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Tang HJ, Lai CC. Doripenem for treating nosocomial pneumonia and ventilator-associated pneumonia. THE LANCET. INFECTIOUS DISEASES 2020; 20:20. [PMID: 31876490 DOI: 10.1016/s1473-3099(19)30693-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan 710, Taiwan.
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Palwe S, Khobragade K, Kharat AS. Preserving the Dwindling β-lactams-Based Empiric Therapy Options for Gram-Negative Infections in Challenging Resistance Scenario: Lessons Learned and Way Forward. Microb Drug Resist 2019; 26:637-651. [PMID: 31851576 DOI: 10.1089/mdr.2019.0195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Appropriate empiric therapy reduces mortality and morbidity associated with serious Gram-negative infections. β-lactams (BLs) owing to their safety, efficacy, and coverage spectrum are the most preferred agents for empiric use. Inappropriate use of older penicillins and cephalosporins led to selection and spread of resistant clones. As a result, these valuable agents have lost their reliability compelling clinicians to often use erstwhile last-line therapies such as carbapenems. Excessive carbapenems use imposed collateral damage by selecting difficult-to-treat carbapenem-resistant organisms. Lack of empiric therapeutic options amenable for use in infections caused by contemporary pathogens was realized by the pharmaceutical industry leading to intensive efforts in discovering novel antibiotics. These efforts led to the approval of newer β-lactams and β-lactamase inhibitor (BL-BLI) combination. This review elaborates the past trends in empirical use of BLs and ensuing patterns of resistance emergence in Gram-negatives. Furthermore, a critical appraisal of newer BL-BLIs has been presented to identify the appropriate clinical situations for their use to ensure clinical efficacy coupled with minimal resistance selection. These learning have been derived from past trends of clinical usage of older empiric therapies so that the therapeutic utility of newer agents is preserved for long in light of dwindling global antibiotics pipeline.
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Affiliation(s)
- Snehal Palwe
- Department of Environmental Science, SB College of Science, Aurangabad, India
| | - Kshama Khobragade
- Department of Environmental Science, SB College of Science, Aurangabad, India
| | - Arun S Kharat
- Laboratory of Microbiology, Jawaharlal Nehru University, New Delhi, India
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Niederman MS, Alder J, Bassetti M, Boateng F, Cao B, Corkery K, Dhand R, Kaye KS, Lawatscheck R, McLeroth P, Nicolau DP, Wang C, Wood GC, Wunderink RG, Chastre J. Inhaled amikacin adjunctive to intravenous standard-of-care antibiotics in mechanically ventilated patients with Gram-negative pneumonia (INHALE): a double-blind, randomised, placebo-controlled, phase 3, superiority trial. THE LANCET. INFECTIOUS DISEASES 2019; 20:330-340. [PMID: 31866328 DOI: 10.1016/s1473-3099(19)30574-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/31/2019] [Accepted: 09/26/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Treatment of ventilated pneumonia is often unsuccessful, even when patients are treated according to established guidelines. Therefore, we aimed to investigate the efficacy of the combination drug device Amikacin Inhale as an adjunctive therapy to intravenous standard-of-care antibiotics for pneumonia caused by Gram-negative pathogens in intubated and mechanically ventilated patients. METHODS INHALE was a prospective, double-blind, randomised, placebo-controlled, phase 3 study comprising two trials (INHALE 1 and INHALE 2) done in 153 hospital intensive-care units in 25 countries. Eligible patients were aged 18 years or older; had pneumonia that had been diagnosed by chest radiography and that was documented as being caused by or showing two risk factors for a Gram-negative, multidrug-resistant pathogen; were intubated and mechanically ventilated; had impaired oxygenation within 48 h before screening; and had a modified Clinical Pulmonary Infection Score of at least 6. Patients were stratified by region and disease severity (according to their Acute Physiology and Chronic Health Evaluation [APACHE] II score) and randomly assigned (1:1) via an interactive voice-recognition system to receive 400 mg amikacin (Amikacin Inhale) or saline placebo, both of which were aerosolised, administered every 12 h for 10 days via the same synchronised inhalation system, and given alongside standard-of-care intravenous antibiotics. All patients and all staff involved in administering devices and monitoring outcomes were masked to treatment assignment. The primary endpoint, survival at days 28-32, was analysed in all patients who received at least one dose of study drug, were infected with a Gram-negative pathogen, and had an APACHE II score of at least 10 at diagnosis. Safety analyses were done in all patients who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, numbers NCT01799993 and NCT00805168. FINDINGS Between April 13, 2013, and April 7, 2017, 807 patients were assessed for eligibility and 725 were randomly assigned to Amikacin Inhale (362 patients) or aerosolised placebo (363 patients). 712 patients received at least one dose of study drug (354 in the Amikacin Inhale group and 358 in the placebo group), although one patient assigned to Amikacin Inhale received placebo in error and was included in the placebo group for safety analyses. 508 patients (255 in the Amikacin Inhale group and 253 in the placebo group) were assessed for the primary endpoint. We found no between-group difference in survival: 191 (75%) patients in the Amikacin Inhale group versus 196 (77%) patients in the placebo group survived until days 28-32 (odds ratio 0·841, 95% CI 0·554-1·277; p=0·43). Similar proportions of patients in the two treatment groups had a treatment-emergent adverse event (295 [84%] of 353 patients in the Amikacin Inhale group vs 303 [84%] of 359 patients in the placebo group) or a serious treatment-emergent adverse event (101 [29%] patients vs 97 [27%] patients). INTERPRETATION Our findings do not support use of inhaled amikacin adjunctive to standard-of-care intravenous therapy in mechanically ventilated patients with Gram-negative pneumonia. FUNDING Bayer AG.
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Affiliation(s)
- Michael S Niederman
- Division of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA.
| | - Jeff Alder
- Anti-Infective Consulting, Margaretville, NY, USA
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Policlinico San Martino Hospital, Genoa, Italy; Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | | | - Rajiv Dhand
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Keith S Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - G Christopher Wood
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, University of Tennessee, Memphis, TN, USA
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jean Chastre
- Intensive Care Unit, Sorbonne University Hospitals, Paris, France
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Abstract
PURPOSE OF REVIEW Whilst many guidelines recommend limiting the use of antibiotics because of the increase in antimicrobial resistance (AMR), this strategy becomes challenging when dealing with severe infections in critically ill patients. Moreover, some Gram-negative bacilli (GNB) can exhibit mechanisms of resistance that make the patient more vulnerable to recurrence of infections. We reviewed recent data on the optimal duration of antibiotic therapy in these patients. RECENT FINDINGS Apart from having no additional clinical benefit at a certain point after initiation, antibiotics might have negative effects. Prolonged antibiotic exposure has been associated to development of AMR and represents a strong reason to avoid long courses of antibiotic therapy in GNB infections. Recent data suggest that also patients with severe infections, in whom source control is adequate, can be managed with short-course antibiotic therapy. SUMMARY The optimal duration of antibiotic therapy depends on many factors, but overall, many infections in the critically ill can be treated with short-course antibiotic therapy (7 days or less). The integration of signs of resolution, biomarkers, clinical judgment, and microbiologic eradication might help to define this optimal duration in patients with life-threatening infections caused by GNB.
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Kollef MH, Nováček M, Kivistik Ü, Réa-Neto Á, Shime N, Martin-Loeches I, Timsit JF, Wunderink RG, Bruno CJ, Huntington JA, Lin G, Yu B, Butterton JR, Rhee EG. Ceftolozane-tazobactam versus meropenem for treatment of nosocomial pneumonia (ASPECT-NP): a randomised, controlled, double-blind, phase 3, non-inferiority trial. THE LANCET. INFECTIOUS DISEASES 2019; 19:1299-1311. [PMID: 31563344 DOI: 10.1016/s1473-3099(19)30403-7] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/04/2019] [Accepted: 07/09/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Nosocomial pneumonia due to antimicrobial-resistant pathogens is associated with high mortality. We assessed the efficacy and safety of the combination antibacterial drug ceftolozane-tazobactam versus meropenem for treatment of Gram-negative nosocomial pneumonia. METHODS We conducted a randomised, controlled, double-blind, non-inferiority trial at 263 hospitals in 34 countries. Eligible patients were aged 18 years or older, were undergoing mechanical ventilation, and had nosocomial pneumonia (either ventilator-associated pneumonia or ventilated hospital-acquired pneumonia). Patients were randomly assigned (1:1) with block randomisation (block size four), stratified by type of nosocomial pneumonia and age (<65 years vs ≥65 years), to receive either 3 g ceftolozane-tazobactam or 1 g meropenem intravenously every 8 h for 8-14 days. The primary endpoint was 28-day all-cause mortality (at a 10% non-inferiority margin). The key secondary endpoint was clinical response at the test-of-cure visit (7-14 days after the end of therapy; 12·5% non-inferiority margin). Both endpoints were assessed in the intention-to-treat population. Investigators, study staff, patients, and patients' representatives were masked to treatment assignment. Safety was assessed in all randomly assigned patients who received study treatment. This trial was registered with ClinicalTrials.gov, NCT02070757. FINDINGS Between Jan 16, 2015, and April 27, 2018, 726 patients were enrolled and randomly assigned, 362 to the ceftolozane-tazobactam group and 364 to the meropenem group. Overall, 519 (71%) patients had ventilator-associated pneumonia, 239 (33%) had Acute Physiology and Chronic Health Evaluation II scores of at least 20, and 668 (92%) were in the intensive care unit. At 28 days, 87 (24·0%) patients in the ceftolozane-tazobactam group and 92 (25·3%) in the meropenem group had died (weighted treatment difference 1·1% [95% CI -5·1 to 7·4]). At the test-of-cure visit 197 (54%) patients in the ceftolozane-tazobactam group and 194 (53%) in the meropenem group were clinically cured (weighted treatment difference 1·1% [95% CI -6·2 to 8·3]). Ceftolozane-tazobactam was thus non-inferior to meropenem in terms of both 28-day all-cause mortality and clinical cure at test of cure. Treatment-related adverse events occurred in 38 (11%) of 361 patients in the ceftolozane-tazobactam group and 27 (8%) of 359 in the meropenem group. Eight (2%) patients in the ceftolozane-tazobactam group and two (1%) in the meropenem group had serious treatment-related adverse events. There were no treatment-related deaths. INTERPRETATION High-dose ceftolozane-tazobactam is an efficacious and well tolerated treatment for Gram-negative nosocomial pneumonia in mechanically ventilated patients, a high-risk, critically ill population. FUNDING Merck & Co.
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Affiliation(s)
- Marin H Kollef
- Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | | | - Ignacio Martin-Loeches
- St James's Hospital, Dublin, Ireland; Universitat de Barcelona, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Barcelona, Spain
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Lai CC, Cheng IL, Chen YH, Tang HJ. The Efficacy and Safety of Doripenem in the Treatment of Acute Bacterial Infections-A Systemic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2019; 8:jcm8070958. [PMID: 31269697 PMCID: PMC6679183 DOI: 10.3390/jcm8070958] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/16/2022] Open
Abstract
This study aims to assess the efficacy and safety of doripenem on treating patients with acute bacterial infections. The Pubmed, Embase, and Cochrane databases were searched up to April 2019. Only randomized clinical trials comparing doripenem and other comparators for the treatment of acute bacterial infection were included. The primary outcome was the clinical success rate and the secondary outcomes were microbiological eradication rate and risk of adverse events. Eight randomized controlled trials (RCTs) were included. Overall, doripenem had a similar clinical success rate with comparators (odds ratio [OR], 1.15; 95% CI, 0.79-1.66, I2 = 58%). Similar clinical success rates were noted between doripenem and comparators for pneumonia (OR, 0.84; 95% CI, 0.46-1.53, I2 = 72%) and for intra-abdominal infections (OR, 1.00; 95% CI, 0.57-1.72). For complicated urinary tract infection, doripenem was associated with higher success rate than comparators (OR, 1.89, 95% CI, 1.13-3.17, I2 = 0%). The pool analysis comparing doripenem and other carbapenems showed no significant differences between each other (OR, 0.96, 95% CI, 0.59-1.58, I2 = 63%). Doripenem also had a similar microbiological eradication rate with comparators (OR, 1.08; 95% CI, 0.86-1.36, I2 = 0%). Finally, doripenem had a similar risk of treatment-emergent adverse events as comparators (OR, 0.98; 95% CI, 0.83-1.17, I2 = 33%). In conclusion, the clinical efficacy of doripenem is as high as that of the comparator drugs in the treatment of acute bacterial infection; furthermore, this antibiotic is as well tolerated as the comparators.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying 73657, Taiwan
| | - I-Ling Cheng
- Department of Pharmacy, Chi Mei Medical Center, Liouying 73657, Taiwan
| | - Yu-Hung Chen
- Department of Pharmacy, Chi Mei Medical Center, Liouying 73657, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan 71004, Taiwan.
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sarda C, Fazal F, Rello J. Management of ventilator-associated pneumonia (VAP) caused by resistant gram-negative bacteria: which is the best strategy to treat? Expert Rev Respir Med 2019; 13:787-798. [PMID: 31210549 DOI: 10.1080/17476348.2019.1632195] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Treatment of ventilator-associated pneumonia (VAP) is a major challenge. The increase in multi-drug resistant bacteria has not been accompanied by the validation of new drugs, or by any new antimicrobial strategies to exploit the available agents. VAP due to Gram-negative bacteria has increased mortality, both due to the resistant pathogens themselves and due to inappropriate treatment. Local epidemiology, patients' characteristics and clinical responses provide the most important information for therapeutic decision-making. Moreover, data on VAP therapy due to resistant bacteria are lacking, and the choice of treatment is often based on clinical practice and individual experience. Areas covered: This review summarizes the strategies available for treating the three most prevalent resistant Gram-negative organisms causing VAP: Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae. The review covers the results of a Pubmed search, clinical practice guidelines and reviews, and the authors' experience. Expert opinion: The existing evidence focuses on bloodstream infections or other sites rather than pneumonia and there are no recommendations for the treatment of VAP by multi-drug resistant Gram-negative bacteria, especially for combination regimens. The approval of new drugs is needed to provide effective and safe alternatives for treating carbapenemase-producing strains. Precision medicine and personalized approach are also fundamental in future research.
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Affiliation(s)
- Cristina Sarda
- a Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, University of Pavia , Pavia , Italy
| | - Farhan Fazal
- b Department of Medicine and Microbiology (Infectious Disease), All India Institute of Medical Science (AIIMS) New Delhi , New Delhi , India
| | - Jordi Rello
- c Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Motos A, Yang H, Yang M, Torres A. Perspectives on synthetic pharmacotherapy for the treatment of nosocomial pneumonia. Expert Opin Pharmacother 2019; 20:1439-1448. [PMID: 31095426 DOI: 10.1080/14656566.2019.1617852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Nosocomial pneumonia is the second most common infection in hospital settings, resulting in substantial increases in morbidity, mortality, and length of hospital stay. The rapid increase in resistance of nosocomial pathogens to many antibiotics and the high dissemination of resistance genes highlight the need for innovative approaches to combat difficult-to-treat nosocomial respiratory infections. Areas covered: This review summarizes the synthetic antimicrobials that are currently in development for the treatment of nosocomial pneumonia, focusing on antibiotics in the final phases of clinical development and on the strategies employed by novel synthetic antimicrobial peptides. Expert opinion: Several novel synthetic antimicrobials are currently in the pipeline, and it appears that new antimicrobial peptides or mimetics will soon be made available, expanding the opportunities to treat nosocomial pneumonia. However, the approval process for use in the treatment of nosocomial pneumonia is arduous. Given that significant investments by pharmaceutical companies have ended in failure to obtain the approval of regulatory agencies, novel platforms for antimicrobial discovery are needed. The identification of new and fully synthetic chemical structures with activity against nosocomial pathogens needs to be followed by preclinical studies in large animals and by pharmacokinetic and pharmacodynamic studies in specific critically ill populations to assess lung penetration.
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Affiliation(s)
- Ana Motos
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer , Barcelona , Spain.,Faculty of Medicine, University of Barcelona , Barcelona , Spain
| | - Hua Yang
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain
| | - Minlan Yang
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Faculty of Medicine, University of Barcelona , Barcelona , Spain
| | - Antoni Torres
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer , Barcelona , Spain.,Faculty of Medicine, University of Barcelona , Barcelona , Spain
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Liu WD, Shih MC, Chuang YC, Wang JT, Sheng WH. Comparative efficacy of doripenem versus meropenem for hospital-acquired and ventilator-associated pneumonia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:788-795. [PMID: 31155463 DOI: 10.1016/j.jmii.2019.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/15/2019] [Accepted: 04/19/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Doripenem shows good in vitro activity against common nosocomial pathogens, such as extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii. However, the use of doripenem for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains controversial. The aim of this study was to compare the efficacy and safety between doripenem and meropenem for patients with HAP or VAP. METHODS Adult patients diagnosed with HAP and VAP at National Taiwan University Hospital, who received doripenem or meropenem for more than 48 h between January 2015 and November 2017, were retrospectively reviewed. All-cause mortality on the 30th day was used as the primary outcome measurements. RESULTS Fifty-seven patients with doripenem and 252 patients with meropenem were analyzed. Compared to the meropenem group, the doripenem group was younger and had a higher Sequential Organ Failure Assessment (SOFA) score. Multivariable Cox regression analysis revealed that presence of solid organ malignancies (adjusted hazard ratio [AHR], 1.82; 95% CI, 1.04-3.19, p = 0.003) and SOFA score (AHR, 1.10; 95% CI, 1.03-1.17, p = 0.003) were independent factors associated with mortality. There was no survival difference of 30-day mortality between patients receiving doripenem and meropenem for HAP or VAP (log-rank p = 0.113). However, a poorer outcome was observed among patients with hematological disease in the doripenem group (log-rank p = 0.012). CONCLUSION Our results demonstrate that doripenem has similar efficacy as meropenem in HAP or VAP patients. With an aim to enhance antibiotic diversity, doripenem could be an alternative choice for patients with HAP or VAP, except for those with hematological malignancies.
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Affiliation(s)
- Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Tansarli GS, Andreatos N, Pliakos EE, Mylonakis E. A Systematic Review and Meta-analysis of Antibiotic Treatment Duration for Bacteremia Due to Enterobacteriaceae. Antimicrob Agents Chemother 2019; 63:e02495-18. [PMID: 30803971 PMCID: PMC6496097 DOI: 10.1128/aac.02495-18] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/14/2019] [Indexed: 11/20/2022] Open
Abstract
The duration of antibiotic therapy for bacteremia due to Enterobacteriaceae is not well defined. We sought to evaluate the clinical outcomes with shorter- versus longer-course treatment. We performed a systematic search of the PubMed and EMBASE databases through May 2018. Studies presenting comparative outcomes between patients receiving antibiotic treatment for ≤10 days ("short-course") and those treated for >10 days ("long-course") were considered eligible. Four retrospective cohort studies and one randomized controlled trial comprising 2,865 patients met the inclusion criteria. The short- and long-course antibiotic treatments did not differ in 30-day all-cause mortality (1,374 patients; risk ratio [RR] = 0.99; 95% confidence interval [CI], 0.69 to 1.43), 90-day all-cause mortality (1,750 patients; RR = 1.16; 95% CI, 0.81 to 1.66), clinical cure (1,080 patients; RR = 1.02; 95% CI, 0.96 to 1.08), or relapse at 90 days (1,750 patients; RR = 1.08; 95% CI, 0.69 to 1.67). In patients with bacteremia due to Enterobacteriaceae, the short- and long-course antibiotic treatments did not differ significantly in terms of clinical outcomes. Further well-designed studies are needed before treatment for 10 days or less is adopted in clinical practice.
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Affiliation(s)
- Giannoula S Tansarli
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nikolaos Andreatos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Elina E Pliakos
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, 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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Caffrey AR, Babcock ZR, Lopes VV, Timbrook TT, LaPlante KL. Heterogeneity in the treatment of bloodstream infections identified from antibiotic exposure mapping. Pharmacoepidemiol Drug Saf 2019; 28:707-715. [PMID: 30916833 PMCID: PMC6593441 DOI: 10.1002/pds.4761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 01/24/2019] [Accepted: 02/11/2019] [Indexed: 11/10/2022]
Abstract
Purpose As changes in antibiotic therapy are common, intent‐to‐treat and definitive therapy exposure definitions in infectious disease clinical trials and observational studies may not accurately reflect all antibiotics received over the course of the infection. Therefore, we sought to describe changes in antibiotic therapy and unique treatment patterns among patients with bacteremia. Methods We conducted a retrospective cohort study of hospitalizations from Veterans Affairs (VA) Medical Centers (January 2002‐September 2015) and community hospitals (de‐identified Optum Clinformatics DataMart with matched Premier Hospital data; October 2009‐March 2013). In the VA population, antibiotic exposures were mapped from the culture collection date among those with positive Staphylococcus aureus cultures. In the Optum‐Premier population, exposures were mapped from the admission date among those with a primary diagnosis of bacteremia. Results Our study included 50 467 bacteremia admissions, with only 14% of admissions having the same treatment pattern as another admission. For every 100 bacteremia admissions, 89 had changes in antibiotic therapy. For every 100 bacteremia admissions with changes in therapy, 95 had unique antibiotic treatment patterns. These findings were consistent in both populations, over time, and among different facilities within study populations. The median time to first therapy change was 2 days after initial therapy, with a median of three changes. Conclusions Changes in antibiotic therapy for bloodstream infections were nearly universal regardless of hospital setting. Based on our findings, common antibiotic exposure definitions of intent‐to‐treat and definitive therapy would misclassify exposure in 86% of admissions, which highlights the need for better operational definitions of exposure in infectious diseases research.
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Affiliation(s)
- Aisling R Caffrey
- Infectious Diseases Research Program and Center of Innovation in Long-term Services and Supports, Veterans Affairs Medical Center, Providence, Rhode Island, USA.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA.,Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Zachary R Babcock
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program and Center of Innovation in Long-term Services and Supports, Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Tristan T Timbrook
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program and Center of Innovation in Long-term Services and Supports, Veterans Affairs Medical Center, Providence, Rhode Island, USA.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
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64
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The Answer for Inhaled Antibiotics in Pneumonia Is Still Blowing in the Wind. Chest 2019; 151:1201-1203. [PMID: 28599925 DOI: 10.1016/j.chest.2016.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 12/29/2022] Open
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Hammond DA, McCreary EK, Rech MA, Smith MN, Yeo QM, Lusardi K, Rhodes NJ, Swanson JM, Bland CM. Perceptions and practices for beta-lactam antibiotic dosing, administration, and monitoring in critically ill patients: Current views and use among critical care and infectious diseases pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Drayton A. Hammond
- Department of Pharmacy; Rush University Medical Center; Chicago Illinois
| | - Erin K. McCreary
- Department of Pharmacy; University of Wisconsin Health; Madison Wisconsin
| | - Megan A. Rech
- Department of Pharmacy; Loyola University Medical Center; Chicago Illinois
| | - Melanie N. Smith
- Department of Pharmacy; Medical University of South Carolina; Charleston South Carolina
| | - Qiu Min Yeo
- Department of Pharmacy; Changi General Hospital; Simei Singapore
| | - Katherine Lusardi
- Department of Pharmacy; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Nathaniel J. Rhodes
- Department of Pharmacy Practice; Midwestern University; Downers Grove Illinois
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
| | - Joseph M. Swanson
- Department of Pharmacy Practice; University of Tennessee College of Pharmacy; Memphis Tennessee
| | - Christopher M. Bland
- Department of Pharmacy Practice; University of Georgia College of Pharmacy; Savannah Georgia
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66
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Chen L, Su Y, Quan L, Zhang Y, Du L. Clinical Trials Focusing on Drug Control and Prevention of Ventilator-Associated Pneumonia: A Comprehensive Analysis of Trials Registered on ClinicalTrials.gov. Front Pharmacol 2019; 9:1574. [PMID: 30863312 PMCID: PMC6399618 DOI: 10.3389/fphar.2018.01574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 12/31/2018] [Indexed: 02/05/2023] Open
Abstract
Objective: Clinical trials have emerged as the main force in driving the development of medicine. However, little is known about the current status of clinical trials regarding drug control and prevention of ventilator-associated pneumonia (VAP). This study aimed at providing a comprehensive landscape of these trials on the basis of ClinicalTrials.gov. Methods: A cross-sectional, descriptive study of clinical trials on drug control and prevention of VAP which have been registered on the ClinicalTrials.gov up to 25th August 2018 was conducted. Results: A total of 109 eligible trials were identified. Trials were started from 1998 to 2018, and most trials focused on adult patients. More than half trials were completed, while only 11.9% trials had results available. Sample sizes were relatively large, with a median enrollment of 146. Universities were listed as the primary sponsor for 36.7% trials, industry for 28.4% trials and hospitals for 19.3% trials. Of the 109 VAP trials, 37 trials were from in Europe, 36 in North America and 27 in Asia. Among the 97 interventional trials, 32 were phase 3 trials, 21 were phase 4 trials, and 16 were phase 2 trials. Most interventional trials were randomized trials with a parallel assignment, and 57.7% trials were blinded. Of the 12 observational trials, 9 were cohort studies, and 10 trials were prosepctive studies. Drugs about oral care, preemptive antibiotics and probiotics were most investigated for prevention. A total of 61 trials investigated drugs for the treatment of VAP, mainly focused on antibiotics. A total of 36 kinds of antibiotics were investigated for monotherapy or combination therapy. Beta-lactams were most studied, followed by aminoglycosides and polypeptides. Conclusion: Most clinical trials registered on ClinicalTrials.gov about drugs for VAP were interventional trials with the purpose for treatment. A high proportion of interventional trials were randomized, parallel assigned and masked. Our analysis highlights the need for improvement in completeness of study results on the ClinicalTrials.gov.
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Affiliation(s)
- Lingmin Chen
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yanling Su
- Unit of General Practice, West China Hospital, Sichuan University, Chengdu, China
| | - Liuliu Quan
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yonggang Zhang
- Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Du
- Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
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67
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Peri AM, Doi Y, Potoski BA, Harris PNA, Paterson DL, Righi E. Antimicrobial treatment challenges in the era of carbapenem resistance. Diagn Microbiol Infect Dis 2019; 94:413-425. [PMID: 30905487 DOI: 10.1016/j.diagmicrobio.2019.01.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/14/2019] [Accepted: 01/28/2019] [Indexed: 12/22/2022]
Abstract
Infections due to carbapenem-resistant Gram-negative bacteria are burdened by high mortality and represent an urgent threat to address. Clinicians are currently at a dawn of a new era in which antibiotic resistance in Gram-negative bacilli is being dealt with by the availability of the first new antibiotics in this field for many years. Although new antibiotics have shown promising results in clinical trials, there is still uncertainty over whether their use will improve clinical outcomes in real world practice. Some observational studies have reported a survival benefit in carbapenem-resistant Enterobacteriaceae bloodstream infections using combination therapy, often including "old" antibiotics such as colistin, aminoglycosides, tigecycline, and carbapenems. These regimens, however, are linked to increased risk of antimicrobial resistance, and their efficacy has yet to be compared to new antimicrobial options. While awaiting more definitive evidence, antibiotic stewards need clear direction on how to optimize the use of old and novel antibiotic options. Furthermore, carbapenem-sparing regimens should be carefully considered as a potential tool to reduce selective antimicrobial pressure.
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Affiliation(s)
- Anna Maria Peri
- Infectious Diseases Unit, Department of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy; The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Yohei Doi
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian A Potoski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, PA, USA
| | - Patrick N A Harris
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - David L Paterson
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Elda Righi
- The University of Queensland Centre for Clinical Research (UQCCR), Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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Burgos J, Falcó V, Almirante B. Chemical pharmacotherapy for hospital-acquired pneumonia in the elderly. Expert Opin Pharmacother 2019; 20:423-434. [PMID: 30614744 DOI: 10.1080/14656566.2018.1559820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Hospital-acquired pneumonia (HAP) is a potentially serious infection that primarily affects older patients. The number of patients affected by multidrug-resistant (MDR) bacteria is increasing, including infection from strains of Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa. AREAS COVERED This article focuses specifically on HAP, excluding patients afflicted by ventilator-associated pneumonia (VAP). The pathogenesis and clinical features of HAP in the elderly are discussed as well as specific drug pharmacokinetic and pharmacodynamic considerations in elderly patients. The current recommended guidelines for the management of HAP are also discussed. Finally, the authors provide evidence on the empirical therapy used for the treatment of HAP and widely consider specific-pathogen treatment of HAP in elderly patients. EXPERT OPINION In patients not at risk of MDR organism infection, antibiotics including piperacillin-tazobactam, cefepime, carbapenems or fluorquinolones are recommended. However, the emergence of MDR organisms as causal agents of HAP makes it necessary to accurately assess risk factors to these pathogens and revise our knowledge on specific antimicrobial susceptibility patterns from each institution. The authors believe that broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are best recommended in elderly patients at risk of HAP infection by MDR strains.
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Affiliation(s)
- Joaquin Burgos
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
| | - Vicenç Falcó
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
| | - Benito Almirante
- a Infectious Diseases Department , University Hospital Vall d'Hebron, Autonomous University of Barcelona , Barcelona , Spain
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Pharmacokinetics of Doripenem in Healthy Koreans and Monte Carlo Simulations to Explore Optimal Dosage Regimens in Patients With Normal and Enhanced Renal Function. Ther Drug Monit 2018; 40:425-434. [PMID: 29746394 PMCID: PMC6075885 DOI: 10.1097/ftd.0000000000000528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Dose adjustment is often required in patients with normal or enhanced renal function. The aim of this study is to investigate the pharmacokinetic (PK) properties of doripenem and explore optimal dosing regimens in patients with normal or enhanced renal function according to various minimum inhibitory concentrations (MICs). Methods: The authors conducted a clinical trial and analyzed PK samples in 11 healthy Korean subjects applying noncompartmental analysis and a population approach. The population PK parameter estimates were used in Monte Carlo simulations to explore optimal dosing regimens for a probability of target attainment of 90% at 40% fTMIC (free drug concentrations above MIC). Results: The time course of doripenem concentrations was well described by a 2-compartment model. The population typical values of clearance and steady-state volume were 22.9 L/h and 19.1 L, respectively, and were consistent with our noncompartmental analysis results. When the MIC was greater than 1 mcg/mL, at least increasing the dose or prolonging the infusion time was essential in patients with normal or enhanced renal function. Conclusions: These results suggest that dosage adjustment such as increasing the dose or lengthening the infusion time should be considered in patients with normal or enhanced renal function.
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71
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[Hospital-acquired pneumonia]. Med Klin Intensivmed Notfmed 2018; 113:685-695. [PMID: 30302527 DOI: 10.1007/s00063-018-0494-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/10/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
Hospital-acquired pneumonia (HAP) is a frequent complication of hospitalisation. Due to rising multidrug resistant bacteria an appropriate, empiric and targeted therapy is essential and requires an accurate assessment of risk for multidrug resistant bacteria. A targeted, temporal therapy is indispensable and should begin after a focussed diagnosis. Re-evaluation of therapy is important, as clinical course, microbiological and laboratory results might lead to de-escalation of therapy. In this review article the current German guidelines on the diagnosis and therapy of hospital-acquired pneumonia are summarized. Special focus is put on targeted, risk-adapted therapy.
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72
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Shortened Courses of Antibiotics for Bacterial Infections: A Systematic Review of Randomized Controlled Trials. Pharmacotherapy 2018; 38:674-687. [DOI: 10.1002/phar.2118] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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73
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Royer S, DeMerle KM, Dickson RP, Prescott HC. Shorter Versus Longer Courses of Antibiotics for Infection in Hospitalized Patients: A Systematic Review and Meta-Analysis. J Hosp Med 2018; 13:336-342. [PMID: 29370318 PMCID: PMC5945333 DOI: 10.12788/jhm.2905] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Infection is a leading cause of hospitalization with high morbidity and mortality, but there are limited data to guide the duration of antibiotic therapy. PURPOSE Systematic review to compare outcomes of shorter versus longer antibiotic courses among hospitalized adults and adolescents. DATA SOURCES MEDLINE and Embase databases, 1990-2017. STUDY SELECTION Inclusion criteria were human randomized controlled trials (RCTs) in English comparing a prespecified short course of antibiotics to a longer course for treatment of infection in hospitalized adults and adolescents aged 12 years and older. DATA EXTRACTION Two authors independently extracted study characteristics, methods of statistical analysis, outcomes, and risk of bias. DATA SYNTHESIS Of 5187 unique citations identified, 19 RCTs comprising 2867 patients met our inclusion criteria, including the following: 9 noninferiority trials, 1 superiority design trial, and 9 pilot studies. Across 13 studies evaluating 1727 patients, no significant difference in clinical efficacy was observed (d = 1.6% [95% confidence interval (CI), -1.0%-4.2%]). No significant difference was detected in microbiologic cure (8 studies, d = 1.2% [95% CI, -4.1%-6.4%]), short-term mortality (8 studies, d = 0.3% [95% CI, -1.2%-1.8%]), longer-term mortality (3 studies, d = -0.4% [95% CI, -6.3%-5.5%]), or recurrence (10 studies, d = 2.1% [95% CI, -1.2%-5.3%]). Heterogeneity across studies was not significant for any of the primary outcomes. CONCLUSIONS Based on the available literature, shorter courses of antibiotics can be safely utilized in hospitalized patients with common infections, including pneumonia, urinary tract infection, and intra-abdominal infection, to achieve clinical and microbiologic resolution without adverse effects on mortality or recurrence.
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Affiliation(s)
- Stephanie Royer
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kimberley M DeMerle
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert P Dickson
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Rhodes NJ, Cruce CE, O'Donnell JN, Wunderink RG, Hauser AR. Resistance Trends and Treatment Options in Gram-Negative Ventilator-Associated Pneumonia. Curr Infect Dis Rep 2018; 20:3. [PMID: 29511909 DOI: 10.1007/s11908-018-0609-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Hospital-acquired and ventilator-associated pneumonia (VAP) are frequent causes of infection among critically ill patients. VAP is the most common hospital-acquired bacterial infection among mechanically ventilated patients. Unfortunately, many of the nosocomial Gram-negative bacteria that cause VAP are increasingly difficult to treat. Additionally, the evolution and dissemination of multi- and pan-drug resistant strains leave clinicians with few treatment options. VAP patients represent a dynamic population at risk for antibiotic failure and under-dosing due to altered antibiotic pharmacokinetic parameters. Since few antibiotic agents have been approved within the last 15 years, and no new agents specifically targeting VAP have been approved to date, it is anticipated that this problem will worsen. Given the public health crisis posed by resistant Gram-negative bacteria, it is essential to establish a firm understanding of the current epidemiology of VAP, the changing trends in Gram-negative resistance in VAP, and the current issues in drug development for Gram-negative bacteria that cause VAP. RECENT FINDINGS Rapid identification technologies and phenotypic methods, new therapeutic strategies, and novel treatment paradigms have evolved in an attempt to improve treatment outcomes for VAP; however, clinical data supporting alternative treatment strategies and adjunctive therapies remain sparse. Importantly, new classes of antimicrobials, novel virulence factor inhibitors, and beta-lactam/beta-lactamase inhibitor combinations are currently in development. Conscientious stewardship of new and emerging therapeutic agents will be needed to ensure they remain effective well into the future.
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Affiliation(s)
- Nathaniel J Rhodes
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, 555 31st St., Downers Grove, IL, 60515, USA. .,Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.
| | - Caroline E Cruce
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, 555 31st St., Downers Grove, IL, 60515, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - J Nicholas O'Donnell
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Richard G Wunderink
- Department of Internal Medicine, Division of Pulmonary Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alan R Hauser
- Department of Internal Medicine, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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76
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Heffernan A, Lipman J, Roberts J. Re: 'Is a randomized trial of a short course of aminoglycoside added to β-lactam antibiotics for empirical treatment in critically ill patients with sepsis justified?' Pharmacokinetic/pharmacodynamic considerations. Clin Microbiol Infect 2018; 24:666-667. [PMID: 29309932 DOI: 10.1016/j.cmi.2017.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- A Heffernan
- School of Medicine, Griffith University, Gold Coast, Qld, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, Qld, Australia
| | - J Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia; Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - J Roberts
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia; Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.
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77
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Rodvold KA, Hope WW, Boyd SE. Considerations for effect site pharmacokinetics to estimate drug exposure: concentrations of antibiotics in the lung. Curr Opin Pharmacol 2017; 36:114-123. [PMID: 29096171 DOI: 10.1016/j.coph.2017.09.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/25/2017] [Accepted: 09/29/2017] [Indexed: 12/18/2022]
Abstract
Bronchoalveolar lavage (BAL) and microdialysis have become the most reliable and relevant methods for measuring lung concentrations of antibiotics, with the majority of BAL studies involving either healthy adult subjects or patients undergoing diagnostic bronchoscopy. Emphasis on the amount of drug that reaches the site of infection is increasingly recognized as necessary to determine whether a dose selection will translate to good clinical outcomes in the treatment of patients with pneumonia. Observed concentrations and/or parameters of exposure (e.g. area-under-the-curve) need to be incorporated with pharmacokinetic-pharmacodynamic indices so that rational dose selection can be identified for specific pathogens and types of pneumonic infection (community-acquired vs hospital-acquired bacterial pneumonia, including ventilator-associated bacterial pneumonia). Although having measured plasma or lung concentration-time data from critically ill patients to incorporate into pharmacokinetic-pharmacodynamic models is very unlikely during drug development, it is essential that altered distribution, augmented renal clearance, and renal or hepatic dysfunction should be considered. Notably, the number of published studies involving microdialysis and intrapulmonary penetration of antibiotics has been limited and mainly involve beta-lactam agents, levofloxacin, and fosfomycin. Opportunities to measure in high-resolution effect site spatial pharmacokinetics (e.g. with MALDI-MSI or PET imaging) and in vivo continuous drug concentrations (e.g. with aptamer-based probes) now exist. Going forward these studies could be incorporated into antibiotic development programs for pneumonia in order to further increase the probability of candidate success.
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Affiliation(s)
- Keith A Rodvold
- Colleges of Pharmacy and Medicine, University of Illinois at Chicago, Chicago, IL, USA.
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Sara E Boyd
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK; Division of Infectious Diseases & Immunity, Imperial College London, London, UK
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78
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Oesterreicher Z, Minichmayr I, Sauermann R, Marhofer D, Lackner E, Jäger W, Maier-Salamon A, Schwameis R, Kloft C, Zeitlinger M. Pharmacokinetics of doripenem in plasma and epithelial lining fluid (ELF): comparison of two dosage regimens. Eur J Clin Pharmacol 2017; 73:1609-1613. [PMID: 28920154 PMCID: PMC5684299 DOI: 10.1007/s00228-017-2327-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/22/2017] [Indexed: 11/30/2022]
Abstract
Purpose In 2014, FDA released a warning for prescription of doripenem for ventilator-associated bacterial pneumonia due to unsatisfactory clinical cure rates. The present study explores if the observed lack of efficacy might be explained by insufficient target site pharmacokinetics in intensive care patients after two different infusion schemes. Methods Plasma and bronchoalveolar lavage sampling was performed in 16 intubated patients with pneumonia receiving doripenem either as 1-h or as 4-h infusion. Doripenem concentrations were measured at steady state in plasma over 8 h, bronchoalvoelar lavage was performed in each patient once either after 0 h, 2 h, 4 h or 6 h. Results In plasma, mean values of Cmax, Tmax and AUC0–8 were 16.87 mg/L, 0.69 h and 52.98 mg/L×h after 1 h of infusion, and 12.94 mg/L, 3.21 h and 70.64 mg/L×h after 4 h of infusion, respectively. While the later tmax in plasma was with delay mirrored in the lung, for ELF, much lower concentrations were observed (Cmax, Tmax and AUC0–8 after 1-h infusion of 4.6 mg/L, 2 h and 15.3 mg/L×h and after 4-h infusion 6.9 mg/L, 4 h and 14.8 mg/L×h). Conclusion The difference in plasma pharmacokinetics after 1-h and 4-h infusion reflects in the concentration versus time profile in the lung, but concentration at the target site was not only considerably lower but also subject to high inter-individual variability. We hypothesise that insufficient concentrations at the target site might have contributed to the previously described lack of clinical efficacy and confirmed the demand for assessment of target site pharmacokinetics in larger patient collectives.
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Affiliation(s)
- Zoe Oesterreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Iris Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Robert Sauermann
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Daniela Marhofer
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Edith Lackner
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Walter Jäger
- Department of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, Austria
| | | | - Richard Schwameis
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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79
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Kollef MH, Bassetti M, Francois B, Burnham J, Dimopoulos G, Garnacho-Montero J, Lipman J, Luyt CE, Nicolau DP, Postma MJ, Torres A, Welte T, Wunderink RG. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 2017; 43:1187-1197. [PMID: 28160023 PMCID: PMC6204331 DOI: 10.1007/s00134-017-4682-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/06/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Bruno Francois
- Service de Réanimation Polyvalente, Inserm CIC-1435, CHU Dupuytren, Limoges, France
| | - Jason Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - George Dimopoulos
- Department of Critical Care, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Seville, Spain
- Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, Australia
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Herston, Brisbane, QLD, Australia
| | - Charles-Edouard Luyt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS 1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-infective Research and Development and Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Maarten J Postma
- Unit of PharmacoTherapy, Epidemiology & Economics, Department of Pharmacy and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antonio Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, CIBERES, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Tobias Welte
- Department of Pulmonology, Hannover Medical School, Hannover, Germany
| | - Richard G Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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80
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Garnacho-Montero J, Arenzana-Seisdedos A, De Waele J, Kollef MH. To which extent can we decrease antibiotic duration in critically ill patients? Expert Rev Clin Pharmacol 2017; 10:1215-1223. [PMID: 28837364 DOI: 10.1080/17512433.2017.1369879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Inadequate empirical antibiotic therapy is associated with higher mortality in critically ill patients with severe infections. Nevertheless, prolonged duration of antibiotic treatment is also potentially harmful. Development of new infections with more resistant pathogens is one of the arguments against the administration of prolonged courses of antibiotics. Areas covered: We aim to describe the optimal duration of antimicrobial therapy in the most common infections affecting critically ill patients. A literature search was performed to identify all clinical trials, observational studies, meta-analysis, and reviews about this topic from PubMed. Expert commentary: Diverse observational studies have reported a poor outcome in critically ill patients without a documented infection who receive prolonged antibiotic therapy. We summarize the available information about the optimal duration of antimicrobial therapy in critically ill patients with severe infections including community-acquired pneumonia, intra-abdominal infections, bacteremia, meningitis and urinary-tract infections as well as the clinical consequences of short antimicrobial courses in certain severe infections. The utility of procalcitonin to reduce the duration of antibiotics is also discussed. Finally, we give clear recommendations about the length of treatment for the most common infections in critically ill patients.
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Affiliation(s)
- José Garnacho-Montero
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain
| | - Angel Arenzana-Seisdedos
- a Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena , Sevilla , Spain
| | - Jan De Waele
- b Department of Critical Care Medicine , Ghent University Hospital , Ghent , Belgium
| | - Marin H Kollef
- c Pulmonary and Critical Care Division , Washington University School of Medicine , St. Louis MO , USA
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81
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Nebulized antibiotics in mechanically ventilated patients: a challenge for translational research from technology to clinical care. Ann Intensive Care 2017; 7:78. [PMID: 28766281 PMCID: PMC5539056 DOI: 10.1186/s13613-017-0301-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/17/2017] [Indexed: 01/20/2023] Open
Abstract
Nebulized antibiotic therapy directly targets airways and lung parenchyma resulting in high local concentrations and potentially lower systemic toxicities. Experimental and clinical studies have provided evidence for elevated lung concentrations and rapid bacterial killing following the administration of nebulized antibiotics during mechanical ventilation. Delivery of high concentrations of antibiotics to infected lung regions is the key to achieving efficient nebulized antibiotic therapy. However, current non-standardized clinical practice, the difficulties with implementing optimal nebulization techniques and the lack of robust clinical data have limited its widespread adoption. The present review summarizes the techniques and clinical constraints for optimal delivery of nebulized antibiotics to lung parenchyma during invasive mechanical ventilation. Pulmonary pharmacokinetics and pharmacodynamics of nebulized antibiotic therapy to treat ventilator-associated pneumonia are discussed and put into perspective. Experimental and clinical pharmacokinetics and pharmacodynamics support the use of nebulized antibiotics. However, its clinical benefits compared to intravenous therapy remain to be proved. Future investigations should focus on continuous improvement of nebulization practices and techniques. Before expanding its clinical use, careful design of large phase III randomized trials implementing adequate therapeutic strategies in targeted populations is required to demonstrate the clinical effectiveness of nebulized antibiotics in terms of patient outcomes and reduction in the emergence of antibiotic resistance.
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82
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Association between augmented renal clearance and clinical failure of antibiotic treatment in brain-injured patients with ventilator-acquired pneumonia: A preliminary study. Anaesth Crit Care Pain Med 2017; 37:35-41. [PMID: 28756331 DOI: 10.1016/j.accpm.2017.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This preliminary study aimed to determine whether augmented renal clearance (ARC) impacts negatively on the clinical outcome in traumatic brain-injured patients (TBI) treated for a first episode of ventilator-acquired pneumonia (VAP). METHODS During a 5-year period, all TBI patients who had developed VAP were retrospectively reviewed to assess variables associated with clinical failure in multivariate analysis. Clinical failure was defined as an impaired clinical response with a need for escalating antibiotics during treatment and/or within 15 days after the end-of-treatment. Recurrence was considered if at least one of the initial causative bacterial strains was growing at a significant concentration from a second sample. Augmented renal clearance (ARC) was defined by an enhanced creatinine clearance exceeding 130mL/min/1.73m2 calculated from a urinary sample during the first three days of antimicrobial therapy. MAIN RESULTS During the study period, 223 TBI patients with VAP were included and 59 (26%) presented a clinical failure. Factors statistically associated with clinical failure were GSC≤7 (OR=2.2 [1.1-4.4], P=0.03), early VAP (OR=3.9 [1.9-7.8], P=0.0001), bacteraemia (OR=11 [2.2-54], P=0.003) and antimicrobial therapy≤7 days (OR=3.7 [1.8-7.4], P=0.0003). ARC was statistically associated with recurrent infections with an OR of 4.4 [1.2-16], P=0.03. CONCLUSION ARC was associated with recurrent infection after a first episode of VAP in TBI patients. The optimal administration and dosing of the antimicrobial agents in this context remain to be determined.
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83
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Ambrose PG. Antibacterial drug development program successes and failures: a pharmacometric explanation. Curr Opin Pharmacol 2017; 36:1-7. [PMID: 28688237 DOI: 10.1016/j.coph.2017.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/17/2017] [Indexed: 10/19/2022]
Abstract
My thesis is a simple one. We have not been doing a good enough job selecting dose regimens for serious infections during the drug development process. If we are to do a better job in the future, we need to revisit some uncomfortable places. That is, some notable program failures. To be clear, we are not revisiting program failures to make anyone uncomfortable or cast aspersions - but rather so that we sow the seeds for a better future. To that end, we will examine program failures and successes through a pharmacometric lens. Through this powerful lens, we will come to understand that many of our failures were not only predictable, but perhaps expected and entirely avoidable. The goal of this communication is to set forth the type of thinking and data that is necessary for rational dose selection.
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84
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Population Pharmacokinetic Analysis of Doripenem after Intravenous Infusion in Korean Patients with Acute Infections. Antimicrob Agents Chemother 2017; 61:AAC.02185-16. [PMID: 28223378 DOI: 10.1128/aac.02185-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 02/12/2017] [Indexed: 11/20/2022] Open
Abstract
We investigated the population pharmacokinetics (PK) of doripenem in Korean patients with acute infections and determined an appropriate dosing regimen using a Monte Carlo simulation for predicting pharmacodynamics (PD). Patients (n = 37) with a creatinine clearance (CLCR) of 20 to 50 ml/min or >50 ml/min who received a 250-mg or 500-mg dose of doripenem over the course of 1 h every 8 h, respectively, were included in this study. Blood samples were taken predosing and 0 h, 0.5 h, and 4 to 6 h after the fourth infusion. A nonlinear mixed-effect modeling tool was used for the PK analysis and pharmacodynamic simulation; doripenem PK were well described by a one-compartment model. The population mean values of the body weight (WT)-normalized clearance (CL/WT) and the body weight-normalized volume of distribution (V/WT) were 0.109 liter/h/kg of body weight (relative standard error, 9.197%) and 0.280 liter/kg (relative standard error, 9.56%), respectively. Doripenem CL was significantly influenced by CLCR The proposed equation to estimate doripenem CL in Korean patients was CL/WT = 0.109 × WT × (CLCR/57)0.688, where CL/WT is in liters per hour per kilogram. CL in Korean patients was expected to be lower than that in Caucasian patients, regardless of renal function. The Monte Carlo simulation showed that 90% attainment of target PK/PD magnitudes could be achieved with the usual dosing regimens when the MIC was ≤1 mg/liter. However, prolonged infusions (4 h) should be considered, especially when patients have augmented renal function and for patients infected with pathogens with a high MIC. Our results provide an individualized doripenem dosing regimen for patients with various renal functions and for patients infected with bacteria with decreased susceptibility.
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85
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Continuous and Prolonged Intravenous β-Lactam Dosing: Implications for the Clinical Laboratory. Clin Microbiol Rev 2017; 29:759-72. [PMID: 27413094 DOI: 10.1128/cmr.00022-16] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Beta-lactam antibiotics serve as a cornerstone in the management of bacterial infections because of their wide spectrum of activity and low toxicity. Since resistance rates among bacteria are continuously on the rise and the pipeline for new antibiotics does not meet this trend, an optimization of current beta-lactam treatment is needed. This review provides an overview of optimization through use of prolonged- and continuous-infusion dosing strategies compared with more traditional intermittent infusions. Included is an overview of the scientific basis for using these nontraditional prolonged- and continuous-infusion-based regimens, with a focus on major areas in which the clinical laboratory can support the clinical use of these regimens.
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86
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Yilmaz G, Salyan S, Aksoy F, Köksal İ. Individualized antibiotic therapy in patients with ventilator-associated pneumonia. J Med Microbiol 2017; 66:78-82. [PMID: 27911257 DOI: 10.1099/jmm.0.000401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The optimal duration of the treatment of ventilator-associated pneumonia (VAP) is still the subject of debate. While 1 week treatment has been reported as possibly sufficient, patients generally receive antibiotic therapy for 10 to 14 days. The purpose of our study was to investigate whether length of treatment in patients with VAP can be reduced with an individualized therapeutic strategy. The study was performed prospectively with patients diagnosed with VAP in our hospital's intensive care units between 1 January and 31 December 2015. Duration of antibiotic therapy was determined with 5 day clinical evaluation according to previously established criteria. Patients were divided into two groups depending on length of treatment, short (7-10 days) and long treatment (>10 days). Nineteen patients received 7 to 10 day antibiotic therapy, and 30 received >10 day antibiotic therapy. Demographic and clinical characteristics, Glasgow Coma Scale score, CPIS and the PaO2/FiO2 ratio at the time of diagnosis of VAP were statistically similar between the two groups (P>0.05). A second VAP attack occurred post-treatment in three patients receiving short-term treatment and in four receiving long-term treatment (P=0.561). The numbers of antibiotic-free days were 15.6±6.2 in the short-term treatment group and 8.3±7.5 in the long-term group (P<0.0001). One of the patients receiving short-term treatment died within 28 days after treatment, and four of the patients receiving long-term treatment (P=0.348) did so. The most commonly observed micro-organisms in both groups were Acinetobacterbaumannii and Pseudomonasaeruginosa. Short-term treatment can be administered in cases with early clinical and laboratory response started on VAP treatment by considering individual characteristics and monitoring fever, CPIS, the PaO2/FiO2 ratio, C-reactive protein and procalcitonin values.
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Affiliation(s)
- Gürdal Yilmaz
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
| | - Sedat Salyan
- Department of Anesthesiology and Reanimation, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
| | - Firdevs Aksoy
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
| | - İftihar Köksal
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University Medical Faculty, Trabzon, Turkey
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87
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Metersky ML, Kalil AC. Letter to the editor: 'challenges and opportunities in the treatment of ventilator-associated pneumonia'. Expert Rev Anti Infect Ther 2017; 15:191-192. [PMID: 28117609 DOI: 10.1080/14787210.2017.1286981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Mark L Metersky
- a Department of Medicine, Division of Pulmonary and Critical Care , University of Connecticut School of Medicine , Farmington , CT , USA
| | - Andre C Kalil
- b Department of Medicine, Division of Infectious Diseases , University of Nebraska Medical Center , Omaha , NE , USA
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88
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Schreiber MP, Shorr AF. Response to: 'letter to the editor: "Challenges and opportunities in the treatment of ventilator-associated pneumonia"'. Expert Rev Anti Infect Ther 2017; 15:193. [PMID: 28118759 DOI: 10.1080/14787210.2017.1286982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Matthew P Schreiber
- a Department of Internal Medicine , Section of Pulmonary Disease Critical Care , Washington , DC , USA
| | - Andrew F Shorr
- a Department of Internal Medicine , Section of Pulmonary Disease Critical Care , Washington , DC , USA
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89
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Bouglé A, Foucrier A, Dupont H, Montravers P, Ouattara A, Kalfon P, Squara P, Simon T, Amour J. Impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia: study protocol for a randomized controlled study. Trials 2017; 18:37. [PMID: 28114979 PMCID: PMC5260072 DOI: 10.1186/s13063-017-1780-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 01/02/2017] [Indexed: 11/16/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) accounts for 25% of infections in intensive care units. Compared to a long duration (LD) of antibiotic therapy, a short duration (SD) has a comparable clinical efficacy with less antibiotic use and less multidrug-resistant (MDR) pathogen emergence, with the exception of documented VAP of non-fermenting Gram-negative bacilli (NF-GNB), including Pseudomonas aeruginosa (PA). These results have led the American Thoracic Society to recommend SD therapy for VAP, except for PA-VAP. Thus the beneficial effect of SD therapy in PA-VAP is still a matter of debate. We aimed to assess the non-inferiority of a short duration of antibiotics (8 days) versus prolonged antibiotic therapy (15 days) in PA-VAP. Methods/design The impact of the duration of antibiotics on clinical events in patients with Pseudomonas aeruginosa ventilator-associated pneumonia (iDIAPASON) trial is a randomized, open-labeled non-inferiority controlled trial, conducted in 34 French intensive care units (ICUs), comparing two groups of patients with PA-VAP according to the duration (8 days or 15 days) of effective antibiotic therapy against PA. The primary outcome is a composite endpoint combining day 90 mortality and PA-VAP recurrence rate during hospitalization in the ICU. Furthermore, durations of mechanical ventilation and hospitalization, as well as number and types of extrapulmonary infections or acquisition of MDR pathogens during the hospitalization in the ICU will be recorded. Recurrence with predefined criteria (clinical suspicion of VAP associated with a positive quantitative culture of a respiratory sample) will be evaluated by two independent experts. Discussion Demonstrating that an SD (8 days) versus LD (15 days) therapy strategy in PA-VAP treatment is safe and not associated with an increased mortality or recurrence rate could lead to a change in practices and guidelines in the management of antibiotic therapy of this frequent ICU complication. This strategy could lead to decreased antibiotic exposure during hospitalization in the ICU and in turn reduce the acquisition and the spread of MDR pathogens. Trial registration ClinicalTrials.gov: NCT02634411. Registered on 19 November 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1780-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrien Bouglé
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.
| | - Arnaud Foucrier
- Department of Anesthesiology and Critical Care, Hôpital Beaujon, APHP, Paris, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care, CHU Amiens, Amiens, France.,Université de Picardie Jules Verne, Amiens, France
| | - Philippe Montravers
- Department of Anesthesiology and Critical Care, CHU Bichat, APHP, Paris, France.,Université Diderot, Paris, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Critical Care, Groupe Hospitalier Sud, Pessac, Bordeaux, France.,Université Bordeaux Segalen, Bordeaux, France
| | - Pierre Kalfon
- Intensive Care Unit, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - Pierre Squara
- Intensive Care Unit, Clinique Ambroise Paré, Neuilly-sur-Seine, France
| | - Tabassome Simon
- Unité de Recherche Clinique du GH HUEP (URC-Est), Hôpital Saint-Antoine, APHP, Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care, CHU La Pitié-Salpêtrière, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France.,UPMC - Sorbonne universités (Paris 6), Paris, France
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90
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Wunderink RG. POINT: Should Inhaled Antibiotic Therapy Be Used Routinely for the Treatment of Bacterial Lower Respiratory Tract Infections in the ICU Setting? Yes. Chest 2016; 151:737-739. [PMID: 27916621 DOI: 10.1016/j.chest.2016.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- Richard G Wunderink
- Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL.
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91
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Zilahi G, McMahon MA, Povoa P, Martin-Loeches I. Duration of antibiotic therapy in the intensive care unit. J Thorac Dis 2016; 8:3774-3780. [PMID: 28149576 DOI: 10.21037/jtd.2016.12.89] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There are certain well defined clinical situations where prolonged therapy is beneficial, but prolonged duration of antibiotic therapy is associated with increased resistance, medicalising effects, high costs and adverse drug reactions. The best way to decrease antibiotic duration is both to stop antibiotics when not needed (sterile invasive cultures with clinical improvement), not to start antibiotics when not indicated (treating colonization) and keep the antibiotic course as short as possible. The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown, however, there is a growing evidence that reduction in the length of antibiotic courses to 7-8 days can minimize the consequences of antibiotic overuse in critical care, including antibiotic resistance, adverse effects, collateral damage and costs. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) do have a valuable role in helping guide antibiotic duration but should be interpreted cautiously in the context of the clinical situation. On the other hand, microbiological criteria alone are not reliable and should not be used to justify a prolonged antibiotic course, as clinical cure does not equate to microbiological eradication. We do not recommend a 'one size fits all' approach and in some clinical situations, including infection with non-fermenting Gram-negative bacilli (NF-GNB) clinical evaluation is needed but shortening the antibiotic course is an effective and safe way to decrease inappropriate antibiotic exposure.
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Affiliation(s)
- Gabor Zilahi
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland
| | - Mary Aisling McMahon
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland
| | - Pedro Povoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal;; NOVA Medical School, Faculdade de Ciências Médicas, CEDOC, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland;; Welcome Trust-HRB Clinical Research, Dublin, Ireland;; Department of Clinical Medicine, Trinity Centre for Health Sciences, Dublin, Ireland
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Clinical Experience of Patients Receiving Doripenem-Containing Regimens for the Treatment of Healthcare-Associated Infections. PLoS One 2016; 11:e0167522. [PMID: 27907197 PMCID: PMC5132221 DOI: 10.1371/journal.pone.0167522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/15/2016] [Indexed: 01/02/2023] Open
Abstract
In this study, we retrospectively reviewed the clinical experience of patients receiving doripenem-containing regimens for the treatment of healthcare-associated infections (HCAIs) in a tertiary care center and assessed the clinical usefulness of doripenem therapy in this clinical setting. In this retrospective study, the medical records of all adult patients who had ever received doripenem-containing therapy for the treatment of HCAIs were reviewed between September 1, 2012 and August 31, 2014, and the following data were extracted: age, gender, type of infection, disease severity, underlying comorbidities or conditions, and laboratory results. Additionally, we also extracted data regarding the rates of mortality and clinical and microbiological response. A total of 184 adult patients with HCAIs who had received doripenem-containing therapy were included in this study. Respiratory tract infections (n = 91, 49.5%) were the most common type of infection, followed by urinary tract infections, intra-abdominal infections and skin and soft tissue infections. The mean APACHE II score was 14.5. The rate of clinical success was 78.2%, and the overall in-hospital mortality rate was only 13.0%. Among patients, in-hospital mortality was independently and significantly associated with APACHE II score (odds ratio (OR), 1.2825; 95% CI, 1.1123–1.4788) and achieving clinical success (OR, 0.003; 95% CI, 0.0003–0.409). In conclusion, the overall in-hospital mortality rate was low and the clinical success rate was high among HCAI patients receiving doripenem treatment. These results suggest that doripenem may be judiciously used for the treatment of patients with HCAIs.
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Rahbar AJ, Lodise TP, Abraham P, Lockwood A, Pai MP, Patka J, Rabinovich M, Curzio K, Chester K, Williams B, Morse B, Chaar M, Huang V, Salomone J. Pharmacokinetic and Pharmacodynamic Evaluation of Doripenem in Critically Ill Trauma Patients with Sepsis. Surg Infect (Larchmt) 2016; 17:675-682. [PMID: 27841954 DOI: 10.1089/sur.2015.113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Doripenem is approved by the Food and Drug Administration for the treatment of patients with complicated intra-abdominal infections and complicated urinary tract infections. While studies have described the pharmacokinetics/pharmacodynamics (PK/PD) of doripenem in the critically ill, no study has described the probability of target attainment profile among trauma patients with sepsis. PATIENTS AND METHODS This study was a prospective, open-label, pharmacokinetic study in the surgical intensive care unit (SICU) at Grady Health System. Thirty trauma patients with sepsis admitted to the SICU received doripenem 1 g infused over 4 hours every 8 hours for three doses. Blood samples were taken just before and after the third dose. A two-compartment model was fit to the data using non-parametric population PK modeling software. Embedded with the final PK model, a Monte Carlo Simulations (MCS) was performed to determine the PK/PD profile of doripenem 1 g, infused over 4 hours, every 8 hours after administration of the first and fourth doses. RESULTS Overall, the model fit the data well, and mean (standard deviation) clearance and volume of the central compartment were 16.9 (11.4) L/h and 28.5 (16.0) L, respectively. In the MCS analyses, doripenem 1 g, infused over 4 hours, administered every 8 hours, conferred >90% probabilities of achieving 30-50% time greater than the minimum inhibitory concentration (30-50% T>MIC) for MICs ≤2 mg/L after infusion of both the first and fourth doses. The MCS indicated that more intensive doripenem dosing schemes should be considered for organisms with MIC values in excess of 2 mg/L. CONCLUSIONS This is the first study to describe the doripenem PK/PD in critically ill patients with trauma. Among these patients, the MCS analyses suggest that current dosing strategies may be ineffective when the MIC value for the infecting pathogen is expected to be above 2 mg/L.
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Affiliation(s)
- Aryan J Rahbar
- 1 University Medical Center of Southern Nevada , Las Vegas, Nevada
| | - Thomas P Lodise
- 2 Albany College of Pharmacy and Health Sciences , Albany, New York
| | | | | | - Manjunath P Pai
- 2 Albany College of Pharmacy and Health Sciences , Albany, New York
| | - John Patka
- 3 Grady Health System , Atlanta, Georgia
| | | | - Karen Curzio
- 5 Emory Saint Joseph's Hospital , Atlanta, Georgia
| | | | | | - Bryan Morse
- 7 Emory University School of Medicine , Atlanta, Georgia
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Schreiber MP, Shorr AF. Challenges and opportunities in the treatment of ventilator-associated pneumonia. Expert Rev Anti Infect Ther 2016; 15:23-32. [DOI: 10.1080/14787210.2017.1250625] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality, complicating the medical course of approximately 10% of mechanically-ventilated patients, with an estimated attributable mortality of 13%. To treat VAP empirically, the American Thoracic Society currently recommends antibiotic therapy based on the patients' risk of colonisation by an organism with multidrug resistance. The selection of initial antibiotic therapy in VAP is important, as inappropriate initial antimicrobial treatment is associated with higher mortality and longer hospital stay in intensive care unit (ICU) patients.While guidelines exist for the antibiotic treatment of hospital-acquired pneumonia (HAP) from the American Thoracic Society and the British Society for Antimicrobial Chemotherapy, there are many limitations in the quality of available evidence. This systematic review aimed to summarise the results of all randomised controlled trials (RCTs) that compare empirical antibiotic regimens for VAP. OBJECTIVES The primary objective of this review was to assess the effect of different empirical antimicrobial therapies on the survival and clinical cure of adult patients with ventilator-associated pneumonia (VAP). Secondary objectives included reporting the incidence of adverse events, new superinfections, length of hospital stay, and length of intensive care unit (ICU) stay associated with these therapies. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CINAHL and Web of Science to December 2015; we searched ClinicalTrials.gov to September 2016. SELECTION CRITERIA Two review authors independently assessed RCTs comparing empirical antibiotic treatments of VAP in adult patients, where VAP was defined as new-onset pneumonia that developed more than 48 hours after endotracheal intubation. Physicians and researchers were not required to be blinded for inclusion in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study data. We pooled studies and analysed them in two ways. We examined monotherapy, or a single experimental antimicrobial drug, versus combination therapy, or multiple experimental antimicrobial drugs. We also examined carbapenem therapy versus non-carbapenem therapy. MAIN RESULTS We included 12 studies with 3571 participants. All included studies examined the empiric use of one antimicrobial regimen versus another for the treatment of adults with VAP, but the particular drug regimens examined by each study varied. There was potential for bias because some studies did not report outcomes for all participants. All but one study reported sources of funding or author affiliations with pharmaceutical companies.We found no statistical difference in all-cause mortality between monotherapy and combination therapy (N = 4; odds ratio (OR) monotherapy versus combination 0.97, 95% confidence interval (CI) 0.73 to 1.30), clinical cure (N = 2; OR monotherapy versus combination 0.88, 95% CI 0.56 to 1.36), length of stay in ICU (mean difference (MD) 0.65, 95% CI 0.07 to 1.23) or adverse events (N = 2; OR monotherapy versus combination 0.93, 95% CI 0.68 to 1.26). We downgraded the quality of evidence for all-cause mortality, adverse events, and length of ICU stay to moderate for this comparison. We determined clinical cure for this comparison to be of very low-quality evidence.For our second comparison of combination therapy with optional adjunctives only one meta-analysis could be performed due to a lack of trials comparing the same antibiotic regimens. Two studies compared tigecycline versus imipenem-cilastatin for clinical cure in the clinically evaluable population and there was a statistically significant increase in clinical cure for imipenem-cilastatin (N = 2; OR tigecycline versus imipenem-cilastatin 0.44, 95% CI 0.23 to 0.84). Of importance, this effect was due to a single study.We found no statistical difference in all-cause mortality between carbapenem and non-carbapenem therapies (N = 1; OR carbapenem versus non-carbapenem 0.59, 95% CI 0.30 to 1.19) or adverse events (N = 3; OR carbapenem versus non-carbapenem 0.78, 95% CI 0.56 to 1.09), but we found that carbapenems are associated with a statistically significant increase in the clinical cure (N = 3; OR carbapenem versus non-carbapenem 1.53, 95% CI 1.11 to 2.12 for intention-to-treat (ITT) analysis and N = 2; OR carbapenem versus non-carbapenem 2.29, 95% CI 1.19 to 4.43 for clinically evaluable patients analysis). For this comparison we downgraded the quality of evidence for mortality, and clinical cure (ITT and clinically evaluable populations) to moderate. We determined the quality of evidence for adverse events to be low. AUTHORS' CONCLUSIONS We did not find a difference between monotherapy and combination therapy for the treatment of people with VAP. Since studies did not identify patients with increased risk for multidrug-resistant bacteria, these data may not be generalisable to all patient groups. However, this is the largest meta-analysis comparing monotherapy to multiple antibiotic therapies for VAP and contributes further evidence to the safety of using effective monotherapy for the empiric treatment of VAP.Due to lack of studies, we could not evaluate the best antibiotic choice for VAP, but carbapenems as a class may result in better clinical cure than other tested antibiotics.
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Affiliation(s)
- Lauren E Arthur
- School of Medicine, University of QueenslandOchsner Clinical SchoolNew OrleansLAUSA
| | - Russell S Kizor
- The University of QueenslandSchool of Medicine16/205 Coronation DriveMiltonBrisbaneQueenslandAustralia4064
| | - Adrian G Selim
- Bond UniversityFaculty of Health Sciences and MedicineGold CoastQldAustralia4229
| | - Mieke L van Driel
- The University of QueenslandDiscipline of General Practice, School of MedicineBrisbaneQueenslandAustralia4029
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)Gold CoastQueenslandAustralia4229
- Ghent UniversityDepartment of Family Medicine and Primary Health Care1K3, De Pintelaan 185GhentBelgium9000
| | - Leonardo Seoane
- Ochsner Health SystemDepartment of Pulmonary/Critical Care Medicine1514 Jefferson HwyNew OrleansLAUSA70121
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Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61-e111. [PMID: 27418577 PMCID: PMC4981759 DOI: 10.1093/cid/ciw353] [Citation(s) in RCA: 2042] [Impact Index Per Article: 255.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.
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Affiliation(s)
- Andre C. Kalil
- Departmentof Internal Medicine, Division of Infectious Diseases,
University of Nebraska Medical Center,
Omaha
| | - Mark L. Metersky
- Division of Pulmonary and Critical Care Medicine,
University of Connecticut School of Medicine,
Farmington
| | - Michael Klompas
- Brigham and Women's Hospital and Harvard Medical School
- Harvard Pilgrim Health Care Institute, Boston,
Massachusetts
| | - John Muscedere
- Department of Medicine, Critical Care Program,Queens University, Kingston, Ontario,
Canada
| | - Daniel A. Sweeney
- Division of Pulmonary, Critical Care and Sleep Medicine,
University of California, San
Diego
| | - Lucy B. Palmer
- Department of Medicine, Division of Pulmonary Critical Care and Sleep
Medicine, State University of New York at Stony
Brook
| | - Lena M. Napolitano
- Department of Surgery, Division of Trauma, Critical Care and Emergency
Surgery, University of Michigan, Ann
Arbor
| | - Naomi P. O'Grady
- Department of Critical Care Medicine, National
Institutes of Health, Bethesda
| | - John G. Bartlett
- Johns Hopkins University School of Medicine,
Baltimore, Maryland
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari
de Bellvitge, Bellvitge Biomedical Research Institute, Spanish Network for Research in
Infectious Diseases, University of Barcelona,
Spain
| | - Ali A. El Solh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep
Medicine, University at Buffalo, Veterans Affairs Western New
York Healthcare System, New York
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious
Diseases, EVK Herne and Augusta-Kranken-Anstalt
Bochum, Germany
| | - Paul D. Fey
- Department of Pathology and Microbiology, University of
Nebraska Medical Center, Omaha
| | | | - Marcos I. Restrepo
- Department of Medicine, Division of Pulmonary and Critical Care
Medicine, South Texas Veterans Health Care System and University
of Texas Health Science Center at San Antonio
| | - Jason A. Roberts
- Burns, Trauma and Critical Care Research Centre, The
University of Queensland
- Royal Brisbane and Women's Hospital,
Queensland
| | - Grant W. Waterer
- School of Medicine and Pharmacology, University of
Western Australia, Perth,
Australia
| | - Peggy Cruse
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Shandra L. Knight
- Library and Knowledge Services, National Jewish
Health, Denver, Colorado
| | - Jan L. Brozek
- Department of Clinical Epidemiology and Biostatistics and Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
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Abstract
PURPOSE OF REVIEW To highlight the importance of escalating pathogen resistance in ventilator-associated pneumonia (VAP) along with diagnostic and treatment implications. RECENT FINDINGS In a period of rising bacterial resistance, VAP remains an important infection occurring in critically ill patients. Risk factors for multidrug-resistant pathogens depend on both local epidemiology and host factors. New diagnostic techniques and antimicrobials can help with rapid bacterial identification and timely and appropriate treatment while avoiding emergence of bacterial resistance. SUMMARY Clinicians should be aware of risk factors for multidrug-resistant pathogens causing VAP and also of particularities of diagnosis and treatment of this important clinical entity.
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98
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Abstract
INTRODUCTION Hospital-acquired pneumonia (HAP) is one of the leading nosocomial infections worldwide and is associated with an elevated morbidity and mortality and increased hospital costs. Nevertheless, prompt and adequate antimicrobial treatment is mandatory following VAP development, especially in the face of multidrug resistant pathogens. AREAS COVERED We searched Pubmed and ClinicalTrials.gov site reports in English language of phase III clinical trials, between 2000-2016 referring to the antibiotic treatment of nosocomial pneumonia. We provide a summary of latest approved drugs for HAP and emerging drugs with potential indication nosocomial pneumonia. EXPERT OPINION There are several promising compounds on their way, as tedizolid-a new oxazolidone, iclaprim-a novel drug, related to trimethoprim, plazomicin-a new aminoglycoside and two combinations of ceftazidime/avibactam and ceftolozane/tazobactam against MDR bacteria, especially against MRSA and Gram-negative ESBL bacteria.
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Affiliation(s)
- Adamantia Liapikou
- a 6th Respiratory Department , Sotiria Chest Diseases Hospital , Athens , Greece
| | - Antoni Torres
- b Department of Pneumology, Institut Clinic del Tórax, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigaciones biomedicas En Red-Enfermedades Respiratorias (CibeRes CB06/06/0028)-ISCIII, Hospital Clinic , University of Barcelona , Barcelona , Spain
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Nicolau DP, Dimopoulos G, Welte T, Luyt CE. Can we improve clinical outcomes in patients with pneumonia treated with antibiotics in the intensive care unit? Expert Rev Respir Med 2016; 10:907-18. [PMID: 27181707 DOI: 10.1080/17476348.2016.1190277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Pneumonia in the intensive care unit (ICU) is associated with high morbidity, mortality and healthcare costs. However, treatment outcomes with conventional intravenous (IV) antibiotics remain suboptimal, and there is an urgent need for improved therapy options. AREAS COVERED We review how clinical outcomes in patients with pneumonia treated in the ICU could be improved; we discuss the importance of choosing appropriate outcome measures in clinical trials, highlight the current suboptimal outcomes in patients with pneumonia, and outline potential solutions. We have included key studies and papers based on our clinical expertise, therefore a systematic literature review was not conducted. Expert commentary: Reasons for poor outcomes in patients with nosocomial pneumonia in the ICU include inappropriate initial therapy, increasing bacterial resistance and the complexities of IV dosing in critically ill patients. Robust clinical trial endpoints are needed to enable an accurate assessment of the success of new treatment approaches, but progress in this field has been slow. In addition, only very few new antimicrobials are currently in development for nosocomial pneumonia; two potential alternative solutions to improve outcomes could therefore include the optimization of pharmacokinetic/pharmacodynamics (PK/PD) and dosing of existing therapies, and the refinement of antimicrobial delivery by inhalation.
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Affiliation(s)
- David P Nicolau
- a Center for Anti-infective Research and Development , Hartford Hospital , Hartford , CT , USA
| | - George Dimopoulos
- b Department of Critical Care Medicine, Medical School , University of Athens , Athens , Greece
| | - Tobias Welte
- c Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany
| | - Charles-Edouard Luyt
- d Service de Réanimation, Institut de Cardiologie , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris , Paris , France.,e UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition , Sorbonne Universités , Paris , France
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van Hasselt JGC, Rizk ML, Lala M, Chavez-Eng C, Visser SAG, Kerbusch T, Danhof M, Rao G, van der Graaf PH. Pooled population pharmacokinetic model of imipenem in plasma and the lung epithelial lining fluid. Br J Clin Pharmacol 2016; 81:1113-23. [PMID: 26852277 PMCID: PMC4876184 DOI: 10.1111/bcp.12901] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/08/2016] [Accepted: 02/02/2016] [Indexed: 01/01/2023] Open
Abstract
AIMS Several clinical trials have confirmed the therapeutic benefit of imipenem for treatment of lung infections. There is however no knowledge of the penetration of imipenem into the lung epithelial lining fluid (ELF), the site of action relevant for lung infections. Furthermore, although the plasma pharmacokinetics (PK) of imipenem has been widely studied, most studies have been based on selected patient groups. The aim of this analysis was to characterize imipenem plasma PK across populations and to quantify imipenem ELF penetration. METHODS A population model for imipenem plasma PK was developed using data obtained from healthy volunteers, elderly subjects and subjects with renal impairment, in order to identify predictors for inter-individual variability (IIV) of imipenem PK. Subsequently, a clinical study which measured plasma and ELF concentrations of imipenem was included in order to quantify lung penetration. RESULTS A two compartmental model best described the plasma PK of imipenem. Creatinine clearance and body weight were included as subject characteristics predictive for IIV on clearance. Typical estimates for clearance, central and peripheral volume, and inter-compartmental clearance were 11.5 l h(-1) , 9.37 l, 6.41 l, 13.7 l h(-1) , respectively (relative standard error (RSE) <8%). The distribution of imipenem into ELF was described using a time-independent penetration coefficient of 0.44 (RSE 14%). CONCLUSION The identified lung penetration coefficient confirms the clinical relevance of imipenem for treatment of lung infections, while the population PK model provided insights into predictors of IIV for imipenem PK and may be of relevance to support dose optimization in various subject groups.
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Affiliation(s)
- J G Coen van Hasselt
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | | | | | | | | | | | - Meindert Danhof
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Gauri Rao
- University at Buffalo, Buffalo, New York, USA
| | - Piet H van der Graaf
- Division of Pharmacology, Cluster Systems Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
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