Update on colistin in clinical practice

Area of Science:

• Pharmacology
• Infectious Diseases
• Critical Care Medicine

Background:

• Colistin (colistin methanesulfonate, CMS) is a critical antibiotic for multidrug-resistant Gram-negative infections.
• Optimal dosing and administration routes for CMS remain areas of active investigation.

Purpose of the Study:

• To review the current evidence on the optimal clinical use of colistin.
• To evaluate the efficacy and safety of different CMS administration strategies.

Main Methods:

• Review of recent clinical studies and guidelines on colistin use.
• Analysis of data regarding intravenous, inhaled, and intrathecal/intra-ventricular CMS administration.
• Assessment of evidence for combination therapies involving CMS.

Main Results:

• Higher intravenous CMS doses, potentially including a loading dose, are associated with improved outcomes in critically ill patients.
• Increased nephrotoxicity risk is observed with higher CMS doses, but it is generally reversible.
• Intravenous CMS is effective but should be reserved for situations lacking safer alternatives.
• Evidence supporting inhaled colistin monotherapy or adjunctive therapy is currently insufficient for non-cystic fibrosis patients.
• Intrathecal or intra-ventricular CMS is appropriate for neurosurgical meningitis.

Conclusions:

• Optimizing intravenous CMS dosing is crucial, balancing efficacy with nephrotoxicity monitoring.
• Alternative administration routes like intrathecal/intra-ventricular CMS have specific indications.
• Further research, including randomized controlled trials, is needed to clarify the role of inhaled colistin and combination therapies.