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Lepak AJ, Trang M, Hammel JP, Sader HS, Bhavnani SM, VanScoy BD, Pogue JM, Ambrose PG, Andes DR. Development of Modernized Acinetobacter baumannii Susceptibility Test Interpretive Criteria for Recommended Antimicrobial Agents Using Pharmacometric Approaches. Antimicrob Agents Chemother 2023; 67:e0145222. [PMID: 36946729 PMCID: PMC10112158 DOI: 10.1128/aac.01452-22] [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: 10/28/2022] [Accepted: 02/13/2023] [Indexed: 03/23/2023] Open
Abstract
Acinetobacter baumannii-Acinetobacter calcoaceticus complex (referred to herein as A. baumannii) treatment guidelines contain numerous older antimicrobial agents with susceptibility test interpretive criteria (STIC, also known as susceptibility breakpoints) set using only epidemiological data. We utilized a combination of in vitro surveillance data, preclinical murine thigh and lung infection models, population pharmacokinetics, simulation, and pharmacokinetic/pharmacodynamic (PK/PD) target attainment analyses to evaluate A. baumannii STIC for four commonly recommended antimicrobials from different classes (amikacin, ceftazidime, ciprofloxacin, and minocycline). Antimicrobial in vitro surveillance data were based on 1,647 clinical A. baumannii isolates obtained from 109 centers in the United States and Europe. Among these isolates, 5 were selected for evaluation in murine infection models based on fitness and MIC variability. PK and dose-ranging studies were conducted using neutropenic murine thigh and lung infection models The MIC ranges for the 5 isolates evaluated were as follows: amikacin, 2 to 32 μg/mL; ceftazidime, 4 to 16 μg/mL; ciprofloxacin, 0.12 to 2 μg/mL; minocycline, 0.25 to 4 μg/mL. All organisms grew ≥1.5 log10 CFU in both models in untreated controls. Plasma and epithelial lining fluid (ELF) pharmacokinetics for all drugs were determined in mice using liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods. For each isolate, 5 dose levels of each drug were tested individually in the thigh and lung infection model. The inoculum ranged from 7.9 to 8.4 and 6.8 to 7.7 log10 CFU/mL for the lung and thigh models, respectively. PK/PD targets associated with net bacterial stasis and 1- and 2-log10 CFU reductions from baseline were identified for each organism/infection model using Hill-type models. Population pharmacokinetic models for each agent were identified from the literature. Using demographic variables for simulated patients with hospital-acquired or ventilator-associated bacterial pneumonia or urinary tract infections (including acute pyelonephritis) who were administered maximal dosing regimens of each agent, estimates of protein binding, and ELF penetration ratios based on data from the literature, free-drug plasma and total-drug concentration-time profiles were generated, and PK/PD indices by MIC were calculated. Percent probabilities of attaining median and randomly assigned PK/PD targets associated with the above-described endpoints were determined. Recommended susceptible breakpoints for each agent were those representing the highest MIC at which the percent probabilities of achieving PK/PD targets associated with a 1-log10 CFU reduction from baseline approached or were ≥90%. The following susceptible breakpoints for A. baumannii were identified: amikacin, ≤8 μg/mL for pneumonia; ceftazidime, ≤32 and ≤8 μg/mL for pneumonia; ciprofloxacin, ≤1 μg/mL; and minocycline, ≤0.5/≤1 μg/mL which correspond to the standard and high minocycline dosing regimens of 200 mg per day and 200 mg every 12 h, respectively. Implementation of appropriate STIC will help clinicians optimally use the above-described agents and improve the likelihood of successful patient outcomes.
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Affiliation(s)
- A. J. Lepak
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
| | - M. Trang
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - J. P. Hammel
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | | | - S. M. Bhavnani
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - B. D. VanScoy
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - J. M. Pogue
- University of Michigan, Ann Arbor, Michigan, USA
| | - P. G. Ambrose
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
| | - D. R. Andes
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
| | - United States Committee on Antimicrobial Susceptibility Testing
- University of Wisconsin—Madison, Department of Medicine, Madison, Wisconsin, USA
- Institute for Clinical Pharmacodynamics, Schenectady, New York, USA
- JMI Laboratories, North Liberty, Iowa, USA
- University of Michigan, Ann Arbor, Michigan, USA
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Pogue JM, Lee J, Marchaim D, Yee V, Zhao JJ, Chopra T, Lephart P, Kaye KS. Incidence of and Risk Factors for Colistin-Associated Nephrotoxicity in a Large Academic Health System. Clin Infect Dis 2011; 53:879-84. [DOI: 10.1093/cid/cir611] [Citation(s) in RCA: 246] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Pogue JM, DePestel DD, Kaul DR, Khaled Y, Frame DG. Systemic absorption of oral vancomycin in a peripheral blood stem cell transplant patient with severe graft-versus-host disease of the gastrointestinal tract. Transpl Infect Dis 2009; 11:467-70. [PMID: 19638004 DOI: 10.1111/j.1399-3062.2009.00426.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Oral vancomycin is often considered the drug of choice for severe Clostridium difficile-associated disease due to both its efficacy and pharmacokinetics. The potential for absorption is not well described in patients with impaired gastrointestinal (GI) mucosa. We describe a case of significant and potentially toxic absorption of oral vancomycin in a peripheral blood stem cell transplant patient with grade IV graft-versus-host disease (GVHD) of the GI tract. In patients with GI GVHD clinicians need to be aware of the potential for oral absorption and, in select cases, monitoring of levels may be appropriate.
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Affiliation(s)
- J M Pogue
- Department of Pharmacy Services, Sinai Grace Hospital, Detroit Medical Center, Detroit, Michigan 48235-2624, USA.
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Pogue JM, Yusuf S. Cumulating evidence from randomized trials: utilizing sequential monitoring boundaries for cumulative meta-analysis. Control Clin Trials 1997; 18:580-93; discussion 661-6. [PMID: 9408720 DOI: 10.1016/s0197-2456(97)00051-2] [Citation(s) in RCA: 301] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We propose the adaptation of classical monitoring boundaries for use in cumulative meta-analysis as guidelines for deciding when accumulating evidence is statistically significant and medically convincing. The interpretation of information from a randomized controlled trial is compared with that from a meta-analysis. The concept of optimal information size for a meta-analysis is developed and used to adapt monitoring boundaries to cumulative meta-analysis.
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Affiliation(s)
- J M Pogue
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Flather MD, Farkouh ME, Pogue JM, Yusuf S. Strengths and limitations of meta-analysis: larger studies may be more reliable. Control Clin Trials 1997; 18:568-79; discussion 661-6. [PMID: 9408719 DOI: 10.1016/s0197-2456(97)00024-x] [Citation(s) in RCA: 156] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Meta-analysis of randomized controlled trials combines information from independent studies that address a similar question to provide more reliable estimates of treatment effects. At the present time, the methodology and usefulness of meta-analysis is under scrutiny. In the first part of this paper, we summarize the limitations of meta-analysis and make suggestions for improvements. In the second part, we illustrate strengths and limitations using examples of meta-analyses and subsequent large trials that address the same question. We develop the hypothesis that the size of the meta-analysis may be a useful measure of reliability. Small meta-analyses (i.e., those with less than 200 outcome events) may only be useful for summarizing the available information and generating hypotheses for future research. The results of small meta-analyses should be regarded with caution, even if the p value shows extreme statistical significance. Larger meta-analyses (i.e., those with several hundred events) are likely to be more reliable and may be clinically useful. Well-conducted meta-analyses of large trials using individual patient data may provide the best estimates of treatment effects in the cohort overall and in clinically important subgroups.
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Affiliation(s)
- M D Flather
- Preventive Cardiology and Therapeutics Programme, Hamilton Civic Hospitals' Research Centre, Ontario, Canada
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Osimani A, Ichise M, Chung DG, Pogue JM, Freedman M. SPECT for differential diagnosis of dementia and correlation of rCBF with cognitive impairment. Can J Neurol Sci 1994; 21:104-11. [PMID: 8087734 DOI: 10.1017/s0317167100049015] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [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: 01/28/2023]
Abstract
99mTc-HM-PAO single photon emission computed tomography (SPECT) was used to image 30 patients referred for the assessment of dementia. SPECT images revealed various patterns of regional cerebral perfusion (rCBF) in the subgroups of patients with the clinical diagnoses of Alzheimer's disease (AD, n = 14), Pick's disease (n = 1), and multi-infarct dementia (n = 7). In three patients, SPECT clarified the clinical differential diagnostic possibilities. Using a relative rCBF quantification technique, the relationship between specific cognitive impairments and rCBF in the AD patients was determined. There was a significant correlation between language impairment and left hemisphere hypoperfusion, whereas, apraxia correlated with hypoperfusion in the left parietal region. Thus, HM-PAO SPECT is useful as an aid in the differential diagnosis of dementia and the technique of relative rCBF quantification with SPECT may contribute to the understanding of the clinico-anatomical relations of cognitive deficits in dementia.
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Affiliation(s)
- A Osimani
- Rotman Research Institute of Baycrest Centre for Geriatric Care, University of Toronto, Toronto, Ontario, Canada
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