 µg/kg/min decrease in norepinephrine-equivalent dose. Cefepime PK/PD did not have an impact on the daily change in SOFA score. CONCLUSIONS AND RELEVANCE Achieving 100% T>MIC was associated with negligible decrease in vasopressors requirement in ICU patients with Gram-negative pneumonia and BSI. There was no impact on the change in SOFA score.
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Affiliation(s)
- Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Roy Williams
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Mays J Mousa
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Kaitlin M Alexander
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Kelly L Maguigan
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Kayihura Manigaba
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Bethany R Shoulders
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Timothy W Felton
- North West Ventilation Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Sumith K Mathew
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
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13
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Köhler N, Karaköse H, Grobbel HP, Hillemann D, Andres S, König C, Kalsdorf B, Brehm TT, Böttcher L, Friesen I, Hoffmann H, Strelec D, Schaub D, Peloquin CA, Schmiedel S, Decosterd LA, Choong E, Wicha SG, Aarnoutse RE, Lange C, Sánchez Carballo PM. A Single-Run HPLC-MS Multiplex Assay for Therapeutic Drug Monitoring of Relevant First- and Second-Line Antibiotics in the Treatment of Drug-Resistant Tuberculosis. Pharmaceutics 2023; 15:2543. [PMID: 38004523 PMCID: PMC10674734 DOI: 10.3390/pharmaceutics15112543] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
The treatment of drug-resistant Mycobacterium tuberculosis relies on complex antibiotic therapy. Inadequate antibiotic exposure can lead to treatment failure, acquired drug resistance, and an increased risk of adverse events. Therapeutic drug monitoring (TDM) can be used to optimize the antibiotic exposure. Therefore, we aimed to develop a single-run multiplex assay using high-performance liquid chromatography-mass spectrometry (HPLC-MS) for TDM of patients with multidrug-resistant, pre-extensively drug-resistant and extensively drug-resistant tuberculosis. A target profile for sufficient performance, based on the intended clinical application, was established and the assay was developed accordingly. Antibiotics were analyzed on a zwitterionic hydrophilic interaction liquid chromatography column and a triple quadrupole mass spectrometer using stable isotope-labeled internal standards. The assay was sufficiently sensitive to monitor drug concentrations over five half-lives for rifampicin, rifabutin, levofloxacin, moxifloxacin, bedaquiline, linezolid, clofazimine, terizidone/cycloserine, ethambutol, delamanid, pyrazinamide, meropenem, prothionamide, and para-amino salicylic acid (PAS). Accuracy and precision were sufficient to support clinical decision making (≤±15% in clinical samples and ±20-25% in spiked samples, with 80% of future measured concentrations predicted to fall within ±40% of nominal concentrations). The method was applied in the TDM of two patients with complex drug-resistant tuberculosis. All relevant antibiotics from their regimens could be quantified and high-dose therapy was initiated, followed by microbiological conversion. In conclusion, we developed a multiplex assay that enables TDM of the relevant first- and second-line anti-tuberculosis medicines in a single run and was able to show its applicability in TDM of two drug-resistant tuberculosis patients.
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Affiliation(s)
- Niklas Köhler
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
| | - Hande Karaköse
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Bioanalytical Chemistry, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
| | - Hans-Peter Grobbel
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
| | - Doris Hillemann
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, 23845 Borstel, Germany
| | - Sönke Andres
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, 23845 Borstel, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Department of Pharmacy, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Barbara Kalsdorf
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
| | - Thomas Theo Brehm
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, 20246 Hamburg, Germany
| | - Laura Böttcher
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
| | - Inna Friesen
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, 23845 Borstel, Germany
| | - Harald Hoffmann
- Institute of Microbiology and Laboratory Medicine, World Health Organization Supranational Reference Laboratory of TB, IML red GmbH, 82131 Gauting, Germany
- SYNLAB Gauting, SYNLAB MVZ of Human Genetics Munich, 82131 Gauting, Germany
| | - Dražen Strelec
- Department for Lung Diseases, Hospital for Lung Diseases and Tuberculosis, 42244 Klenovnik, Croatia
| | - Dagmar Schaub
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Stefan Schmiedel
- Division of Infectious Diseases, I. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, 20246 Hamburg, Germany
| | - Laurent A. Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Eva Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | | | - Rob E. Aarnoutse
- Department of Pharmacy, Radboud Institute for Medical Innovation, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Christoph Lange
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
- Baylor College of Medicine and Texas Childrens’ Hospital, Houston, TX 77030, USA
| | - Patricia M. Sánchez Carballo
- Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, 23845 Borstel, Germany
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, 23845 Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, 23562 Lübeck, Germany
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14
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Haley CA, Schechter MC, Ashkin D, Peloquin CA, Peter Cegielski J, Andrino BB, Burgos M, Caloia LA, Chen L, Colon-Semidey A, DeSilva MB, Dhanireddy S, Dorman SE, Dworkin FF, Hammond-Epstein H, Easton AV, Gaensbauer JT, Ghassemieh B, Gomez ME, Horne D, Jasuja S, Jones BA, Kaplan LJ, Khan AE, Kracen E, Labuda S, Landers KM, Lardizabal AA, Lasley MT, Letzer DM, Lopes VK, Lubelchek RJ, Patricia Macias C, Mihalyov A, Misch EA, Murray JA, Narita M, Nilsen DM, Ninneman MJ, Ogawa L, Oladele A, Overman M, Ray SM, Ritger KA, Rowlinson MC, Sabuwala N, Schiller TM, Schwartz LE, Spitters C, Thomson DB, Tresgallo RR, Valois P, Goswami ND. Implementation of Bedaquiline, Pretomanid, and Linezolid in the United States: Experience Using a Novel All-Oral Treatment Regimen for Treatment of Rifampin-Resistant or Rifampin-Intolerant Tuberculosis Disease. Clin Infect Dis 2023; 77:1053-1062. [PMID: 37249079 PMCID: PMC11001496 DOI: 10.1093/cid/ciad312] [Citation(s) in RCA: 2] [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: 02/07/2023] [Revised: 03/20/2023] [Accepted: 05/27/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Rifampin-resistant tuberculosis is a leading cause of morbidity worldwide; only one-third of persons start treatment, and outcomes are often inadequate. Several trials demonstrate 90% efficacy using an all-oral, 6-month regimen of bedaquiline, pretomanid, and linezolid (BPaL), but significant toxicity occurred using 1200-mg linezolid. After US Food and Drug Administration approval in 2019, some US clinicians rapidly implemented BPaL using an initial 600-mg linezolid dose adjusted by serum drug concentrations and clinical monitoring. METHODS Data from US patients treated with BPaL between 14 October 2019 and 30 April 2022 were compiled and analyzed by the BPaL Implementation Group (BIG), including baseline examination and laboratory, electrocardiographic, and clinical monitoring throughout treatment and follow-up. Linezolid dosing and clinical management was provider driven, and most patients had linezolid adjusted by therapeutic drug monitoring. RESULTS Of 70 patients starting BPaL, 2 changed to rifampin-based therapy, 68 (97.1%) completed BPaL, and 2 of the 68 (2.9%) experienced relapse after completion. Using an initial 600-mg linezolid dose daily adjusted by therapeutic drug monitoring and careful clinical and laboratory monitoring for adverse effects, supportive care, and expert consultation throughout BPaL treatment, 3 patients (4.4%) with hematologic toxicity and 4 (5.9%) with neurotoxicity required a change in linezolid dose or frequency. The median BPaL duration was 6 months. CONCLUSIONS BPaL has transformed treatment for rifampin-resistant or intolerant tuberculosis. In this cohort, effective treatment required less than half the duration recommended in 2019 US guidelines for drug-resistant tuberculosis. Use of individualized linezolid dosing and monitoring likely enhanced safety and treatment completion. The BIG cohort demonstrates that early implementation of new tuberculosis treatments in the United States is feasible.
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Affiliation(s)
- Connie A Haley
- Southeastern National Tuberculosis Center, Division of Infectious Diseases and Global Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, Florida, USA
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcos C Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia State Tuberculosis Program, Atlanta, Georgia, USA
| | - David Ashkin
- Southeastern National Tuberculosis Center, Division of Infectious Diseases and Global Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Translational Research, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - J Peter Cegielski
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Marcos Burgos
- New Mexico Department of Health, Santa Fe, New Mexico, USA
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico, USA
| | - Lori A Caloia
- Louisville Metro Department of Public Health and Wellness, Louisville, Kentucky, USA
- Humana Healthy Horizons in Kentucky, Louisville, Kentucky, USA
| | - Lisa Chen
- Curry International Tuberculosis Center, University of California, San Francisco, California, USA
| | | | - Malini B DeSilva
- Saint Paul–Ramsey County Public Health, Saint Paul, Minnesota, USA
- HealthPartners Institute, Bloomington, Minnesota, USA
| | - Shireesha Dhanireddy
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan E Dorman
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- South Carolina Department of Health and Environmental Control, Greenville, South Carolina, USA
| | - Felicia F Dworkin
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | - Heidi Hammond-Epstein
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | - Alice V Easton
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | - James T Gaensbauer
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan Ghassemieh
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Maria E Gomez
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | - David Horne
- Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Supriya Jasuja
- Cook County Department of Public Health, Forest Park, Illinois, USA
| | - Betsy A Jones
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
| | - Leonard J Kaplan
- Division of Infectious Diseases, Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Elizabeth Kracen
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sarah Labuda
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Puerto Rico Department of Health, San Juan, Puerto Rico, USA
| | - Karen M Landers
- Alabama Department of Public Health, Montgomery, Alabama, USA
| | | | - Maria T Lasley
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | | | - Vinicius K Lopes
- Sheboygan County Health and Human Services, Sheboygan, Wisconsin, USA
- Southern California Infectious Diseases Associates, Inc., Newport Beach, California, USA
| | - Ronald J Lubelchek
- Cook County Department of Public Health, Forest Park, Illinois, USA
- Division of Infectious Diseases, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - C Patricia Macias
- Health Transformation Program NorthShore University, Chicago, Illinois, USA
- The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Aimee Mihalyov
- Louisville Metro Department of Public Health and Wellness, Louisville, Kentucky, USA
| | - Elizabeth Ann Misch
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jason A Murray
- Emergency Medicine, Saint Elizabeth Healthcare System, Edgewood, Kentucky, USA
- Northern Kentucky Health Department, Florence, Kentucky, USA
| | - Masahiro Narita
- Public Health—Seattle & King County, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Diana M Nilsen
- New York City Department of Health and Mental Hygiene, Bureau of Tuberculosis Control, New York, New York, USA
| | | | - Lynne Ogawa
- Saint Paul–Ramsey County Public Health, Saint Paul, Minnesota, USA
| | | | - Melissa Overman
- South Carolina Department of Health and Environmental Control, Greenville, South Carolina, USA
| | - Susan M Ray
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Georgia State Tuberculosis Program, Atlanta, Georgia, USA
| | | | - Marie-Claire Rowlinson
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
- Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Nadya Sabuwala
- Minnesota Department of Health, Saint Paul, Minnesota, USA
| | | | | | - Christopher Spitters
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Snohomish County Health Department, Everett, Washington, USA
- Washington State Department of Health, Shoreline, Washington, USA
| | - Douglas B Thomson
- Barren River District Health Department, Bowling Green, Kentucky, USA
| | - Rene Rico Tresgallo
- Department of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA
| | - Patrick Valois
- Bureau of Public Health Laboratories, Florida State Tuberculosis Program, Jacksonville, Florida, USA
| | - Neela D Goswami
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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15
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Jin Y, Benkeser D, Kipiani M, Maranchick NF, Mikiashvili L, Barbakadze K, Avaliani Z, Alghamdi WA, Alshaer MH, Peloquin CA, Blumberg HM, Kempker RR. The effect of anti-tuberculosis drug pharmacokinetics on QTc prolongation. Int J Antimicrob Agents 2023; 62:106939. [PMID: 37517627 PMCID: PMC10538394 DOI: 10.1016/j.ijantimicag.2023.106939] [Citation(s) in RCA: 1] [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: 12/15/2022] [Revised: 04/19/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Implementation of newer anti-tuberculosis (TB) drugs may prolong the QT interval, increasing the risk of arrythmias and sudden cardiac death. The potential for cardiac adverse events has prompted recommendations for frequent cardiac monitoring during treatment. However, unknowns remain, including the association between drug concentrations and QT interval. METHODS An observational prospective cohort study design was used. Patients undergoing treatment for drug-resistant TB in Georgia were assessed. Serial blood samples were collected at 4-6 weeks for pharmacokinetics. Electrocardiograms were recommended to be performed monthly. A generalized estimating equation spline model was used to investigate (1) the effect difference between bedaquiline and delamanid, (2) the cumulative effect of number of anti-TB drugs, and (3) the relationship between serum drug concentrations on QTc interval. RESULTS Among 94 patients receiving either bedaquiline (n = 64) or delamanid (n = 30)-based treatment, most were male (82%), and the mean age was 39 years. The mean maximum QTc increase during the first six months was 37.5 ms (IQR: 17.8-56.8). Bedaquiline- and delamanid-based regimens displayed similar increased mean QTc change from baseline during drug administration (P = 0.12). Increasing number of anti-TB drugs was associated with an increased QTc (P = 0.01), but participants trended back towards baseline after drug discontinuation (P = 0.25). A significant association between AUC, Cmin, Cmax, and increased QTc interval was found for bedaquiline (months 1-6) and levofloxacin (months 1-12). CONCLUSION Bedaquiline- and delamanid-based regimens and increasing number of QT prolonging agents led to modest increases in the QTc interval with minimal clinical effect.
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Affiliation(s)
- Yutong Jin
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.
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16
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Chang J, Liu J, Alshaer MH, Venugopalan V, Maranchick N, Peloquin CA, Rhodes NJ, Scheetz MH. Making the case for precision dosing: visualizing the variability of cefepime exposures in critically ill adults. J Antimicrob Chemother 2023; 78:2170-2174. [PMID: 37449472 PMCID: PMC10686690 DOI: 10.1093/jac/dkad211] [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: 04/03/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To investigate and describe the variability in cefepime exposures among 'real-world', critically ill patients by using population pharmacokinetic modelling and simulations, and with translation of these findings to visualizations. METHODS A cohort of adult medical ICU patients who received cefepime with therapeutic drug monitoring was studied. Two compartment models were developed to estimate cefepime clearance (Model 1) and simulate cefepime exposures among 1000 patients, each with identical creatinine clearance of 60 mL/min and receiving a regimen of cefepime 1 gram IV over 30 minutes, every 8 hours (Model 2). Variability in the relationship between cefepime clearance and creatinine clearance (CrCL) was visualized, and a random, representative sample of 10 simulated patients was utilized to illustrate variability in cefepime exposures. RESULTS A total of 75 adult medical ICU patients (52% female) and 98 serum cefepime samples were included in the study. Population parameter estimates for cefepime displayed a wide range of variation in Model 1 (CV: 45% to 95%), with low bias at the individual level at 0.226 mg/L but high bias in the population model 10.6 mg/L. Model 2 displayed similar fits, demonstrating that correcting for individual patient creatinine clearance slightly improves the bias of the population model (bias = 4.31 mg/L). Among 10 simulated patients that a clinician would deem similar from a dosing perspective (i.e. equivalent creatinine clearance), maximum concentrations after three simulated doses varied more than 8-fold from 41.2 to 339 mg/L at the 5th and 95th percentiles, and clearance profiles were highly different. CONCLUSION Creatinine clearance estimates alone are inadequate for predicting cefepime exposures. Wide variations in cefepime exposure exist among ICU patients, even for those with similar kidney function estimates. Current population adjustment schemes based solely on creatinine clearance will result in unintended high and low exposures leading to safety and efficacy concerns, respectively.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jiajun Liu
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, United States Food and Drug Administration, Silver Spring, MD, USA
- Work was carried out while employed at Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, 555 31st St., Downers Grove, IL 60515, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
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17
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Thomas TA, Lukumay S, Yu S, Rao P, Siemiątkowska A, Kagan L, Augustino D, Mejan P, Mosha R, Handler D, Petros de Guex K, Mmbaga B, Pfaeffle H, Reiss R, Peloquin CA, Vinnard C, Mduma E, Xie YL, Heysell SK. Rifampin urinary excretion to predict serum targets in children with tuberculosis: a prospective diagnostic accuracy study. Arch Dis Child 2023; 108:616-621. [PMID: 37171408 PMCID: PMC10766442 DOI: 10.1136/archdischild-2022-325250] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/13/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Pharmacokinetic variability drives tuberculosis (TB) treatment outcomes but measurement of serum drug concentrations for personalised dosing is inaccessible for children in TB-endemic settings. We compared rifampin urine excretion for prediction of a serum target associated with treatment outcome. DESIGN Prospective diagnostic accuracy study. SETTING Inpatient wards and outpatient clinics, northern Tanzania. PATIENTS Children aged 4-17 years were consecutively recruited on initiation of WHO-approved treatment regimens. INTERVENTIONS Samples were collected after directly observed therapy at least 2 weeks after initiation in the intensive phase: serum at pre-dose and 1, 2 and 6 hours post-dose, later analysed by liquid chromatography-tandem mass spectrometry for calculation of rifampin total exposure or area under the concentration time curve (AUC0-24); urine at post-dose intervals of 0-4, 4-8 and 8-24 hours, with rifampin excretion amount measured onsite by spectrophotometry. MAIN OUTCOME MEASURES Receiver operating characteristic (ROC) curve for percentage of rifampin dose excreted in urine measured by spectrophotometry to predict serum rifampin AUC0-24 target of 31.7 mg*hour/L. RESULTS 89 children, 52 (58%) female, with median age of 9.1 years, had both serum and urine collection. Only 59 (66%) reached the serum AUC0-24 target, reflected by a range of urine excretion patterns. Area under the ROC curve for percentage of rifampin dose excreted in urine over 24 hours predicting serum AUC0-24 target was 69.3% (95% CI 56.7% to 81.8%), p=0.007. CONCLUSIONS Urine spectrophotometry correlated with a clinically relevant serum target for rifampin, representing a step toward personalised dosing for children in TB-endemic settings.
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Affiliation(s)
- Tania A Thomas
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Saning'o Lukumay
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Sijia Yu
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Prakruti Rao
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Anna Siemiątkowska
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
- Pharmacy, Poznań University, Poznan, Poland
| | - Leonid Kagan
- Pharmacy, Rutgers The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Domitila Augustino
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Paulo Mejan
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Restituta Mosha
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Deborah Handler
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kristen Petros de Guex
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Blandina Mmbaga
- Department of Pediatrics, Kilimanjaro Christian Medical College, Moshi, Tanzania, United Republic of
| | - Herman Pfaeffle
- Department of Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - Robert Reiss
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | - Christopher Vinnard
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Estomih Mduma
- Department of Global Health Research, Haydom Lutheran Hospital, Mbulu, Tanzania, United Republic of
| | - Yingda L Xie
- Department of Medicine, Infectious Diseases, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Scott K Heysell
- Department of Medicine, Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
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18
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Martyn-Dickens C, Ojewale O, Sly-Moore E, Dompreh A, Enimil A, Amissah AK, Bosomtwe D, Frimpong Appiah A, Sarfo AD, Opoku T, Asiedu P, Dong SK, Kusi-Amponsah I, Maranchick N, Peloquin CA, Antwi S, Kwara A. Pharmacokinetics and pharmacodynamics of adult dolutegravir tablets in treatment-experienced children with HIV weighing at least 20 kg. AIDS 2023; 37:1409-1417. [PMID: 37070558 PMCID: PMC10330225 DOI: 10.1097/qad.0000000000003576] [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] [Indexed: 04/19/2023]
Abstract
OBJECTIVE Limited pharmacokinetic/pharmacodynamic data are a barrier to the scale-up of dolutegravir-based antiretroviral therapy (ART) in children. We examined the pharmacokinetics/pharmacodynamics of the adult film-coated dolutegravir 50 mg tablets in children with HIV infection weighing at least 20 kg. DESIGN A prospective, observational, pharmacokinetic, and safety study. METHODS Treatment-experienced children with HIV weighing at least 20 kg and evidence of viral load suppression on ART were enrolled and switched to dolutegravir-based therapy. After at least 4 weeks and 7 months on dolutegravir-based therapy, blood samples were collected at 0, 1, 4, 8, 12, and 24-h postdose. Dolutegravir concentrations were measured using validated LCMS/MS and pharmacokinetic parameters calculated by noncompartmental analysis. Descriptive statistics were used to summarize pharmacokinetic parameters and comparisons with published reference values. RESULTS Of 25 participants, 92% were on efavirenz-based ART and 60.0% were men. Dolutegravir mean exposure, peak and trough concentrations at both pharmacokinetic visits were higher than the mean reference values in adults and children weighing 20 kg to less than 40 kg treated with 50 mg once daily, but were closer to the mean values in adults given 50 mg twice a day. Children weighing 20 kg to less than 40 kg had even higher dolutegravir exposures. The regimens were well tolerated with good virologic efficacy through week 48. CONCLUSION The higher dolutegravir exposure in our study population suggests that further studies and close monitoring should investigate the adverse effects of dolutegravir in more children and in the long term.
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Affiliation(s)
| | - Oluwayemisi Ojewale
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Eugenia Sly-Moore
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Albert Dompreh
- Department of Clinical Microbiology, Komfo Anokye Teaching Hospital
- Department of Medical Diagnostics
| | - Anthony Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology
| | | | - Dennis Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Ama D Sarfo
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Theresah Opoku
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Priscilla Asiedu
- Department of Pharmacy, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Stephen K Dong
- Department of Pharmacy, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida
| | - Sampson Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology
| | - Awewura Kwara
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
- Medical Service, North Florida South Georgia Veterans Health System, Gainesville, Florida, USA
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19
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Kempker RR, Kipiani M, Peloquin CA. Reply to Upton et al. Clin Infect Dis 2023; 77:158-159. [PMID: 36978221 DOI: 10.1093/cid/ciad188] [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: 03/14/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Affiliation(s)
- Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
- The University of Georgia, Tbilisi, Georgia, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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20
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Singh KP, Carvalho ACC, Centis R, D Ambrosio L, Migliori GB, Mpagama SG, Nguyen BC, Aarnoutse RE, Aleksa A, van Altena R, Bhavani PK, Bolhuis MS, Borisov S, van T Boveneind-Vrubleuskaya N, Bruchfeld J, Caminero JA, Carvalho I, Cho JG, Davies Forsman L, Dedicoat M, Dheda K, Dooley K, Furin J, García-García JM, Garcia-Prats A, Hesseling AC, Heysell SK, Hu Y, Kim HY, Manga S, Marais BJ, Margineanu I, Märtson AG, Munoz Torrico M, Nataprawira HM, Nunes E, Ong CWM, Otto-Knapp R, Palmero DJ, Peloquin CA, Rendon A, Rossato Silva D, Ruslami R, Saktiawati AMI, Santoso P, Schaaf HS, Seaworth B, Simonsson USH, Singla R, Skrahina A, Solovic I, Srivastava S, Stocker SL, Sturkenboom MGG, Svensson EM, Tadolini M, Thomas TA, Tiberi S, Trubiano J, Udwadia ZF, Verhage AR, Vu DH, Akkerman OW, Alffenaar JWC, Denholm JT. Clinical standards for the management of adverse effects during treatment for TB. Int J Tuberc Lung Dis 2023; 27:506-519. [PMID: 37353868 PMCID: PMC10321364 DOI: 10.5588/ijtld.23.0078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND: Adverse effects (AE) to TB treatment cause morbidity, mortality and treatment interruption. The aim of these clinical standards is to encourage best practise for the diagnosis and management of AE.METHODS: 65/81 invited experts participated in a Delphi process using a 5-point Likert scale to score draft standards.RESULTS: We identified eight clinical standards. Each person commencing treatment for TB should: Standard 1, be counselled regarding AE before and during treatment; Standard 2, be evaluated for factors that might increase AE risk with regular review to actively identify and manage these; Standard 3, when AE occur, carefully assessed and possible allergic or hypersensitivity reactions considered; Standard 4, receive appropriate care to minimise morbidity and mortality associated with AE; Standard 5, be restarted on TB drugs after a serious AE according to a standardised protocol that includes active drug safety monitoring. In addition: Standard 6, healthcare workers should be trained on AE including how to counsel people undertaking TB treatment, as well as active AE monitoring and management; Standard 7, there should be active AE monitoring and reporting for all new TB drugs and regimens; and Standard 8, knowledge gaps identified from active AE monitoring should be systematically addressed through clinical research.CONCLUSION: These standards provide a person-centred, consensus-based approach to minimise the impact of AE during TB treatment.
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Affiliation(s)
- K P Singh
- Department of Infectious diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia, Victorian Infectious Disease Unit, Royal Melbourne Hospital, VIC, Australia
| | - A C C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - S G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania, Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, United Republic of Tanzania
| | - B C Nguyen
- Woolcock Institute of Medical Research, Viet Nam and University of Sydney, NSW, Australia
| | - R E Aarnoutse
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Aleksa
- Grodno State Medical University, Grodno, Belarus
| | - R van Altena
- Asian Harm Reduction Network (AHRN) and Medical Action Myanmar (MAM), Yangon, Myanmar
| | - P K Bhavani
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - M S Bolhuis
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - S Borisov
- Moscow Research and Clinical Center for Tuberculosis Control, Moscow, Russia
| | - N van T Boveneind-Vrubleuskaya
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands, Department of Public Health TB Control, Metropolitan Public Health Services, The Hague, The Netherlands
| | - J Bruchfeld
- Departement of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Stokholm, Sweden, Departement of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J A Caminero
- Department of Pneumology. University General Hospital of Gran Canaria "Dr Negrin", Las Palmas, Spain, ALOSA (Active Learning over Sanitary Aspects) TB Academy, Spain
| | - I Carvalho
- Paediatric Department, Vila Nova de Gaia Hospital Centre, Vila Nova de Gaia Outpatient Tuberculosis Centre, Vila Nova de Gaia, Portugal
| | - J G Cho
- Sydney Infecious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Parramatta Chest Clinic, Parramatta, NSW, Australia
| | - L Davies Forsman
- Departement of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Stokholm, Sweden, Departement of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - M Dedicoat
- Department of Infectious Diseases, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - K Dheda
- Centre for Lung Infection and Immunity Unit, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa, South African Medical Research Council Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - K Dooley
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - J M García-García
- Tuberculosis Research Programme, SEPAR (Sociedad Española de Neumología y Cirugía Torácica), Barcelona, Spain
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa, Department of Pediatrics, University of Wisconsin, Madison, WI, USA
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Y Hu
- Department of Epidemiology, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai, China
| | - H Y Kim
- Sydney Infecious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - S Manga
- Tuberculosis Department Latin American Society of Thoracic Diseases, Lima, Peru
| | - B J Marais
- Sydney Infecious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia, Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia
| | - I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - A-G Märtson
- Centre of Excellence in Infectious Diseases Research, Antimicrobial Pharmacodynamics and Therapeutics Group, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - M Munoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
| | - H M Nataprawira
- Division of Paediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - E Nunes
- Department of Pulmonology of Central Hospital of Maputo, Maputo, Mozambique, Faculty of Medicine of Eduardo Mondlane University, Maputo, Mozambique
| | - C W M Ong
- Infectious Disease Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - R Otto-Knapp
- German Central Committee Against Tuberculosis (DZK), Berlin, Germany
| | - D J Palmero
- Hospital Muniz and Instituto Vaccarezza, Buenos Aires, Argentina
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - A Rendon
- Universidad Autonoma de Nuevo Leon, Facultad de Medicina, Neumología, CIPTIR, Monterrey, Mexico
| | - D Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - R Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - A M I Saktiawati
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia, Centre for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - P Santoso
- Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - H S Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - B Seaworth
- University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - U S H Simonsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - R Singla
- Department of TB & Respiratory Diseases, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - A Skrahina
- Republican Research and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - I Solovic
- National Institute of Tuberculosis, Lung Diseases and Thoracic Surgery, Faculty of Health, Catholic University, Ružomberok, Vyšné Hágy, Slovakia
| | - S Srivastava
- University of Texas Health Science Center at Tyler, Tyler, TX, USA, Department of Medicine, The University of Texas at Tyler School of Medicine, TX, USA, Department of Pharmacy Practice, Texas Tech University Health Science Center, Dallas, TX, USA
| | - S L Stocker
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia, Department of Clinical Pharmacology and Toxicology, St Vincent´s Hospital, Sydney, NSW, Australia
| | - M G G Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - E M Svensson
- Department of Pharmacy, Research Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - M Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant´Orsola, Bologna, Italy, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - J Trubiano
- Department of Infectious diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia, Department of Infectious Diseases, Austin Hospital, Melbourne, VIC, Australia
| | - Z F Udwadia
- P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - A R Verhage
- Department of Paediatrics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - D H Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - O W Akkerman
- Department of Pulmonary Diseases and Tuberculosis, Groningen, Haren, the Netherlands, Tuberculosis Center Beatrixoord, University Medical Center Groningen, University of Groningen, Haren, the Netherlands
| | - J W C Alffenaar
- Sydney Infecious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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21
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Séraphin MN, Bellot J, Peloquin CA, Mai V. 16S rRNA gene sequencing of stool samples collected from patients with latent tuberculosis infection before, during, and two months after treatment with 3HP or 4R. BMC Res Notes 2023; 16:100. [PMID: 37308931 PMCID: PMC10258780 DOI: 10.1186/s13104-023-06370-7] [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: 10/24/2022] [Accepted: 05/25/2023] [Indexed: 06/14/2023] Open
Abstract
OBJECTIVE We present 16s rRNA gene sequencing (V1-V2 region) and sample data from a pilot observational cohort study to describe the gut microbiota dynamics of subjects with latent tuberculosis infection (LTBI) treated with daily 600 mg rifampicin for four months (4R) or a weekly dose of 900 mg combination of rifapentine and isoniazid for three months (3HP). Our objectives were to (1) document changes to the gut microbiota immediately following exposure to the rifamycins and (2) document recovery to baseline two months after treatment completion. DATA DESCRIPTION We enrolled six subjects with subjects with LTBI and prospectively followed them for 5-6 months. Each subject provided stool samples before, during, and two months after treatment. Six healthy controls were sampled in parallel with the patients with LTBIs. We report amplicon sequence variants (ASVs) and taxonomic assignments for 60 stool samples. Additionally, we provide access to the raw amplicon sequences, and subject responses to questionnaires about their diet, medication, and lifestyle changes over the study follow-up period. Furthermore, we provide the concentration of the parent and partially active rifamycin metabolite concentrations measured validated LC-MS-MS assays of phosphate buffer washes of the stool samples collected from the LTBI participants. This comprehensive dataset is a valuable resource for future systematic reviews and meta-analyses of the impact of LTBI therapy on the gut microbiota.
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Affiliation(s)
- Marie Nancy Séraphin
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, 32610 USA
- Department of Medicine, Division of Infectious Diseases and Global Medicine, University of Florida, Gainesville, FL USA
| | - Julia Bellot
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, 32610 USA
- Department of Medicine, Division of Infectious Diseases and Global Medicine, University of Florida, Gainesville, FL USA
| | - Charles A. Peloquin
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, 32610 USA
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL USA
| | - Volker Mai
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, 32610 USA
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, FL USA
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22
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Ashkin A, Alexis A, Ninneman M, Tresgallo RR, Ashkin D, Peloquin CA. Concomitant Treatment of Tuberculosis and Hepatitis C Virus in Coinfected Patients Using Serum Drug Concentration Monitoring. Open Forum Infect Dis 2023; 10:ofad237. [PMID: 37383253 PMCID: PMC10296065 DOI: 10.1093/ofid/ofad237] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/25/2023] [Indexed: 06/30/2023] Open
Abstract
Background Concern for drug-drug interactions leading to treatment failure and drug-resistant strains have discouraged clinicians from attempting concomitant treatment of hepatitis C virus (HCV) and tuberculosis (TB). Increased metabolism of direct-acting antivirals (DAAs) by rifamycins has hindered concurrent use. Development of an assay for ledipasvir and sofosbuvir (LDV/SOF) serum concentrations for therapeutic drug monitoring (TDM) can ensure adequate therapy. We present the first cases of concomitant therapy of active TB and HCV with rifamycin-containing regimens and DAAs using TDM. Methods Using TDM, we aim to determine whether concomitant therapy with rifamycin-containing regimens and DAAs is safe and effective for patients coinfected with TB and HCV. Five individuals with TB and HCV who experienced transaminitis before or during TB therapy were concomitantly treated with rifamycin-containing regimens and LDV/SOF. Therapeutic drug monitoring was performed for LDV, SOF, and rifabutin during therapy. Baseline laboratory tests and serial liver enzymes were performed. Hepatitis C virus viral load and mycobacterial sputum cultures were obtained upon completion of therapy to determine efficacy of therapy. Results All patients were found to have nondetectable HCV viral loads and negative mycobacterial sputum cultures upon completion of therapy. No clinically significant adverse effects were reported. Conclusions These cases illustrate concomitant use of LDV/SOF and rifabutin in patients with HCV/TB coinfection. Utilizing serum drug concentration monitoring to guide dosing, correction of transaminitis were achieved, which allowed the use rifamycin-containing TB therapy. These findings suggest that concomitant therapy of TB/HCV is possible, safe, and effective.
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Affiliation(s)
- Alex Ashkin
- Internal Medicine Resident, NCH Healthcare System, Naples, Florida, USA
| | - Afe Alexis
- Jackson Memorial Hospital, University of Miami, Miami, Florida, USA
| | - Megan Ninneman
- Jackson Memorial Hospital, Respiratory Care Unit, Miami, Florida, USA
| | - Rene Rico Tresgallo
- Jackson Memorial Hospital, University of Miami, Pulmonary and Critical Care Division, Miami, Florida, USA
| | - David Ashkin
- Bureau of Communicable Disease, Florida Department of Health, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Correspondence: Charles A. Peloquin, PharmD, College of Pharmacy and Emerging Pathogens Institute, University of Florida, PO Box 100486, Gainesville, FL 32610-0486 ()
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23
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Kwara A, Yang H, Martyn-Dickens C, Enimil A, Amissah AK, Ojewale O, Dompreh A, Bosomtwe D, Sly-Moore E, Opoku T, Appiah AF, Obeng R, Asiedu P, Maranchick N, Alshaer MH, Peloquin CA, Antwi S. Adequacy of WHO weight-band dosing and fixed-dose combinations for the treatment of TB in children. Int J Tuberc Lung Dis 2023; 27:401-407. [PMID: 37143230 DOI: 10.5588/ijtld.22.0591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND: We examined whether the updated WHO weight-band dosing recommendations and fixed-dose combination tablets for the treatment of TB in children achieves recommended calculated dosages and adequate drug plasma exposure.DESIGN/METHODS: Children on first-line TB treatment per WHO guidelines were enrolled. Blood sampling at pre-dose, 1, 2, 4, 8, and 12 h post-dose after at least 4 weeks of treatment was performed. Drugs concentrations were measured using validated liquid chromatography tandem with mass spectrometry and pharmacokinetic parameters calculated using noncompartmental analysis. Plasma drug exposure below the lower limit of the 95% confidence interval of the mean for children was considered low and above the upper limit was high.RESULTS: Of 71 participants, 34 (47.9%) had HIV coinfection. The median calculated dose for isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) was 10.0 (range 4.3-13.3), 15.0 (range 8.6-20.0), 30.0 (range 21.0-40.0), and 20.4 (range 14.3-26.7) mg/kg, respectively. Overall, most patients had under-exposure for RIF and PZA and over-exposure for INH and EMB. Drug dose and weight-for-age Z-score were associated with area under the curve from time 0-24 h for all drugs.CONCLUSIONS: Despite adherence to WHO dosing guidelines, low PZA and RIF plasma exposures were frequent in our study population. Higher than currently recommended dosages of RIF and PZA may be needed in children.
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Affiliation(s)
- A Kwara
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA, Medical Service, North Florida South Georgia Veterans Health System, Gainesville, FL, USA
| | - H Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - C Martyn-Dickens
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - A Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana, Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - A K Amissah
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - O Ojewale
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - A Dompreh
- Department of Clinical Microbiology, KATH, Kumasi, Ghana, Department of Medical Diagnostics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - D Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - E Sly-Moore
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - T Opoku
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - A F Appiah
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana
| | - R Obeng
- Deapratment of Pharmacy, KATH, Kumasi, Ghana
| | - P Asiedu
- Deapratment of Pharmacy, KATH, Kumasi, Ghana
| | - N Maranchick
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - M H Alshaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S Antwi
- Directorate of Child Health, Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana, Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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24
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Gafar F, Wasmann RE, McIlleron HM, Aarnoutse RE, Schaaf HS, Marais BJ, Agarwal D, Antwi S, Bang ND, Bekker A, Bell DJ, Chabala C, Choo L, Davies GR, Day JN, Dayal R, Denti P, Donald PR, Engidawork E, Garcia-Prats AJ, Gibb D, Graham SM, Hesseling AC, Heysell SK, Idris MI, Kabra SK, Kinikar A, Kumar AKH, Kwara A, Lodha R, Magis-Escurra C, Martinez N, Mathew BS, Mave V, Mduma E, Mlotha-Mitole R, Mpagama SG, Mukherjee A, Nataprawira HM, Peloquin CA, Pouplin T, Ramachandran G, Ranjalkar J, Roy V, Ruslami R, Shah I, Singh Y, Sturkenboom MGG, Svensson EM, Swaminathan S, Thatte U, Thee S, Thomas TA, Tikiso T, Touw DJ, Turkova A, Velpandian T, Verhagen LM, Winckler JL, Yang H, Yunivita V, Taxis K, Stevens J, Alffenaar JWC. Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis. Eur Respir J 2023; 61:2201596. [PMID: 36328357 PMCID: PMC9996834 DOI: 10.1183/13993003.01596-2022] [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: 08/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level. METHODS We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models. RESULTS Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24. CONCLUSIONS This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.
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Affiliation(s)
- Fajri Gafar
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Roeland E Wasmann
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Helen M McIlleron
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - H Simon Schaaf
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, Sydney, Australia
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
| | - Dipti Agarwal
- Ram Manohar Lohia Institute of Medical Sciences, Department of Paediatrics, Lucknow, India
| | - Sampson Antwi
- Komfo Anokye Teaching Hospital, Department of Child Health, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Department of Child Health, Kumasi, Ghana
| | | | - Adrie Bekker
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - David J Bell
- NHS Greater Glasgow and Clyde, Infectious Diseases Unit, Glasgow, UK
| | - Chishala Chabala
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospitals - Children's Hospital, Lusaka, Zambia
| | - Louise Choo
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Geraint R Davies
- Malawi Liverpool Wellcome Clinical Research Programme, Clinical Department, Blantyre, Malawi
- University of Liverpool, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Oxford, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Rajeshwar Dayal
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Paolo Denti
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Peter R Donald
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ephrem Engidawork
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa, Ethiopia
| | - Anthony J Garcia-Prats
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Pediatrics, Madison, WI, USA
| | - Diana Gibb
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Stephen M Graham
- University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Anneke C Hesseling
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Misgana I Idris
- University of Alabama at Birmingham, Department of Biology, Birmingham, AL, USA
| | - Sushil K Kabra
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Agibothu K Hemanth Kumar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Awewura Kwara
- University of Florida, Emerging Pathogens Institute, College of Medicine, Gainesville, FL, USA
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | | | - Nilza Martinez
- Instituto Nacional de Enfermedades Respiratorias y Del Ambiente, Asunción, Paraguay
| | - Binu S Mathew
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University, Department of Medicine and Infectious Diseases, Baltimore, MD, USA
| | - Estomih Mduma
- Haydom Lutheran Hospital, Center for Global Health Research, Haydom, Tanzania
| | | | | | - Aparna Mukherjee
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Heda M Nataprawira
- Universitas Padjadjaran, Hasan Sadikin Hospital, Faculty of Medicine, Department of Child Health, Division of Paediatric Respirology, Bandung, Indonesia
| | | | - Thomas Pouplin
- Mahidol University, Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Geetha Ramachandran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Jaya Ranjalkar
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vandana Roy
- Maulana Azad Medical College, Department of Pharmacology, New Delhi, India
| | - Rovina Ruslami
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Ira Shah
- Bai Jerbai Wadia Hospital for Children, Department of Pediatric Infectious Diseases, Pediatric TB Clinic, Mumbai, India
| | - Yatish Singh
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Uppsala University, Department of Pharmacy, Uppsala, Sweden
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- World Health Organization, Public Health Division, Geneva, Switzerland
| | - Urmila Thatte
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Department of Clinical Pharmacology, Mumbai, India
| | - Stephanie Thee
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Tania A Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Tjokosela Tikiso
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Anna Turkova
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Thirumurthy Velpandian
- All India Institute of Medical Sciences, Ocular Pharmacology and Pharmacy Division, Dr R.P. Centre, New Delhi, India
| | - Lilly M Verhagen
- Radboud University Medical Center, Radboud Center for Infectious Diseases, Laboratory of Medical Immunology, Section of Pediatric Infectious Diseases, Nijmegen, The Netherlands
- Radboud University Medical Center, Amalia Children's Hospital, Department of Paediatric Infectious Diseases and Immunology, Nijmegen, The Netherlands
- Stellenbosch University, Family Centre for Research with UBUNTU, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Jana L Winckler
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Hongmei Yang
- University of Rochester, School of Medicine and Dentistry, Department of Biostatistics and Computational Biology, Rochester, NY, USA
| | - Vycke Yunivita
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Jasper Stevens
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Both authors contributed equally and shared senior authorship
| | - Jan-Willem C Alffenaar
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Both authors contributed equally and shared senior authorship
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25
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Koehler N, Andres S, Merker M, Dreyer V, John A, Kuhns M, Krieger D, Choong E, Verougstraete N, Zur Wiesch PA, Wicha SG, König C, Kalsdorf B, Sanchez Carballo PM, Schaub D, Werngren J, Schön T, Peloquin CA, Schönfeld N, Verstraete AG, Decosterd LA, Aarnoutse R, Niemann S, Maurer FP, Lange C. Pretomanid-resistant tuberculosis. J Infect 2023; 86:520-524. [PMID: 36738862 DOI: 10.1016/j.jinf.2023.01.039] [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: 01/16/2023] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Niklas Koehler
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Sönke Andres
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, Parkallee 18, 23845 Borstel, Germany
| | - Matthias Merker
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Evolution of the Resistome, Research Center Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Viola Dreyer
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Agnieszka John
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany
| | - Martin Kuhns
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, Parkallee 18, 23845 Borstel, Germany
| | - David Krieger
- Department of Pulmonology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Walterhöferstraße 11, 14165 Berlin, Germany
| | - Eva Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Nick Verougstraete
- Department of Laboratory Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Pia Abel Zur Wiesch
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, Hansine Hansens veg 18, 9019 Tromsø, Norway; Centre for Molecular Medicine Norway, Nordic EMBL Partnership, Forskningsparken, Gaustadalléen 21, 0349 Oslo, Norway; Department of Biology, The Pennsylvania State University, University Park Pennsylvania, Mueller Laboratory, 208 Curtin Rd, State College, PA 16801, USA; Huck Institutes of the Life Sciences, The Pennsylvania State University, University Park Pennsylvania, 101 Huck Life Sciences Building, University Park, PA 16802, USA
| | - Sebastian G Wicha
- Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146 Hamburg, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinstraße 52, 20246 Hamburg, Germany; Department of Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Barbara Kalsdorf
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Patricia M Sanchez Carballo
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Dagmar Schaub
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Jim Werngren
- Department of Microbiology, Unit for Laboratory Surveillance of Bacterial Pathogens, Public Health Agency of Sweden, Nobels väg 18, 171 65 Solna, Sweden
| | - Thomas Schön
- Department of Infectious Diseases, Linköping University Hospital, Universitetssjukhuset, 581 85 Linköping, Sweden; Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection, Linköping University, Universitetssjukhuset, 581 85 Linköping, Sweden
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, 2055 Mowry Rd, Gainesville, FL 32610, USA; Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1225 Center Dr, Gainesville, FL 32610, USA
| | - Nicolas Schönfeld
- Department of Pulmonology, Lungenklinik Heckeshorn, HELIOS Klinikum Emil von Behring, Walterhöferstraße 11, 14165 Berlin, Germany
| | - Alain G Verstraete
- Department of Laboratory Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Laurent A Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Rob Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - Stefan Niemann
- German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, Parkallee 18, 23845 Borstel, Germany; Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Florian P Maurer
- National and World Health Organization Supranational Reference Laboratory for Mycobacteria, Research Center Borstel, Parkallee 18, 23845 Borstel, Germany; Institute for Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Martinstraße 52, 20246 Hamburg, Germany
| | - Christoph Lange
- Department of Clinical Infectious Diseases, Research Center Borstel, Leibniz Lung Center, Parkallee 35, 23845 Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Borstel-Hamburg-Lübeck-Riems, Parkallee 1-40, 23845 Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany; Baylor College of Medicine and Texas Childrens' Hospital, 1 Baylor Plaza, Houston, TX 77030, USA.
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Alkabab Y, Warkentin J, Cummins J, Katz B, Denison BM, Bartok A, Khalil A, Young LR, Timme E, Peloquin CA, Ashkin D, Houpt ER, Heysell SK. Therapeutic drug monitoring and TB treatment outcomes in patients with diabetes mellitus. Int J Tuberc Lung Dis 2023; 27:135-139. [PMID: 36853114 PMCID: PMC9904402 DOI: 10.5588/ijtld.22.0448] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND: Diabetes mellitus (DM) increases the risk of TB disease and poor treatment outcomes such as delayed sputum culture conversion due to inadequate drug exposure. Therapeutic drug monitoring (TDM) has improved these outcomes in some settings.METHODS: To compare treatment outcomes in programs with routine TDM vs. programs that did not use TDM, we conducted a retrospective study among people with DM and TB at health departments in four US states.RESULTS: A total of 170 patients were enrolled (73 patients in the non-TDM group and 97 patients in the TDM group). Days to sputum culture conversion and total treatment duration were significantly shorter in the TDM group vs. the non-TDM group. In adjusted analyses, patients who underwent TDM were significantly more likely to achieve sputum culture conversion at 2 months (P = 0.007).CONCLUSION: TDM hastened microbiological cure from TB among people with DM and a high risk for poor treatment outcomes in the programmatic setting.
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Affiliation(s)
- Y Alkabab
- Medical University of South Carolina, Charleston, SC, USA
| | - J Warkentin
- Tennessee Department of Health, Nashville, TN, USA
| | - J Cummins
- Tennessee Department of Health, Nashville, TN, USA
| | - B Katz
- Tennessee Department of Health, Nashville, TN, USA
| | - B M Denison
- New Mexico Department of Health, Santa Fe, NM, USA
| | - A Bartok
- New Mexico Department of Health, Santa Fe, NM, USA
| | - A Khalil
- Virginia Department of Health, Richmond, VA, USA
| | - L R Young
- Virginia Department of Health, Richmond, VA, USA
| | - E Timme
- Arizona Department of Health Services, Phoenix, AZ, USA
| | | | - D Ashkin
- University of Florida, Gainesville, FL, USA
| | - E R Houpt
- University of Virginia, Charlottesville, VA, USA
| | - S K Heysell
- University of Virginia, Charlottesville, VA, USA
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27
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Venugopalan V, Casaus D, Kainz L, Slaton CN, Hurst N, Bruzzone M, Hu C, Sword G, Cherabuddi K, Iovine N, Liu J, Scheetz MH, Rhodes N, Maranchick N, Peloquin CA, Klinker K, Alshaer MH. Use of therapeutic drug monitoring to characterize cefepime-related neurotoxicity. Pharmacotherapy 2023; 43:6-14. [PMID: 36401796 DOI: 10.1002/phar.2744] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES Data evaluating cefepime thresholds associated with neurotoxicity remain limited. The objectives of this study were to evaluate the incidence of cefepime-related neurotoxicity (CRN) in patients with plasma cefepime concentrations, assess the relationship between cefepime exposure and CRN, investigate clinical factors associated with CRN, and describe electroencephalogram (EEG) abnormalities in CRN. DESIGN This was a retrospective study of adult inpatients admitted between 2016 and 2018 who received cefepime therapeutic drug monitoring (TDM). Potential CRN cases were identified utilizing a standard definition. The primary outcomes of the study were to determine the incidence of CRN and evaluate the relationship between cefepime trough concentrations, the average daily AUC, and neurotoxicity. Bayesian posteriors were generated for each patient using a cefepime pharmacokinetic (PK) model, and the mean daily area under the concentration-time curve (AUC) was calculated. Multiple regression was performed to assess the association between CRN, cefepime PK, and clinical predictors of neurotoxicity. MAIN RESULTS Four hundred eighty-one patients with 503 hospital encounters received cefepime TDM and were included in the analysis. The incidence of CRN was 4.4% (22/503). Patients with CRN had a higher incidence of renal dysfunction, hypertension, and diabetes mellitus compared to patients without CRN (non-NT). The mean cefepime trough concentration was significantly greater in the CRN patients than in the non-NT group (61.8 ± 33.7 vs. 30 ± 27.7 mg/L, respectively, p = 0.0002). Cefepime trough concentration and renal dysfunction were independently associated with increased risk of CRN in the adjusted multiple regression model. Moderate generalized slowing of the background rhythm was the most common EEG pattern associated with CRN. Delaying cefepime TDM greater than 72 h after the initiation of cefepime was associated with a 3-fold increased risk of CRN. CONCLUSION Cefepime should be used cautiously in hospitalized patients with renal dysfunction due to the risk of neurotoxicity. Dose optimization utilizing TDM early in cefepime treatment may minimize adverse effects and improve patient safety.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Danielle Casaus
- Department of Pharmacy, University of Florida Health-Shands Hospital, Gainesville, Florida, USA
| | - Leonie Kainz
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Cara N Slaton
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Natalie Hurst
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Calvin Hu
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Gabriel Sword
- Division of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nicole Iovine
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jiajun Liu
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Marc H Scheetz
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Nathaniel Rhodes
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA.,Northwestern Memorial Hospital, Chicago, Illinois, USA.,Pharmacometrics Center of Excellence, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
| | - Kenneth Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, Florida, USA
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Mota F, Ruiz-Bedoya CA, Tucker EW, Holt DP, De Jesus P, Lodge MA, Erice C, Chen X, Bahr M, Flavahan K, Kim J, Brosnan MK, Ordonez AA, Peloquin CA, Dannals RF, Jain SK. Dynamic 18F-Pretomanid PET imaging in animal models of TB meningitis and human studies. Nat Commun 2022; 13:7974. [PMID: 36581633 PMCID: PMC9800570 DOI: 10.1038/s41467-022-35730-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 08/25/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022] Open
Abstract
Pretomanid is a nitroimidazole antimicrobial active against drug-resistant Mycobacterium tuberculosis and approved in combination with bedaquiline and linezolid (BPaL) to treat multidrug-resistant (MDR) pulmonary tuberculosis (TB). However, the penetration of these antibiotics into the central nervous system (CNS), and the efficacy of the BPaL regimen for TB meningitis, are not well established. Importantly, there is a lack of efficacious treatments for TB meningitis due to MDR strains, resulting in high mortality. We have developed new methods to synthesize 18F-pretomanid (chemically identical to the antibiotic) and performed cross-species positron emission tomography (PET) imaging to noninvasively measure pretomanid concentration-time profiles. Dynamic PET in mouse and rabbit models of TB meningitis demonstrates excellent CNS penetration of pretomanid but cerebrospinal fluid (CSF) levels does not correlate with those in the brain parenchyma. The bactericidal activity of the BPaL regimen in the mouse model of TB meningitis is substantially inferior to the standard TB regimen, likely due to restricted penetration of bedaquiline and linezolid into the brain parenchyma. Finally, first-in-human dynamic 18F-pretomanid PET in six healthy volunteers demonstrates excellent CNS penetration of pretomanid, with significantly higher levels in the brain parenchyma than in CSF. These data have important implications for developing new antibiotic treatments for TB meningitis.
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Affiliation(s)
- Filipa Mota
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Camilo A. Ruiz-Bedoya
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Elizabeth W. Tucker
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Daniel P. Holt
- grid.21107.350000 0001 2171 9311Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Patricia De Jesus
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Martin A. Lodge
- grid.21107.350000 0001 2171 9311Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Clara Erice
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Xueyi Chen
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Melissa Bahr
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Kelly Flavahan
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - John Kim
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Mary Katherine Brosnan
- grid.21107.350000 0001 2171 9311Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Alvaro A. Ordonez
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Charles A. Peloquin
- grid.15276.370000 0004 1936 8091Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL 32610 USA
| | - Robert F. Dannals
- grid.21107.350000 0001 2171 9311Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Sanjay K. Jain
- grid.21107.350000 0001 2171 9311Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA ,grid.21107.350000 0001 2171 9311Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
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Haley CA, Ashkin D, Peloquin CA. 2354. Implementation of BPaL in the United States: Experience using a novel all-oral treatment regimen for rifampin-resistant or treatment-intolerant TB disease. Open Forum Infect Dis 2022. [PMCID: PMC9752306 DOI: 10.1093/ofid/ofac492.161] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Tuberculosis (TB) remains a leading infectious cause of death and morbidity globally. Rifampin-resistance or intolerance requires prolonged treatment using less effective, more toxic regimens. Recent trials demonstrated that the all-oral six-month “BPaL” regimen, Bedaquiline, Pretomanid and Linezolid, is 90% effective. In these trials, linezolid-induced hematologic and neurologic toxicity was high using 1200mg daily, whereas lower exposure (dose or duration) reduced toxicity. Therapeutic drug monitoring (TDM) is used by U.S. TB experts to maintain a serum linezolid trough < 2ug/ml, which correlates with reduced toxicity. Since U.S. FDA approval in 2019, BPaL has been widely implemented for the treatment of rifampin-intolerant or resistant TB disease. Methods We evaluated a cohort of patients with TB treated from October, 2019 through April, 2022, describing patient demographics, BPaL treatment dosing, and adverse events. TDM was performed for clinical purposes using liquid chromatography–mass spectrometry to measure serum levels at trough and 2 and 6h post-linezolid dose. Clinical providers adjusted linezolid dose and dosing interval targeting a trough < 2ug/ml and peak of 12–26ug/ml. Results Among 64 BPaL patients, ages were 15–83 years, 22 (34.3%) were female, 6 (9.3%) U.S.-born, 4 (6.3%) HIV-infected. 50 (78.1%) had only pulmonary disease, 6 extrapulmonary, and 8 had both; 61 (91.0%) were culture-confirmed. Most (n=62) started linezolid 600mg daily. Linezolid was adjusted for 39 (66.1%) of the 59 patients with TDM; 18 had a trough >2ug/ml, 30 had dosing interval increased to thrice-weekly, and 17 had a dose increase. 52 (81.3%) patients completed BPaL and 12 remain on therapy. One 81-year-old female with diabetes, hypothyroidism, and B12 deficiency discontinued linezolid at 12 weeks for worsened neuropathy (linezolid trough=1.13ug/ml). She completed 26 weeks of bedaquiline/pretomanid and her symptoms returned to baseline. Conclusion Use of BPaL with clinical and TDM monitoring has transformed treatment of rifampin-resistant or intolerant TB in the U.S. Patients previously sentenced to 18–24 months of treatment with 5–7 hard-to-tolerate medications and modest efficacy can now complete treatment in 6–9 months with little toxicity and exceptional cure rates. Disclosures All Authors: No reported disclosures.
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Affiliation(s)
| | - David Ashkin
- University of Miami / Florida Health Department, Miami, Florida
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30
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Mendoza MA, Alshaer MH, Roldan G, Castro JG, Peloquin CA, Boulanger C. 604. Effect of rifabutin in dolutegravir dosing: a case series. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.656] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) is the leading cause of death in human immunodeficiency virus (HIV) infected people worldwide. Patients with HIV who have latent TB are 20-30 times more likely to develop active TB. Integrated antiretroviral therapy (ART) early in the treatment for tuberculosis is recommended due to improved morbidity and mortality, however, there can be serious drug interactions.
Rifamycins are potent inducers of the CYP3A4 isoform, which can cause sub-therapeutic concentrations of anti-retroviral drugs, among these, rifabutin (RBN) is a less potent inducer of CYP3A4. Pharmacokinetic (PK) studies done on healthy adults showed that rifampin decreased dolutegravir (DTG) concentrations by more than 50 % whereas RBN decreased it by 30%. RBN has been preferred given that its favorable pharmacokinetic and toxicity profile. Currently there are no studies examining the use of RBN and DTG in co-infected persons. This is a case series of 4 co-infected patients receiving both agents who underwent PK analysis.
Methods
Retrospective analysis of patients in the respiratory care unit (RCU) at Jackson Memorial Hospital in Miami. We included adult patients, admitted to the RCU, with a concomitant diagnosis of HIV and active TB disease who received DTG and RBN, and for which DTG and RBN plasma concentrations were measured for therapeutic drug monitoring (TDM). A non-compartmental analysis was performed and the area under the concentration-time curve (AUC) was calculated for DTG and RBN.
Results
We report 4 patients (Figure 1) that met criteria and underwent PK analysis. All patients with TB who were treated with RBN had low concentrations of DTG, requiring higher doses of DTG (Table 1 & 2). After adjustments based on PK analysis, there was evidence of a favorable response to treatment in 2 patients, with a less than robust in the 2 others. Adequate suppression of viral load could not be determined for 3 of the patients because of the short observation time. Figure 1:Timelines of patients describing admission and HIV and tuberculosis treatment providedDTG, dolutegravir. RFB, rifabutin. VL, viral load. AFB, Acid fast bacilli. LAD, lymphadenopathy. TAF, Tenofovir alafenamide. FTC, Emtricitabine. TDF, Tenofovir Disoproxil Fumarate. INH, Isoniazid. PYZ, Pyrazinamide. BID, twice a day. QD, daily. IRIS, Immune reconstitution inflammatory syndrome. GU, genitourinary. TB, tuberculosis.Table 1:Patients’ pharmacokinetics of DTGAUCX-Y, area under the concentration-time curve from time X to Y hours; AUC0-tau, area under the concentration-time curve from time zero to the end of the dosing interval; DTG, dolutegravir; TDM, therapeutic drug monitoring. a) AUC0-6 was calculated.Table 2:Patients’ pharmacokinetics of RBNAUCX-Y, area under the concentration-time curve from time X to Y hours; AUC0-tau, area under the concentration-time curve from time zero to the end of the dosing interval; RBN, Rifabutin; TDM, therapeutic drug monitoring. a) All RBN doses given every 24 hours, b) RBN value was trace and AUC was not calculated.
Conclusion
All patients with HIV and TB who were treated with RBN had low concentrations of DTG. This case series demonstrates that for optimal concomitant use of rifabutin and dolutegravir it is highly recommended to use TDM. Prospective clinical studies are needed to further determine the PK interactions between RBN and DTG and virologic response to treatment.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Jose G Castro
- University of Miami Miller School of Medicine , Miami, Florida
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31
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Maranchick NF, Alshaer MH, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Kipiani M, Peloquin CA, Kempker RR. Cerebrospinal fluid concentrations of fluoroquinolones and carbapenems in tuberculosis meningitis. Front Pharmacol 2022; 13:1048653. [PMID: 36578553 PMCID: PMC9791083 DOI: 10.3389/fphar.2022.1048653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Tuberculosis meningitis (TBM) is the most lethal form of TB. It is difficult to treat in part due to poor or uncertain drug penetration into the central nervous system (CNS). To help fill this knowledge gap, we evaluated the cerebrospinal fluid (CSF) concentrations of fluoroquinolones and carbapenems in patients being treated for TBM. Methods: Serial serum and CSF samples were collected from hospitalized patients being treated for TBM. CSF was collected from routine lumbar punctures between alternating timepoints of 2 and 6 h after drug administration to capture early and late CSF penetration. Rich serum sampling was collected after drug administration on day 28 for non-compartmental analysis. Results: Among 22 patients treated for TBM (8 with confirmed disease), there was high use of fluoroquinolones (levofloxacin, 21; moxifloxacin, 10; ofloxacin, 6) and carbapenems (imipenem, 11; meropenem, 6). Median CSF total concentrations of levofloxacin at 2 and 6 h were 1.34 mg/L and 3.36 mg/L with adjusted CSF/serum ratios of 0.41 and 0.63, respectively. For moxifloxacin, the median CSF total concentrations at 2 and 6 h were 0.78 mg/L and 1.02 mg/L with adjusted CSF/serum ratios of 0.44 and 0.62. Serum and CSF concentrations of moxifloxacin were not affected by rifampin use. Among the 76 CSF samples measured for carbapenem concentrations, 79% were undetectable or below the limit of detection. Conclusion: Fluoroquinolones demonstrated high CSF penetration indicating their potential usefulness for the treatment of TBM. Carbapenems had lower than expected CSF concentrations.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Alison G. C. Smith
- Department of Medicine, Division of Internal Medicine, Duke University, Durham, NC, United States
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, United States
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Graciaa DS, Kipiani M, Magee MJ, Mikiashvili L, Barbakadze K, Bablishvili N, Auld SC, Alghamdi WA, Alshaer MH, Peloquin CA, Avaliani Z, Blumberg HM, Kempker RR. Linezolid Exposure Is Associated with Cytopenias in Patients Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2022; 66:e0040822. [PMID: 35916515 PMCID: PMC9487506 DOI: 10.1128/aac.00408-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 03/28/2022] [Accepted: 07/17/2022] [Indexed: 02/04/2023] Open
Abstract
Although linezolid is effective for multidrug-resistant TB (MDR-TB) tuberculosis treatment, it is associated with cytopenias after 4 weeks of administration. Data on toxicities with long-term use of linezolid and drug pharmacodynamics in MDR-TB treatment are limited, and concerns about toxicity present barriers to wider implementation. This was a secondary analysis of a prospective cohort study of patients treated for MDR-TB in the country of Georgia from 2015 to 2017. Intensive blood sampling 4 to 6 weeks after treatment initiation with linezolid 600 mg daily was performed for pharmacokinetic (PK) analysis, including linezolid trough concentration (Cmin) and area under the curve from 0 to 24 hours (AUC0-24). Linezolid exposure was defined using literature-reported thresholds. Cytopenias were defined using an NIH adverse event (AE) scale. Logistic regression was used to evaluate the relationship between linezolid exposure and cytopenias. Among 76 patients receiving linezolid in their baseline treatment regimen and who had PK data available, cytopenia AEs occurred in 30 (39.5%) for an incidence rate of 46 per 100 person-years. The median duration of linezolid therapy was 526 days. No patients required dose reduction or interruption due to cytopenias. Median linezolid Cmin was 0.235 mg/L (interquartile range [IQR], 0.069 to 0.529), and median AUC0-24 was 89.6 mg·h/L (IQR, 69.2 to 116.2). Cytopenias were associated with linezolid PK parameters (Cmin > 2 mg/L and AUC0-24 > 160 mg·h/L). Cytopenias occurred frequently with long-term use of linezolid 600 mg/day and were associated with PK parameters but did not result in the need for treatment interruption in the management of a cohort of patients with MDR-TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Matthew J. Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Ketevan Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Sara C. Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wael A. Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Sharan R, Ganatra SR, Singh DK, Cole J, Foreman TW, Thippeshappa R, Peloquin CA, Shivanna V, Gonzalez O, Day CL, Gandhi NR, Dick EJ, Hall-Ursone S, Mehra S, Schlesinger LS, Rengarajan J, Kaushal D. Isoniazid and rifapentine treatment effectively reduces persistent M. tuberculosis infection in macaque lungs. J Clin Invest 2022; 132:e161564. [PMID: 35862216 PMCID: PMC9479578 DOI: 10.1172/jci161564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 05/13/2022] [Accepted: 07/19/2022] [Indexed: 02/01/2023] Open
Abstract
A once-weekly oral dose of isoniazid and rifapentine for 3 months (3HP) is recommended by the CDC for treatment of latent tuberculosis infection (LTBI). The aim of this study is to assess 3HP-mediated clearance of M. tuberculosis bacteria in macaques with asymptomatic LTBI. Twelve Indian-origin rhesus macaques were infected with a low dose (~10 CFU) of M. tuberculosis CDC1551 via aerosol. Six animals were treated with 3HP and 6 were left untreated. The animals were imaged via PET/CT at frequent intervals. Upon treatment completion, all animals except 1 were coinfected with SIV to assess reactivation of LTBI to active tuberculosis (ATB). Four of 6 treated macaques showed no evidence of persistent bacilli or extrapulmonary spread until the study end point. PET/CT demonstrated the presence of significantly more granulomas in untreated animals relative to the treated group. The untreated animals harbored persistent bacilli and demonstrated tuberculosis (TB) reactivation following SIV coinfection, while none of the treated animals reactivated to ATB. 3HP treatment effectively reduced persistent infection with M. tuberculosis and prevented reactivation of TB in latently infected macaques.
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Affiliation(s)
- Riti Sharan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Shashank R. Ganatra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Dhiraj K. Singh
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Journey Cole
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Taylor W. Foreman
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Rajesh Thippeshappa
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | | | - Vinay Shivanna
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Olga Gonzalez
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | | | - Neel R. Gandhi
- Emory Tuberculosis Center and
- Emory Vaccine Center, Emory National Primate Research Center, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward J. Dick
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Shannan Hall-Ursone
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Smriti Mehra
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Larry S. Schlesinger
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
| | - Jyothi Rengarajan
- Emory Tuberculosis Center and
- Emory Vaccine Center, Emory National Primate Research Center, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Deepak Kaushal
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, Texas, USA
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Kempker RR, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Collins JM, Blumberg HM, Alshaer MH, Peloquin CA, Kipiani M. Cycloserine and Linezolid for Tuberculosis Meningitis: Pharmacokinetic Evidence of Potential Usefulness. Clin Infect Dis 2022; 75:682-689. [PMID: 34849645 PMCID: PMC9464073 DOI: 10.1093/cid/ciab992] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 09/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ability of antituberculosis drugs to cross the blood-brain barrier and reach the central nervous system is critical to their effectiveness in treating tuberculosis meningitis (TBM). We sought to fill a critical knowledge gap by providing data on the ability of new and repurposed antituberculosis drugs to penetrate into the cerebrospinal fluid (CSF). METHODS We conducted a clinical pharmacology study among patients treated for TBM in Tbilisi, Georgia, from January 2019 until January 2020. Serial serum and CSF samples were collected while patients were hospitalized. CSF was collected from routine lumbar punctures with the timing of the lumbar puncture alternating between 2 and 6 hours to capture early and late CSF penetration. RESULTS A total of 17 patients treated for TBM (8 with confirmed disease) were included; all received linezolid, with a subset receiving cycloserine (5), clofazimine (5), delamanid (4), and bedaquiline (2). All CSF measurements of bedaquiline (12), clofazimine (24), and delamanid (19) were below the limit of detection. The median CSF concentrations of cycloserine at 2 and 6 hours were 15.90 and 15.10 µg/mL with adjusted CSF/serum ratios of 0.52 and 0.66. CSF concentrations of linezolid were 0.90 and 3.14 µg/mL at 2 and 6 hours, with adjusted CSF/serum ratios of 0.25 and 0.59, respectively. CSF serum linezolid concentrations were not affected by rifampin coadministration. CONCLUSIONS Based on moderate to high CSF penetration, linezolid and cycloserine may be effective drugs for TBM treatment, whereas the utility of bedaquiline, delamanid, and clofazimine is uncertain given their low CSF penetration.
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Affiliation(s)
- Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | | | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- The University of Georgia, Tbilisi, Georgia
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Masiphephethu MV, Sariko M, Walongo T, Maro A, Mduma D, Gratz J, Alshaer M, Peloquin CA, Mduma E, Mpagama SG, Thomas T, Houpt ER, Traore A, Bessong P, Heysell SK, Operario DJ. Pharmacogenetic testing for NAT2 genotypes in a Tanzanian population across the lifespan to guide future personalized isoniazid dosing. Tuberculosis (Edinb) 2022; 136:102246. [PMID: 35961094 PMCID: PMC9884397 DOI: 10.1016/j.tube.2022.102246] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/12/2022] [Accepted: 08/03/2022] [Indexed: 01/31/2023]
Abstract
Despite updated recommendations for weight-based isoniazid dosing in children with drug-susceptible tuberculosis (TB) and higher dose isoniazid in regimens for adults with drug-resistant TB, individual pharmacokinetic variability can lead to sub-target isoniazid exposure. Host pharmacogenetics and isoniazid exposure remain understudied, especially in the East African population. We therefore employed a real-time polymerase chain reaction (qPCR) assay system to test genomic DNA extracted from saliva samples targeting the NAT2 gene responsible for isoniazid metabolism to describe the frequency of human single nucleotide polymorphisms in NAT2 within populations of children and adults in Tanzania, ascribe those polymorphisms to acetylator phenotype, and correlate to serum isoniazid exposures. In adults treated with higher dose isoniazid, genotypes with a predicted allelic phenotype of slow or intermediate acetylation were able to achieve a 0.41 μg/mL higher Cmax (p = 0.018) and a 2.9h*μg/mL higher AUC0-12 (p = 0.003) per mg/kg increase in isoniazid dosage versus adults with rapid acetylation phenotype. A similar relationship was not found in the younger age population as predicted by timing of NAT2 maturation. This saliva based qPCR assay was fieldable to guide personalized isoniazid dosing in adults but not young children that may not have full NAT2 maturation and activity.
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Affiliation(s)
| | - Margaretha Sariko
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | | | - Athanasia Maro
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Dorcus Mduma
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Jean Gratz
- University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Tania Thomas
- University of Virginia, Charlottesville, VA, USA
| | - Eric R Houpt
- University of Virginia, Charlottesville, VA, USA
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Heysell SK, Mpagama SG, Ogarkov OB, Conaway M, Ahmed S, Zhdanova S, Pholwat S, Alshaer MH, Chongolo AM, Mujaga B, Sariko M, Saba S, Rahman SMM, Uddin MKM, Suzdalnitsky A, Moiseeva E, Zorkaltseva E, Koshcheyev M, Vitko S, Mmbaga BT, Kibiki GS, Pasipanodya JG, Peloquin CA, Banu S, Houpt ER. Pharmacokinetic-Pharmacodynamic Determinants of Clinical Outcomes for Rifampin-Resistant Tuberculosis: A Multisite Prospective Cohort Study. Clin Infect Dis 2022; 76:497-505. [PMID: 35731948 PMCID: PMC9907514 DOI: 10.1093/cid/ciac511] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Rifampin-resistant and/or multidrug-resistant tuberculosis (RR/MDR-TB) treatment requires multiple drugs, and outcomes remain suboptimal. Some drugs are associated with improved outcome. It is unknown whether particular pharmacokinetic-pharmacodynamic relationships predict outcome. METHODS Adults with pulmonary RR/MDR-TB in Tanzania, Bangladesh, and the Russian Federation receiving local regimens were enrolled from June 2016 to July 2018. Serum was collected after 2, 4, and 8 weeks for each drug's area under the concentration-time curve over 24 hours (AUC0-24). Quantitative susceptibility of the M. tuberculosis isolate was measured by minimum inhibitory concentrations (MICs). Individual drug AUC0-24/MIC targets were assessed by adjusted odds ratios (ORs) for favorable treatment outcome, and hazard ratios (HRs) for time to sputum culture conversion. K-means clustering algorithm separated the cohort of the most common multidrug regimen into 4 clusters by AUC0-24/MIC exposures. RESULTS Among 290 patients, 62 (21%) experienced treatment failure, including 30 deaths. Moxifloxacin AUC0-24/MIC target of 58 was associated with favorable treatment outcome (OR, 3.75; 95% confidence interval, 1.21-11.56; P = .022); levofloxacin AUC0-24/MIC of 118.3, clofazimine AUC0-24/MIC of 50.5, and pyrazinamide AUC0-24 of 379 mg × h/L were associated with faster culture conversion (HR >1.0, P < .05). Other individual drug exposures were not predictive. Clustering by AUC0-24/MIC revealed that those with the lowest multidrug exposures had the slowest culture conversion. CONCLUSIONS Amidst multidrug regimens for RR/MDR-TB, serum pharmacokinetics and M. tuberculosis MICs were variable, yet defined parameters to certain drugs-fluoroquinolones, pyrazinamide, clofazimine-were predictive and should be optimized to improve clinical outcome. CLINICAL TRIALS REGISTRATION NCT03559582.
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Affiliation(s)
- Scott K Heysell
- Correspondence: Scott K. Heysell, 345 Crispell Drive, MR-6; Charlottesville, VA 29908, USA ()
| | | | - Oleg B Ogarkov
- Department of Epidemiology and Microbiology, Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Shahriar Ahmed
- International Center for Diarrheal Diseases Research, Bangladesh, Dhaka, Bangladesh
| | - Svetlana Zhdanova
- Department of Epidemiology and Microbiology, Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation
| | - Suporn Pholwat
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Anna M Chongolo
- Kibong’oto Infectious Diseases Hospital, Sanya Juu, Tanzania
| | - Buliga Mujaga
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Margaretha Sariko
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Sabrina Saba
- International Center for Diarrheal Diseases Research, Bangladesh, Dhaka, Bangladesh
| | - S M Mazidur Rahman
- International Center for Diarrheal Diseases Research, Bangladesh, Dhaka, Bangladesh
| | | | - Alexey Suzdalnitsky
- Irkutsk Regional Tuberculosis Referral Hospital, Irkutsk, Russian Federation
| | - Elena Moiseeva
- Irkutsk Regional Tuberculosis Referral Hospital, Irkutsk, Russian Federation
| | - Elena Zorkaltseva
- Irkutsk State Medical Academy of Postgraduate Education–Branch of Russian Medical Academy of Continuing Professional Education, Irkutsk, Russian Federation
| | - Mikhail Koshcheyev
- Irkutsk Regional Tuberculosis Referral Hospital, Irkutsk, Russian Federation
| | - Serhiy Vitko
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Gibson S Kibiki
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Jotam G Pasipanodya
- Quantitative Preclinical & Clinical Sciences Department, Praedicare Inc, Dallas, Texas, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Venugopalan V, Hamza M, Santevecchi B, DeSear K, Cherabuddi K, Peloquin CA, Al-Shaer MH. Implementation of a β-lactam therapeutic drug monitoring program: Experience from a large academic medical center. Am J Health Syst Pharm 2022; 79:1586-1591. [PMID: 35704702 DOI: 10.1093/ajhp/zxac171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the implementation and operationalization of a β-lactam (BL) therapeutic drug monitoring(TDM) program at a large academic center. SUMMARY BLs are the most used class of antibiotics. Suboptimal antibiotic exposure is a significant concern in hospitalized patients, particularly in those with altered pharmacokinetics. BL-TDM provides clinicians the opportunity to optimize drug concentrations to ensure maximal therapeutic efficacy while minimizing toxicity. However, BL-TDM has not been widely adopted due to the lack of access to assays. The University of Florida Shands Hospital developed a BL-TDM program in 2015. This is a consultative service primarily run by pharmacists and is conducted in all patient care areas. An analysis was performed on the first BL-TDM encounter for 1,438 patients. BL-TDM was most frequently performed for cefepime (61%, n = 882), piperacillin (15%, n = 218), and meropenem (11%, n = 151). BL-TDM was performed a median of 3 days (interquartile range, 1-5 days) from BL initiation. Among patients with available minimum inhibitory concentration (MIC) values and trough concentrations, the pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT>MIC was attained in 308 patients (88%). BL-TDM resulted in a dosage adjustment in 25% (n = 361) of patients. CONCLUSION Implementation of a BL-TDM program requires the concerted efforts of physicians, pharmacists, nursing staff, phlebotomists, and personnel in the analytical laboratory. Standard antibiotic dosing failed to achieve optimal PK/PD targets in all patients; utilizing BL-TDM, dose adjustments were made in 1 of every 4 patients.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Malva Hamza
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Barbara Santevecchi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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Alffenaar JWC, Stocker SL, Forsman LD, Garcia-Prats A, Heysell SK, Aarnoutse RE, Akkerman OW, Aleksa A, van Altena R, de Oñata WA, Bhavani PK, Van't Boveneind-Vrubleuskaya N, Carvalho ACC, Centis R, Chakaya JM, Cirillo DM, Cho JG, D Ambrosio L, Dalcolmo MP, Denti P, Dheda K, Fox GJ, Hesseling AC, Kim HY, Köser CU, Marais BJ, Margineanu I, Märtson AG, Torrico MM, Nataprawira HM, Ong CWM, Otto-Knapp R, Peloquin CA, Silva DR, Ruslami R, Santoso P, Savic RM, Singla R, Svensson EM, Skrahina A, van Soolingen D, Srivastava S, Tadolini M, Tiberi S, Thomas TA, Udwadia ZF, Vu DH, Zhang W, Mpagama SG, Schön T, Migliori GB. Clinical standards for the dosing and management of TB drugs. Int J Tuberc Lung Dis 2022; 26:483-499. [PMID: 35650702 PMCID: PMC9165737 DOI: 10.5588/ijtld.22.0188] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.
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Affiliation(s)
- J W C Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - S L Stocker
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Department of Clinical Pharmacology and Toxicology, St Vincent´s Hospital, Sydney, NSW, Australia, St Vincent´s Clinical Campus, University of NSW, Kensington, NSW, Australia
| | - L Davies Forsman
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, Sweden, Department of Infectious Diseases Karolinska University Hospital, Solna, Sweden
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa, Department of Pediatrics, University of Wisconsin, Madison, WI
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - R E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - O W Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands, University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord, Haren, The Netherlands
| | - A Aleksa
- Educational Institution "Grodno State Medical University", Grodno, Belarus
| | - R van Altena
- Asian Harm Reduction Network (AHRN) and Medical Action Myanmar (MAM) in Yangon, Myanmar
| | - W Arrazola de Oñata
- Belgian Scientific Institute for Public Health (Belgian Lung and Tuberculosis Association), Brussels, Belgium
| | - P K Bhavani
- Indian Council of Medical Research-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - N Van't Boveneind-Vrubleuskaya
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Department of Public Health TB Control, Metropolitan Public Health Services, The Hague, The Netherlands
| | - A C C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - J M Chakaya
- Department of Medicine, Therapeutics and Dermatology, Kenyatta University, Nairobi, Kenya, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - D M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - J G Cho
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Parramatta Chest Clinic, Parramatta, NSW, Australia
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - M P Dalcolmo
- Reference Center Hélio Fraga, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - P Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - K Dheda
- Centre for Lung Infection and Immunity, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa, University of Cape Town Lung Institute & South African MRC Centre for the Study of Antimicrobial Resistance, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - G J Fox
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - H Y Kim
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - C U Köser
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - B J Marais
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia
| | - I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A G Märtson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Munoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, Mexico
| | - H M Nataprawira
- Division of Paediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - C W M Ong
- Infectious Disease Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - R Otto-Knapp
- German Central Committee against Tuberculosis (DZK), Berlin, Germany
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - R Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - P Santoso
- Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, Division of Pulmonary and Critical Care Medicine, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Singla
- Department of TB & Respiratory Diseases, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - E M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - A Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - D van Soolingen
- National Institute for Public Health and the Environment, TB Reference Laboratory (RIVM), Bilthoven, The Netherlands
| | - S Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - M Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Z F Udwadia
- P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - D H Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - W Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, People´s Republic of China
| | - S G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania, Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, United Republic of Tanzania
| | - T Schön
- Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden, Institute of Biomedical and Clinical Sciences, Division of Infection and Inflammation, Linköping University, Linköping, Sweden, Department of Infectious Diseases, Kalmar County Hospital, Kalmar, Linköping University, Linköping, Sweden
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
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Affiliation(s)
- Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Medical Science Building, PO Box 100486, Gainesville, FL, 32610, USA. .,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy and Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Medical Science Building, PO Box 100486, Gainesville, FL, 32610, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
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Georghiou SB, Rodwell TC, Korobitsyn A, Abbadi SH, Ajbani K, Alffenaar JW, Alland D, Alvarez N, Andres S, Ardizzoni E, Aubry A, Baldan R, Ballif M, Barilar I, Böttger EC, Chakravorty S, Claxton PM, Cirillo DM, Comas I, Coulter C, Denkinger CM, Derendinger B, Desmond EP, de Steenwinkel JE, Dheda K, Diacon AH, Dolinger DL, Dooley KE, Egger M, Ehsani S, Farhat MR, Fattorini L, Finci I, Le Ray LF, Furió V, Groenheit R, Gumbo T, Heysell SK, Hillemann D, Hoffmann H, Hsueh PR, Hu Y, Huang H, Hussain A, Ismail F, Izumi K, Jagielski T, Johnson JL, Kambli P, Kaniga K, Eranga Karunaratne G, Sharma MK, Keller PM, Kelly EC, Kholina M, Kohli M, Kranzer K, Laurenson IF, Limberis J, Grace Lin SY, Liu Y, López-Gavín A, Lyander A, Machado D, Martinez E, Masood F, Mitarai S, Mvelase NR, Niemann S, Nikolayevskyy V, Maurer FP, Merker M, Miotto P, Omar SV, Otto-Knapp R, Palaci M, Palacios Gutiérrez JJ, Peacock SJ, Peloquin CA, Perera J, Pierre-Audigier C, Pholwat S, Posey JE, Prammananan T, Rigouts L, Robledo J, Rockwood N, Rodrigues C, Salfinger M, Schechter MC, Seifert M, Sengstake S, Shinnick T, Shubladze N, Sintchenko V, Sirgel F, Somasundaram S, Sterling TR, Spitaleri A, Streicher E, Supply P, Svensson E, Tagliani E, Tahseen S, Takaki A, Theron G, Torrea G, Van Deun A, van Ingen J, Van Rie A, van Soolingen D, Vargas Jr R, Venter A, Veziris N, Villellas C, Viveiros M, Warren R, Wen S, Werngren J, Wilkinson RJ, Yang C, Yılmaz FF, Zhang T, Zimenkov D, Ismail N, Köser CU, Schön T. Updating the approaches to define susceptibility and resistance to anti-tuberculosis agents: implications for diagnosis and treatment. Eur Respir J 2022; 59:2200166. [PMID: 35422426 PMCID: PMC9059840 DOI: 10.1183/13993003.00166-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/05/2022] [Indexed: 11/07/2022]
Abstract
Approximately 85 000 deaths globally in 2019 were due to drug-resistant tuberculosis (TB), which corresponds to 7% of global deaths attributable to bacterial antimicrobial resistance [1]. Yet concerns have been mounting that drug-resistant TB was being underestimated because the approaches to define susceptibility and resistance to anti-TB agents had not kept up with those used for other major bacterial pathogens [2–9]. Here, we outline the recent, evidence-based initiatives spearheaded by the World Health Organization (WHO) and others to update breakpoints (traditionally referred to as critical concentrations (CCs)) that are used for phenotypic antimicrobial susceptibility testing (AST), also called drug susceptibility testing in the TB literature. Inappropriately high breakpoints have resulted in systematic false-susceptible AST results to anti-TB drugs. MIC, PK/PD and clinical outcome data should be combined when setting breakpoints to minimise the emergence and spread of antimicrobial resistance. https://bit.ly/3i43wb6
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Margineanu I, Akkerman O, Cattaneo D, Goletti D, Marriott DJE, Migliori GB, Mirzayev F, Peloquin CA, Stienstra Y, Alffenaar JW. Practices of therapeutic drug monitoring in tuberculosis: an international survey. Eur Respir J 2022; 59:2102787. [PMID: 35086830 PMCID: PMC9030066 DOI: 10.1183/13993003.02787-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 11/02/2021] [Accepted: 01/02/2022] [Indexed: 11/08/2022]
Abstract
Tuberculosis (TB) is still one of the top 10 causes of death in low and lower-middle income countries [1]. TB's long and complex treatment, side-effects, and development of resistant bacteria compromise treatment success. To improve treatment outcomes, therapeutic drug monitoring (TDM) has been included in TB treatment guidelines [2–4] to be considered for specific situations in which there is documented or expected poor response to treatment, drug toxicity, or a lower drug concentration. Several strategies for implementation of TDM for programmatic use have been proposed to overcome barriers to widespread use of TDM [5, 6], including more accessible techniques such as dried blood spot analysis or saliva and urine testing [7], but uptake in programmatic care is still limited [8]. Survey responses indicate that there is concern surrounding cost-effectiveness and the resources available in different settings to implement therapeutic drug monitoring in TB. Robust research is needed to better inform of the potential long-term benefits. https://bit.ly/34PFSfd
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Affiliation(s)
- Ioana Margineanu
- Dept of Clinical Pharmacy and Pharmacology, Rijksuniversiteit Groningen, University Medical Centrum Groningen, Groningen, The Netherlands
| | - Onno Akkerman
- University of Groningen, University Medical Centrum Groningen, Dept of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands
- University Of Groningen, University Medical Centrum Groningen, TB center Beatrixoord, Groningen, The Netherlands
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
- In alphabetical order
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases (INMI), Rome, Italy
- In alphabetical order
| | - Deborah J E Marriott
- Dept of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia
- In alphabetical order
| | | | - Fuad Mirzayev
- Global TB Programme, World Health Organization, Geneva, Switzerland
- In alphabetical order
| | - Charles A Peloquin
- University of Florida, College of Pharmacy and Emerging Pathogens Institute, Gainesville, FL, USA
- In alphabetical order
| | - Ymkje Stienstra
- Dept of Internal Medicine, Rijksuniversiteit Groningen, University Medical Centrum Groningen, Groningen, The Netherlands
| | - Jan-Willem Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Ruiz-Bedoya CA, Mota F, Tucker EW, Mahmud FJ, Reyes-Mantilla MI, Erice C, Bahr M, Flavahan K, De Jesus P, Kim J, Foss CA, Peloquin CA, Hammoud DA, Ordonez AA, Pardo CA, Jain SK. High-dose rifampin improves bactericidal activity without increased intracerebral inflammation in animal models of tuberculous meningitis. J Clin Invest 2022; 132:155851. [PMID: 35085105 PMCID: PMC8920328 DOI: 10.1172/jci155851] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Abstract
Tuberculous meningitis (TB meningitis) is the most severe form of tuberculosis (TB), requiring 12 months of multidrug treatment for cure, and is associated with high morbidity and mortality. High-dose rifampin (35 mg/kg/d) is safe and improves the bactericidal activity of the standard-dose (10 mg/kg/d) rifampin-containing TB regimen in pulmonary TB. However, there are conflicting clinical data regarding its benefit for TB meningitis, where outcomes may also be associated with intracerebral inflammation. We conducted cross-species studies in mice and rabbits, demonstrating that an intensified high-dose rifampin-containing regimen has significantly improved bactericidal activity for TB meningitis over the first-line, standard-dose rifampin regimen, without an increase in intracerebral inflammation. Positron emission tomography in live animals demonstrated spatially compartmentalized, lesion-specific pathology, with postmortem analyses showing discordant brain tissue and cerebrospinal fluid rifampin levels and inflammatory markers. Longitudinal multimodal imaging in the same cohort of animals during TB treatment as well as imaging studies in two cohorts of TB patients demonstrated that spatiotemporal changes in localized blood-brain barrier disruption in TB meningitis are an important driver of rifampin brain exposure. These data provide unique insights into the mechanisms underlying high-dose rifampin in TB meningitis with important implications for developing new antibiotic treatments for infections.
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Affiliation(s)
- Camilo A Ruiz-Bedoya
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Filipa Mota
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Elizabeth W Tucker
- Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Farina J Mahmud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Maria I Reyes-Mantilla
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Clara Erice
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Melissa Bahr
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Kelly Flavahan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Patricia De Jesus
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - John Kim
- Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Catherine A Foss
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, University of Florida College of Pharmacy, Gainesville, United States of America
| | - Dima A Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, NIH, Bethesda, United States of America
| | - Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Carlos A Pardo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, United States of America
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, United States of America
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Maciel CB, Teixeira FJP, Dickinson KJ, Spana JC, Merck LH, Rabinstein AA, Sergott R, Shan G, Miao G, Peloquin CA, Busl KM, Hirsch LJ. Early vigabatrin augmenting GABA-ergic pathways in post-anoxic status epilepticus (VIGAB-STAT) phase IIa clinical trial study protocol. Neurol Res Pract 2022; 4:4. [PMID: 35067230 PMCID: PMC8785535 DOI: 10.1186/s42466-022-00168-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Nearly one in three unconscious cardiac arrest survivors experience post-anoxic status epilepticus (PASE). Historically, PASE has been deemed untreatable resulting in its exclusion from status epilepticus clinical trials. However, emerging reports of survivors achieving functional independence following early and aggressive treatment of PASE challenged this widespread therapeutic nihilism. In the absence of proven therapies specific to PASE, standard of care treatment leans on general management strategies for status epilepticus. Vigabatrin—an approved therapy for refractory focal-onset seizures in adults—inhibits the enzyme responsible for GABA catabolism, increases brain GABA levels and may act synergistically with anesthetic agents to abort seizures. Our central hypothesis is that early inhibition of GABA breakdown is possible in the post-cardiac arrest period and may be an effective adjunctive treatment in PASE.
Methods
This is a phase IIa, single-center, open-label, pilot clinical trial with blinded outcome assessment, of a single dose of vigabatrin in 12 consecutive PASE subjects. Subjects will receive a single loading dose of 4500 mg of vigabatrin (or dose adjusted in moderate and severe renal impairment) via enteric tube within 48 h of PASE onset. Vigabatrin levels will be monitored at 0- (baseline), 0.5-, 1-, 2-, 3-, 6-, 12-, 24-, 48-, 72- and 168-h (7 days) post-vigabatrin. Serum biomarkers of neuronal injury will be measured at 0-, 24-, 48-, 72- and 96-h post-vigabatrin. The primary feasibility endpoint is the proportion of enrolled subjects among identified eligible subjects receiving vigabatrin within 48 h of PASE onset. The primary pharmacokinetic endpoint is the measured vigabatrin level at 3 h post-administration. Descriptive statistics with rates and proportions will be obtained regarding feasibility outcomes, along with the noncompartmental method for pharmacokinetic analyses. The area under the vigabatrin concentration-time curve in plasma from zero to the time of the last quantifiable concentration (AUC0-tlqc) will be calculated to estimate dose-linear pharmacokinetics.
Perspective
Vigabatrin demonstrates high potential for synergism with current standard of care therapies. Demonstration of the feasibility of vigabatrin administration and preliminary safety in PASE will pave the way for future efficacy and safety trials of this pharmacotherapeutic.
Trial Registration NCT04772547.
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Mendoza MA, Alshaer MH, Roldan G, Castro JG, Ashkin D, Peloquin CA, Boulanger CV. Effect of Rifabutin in Dolutegravir Dosing: A Case Series. J Int Assoc Provid AIDS Care 2022; 21:23259582221111077. [PMID: 36026587 PMCID: PMC9421219 DOI: 10.1177/23259582221111077] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Tuberculosis (TB) is the leading cause of death in human immunodeficiency virus (HIV)-infected people worldwide. Currently there are no studies examining the use of Rifabutin (RBN) and Dolutegravir (DTG) in co-infected persons. This is a case series of 4 co-infected patients receiving both agents who underwent Pharmacokinetic (PK) analysis. Methods and Results: This is a retrospective chart review study of four patients diagnosed with both HIV and TB, receiving RBN and DTG and undergoing therapeutic drug monitoring. All 4 cases had lower than expected DTG concentrations at least once, including those on the current recommended dose of DTG with RBN, and even those receiving higher doses. Conclusions: Given the frequency of low DTG and RBN concentrations, therapeutic drug monitoring (TDM) for these drugs is advisable. Prospective clinical studies are needed to further determine the PK interactions between RBN and DTG, and virologic response to treatment.
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Affiliation(s)
- Maria A Mendoza
- Department of Medicine, University of Miami, Miami, FL, USA.,Department of Infectious Diseases, 12235Mayo Clinic, Rochester, MN, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy, and Emerging Pathogens Institute, 3463University of Florida, Miami, FL, USA
| | | | - Jose Guillermo Castro
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David Ashkin
- Bureau of Communicable Diseases, 7824TB Control Section Florida Department of Health, Tallahassee, FL, USA
| | - Charles A Peloquin
- Bureau of Communicable Diseases, 7824TB Control Section Florida Department of Health, Tallahassee, FL, USA
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Kim S, Louie A, Drusano GL, Almoslem M, Kim S, Myrick J, Nole J, Duncanson B, Peloquin CA, Scanga CA, Yamada W, Neely M, Schmidt S. Evaluating the effect of clofazimine against Mycobacterium tuberculosis when given alone or in combination with pretomanid, bedaquiline or linezolid. Int J Antimicrob Agents 2021; 59:106509. [PMID: 34958863 DOI: 10.1016/j.ijantimicag.2021.106509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 11/19/2022]
Abstract
Clofazimine (CFZ) has been regaining prominence for treating tuberculosis in recent years. However, as a single drug, it shows limited efficacy and optimal combination partners have not been identified. Therefore, the objective of our analysis was to evaluate the efficacy of CFZ-containing two-drug regimen with pretomanid (PMD), bedaquiline (BDQ) or linezolid (LZD) by determining: i) their pharmacodynamic (PD) mode of interaction against Mycobacterium tuberculosis (Mtb) strain H37Rv in log- and acid-metabolic states, and Mtb strain 18b in a non-replicating persister metabolic state, ii) to predict bacterial cell kill of the drugs alone and in combination, and iii) to evaluate the relationship between the interaction mode and bacterial cell kill amount. The results of our Greco universal response surface analysis showed that CFZ was at least additive with a clear trend towards synergy when combined with PMD, BDQ, and LZD against Mtb in all explored metabolic states under in vitro checkerboard assay conditions. They further showed that all 2-drug combination regimens exerted more bacterial kill than any of the drugs alone. CFZ alone showed the least antimicrobial efficacy amongst the evaluated drugs and there was a lack of correlation between the mode of interaction and the amount of bacterial kill. However, we may underestimate the effect of CFZ in this screening approach due to limited in vitro study duration and neglect of target site accumulation.
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Affiliation(s)
- Sarah Kim
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, 6550 Sanger Road, Orlando, FL, 32827, USA
| | - Arnold Louie
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - George L Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - Mohammed Almoslem
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, 6550 Sanger Road, Orlando, FL, 32827, USA; Department of Clinical Pharmacy, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
| | - Soyoung Kim
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, 6550 Sanger Road, Orlando, FL, 32827, USA
| | - Jenny Myrick
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - Jocelyn Nole
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - Brandon Duncanson
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Orlando, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy, and Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Charles A Scanga
- Department of Microbiology and Molecular Genetics, and Center for Vaccine Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walter Yamada
- Laboratory of Applied Pharmacokinetics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael Neely
- Laboratory of Applied Pharmacokinetics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stephan Schmidt
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, College of Pharmacy, University of Florida, 6550 Sanger Road, Orlando, FL, 32827, USA.
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Mota F, Ruiz-Bedoya C, Tucker E, De Jesus P, Flavahan K, Turner M, Erice C, Bahr M, Kim J, Mahmud F, Peloquin CA, Peloquin CA, Ordonez AA, Jain SK, Jain SK. 1411. Noninvasive Assessment of Intralesional Antimicrobial Concentration-Time Profiles in Pulmonary and Central Nervous System Tuberculosis using Dynamic 18F-Pretomanid Positron Emission Tomography. Open Forum Infect Dis 2021. [PMCID: PMC8644115 DOI: 10.1093/ofid/ofab466.1603] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Pretomanid is used in combination with bedaquiline and linezolid (BPaL regimen) in the treatment of multidrug-resistant tuberculosis (MDR-TB). However, the penetration of pretomanid in privileged sites remain unknown. Antimicrobial pharmacokinetic (PK) parameters are traditionally derived from clinical samples (blood and cerebrospinal fluid), which may not accurately represent the intralesional tissue PK, affected by drug properties, vascular supply, barrier permeability, and the microenvironment.
Methods
We developed 18F-pretomanid (chemically identical to pretomanid) for in vivo multi-compartment PK by positron emission tomography (PET). Dynamic 18F-pretomanid PET was used to obtain cross species pretomanid concentration-time profiles in animal models of TB (mice and rabbits) to quantify penetration into pulmonary and brain lesions. A subset of animals underwent PET/CT imaging with 18F-py-albumin and 18F-FDG to assess vascular supply and inflammation. Postmortem 18F-pretomanid autoradiography (high-resolution) and mass spectrometry were performed in infected tissues. A mouse model of TB meningitis was used to evaluate the bactericidal activity of the BPaL regimen (Figure 1).
Figure 1. Experimental schematics.
(A) A new synthetic approach was developed to obtain radiofluorinated pretomanid (18F-pretomanid), which is chemically identical to pretomanid and therefore undergoes identical PK and metabolism in vivo. Dynamic 18F-pretomanid PET/CT imaging was performed in validated preclinical models of tuberculosis following intravenous administration of 18F-pretomanid. (B) PET signal was quantified in multiple compartments to generate time activity curves (TACs) used to calculate area under the curve (AUC) over 0-60 minutes. A subset of animals also underwent PET/CT imaging of 18F-py-albumin to assess vascular supply to lung and brain lesions, and with 18F-FDG to confirm the presence of neuroinflammation in the mouse and rabbit models of TB meningitis. Tissue resection post-mortem was used to visualize the intralesional retention of 18F-pretomanid using high-resolution (10 µm) autoradiography. The efficacy of the BPaL regimen in TB meningitis was compared to that of standard treatment with rifampin, isoniazid, and pyrazinamide in the mouse model. Mass spectrometry was performed following oral administration of BPaL to determine brain drug levels. (C) These data provide multicompartment PK analysis, intralesional levels of pretomanid, and insights into the mechanism that govern pretomanid tissue distribution.
Results
18F-Pretomanid PET provided detailed concentration-time profiles in infected tissues demonstrating excellent lung and brain tissue penetration (AUC ratio to plasma > 1) in both animal species, which was spatially compartmentalized, likely due to differential vascular supply (18F-py-albumin PET) (Figure 2). Brain lesions (identified by 18F-FDG PET) demonstrated localized leakiness on 18F-py-albumin PET. Autoradiography and mass spectrometry corroborated the imaging findings. The efficacy of the BPaL regimen in TB meningitis was substantially lower than standard TB treatment (Figure 3), likely due to restricted penetration of bedaquiline and linezolid into the brain parenchyma.
Figure 2. Spatial heterogeneity of 18F-Pretomanid penetration and vascular supply to pulmonary TB lesions.
(A) A novel synthetic was devised to obtain 18F-pretomanid, which is chemically identical to pretomanid. (B) Maximum intensity projection (MIP) of 18F-Pretomanid PET/CT in M.tb.-infected mice over 3 hrs shows hepatobiliary and renal excretion, high uptake into brown fat, brain, and lungs. (C) Resection of infected lungs 30 minutes post intravenous administration of 18F-pretomanid shows heterogenous distribution of 18F-pretomanid into the lungs visible by high resolution autoradiography. Areas of pneumonia are identifiable by hematoxylin and eosin (H&E) staining of the same tissue section used for autoradiography. (D) Time-activity curves of 18F-Pretomanid in infected mouse lung (0-3 hours) and derived area under the curve (AUC) ratios to plasma (E) in infected mouse lung. Representative MIP of 18F-pretomanid (F) and 18F-py-albumin (H) PET/CT in a rabbit with cavitary TB and quantification of the AUC ratios to plasma show reduced penetration into lung lesions and cavitary wall compared to areas of unaffected lung (G and I). Data are represented as median ± interquartile range, n=3-4 group.
Figure 3. Exposure levels of 18/19F-pretomanid in models of TB meningitis.
(A) Experimental timeline used to assess the penetration of pretomanid into infected mouse brain before and during treatment with antimicrobials bedaquiline (B), pretomanid (Pa), and linezolid (L), and corticosteroid dexamethasone (D). (B) Representative three-dimensional MIP of 18F-pretomanid PET/CT in the CNS-TB model, 10 min post-injection, and transverse section showing high and heterogeneous brain uptake. (C) High-resolution autoradiography was performed to confirm heterogeneous penetration of 18F-pretomanid into infected brain lesions in the mouse. (D). 8F-pretomanid AUC ratios of tissue to plasma in mouse brain before (day 0) and two weeks into treatment show a reduction in penetration at week 2. (E). Pretomanid concentrations (µg/mL) in mouse plasma and brain, at day 0 and two weeks into treatment, measured by mass spectrometry and derived concentration ratios of brain to plasma (F) suggest drug accumulation due to the long half-life. (G) While 18F-py-albumin and 18F-FDG PET/CT show vascular leakage and neuroinflammation in the rabbit model of TB meningitis, the penetration of 18F-pretomanid is heterogeneous and reduced at the lesion site (indicated by white arrow). (H) Quantification of the PET signal shows variability within the same animal. Data are represented as median ± interquartile range, n=3-5 group.
Figure 4. Evaluation of a pretomanid-containing regimen in TB meningitis.
(A) Mice with experimentally induced TB meningitis were treated with Bedaquiline (25 mg/day), Pretomanid (100 mg/day), Linezolid (100 mg/day), and Dexamethasone (2 mg/day) or Rifampin (10 mg/day), Isoniazid (10 mg/day), Pyrazinamide (150 mg/day) and Dexamethasone (2mg/day) for 8 weeks. Treatment efficacy was determined based on the brain bacterial burden after 2, 4, 6, and 8 weeks of treatment. (B) The penetration of 76Br-bedaquiline, 18F-linezolid, and 18F-pretomanid into the brain parenchyma was measured non-invasively by PET and revealed low penetration of 76Br-bedaquiline (AUC radio to plasma 0.15) and 18F-linezolid (AUC radio to plasma 0.3). (C) Mass spectrometry analysis was performed to confirm the brain penetration of bedaquiline, linezolid, and pretomanid following oral administration.
Conclusion
Dynamic 18F-pretomanid PET provided holistic data on pretomanid exposures showing excellent penetration into infected lung and brain tissues. The BPaL regimen was inferior to standard TB treatment for TB meningitis. Thus, new pretomanid-containing regimens need to be developed for the treatment of MDR-TB meningitis.
Disclosures
Charles A. Peloquin, Pharm.D., Nothing to disclose Alvaro A. Ordonez, MD, Cubresa (Consultant)Fujirebio Diagnostics (Research Grant or Support) Sanjay K. Jain, MD, Fujirebio Diagnostics, Inc., USA (Research Grant or Support)Novobiotic LLC, USA (Research Grant or Support)T3 Pharma, Switzerland (Research Grant or Support) Sanjay K. Jain, MD, Fujirebio Diagnostics, Inc., USA (Individual(s) Involved: Self): Research Grant or Support; Novobiotic LLC, USA (Individual(s) Involved: Self): Research Grant or Support; T3 Pharma, Switzerland (Individual(s) Involved: Self): Research Grant or Support
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Affiliation(s)
| | | | | | | | | | | | | | | | - John Kim
- Johns Hopkins, Baltimore, Maryland
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Ruiz-Bedoya CA, Mota F, Tucker E, Mahmud F, Erice C, Bahr M, Flavahan K, De Jesus P, Kim J, Rosa MDC, Yamashita AS, Foss CA, Peloquin CA, Peloquin CA, Ordonez AA, Jain SK, Jain SK. 191. High-Dose Rifampin-containing Regimens for the Treatment of TB Meningitis. Open Forum Infect Dis 2021. [PMCID: PMC8644107 DOI: 10.1093/ofid/ofab466.191] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
TB meningitis is the most severe form of tuberculosis (TB), associated with high morbidity and mortality. High-dose rifampin (35mg/kg/day) is safe in adults and substantially improves the bactericidal activity of standard TB regimen. However, there is conflicting data regarding its benefit in TB meningitis where outcomes may also be associated with intracerebral inflammatory responses.
Methods
A novel mouse and a validated rabbit model of TB meningitis utilizing intracranial Mycobacterium tuberculosis infections were used for these studies (Fig. 1). Animals received high-dose (35 mg/kg/day) or standard-dose (10 mg/kg/day) rifampin in combination with isoniazid, pyrazinamide and dexamethasone at human equipotent dosing. Bacterial burden, multi-modality positron emission tomography (PET) imaging, tissue drug concentrations, markers of neuroinflammation, and vascular leak were measured. Imaging data from a patient with TB meningitis was analyzed and correlated with the findings in animals.
Figure 1. Mouse model of TB meningitis replicates human histopathology hallmarks. (A) Scheme of infection. (B) Histopathology hematoxylin-eosin (H&E) and acid-fast bacilli (AFB) staining in a representative M. tuberculosis-infected mouse shows regions of meningitis, ventriculitis, choroiditis, necrotizing and non-necrotizing granulomas. The bar represents 100µm. (C) Images show immunofluorescence of microglia activation in red (Iba-1) and nuclear stain in blue (DAPI). The rabbit model of TB meningitis has been described previously (Tucker et al. Dis Model Mech. 2016 and Tucker et al. Sci Transl Med. 2018). Animal studies were approved by the Johns Hopkins Animal Care and Use Committee.
Results
Administration of the high-dose rifampin regimen achieved four times higher brain concentration than the standard-dose regimen and displayed higher bactericidal activity in both mice and rabbits (P < 0.01) (Fig. 2). There were no differences in intracerebral microglial activation (124I-DPA-713 PET and iDISCO) and pro-inflammatory cytokines during treatment in animals receiving high- or standard-dose rifampin regimens (Fig. 3). Whole-brain PET and immunolabeling demonstrated spatially compartmentalized inflammation, vascular leak and rifampin exposures (Fig. 4). Longitudinal imaging in the same animals showed a 40% decrease in vascular leak after two weeks of TB treatment. Spatially compartmentalized brain rifampin exposures and decreases in vascular edema over TB treatment were also noted in the TB meningitis patient.
Figure 2. High-dose rifampin treatment in mouse and rabbit models of TB meningitis. (A) Experimental scheme. R10 (rifampin 10mg/kg), R35 (rifampin 35mg/kg), H (isoniazid), Z (pyrazinamide), D (dexamethasone). (B) Bactericidal activity of high-dose rifampin (n = 60 animals) and standard-dose rifampin (n = 60 animals) regimens in mice. (C) Grouped colony forming units (CFU) and (D) rifampin brain concentration in mice after 42 days of TB treatments. (E) Bactericidal activity of high-dose rifampin (n = 4 animals) and standard-dose rifampin (n = 3 animals) regimens in rabbits. Data from untreated rabbits (n = 2 animals) is also shown. (F) Grouped CFU and (G) rifampin brain concentration in rabbits after 14 days of TB treatments. Tissues were assayed using validated ultra-high-performance liquid chromatography and tandem mass spectrometry (LC-MS/MS) for rifampin at the Infectious Diseases Pharmacokinetics Laboratory of the University of Florida. The bacterial burden is represented as CFU per gram of tissue and presented on a logarithmic scale. CFU and mass spectrometry data are represented as mean ± SD. *P < 0.05, **P < 0.01 and ***P < 0.001 calculated using a two-way ANOVA test.
Figure 3. Neuroinflammatory responses during TB treatment. (A) Iba-1 and DAPI immunofluorescence in a representative untreated, high-dose and low-dose-treated mouse. (B) Quantification of Iba-1 immunofluorescence before treatment and after 6 weeks of treatment (n = 3 mice per group). Sections were imaged at 40X with Nikon A1+ confocal microscope. HALO was used for visualization and quantification. Quantification of intraparenchymal (C) INF-γ, (D) TNF and (E) MCP-1 in untreated and treated mice (Milliplex Multiplex Luminex assay). (F) Coronal CT and 124I-DPA-713 PET/CT of a representative mouse with TB meningitis before treatment initiation. (G) 124I-DPA-713 PET quantification before treatment (n = 15 animals) and after 2 (n = 5 animals per group) and 6 (n = 5 animals per group) weeks of TB treatment. PET data is represented as median ± IQ. *P < 0.05, **P < 0.01 and ***P < 0.001 were calculated using a two-way ANOVA test.
Figure 4. Changes in vascular leakage and rifampin penetration during TB treatment. (A) Experimental scheme in mice. (B) Whole-brain immunolabeling (iDISCO) of a representative M. tuberculosis-infected mouse prior to treatment initiation. Images show immunolabeling of α-smooth muscle actin in grey and microglia activation in red (Iba-1). Asterix represents the areas of vascular amputation. (C) Coronal 18F-py-Albumin PET/CT and quantification (tissue to plasma ratio) in untreated and 2 weeks-treated mice (n = 10 animals at each time-point). (D) Serial imaging in a patient with TB meningitis. (E) Transverse T2 post-contrast section and maximal intensity projection (MIP) showing vasogenic edema. (F) Co-registered T2 post-contrast MIP with transverse 11C-rifampin area under the curve (AUC) heat-map, and 11C-rifampin tissue to plasma ratio quantification of the areas with and without vasogenic edema, and unaffected brain. (G) T2 post-contrast MIP at 3 and 45 months after treatment initiation. The patient with TB meningitis was recruited as part of a 11C-rifampin PET research study performed under the U.S. FDA Radioactive Drug Research Committee program for investigational drugs (Tucker et al. Sci Transl Med. 2018; Ordonez et al. Nat Med. 2020). Human studies were approved by the Johns Hopkins University Institutional Review Board Committee. M = moxifloxacin. PET data is represented as median ± IQ. *P < 0.05, **P < 0.01 and ***P < 0.001 calculated using a two-way ANOVA test.
Conclusion
Our cross-species findings suggest that an intensified high-dose rifampin regimen is more efficacious than the standard treatment for TB meningitis without an increase in neuroinflammation. Vascular leak decreases during TB treatment and may account for decreases in rifampin permeability over time. These studies have important implications for antimicrobial development for TB meningitis.
Disclosures
Charles A. Peloquin, Pharm.D., Nothing to disclose Alvaro A. Ordonez, MD, Cubresa (Consultant)Fujirebio Diagnostics (Research Grant or Support) Sanjay K. Jain, MD, Fujirebio Diagnostics, Inc., USA (Research Grant or Support)Novobiotic LLC, USA (Research Grant or Support)T3 Pharma, Switzerland (Research Grant or Support) Sanjay K. Jain, MD, Fujirebio Diagnostics, Inc., USA (Individual(s) Involved: Self): Research Grant or Support; Novobiotic LLC, USA (Individual(s) Involved: Self): Research Grant or Support; T3 Pharma, Switzerland (Individual(s) Involved: Self): Research Grant or Support
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Affiliation(s)
| | | | | | | | - Clara Erice
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Melissa Bahr
- Johns Hopkins University, School of Medicine, Baltimore, MD
| | | | | | - John Kim
- Johns Hopkins University, School of Medicine, Baltimore, MD
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Veena V, Hamza M, Santevecchi BA, DeSear K, Cherabuddi K, Peloquin CA, Peloquin CA, Al-Shaer MH. 1101. Implementing a Beta-Lactam Therapeutic Drug Monitoring Program: Experience from a Large Academic Medical Center. Open Forum Infect Dis 2021. [PMCID: PMC8644826 DOI: 10.1093/ofid/ofab466.1295] [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: 12/05/2022] Open
Abstract
Background Beta-lactams (BL) are the cornerstone of antimicrobial treatment for infections. Beta-lactam therapeutic drug monitoring (BL-TDM) optimizes drug concentrations to ensure maximal efficacy and minimal toxicity. The goals of this study were to describe the implementation process of a BL-TDM program and to further describe our experience using BL-TDM in clinical practice. Methods This was a retrospective review of adult patients with available BL-TDM between January 2016 and November 2019 at the University of Florida (UF) Health Shands Hospital. Total serum concentrations of BL were measured in the Infectious Diseases Pharmacokinetics Lab (IDPL) at UF, using a validated ultrahigh pressure liquid chromatography assay with triple quadrupole mass spectroscopy (LC-MS-MS). At our institution, TDM is available for 11 BLs and in-house assays are performed from Mon-Fri for most BLs. Results A total of 3,030 BL concentrations were obtained. An analysis was performed on the first BL-TDM encounter in 1,438 patients. The median age was 57 years (IQR, 41-69) and the median BMI was 27.5 kg/m2 (IQR, 22.5-34.5). On the day of BL-TDM, the median serum creatinine was 0.83 (IQR, 0.59-1.30). Fifty-one percent of patients (n=735) were in an ICU at the time of BL-TDM with a median SOFA score of 6 (IQR, 3-9). BL-TDM was most frequently performed on cefepime (61%, n=882), piperacillin (15%, n=218), and meropenem (11%, n=151). The BL was administered as a continuous infusion in 211 (15%) patients. An interim analysis of 548 patients showed that BL-TDM was performed a median of 2 days (IQR, 1-4) from the start of BL therapy and resulted in a dosage adjustment in 26% (n=145). Conclusion BL-TDM was performed in older, non-obese patients with normal renal function. Over half of the evaluated patients were in an ICU at the time of TDM. This finding emphasizes the value of BL-TDM in the ICU setting because altered pharmacokinetics during critical illness has been linked to enhanced BL clearance. Interestingly, BL-TDM resulted in dosage adjustment in 1 in 4 patients who were receiving licensed BL dosing regimens, thus highlighting the role of TDM in dose individualization. BL-TDM was performed most commonly within the 72-hours of therapy initiation. Early BL-TDM has been shown to improve patient outcomes and should be promoted. Disclosures Venugopalan Veena, PharmD, Melinta (Other Financial or Material Support, Received a stipend for participation in a drug registry)Merck (Other Financial or Material Support, Received a stipend for participation in a drug registry) Charles A. Peloquin, Pharm.D., Nothing to disclose
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Affiliation(s)
| | - Malva Hamza
- University of Florida College of Pharmacy, Gainesville, Florida
| | | | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, Florida
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Gordon O, Lee DE, Liu B, Langevin B, Ordonez AA, Dikeman DA, Shafiq B, Thompson JM, Sponseller PD, Flavahan K, Lodge MA, Rowe SP, Dannals RF, Ruiz-Bedoya CA, Read TD, Peloquin CA, Archer NK, Miller LS, Davis KM, Gobburu JVS, Jain SK. Dynamic PET-facilitated modeling and high-dose rifampin regimens for Staphylococcus aureus orthopedic implant-associated infections. Sci Transl Med 2021; 13:eabl6851. [PMID: 34851697 PMCID: PMC8693472 DOI: 10.1126/scitranslmed.abl6851] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus is a major human pathogen causing serious implant–associated infections. Combination treatment with rifampin (10 to 15 mg/kg per day), which has dose-dependent activity, is recommended to treat S. aureus orthopedic implant–associated infections. Rifampin, however, has limited bone penetration. Here, dynamic 11C-rifampin positron emission tomography (PET) performed in prospectively enrolled patients with confirmed S. aureus bone infection (n = 3) or without orthopedic infection (n = 12) demonstrated bone/plasma area under the concentration-time curve ratio of 0.14 (interquartile range, 0.09 to 0.19), exposures lower than previously thought. PET-based pharmacokinetic modeling predicted rifampin concentration-time profiles in bone and facilitated studies in a mouse model of S. aureus orthopedic implant infection. Administration of high-dose rifampin (human equipotent to 35 mg/kg per day) substantially increased bone concentrations (2 mg/liter versus <0.2 mg/liter with standard dosing) in mice and achieved higher bacterial killing and biofilm disruption. Treatment for 4 weeks with high-dose rifampin and vancomycin was noninferior to the recommended 6-week treatment of standard-dose rifampin with vancomycin in mice (risk difference, −6.7% favoring high-dose rifampin regimen). High-dose rifampin treatment ameliorated antimicrobial resistance (0% versus 38%; P = 0.04) and mitigated adverse bone remodeling (P < 0.01). Last, whole-genome sequencing demonstrated that administration of high-dose rifampin in mice reduced selection of bacterial mutations conferring rifampin resistance (rpoB) and mutations in genes potentially linked to persistence. These data suggest that administration of high-dose rifampin is necessary to achieve optimal bone concentrations, which could shorten and improve treatments for S. aureus orthopedic implant infections.
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Affiliation(s)
- Oren Gordon
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Donald E. Lee
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Bessie Liu
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Alvaro A. Ordonez
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dustin A. Dikeman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - John M. Thompson
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Paul D. Sponseller
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kelly Flavahan
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martin A. Lodge
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Steven P. Rowe
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert F. Dannals
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Camilo A. Ruiz-Bedoya
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Timothy D. Read
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
| | - Nathan K. Archer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lloyd S. Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Immunology, Janssen Research and Development, Spring House, PA 19477, USA
| | - Kimberly M. Davis
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Jogarao V. S. Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Sanjay K. Jain
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Maguigan KL, Al-Shaer MH, Peloquin CA. Beta-Lactams Dosing in Critically Ill Patients with Gram-Negative Bacterial Infections: A PK/PD Approach. Antibiotics (Basel) 2021; 10:1154. [PMID: 34680734 PMCID: PMC8532626 DOI: 10.3390/antibiotics10101154] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
Beta-lactam antibiotics are often the backbone of treatment for Gram-negative infections in the critically ill. Beta-lactams exhibit time-dependent killing, and their efficacy depends on the percentage of dosing interval that the concentration remains above the minimum inhibitory concentration. The Gram-negative resistance rates of pathogens are increasing in the intensive care unit (ICU), and critically ill patients often possess physiology that makes dosing more challenging. The volume of distribution is usually increased, and drug clearance is variable. Augmented renal clearance and hypermetabolic states increase the clearance of beta-lactams, while acute kidney injury reduces the clearance. To overcome the factors affecting ICU patients and decreasing susceptibilities, dosing strategies involving higher doses, and extended or continuous infusions may be required. In this review, we specifically examined pharmacokinetic models in ICU patients, to determine the desired beta-lactam regimens for clinical breakpoints of Enterobacterales and Pseudomonas aeruginosa, as determined by the European Committee on Antimicrobial Susceptibility Testing. The beta-lactams evaluated included penicillins, cephalosporins, carbapenems, and monobactams. We found that when treating less-susceptible pathogens, especially P. aeruginosa, continuous infusions are frequently needed to achieve the desired pharmacokinetic/pharmacodynamic targets. More studies are needed to determine optimal dosing strategies in the novel beta-lactams.
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Affiliation(s)
- Kelly L. Maguigan
- Pharmacy Department, University of Florida Health Shands Hospital, Gainesville, FL 32608, USA;
| | - Mohammad H. Al-Shaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
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