Omadacycline for a Carbapenem-Resistant Enterobacter cloacae-Associated Wound Infection.

Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) are problematic pathogens because infections caused by these organisms are associated with significant morbidity and mortality. These organisms often harbor multiple resistance mechanisms, which makes it difficult to treat their associated infections. Treatment typically consists of intravenous antibiotics that are selected based on the specific susceptibility pattern for the pathogen. Data on the use of oral antibiotics for the treatment of infections caused by CRE are sparse. Case Presentation: In this case, a 62-year-old female presented with a chronic left leg wound infection. She previously underwent surgical debridement and skin grafting, which were unsuccessful. She was initially prescribed minocycline for the infection, but the wound got re-infected. At this time, the wound had significant surrounding erythema, drainage, and slough. A wound culture was obtained and demonstrated growth of carbapenem-resistant Enterobacter cloacae and methicillin-resistant Staphylococcus aureus. The patient was initiated on oral omadacycline, and she responded with resolution of the cellulitis and wound drainage. Conclusion: This case demonstrates that omadacycline may be beneficial as an oral medication for the treatment of complicated acute bacterial skin and skin structure infections caused by carbapenem-resistant Enterobacter cloacae.

Cost comparison of AUC:MIC- versus trough-based vancomycin monitoring for MRSA bacteremia.

OBJECTIVES: It is anticipated that the updated vancomycin monitoring guidelines will reconsider area under the concentration-time curve to minimum inhibitory concentration ratio (AUC:MIC)-based monitoring instead of trough-based monitoring for methicillin-resistant Staphylococcus aureus (MRSA) infections. The AUC:MIC can be estimated using 2 steady-state serum concentrations and first-order pharmacokinetic equations or Bayesian modeling. The cost of AUC:MIC-based monitoring compared with trough-based monitoring is unknown and has been cited as a potential barrier to implementing this monitoring method. The objective of this study was to compare the total vancomycin drug and monitoring cost for patients with MRSA bacteremia who received AUC:MIC- or trough-based monitoring. DESIGN: This was a single-center, retrospective cohort study. SETTING AND PARTICIPANTS: This study included patients who were treated for MRSA bacteremia between May 1, 2013 and December 31, 2018, with an 8-month washout period between trough and AUC:MIC-based monitoring at our institution. OUTCOME MEASURES: The primary outcome was the aggregate cost of vancomycin therapy, which included the cost associated with sample collection (i.e., supply cost and nursing time), sample analysis (i.e., assay cost and laboratory technician time), result interpretation (i.e., pharmacist time), and drug cost (i.e., cost of total administered vancomycin dose) during the hospital stay. RESULTS: A total of 52 patients met inclusion criteria with 26 patients in each group. The median (interquartile range) total vancomycin drug and monitoring cost was $338.14 ($235.07-$601.05) for the AUC:MIC-based group compared with $316.79 ($253.36-$520.96) for the trough-based group (P = 0.687). CONCLUSION: Vancomycin monitoring using 2 steady-state serum concentrations and first-order pharmacokinetic equations to calculate AUC:MIC was no more costly than a trough-based approach in patients with MRSA bacteremia at our institution.

Ibalizumab, a Novel Monoclonal Antibody for the Management of Multidrug-Resistant HIV-1 Infection.

Limited antiretrovirals are currently available for the management of multidrug-resistant (MDR) HIV-1 infection. Ibalizumab, a recombinant humanized monoclonal antibody, represents the first novel agent for HIV-1 management in over a decade and is the first monoclonal antibody for the treatment of MDR HIV-1 infection in combination with other forms of antiretroviral therapy in heavily treatment-experienced adults who are failing their current antiretroviral regimen. Ibalizumab demonstrates a novel mechanism of action as a CD4-directed postattachment inhibitor and has a favorable pharmacokinetic profile that allows for a dosing interval of every 14 days after an initial loading dose. Clinical studies have demonstrated reasonably substantial antiretroviral activity with ibalizumab among a complex patient population with advanced HIV-1 infection who are receiving an optimized background regimen, where limited therapeutic options exist. Ibalizumab was well tolerated in clinical trials, and the most common adverse effects included diarrhea, nausea, dizziness, fatigue, pyrexia, and rash. Resistance to ibalizumab has also been observed via reduced expression or loss of the potential N-linked glycosylation sites in the V5 loop of the envelope glycoprotein 120. The mechanism of action, pharmacokinetic parameters, efficacy, and safety of ibalizumab present an advance in the management of MDR HIV-1 infection. Future studies and postmarketing experience will further determine longer-term clinical efficacy, safety, and resistance data for ibalizumab.

Readiness to implement vancomycin monitoring based on area under the concentration-time curve: A cross-sectional survey of a national health consortium.

PURPOSE: The purpose of this study was to (1) determine whether academic medical centers implemented area under the concentration-time curve (AUC)-based monitoring for vancomycin and (2) characterize perceived barriers to implementation and challenges experienced during the implementation process. METHODS: A multicenter, cross-sectional electronic survey was distributed to pharmacy representatives from 124 academic medical centers within the Vizient University Health System Consortium Pharmacy Network. RESULTS: Seventy-eight institutions completed the survey, representing a 62.9% response rate. Most institutions were approximately 500-1,000 beds (68/78, 87.2%), and pharmacists were primarily responsible for vancomycin therapeutic drug monitoring (66/78, 84.6%) using pharmacist-driven protocols (57/78, 73.1%). Less than one fourth (18/78, 23.1%) of responding academic medical centers performed AUC-based vancomycin monitoring, and the majority (12/18, 66.7%) used 2-point pharmacokinetics, with a smaller fraction using either Bayesian software or population-based pharmacokinetics. Of the responding institutions that only perform trough-based therapeutic drug monitoring (60/78, 76.9%), most (53/60, 88.3%) did not plan to or were unsure about transitioning to AUC-based monitoring within the next year. Both the most common challenge encountered (13/18, 72.2%) for institutions performing AUC-based monitoring and the most common barrier (44/60, 73.3%) to implementation of this monitoring strategy were pharmacist and/or provider unfamiliarity. CONCLUSION: The majority of surveyed academic medical centers have not yet implemented AUC-based vancomycin monitoring, and most institutions did not plan to adopt or were unsure about adopting this monitoring strategy within the next year.

Effect of the length of the cycle on biodegradable polymer production and microbial community selection in a sequencing batch reactor.

The effect of the length of the cycle on the enrichment and selection of mixed cultures in sequencing batch reactors (SBRs) has been studied, with the aim of biodegradable polymers (namely, polyhydroxyalkanoates (PHAs)) production from organic wastes. At a fixed feed concentration (20 gCOD/L) and organic loading rate (20 gCOD/L/day), the SBR was operated at different lengths of the cycle, in the range 1-8 h. Process performance was measured by considering the rates and yields of polymer storage and of the competing phenomenon of growth. The selected biomass was enriched with microorganisms that were able to store PHAs at high rates and yields only when the length of the cycle was 2 or 4 h, even though in these conditions the process was unstable. On the other hand, when the length of the cycle was 1 or 8 h, the dynamic response of the selected microorganisms was dominated by growth. The best process performance was characterized by storage rates in the range 500-600 mgCOD/gCOD/h and storage yields of 0.45-0.55 COD/COD. The corresponding productivity of the process was in the range 0.25-0.30 gPHA/L/h, the highest values obtained until now for mixed cultures. The microbial composition of the selected biomasses was analyzed through denaturing gradient gel electrophoresis (DGGE) and reverse-transcriptase denaturing gradient gel electrophoresis (RT-DGGE). The instability of the runs characterized by high storage rate was associated with a higher microbial heterogeneity compared to the runs with a stable growth response.

Effect of periodic feeding on substrate uptake and storage rates by a pure culture of Thiothrix (CT3 strain).

A pure culture of Thiothrix strain CT3 has been aerobically cultured under periodic acetate feeding in a Sequencing Batch Reactor (SBR) at volumetric organic load rate of 0.12gCODL(-1)d(-1). Two different culture residence times (12d or 20d) were adopted as well as two different feed frequencies (1 and 4d(-1), for each culture residence time), the volumetric organic load rate being the same under all conditions. The transient response of the microorganism to the periodic acetate feed was investigated through batch tests with biomass withdrawn from the SBR, as function of the different SBR operating conditions. In all tested conditions, a quick transient response to the acetate spike was observed with fast increase of acetate uptake rate (ranging from 71 to 247mgCODgCOD(-1)h(-1)). This transient response was mainly due to acetate storage in form of poly-hydroxybutyrate (ranging from 45% to 64% of the observed yield) whereas the growth response (i.e. increase of production rate of active biomass) generally played a minor role (ranging from 21% to 38% of the observed yield). Apart from this general trend, culture residence time as well as feed frequency had a strong impact on transient behaviour of cultured cells. The overall transient response (i.e. maximum specific substrate removal rate) increased as culture residence time decreased or as feed frequency increased. Moreover, the ratio of storage response and growth response increased as the overall transient response decreased, i.e. the storage response was preferentially maintained when cells presented a lower transient response. The ability of the cells to increase their growth rate with respect to SBR average value was the lowest under the most unfavourable conditions (residence time 20d, feed frequency 1d(-1)) and increased with the increase in maximum substrate uptake rate.

Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review.

INTRODUCTION: Hyperkalemia is a serious medical condition that often manifests in patients with chronic kidney disease and heart failure. Renin-angiotensin-aldosterone system inhibitors are known to improve outcomes in these disease states but can also cause drug-induced hyperkalemia. New therapeutic options exist for managing hyperkalemia in these patients which warrant evidence-based evaluation. AIM: The objective of this article was to review the efficacy and safety evidence for patiromer, sodium zirconium cyclosilicate (ZS9), and sodium polystyrene sulfonate (SPS) for the treatment of hyperkalemia. EVIDENCE REVIEW: Current treatment options to enhance potassium excretion are SPS and loop diuretics, which are complicated by ambiguous efficacy and known toxicities. Patiromer and ZS9 are new agents designed to address this treatment gap. Both unabsorbable compounds bind potassium in the gastrointestinal (GI) tract to facilitate fecal excretion. The capacity to bind other medications in the GI tract infers high drug-drug interaction potential, which has been demonstrated with patiromer but not yet investigated with ZS9 or SPS. Phase II and III clinical trials of patiromer and ZS9 demonstrated clear evidence of a dose-dependent potassium-lowering effect and the ability to initiate, maintain, or titrate renin-angiotensin-aldosterone system inhibitors. There is limited evidence base for SPS: two small clinical trials indicated potassium reduction in chronic hyperkalemia. All agents may cause adverse GI effects, although they are less frequent with ZS9. Concerns remain for SPS to cause rare GI damage. Electrolyte abnormalities occurred with patiromer and SPS, whereas urinary tract infections, edema, and corrected QT-interval prolongations were reported with ZS9. CONCLUSION: Patiromer and ZS9 have improved upon the age-old standard SPS for the treatment of hyperkalemia. Additional research should focus on drug-drug interactions in patients on multiple medications, incidence of rare adverse events, and use in high-risk populations.

Effect of culture residence time on substrate uptake and storage by a pure culture of Thiothrix (CT3 strain) under continuous or batch feeding.

A pure culture of the filamentous bacterium Thiothrix, strain CT3, was aerobically cultured in a chemostat under continuous acetate feeding at three different culture residence times (RT 6, 12 or 22 d) and the same volumetric organic load rate (OLR 0.12gCOD/L/d). Cells cultured at decreasing RT in the chemostat had an increasing transient response to acetate spikes in batch tests. The maximum specific acetate removal rate increased from 25 to 185mgCOD/gCOD/h, corresponding to a 1.8 to 8.1 fold higher respective steady-state rate in the chemostat. The transient response was mainly due to acetate storage in the form of poly(3-hydroxybutyrate) (PHB), whereas no growth response was observed at any RT. Interestingly, even though the storage rate also decreased as the RT increased, the storage yield increased from 0.41 to 0.50 COD/COD. This finding does not support the traditional view that storage plays a more important role as the transient response increases. The transient response of the steady-state cells was much lower than in cells cultured under periodic feeding (at 6 d RT, from 82 to 247mgCOD/gCOD/h), with the latter cells showing both storage and growth responses. On the other hand, even though steady-state cells had no growth response and their storage rate was also less, steady-state cells showed a higher storage yield than cells cultured under dynamic feeding. This suggests that in Thiothrix strain CT3, the growth response is triggered by periodic feeding, whereas the storage response is a constitutive mechanism, independent from previous acclimation to transient conditions.

Systematic Review and Meta-Analysis of Patiromer and Sodium Zirconium Cyclosilicate: A New Armamentarium for the Treatment of Hyperkalemia.

OBJECTIVE: To compare and contrast the efficacy and safety of patiromer and sodium zirconium cyclosilicate (ZS-9) in the treatment of hyperkalemia. DESIGN: A systematic review and meta-analysis of phase II and III clinical trial data was completed. PATIENTS OR PARTICIPANTS: Eight studies (two phase II and four phase III trials with two subgroup analyses) were included in the qualitative analysis, and six studies (two phase II and four phase III trials) were included in the meta-analysis. MEASUREMENTS AND RESULTS: Significant heterogeneity was found in the meta-analysis with an I2 value ranging from 80.6-99.6%. A random-effects meta-analysis was applied for all end points. Each clinical trial stratified results by hyperkalemia severity and dosing; therefore, these were considered separate treatment groups in the meta-analysis. For patiromer, a significant -0.70 mEq/L (95% confidence interval [CI] -0.48 to -0.91 mEq/L) change was noted in potassium at 4 weeks. At day 3 of patiromer treatment, potassium change was -0.36 mEq/L (range of standard deviation 0.07-0.30). The primary end point for ZS-9-change in potassium at 48 hours-was -0.67 mEq/L (95% CI -0.45 to -0.89 mEq/L). By 1 hour after ZS-9 administration, change in potassium was -0.17 mEq/L (95% CI -0.05 to -0.30). Analysis of pooled adverse effects from these trials indicates that patiromer was associated with more gastrointestinal upset (7.6% constipation, 4.5% diarrhea) and electrolyte depletion (7.1% hypomagnesemia), whereas ZS-9 was associated with the adverse effects of urinary tract infections (1.1%) and edema (0.9%). CONCLUSION: Patiromer and ZS-9 represent significant pharmacologic advancements in the treatment of hyperkalemia. Both agents exhibited statistically and clinically significant reductions in potassium for the primary end point of this meta-analysis. Given the adverse effect profile and the observed time-dependent effects, ZS-9 may play more of a role in treating acute hyperkalemia.

Enrichment from activated sludges of aerobic mixed cultures capable to degrade vinyl chloride (VC) as the sole carbon source.

Two microbial cultures able to degrade high concentrations of VC as the sole carbon source have been obtained by enrichment from activated sludge. The cultures began consuming VC (0.02 mmol l(-1)) only after a long initial acclimation period (1-2 months). After then the concentration of VC was gradually increased (from 0.02 to 0.8 mmol l(-1)) and the cultures were able to maintain VC degrading ability for long time (over 500 days). VC-degrading biomass in the two cultures was characterized by low specific maximum growth rates (0.19-0.21 d(-1)) compared to heterotrophic organisms typically present in activated sludge processes. Monod half-saturation constant was rather low (0.7-1.6 mg VC l(-1)) indicating that it is possible to effectively remove VC to low residual concentrations. The cultures were highly sensitive to even short periods of VC lack (with quick decrease of VC degradation rates) whereas they were not to sudden load increases (up to 3.4 mmol l(-1)). After being cultured with only ethene as the sole carbon and energy source, the cultures kept the ability of degrading VC. Possibility of maintaining the mixed cultures on non-toxic ethene, without loosing VC degradation ability, is very promising for bioaugmentation treatments.

Feed frequency in a sequencing batch reactor strongly affects the production of polyhydroxyalkanoates (PHAs) from volatile fatty acids.

The production of polyhydroxyalkanoates (PHAs) by activated sludge selected in a sequencing batch reactor (SBR) has been investigated. Several SBR runs were performed at the same applied organic load rate (OLR), hydraulic retention time (HRT) and feed concentration (8.5 g COD L(-1) of volatile fatty acids, VFAs) under aerobic conditions. The effect of the feeding time was only evaluated with a cycle length of 8h; for this particular cycle length, an increase in the storage response was observed by increasing the rate at which the substrate was fed into the reactor (at a fixed feeding frequency). Furthermore, a significantly stronger effect was observed by decreasing the cycle length from 8h to 6h and then to 2h, changing the feed frequency or changing the organic load given per cycle (all of the other conditions remained the same): the length of the feast phase decreased from 26 to 20.0 and then to 19.7% of the overall cycle length, respectively, due to an increase in the substrate removal rate. This removal rate was high and similar for the runs with cycle lengths of 2h and 6h in the SBR. This result was due to an increase in the selective pressure and the specific storage properties of the selected biomass. The highest polymer productivity after long-term accumulation batch tests was 1.7 g PHA L(-1)d(-1), with PHA content in the biomass of approximately 50% on a COD basis under nitrogen limitation. The DGGE profiles showed that the good storage performance correlated to the development of Lampropedia hyalina, which was only observed in the SBR runs characterized by a shorter cycle length.

Study of performances, stability and microbial characterization of a Sequencing Batch Biofilter Granular Reactor working at low recirculation flow.

The Sequencing Batch Biofilter Granular Reactor (SBBGR) is a promising wastewater treatment technology characterized by high biomass concentration in the system, good depuration performance and low sludge production. Its main drawback is the high energy consumption required for wastewater recirculation through the reactor bed to ensure both shear stress and oxygen supply. Therefore, the effect of low recirculation flow on the long-term (38 months) performance of a laboratory scale SBBGR was studied. Both the microbial components of the granules, and their main metabolic activities were evaluated (heterotrophic oxidation, nitrification, denitrification, fermentation, sulphate reduction and methanogenesis). The results indicate that despite reduced recirculation, the SBBGR system maintained many of its advantageous characteristics.

High-rate anaerobic treatment of Fischer-Tropsch wastewater in a packed-bed biofilm reactor.

This study investigates the anaerobic treatment of an industrial wastewater from a Fischer-Tropsch (FT) process in a continuous-flow packed-bed biofilm reactor operated under mesophilic conditions (35 degrees C). The considered synthetic wastewater has an overall chemical oxygen demand (COD) concentration of around 28g/L, mainly due to alcohols. A gradual increase of the organic load rate (OLR), from 3.4gCOD/L/d up to 20gCOD/L/d, was adopted in order to overcome potential inhibitory effects due to long-chain alcohols (>C6). At the highest applied OLR (i.e., 20gCOD/L/d) and a hydraulic retention time of 1.4d, the COD removal was 96% with nearly complete conversion of the removed COD into methane. By considering a potential of 200tCOD/d to be treated, this would correspond to a net production of electric energy of about 8x10(7)kWh/year. During stable reactor operation, a COD balance and batch tests showed that about 80% of the converted COD was directly metabolized through H(2)(-) and acetate-releasing reactions, which proceeded in close syntrophic cooperation with hydrogenotrophic and acetoclastic methanogenesis (contributing to about 33% and 54% of overall methane production, respectively). Finally, energetic considerations indicated that propionic acid oxidation was the metabolic conversion step most dependent on the syntrophic partnership of hydrogenotrophic methanogens and accordingly the most susceptible to variations of the applied OLR or toxicity effects.

Effect of the applied organic load rate on biodegradable polymer production by mixed microbial cultures in a sequencing batch reactor.

This article studies the operation of a new process for the production of biopolymers (polyhydroxyalkanoates, PHAs) at different applied organic load rates (OLRs). The process is based on the aerobic enrichment of activated sludge to obtain mixed cultures able to store PHAs at high rates and yields. A mixture of acetic, lactic, and propionic acids at different concentrations (in the range 8.5-31.25 gCOD/L) was fed every 2 h in a sequencing batch reactor (SBR). The resulting applied OLR was in the range 8.5-31.25 gCOD/L/day. Even though, as expected, the increase in the OLR caused an increase in biomass concentration (up to about 8.7 g COD/L), it also caused a relevant decrease of maximal polymer production rate. This decrease in polymer production rate was related to the different extent of "feast and famine" conditions, as function of the applied OLR and of the start-up conditions. As a consequence the best performance of the process was obtained at an intermediate OLR (20 gCOD/L/day) where both biomass productivity and PHA storage were high enough. However, at this high OLR the process was unstable and sudden decrease of performance was also observed. The sludge characterized by the highest PHA storage response was investigated by 16S rDNA clone library. The clone library contained sequences mostly from PHA producers (e.g., Alcaligenes and Comamonas genera); however many genera and among them, one of the dominant (Thauera), were never described before in relation to PHA storage response.

Biodegradable polymers from organic acids by using activated sludge enriched by aerobic periodic feeding.

This article describes a new process for the production of biopolymers (polyhydroxyalkanoates, PHAs) based on the aerobic enrichment of activated sludge to obtain mixed cultures able to store PHAs at high rates and yields. Enrichment was obtained through the selective pressure established by feeding the carbon source in a periodic mode (feast and famine regime) in a sequencing batch reactor. A concentrated mixture of acetic, lactic, and propionic acids (overall concentration of 8.5 gCOD L(-1)) was fed every 2 h at 1 day(-1) overall dilution rate. Even at such high organic load (8.5 gCOD L(-1) day(-1)), the selective pressure due to periodic feeding was effective in obtaining a biomass with a storage ability much higher than activated sludges. The immediate biomass response to substrate excess (as determined thorough short-term batch tests) was characterized by a storage rate and yield of 649 mgPHA (as COD) g biomass (as COD)(-1) h(-1) and 0.45 mgPHA (as COD) mg removed substrates (as COD(-1)), respectively. When the substrate excess was present for more than 2 h (long-term batch tests), the storage rate and yield decreased, whereas growth rate and yield significantly increased due to biomass adaptation. A maximum polymer fraction in the biomass was therefore obtained at about 50% (on COD basis). As for the PHA composition, the copolymer poly(beta-hydroxybutyrate/beta-hydroxyvalerate) with 31% of hydroxyvalerate monomer was produced from the substrate mixture. Comparison of the tests with individual and mixed substrates seemed to indicate that, on removing the substrate mixture for copolymer production, propionic acid was fully utilized to produce propionylCoA, whereas the acetylCoA was fully provided by acetic and lactic acid.