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Boidin C, Moshiri P, Dahyot-Fizelier C, Goutelle S, Lefeuvre S. Pharmacokinetic variability of beta-lactams in critically ill patients: A narrative review. Anaesth Crit Care Pain Med 2019; 39:87-109. [PMID: 31513935 DOI: 10.1016/j.accpm.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/05/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022]
Abstract
The use of antibacterial drugs is very common in critically ill patients and beta-lactam agents are widely used in this context. Critically ill patients show several characteristics (e.g., sepsis, renal impairment or conversely augmented renal clearance, renal replacement therapy) that may alter beta-lactam pharmacokinetics (PK) in comparison with non-critically ill patients. This narrative literature review aims to identify recent studies quantifying the variability of beta-lactams volume of distribution and clearance and to determine its main determinants. Seventy studies published between 2000 and 2018 were retained. Data on volume of distribution and clearance variability were reported for 5 penicillins, 3 beta-lactamase inhibitors, 6 cephalosporins and 4 carbapenems. Data confirm specific changes in PK parameters and important variability of beta-lactam PK in critically ill patients. Renal function, body weight and use of renal replacement therapy are the principal factors influencing PK parameters described in this population. Few studies have directly compared beta-lactam PK in critically ill versus non-critically ill patients. Conclusions are also limited by small study size and sparse PK data in several studies. These results suggest approaches to assess this PK variability in clinical practice. Beta-lactam therapeutic drug monitoring seems to be the best way to deal with this issue.
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Affiliation(s)
- Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France.
| | - Parastou Moshiri
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Service d'Anesthésie-Réanimation, 2, rue de la Milétrie, 86021 Poitiers, France; Université de Poitiers, UMR 1070, 6, rue de la Milétrie, 86073 Poitiers, France.
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France; Univ Lyon, Université Claude Bernard Lyon 1, ISPB - Faculté de Pharmacie de Lyon, 8, avenue Rockefeller, 69008 Lyon, France.
| | - Sandrine Lefeuvre
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
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Nowak H, Weidemann C, Martini S, Oesterreicher ZA, Dorn C, Adamzik M, Kees F, Zeitlinger M, Rahmel T. Repeated determination of moxifloxacin concentrations in interstitial space fluid of muscle and subcutis in septic patients. J Antimicrob Chemother 2019; 74:2681-2689. [PMID: 31299075 DOI: 10.1093/jac/dkz259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/07/2019] [Accepted: 05/22/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For an effective antimicrobial treatment, it is crucial that antibiotics reach sufficient concentrations in plasma and tissue. Currently no data exist regarding moxifloxacin plasma concentrations and exposure levels in tissue under septic conditions. OBJECTIVES To determine the pharmacokinetics of moxifloxacin in plasma and interstitial space fluid over a prolonged period. PATIENTS AND METHODS Ten septic patients were treated with 400 mg of moxifloxacin once a day; on days 1, 3 and 5 of treatment plasma sampling and microdialysis in the subcutis and muscle of the upper thigh were performed to determine concentrations of moxifloxacin in different compartments. This trial was registered in the German Clinical Trials Register (DRKS, register number DRKS00012985). RESULTS Mean unbound fraction of moxifloxacin in plasma was 85.5±3.4%. On day 1, Cmax in subcutis and muscle was 2.8±1.8 and 2.5±1.3 mg/L, respectively, AUC was 24.8±15.1 and 21.3±10.5 mg·h/L, respectively, and fAUC0-24/MIC was 100.9±62.9 and 86.5±38.3 h, respectively. Cmax for unbound moxifloxacin in plasma was 3.5±0.9 mg/L, AUC was 23.5±7.5 mg·h/L and fAUC0-24/MIC was 91.6±24.8 h. Key pharmacokinetic parameters on days 3 and 5 showed no significant differences. Clearance was higher than in healthy adults, but tissue concentrations were comparable, most likely due to a lower protein binding. CONCLUSIONS Surprisingly, the first dose already achieved exposure comparable to steady-state conditions. The approved daily dose of 400 mg was adequate in our patient population. Thus, it seems that in septic patients a loading dose on the first day of treatment with moxifloxacin is not required.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Caroline Weidemann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Stefan Martini
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Zoe Anne Oesterreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Michael Adamzik
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
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High-Dose Ceftriaxone for Bacterial Meningitis and Optimization of Administration Scheme Based on Nomogram. Antimicrob Agents Chemother 2019; 63:AAC.00634-19. [PMID: 31235630 DOI: 10.1128/aac.00634-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/20/2019] [Indexed: 11/20/2022] Open
Abstract
High dosages of ceftriaxone are used to treat central nervous system (CNS) infections. Dosage adaptation according to the glomerular filtration rate is currently not recommended. Ceftriaxone pharmacokinetics (PK) was investigated by a population approach in patients enrolled in a French multicenter prospective cohort study who received high-dose ceftriaxone for CNS infection as recommended by French guidelines (75 to 100 mg/kg of body weight/day without an upper limit). Only those with suspected bacterial meningitis were included in the PK analysis. A population model was developed using Pmetrics. Based on this model, a dosing nomogram was developed, using the estimated glomerular filtration rate (eGFR) and total body weight as covariates to determine the optimal dosage allowing achievement of targeted plasma trough concentrations. Efficacy and toxicity endpoints were based on previous reports, as follows: total plasma ceftriaxone concentrations of ≥20 mg/liter in >90% of patients for efficacy and ≤100 mg/liter in >90% of patients for toxicity. Based on 153 included patients, a two-compartment model including eGFR and total body weight as covariates was developed. The median value of the unbound fraction was 7.57%, and the median value of the cerebral spinal fluid (CSF)/plasma ratio was 14.39%. A nomogram was developed according to a twice-daily regimen. High-dose ceftriaxone administration schemes, used to treat meningitis, should be adapted to the eGFR and weight, especially to avoid underdosing using current guidelines. (This study has been registered at ClinicalTrials.gov under identifier NCT01745679.).
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Ebisch RMF, Meenks SD, Foudraine N, Janssen PKC, le Noble JLML. Ceftriaxone Dosing in a Critically Ill Patient With Hypoalbuminemia During Continuous Venous Hemofiltration: Emphasis on Unbound Pharmacokinetics. J Clin Pharmacol 2019; 60:140-142. [PMID: 31407809 DOI: 10.1002/jcph.1503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/16/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Renée M F Ebisch
- Department of Intensive Care, VieCuri Medical Center Venlo, Venlo, the Netherlands
| | - Sjoerd D Meenks
- Department of Hospital Pharmacy, VieCuri Medical Center Venlo, Venlo, the Netherlands.,Department of Clinical Pharmacy and Toxicology, CAPHRI School of Public Health and Primary Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Norbert Foudraine
- Department of Intensive Care, VieCuri Medical Center Venlo, Venlo, the Netherlands
| | - Paddy K C Janssen
- Department of Hospital Pharmacy, VieCuri Medical Center Venlo, Venlo, the Netherlands.,Department of Clinical Pharmacy and Toxicology, CAPHRI School of Public Health and Primary Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jos L M L le Noble
- Department of Intensive Care, VieCuri Medical Center Venlo, Venlo, the Netherlands.,Department of Pharmacology and Toxicology, Maastricht University, Maastricht, the Netherlands
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Strein M, Holton-Burke JP, Smith LR, Brophy GM. Prevention, Treatment, and Monitoring of Seizures in the Intensive Care Unit. J Clin Med 2019; 8:E1177. [PMID: 31394791 PMCID: PMC6722541 DOI: 10.3390/jcm8081177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/25/2022] Open
Abstract
The diagnosis and management of seizures in the critically ill patient can sometimes present a unique challenge for practitioners due to lack of exposure and complex patient comorbidities. The reported incidence varies between 8% and 34% of critically ill patients, with many patients often showing no overt clinical signs of seizures. Outcomes in patients with unidentified seizure activity tend to be poor, and mortality significantly increases in those who have seizure activity longer than 30 min. Prompt diagnosis and provision of medical therapy are crucial in order to attain successful seizure termination and prevent poor outcomes. In this article, we review the epidemiology and pathophysiology of seizures in the critically ill, various seizure monitoring modalities, and recommended medical therapy.
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Affiliation(s)
- Micheal Strein
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA
| | - John P Holton-Burke
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - LaTangela R Smith
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA.
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Guilhaumou R, Benaboud S, Bennis Y, Dahyot-Fizelier C, Dailly E, Gandia P, Goutelle S, Lefeuvre S, Mongardon N, Roger C, Scala-Bertola J, Lemaitre F, Garnier M. Optimization of the treatment with beta-lactam antibiotics in critically ill patients-guidelines from the French Society of Pharmacology and Therapeutics (Société Française de Pharmacologie et Thérapeutique-SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation-SFAR). Crit Care 2019; 23:104. [PMID: 30925922 PMCID: PMC6441232 DOI: 10.1186/s13054-019-2378-9] [Citation(s) in RCA: 302] [Impact Index Per Article: 60.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/26/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Beta-lactam antibiotics (βLA) are the most commonly used antibiotics in the intensive care unit (ICU). ICU patients present many pathophysiological features that cause pharmacokinetic (PK) and pharmacodynamic (PD) specificities, leading to the risk of underdosage. The French Society of Pharmacology and Therapeutics (SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (SFAR) have joined forces to provide guidelines on the optimization of beta-lactam treatment in ICU patients. METHODS A consensus committee of 18 experts from the two societies had the mission of producing these guidelines. The entire process was conducted independently of any industry funding. A list of questions formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes) was drawn-up by the experts. Then, two bibliographic experts analysed the literature published since January 2000 using predefined keywords according to PRISMA recommendations. The quality of the data identified from the literature was assessed using the GRADE® methodology. Due to the lack of powerful studies having used mortality as main judgement criteria, it was decided, before drafting the recommendations, to formulate only "optional" recommendations. RESULTS After two rounds of rating and one amendment, a strong agreement was reached by the SFPT-SFAR guideline panel for 21 optional recommendations and a recapitulative algorithm for care covering four areas: (i) pharmacokinetic variability, (ii) PK-PD relationship, (iii) administration modalities, and (iv) therapeutic drug monitoring (TDM). The most important recommendations regarding βLA administration in ICU patients concerned (i) the consideration of the many sources of PK variability in this population; (ii) the definition of free plasma concentration between four and eight times the Minimal Inhibitory Concentration (MIC) of the causative bacteria for 100% of the dosing interval as PK-PD target to maximize bacteriological and clinical responses; (iii) the use of continuous or prolonged administration of βLA in the most severe patients, in case of high MIC bacteria and in case of lower respiratory tract infection to improve clinical cure; and (iv) the use of TDM to improve PK-PD target achievement. CONCLUSIONS The experts strongly suggest the use of personalized dosing, continuous or prolonged infusion and therapeutic drug monitoring when administering βLA in critically ill patients.
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Affiliation(s)
- Romain Guilhaumou
- AP-HM Hôpital de la Timone, Service de Pharmacologie Clinique et Pharmacovigilance, 264 rue Saint Pierre, 13005 Marseille, France
| | - Sihem Benaboud
- AP-HP Hôpital Cochin, Service de Pharmacologie, 27 rue du Faubourg St-Jacques, 75679 Paris Cedex 14, France
| | - Youssef Bennis
- CHU d’Amiens Picardie, Service de Pharmacologie Clinique, UPJV EA7517, Avenue Laennec, 80054 Amiens Cedex 1, France
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Département d’Anesthésie Réanimation, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Eric Dailly
- CHU de Nantes, Département de Pharmacologie Clinique, 5 allée de l’île gloriette, 44093 Nantes Cedex 01, France
| | - Peggy Gandia
- CHU de Toulouse, Laboratoire de Pharmacocinétique et Toxicologie Clinique, Institut Fédératif de Biologie, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France
| | - Sylvain Goutelle
- CHU de Lyon, Service de Pharmacie, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69322 Lyon cedex 05, France
| | - Sandrine Lefeuvre
- CHR d’Orléans, Laboratoire de Biochimie, 14 Avenue de l’Hôpital, 45067 Orléans, France
| | - Nicolas Mongardon
- AP-HP Hôpital Henri Mondor, Département d’Anesthésie-Réanimation, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Claire Roger
- CHU de Nîmes, Département d’anesthésie, réanimation, douleur et médicine d’urgence, Place du Pr Robert Debré, 30029 Nîmes cedex 9, France
| | - Julien Scala-Bertola
- CHRU de Nancy, Département de pharmacologie clinique et de toxicologie, 29 rue Lionnois, 54000 Nancy, France
| | - Florian Lemaitre
- CHU Pontchaillou, Service de Pharmacologie Clinique et épidémiologique, 2 Rue Henri le Guilloux, 35000 Rennes, France
| | - Marc Garnier
- AP-HP Hôpital Tenon, Département d’Anesthésie et Réanimation, 4 rue de la Chine, 75020 Paris, France
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Aslanli A, Lyagin I, Efremenko E. Novel approach to quorum quenching: rational design of antibacterials in combination with hexahistidine-tagged organophosphorus hydrolase. Biol Chem 2019; 399:869-879. [PMID: 29870390 DOI: 10.1515/hsz-2018-0162] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/02/2018] [Indexed: 11/15/2022]
Abstract
N-acyl homoserine lactones (AHLs) are quorum sensing (QS) signal molecules used by most Gram-negative pathogenic bacteria. In this article the lactonase activity of the preparations based on hexahistidine-tagged organophosphorus hydrolase (His6-OPH) towards AHLs was studied. Initially, three of the most interesting β-lactam antibiotics were selected from seven that were trialed during molecular docking to His6-OPH. Combinations of antibiotics (meropenem, imipenem, ceftriaxone) and His6-OPH taken in the native form or in the form of non-covalent enzyme-polyelectrolyte complexes (EPCs) with poly(glutamic acid) or poly(aspartic acid) were obtained and investigated. The lactonase activity of the preparations was investigated under different physical-chemical conditions in the hydrolysis of AHLs [N-butyryl-D,L-homoserine lactone, N-(3-oxooctanoyl)-D,L-homoserine lactone, N-(3-oxododecanoyl)-L-homoserine lactone]. An increased efficiency of catalytic action and stability of the lactonase activity of His6-OPH was shown for its complexes with antibiotics and was confirmed in trials with bacterial strains. The broadening of the catalytic action of the enzyme against AHLs was revealed in the presence of the meropenem. Results of molecular docking of AHLs to the surface of the His6-OPH dimer in the presence of antibiotics allowed proposing the mechanism of such interference based on a steric repulsion of the carbon chain of hydrolyzed AHLs by the antibiotics bounded to the enzyme surface.
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Affiliation(s)
- Aysel Aslanli
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow 119991, Russia
| | - Ilya Lyagin
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow 119991, Russia
| | - Elena Efremenko
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow 119991, Russia
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Ollivier J, Carrié C, d'Houdain N, Djabarouti S, Petit L, Xuereb F, Legeron R, Biais M, Breilh D. Are Standard Dosing Regimens of Ceftriaxone Adapted for Critically Ill Patients with Augmented Creatinine Clearance? Antimicrob Agents Chemother 2019; 63:e02134-18. [PMID: 30602511 PMCID: PMC6395919 DOI: 10.1128/aac.02134-18] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/11/2018] [Indexed: 01/21/2023] Open
Abstract
The objective of the present study was to determine whether augmented renal clearance (ARC) impacts negatively on ceftriaxone pharmacokinetic (PK)/pharmacodynamic (PD) target attainment in critically ill patients. Over a 9-month period, all critically ill patients treated with ceftriaxone were eligible. During the first 3 days of antimicrobial therapy, every patient underwent 24-h creatinine clearance (CLCR) measurements and therapeutic drug monitoring of unbound ceftriaxone. ARC was defined by a CLCR of ≥150 ml/min. Empirical underdosing was defined by a trough unbound ceftriaxone concentration under 2 mg/liter (percentage of the time that the concentration of the free fraction of drug remained greater than the MIC [fT>MIC], 100%). Monte Carlo simulation (MCS) was performed to determine the probability of target attainment (PTA) of different dosing regimens for various MICs and three groups of CLCR (<150, 150 to 200, and >200 ml/min). Twenty-one patients were included. The rate of empirical ceftriaxone underdosing was 62% (39/63). A CLCR of ≥150 ml/min was associated with empirical target underdosing with an odds ratio (OR) of 8.8 (95% confidence interval [CI] = 2.5 to 30.7; P < 0.01). Ceftriaxone PK concentrations were best described by a two-compartment model. CLCR was associated with unbound ceftriaxone clearance (P = 0.02). In the MCS, the proportion of patients who would have failed to achieve a 100% fT>MIC was significantly higher in ARC patients for each dosage regimen (OR = 2.96; 95% CI = 2.74 to 3.19; P < 0.01). A dose of 2 g twice a day was best suited to achieve a 100% fT>MIC When targeting a 100% fT>MIC for the less susceptible pathogens, patients with a CLCR of ≥150 ml/min remained at risk of empirical ceftriaxone underdosing. These data emphasize the need for therapeutic drug monitoring in ARC patients.
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Affiliation(s)
- Julien Ollivier
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
| | - Cédric Carrié
- Anesthesiology and Critical Care Department, CHU Bordeaux, Bordeaux, France
| | - Nicolas d'Houdain
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
| | - Sarah Djabarouti
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
- Pharmacokinetics and PK/PD Group, INSERM 1034, Université Bordeaux, Bordeaux, France
| | - Laurent Petit
- Anesthesiology and Critical Care Department, CHU Bordeaux, Bordeaux, France
| | - Fabien Xuereb
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
- Pharmacokinetics and PK/PD Group, INSERM 1034, Université Bordeaux, Bordeaux, France
- Université Bordeaux Segalen, Bordeaux, France
| | - Rachel Legeron
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
- Pharmacokinetics and PK/PD Group, INSERM 1034, Université Bordeaux, Bordeaux, France
- Université Bordeaux Segalen, Bordeaux, France
| | - Matthieu Biais
- Anesthesiology and Critical Care Department, CHU Bordeaux, Bordeaux, France
- Université Bordeaux Segalen, Bordeaux, France
| | - Dominique Breilh
- Pharmacy and Clinical Pharmacy Department, CHU Bordeaux, Bordeaux, France
- Pharmacokinetics and PK/PD Group, INSERM 1034, Université Bordeaux, Bordeaux, France
- Université Bordeaux Segalen, Bordeaux, France
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Effects of Plasma Albumin on the Pharmacokinetics of Esomeprazole in ICU Patients. BIOMED RESEARCH INTERNATIONAL 2019; 2018:6374374. [PMID: 30643812 PMCID: PMC6311297 DOI: 10.1155/2018/6374374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/28/2018] [Accepted: 11/26/2018] [Indexed: 11/18/2022]
Abstract
Objectives To evaluate the effects of plasma albumin on pharmacokinetics of esomeprazole in ICU patients. Methods This study was performed in 32 consecutive intensive care unit (ICU) patients. They were divided into two groups according to the plasma albumin levels. Nineteen patients with low plasma albumin levels (<30 g/L; male/female, 12/7) were assigned to low plasma albumin group (LPAG). Thirteen patients with plasma albumin levels >30 g/L (male/female, 9/4) were assigned to high plasma albumin group (HPAG). All patients were received intravenous (IV) of 40 mg esomeprazole in 5 min. Blood samples were collected via basilic vein at different time points and concentrations of esomeprazole were determined by UPLC-MS/MS. Results MRT(0-∞), t1/2, V, CL, and Cmax between two groups were significantly difference (P<0.05). Compared with HPAG, MRT(0-∞), t1/2, and V of esomeprazole in LPAG were increased by 1.42-fold, 1.49-fold, and 1.24-fold, respectively; the maximum drug concentration of esomeprazole in LPAG was decreased to 82.5%. AUC(0-∞) of LPAG was 1.23 times than that of group B. CL in LPAG was 80% of HPAG. There was no statistical difference between the two groups of AUC(0-∞) and CL. Conclusions Some pharmacokinetic parameters of esomeprazole may be changed in ICU patients with low plasma albumin.
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60
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Standing JF, Ongas MO, Ogwang C, Kagwanja N, Murunga S, Mwaringa S, Ali R, Mturi N, Timbwa M, Manyasi C, Mwalekwa L, Bandika VL, Ogutu B, Waichungo J, Kipper K, Berkley JA. Dosing of Ceftriaxone and Metronidazole for Children With Severe Acute Malnutrition. Clin Pharmacol Ther 2018; 104:1165-1174. [PMID: 29574688 PMCID: PMC6282491 DOI: 10.1002/cpt.1078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/15/2018] [Accepted: 03/18/2018] [Indexed: 12/12/2022]
Abstract
Infants and young children with severe acute malnutrition (SAM) are treated with empiric broad-spectrum antimicrobials. Parenteral ceftriaxone is currently a second-line agent for invasive infection. Oral metronidazole principally targets small intestinal bacterial overgrowth. Children with SAM may have altered drug absorption, distribution, metabolism, and elimination. Population pharmacokinetics of ceftriaxone and metronidazole were studied, with the aim of recommending optimal dosing. Eighty-one patients with SAM (aged 2-45 months) provided 234 postdose pharmacokinetic samples for total ceftriaxone, metronidazole, and hydroxymetronidazole. Ceftriaxone protein binding was also measured in 190 of these samples. A three-compartment model adequately described free ceftriaxone, with a Michaelis-Menten model for concentration and albumin-dependent protein binding. A one-compartment model was used for both metronidazole and hydroxymetronidazole, with only 1% of hydroxymetronidazole predicted to be formed during first-pass. Simulations showed 80 mg/kg once daily of ceftriaxone and 12.5 mg/kg twice daily of metronidazole were sufficient to reach therapeutic targets.
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Affiliation(s)
- Joseph F. Standing
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and Immunity, St. George's, University of LondonLondonUK
| | - Martin O. Ongas
- Center for Research in Therapeutic SciencesStrathmore UniversityNairobiKenya
- KEMRI‐Centre for Clinical ResearchNairobiKenya
| | | | | | | | | | - Rehema Ali
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Neema Mturi
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Moline Timbwa
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Mbagathi County HospitalNairobiKenya
| | - Christine Manyasi
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Mbagathi County HospitalNairobiKenya
| | - Laura Mwalekwa
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Coast General HospitalMombasaKenya
| | | | - Bernhards Ogutu
- Center for Research in Therapeutic SciencesStrathmore UniversityNairobiKenya
- KEMRI‐Centre for Clinical ResearchNairobiKenya
| | | | - Karin Kipper
- Analytical Services International, St George's University of LondonLondonUK
- Institute of ChemistryUniversity of TartuTartuEstonia
| | - James A. Berkley
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of MedicineUniversity of OxfordOxfordUK
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Olbrisch K, Kisch T, Thern J, Kramme E, Rupp J, Graf T, Wicha SG, Mailänder P, Raasch W. After standard dosage of piperacillin plasma concentrations of drug are subtherapeutic in burn patients. Naunyn Schmiedebergs Arch Pharmacol 2018; 392:229-241. [PMID: 30368548 DOI: 10.1007/s00210-018-1573-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/19/2018] [Indexed: 12/21/2022]
Abstract
Infections are a major problem in patients with burn diseases. Mortality is high despite antibiotic therapy as studies are controversial concerning drug underdosing. The aims of this prospective, observational study were to monitor plasma concentrations of piperacillin during standard piperacillin/tazobactam treatment in 20 burn patients and 16 controls from the intensive care unit (ICU) and to optimize doses by in silico analyses. Piperacillin/tazobactam (4/0.5 g, tid) was administered over 0.5 h. Blood samples were taken at 1, 4, and 7.5 h after the end of the infusion. Free piperacillin plasma concentrations were determined. Pharmacokinetic parameters and in silico analysis results were calculated using the freeware TDMx. The primary target was defined as percentage of the day (fT>1xMIC; fT>4xMIC) when piperacillin concentrations exceeded 1xMIC/4xMIC (minimum inhibitory concentration), considering a MIC breakpoint of 16 mg/L for Pseudomonas aeruginosa. In an off-label approach, two burn patients were treated with 8/1 g piperacillin/tazobactam, 3 h qid. fT>1xMIC (55 ± 22% vs. 77 ± 24%) and fT>4xMIC (17 ± 11% vs. 30 ± 11%) were lower in burn than in ICU patients after 4/0.5 g, 0.5 h, tid. In silico analyses indicated that fT>1xMIC (93 ± 12% burn, 97 ± 4% ICU) and fT>4xMIC (62 ± 23% burn, 84 ± 19% ICU) values increase by raising the piperacillin dosage to 8/1 g qid and prolonging the infusion time to 3 h. Off-label treatment results were similar to in silico data for burn patients (84%fT>1xMIC and 47%fT>4xMIC). Standard dosage regimens for piperacillin/tazobactam resulted in subtherapeutic piperacillin concentrations in burn and ICU patients. Dose adjustments via in silico analyses can help to optimize antibiotic therapy and to predict respective concentrations in vivo. Trial registration: NCT03335137, registered 07.11.2017, retrospectively.
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Affiliation(s)
- Katharina Olbrisch
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
- Department of Pharmacy, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Kisch
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Julia Thern
- Department of Pharmacy, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Evelyn Kramme
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Graf
- University Heart Centre Lübeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Sebastian G Wicha
- Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Peter Mailänder
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Walter Raasch
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany.
- CBBM (Center of Brain, Behavior and Metabolism), University of Lübeck, Lübeck, Germany.
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62
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Salivary Gland Extract from Aedes aegypti Improves Survival in Murine Polymicrobial Sepsis through Oxidative Mechanisms. Cells 2018; 7:cells7110182. [PMID: 30360497 PMCID: PMC6262460 DOI: 10.3390/cells7110182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/31/2022] Open
Abstract
Sepsis is a systemic disease with life-threatening potential and is characterized by a dysregulated immune response from the host to an infection. The organic dysfunction in sepsis is associated with the production of inflammatory cascades and oxidative stress. Previous studies showed that Aedes aegypti saliva has anti-inflammatory, immunomodulatory, and antioxidant properties. Considering inflammation and the role of oxidative stress in sepsis, we investigated the effect of pretreatment with salivary gland extract (SGE) from Ae. aegypti in the induction of inflammatory and oxidative processes in a murine cecum ligation and puncture (CLP) model. Here, we evaluated animal survival for 16 days, as well as bacterial load, leukocyte migration, and oxidative parameters. We found that the SGE pretreatment improved the survival of septic mice, reduced bacterial load and neutrophil influx, and increased nitric oxide (NO) production in the peritoneal cavity. With regard to oxidative status, SGE increased antioxidant defenses as measured by Trolox equivalent antioxidant capacity (TEAC) and glutathione (GSH), while reducing levels of the oxidative stress marker malondialdehyde (MDA). Altogether, these data suggest that SGE plays a protective role in septic animals, contributing to oxidative and inflammatory balance during sepsis. Therefore, Ae. aegypti SGE is a potential source for new therapeutic molecule(s) in polymicrobial sepsis, and this effect seems to be mediated by the control of inflammation and oxidative damage.
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63
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Venugopalan V, Manigaba K, Borgert SJ, Cope J, Peloquin CA, Klinker KP. Training a Drug to Do New Tricks: Insights on Stability of Meropenem Administered as a Continuous Infusion. Microbiol Insights 2018; 11:1178636118804549. [PMID: 30349291 PMCID: PMC6194917 DOI: 10.1177/1178636118804549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/07/2018] [Indexed: 11/17/2022] Open
Abstract
Background The antibiotic armamentarium used to combat multi-drug resistant organisms (MDROs) include carbapenems. Continuous infusion (CI) dosing is frequently employed to maximize beta-lactam efficacy; however, use of meropenem CI has been limited due to concerns with product instability. Objective The primary objective of this study was to quantify meropenem serum concentrations to reflect drug stability when administered as CI over 8- or 12-h exchanges. In addition, a stability experiment was performed to further establish meropenem integrity over 12 h. The secondary objectives were to assess the ability of meropenem to achieve target pharmacokinetic/pharmacodynamic (PK/PD) exposures relative to the minimum inhibitory concentration (MIC) of the pathogen, and to determine clinical cure. Methods This was a retrospective, observational study on use of CI meropenem (infused either over 8- or 12- h) at a 1% concentration. The stability experiment was conducted on 1% meropenem at room temperature. Results In 22 patients, a median meropenem daily dose of 6 g/day (range 2-6 g/day) resulted in a median serum concentration of 17.8 mg/L (interquartile range, 9.3-27.8 mg/L). In 95% of cases, meropenem delivered as CI resulted in free drug concentrations at or above the MIC of the pathogen for the entire dosing interval. Clinical cure was achieved in 80% of patients included in this review. The stability experiment revealed negligible drug degradation at the end of the 12-h dosing interval. Conclusions The data from this study provides compelling evidence for the use of meropenem as CI utilizing either a 12- or 8-h exchange process.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kayihura Manigaba
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Samuel J Borgert
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Jessica Cope
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kenneth P Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
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64
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Veiga RP, Paiva JA. Pharmacokinetics-pharmacodynamics issues relevant for the clinical use of beta-lactam antibiotics in critically ill patients. Crit Care 2018; 22:233. [PMID: 30244674 PMCID: PMC6151903 DOI: 10.1186/s13054-018-2155-1] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/08/2018] [Indexed: 12/15/2022] Open
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients and beta-lactams are the most common antibiotic class used. Critically ill patient's pathophysiological factors lead to altered pharmacokinetics and pharmacodynamics of beta-lactams.A comprehensive bibliographic search in PubMed database of all English language articles published from January 2000 to December 2017 was performed, allowing the selection of articles addressing the pharmacokinetics or pharmacodynamics of beta-lactam antibiotics in critically ill patients.In critically ill patients, several factors may increase volume of distribution and enhance renal clearance, inducing high intra- and inter-patient variability in beta-lactam concentration and promoting the risk of antibiotic underdosing. The duration of infusion of beta-lactams has been shown to influence the fT > minimal inhibitory concentration and an improved beta-lactam pharmacodynamics profile may be obtained by longer exposure with more frequent dosing, extended infusions, or continuous infusions.The use of extracorporeal support techniques in the critically ill may further contribute to this problem and we recommend not reducing standard antibiotic dosage since no drug accumulation was found in the available literature and to maintain continuous or prolonged infusion, especially for the treatment of infections caused by multidrug-resistant bacteria.Prediction of outcome based on concentrations in plasma results in overestimation of antimicrobial activity at the site of infection, namely in cerebrospinal fluid and the lung. Therefore, although no studies have assessed clinical outcome, we recommend using higher than standard dosing, preferably with continuous or prolonged infusions, especially when treating less susceptible bacterial strains at these sites, as the pharmacodynamics profile may improve with no apparent increase in toxicity.A therapeutic drug monitoring-guided approach could be particularly useful in critically ill patients in whom achieving target concentrations is more difficult, such as obese patients, immunocompromised patients, those infected by highly resistant bacterial strains, patients with augmented renal clearance, and those undergoing extracorporeal support techniques.
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Affiliation(s)
- Rui Pedro Veiga
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
| | - José-Artur Paiva
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
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65
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de Velde F, Mouton JW, de Winter BCM, van Gelder T, Koch BCP. Clinical applications of population pharmacokinetic models of antibiotics: Challenges and perspectives. Pharmacol Res 2018; 134:280-288. [PMID: 30033398 DOI: 10.1016/j.phrs.2018.07.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 11/26/2022]
Abstract
Because of increasing antimicrobial resistance and the shortage of new antibiotics, there is a growing need to optimize the use of old and new antibiotics. Modelling of the pharmacokinetic/pharmacodynamic (PK/PD) characteristics of antibiotics can support the optimization of dosing regimens. Antimicrobial efficacy is determined by susceptibility of the drug to the microorganism and exposure to the drug, which relies on the PK and the dose. Population PK models describe relationships between patients characteristics and drug exposure. This article highlights three clinical applications of these models applied to antibiotics: 1) dosing evaluation of old antibiotics, 2) setting clinical breakpoints and 3) dosing individualization using therapeutic drug monitoring (TDM). For each clinical application, challenges regarding interpretation are discussed. An important challenge is to improve the understanding of the interpretation of modelling results for good implementation of the dosing recommendations, clinical breakpoints and TDM advices. Therefore, also background information on PK/PD principles and approaches to analyse PK/PD data are provided.
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Affiliation(s)
- Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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66
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Abdul-Aziz MH, Driver E, Lipman J, Roberts JA. New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods. Expert Opin Drug Metab Toxicol 2018; 14:693-708. [PMID: 29865877 DOI: 10.1080/17425255.2018.1484452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.
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Affiliation(s)
- Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Elicia Driver
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Jeffrey Lipman
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,c Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics , The University of Queensland , Brisbane , Queensland , Australia
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67
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Pharmacokinetic/Pharmacodynamic Considerations of Beta-Lactam Antibiotics in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:9. [PMID: 29619607 DOI: 10.1007/s11908-018-0613-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Beta-lactam antibiotics are commonly prescribed in critically ill patients for a variety of infectious conditions. Our understanding of how critical illness alters beta-lactam pharmacokinetics/pharmacodynamics (PK/PD) is rapidly evolving. RECENT FINDINGS There is a growing body of literature in adult patients demonstrating that physiological alterations occurring in critically ill patients may limit our ability to optimally dose beta-lactam antibiotics to reach these PK/PD targets. These alterations include changes in volume of distribution and renal clearance with multiple, often overlapping causative pathways, including hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Strategies to overcome these PK alterations include extended infusions and therapeutic drug monitoring. Combined data has demonstrated a possible survival benefit associated with extending beta-lactam infusions in critically ill adult patients. This review highlights research on physiological derangements affecting beta-lactam concentrations and strategies to optimize beta-lactam PK/PD in critically ill adults.
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68
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Bos JC, Prins JM, Mistício MC, Nunguiane G, Lang CN, Beirão JC, Mathôt RAA, van Hest RM. Pharmacokinetics and pharmacodynamic target attainment of ceftriaxone in adult severely ill sub-Saharan African patients: a population pharmacokinetic modelling study. J Antimicrob Chemother 2018. [DOI: 10.1093/jac/dky071] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Jeannet C Bos
- Academic Medical Centre (AMC), University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jan M Prins
- Academic Medical Centre (AMC), University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mabor C Mistício
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Ginto Nunguiane
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Cláudia N Lang
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - José C Beirão
- Catholic University of Mozambique (UCM), Research Centre for Infectious Diseases of the Faculty of Health Sciences (CIDI), Rua Marquês do Soveral 960, CP 821, Beira, Mozambique
| | - Ron A A Mathôt
- Academic Medical Centre (AMC), University of Amsterdam, Department of Hospital Pharmacy, Division of Clinical Pharmacology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Reinier M van Hest
- Academic Medical Centre (AMC), University of Amsterdam, Department of Hospital Pharmacy, Division of Clinical Pharmacology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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69
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Ongas M, Standing J, Ogutu B, Waichungo J, Berkley JA, Kipper K. Liquid chromatography-tandem mass spectrometry for the simultaneous quantitation of ceftriaxone, metronidazole and hydroxymetronidazole in plasma from seriously ill, severely malnourished children. Wellcome Open Res 2018. [PMID: 29479566 DOI: 10.12688/wellcomeopenres.11728.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We have developed and validated a novel, sensitive, selective and reproducible reversed-phase high-performance liquid chromatography method coupled with electrospray ionization mass spectrometry (HPLC-ESI-MS/MS) for the simultaneous quantitation of ceftriaxone (CEF), metronidazole (MET) and hydroxymetronidazole (MET-OH) from only 50 µL of human plasma, and unbound CEF from 25 µL plasma ultra-filtrate to evaluate the effect of protein binding. Cefuroxime axetil (CEFU) was used as an internal standard (IS). The analytes were extracted by a protein precipitation procedure with acetonitrile and separated on a reversed-phase Polaris 5 C18-Analytical column using a mobile phase composed of acetonitrile containing 0.1% (v/v) formic acid and 10 mM aqueous ammonium formate pH 2.5, delivered at a flow-rate of 300 µL/min. Multiple reaction monitoring was performed in the positive ion mode using the transitions m/z555.1→ m/z396.0 (CEF), m/z172.2→ m/z 128.2 (MET), m/z188.0→ m/z125.9 (MET-OH) and m/z528.1→ m/z 364.0 (CEFU) to quantify the drugs. Calibration curves in spiked plasma and ultra-filtrate were linear ( r 2 ≥ 0.9948) from 0.4-300 µg/mL for CEF, 0.05-50 µg/mL for MET and 0.02 - 30 µg/mL for MET-OH. The intra- and inter- assay precisions were less than 9% and the mean extraction recoveries were 94.0% (CEF), 98.2% (MET), 99.6% (MET-OH) and 104.6% (CEF in ultra-filtrate); the recoveries for the IS were 93.8% (in plasma) and 97.6% (in ultra-filtrate). The validated method was successfully applied to a pharmacokinetic study of CEF, MET and MET-OH in hospitalized children with complicated severe acute malnutrition following an oral administration of MET and intravenous administration of CEF over the course of 72 hours.
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Affiliation(s)
- Martin Ongas
- Center for Research in Therapeutic Sciences, Strathmore University, Ole Sangale Road, Nairobi, Kenya.,KEMRI-Centre for Clinical Research, Nairobi, Kenya
| | - Joseph Standing
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Bernhards Ogutu
- Center for Research in Therapeutic Sciences, Strathmore University, Ole Sangale Road, Nairobi, Kenya.,KEMRI-Centre for Clinical Research, Nairobi, Kenya
| | | | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Lenana Place, Nairobi, Kenya
| | - Karin Kipper
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,Analytical Services International, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Institute of Chemistry, University of Tartu, Tartu, Estonia
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70
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Variable Linezolid Exposure in Intensive Care Unit Patients-Possible Role of Drug-Drug Interactions. Ther Drug Monit 2017; 38:573-8. [PMID: 27631464 DOI: 10.1097/ftd.0000000000000324] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard doses of linezolid may not be suitable for all patient groups. Intensive care unit (ICU) patients in particular may be at risk of inadequate concentrations. This study investigated variability of drug exposure and its potential sources in this population. METHODS Plasma concentrations of linezolid were determined by high-performance liquid chromatography in a convenience sample of 20 ICU patients treated with intravenous linezolid 600 mg twice daily. Ultrafiltration applying physiological conditions (pH 7.4/37°C) was used to determine the unbound fraction. Individual pharmacokinetic (PK) parameters were estimated by population PK modeling. As measures of exposure to linezolid, area under the concentration-time curve (AUC) and trough concentrations (Cmin) were calculated and compared with published therapeutic ranges (AUC 200-400 mg*h/L, Cmin 2-10 mg/L). Coadministered inhibitors or inducers of cytochrome P450 and/or P-glycoprotein were noted. RESULTS Data from 18 patients were included into the PK evaluation. Drug exposure was highly variable (median, range: AUC 185, 48-618 mg*h/L, calculated Cmin 2.92, 0.0062-18.9 mg/L), and only a minority of patients had values within the target ranges (6 and 7, respectively). AUC and Cmin were linearly correlated (R = 0.98), and classification of patients (underexposed/within therapeutic range/overexposed) according to AUC or Cmin was concordant in 15 cases. Coadministration of inhibitors was associated with a trend to higher drug exposure, whereas 3 patients treated with levothyroxine showed exceedingly low drug exposure (AUC ∼60 mg*h/L, Cmin <0.4 mg/L). The median unbound fraction in all 20 patients was 90.9%. CONCLUSIONS Drug exposure after standard doses of linezolid is highly variable and difficult to predict in ICU patients, and therapeutic drug monitoring seems advisable. PK drug-drug interactions might partly be responsible and should be further investigated; protein binding appears to be stable and irrelevant.
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71
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Schwameis R, Syré S, Sarahrudi K, Appelt A, Marhofer D, Burau D, Kloft C, Zeitlinger M. Penetration of linezolid into synovial fluid and muscle tissue after elective arthroscopy. J Antimicrob Chemother 2017; 72:2817-2822. [DOI: 10.1093/jac/dkx219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 06/08/2017] [Indexed: 01/02/2023] Open
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72
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Ongas M, Standing J, Ogutu B, Waichungo J, Berkley JA, Kipper K. Liquid chromatography-tandem mass spectrometry for the simultaneous quantitation of ceftriaxone, metronidazole and hydroxymetronidazole in plasma from seriously ill, severely malnourished children. Wellcome Open Res 2017; 2:43. [PMID: 29479566 PMCID: PMC5801568 DOI: 10.12688/wellcomeopenres.11728.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/18/2022] Open
Abstract
We have developed and validated a novel, sensitive, selective and reproducible reversed-phase high-performance liquid chromatography method coupled with electrospray ionization mass spectrometry (HPLC-ESI-MS/MS) for the simultaneous quantitation of ceftriaxone (CEF), metronidazole (MET) and hydroxymetronidazole (MET-OH) from only 50 µL of human plasma, and unbound CEF from 25 µL plasma ultra-filtrate to evaluate the effect of protein binding. Cefuroxime axetil (CEFU) was used as an internal standard (IS). The analytes were extracted by a protein precipitation procedure with acetonitrile and separated on a reversed-phase Polaris 5 C18-Analytical column using a mobile phase composed of acetonitrile containing 0.1% (v/v) formic acid and 10 mM aqueous ammonium formate pH 2.5, delivered at a flow-rate of 300 µL/min. Multiple reaction monitoring was performed in the positive ion mode using the transitions m/z555.1→ m/z396.0 (CEF), m/z172.2→ m/z 128.2 (MET), m/z188.0→ m/z125.9 (MET-OH) and m/z528.1→ m/z 364.0 (CEFU) to quantify the drugs. Calibration curves in spiked plasma and ultra-filtrate were linear ( r 2 ≥ 0.9948) from 0.4-300 µg/mL for CEF, 0.05-50 µg/mL for MET and 0.02 - 30 µg/mL for MET-OH. The intra- and inter- assay precisions were less than 9% and the mean extraction recoveries were 94.0% (CEF), 98.2% (MET), 99.6% (MET-OH) and 104.6% (CEF in ultra-filtrate); the recoveries for the IS were 93.8% (in plasma) and 97.6% (in ultra-filtrate). The validated method was successfully applied to a pharmacokinetic study of CEF, MET and MET-OH in hospitalized children with complicated severe acute malnutrition following an oral administration of MET and intravenous administration of CEF over the course of 72 hours.
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Affiliation(s)
- Martin Ongas
- Center for Research in Therapeutic Sciences, Strathmore University, Ole Sangale Road, Nairobi, Kenya
- KEMRI-Centre for Clinical Research, Nairobi, Kenya
| | - Joseph Standing
- Inflammation, Infection and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Bernhards Ogutu
- Center for Research in Therapeutic Sciences, Strathmore University, Ole Sangale Road, Nairobi, Kenya
- KEMRI-Centre for Clinical Research, Nairobi, Kenya
| | | | - James A. Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Lenana Place, Nairobi, Kenya
| | - Karin Kipper
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
- Analytical Services International, St George’s University of London, Cranmer Terrace, London, SW17 0RE, UK
- Institute of Chemistry, University of Tartu, Tartu, Estonia
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73
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Campos ML, de Moura Alonso J, dos Santos Martins E, Oliveira JA, Hussni CA, Peccinini RG. Ceftriaxone pharmacokinetics by new simple and sensitive ultra-high-performance liquid chromatography method. Diagn Microbiol Infect Dis 2017; 88:95-99. [DOI: 10.1016/j.diagmicrobio.2017.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/21/2016] [Accepted: 02/21/2017] [Indexed: 11/28/2022]
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Economou CJP, Wong G, McWhinney B, Ungerer JPJ, Lipman J, Roberts JA. Impact of β-lactam antibiotic therapeutic drug monitoring on dose adjustments in critically ill patients undergoing continuous renal replacement therapy. Int J Antimicrob Agents 2017; 49:589-594. [PMID: 28341612 DOI: 10.1016/j.ijantimicag.2017.01.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/29/2022]
Abstract
The objective of this study was to describe the effect of therapeutic drug monitoring (TDM) and dose adjustments of β-lactam antibiotics administered to critically ill patients undergoing continuous renal replacement therapy (CRRT) in a 30-bed tertiary intensive care unit (ICU). β-Lactam TDM data in our tertiary referral ICU were retrospectively reviewed. Clinical, demographic and dosing data were collected for patients administered β-lactam antibiotics while undergoing CRRT. The target trough concentration range was 1-10× the minimum inhibitory concentration (MIC). A total of 111 TDM samples from 76 patients (46 male) with a mean ± standard deviation age of 56.6 ± 15.9 years and weight of 89.1 ± 25.8 kg were identified. The duration of antibiotic therapy was between 2 days and 42 days. TDM identified a need for dose modification of β-lactam antibiotics in 39 (35%) instances; in 27 (24%) samples, TDM values resulted in decreasing the prescribed dose of β-lactam antibiotic whereas an increase in the prescribed dose occurred in 12 (11%) cases. In patients treated for hospital-acquired pneumonia and primary or secondary bacteraemia, the dose was required to be decreased in 10/25 (40%) and 7/46 (15%) cases, respectively, to attain target concentrations. β-Lactam TDM is a useful tool for guiding drug dosing in complex patients such as those receiving CRRT. Although over one-third of patients manifested concentrations outside the therapeutic range, most of these CRRT patients had excessive β-lactam concentrations.
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Affiliation(s)
- Caleb J P Economou
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Research, ICON Cancer Foundation, Brisbane, QLD, Australia
| | - Gloria Wong
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, QLD, Australia.
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75
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Selmi V, Loriga B, Vitali L, Carlucci M, Di Filippo A, Carta G, Sgambati E, Tofani L, De Gaudio AR, Novelli A, Adembri C. Changes in ceftriaxone pharmacokinetics/pharmacodynamics during the early phase of sepsis: a prospective, experimental study in the rat. J Transl Med 2016; 14:316. [PMID: 27846855 PMCID: PMC5111190 DOI: 10.1186/s12967-016-1072-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sepsis is characterized by the loss of the perm-selectivity properties of the glomerular filtration barrier (GFB) with consequent albuminuria. We examined whether the pharmacokinetics-pharmacodynamics (PK/PD) of ceftriaxone (CTX), an extensively protein-bound 3rd generation cephalosporin, is altered during early sepsis and whether an increase in urinary loss of bound-CTX, due to GFB alteration, can occur in this condition. METHODS A prospective, experimental, randomized study was carried out in adult male Sprague-Dawley rats. Sepsis was induced by cecal ligation and puncture (CLP). Rats were divided into two groups: Sham-operated and CLP. CTX (100 mg i.p., equivalent to 1 g dose in humans) was administered in order to measure plasma and lung CTX concentrations at several time-points: baseline and 1, 2, 4 and 6 h after administration. CTX was measured by High Performance Liquid Chromatography (HPLC). The morphological status of the sialic components of the GFB barrier was assessed by lectin histo-chemistry. Monte Carlo simulation was performed to calculate the probability of target attainment (PTA >90%) for 80 and 100% of Tfree > minimum inhibitory concentration (MIC) for 80 and 100% of dosing interval. MEASUREMENTS AND MAIN RESULTS After CLP, sepsis developed in rats as documented by the growth of polymicrobial flora in the peritoneal fluid (≤1 × 101 CFU in sham rats vs 5 × 104-1 × 105 CFU in CLP rats). CTX plasma concentrations were higher in CLP than in sham rats at 2 and 4 h after administration (difference at 2 h was 47.3, p = 0.012; difference at 4 h was 24.94, p = 0.004), while lung penetration tended to be lower. An increased urinary elimination of protein-bound CTX occurred (553 ± 689 vs 149 ± 128 mg/L, p < 0.05; % of bound/total CTX 22 ± 6 in septic rats vs 11 ± 4 in sham rats, p < 0.01) and it was associated with loss of the GFB sialic components. According to Monte Carlo simulation a PTA > 90% for 100% of the dosing interval was reached neither for sham nor CLP rats using MIC = 1 mg/L, the clinical breakpoint for Enterobacteriacee. CONCLUSIONS Sepsis causes changes in the PK of CTX and an alteration in the sialic components of the GFB, with consequent loss of protein-bound CTX. Among factors that can affect drug pharmacokinetics during the early phases of sepsis, urinary loss of both free and albumin-bound antimicrobials should be considered.
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Affiliation(s)
- Valentina Selmi
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Beatrice Loriga
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - Luca Vitali
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Martina Carlucci
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Alessandro Di Filippo
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Giulio Carta
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Eleonora Sgambati
- Department of Biosciences and Territory, University of Molise, Contrada Fonte Lappone, 86090, Pesche, IS, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Angelo Raffaele De Gaudio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Novelli
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Chiara Adembri
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
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76
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Total and unbound ceftriaxone pharmacokinetics in critically ill Australian Indigenous patients with severe sepsis. Int J Antimicrob Agents 2016; 48:748-752. [PMID: 27838278 DOI: 10.1016/j.ijantimicag.2016.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/04/2016] [Accepted: 09/15/2016] [Indexed: 11/21/2022]
Abstract
In the absence of specific data to guide optimal dosing, this study aimed to describe the pharmacokinetics of ceftriaxone in severely septic Australian Indigenous patients and to assess achievement of the pharmacodynamic target of the regimens prescribed. A pharmacokinetic study was conducted in a remote hospital intensive care unit in patients receiving ceftriaxone dosing of 1 g every 12 h (q12h). Serial blood and urine samples were collected over one dosing interval on two consecutive days. Samples were assayed using a validated chromatography method for total and unbound concentrations. Concentration-time data collected were analysed with a non-compartmental approach. A total of 100 plasma samples were collected from five subjects. Ceftriaxone clearance, volume of distribution at steady-state, elimination half-life and elimination rate constant estimates were 0.9 (0.6-1.5) L/h, 11.2 (7.6-13.4) L, 9.5 (3.2-10.2) h and 0.07 (0.07-0.21) h-1, respectively. The unbound fraction of ceftriaxone ranged between 14% and 43%, with a higher unbound fraction present at higher total concentrations. The unbound concentrations at 720 min from the initiation of infusion for the first and second dosing intervals were 7.2 (4.8-10.7) mg/L and 7.8 (4.7-12.1) mg/L respectively, which exceeds the minimum inhibitory concentration of all typical target pathogens. In conclusion, the regimen of ceftriaxone 1 g q12h is adequate for critically ill Australian Indigenous patients with severe sepsis caused by non-resistant pathogens.
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Dorofaeff T, Bandini RM, Lipman J, Ballot DE, Roberts JA, Parker SL. Uncertainty in Antibiotic Dosing in Critically Ill Neonate and Pediatric Patients: Can Microsampling Provide the Answers? Clin Ther 2016; 38:1961-75. [PMID: 27544661 DOI: 10.1016/j.clinthera.2016.07.093] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/20/2016] [Accepted: 07/22/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume (<50 μL), can improve opportunities to conduct pharmacokinetic studies. METHODS We performed a literature search to find relevant articles using the following search terms: sepsis, critically ill, severe infection, intensive care AND antibiotic, pharmacokinetic, p(a)ediatric, neonate. For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling. Databases searched include Web of Knowledge, PubMed, and EMbase. FINDINGS Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation. IMPLICATIONS Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result.
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Affiliation(s)
- Tavey Dorofaeff
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Paediatric Intensive Care, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Rossella M Bandini
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Faculty of Health, Brisbane, Queensland University of Technology, Brisbane, Australia
| | - Daynia E Ballot
- Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Department of Pharmacy, Royal Brisbane Hospital, Brisbane, Australia; School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Suzanne L Parker
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.
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Vermeij JD, Westendorp WF, Roos YB, Brouwer MC, van de Beek D, Nederkoorn PJ. Preventive Ceftriaxone in Patients with Stroke Treated with Intravenous Thrombolysis: Post Hoc Analysis of the Preventive Antibiotics in Stroke Study. Cerebrovasc Dis 2016; 42:361-369. [PMID: 27336314 DOI: 10.1159/000446160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/10/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The Preventive Antibiotics in Stroke Study (PASS), a randomized open-label masked endpoint trial, showed that preventive ceftriaxone did not improve functional outcome at 3 months in patients with acute stroke (adjusted common OR 0.95; 95% CI 0.82-1.09). Post-hoc analyses showed that among patients who received intravenous thrombolysis (IVT), patients who received ceftriaxone had a significantly better outcome as compared with the control group. This study aimed to gain more insight into the characteristics of these patients. METHODS In PASS, 2,550 patients were randomly assigned to preventive antibiotic treatment with ceftriaxone or standard care. In current post-hoc analysis, 836 patients who received IVT were included. Primary outcome included functional status on the modified Rankin Scale, analyzed with adjusted ordinal regression. Secondary outcomes included infection rate and symptomatic intracerebral hemorrhage (sICH) rate. RESULTS For all patients in PASS, the p value for the interaction between IVT and preventive ceftriaxone regarding functional outcome was 0.03. Of the 836 IVT-treated patients, 437 were administered ceftriaxone and 399 were allocated to the control group. Baseline characteristics were similar. In the IVT subgroup, preventive ceftriaxone was associated with a significant reduction in unfavorable outcome (adjusted common OR 0.77; 95% CI 0.61-0.99; p = 0.04). Mortality at 3 months was similar (OR 0.75; 95% CI 0.48-1.18). Preventive ceftriaxone was associated with a reduction in infections (OR 0.43; 95% CI 0.28-0.66), and a trend towards an increased risk for sICH (OR 3.09; 95% CI 0.85-11.31). Timing of ceftriaxone administration did not influence the outcome (aOR 1.00; 95% CI 0.98-1.03; p = 0.85). CONCLUSIONS According to the post-hoc analysis of PASS, preventive ceftriaxone may improve the functional outcome in IVT-treated patients with acute stroke, despite a trend towards an increased rate of post-IVT-sICH.
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Affiliation(s)
- Jan-Dirk Vermeij
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Parker SL, Dorofaeff T, Lipman J, Ballot DE, Bandini RM, Wallis SC, Roberts JA. Is there a role for microsampling in antibiotic pharmacokinetic studies? Expert Opin Drug Metab Toxicol 2016; 12:601-14. [PMID: 27087416 DOI: 10.1080/17425255.2016.1178238] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Clinical pharmacokinetic studies of antibiotics can establish evidence-based dosing regimens that improve the likelihood of eradicating the pathogen at the site of infection, reduce the potential for selection of resistant pathogens, and minimize harm to the patient. Innovations in small volume sampling (< 50 μL) or 'microsampling' may result in less-invasive sample collection, self-sampling and dried storage. Microsampling may open up opportunities in patient groups where sampling is challenging. AREAS COVERED The challenges for implementation of microsampling to assure suitability of the results, include: acceptable study design, regulatory agency acceptance, and meeting bioanalytical validation requirements. This manuscript covers various microsampling methods, including dried blood/plasma spots, volumetric absorptive microsampling, capillary microsampling, plasma preparation technologies and solid-phase microextraction. EXPERT OPINION The available analytical technology is being underutilized due to a lack of bridging studies and validated bioanalytical methods. These deficiencies represent major impediments to the application of microsampling to antibiotic pharmacokinetic studies. A conceptual framework for the assessment of the suitability of microsampling in clinical pharmacokinetic studies of antibiotics is provided. This model establishes a 'contingency approach' with consideration of the antibiotic and the type and location of the patient, as well as the more prescriptive bioanalytical validation protocols.
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Affiliation(s)
- Suzanne L Parker
- a Burns, Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia
| | - Tavey Dorofaeff
- a Burns, Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,b Paediatric Intensive Care , Lady Cilento Children's Hospital , Brisbane , Australia
| | - Jeffrey Lipman
- a Burns, Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,d Faculty of Health , Queensland University of Technology , Brisbane , Australia
| | - Daynia E Ballot
- e Department of Paediatrics and Child Health , University of the Witwatersrand , Johannesburg , South Africa.,f Wits UQ Critical Care Infection Collaboration , Johannesburg , South Africa
| | - Rossella M Bandini
- g School of Physiology , University of the Witwatersrand , Johannesburg , South Africa
| | - Steven C Wallis
- a Burns, Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia
| | - Jason A Roberts
- a Burns, Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,h Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Australia.,i School of Pharmacy , The University of Queensland , Brisbane , Australia
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