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Wistrand-Yuen P, Olsson A, Skarp KP, Friberg L, Nielsen E, Lagerbäck P, Tängdén T. Evaluation of polymyxin B in combination with 13 other antibiotics against carbapenemase-producing Klebsiella pneumoniae in time-lapse microscopy and time-kill experiments. Clin Microbiol Infect 2020; 26:1214-1221. [DOI: 10.1016/j.cmi.2020.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/17/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
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Märtson AG, Sturkenboom MGG, Stojanova J, Cattaneo D, Hope W, Marriott D, Patanwala AE, Peloquin CA, Wicha SG, van der Werf TS, Tängdén T, Roberts JA, Neely MN, Alffenaar JWC. How to design a study to evaluate therapeutic drug monitoring in infectious diseases? Clin Microbiol Infect 2020; 26:1008-1016. [PMID: 32205294 DOI: 10.1016/j.cmi.2020.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 12/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM. OBJECTIVES We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM. SOURCES The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM. CONTENT This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design. IMPLICATIONS This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.
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Affiliation(s)
- A-G Märtson
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - M G G Sturkenboom
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - J Stojanova
- Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
| | - D Cattaneo
- ASST Fatebenefratelli Sacco University Hospital, Unit of Clinical Pharmacology, Department of Laboratory Medicine, Milan, Italy
| | - W Hope
- University of Liverpool, Antimicrobial Pharmacodynamics and Therapeutics, Liverpool, UK; Royal Liverpool Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - D Marriott
- St Vincent's Hospital, Sydney, Australia
| | - A E Patanwala
- The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S G Wicha
- University of Hamburg, Department of Clinical Pharmacy, Institute of Pharmacy, Hamburg, Germany
| | - T S van der Werf
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, the Netherlands
| | - T Tängdén
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - M N Neely
- Children's Hospital of Los Angeles, Laboratory of Applied Pharmacokinetics and Bioinformatics, Los Angeles, CA, USA
| | - J-W C Alffenaar
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands; The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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Ungphakorn W, Lagerbäck P, Nielsen EI, Tängdén T. Automated time-lapse microscopy a novel method for screening of antibiotic combination effects against multidrug-resistant Gram-negative bacteria. Clin Microbiol Infect 2017; 24:778.e7-778.e14. [PMID: 29108951 DOI: 10.1016/j.cmi.2017.10.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 07/13/2017] [Revised: 09/28/2017] [Accepted: 10/31/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Antibiotic combinations are often used for carbapenemase-producing Enterobacteriaceae (CPE) but more data are needed on the optimal selection of drugs. This study aimed to evaluate the feasibility of a novel automated method based on time-lapse microscopy (the oCelloScope, Philips BioCell A/S, Allerød, Denmark) to determine in vitro combination effects against CPE and to discuss advantages and limitations of the oCelloScope in relation to standard methods. METHODS Four Klebsiella pneumoniae and two Escherichia coli were exposed to colistin, meropenem, rifampin and tigecycline, alone and in combination. In the oCelloScope experiments, a background corrected absorption (BCA) value of ≤8 at 24 h was used as a primary cut-off indicating inhibition of bacterial growth. A new approach was used to determine synergy, indifference and antagonism based on the number of objects (bacteria) in the images. Static time-kill experiments were performed for comparison. RESULTS The time-kill experiments showed synergy with 12 of 36 regimens, most frequently with colistin plus rifampin. BCA values ≤8 consistently correlated with 24-h bacterial concentrations ≤6 log10 CFU/mL. The classification of combination effects agreed with the time-kill results for 33 of 36 regimens. In three cases, the interactions could not be classified with the microscopy method because of low object counts. CONCLUSIONS Automated time-lapse microscopy can accurately determine the effects of antibiotic combinations. The novel method is highly efficient compared with time-kill experiments, more informative than checkerboards and can be useful to accelerate the screening for combinations active against multidrug-resistant Gram-negative bacteria.
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Affiliation(s)
- W Ungphakorn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - P Lagerbäck
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - E I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - T Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
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Tängdén T, Ramos Martín V, Felton TW, Nielsen EI, Marchand S, Brüggemann RJ, Bulitta JB, Bassetti M, Theuretzbacher U, Tsuji BT, Wareham DW, Friberg LE, De Waele JJ, Tam VH, Roberts JA. The role of infection models and PK/PD modelling for optimising care of critically ill patients with severe infections. Intensive Care Med 2017; 43:1021-1032. [PMID: 28409203 DOI: 10.1007/s00134-017-4780-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/18/2017] [Indexed: 01/14/2023]
Abstract
Critically ill patients with severe infections are at high risk of suboptimal antimicrobial dosing. The pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in these patients differ significantly from the patient groups from whose data the conventional dosing regimens were developed. Use of such regimens often results in inadequate antimicrobial concentrations at the site of infection and is associated with poor patient outcomes. In this article, we describe the potential of in vitro and in vivo infection models, clinical pharmacokinetic data and pharmacokinetic/pharmacodynamic models to guide the design of more effective antimicrobial dosing regimens. Individualised dosing, based on population PK models and patient factors (e.g. renal function and weight) known to influence antimicrobial PK, increases the probability of achieving therapeutic drug exposures while at the same time avoiding toxic concentrations. When therapeutic drug monitoring (TDM) is applied, early dose adaptation to the needs of the individual patient is possible. TDM is likely to be of particular importance for infected critically ill patients, where profound PK changes are present and prompt appropriate antibiotic therapy is crucial. In the light of the continued high mortality rates in critically ill patients with severe infections, a paradigm shift to refined dosing strategies for antimicrobials is warranted to enhance the probability of achieving drug concentrations that increase the likelihood of clinical success.
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Affiliation(s)
- T Tängdén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - V Ramos Martín
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - T W Felton
- Intensive Care Unit, University Hospital of South Manchester, Manchester, UK
| | - E I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - S Marchand
- Inserm U1070, Pole Biologie Santé, Poitiers, France.,UFR Médecine-Pharmacie, Université de Poitiers, Poitiers, France
| | - R J Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, USA
| | - M Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital and University of Udine, Udine, Italy
| | | | - B T Tsuji
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, USA
| | - D W Wareham
- Antimicrobial Research Group, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - L E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - V H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, USA
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia. .,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Level 3, Ned Hanlon Building, Herston, Brisbane, QLD, 4029, Australia.
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Lagerbäck P, Khine WWT, Giske CG, Tängdén T. Evaluation of antibacterial activities of colistin, rifampicin and meropenem combinations against NDM-1-producing Klebsiella pneumoniae in 24 h in vitro time-kill experiments. J Antimicrob Chemother 2016; 71:2321-5. [PMID: 27334665 DOI: 10.1093/jac/dkw213] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/06/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To investigate the activity of colistin alone or in double and triple combination with rifampicin and meropenem against NDM-1-producing Klebsiella pneumoniae. METHODS Eight isolates of NDM-1-producing K. pneumoniae were exposed to clinically relevant antibiotic concentrations in 24 h time-kill experiments. Three colistin concentrations were used for two of the strains. Resistance development was assessed with population analysis and sequencing of the mgrB and pmrB genes. RESULTS Initial killing was achieved with colistin alone, but with considerable regrowth at 24 h. Combinations including colistin and rifampicin were bacteriostatic or bactericidal against all strains. Colistin plus meropenem was bactericidal against one strain, but, overall, meropenem showed little additive effects. Higher concentrations of colistin did not enhance antibacterial activity. Resistant populations and deletion or mutations in the mgrB and pmrB genes were frequently detected in endpoint samples after exposure to colistin alone. CONCLUSIONS Based on the results of this and previous studies, the combination of colistin and rifampicin seems promising and should be further explored in vivo and considered for clinical evaluation. Meropenem seems less useful in the treatment of infections caused by high-level carbapenem-resistant NDM-1-producing K. pneumoniae. Higher colistin concentrations did not result in significantly better activity, suggesting that combination therapy might be superior to monotherapy also when colistin is prescribed using high-dose regimens in accordance with current recommendations.
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Affiliation(s)
- P Lagerbäck
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - W W T Khine
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - C G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - T Tängdén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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Tängdén T, Giske CG. Global dissemination of extensively drug-resistant carbapenemase-producing Enterobacteriaceae: clinical perspectives on detection, treatment and infection control. J Intern Med 2015; 277:501-12. [PMID: 25556628 DOI: 10.1111/joim.12342] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The prevalence of carbapenem-resistant Gram-negative bacilli is on the rise worldwide, posing a major public health threat. Previously, this was mostly a problem in Pseudomonas and Acinetobacter, but during the last decade, carbapenem resistance has escalated in medically important species such as Klebsiella pneumoniae and Escherichia coli. In particular, the rising trend in E. coli is of concern, as this may lead to almost untreatable community-acquired infections. Resistance is conferred by carbapenemases, which are beta-lactamases that can breakdown essentially all beta-lactams. Moreover, bacteria carrying these resistance determinants are often resistant to other treatment options, due to the frequent co-acquisition of non-beta-lactam resistance genes located on the same mobile genetic elements. The detection of carbapenemase-producing Enterobacteriaceae (CPE) is a challenge, because some carbapenemases produce relatively discrete levels of carbapenem resistance. Current clinical evidence for treatment guidance is limited and based on retrospective observational studies and case reports. Existing data support the use of combination therapy for treatment of severe infections caused by CPE. Combination regimens including colistin, carbapenems, tigecycline, aminoglycosides and fosfomycin have been used. Randomized controlled studies of combination regimens are ongoing and may help to determine the optimal therapy. Novel beta-lactamase inhibitors may also have a role in future treatment of these infections. Strict infection control measures including isolation or cohort care of affected patients as well as contact tracing and active screening are needed to curb the spread of CPE. In this review, we provide a clinical perspective on the management of patients infected or colonized with CPE.
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Affiliation(s)
- T Tängdén
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
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