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Peptide

Colistin (Polymyxin E)

Colistin is a cyclic lipopeptide antibiotic (polymyxin E) discovered 1947, FDA-approved 1959. Administered as inactive prodrug colistimethate sodium (CMS) for parenteral use. WHO Essential Medicine and critically important for human medicine. Last-resort therapy for MDR gram-negative infections. Meta-analysis of 5 RCTs (n=377): 36% nephrotoxicity incidence vs 15% comparators (NNH=5). Pediatric review (17 studies, n=312): Effective for BSI, pneumonia, meningitis in neonates. SAFETY CONCERN: Dose-dependent nephrotoxicity (40-45% incidence); neurotoxicity reported; 75% AKI recovery upon discontinuation.

Research notice. This page is for education and research. Peptides may not be FDA-approved for human use and may only be legally available for research. Talk to a qualified clinician before considering any peptide.

Best evidence
Grade A
Conditions studied
1
Outcomes
9
Graded outcomes
3330

Evidence by condition

  • Strong
  • Moderate
  • Limited
  • Very limited

1 condition, plus general outcomes

Multidrug-Resistant Bacterial Infections

Multidrug-Resistant Bacterial Infections: outcomes studied for Colistin (Polymyxin E)
GradeOutcomeEffectSizeStudiesPeopleStudies list
MDR Gram-Negative Infections

Meta-analysis of 5 RCTs (n=377): Effective last-resort option for MDR infections. Cochrane reviews support use for pneumonia, BSI. Clinical success 59.5% in PK study. WHO Essential Medicine designation.

Improves (the measure goes up)Moderate effect16 studies

Studies that measured mdr gram-negative infections

and 6 more in the citations list

Ventilator-Associated Pneumonia

Most common indication in RCTs. Nebulized colistin shows similar efficacy to IV with potentially less nephrotoxicity. Clinical cure rates comparable to β-lactam regimens.

Improves (the measure goes up)Moderate effect15 studies

Studies that measured ventilator-associated pneumonia

and 5 more in the citations list

Nephrotoxicity Incidence

SAFETY CONCERN: Meta-analysis: 36.2% nephrotoxicity vs 15% comparators (RR 2.40, NNH=5). Comprehensive study (n=178): 44.9% incidence. Median onset 4-6 days. 75% recovery within 10 days of discontinuation. Reversible tubular damage.

Worsens (the measure goes up)Large effect14 studies

Studies that measured nephrotoxicity incidence

and 4 more in the citations list

Pediatric/Neonatal Infections

Systematic review (17 studies, n=312 neonates/infants): Effective for BSI, pneumonia, meningitis. Doses 25,000-225,000 IU/kg/day. PK studies suggest >150,000 IU/kg/day needed. Limited nephrotoxicity data in children.

Improves (the measure goes up)Moderate effect15 studies

Studies that measured pediatric/neonatal infections

and 5 more in the citations list

Neurotoxicity Risk

SAFETY CONCERN: Neurotoxicity reported including paresthesias, ataxia, neuromuscular blockade. Appears reversible upon discontinuation or dose reduction. Less common than nephrotoxicity.

Worsens (the measure goes up)Small effect15 studies

Studies that measured neurotoxicity risk

and 5 more in the citations list

General

General: outcomes studied for Colistin (Polymyxin E)
GradeOutcomeEffectSizeStudiesPeopleStudies list
Kidney Function

8 human trials and systematic reviews support this finding. Evidence includes systematic reviews/meta-analyses. Human clinical trial data available.

Improves (the measure goes up)Moderate effect16 studies

Studies that measured kidney function

and 6 more in the citations list

Safety/Tolerability

15 systematic reviews and preclinical studies support this finding. Evidence includes systematic reviews/meta-analyses. Primarily preclinical evidence.

Improves (the measure goes up)Moderate effect18 studies

Studies that measured safety/tolerability

and 8 more in the citations list

Antimicrobial Activity

16 systematic reviews and preclinical studies support this finding. Evidence includes systematic reviews/meta-analyses. Primarily preclinical evidence.

Improves (the measure goes up)Moderate effect18 studies

Studies that measured antimicrobial activity

and 8 more in the citations list

Liver Protection

3 human trials support this finding. Human clinical trial data available.

Improves (the measure goes up)Small effect11 studies

Studies that measured liver protection

and 1 more in the citations list

Key findings

  • MDR Gram-Negative InfectionsMultidrug-Resistant Bacterial InfectionsImproves (the measure goes up)
  • Ventilator-Associated PneumoniaMultidrug-Resistant Bacterial InfectionsImproves (the measure goes up)
  • Nephrotoxicity IncidenceMultidrug-Resistant Bacterial InfectionsWorsens (the measure goes up)

Studies cited

49 studies from PubMed

  1. Prevalence of colistin resistance in clinical Klebsiella pneumoniae isolates: a systematic review and meta-analysis.Future microbiology, 2025 · PMID 40619750
  2. Novel strategies for combating colistin-resistant isolates: a review.Archives of microbiology, 2025 · PMID 41134327
  3. Battle of polymyxin induced nephrotoxicity: Polymyxin B versus colistin.International journal of antimicrobial agents, 2024 · PMID 37979889
  4. Prevention of colistin-induced neurotoxicity: a narrative review of preclinical data.Naunyn-Schmiedeberg's archives of pharmacology, 2024 · PMID 38091077
  5. Unravelling the Hepatic Elimination Mechanisms of Colistin.Pharmaceutical research, 2023 · PMID 37258948
  6. Liposomes Co-Delivering Curcumin and Colistin to Overcome Colistin Resistance in Bacterial Infections.Advanced healthcare materials, 2023 · PMID 37523195
  7. Prostaglandin F2α analogue, bimatoprost ameliorates colistin-induced nephrotoxicity.Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 2023 · PMID 37918255
  8. Population Pharmacokinetics of Colistin Sulfate in Critically Ill Patients: Exposure and Clinical EfficacyAntimicrob Agents Chemother, 2022 · PMID 35784679
  9. Efficacy of stem cell-based therapies for colistin-induced nephrotoxicity.Environmental toxicology and pharmacology, 2022 · PMID 35863655
  10. Global colistin use: a review of the emergence of resistant Enterobacterales and the impact on their genetic basis.FEMS microbiology reviews, 2022 · PMID 34612488
  11. Prevalence of colistin resistance of Klebsiella pneumoniae isolates in Iran: a systematic review and meta-analysis.Annals of clinical microbiology and antimicrobials, 2022 · PMID 35765073
  12. Molecular mechanisms and clonal lineages of colistin-resistant bacteria across the African continent: a scoping review.Letters in applied microbiology, 2022 · PMID 36000241
  13. Prevention of colistin induced nephrotoxicity: a review of preclinical and clinical data.Expert review of clinical pharmacology, 2021 · PMID 34015235
  14. Can magnesium sulfate prophylaxis reduce colistin nephrotoxicity?Nefrologia, 2021 · PMID 36165156
  15. Mobilized colistin resistance (mcr) genes from 1 to 10: a comprehensive review.Molecular biology reports, 2021 · PMID 33839987
  16. Assesment of colistin related side effects in premature neonates.The Turkish journal of pediatrics, 2020 · PMID 33108082
  17. Colistin and its role in the Era of antibiotic resistance: an extended review (2000-2019).Emerging microbes & infections, 2020 · PMID 32284036
  18. Colistin heteroresistance in Acinetobacter spp.: systematic review and meta-analysis of the prevalence and discussion of the mechanisms and potential therapeutic implications.International journal of antimicrobial agents, 2020 · PMID 32599229
  19. The Use of Colistin for the Treatment of Multidrug-resistant Gram-negative Infections in Neonates and Infants: A Review of the LiteraturePediatr Infect Dis J, 2019 · PMID 31469781
  20. Safety and efficacy of colistin alone or in combination in adults with Acinetobacter baumannii infection: A systematic review and meta-analysis.International journal of antimicrobial agents, 2019 · PMID 30447379
  21. Colistin induced peripheral neurotoxicity involves mitochondrial dysfunction and oxidative stress in mice.Molecular biology reports, 2019 · PMID 30783935
  22. Antimicrobial Susceptibility Testing for Polymyxins: Challenges, Issues, and Recommendations.Journal of clinical microbiology, 2019 · PMID 30541939
  23. History, Chemistry and Antibacterial Spectrum.Advances in experimental medicine and biology, 2019 · PMID 31364069
  24. Colistin Use in Patients with Extreme Renal Function: From Dialysis to Augmented Clearance.Medicina (Kaunas, Lithuania), 2019 · PMID 30709064
  25. Rational use of intravenous polymyxin B and colistin: A review.The Medical journal of Malaysia, 2018 · PMID 30350826
  26. Gelofusine Ameliorates Colistin-Induced Nephrotoxicity.Antimicrobial agents and chemotherapy, 2017 · PMID 28923868
  27. A network perspective on antimicrobial peptide combination therapies: the potential of colistin, polymyxin B and nisin.International journal of antimicrobial agents, 2017 · PMID 28457834
  28. Pharmacokinetics/pharmacodynamics of colistin and polymyxin B: are we there yet?Int J Antimicrob Agents, 2016 · PMID 27793510
  29. Plasmid-mediated colistin resistance: an additional antibiotic resistance menace.Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 2016 · PMID 27021419
  30. Resistance to colistin: what is the fate for this antibiotic in pig production?International journal of antimicrobial agents, 2016 · PMID 27234675
  31. Colistin Use in Patients With Reduced Kidney Function.American journal of kidney diseases : the official journal of the National Kidney Foundation, 2016 · PMID 27160031
  32. Colistin: understanding and applying recent pharmacokinetic advancesClin Microbiol Infect, 2015 · PMID 25187500
  33. A review on colistin nephrotoxicityEur J Clin Pharmacol, 2015 · PMID 26008213
  34. Colistin: efficacy and safety in different populations.Expert review of clinical pharmacology, 2015 · PMID 26041134
  35. Colistin neurotoxicity: revisited.BMJ case reports, 2015 · PMID 26206782
  36. Colistin: Revival of an Old Polymyxin Antibiotic.Therapeutic drug monitoring, 2015 · PMID 25549206
  37. Colistin: an antibiotic and its role in multiresistant Gram-negative infections.Acta medica Indonesiana, 2015 · PMID 26260559
  38. Colistin-mediated neurotoxicity.BMJ case reports, 2014 · PMID 25199193
  39. Systematic review of the evidence for rational dosing of colistin.South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2014 · PMID 24897820
  40. Colistin for the treatment of ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria: a systematic review and meta-analysis.International journal of antimicrobial agents, 2014 · PMID 25199968
  41. Colistin: re-emergence of the 'forgotten' antimicrobial agent.Journal of postgraduate medicine, 2013 · PMID 24029199
  42. PmrB mutations promote polymyxin resistance of Pseudomonas aeruginosa isolated from colistin-treated cystic fibrosis patients.Antimicrobial agents and chemotherapy, 2012 · PMID 22106224
  43. Colistin: new lessons on an old antibiotic.Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 2012 · PMID 22168320
  44. Colistin resistance of Acinetobacter baumannii: clinical reports, mechanisms and antimicrobial strategies.The Journal of antimicrobial chemotherapy, 2012 · PMID 22441575
  45. Resurgence of colistin: a review of resistance, toxicity, pharmacodynamics, and dosingInt J Antimicrob Agents, 2010 · PMID 21114395
  46. Polymyxin E sulfate-loaded liposome for intravenous use: preparation, lyophilization, and toxicity assessment in vivo.PDA journal of pharmaceutical science and technology, 2009 · PMID 19634354
  47. Multidrug-resistant Gram-negative infections: the use of colistinExpert Rev Anti Infect Ther, 2008 · PMID 20818945
  48. Colistin: the re-emerging antibiotic for multidrug-resistant Gram-negative bacterial infectionsLancet Infect Dis, 2006 · PMID 16931410
  49. Polymyxin B sulfate and colistin: old antibiotics for emerging multiresistant gram-negative bacteriaAnn Pharmacother, 1999 · PMID 10492501