The emergence of multidrug resistant (MDR)
infections and the shortage of new therapeutic options have made
colistin, a
polymyxin antibiotic, the main option for the treatment of MDR
Gram-negative bacterial infections in the last decade. However, the rapid onset of renal damage often prevents the achievement of optimal therapeutic doses and/or forces the physicians to interrupt the
therapy, increasing the risk of drug resistance. The proper management of
colistin-induced nephrotoxicity remains challenging, mostly because the investigation of the cellular and molecular pharmacology of this drug, off the market for decades, has been largely neglected. For years, the renal damage induced by
colistin was considered a mere consequence of the
detergent activity of this drug on the cell membrane of proximal tubule cells. Lately, it has been proposed that the intracellular accumulation is a precondition for
colistin-mediated renal damage, and that mitochondria might be a primary site of damage.
Antioxidant approaches (e.g.,
ascorbic acid) have shown promising results in protecting the kidney of rodents exposed to
colistin, yet none of these strategies have yet reached the bedside. Here we provide a critical overview of the possible mechanisms that may contribute to
colistin-induced renal damage and the potential protective strategies under investigation.