Factors Associated with Mortality and Short-Term Patient Outcomes for Hip Fracture Repair in the Elderly Based on Preoperative Anticoagulation Status

Background: The one-year mortality risk for elderly patients undergoing proximal femur fracture repair surgery is three to four times higher compared to the general population. Other than time to surgery, risk factors for postoperative morbidity and mortality following surgery are poorly understood in the elderly. We sought to identify risk factors associated with morbidity and mortality in geriatric patients by anticoagulation status undergoing hip fracture repair. Methods: Patients aged ≥65 years undergoing surgery for hip fracture repair were included (2009-2019) from a US-based hip fracture registry. Factors associated with 90-day mortality were determined using multivariable logistic regression and stratified by antithrombotic agent medication use prior to surgery. Direct oral anticoagulation (DOAC) medications were the largest group, and all antithrombotic agents were included in the delineation. Results: A total of 35,463 patients were identified, and 87.1% (N = 30,902) were DOAC-naïve. Risk factors for 90-day mortality in DOAC-naïve patients were an American Society of Anesthesiologist's (ASA) classification ≥3 (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 2.24-2.93), preoperative myocardial infarction (OR = 1.87, 95% CI = 1.33-2.64), male gender (OR = 1.73, 95% CI = 1.59-1.88), congestive heart failure (CHF) (OR = 1.64, 95% CI = 1.50-1.80), psychoses (OR = 1.27, 95% CI = 1.15-1.42), renal failure (OR = 1.29, 95% CI = 1.19-1.40), smoking history (OR = 1.19, 95% CI = 1.09-1.29), chronic pulmonary disease (OR = 1.14, 95% CI = 1.05-1.25), increasing age (OR = 1.07, 95% CI = 1.06-1.07), and decreasing body mass index (BMI) (OR = 1.06, 95% CI = 1.05-1.08). Identified factors for mortality in the DOAC group also included ASA classification ≥3 (OR = 2.15, 95% CI = 1.44-3.20), male gender (OR = 1.68, 95% CI = 1.41-2.01), CHF (OR = 1.45, 95% CI = 1.22-1.73), chronic pulmonary disease (OR = 1.34, 95% CI = 1.12-1.61), decreasing BMI (OR = 1.04, 95% CI = 1.02-1.06), and increasing age (OR = 1.02, 95% CI = 1.01-1.03). Conclusions: Regardless of preoperative DOAC status, ASA classification, gender, CHF, chronic pulmonary disease, lower BMI, and higher age are associated with an increased risk of mortality. Some of these comorbidities can be utilized for risk stratification prior to surgery.

Febrile neutropenia management in high-risk neutropenic patients: a narrative review on antibiotic prophylaxis and empirical treatment

INTRODUCTION

Although febrile neutropenia (FN) remains a major cause of morbidity and mortality in patients with hematologic malignancies and hematopoietic stem cell transplant (HSCT) recipients, the increasing prevalence of antimicrobial resistance necessitates a reassessment of antibiotic prophylaxis and treatment strategies.

AREAS COVERED

This review explores the prophylactic and therapeutic use of antibiotics in FN management, with a particular focus on patients with hematologic malignancies - particularly acute leukemia - and HSCT recipients.

EXPERT OPINION

Challenges in FN management, including antibiotic prophylaxis and treatment optimization, remain due to the complexity of the condition. Pathogens with emerging antibacterial resistance cause significant concern in the management of patients. Particularly due to selection potential of resistant Gram-negative bacteria (GNB), fluoroquinolones (FQs) have become less attractive agents for prophylaxis. Whereas, emerging data may help to revitalize long-abandoned aminoglycoside containing combination therapies particularly in high-risk patients with presumed sepsis. With only a few agents available for highly resistant bacteria alternative treatment strategies including pharmacokinetic/pharmacodynamic (PK/PD) concerning antibiotic applications may be warranted. Carefully designed, randomized, controlled trials providing large scale data which then can be analyzed with emerging artificial intelligence (AI) technologies are needed. The results from such trials may allow a better, data-driven approaches for management of FN.

Utilizing an Opportunistic Clinical Study and Population-Based Pharmacokinetic Models to Identify Rational Empiric Dosing Regimens for Piperacillin-Tazobactam in Critically Ill Patients

Determining an effective dosing regimen for piperacillin-tazobactam in critically ill patients is challenging due to substantial pharmacokinetic variability caused by complex pathophysiological changes. To address this need, a prospective clinical study was conducted, which enrolled 112 critically ill patients and employed an opportunistic sampling strategy. Population modeling and simulation were performed to characterize the pharmacokinetics (PK) and probability of target attainment (PTA) of piperacillin-tazobactam under various dosing regimens. Both piperacillin and tazobactam final models were one-compartment models with zero-order input and first-order elimination. Significant covariates included lean body weight for piperacillin and creatinine clearance along with continuous renal replacement therapy (CRRT) for both drugs. Monte Carlo simulations demonstrated that continuous infusion can achieve higher PTA than intermittent and extended infusions. When considering the minimum inhibitory concentration (MIC) of 16 mg/L for Pseudomonas aeruginosa (a frequently encountered bacterial pathogen among critically ill patients) and a PK/PD target of 100% fT >MIC, continuous infusion of 6 g/day is recommended for critically ill patients with a CLcr <60 mL/min, 9 g/day for patients with CLcr in the range of 60 to 129 mL/min, and 12 g/day for patients with a CLcr ≥130 mL/min. In addition, extended infusion represents a good alternative, especially the 3 g q6h or 4 g q6h regimens which can achieve the designated European Committee on Antimicrobial Susceptibility Testing (EUCAST) non-species-related PK/PD breakpoint of 8 mg/L. Our study provided valuable insight into PTA outcomes, which, together with individual renal function of future patients and institution-specific piperacillin susceptibility patterns, may assist physicians when making dosing decisions.

Whether to continue combining carbapenems to treat carbapenem-resistant Acinetobacter baumannii nosocomial pneumonia in critically ill patients: a retrospective efficacy and safety analysis

To explore the efficacy and safety of non-carbapenem-containing (NCC) regimens and carbapenem-containing regimens (CC) regimens, along with the factors influencing the outcomes in critically ill patients with carbapenem-resistant Acinetobacter baumannii (CRAB) pneumonia. This study retrospectively enrolled critically ill patients with CRAB pneumonia who were treated with NCC and CC regimens in a teaching hospital. The primary efficacy outcome was the 28-day clinical efficacy rate, and the safety outcome was the incidence of nephrotoxicity. After the propensity score matching analysis removed the differences between the two groups, the differences in outcomes were statistically analyzed. Cox regression and logistic regression models were used to analyze the factors influencing the outcomes of critically ill patients with CRAB pneumonia. Data from 168 critically ill patients with CRAB pneumonia were eventually included in this study for analysis (NCC = 84, CC = 84). The 28-day clinical efficacy rate was significantly lower in the CC group compared to the NCC group (40.5% vs. 57.1%, P = 0.031), and the incidence of nephrotoxicity was not significantly different in the two groups (P > 0.05). Logistic analysis showed that the prescription of carbapenems was the risk factor of decreased clinical efficacy (aOR = 0.494, 95%CI = 0.262-0.932, P = 0.029) and reduced microbiological eradication (aOR = 0.397, 95%CI = 0.201-0.783, P = 0.008) in patients. CC regimen may not contribute to the 28-day clinical efficacy of CRAB pneumonia and further studies are necessary to elucidate the CC regimen when treating CRAB pneumonia in critically ill patients.

Portal vein pulsatility is associated with the cumulative fluid balance: A post hoc longitudinal analysis of a prospective, general intensive care unit cohort

BACKGROUND

Previous studies have explored tools for evaluating the effects of positive fluid balance, with recent emphasis, and controversies, on venous ultrasound parameters and composite scores. The portal vein pulsatility index and the renal venous pattern have emerged as the most promising indicators of volume-induced venous congestion. But in the general intensive care unit (ICU), numerous factors influence cardiovascular homeostasis, affecting venous function.

OBJECTIVES

This study aimed to evaluate the factors associated with portal vein pulsatility index in general ICU patients. Secondary objectives were to examine the correlations between pulsatility index and additional markers of congestion.

DESIGN

This exploratory study was a post hoc analysis of a prospective, multicentric, observational database.

SETTING

The data collection was performed in four ICUs in university-affiliated or tertiary hospitals.

PATIENTS

This study included adult patients within 24 h of general ICU admission with an expected ICU length of stay of more than 2 days.

INTERVENTION

Patients underwent clinical, biological, and echocardiographic assessments at several times: ICU admission, day 1, day 2, day 5 and the last day of ICU.

MAIN OUTCOME MEASURE

The study primary endpoint was the portal vein pulsatility index during the course of the patients' stay on the ICU.

RESULTS

One hundred forty-five patients and 514 haemodynamic evaluations were analysed. The mean age of the patients was 64 ± 15 years, 41% were women, with a median [IQR] admission simplified acute physiology score II of 46 [37 to 59]. The univariable followed by multivariable mixed-effects linear regression analyses demonstrated an association between portal vein pulsatility index, heart rate [estimate -0.002 (95% CI, -0.003 to -0.001), P  < 0.001] and the cumulative fluid balance [estimate 0.0007 (95% CI, 0.00007 to 0.001), P  = 0.024]. Portal vein pulsatility index showed no agreement with CVP of at least 12 mmHg (kappa correlation -0.008, P  = 0.811), negative passive leg raising (kappa correlation -0.036, P  = 0.430), mean inferior vena caval (IVC) diameter greater than 2 cm (kappa correlation -0.090, P  = 0.025), maximal IVC diameter greater than 2 cm (kappa correlation -0.010, P  = 0.835), hepatic vein systolic/diastolic ratio less than 1 (kappa correlation 0.043, P  = 0.276), or renal vein pulsatile pattern (kappa correlation -0.243, P  < 0.001).

CONCLUSION

The study findings emphasise the unique sensitivity of portal vein pulsatility index in assessing fluid balance in general ICU patients. The lack of correlation between portal vein pulsatility index and other parameters of venous congestion underscores its potential to provide distinctive insights into venous congestion.

Can we reduce the risk of neurological injury in critically ill children on initiation of ECLS? A narrative review of potential modifiable factors

Neurological morbidity and mortality remain high in children requiring extracorporeal membrane oxygenation (ECMO). Although the severity of illness at the time of ECMO initiation and the nature of the underlying disease are strongly linked to the development of acute brain injury, several important factors are associated with neurological complications during ECMO support. Many of these factors, particularly those encountered during the early phase of ECMO initiation (first 24 hours), may be modifiable and represent potential targets for interventional studies aiming for improvement of neurological outcomes in pediatric ECMO patients. In this review from the European Extracorporeal Life Support Organization (EuroELSO) Working Group on Neurologic Monitoring and Outcome, we aim to summarize current knowledge on modifiable factors associated with brain injury during ECMO and their potential impact on outcome.

Are corticosteroids in intensive care immunosuppressive? Reflections and hypotheses

This review reconsiders the classification of corticosteroids as immunosuppressants in the management of acute inflammatory conditions in critical care. Despite their widespread use in ARDS and septic shock, the association between corticosteroid therapy and increased infection risk remains contentious. By exploring alternative mechanisms and presenting new hypotheses, this review suggests that the traditional view of corticosteroids as immunosuppressants may be overly simplistic and context dependent.

Hemodynamic effects of slower versus faster intravenous fluid bolus rates in critically ill patients: An observational study

PURPOSE

We compared the immediate and sustained effects of 500 mL of crystalloid administered at slow (333 mL/h) versus fast rates (999 mL/h) on mean arterial pressure (MAP) in critically ill patients.

MATERIALS AND METHODS

Hemodynamic variables were collected immediately before and every 30 min up to 60 min after the end of the infusion. The primary outcome was the adjusted difference in MAP.

RESULTS

We included 146 patients (slow rate: 71, fast rate: 75). One hour after the end of the infusion, there was no difference in the overall mean marginal effect on MAP between the groups [1.9 mmHg (95 % CI: -1.5 to 5.3 mmHg), p = 0.27] or on the perfusion parameters. Similarly, no difference was found in the immediate effect after 90 min [overall marginal effect: 1.1 mmHg (95 % CI: -2.3 to 4.6 mmHg); p = 0.52]. In patients with cardiac output (CO) monitoring, there was an increase in CO in the fast rate group (overall mean marginal effect: 1.78 L/min (95 % CI: 0.08 to 3.48 L/min); p = 0.04).

CONCLUSION

In critically ill patients, crystalloid infusion at both fast and slow rates did not lead to immediate or sustained differences in MAP. However, fast infusion may result in a greater increase in CO.

Characterization of left atrial strain in left ventricular hypertrophy: A study of Fabry disease, sarcomeric hypertrophic cardiomyopathy and cardiac amyloidosis

BACKGROUND

Patients with left ventricular hypertrophy (LVH) often maintain preserved left ventricular ejection fraction in the early stages of the disease. There is a need to identify simple and reliable variables beyond left ventricular ejection fraction to recognize those at risk of developing adverse clinical outcomes.

AIMS

To examine left atrial (LA) strain in patients with hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA) and Fabry disease (FD), pathologies known to cause LVH, and the relationship between LA strain and adverse clinical outcomes.

METHODS

In this retrospective cohort study, LA strain was measured and compared among patients with HCM, CA and FD. Relationships between LA and left ventricular strain, and LA strain and adverse cardiovascular events were evaluated. The primary outcome was first occurrence of cardiovascular mortality, device implantation, heart failure hospitalization, new-onset atrial fibrillation or stroke.

RESULTS

A total of 191 patients were included (24 with FD, 87 with HCM, 80 with CA). LA reservoir strain was highest in patients with HCM (26%, interquartile range [IQR] 20%, 32%), followed by those with FD (20.5%, IQR: 14%, 27.8%) and CA (11%, IQR: 7%, 18.8%) (P<0.001). LA strain correlated well with left ventricular strain in patients with LVH, with CA showing the best correlation (r=-0.70, 95% confidence interval [95% CI]: -0.80 to -0.56; P<0.001). Multivariable Cox regression analysis showed that LA reservoir strain was significantly associated with the primary outcome in all patients (hazard ratio: 0.91, 95% CI: 0.84 to 0.99; P=0.03) and in those with CA (hazard ratio: 0.90, 95% CI: 0.82 to 0.99; P=0.023).

CONCLUSIONS

LA strain was more reduced in CA than in FD and HCM, probably as a result of atrial wall infiltration, and was associated with adverse clinical outcomes in our heterogenous LVH population and patients with CA.

Pharmacokinetics and Target Attainment of Teicoplanin: A Systematic Review

BACKGROUND AND OBJECTIVE

Teicoplanin is a glycopeptide antibiotic used to treat severe Gram-positive infections. This systematic review provides a comprehensive overview of the current knowledge on the pharmacokinetics of teicoplanin across the entire population, with the aim to identify gaps in the existing literature, prioritise pharmacokinetic research, and support optimal dosing strategies.

METHODS

A systematic literature search of the MEDLINE, Embase, Web of Science, and Scopus databases was conducted. Articles published until 1 October 2024 were identified as eligible when they included a pharmacokinetic analysis of teicoplanin. Relevant pharmacokinetic data were extracted from all included articles. Allometric scaling was carried out for reported values of clearance (CL) and volume of distribution (Vd) to an individual of 70 kg. Articles were categorised into eight subgroups. A qualitative assessment of the included studies was conducted using the clinical pharmacokinetic statement checklist.

RESULTS

In total, 85 articles were included in this review. Pharmacokinetic data for 186 healthy volunteers, 130 neonates, 788 children, 1434 adult patients, 48 older adults (≥ 65 years), 674 critically ill patients, 33 patients with impaired renal function, and 159 patients with extracorporeal elimination techniques were extracted for a total of 3452 subjects. Unbound concentrations were assessed in 7.1% of the articles. The Vdscaled ranged from 1.5 to 583 L/70 kg. The CLscaled ranged from 0.0073 to 6.38 L/h/70 kg. Covariates on drug disposition were identified in 55.3% of studies, 65.6% of which identified a relationship between renal function and CL. Target attainment was described in 42.4% of articles. Dosing recommendations were provided in 61.2% of all studies. Studies had an average quality score of 69.9% ± standard deviation 15.7.

CONCLUSION

Individual dosing strategies based on renal function need to be developed, particularly in patients with immature or impaired renal function, using state-of-the art pharmacokinetic/pharmacodynamic modelling approaches. Since teicoplanin is highly plasma protein bound and it is suggested that total concentrations cannot be easily translated to unbound concentrations, future research should also include the measurement of unbound concentrations for pharmacokinetic and target attainment evaluation.

TRIAL REGISTRATION

Prospectively registered in PROSPERO.

TRIAL REGISTRATION NUMBER

CRD42023483334. Registration date: 03/12/2023.

Subtherapeutic Meropenem Antibiotic Exposure in Children With Septic Shock Assessed by Noncompartmental Pharmacokinetic Analysis in a Prospective Dataset

OBJECTIVES

To define meropenem plasma concentrations and pharmacodynamic exposure metrics in children with septic shock during the first 3 days of PICU hospitalization.

DESIGN

Pharmacokinetic sampling was undertaken in 19 subjects receiving standard meropenem dosing (20 mg/kg/dose, 8 hr) recruited from March 2019 to March 2022. Sampling occurred once each day following meropenem given 24 hours apart, during the first 3 PICU days. Data analysis was completed in 2023 and noncompartmental analysis was performed to assess pharmacodynamic exposure targets for sepsis. Clearance and volume of distribution at 20 mg/kg/dose were used to simulate mean exposures at 40 and 60 mg/kg/dose.

SETTING

PICU in a tertiary care center.

SUBJECTS

Patients 4 weeks old or older with hypotension requiring fluid resuscitation and vasopressor therapy, receiving meropenem as empiric therapy for sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Augmented renal clearance (ARC) was documented in eight of 19 subjects, previously associated with subtherapeutic plasma concentrations, while three of 19 had acute kidney injury and decreased renal clearance. When assessed by pharmacodynamic exposure targets for sepsis (plasma meropenem concentrations above the minimum inhibitory concentration [MIC] of Pseudomonas aeruginosa for 70% or 100% of the dosing interval), ten of 19 and nine of 19 children, respectively, had subtherapeutic plasma meropenem exposures during PICU day 1, even for pathogens with an MIC considered "susceptible" by U.S. Food and Drug Administration criteria. Therapeutic meropenem pharmacodynamic exposures were associated with a positive 24-hour fluid balance on PICU day 1 and a negative 24-hour fluid balance by day 3, although profound variability was noted in fluid administered and renal output.

CONCLUSIONS

Given the variability in meropenem systemic exposure in pediatric septic shock, therapeutic drug monitoring, or monitoring for ARC, is suggested during the first days of hospitalization to allow daily assessments of dosing needs to achieve pharmacodynamic exposure targets for sepsis.

A real-world investigation into prescribing patterns and effectiveness of ceftolozane/tazobactam among critically ill patients from SPECTRA

BACKGROUND

Ceftolozane/tazobactam (C/T) real-world use was examined in a global population of critical care patients treated in intensive care unit settings.

METHODS

The Study of Prescribing patterns and Effectiveness of Ceftolozane/Tazobactam Real-world Analysis (SPECTRA) is a multinational, retrospective observational study of 617 adults treated with C/T conducted between 2016 and 2020. Population-associated clinical, treatment-related, and microbiologic characteristics, resource utilization, and clinical outcomes were assessed in critical care patients.

RESULTS

In this SPECTRA critical care cohort (n=298), 81.5% had ≥1 comorbidity. Common infection sites were respiratory (50.0%), skin/wound/tissue (21.1%), blood (13.7%), and urine (10.3%); common pathogens were Pseudomonas aeruginosa (89.7%; 66.7% multidrug resistant), Klebsiella spp. (6.9%), and Escherichia coli (6.4%); 51.7% received C/T as third-line/salvage therapy. Thirty-day readmission rates were 3.4% (all cause) and 1.7% (infection related). Overall clinical success was 53.4% (95% confidence interval: 47.5% to 59.1%) and was greater with first-line C/T (62.2%) versus third line (45.5%). All-cause in-hospital mortality was 35.6%; infection-related mortality was 13.8%.

CONCLUSIONS

In this multinational, high-risk cohort, most patients had beneficial outcomes despite their clinical complexity and late intervention with C/T. These results support C/T use against a wide range of Gram-negative pathogens in critical care settings.

TRIAL REGISTRATION

Not applicable due to retrospective design.

Agreement between manual and automatic ultrasound measurement of the velocity-time integral in the left ventricular outflow tract in intensive care patients: evaluation of the AUTO-VTI® tool

Transthoracic echocardiography is widely used in intensive care unit (ICU) to manage patients with acute circulatory failure. Recently, automated ultrasound (US) measurement applications have been developed but their clinical performance has not been evaluated yet. The aim of this study was to assess the agreement between automated and manual measurements of the velocity-time integral in the left ventricular outflow tract (VTI-LVOT) using the auto-VTI® tool. This prospective, single-center, interventional study included ICU patients with acute circulatory failure. The examination involved two successive manual measurements of VTI-LVOT (mean of 3 consecutive heartbeats in regular sinus rhythm, and 5 heartbeats in irregular rhythm), followed by a measurement using auto-VTI® software. In patients receiving a fluid challenge, trending ability in detecting fluid responsiveness was also evaluated. Seventy patients were included between January 19, 2020, and September 24, 2020, at the Nîmes University Hospital. The feasibility of the auto-VTI® was 94%. The mean difference between the two methods was 11% with limits of agreement from - 19% to 42%. The proportion of agreement at the 15% difference threshold was 68% [58%; 80%]. The precision and least significant change measured for the manual measurement of VTI were 7.4 and 10.5%, respectively, and by inference for the automated method 28% and 40%. The new auto-VTI® tool, despite interesting feasibility, demonstrated an insufficient agreement with a systematic bias and an insufficient precision limiting its implementation in critically ill patients.Clinical trial registration: ClinicalTrials.gov identifier: NCT04360304.

Carotid corrected flow time and Doppler shock index for prediction of post-induction hypotension in patients undergoing elective abdominal surgery: a prospective observational study

BACKGROUND

Abdominal surgical patients who have deficient blood volume are at an elevated risk of post-induction hypotension (PIH). New strategies have been adopted, i.e., carotid ultrasound, to evaluate volume status. The study aimed to investigate and compare the predictive value of various carotid ultrasound parameters for PIH.

METHODS

Adult patients scheduled for abdominal surgery were enrolled. Carotid ultrasound was performed before induction to evaluate the carotid flow time (FT), carotid artery velocity time integral (VTI), and Doppler shock index (the DSIFTc and DSIVTI). Both Wodey's (W) and Bazett's (B) formulae determined the corrected flow time (FTc). The predictive ability of these parameters was analyzed via receiver operating characteristic (ROC) curve analysis.

RESULTS

Finally, 94 patients were analyzed, and of those, 40 (42.6%) developed PIH. The areas under the curve for FT, FTc(W), 1/DSIFTc, and FTc(B) were 0.790 (95% CI 0.697-0.883) (P < 0.05), 0.788 (95% CI 0.695-0.881) (P < 0.001), 0.729 (95% CI 0.626-0.832) (P < 0.001), and 0.689 (95% CI 0.582-0.796) (P < 0.05), respectively. The optimal cut-off for FTc(W) was 334.15 ms (sensitivity 82.5%, specificity 70.4%), while for FT, it was 313.33 ms (sensitivity 72.5%, specificity 79.6%), indicating FTc(W) as the best predictor among these various parameters. The 1/DSIFTc was an inferior predictor of PIH, with an optimal cutoff value of 4.58. The sensitivity (80.0%) and specificity (61.1%) values were obtained.

CONCLUSION

Carotid flow time corrected by Wodey's formula was a reliable indicator of PIH in patients undergoing elective abdominal surgery, superior to FT, DSIFTc, and FTc(B).

Intraoperative Hemoadsorption in Heart Transplant Surgery: A 5-Year Experience

BACKGROUND

Hyperimmune response and cytokine release post-reperfusion might occur after orthotopic heart transplantation (HTx). Intraoperative hemoadsorption (HA) has been introduced to remove such elevated cytokines. We aimed to analyze the effect of intraoperative HA in patients undergoing orthotopic HTx.

METHODS

Between 2018 and 2022, 40 consecutive orthotopic HTx patients who underwent intraoperative hemoadsorption HA integrated into the cardiopulmonary bypass were compared to 41 historical controls. Primary outcome measures included postoperative hemodynamic stability and blood product requirements, while secondary outcomes were the incidence of acute kidney injury requiring dialysis (AKI-d) and 30-day mortality.

RESULTS

Postoperatively, the vasoactive-inotropic score (VIS) did not significantly differ between the groups. However, the use duration for milrinone and dobutamine was shortened by one day compared to controls. The HA group had fewer red blood cell transfusions (765 vs. 1330 mL, p = 0.01) and lower fresh frozen plasma requirements (945 vs. 1200 mL, p = 0.04). Mechanical ventilation duration was reduced (22 vs. 28 h, p = 0.02). AKI-d rates were similar, and 30-day mortality favored non-significantly the HA group (5% vs. 14.6%, p = ns). No device-related adverse events were observed.

CONCLUSION

These findings suggest that intraoperative HA might improve immediate postoperative outcomes; however, further validation in larger randomized controlled trials is warranted.

Clinical characteristics and outcomes of acute myocardial infarction during the COVID-19 pandemic: a multicenter retrospective cohort study in Northern China

BACKGROUND

The impacts of COVID-19 on acute myocardial infarction (AMI) care were heterogeneous. The study aims to analyze the clinical characteristics and outcomes of AMI patients in China during different stages of the COVID-19 pandemic.

METHODS

This is a multicenter retrospective cohort study in Shanxi Province of northern China. Patients diagnosed with AMI during the zero-case, lockdown, and outbreak periods were included. Characteristics and outcomes were analyzed according to time periods and COVID-19 infection. The primary outcome was in-hospital mortality. Additional outcomes included reperfusion times, coronary angiographic measures, procedure or AMI-associated complications, arrhythmia, other adverse events, and left ventricular systolic dysfunction (LVSD).

RESULTS

The study included 1021 AMI patients, with 393, 250, and 378 from the zero-case, lockdown, and outbreak periods. No differences in in-hospital mortality or other adverse events were found by time periods. By infection status, 264 patients were COVID-positive, and 706 were COVID-negative. The COVID-positive ST-elevation myocardial infarction population had longer symptom-to-first medical contact (3.07 vs. 2.31, p = 0.026), pre-hospital time (4.58 vs. 3.67, p = 0.032), door-to-balloon (1.20 vs. 1.08, p = 0.046), and total ischemic time (5.80 vs. 4.70, p = 0.011). No differences in other in-hospital outcomes were found, except that multivariate logistic regression analysis demonstrated COVID-19 infection was correlated with increased risks of LVSD (OR 1.73, 95% CI 1.11-2.69, p = 0.015).

CONCLUSIONS

In-hospital mortality did not differ by time period or COVID-19 infection status. The COVID-positive AMI patients had longer reperfusion times and higher risks of LVSD. AMI treatments were impacted during the pandemic, and measures are warranted to minimize the reperfusion time.

Prevalence of pathogens associated with neonatal gastrointestinal infections: a systematic review and meta-analysis

Gastrointestinal infections represent a significant global health burden, ranking as the second leading cause of mortality among infants and children. Identifying of pathogens causing neonatal gastrointestinal infections has presented tough challenges. This study aimed to summarize the prevalence of common pathogens associated with neonatal gastrointestinal infections through a comprehensive systematic review and meta-analysis of published literature. The last search was performed on January 08, 2025, from databases including EMBASE, PubMed, Cochrane Libary, and Web of Science. The outcome variable was infection rate, and the detection methods used were blood culture, tissue culture, or molecular biology methods. Two researchers independently extracted the research data and evaluated its quality using the JBI Critical Appraisal Tools. Twenty-three studies met the inclusion criteria. The pooled prevalence rates of common pathogens were as follows: Bacteria, including Escherichia (22.2%; 95% CI 8.3-40.4%, I2 = 98%), Clostridium (21.8%; 95% CI 2.2-53.8%, I2 = 96%), Klebsiella (19.2%; 95% CI 8.3-33.4%, I2 = 97%), Staphylococcus (13.6%; 95% CI 6.0-23.7%, I2 = 91%), Enterococcus (12.4%; 95% CI 1.8-30.3%, I2 = 96%), and Streptococcus (6.8%; 95% CI 2.5-12.9%, I2 = 43%). Fungi, including Candida (3.8%; 95% CI 0.6-9.6%, I2 = 84%). Viruses, including Rotavirus (11.6%; 95% CI 1.0-31.5%, I2 = 94%) and Adenovirus (4.1%; 95% CI 0.5-11.0%, I2 = 58%). Peritoneal culture methods demonstrated significantly higher positivity rates compared to other detection methods. Escherichia coli exhibited consistently high positivity rates across the three main detection methods. Klebsiella showed the highest positivity rates among bacterial isolates in both blood and peritoneal cultures. Pathogen detection and prevalence in necrotizing enterocolitis (NEC) cases were markedly higher compared to other conditions. This meta-analysis identifies key pathogens in gastrointestinal infections, including Klebsiella pneumoniae, Escherichia coli, Candida, Rotavirus, Adenovirus, and others that are suspected before clinical sample results are available. It also highlights that intestinal pathogen infections are linked to an increased risk of neonatal necrotizing enterocolitis (NEC) and emphasizes the advantages of peritoneal culture in detecting these infections.

The Effect of Prone Position on Right Ventricular Functions in CARDS: Is Survival Predictable when Evaluated Through Transesophageal Echocardiography?

Objective

To evaluate the cardiopulmonary effect during prone position (PP) on right ventricular (RV) recovery in coronavirus disease-2019 related acute respiratory distress syndrome (C-ARDS) through transesophageal echocardiography (TEE).

Methods

This prospective study included 30 moderate-to-severe C-ARDS patients who were treated with PP in the first 48 h of invasive mechanical ventilation support. It was evaluated with TEE three times: before PP (T0f), the first hour of PP (T1), and the first hour of returning to the supine position (T0 + 24 h) (T2) after 23 hours of PP treatment. RV end-diastolic area/left ventricular (LV) end-diastolic area (RVEDA/LVEDA), tricuspid annular plane systolic excursion (TAPSE) and LV end-systolic eccentricity index were preferred RV evaluations as primary outcomes. Pulmonary effects of PP were evaluated as a secondary outcome, including PaO2/FiO2, driving pressure (dP), static compliance (Cstat), mechanical ventilation parameters, and their association with 28-day survival. Tissue DO2 was examined as a secondary outcome, and it was calculated using the measured cardiac output through TEE.

Results

With the cardiopulmonary effect of PP, the decrease in RVEDA/LVEDA, the increase in TAPSE, PaO2/FiO2, and Cstat, and the decrease in dP were statistically significant (P < 0.05). The Cstat value associated with 28-day survival showed decreased mortality for each unit increase. The Cstat cut-off value, which was statistically significant for survival, was 37.

Conclusion

PP can improve RV recovery and oxygenation, but it isn't always accompanied by increased survival. An increase in the Cstat may improve survival without the development of RV dysfunction while maintaining heart-lung interaction.

Ventilation-induced acute kidney injury in acute respiratory failure: Do PEEP levels matter?

Acute Respiratory Distress Syndrome (ARDS) is a leading cause of morbidity and mortality among critically ill patients, and mechanical ventilation (MV) plays a critical role in its management. One of the key parameters of MV is the level of positive end-expiratory pressure (PEEP), which helps to maintain an adequate lung functional volume. However, the optimal level of PEEP remains controversial. The classical approach in clinical trials for identifying the optimal PEEP has been to compare "high" and "low" levels in a dichotomous manner. High PEEP can improve lung compliance and significantly enhance oxygenation but has been inconclusive in hard clinical outcomes such as mortality and duration of MV. This discrepancy could be related to the fact that inappropriately high or low PEEP levels may adversely affect other organs, such as the heart, brain, and kidneys, which could counteract its potential beneficial effects on the lung. Patients with ARDS often develop acute kidney injury, which is an independent marker of mortality. Three primary mechanisms have been proposed to explain lung-kidney crosstalk during MV: gas exchange abnormalities, such as hypoxemia and hypercapnia; remote biotrauma; and hemodynamic changes, including reduced venous return and cardiac output. As PEEP levels increase, lung volume expands to a variable extent depending on mechanical response. This dynamic underlies two potential mechanisms that could impair venous return, potentially leading to splanchnic and renal congestion. First, increasing PEEP may enhance lung aeration, particularly in highly recruitable lungs, where previously collapsed alveoli reopen, increasing lung volume and pleural pressure, leading to vena cava compression, which can contribute to systemic venous congestion and abdominal organ impairment function. Second, in lungs with low recruitability, PEEP elevation may induce minimal changes in lung volume while increasing airway pressure, resulting in alveolar overdistension, vascular compression, and increased pulmonary vascular resistance. Therefore, we propose that high PEEP settings can contribute to renal congestion, potentially impairing renal function. This review underscores the need for further rigorous research to validate these perspectives and explore strategies for optimizing PEEP settings while minimizing adverse renal effects.

The Effects of Passive Leg Raising and Maintenance Fluid Administration on Pulse Oximetry Waveform Amplitude and Peak Variability in Mechanically Ventilated Patients in Sepsis and Septic Shock

Objective: We sought to assess variations in pulse oximetry waveform amplitude (ΔP) and peak values (ΔS) separately during passive leg raising (PLR) and challenge plus maintenance crystalloid volume resuscitation over time in mechanically ventilated (MV) patients in shock. Methods: Variables were recorded and analayzed using previously described techniques. Findings were compared between the following: at baseline, during passive leg raising (PLR), with 0.9% normal saline administration (or removal), and applying tidal volume (Vt), peak, and mean airway pressure (Paw,peak and Paw,mean, respectively) and positive end-expiratory pressure (PEEP) as covariates in multifactorial logistic regression analysis. Results: Twenty patients with sepsis or septic shock were included in the analysis. Origins of sepsis varied. Their diagnoses upon admission to the intensive care unit included sepsis in nine (45%), septic shock (defined as the need for vasopressors) in nine (45%), and one (5%) rescuscitated from pulseless electrical activity following heroin overdose, all of whom were supported by volume control MV. Eleven patients required vasoactive drugs at the outset, of which seven were on norepinephrine. Three patients required surgical drainage or removal of necrotic tissue. Median ΔP and ΔS decreased, respectively, by 42% and 37% with PLR (p = 0.036 and p = 0.061, respectively). There were no significant changes in ΔP and ΔS between PLR and net fluid volume administered. Correction for body weight did not change these relationships. Application of Vt, Paw,peak, Paw,mean, and PEEP did not significantly influence these changes. Conclusions: Hemodynamic repsonse to slow fluid volume administration can be assessed by changes in the pulse oximetry waveform amplitude over time. The effects of mechanical ventilation are negligible.

Standard versus double dosing of beta-lactam antibiotics in critically ill patients with sepsis: The BULLSEYE study protocol for a multicenter randomized controlled trial

BACKGROUND

Sepsis and septic shock are significant global healthcare challenges with high mortality rates. Effective management requires timely and adequate antimicrobial therapy. Beta-lactam antibiotics, commonly used in patients with sepsis, are crucial for treating these infections. However, standard dosing often leads to insufficient plasma levels due to dynamic physiological changes in critically ill patients. Previous randomized controlled trials highlighted the need for timely dose adjustments to improve clinical outcomes. This is the study protocol for the BULLSEYE trial in which we aim to optimize antibiotic treatment during the initial 48 h of sepsis by comparing standard to double dosing of beta-lactam antibiotics.

METHODS

This open-label, multicenter, randomized controlled trial will compare standard to double dosing of beta-lactam antibiotics (cefuroxime, ceftazidime, ceftriaxone, cefotaxime, amoxicillin, amoxicillin/clavulanic acid, flucloxacillin, meropenem, and piperacillin/clavulanic acid) in critically ill patients with septic shock. Participants will be randomized into two arms: the control arm receiving standard care, and the intervention arm receiving double antibiotic doses for 48 h, irrespective of renal function. Following this period, all patients will receive standard doses as per local protocol. The primary outcome is all cause 28-day mortality, with secondary outcomes including 90-day, 365-day, hospital and ICU mortality, hospital and ICU length of stay, SOFA scores, time to shock reversal, microbiological eradication, clinical cure, pharmacodynamic target attainment, safety, quality of life, and medical consumption.

DISCUSSION

The BULLSEYE trial aims to improve sepsis treatment in critically ill patients. Despite anticipated recruitment challenges, its large sample size ensures robust comparability. This pivotal trial could significantly impact sepsis treatment, leading to better clinical outcomes.

TRIAL REGISTRATION

EU_CT 2024-512950-13-00. Protocol version 2.3, protocol date 09-12-2024. Prospectively registered on 09-01-2025 at Clinicaltrails.gov nr. NCT06766461.

Acute Respiratory Distress Syndrome and Fluid Management: Finding the Perfect Balance

ARDS is a challenging syndrome in which the hallmark is alveolar epithelium damage, with the consequent extravasation of fluids into the interstitium and alveolar space. Patients with severe ARDS almost always require mechanical ventilation and aggressive fluid resuscitation, at least in the initial phases. The increased intrathoracic pressure during positive pressure ventilation reduces cardiac output, worsening the circulatory status of these patients even more. In this pathological context, fluid therapies serve as a means to restore intravascular volume but can simultaneously play a detrimental role, increasing the amount of liquid in the lungs and worsening gas exchange and lung mechanics. Indeed, clinical research suggests that fluid overload leads to worsening outcomes, mostly in terms of gas exchange, days of mechanical ventilation, and ICU stay duration. For these reasons, this review aims to provide basic information about ARDS pathophysiology and heart-lung interactions, the understanding of which is essential to guide fluid therapy, together with the close monitoring of hemodynamics and fluid responsiveness.

Pharmacokinetic variability and significance of therapeutic drug monitoring for broad-spectrum antimicrobials in critically ill patients

Critically ill patients are susceptible to serious infections due to their compromised conditions and extensive use of medical devices, often requiring empiric broad-spectrum antimicrobial therapy. Failure of antimicrobial therapy in this vulnerable population has a direct impact on the patient's survival; hence, selecting the optimal dosage is critical. This population, however, exhibits complex and diverse disease-related physiological changes that can markedly alter antimicrobial disposition. Inflammatory cytokines overexpressed in the systemic inflammatory response syndrome increase vascular permeability, leading to higher volume of distribution for hydrophilic antimicrobials. These cytokines also downregulate metabolic enzyme activities, reducing the clearance of their substrates. Hypoalbuminemia can increase the volume of distribution and clearance of highly protein-bound antimicrobials. Acute kidney injury decreases, while augmented renal clearance increases the clearance of antimicrobials primarily excreted by the kidneys. Furthermore, continuous renal replacement therapy and extracorporeal membrane oxygenation used in critical illness substantially affect antimicrobial pharmacokinetics. The complex interplay of multiple factors observed in critically ill patients poses a significant challenge in predicting the pharmacokinetics of antimicrobials. Therapeutic drug monitoring is the most effective tool to address this issue, and is proactively recommended for vancomycin, teicoplanin, aminoglycosides, voriconazole, β-lactams, and linezolid in critically ill patients. To streamline this process, model-informed precision dosing is expected to promote personalized medicine for this population.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

Population pharmacokinetics of polymyxin B in critically ill patients with carbapenem-resistant organisms infections: insights from steady-state trough and peak plasma concentration

Aims

To establish a population pharmacokinetic (PopPK) model of polymyxin B (PMB) in critically ill patients based on steady-state trough (Ctrough,ss) and peak (Cpeak,ss) concentrations, optimize the dosing regimen, and evaluate the consistency of 24-hour steady-state area under the concentration-time curve (AUCss,24h) estimation between model-based and the two-point (Ctrough,ss and Cpeak,ss) methods.

Methods

PopPK modeling was performed using NONMEM, Monte Carlo simulations were used to optimize PMB dosing regimens. Bland-Altman analysis was used to evaluate the consistency between the two AUCss,24h estimation methods.

Results

A total of 95 patients, contributing 214 blood samples, were included and categorized into a modeling group (n = 80) and a validation group (n = 15). A one-compartment model was developed, with creatinine clearance (CrCL) and platelet count (PLT) identified as significant covariates influencing PK parameters. Simulation results indicated that when a Minimum Inhibitory Concentration (MIC) ≤ 0.5 mg·L-1, a probability of target attainment (PTA) ≥ 90% was achieved in all groups except for the 50 mg every 12 h (q12h) maintenance dose group. PTA decreased as CrCL increased, with slight variations observed across different PLT levels. The 75 mg and 100 mg q12h groups showed a higher proportion of AUCss,24h within the therapeutic window. Bland-Altman analysis revealed a mean bias of 12.98 mg·h·L-1 between the two AUCss,24h estimation methods. The Kappa test (κ = 0.51, P < 0.001) and McNemar's test (P = 0.33) demonstrated moderate agreement, reflecting overall consistency with minor discrepancies in classification outcomes.

Conclusion

The PopPK model of PMB is well-suited for critically ill patients. The 75 mg q12h and 100 mg q12h regimens are appropriate for critically ill patients, with CrCL levels guiding individualized dosing. A two-point sampling strategy can be used for routine therapeutic drug monitoring (TDM) of PMB.

Intranasal liposomal remdesivir induces SARS-CoV-2 clearance in K18-hACE2 mice and ensures survival

A huge challenge after the emergence of COVID-19 has been the discovery of effective antiviral drugs. Although remdesivir (RDV) emerged as one of the most promising drugs, its pharmaceutical formulation Veklury® is limited by moderate efficacy, high toxicity and need for parenteral administration. The aim of the present work was to develop a liposomal formulation of RDV for pulmonary administration and evaluate its efficacy in models of COVID-19. Liposomal RDV nanoformulation (LRDV) was selected based on high drug encapsulation efficiency, sustained drug release property and high in vitro selectivity index. A pharmacokinetic study of intranasal LRDV in mice demonstrated effective delivery of the drug to the lungs. LRDV was then evaluated for its efficacy in SARS-CoV-2-infected K18-hACE2 mice after repeated intranasal administration at 10 mg/kg/bid for 5 days. Veklury® given intraperitoneally at 20 mg/kg/bid was used for comparison. Mice receiving LRDV remained alive up to 15 days post-infection (dpi). On the other hand, the control groups receiving PBS and empty liposomes showed 100 % death at 6 dpi and the Veklury® group had 62.5 % death at 8 dpi. Intranasal LRDV also promoted a strong reduction in viral loads in the brain and lungs of mice and prevented the inflammatory response induced by SARS-CoV-2 in the lungs. This is in contrast with Veklury®, which did not significantly reduce the viral titer in the brain and was poorly effective in preventing the inflammatory response in the lungs. Intranasal LRDV emerges as a promising therapeutic strategy for COVID-19, including "Long COVID".

Urinary Biomarkers and Attainment of Cefepime Therapeutic Targets in Critically Ill Children

BACKGROUND

Critically ill children are at risk for subtherapeutic antibiotic concentrations. The frequency of target attainment and risk factors for subtherapeutic concentrations of cefepime in children have not been extensively studied.

METHODS

We performed an observational study in critically ill children receiving a new prescription of standard dosing of cefepime for suspected sepsis (≥2 systemic inflammatory response syndrome criteria within 48 hours of cefepime start). Three plasma cefepime concentrations were measured at steady state and, a urine sample was collected prior to pharmacokinetics (PK) sampling for measurement of urinary biomarkers. Bayesian analysis determined cefepime PK for each individual, and simulations were used to estimate time above minimum inhibitory concentration (fT > MIC) for 8 µg/mL (breakpoint for Pseudomonas). Clinical factors and urinary biomarkers were compared between patients who did and did not achieve 100% fT > MIC. Correlations between covariates and cefepime PK parameters, as well as optimal cut points to identify <100% fT > MIC, were evaluated.

RESULTS

Twenty-one subjects were enrolled and PK sampling occurred after a median of 5 doses (range, 3-9); 43% of children achieved 100% fT > MIC for an MIC of 8 µg/mL. Younger age and lower urinary biomarkers (neutrophil gelatinase-associated lipocalin and kidney injury molecule-1) were significantly associated with failure to attain 100% fT > 8 µg/mL. Urinary neutrophil gelatinase-associated lipocalin (<122.1-ng/mg creatinine) best identified individuals who failed to attain this putative target (positive predictive value, 91.7%).

CONCLUSIONS

A large proportion of critically ill children failed to attain target concentrations for empiric treatment of Pseudomonas aeruginosa with cefepime. Urinary biomarkers may be a noninvasive means to identify those at higher risk for increased cefepime clearance and subtherapeutic concentrations.

Short, extended and continuous infusion of β-lactams: predicted impact on target attainment and risk for toxicity in an ICU patient cohort

OBJECTIVES

This study aimed to predict the impact of different infusion strategies on pharmacokinetic/pharmacodynamic (PK/PD) target attainment and the potential risk for toxicity in an ICU cohort treated with β-lactams.

METHOD

Using collected patient data from 137 adult ICU patients, and applying population PK models, individual PK parameters were estimated and used to predict concentrations and target attainment following cefotaxime 2 g q8h, piperacillin/tazobactam 4.5 g q6h and meropenem 1 g q8h, applying 15 min short infusions (SI), 3 h extended infusions (EI) and 24 h continuous infusion (CI). The MIC level of the most common primary pathogens, and the worst-case scenario (WCS) pathogen, were used in analyses.

RESULTS

For primary pathogens, target was reached in 94% (129/137) using SI. For WCS pathogens treated with piperacillin/tazobactam and meropenem, 78% (65/83) and 92% (76/83) reached target using SI and EI, respectively. However, target attainment was lower for cefotaxime [SI: 31% (17/54), EI: 44% (24/54)]. Overall, the number of individuals with potentially toxic concentrations was low, both in EI (n = 7) and SI (n = 5). For CI and WCS, target was reached in 50% (27/54), 96% (54/56) and 93% (25/27) for cefotaxime, piperacillin/tazobactam and meropenem, respectively.

CONCLUSIONS

In a Swedish ICU cohort target attainment rates for primary pathogens were high regardless of infusion strategy. In WCS pathogens, SI was insufficient, suggesting the benefit of routine use of EI or CI. However, for cefotaxime, target attainment remained low also with EI and CI. The use of CI might lead to unnecessarily high concentrations, but well-established toxicity levels are lacking and future studies are warranted.

Impact of prolonged versus intermittent infusion of meropenem on mortality and clinical outcomes in patients with severe infection: A systematic review and meta-analysis

OBJECTIVES

To compare the clinical outcomes of patients with severe infection treated with prolonged or intermittent infusion of meropenem.

METHODS

PubMed, Embase, and Cochrane Central databases were searched until July 2023. Randomized controlled trials (RCTs) or observational studies comparing prolonged versus intermittent infusion of meropenem were considered eligible. The primary outcomes included all-cause mortality and clinical improvement, while secondary outcomes encompassed hospital and intensive care unit (ICU) stay duration, microbial eradication rate, and adverse events. A meta-analysis was conducted using a random-effects model. The risk of bias of included studies was assessed using the modified JADAD scale for RCTs and the Newcastle-Ottawa Scale for observational studies.

RESULTS

Fourteen studies were included, with a total of 1698 patients. Prolonged infusion of meropenem was associated with a significantly lower mortality rate compared to intermittent infusion (RR = 0.81, 95 % CI: 0.68-0.98). It also significantly improved clinical improvement rates (RR = 1.35, 95 % CI: 1.11-1.64) and microbial eradication rates (RR = 1.19, 95 % CI: 1.08-1.32). There were no statistically significant differences in ICU length of stay or hospital length of stay. Subgroup analyses showed that prolonged infusion was significantly associated with lower mortality and better clinical improvement rates in patients with an APACHE II score <20.

CONCLUSIONS

Prolonged infusion of meropenem is more effective than intermittent infusion in reducing mortality, improving clinical outcomes, and enhancing microbial eradication, without increasing adverse events. These benefits are particularly evident in patients with lower disease severity (APACHE II < 20), emphasizing the importance of patient stratification in optimizing treatment strategies.

REGISTRATION

This systematic review and meta-analysis is registered with PROSPERO (number: CRD42023445360).

Electrocardiographic Early Changes After Abdominoplasty

INTRODUCTION

Abdominoplasty aims to reduce the abdominal excess tissue and tighten the abdominal wall. The tightening of the abdominal wall has structural and habitual consequences on the body, which might have an early effect on electrocardiography (ECG) of the patients through volumetric and pressure changes in thoracic and abdominal cavities. ECG serves as a diagnostic tool for assessing cardiac electrical conductions in routine clinical practice. In this study, we aimed to examine whether abdominoplasty has any discernible effect on early ECG results, with the goal of assessing potential cardiological benefits for the patients undergoing this procedure by comparing pre- and early postoperative ECGs.

METHOD

Study population included 49 patients who had abdominoplasty. ECG records before the procedure and 12-24 h after the surgery were analyzed retrospectively. Patients had no known cardiac diseases and did not have any diagnosed arrhythmia.

RESULTS

The mean age of the study population was 37.1 ± 8.5. The mean body mass index of the study population was 26.4. The mean weight of total removed abdominal skin tissue was 1057 grams. There were significant changes in ECG of the patients postoperatively. Heart rate was increased, and significant change was found in QRS axis (p < 0.001) and T wave axis (p < 0.001). Atrial conduction parameters such as PR duration (p  < 0.001), Pmax duration (p  =  0.001) and P-wave dispersion (p = 0.003) were significantly changed postoperatively. Ventricular conduction parameters such as QRS duration (p = 0.029), QT interval (p   < 0.001), QTc (p  < 0.001), TPe duration (p < 0.001), TPe / QT (p < 0.001) and TPe / QTc (p < 0.001) ratios were found significantly changed.

CONCLUSION

Abdominoplasty changes the intra-abdominal pressure in the first 24 h after the surgery, which may impact cardiac conduction. The understanding and recognition of possible early ECG changes is crucial during postoperative follow-up of the patients who undergo abdominoplasty surgery.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Imaging of Acute Pulmonary Embolism: An Update

Imaging is essential in the evaluation and management of acute pulmonary embolism. Advances in multi-energy CT including dual-energy CT and photon-counting CT have allowed faster scans with lower radiation dose and optimal quality. Artificial intelligence has a potential role in triaging potentially positive examinations and could serve as a second reader.

Therapeutic Drug Monitoring of High-dose Sulbactam in Pediatric Patients: Preliminary Data From a Prospective Observational Pharmacokinetic Study

BACKGROUND

Rates of carbapenem-resistant Acinetobacter baumannii are rising in Thailand. Although high-dose (HD) sulbactam is recommended for treating carbapenem-resistant A. baumannii infections, data on plasma sulbactam concentrations in children are limited. We aimed to evaluate plasma sulbactam concentrations and pharmacokinetic-pharmacodynamic (PK-PD) target achievement in pediatric patients.

METHODS

Prospective study data (January-November 2023) on children (1 month-18 years) who received sulbactam every 6-8 hours were analyzed. Mid-dosing ( Cmid , 50% f T) and trough ( Ctrough , 100% f T) concentrations were evaluated. PK-PD target achievement [50% f T > minimum inhibitory concentration (MIC), 100% f T > MIC] was evaluated using Clinical and Laboratory Standards Institute 2024 MIC cutoffs and MIC data of isolates of Acinetobacter calcoaceticus-baumannii complex from this study.

RESULTS

Thirty-five patients (median age 50 months) were categorized into standard-dose (SD) or HD groups. The geometric mean Cmid was higher in the HD (41.3 mg/L) versus SD (19.5 mg/L) groups ( P = 0.006). Among 101 isolates of Acinetobacter calcoaceticus-baumannii complex, the MIC50 and MIC90 (concentrations that inhibit 50% and 90% of isolates of the A. calcoaceticus-baumannii complex) were 16 and 128 mg/L, respectively. The HD group achieved Cmid >MIC50 in 87.5% of the patients compared with 63.6% in SD ( P = 0.17). Within the HD group, patients with augmented renal clearance (ARC) had lower Cmid (geometric mean 31.9 mg/L) compared with non-ARC (geometric mean 63.4 mg/L) ( P = 0.04).

CONCLUSIONS

HD sulbactam resulted in higher Cmid and PK-PD achievement. ARC significantly compromised plasma sulbactam concentration. HD sulbactam may be preferable for treating critically ill pediatric patients and those with ARC, especially during the empirical period.

Cracking the Code of AKI: Evaluating the Predictive Power of VExUS Scoring in Critically Ill Noncardiac Patients

Background

Numerous signs of venous congestion exist, but each has limitations. Previous studies have shown the utility of venous excess ultrasound (VExUS) scoring in predicting acute kidney injury (AKI) in patients postcardiac surgery. This study aimed to evaluate whether serial VExUS scoring could predict AKI in intensive care unit (ICU) patients without cardiac conditions.

Materials and methods

This single-center observational study was conducted in the main ICU of PGIMER, Chandigarh, India. Thirty patients with an inferior vena cava (IVC) diameter of ≥2 cm and a normal biventricular function were included. Serial VExUS scoring was performed on admission and daily for up to six days or until AKI developed, whichever occurred first.

Results

Among 30 participants, 22 (73.3%) developed AKI. In the AKI group, mean VExUS scores were 1.95 on day 2, 1.92 on day 3, and 3.0 on day 5 (p = 0.001, 0.003, and 0.002, respectively). A significant positive correlation was observed between VExUS scores and fluid balance on day 2 (ρ = 0.375, p = 0.041) and day 3 (ρ = 0.579, p = 0.006). Multivariate analysis showed no correlation between the VExUS score on day 2 and fluid balance, duration of mechanical ventilation, or ICU length of stay. No association was found between VExUS scores and 30-day mortality.

Conclusion

In critically ill noncardiac patients, VExUS scores do not predict AKI onset. However, higher daily fluid balance may moderately correlate with VExUS scores.

How to cite this article

Khan WA, Saini V, Goel A, Valiyaparambath A. Cracking the Code of AKI: Evaluating the Predictive Power of VExUS Scoring in Critically Ill Noncardiac Patients. Indian J Crit Care Med 2025;29(3):236-243.

Pharmacokinetic and Pharmacodynamic Approaches to Optimize Antibiotic Use in Neonates

Newborn infants (particularly those born preterm) are frequently exposed to empiric antibiotics at birth, and antibiotics are among the most commonly prescribed medications in neonatal intensive care units. Challenges in optimizing neonatal antibiotic dosing include: technical and ethical barriers to neonatal pharmacoanalytic study design and sampling, difficulty in extrapolating adult and pediatric data due to unique neonatal physiology, and a lack of validated pharmacodynamic targets specific to neonatal populations. In this review, we summarize basic concepts in pharmacokinetics (PK) and pharmacodynamics (PD), describe pharmacometric strategies utilized in contemporary PK/PD analyses, and review the evolution of PK/PD data guiding neonatal dosing among 3 commonly used antibiotics.

Veno-arterial ECMO support for severe amlodipine toxicity combined with cardiogenic shock: A case report

INTRODUCTION

Management of severe circulatory collapse in the setting of amlodipine toxicity can be challenging. High doses of vasopressors and conventional therapies fail to improve hemodynamics, resulting in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to treat severe cardiogenic shock and peripheral vasodilatation. Therapeutic plasma exchange (TPE), which helps remove plasma protein-bound toxins and significantly reduces mortality, may be a useful adjunct to invasive hemodynamic support in severe cases of amlodipine poisoning.

CASE SUMMARY

A 32-year-old female with a history of intentional consumption of ninety 5-mg amlodipine tablets (totaling 450 mg) was admitted to our intensive care unit (ICU) after 3 h. Her amlodipine serum concentration was 147 ng/mL. She presented with cardiogenic shock and fatal vasoplegia and received VA-ECMO and TPE. The patient was weaned off ECMO after 4 days and discharged home on Day 10 of hospitalization.

CONCLUSION

Amlodipine toxicity can result in severe cardiac failure with circulatory collapse. We describe the case of a patient with cardiovascular collapse who successfully bridged to recovery from refractory shock secondary to severe amlodipine toxicity as a result of ECMO and TPE treatment.

Intraoperative and Postoperative Outcomes in Patients Undergoing Total Laparoscopic Hysterectomy for Benign Conditions With Drain Placement

INTRODUCTION

Hysterectomy is a common gynecological procedure, with laparoscopic techniques increasingly favored for their minimally invasive nature. The use of drains during total laparoscopic hysterectomy (TLH) remains controversial, with conflicting evidence regarding their efficacy and impact on outcomes.

MATERIALS AND METHODS

This retrospective study analyzed data from 415 patients who underwent TLH for benign indications at Istanbul Zeynep Kamil Women's and Children's Diseases Training and Research Hospital between 2020 and 2022. Patients were categorized into two groups based on drain application. Demographic and clinical data were collected, and perioperative and postoperative outcomes were compared between groups.

RESULTS

Of the 415 patients, 277 (66.7%) received drains during TLH. Analysis revealed that patients who received drains had significantly longer operation times, an increased length of hospital stay, higher complication rates, and a greater need for transfusion than those without drains. Although preoperative hemoglobin levels were similar between groups, postoperative levels were significantly lower in drain recipients. However, there was no significant difference in postoperative gas discharge rates between groups.

CONCLUSIONS

This study suggests drain application during TLH may predict bleeding complications and influence perioperative outcomes. Despite limitations, including their retrospective nature, the findings contribute to the ongoing debate surrounding drain use in TLH and provide valuable insights for clinical practice. Further prospective studies are warranted to validate these findings and guide evidence-based decision-making in gynecological surgery.

In-person, virtual visiting and telephone calls in Australia and New Zealand intensive care units: A point prevalence multicentre study mapping daytime and nighttime interactions

BACKGROUND

Family presence, in-person and via virtual visiting (video calls) and the telephone, is an integral part of patient- and family-centred critical care. Previous studies focussed on visiting policies and their effects. Data mapping the frequency and timing of these interactions are not available.

OBJECTIVES

The aims of this study were to describe the prevalence of in-person visiting and the use of telephone or video conferencing in Australia and New Zealand intensive care units (ICUs).

DESIGN

A point prevalence survey was conducted to map visiting policies, hourly family presence at the bedside, telephone or video calls, and reasons for each interaction.

SETTING

The research was conducted in a 24-h study period in October 2020, corresponding to the end of the 2nd COVID-19 pandemic wave in 40 Australia and New Zealand ICUs.

MEASUREMENTS AND MAIN RESULTS

At the time of survey, 77% of ICUs had restrictions to visiting, median (interquartile range [IQR]) time of 9 (2; 24) hours with permitted visiting per day, a mean of 8 hours less than before the COVID-19 pandemic. There were 532 patients, a median (IQR) of 13 (6; 25) patients per ICU. Two patients had COVID-19. Over 24 h, 65% of patients had at least one in-person visit, median (IQR) of 1 (0; 3) hours with visitors. Telephone calls were received for 52% patients, median (IQR) of 1 (0; 2) calls. Video calls were received for 6% of the patients. In-person visits peaked between 10:00 and 12:00, with a second smaller peak between 16:00 and 17:00. Visiting continued through the evening, and 2% of the patients had visitors overnight. Telephone calls peaked at 10:00, continued through the day and evening, with few calls received overnight. In-person visits were predominantly motivated by family interactions (81%) and telephone calls by clinical updates (51%) and family interactions (47%).

CONCLUSIONS

In a low COVID-19 prevalence period, Australia and New Zealand ICUs had partially reopened to visitors. Most visits happened during the day and evening but persisted overnight. ICU resourcing and visiting policies should take these data into account to facilitate family presence at the bedside, virtual visiting, and obtaining clinical updates via telephone.

Cystatin C-Guided Dosing Nomogram Improves Target Attainment for Cefepime in the Critically Ill

OBJECTIVES

Estimated glomerular filtration rate is more accurate with combined creatinine and cystatin C equations (eGFRcr-cys) than creatinine alone. This study created and evaluated a cefepime dosing nomogram based on eGFRcr-cys for initial dosing in the critically ill.

DESIGN

Pharmacokinetic modeling and simulation study.

SETTING

Academic medical center.

PATIENTS

Critically ill adults treated with cefepime.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from 120 patients with baseline cystatin C and follow-up cefepime levels were used to develop a nomogram based on eGFRcr-cys and weight for initial cefepime dosing. The predicted proportion of patients who achieved a free cefepime concentration above the minimum inhibitory concentration of the organism for 100% of the dosing interval in the first 24 hours (100% ƒT > MIC at 24 hr) was compared between administered doses and those predicted by the nomogram doses. Overall drug exposure was estimated with the free area under the concentration time curve from 0 to 24 hours (ƒAUC0-24) and compared between administered and nomogram doses. Achievement of 100% ƒT > MIC at 24 hours was predicted to be significantly better with the nomogram compared with the administered dose (76% vs. 38%; p < 0.001). The median ƒAUC0-24 as predicted by the nomogram (666 mg·hr/L) was slightly higher than the actual ƒAUC0-24 with administered doses (612 mg·hr/L; p = 0.01), but the nomogram led to fewer ƒAUC0-24 values which were either too high (> 900) or too low (< 300) (7% vs. 20%; p = 0.004).

CONCLUSIONS

Use of a cystatin C-inclusive dosing nomogram for cefepime could improve target attainment without increasing the risk of potentially toxic levels in the critically ill.

Effect of hypoalbuminemia on drug pharmacokinetics

Hypoalbuminemia, defined as serum albumin levels below 35 g/L, is common in patients with conditions such as nephrotic syndrome, cirrhosis, or sepsis. This review examines the impact of hypoalbuminemia on the pharmacokinetics of selected drugs-such as antibiotics, immunosuppressants, antifungals, or anticonvulsants-emphasizing its role in drug efficacy and safety. Albumin is the main drug transporter and key binding protein, which influences the free drug concentration and drug activity. The review includes all studies available in the scientific literature found in the PubMed, Scopus, and Cochrane databases. The paper emphasizes the importance of therapeutic drug monitoring (TDM) in patients with hypoalbuminemia to avoid subtherapeutic or toxic drug levels. Many drugs need for dose adjustments to achieve therapeutic levels, especially in critically ill patients. The results of studies emphasize the need for individualized dosing regimens based on TDM to optimize drug therapy in patients with hypoalbuminemia. Our review is the first article to summarize the influence of hypoalbuminemia on the pharmacokinetic parameters of drugs and may be a useful tool for clinicians in their daily work.

Navigating pharmacokinetic and pharmacodynamics challenges of β-lactam antibiotics in patients with low body weight: efficacy, toxicity, and dosage optimization

Background

Patients with low body weight (LBW) often exhibit altered pharmacokinetics (PK) in renal clearance and total body water. These changes complicate β-lactam antibiotic dosing, potentially resulting in suboptimal efficacy or increased toxicity.

Objectives

To evaluate the attainment of PK/pharmacodynamic (PD) targets, the prevalence of subtherapeutic and supratherapeutic concentrations, and the incidence of neurotoxicity among LBW patients treated with piperacillin/tazobactam (TZP), cefepime (FEP), and meropenem (MEM).

Design

A prospective observational study conducted at a tertiary hospital from January 2020 to December 2022.

Methods

Adult patients with a body mass index ⩽18.5 kg/m2 who received TZP, FEP, or MEM were included. Trough serum concentrations were analyzed for PK/PD targets: 100% time above minimum inhibitory concentration (100% fT > MIC) and 100% time above four times MIC (100% fT > 4MIC). Neurotoxicity was assessed using standardized criteria. Statistical analyses identified factors associated with concentration variability and adverse outcomes.

Results

Seventy-two patients were included: 29 received TZP, 23 FEP, and 20 MEM. Achievement of the 100% fT > MIC target was comparable across all antibiotics (~70%), but 100% fT > 4 MIC attainment was significantly higher for FEP (47.8%) than for TZP (10.3%) and MEM (30%) (p = 0.01). Supratherapeutic concentrations were observed in 34.8% of FEP users compared to 3.4% and 5% for TZP and MEM, respectively (p = 0.002). Neurotoxicity occurred in 13% of FEP patients but was not reported in TZP or MEM groups (p = 0.04). Subtherapeutic concentrations were noted in approximately 30% of patients across all groups.

Conclusion

PK changes complicate β-lactam antibiotic dosing, resulting in frequent failure to achieve PK/PD targets. FEP demonstrated a particularly high risk of supratherapeutic concentrations and neurotoxicity. Therapeutic drug monitoring is crucial to optimize dosing and improve safety in this population.

Population Pharmacokinetics-Based Evaluation of Ceftazidime-Avibactam Dosing Regimens in Critically and Non-Critically Ill Patients With Carbapenem-Resistant Klebsiella pneumoniae

Purpose

This study aimed to describe the population pharmacokinetics (PopPK) of ceftazidime-avibactam (CAZ-AVI) in adult patients, and to develop optimal dosing regimens for both non-critically ill and critically ill patients by combining different pharmacokinetic/pharmacodynamic (PK/PD) targets.

Patients and Methods

A prospective, single-center study involving patients who were infected with CRKP and received CAZ-AVI therapy was conducted. Nonlinear mixed-effect modeling was used to develop a PopPK model. The optimal dosing regimen was assessed using Monte Carlo simulation.

Results

The PopPK analysis of CAZ-AVI included 91 steady-state concentrations from 45 adult patients. The data were modeled using a one-compartment model. The typical population values of CAZ and AVI clearances were 2.96 L/h and 3.09 L/h, and the volumes of distribution were 17.76 L and 18.25 L, respectively. Our study showed that creatinine clearance (CrCL) calculated using the Cockcroft-Gault equation significantly affected the pharmacokinetics of CAZ-AVI. The Monte Carlo simulation optimized the dosing regimen for both non-critically ill and critically ill patients with varying renal functions, providing detailed supplements to the instructions.

Conclusion

Our study established a PopPK model for CAZ-AVI and proposed a reference for dosing regimen adjustment based on the severity of the disease and renal functional status.

Virtual reality cricothyrotomy - a tool in medical emergency education throughout various disciplines

OBJECTIVES

A cricothyrotomy represents an emergency procedure that may be considered a last option for securing the airway. While fortunately rare, it is important to note that such invasive procedures must be mastered if they are to be used. Therefore, regular training is essential to gain routine. The aim of the present study was to investigate whether professional groups with different levels of experience with the procedure succeed in learning the procedure with a virtual reality trainer.

MATERIALS AND METHODS

In a multicenter approach, 146 employees with four different professional backgrounds-otorhinolaryngologists, anesthesiologists, emergency physicians and certified nurses-were included in the study. The participants were required to complete a virtual reality (VR) cricothyrotomy scenario in three consecutive runs, and the time required and errors in the procedure were recorded. The training experience was subsequently evaluated subjectively using a questionnaire.

RESULTS

The study included 146 participants with an average age of 33 years and an average of 5 years of professional experience. The majority of participants (74%) reported an improvement in the speed of the procedure and in the procedural steps (87%). These subjective improvements were confirmed objectively by the time required for completion of the procedure and the points achieved. Gaming experience had a significant effect on both the score (p = 0.023) and procedure time (p = 0.039), whereas age and medical specialization did not. Real-life experience with cricothyrotomy had no significant effect on performance in VR.

CONCLUSION

Virtual reality provides an effective method for training healthcare professionals in cricothyrotomy, regardless of their specialty or prior experience. The participants showed significant improvements in both the speed and accuracy of the procedure after training, regardless of their prior experience or medical background. Further research is necessary to assess the benefits of VR simulation for training cricothyrotomy in real-world procedures.

TRIAL REGISTRATION

DRKS00031736, registered on the 20th of April 2023.

Population Pharmacokinetics of Prolonged Infusion for Meropenem: Tailoring Dosing Recommendations for Chinese Critically Ill Patients on Continuous Renal Replacement Therapy with Consideration for Renal Function

Objective

Extended meropenem infusion is increasingly employed to enhance clinical outcomes in critically ill patients. Nonetheless, investigations into such dosing regimens in renal-impaired patients undergoing continuous renal replacement therapy (CRRT) are scarce. This study aims to perform a population pharmacokinetic (PK) analysis of prolonged meropenem infusion in critically ill CRRT patients to inform optimal dosing regimens.

Methods

Ninety-four concentrations from 21 Chinese critically ill CRRT patients receiving 1 g meropenem every 8-12 hours infused over 2-3 hours were utilized to construct the population PK model. Monte Carlo simulations were employed to assess the efficacy based on PK/PD targets (100% fT>MIC or 100% fT>4×MIC) and the risk of nephrotoxicity (trough concentration ≥45 mg/L) for extended meropenem dosing regimens (0.5-2 g with a 3-hour infusion administered every 6-12 hours).

Results

Meropenem concentration data was adequately described by a one-compartment model with linear elimination, and creatinine clearance (CLCR) significantly influenced meropenem's endogenous clearance. 0.5 g q6h and 1 g q8h could achieve desirable attainment of 100% fT>MIC target against an MIC≤4 mg/L, with negligible risk of toxicity for CRRT patients across a CLCR range of 10-50 mL/min. 2 g q6h and 2 g q8h is required for targeting 100% fT>4×MIC for the patients, but the associated risk of toxicity is very high (>20%).

Conclusion

A population PK model was developed for prolonged meropenem infusion in Chinese CRRT patients, and 0.5 g q6h and 1 g q8h may be the optimal regimen for prolonged infusion.

Interprofessional Therapeutic Drug Monitoring of Piperacillin/Tazobactam Enhances Care for Patients with Acute-on-Chronic Liver Failure in the ICU: A Retrospective Observational Pilot Study

Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing syndrome in patients with liver cirrhosis, often triggered by bacterial infections. Piperacillin/Tazobactam is a key antibiotic in this setting, and therapeutic drug monitoring (TDM) helps optimize its dosing. This study evaluates the impact of an interprofessional TDM strategy for Piperacillin/Tazobactam in ACLF patients in the ICU. Methods: This retrospective ICU study evaluated an interprofessional TDM approach for optimizing Piperacillin/Tazobactam dosing in critically ill ACLF patients. The team, consisting of physicians, clinical pharmacists, and staff nurses, engaged in shared decision making, collaboratively interpreting TDM results and adjusting the dosing accordingly. This study included 26 patients with ACLF who underwent initial TDM and 7 who received follow-up TDM. Piperacillin/Tazobactam dosing was modified based on TDM recommendations, with serum concentrations measured weekly. Adherence to and the implementation of interprofessional dosing recommendations were systematically analyzed to assess the impact of this approach. Results: The initial TDM showed that 30.8% of patients had Piperacillin/Tazobactam levels within the target range, while 53.8% were above and 15.4% below. The interprofessional team recommended dose reductions in seven patients, increases in three, and no change in eleven, with five requiring antibiotic modifications. At the first follow-up TDM, 20.0% reached target levels, while 80.0% remained above, with no subtherapeutic cases. The team recommended one further dose reduction and maintained dosing in four patients. All recommendations were fully implemented, demonstrating strong adherence to the collaborative protocol. Conclusions: The interprofessional TDM strategy optimized Piperacillin/Tazobactam dosing in ACLF patients with full adherence to the recommendations. This collaborative approach improves outcomes and supports global efforts to curb antibiotic resistance.

Population pharmacokinetics of piperacillin-tazobactam in the plasma and cerebrospinal fluid of critically ill patients

Ventriculitis in neurocritical care patients leads to significant morbidity and mortality. Antibiotic dose optimization targeting pharmacokinetic/pharmacodynamic (PK/PD) exposures associated with improved bacterial killing may improve therapeutic outcomes. We sought to develop and apply a population PK model in infected critically ill patients to determine optimal piperacillin-tazobactam (PTZ) dosing regimens to achieve target cerebrospinal fluid (CSF) exposures. Neurosurgical patients with external ventricular drains and receiving PTZ treatment were recruited and had plasma and CSF samples collected and assayed. A population PK model was developed using plasma and CSF piperacillin and tazobactam concentrations. Eight patients were recruited. Median age was 59 years, median weight was 70 kg, and five patients were female. The median creatinine clearance was 84 mL/min/1.73 m2 (range 52-163). Substantial inter-individual PK variability was apparent, particularly in CSF. Piperacillin penetration into CSF had a median of 3.73% (range 0.73%-7.66%), and tazobactam CSF penetration was not predictable. Dosing recommendations to optimize CSF exposures for the treatment of ventriculitis were not possible due to substantial PK variability and very low drug penetration. High plasma PTZ exposures may not translate to effective exposures in CSF.