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Wagenlehner FME, Cloutier DJ, Komirenko AS, Cebrik DS, Krause KM, Keepers TR, Connolly LE, Miller LG, Friedland I, Dwyer JP. Once-Daily Plazomicin for Complicated Urinary Tract Infections. N Engl J Med 2019; 380:729-740. [PMID: 30786187 DOI: 10.1056/nejmoa1801467] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The increasing multidrug resistance among gram-negative uropathogens necessitates new treatments for serious infections. Plazomicin is an aminoglycoside with bactericidal activity against multidrug-resistant (including carbapenem-resistant) Enterobacteriaceae. METHODS We randomly assigned 609 patients with complicated urinary tract infections (UTIs), including acute pyelonephritis, in a 1:1 ratio to receive intravenous plazomicin (15 mg per kilogram of body weight once daily) or meropenem (1 g every 8 hours), with optional oral step-down therapy after at least 4 days of intravenous therapy, for a total of 7 to 10 days of therapy. The primary objective was to show the noninferiority of plazomicin to meropenem in the treatment of complicated UTIs, including acute pyelonephritis, with a noninferiority margin of 15 percentage points. The primary end points were composite cure (clinical cure and microbiologic eradication) at day 5 and at the test-of-cure visit (15 to 19 days after initiation of therapy) in the microbiologic modified intention-to-treat population. RESULTS Plazomicin was noninferior to meropenem with respect to the primary efficacy end points. At day 5, composite cure was observed in 88.0% of the patients (168 of 191 patients) in the plazomicin group and in 91.4% (180 of 197 patients) in the meropenem group (difference, -3.4 percentage points; 95% confidence interval [CI], -10.0 to 3.1). At the test-of-cure visit, composite cure was observed in 81.7% (156 of 191 patients) and 70.1% (138 of 197 patients), respectively (difference, 11.6 percentage points; 95% CI, 2.7 to 20.3). At the test-of-cure visit, a higher percentage of patients in the plazomicin group than in the meropenem group were found to have microbiologic eradication, including eradication of Enterobacteriaceae that were not susceptible to aminoglycosides (78.8% vs. 68.6%) and Enterobacteriaceae that produce extended-spectrum β-lactamases (82.4% vs. 75.0%). At late follow-up (24 to 32 days after initiation of therapy), fewer patients in the plazomicin group than in the meropenem group had microbiologic recurrence (3.7% vs. 8.1%) or clinical relapse (1.6% vs. 7.1%). Increases in serum creatinine levels of 0.5 mg or more per deciliter (≥40 μmol per liter) above baseline occurred in 7.0% of patients in the plazomicin group and in 4.0% in the meropenem group. CONCLUSIONS Once-daily plazomicin was noninferior to meropenem for the treatment of complicated UTIs and acute pyelonephritis caused by Enterobacteriaceae, including multidrug-resistant strains. (Funded by Achaogen and the Biomedical Advanced Research and Development Authority; EPIC ClinicalTrials.gov number, NCT02486627.).
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Affiliation(s)
- Florian M E Wagenlehner
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Daniel J Cloutier
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Allison S Komirenko
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Deborah S Cebrik
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Kevin M Krause
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Tiffany R Keepers
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Lynn E Connolly
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Loren G Miller
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Ian Friedland
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
| | - Jamie P Dwyer
- From the Justus Liebig University, Giessen, Germany (F.M.E.W.); Achaogen, South San Francisco (D.J.C., A.S.K., D.S.C., K.M.K., T.R.K., L.E.C., I.F.), the David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles (L.G.M.), and Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance (L.G.M.) - all in California; and Vanderbilt University Medical Center, Nashville (J.P.D.)
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Keepers TR, Cebrik DS, Cloutier DJ, Komirenko A, Connolly L, Krause K. 124. Microbiological Outcomes With Plazomicin (PLZ) Versus Meropenem (MEM) in Patients With Complicated Urinary Tract Infections (cUTI), Including Acute Pyelonephritis (AP) in the EPIC Study. Open Forum Infect Dis 2018. [PMCID: PMC6253087 DOI: 10.1093/ofid/ofy209.014] [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
Background PLZ is a next-generation aminoglycoside (AG) that is structurally protected from common AG-modifying enzymes (AMEs) in Enterobacteriaceae and with in vitro activity against multidrug-resistant Enterobacteriaceae, including ESBL-producing, AG-resistant, and carbapenem-resistant isolates. We report microbiological outcomes in the EPIC study, including outcomes for resistant pathogens and by the PLZ MIC. Methods EPIC was a multinational, randomized, double-blind study in hospitalized patients with cUTI or AP. Patients received IV PLZ (15 mg/kg q24h) or IV MEM (1 g q8h) for 4–7 days, followed by optional oral therapy, for a total of 7–10 days of therapy. The extended mMITT population included patients with ≥1 qualifying baseline pathogen (≥105 CFU/mL urine) who received study drug. Microbiological outcomes were assessed at TOC (day 15–19). Isolate identification and susceptibility testing were conducted by a central laboratory. Whole-genome sequencing was used to identify AME and β-lactamase genes. Results Of 609 patients enrolled, 407 (66.8%) were included in the extended mMITT population. The most common uropathogen was Escherichia coli (63.4%) followed by Klebsiella pneumoniae (19.7%). PLZ and MEM MIC50/90 for Enterobacteriaceae were 0.5/2 μg/mL (range: ≤0.06–>128 mg/mL) and 0.015/0.06 mg/mL (range: ≤0.004–128 mg/mL), respectively. ESBL and AG-NS phenotypes were found in 29% and 27% of isolates, respectively. Genotyping detected β-lactamase and AME genes in 32.5% and 36.8% of isolates, respectively, most commonly blaCTX-M-15 (n = 98), blaOXA-1/OXA-30 (n = 82), aac(6′)Ib-cr (n = 79), and aac(3)-IIa (n = 56). Rates of microbiological eradication are shown in Table 1. All Enterobacteriaceae in the PLZ group with a PLZ MIC of 4 µg/mL (6/6) were eradicated at TOC (Table 2). Across 49 patients with concurrent bacteremia, 100% (27/27) and 96% (24/25) of Enterobacteriaceae were cleared from the blood at TOC in the PLZ and MEM groups, respectively. Conclusion PLZ demonstrated comparable or higher microbiological eradication rates compared with MEM for common Gram-negative uropathogens, including resistant pathogens. The results support PLZ as a potential treatment option for cUTI, including AP, caused by Enterobacteriaceae with PLZ MICs of ≤4 mg/mL. ![]()
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Disclosures T. R. Keepers, Achaogen, Inc.: Employee, Salary. D. S. Cebrik, Achaogen, Inc.: Employee, Salary. D. J. Cloutier, Achaogen, Inc.: Employee and Shareholder, Salary. A. Komirenko, Achaogen, Inc.: Employee and Shareholder, Salary. L. Connolly, Achaogen, Inc.: Consultant, Consulting fee. K. Krause, Achaogen, Inc.: Employee, Salary.
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