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Intravenous polymyxins: Revival with puzzle
Yun Yu1, Aihua Fei1, Zengbin Wu1
1Department of Emergency, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine.
Bioscience Trends
|September 15, 2017
Summary
Polymyxins are effective last-resort treatments for multidrug-resistant infections, showing improved efficacy and reduced toxicity in recent trials. Optimal combination therapies and dosing strategies require further investigation through larger prospective studies.
Area of Science:
- Infectious Diseases
- Pharmacology
- Clinical Medicine
Background:
- Rising incidence of multidrug-resistant (MDR) bacterial strains, particularly carbapenem-resistant Enterobacteriaceae (CRE).
- Polymyxins (colistin and polymyxin B) are experiencing a resurgence as last-resort agents for treating MDR infections.
Purpose of the Study:
- To evaluate the efficacy and safety of polymyxin-based regimens for multidrug-resistant infections.
- To explore the role of combination therapy versus monotherapy and identify optimal combination agents.
- To review current evidence on polymyxin dosing strategies and potential toxicities.
Main Methods:
- Systematic review and analysis of data from 47 clinical trials and case series.
- Comparison of outcomes for polymyxin monotherapy and combination therapy.
- Assessment of clinical response, mortality, and microbiological eradication rates.
Main Results:
- Polymyxin-based regimens demonstrated effectiveness and reduced toxicity compared to historical data.
- Intravenous polymyxin monotherapy showed variable outcomes: mortality (0–74.3%), clinical response (7–82.1%), and microbiological eradication (27.3–73.9%).
- Combination therapy appears more effective than monotherapy, though further evidence is needed. Optimal combinations and dosing remain unconfirmed.
Conclusions:
- Polymyxins are valuable in treating challenging MDR infections, but controversies persist regarding optimal combination regimens and dosing.
- Loading dose regimens may enhance efficacy, but careful monitoring for adverse effects, especially nephrotoxicity, is crucial.
- Further large-scale prospective trials are essential to clarify optimal polymyxin use, particularly concerning dosing and combination strategies for colistin and polymyxin B.
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