title: Systematic review of the evidence for rational dosing of colistin.
abstract: BACKGROUND
  There is an alarming global increase in the incidence of nosocomial infections with multidrug-resistant Gram-negative bacteria, which are often only susceptible to colistin. Colistin was developed prior to current methods of establishing dosing using pharmacokinetic-pharmacodynamic relationships. Dosing regimens differ in package inserts from different manufacturers and in different guidelines. It is imperative to avoid under-dosing with colistin in order to limit the development of resistance, as it is the last line of defence.
  
  
  METHODS
  We conducted a systematic review of the literature to develop guidelines for rational dosing of intravenous colistin, with a particular focus on critically ill patients.
  
  
  RESULTS
  Colistin is administered as the inactive pro-drug colistimethate sodium. Colistin demonstrates concentration-dependent bacterial killing, suggesting that higher doses should be administered less frequently to achieve higher peak concentrations. Dose-related nephrotoxicity occurs, making it impossible to safely achieve concentrations that prevent the selection of resistant mutants or the effective eradication of bacteria with higher minimum inhibitory concentrations. Theoretically, combination therapy should be used to reduce the risk of selection of resistant bacteria. In critically ill patients, a loading dose should be given to rapidly achieve therapeutic concentrations, followed by maintenance doses of 4.5 MU 12-hourly. Maintenance dose adjustment is necessary with renal impairment.
  
  
  CONCLUSIONS
  Easier access to colistin is needed in South Africa, where it is not a registered medicine. Further research is needed to better characterise colistin's pharmacokinetic-pharmacodynamic relationships in humans and to establish whether combinations of colistin with other antimicrobials result in improved clinical outcomes or a reduction in selection of resistant bacteria.
authors.forename: E Visser
authors.initials: EV
authors.lastname: Kift
authors.forename: G
authors.initials: G
authors.lastname: Maartens
authors.forename: C
authors.initials: C
authors.lastname: Bamford
mesh_terms: D003091:Colistin / Q000008:administration & dosage* / Q000493:pharmacokinetics; D016638:Critical Illness; D019317:Evidence-Based Medicine; D006090:Gram-Negative Bacteria / Q000187:drug effects; D006801:Humans; D007275:Injections, Intravenous
chemical_list: D003091:Colistin