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Personalized Antibiotic Therapy for the Critically Ill: Implementation Strategies and Effects on Clinical Outcome of Piperacillin Therapeutic Drug Monitoring-A Descriptive Retrospective Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121452. [PMID: 34943664 PMCID: PMC8698194 DOI: 10.3390/antibiotics10121452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 12/29/2022] Open
Abstract
Therapeutic drug monitoring (TDM) is increasingly relevant for an individualized antibiotic therapy and subsequently a necessary tool to reduce multidrug-resistant pathogens, especially in light of diminishing antimicrobial capabilities. Critical illness is associated with profound pharmacokinetic and pharmacodynamic alterations, which challenge dose finding and the application of particularly hydrophilic drugs such as β-lactam antibiotics. Methods: Implementation strategy, potential benefit, and practicability of the developed standard operating procedures were retrospectively analyzed from January to December 2020. Furthermore, the efficacy of the proposed dosing target of piperacillin in critically ill patients was evaluated. Results: In total, 160 patients received piperacillin/tazobactam therapy and were subsequently included in the study. Of them, 114 patients received piperacillin/tazobactam by continuous infusion and had at least one measurement of piperacillin serum level according to the standard operating procedure. In total, 271 measurements were performed with an average level of 79.0 ± 46.0 mg/L. Seventy-one piperacillin levels exceeded 100 mg/L and six levels were lower than 22.5 mg/L. The high-level and the low-level group differed significantly in infection laboratory parameters (CRP (mg/dL) 20.18 ± 11.71 vs. 5.75 ± 5.33) and renal function [glomerular filtration rate (mL/min/1.75 m2) 40.85 ± 26.74 vs. 120.50 ± 70.48]. Conclusions: Piperacillin levels are unpredictable in critically ill patients. TDM during piperacillin/tazobactam therapy is highly recommended for all patients. Although our implementation strategy was effective, further strategies implemented into the daily clinical workflow might support the health care staff and increase the clinicians' alertness.
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Alsultan A, Dasuqi SA, Aljamaan F, Omran RA, Syed SA, AlJaloud T, AlAhmadi A, Alqahtani S, Hamad MA. Pharmacokinetics of meropenem in critically ill patients in Saudi Arabia. Saudi Pharm J 2021; 29:1272-1277. [PMID: 34819789 PMCID: PMC8596159 DOI: 10.1016/j.jsps.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/28/2021] [Indexed: 12/24/2022] Open
Abstract
Background Meropenem is commonly used in the ICU to treat gram-negative infections. Due to various pathophysiological changes, critically ill patients are at higher risk of having subtherapeutic concentrations and hence have a higher risk of treatment failure—especially in regions where gram-negative drug resistance is increasing, such as Saudi Arabia. No studies have evaluated the pharmacokinetics of meropenem in critically ill patients in Saudi Arabia. Our primary objective is to assess the percentage of patients achieving the therapeutic target for meropenem. Methods This prospective observational study was conducted in the ICUs of King Khalid University Hospital. Patient were included if >18 years-of-age and received meropenem for a clinically suspected or proven bacterial infection. The primary outcome was to assess the percentage of patients who achieved the pharmacokinetic/pharmacodynamic (PKPD) therapeutic target of a free trough concentration four times the MIC. The secondary outcome was to estimate the pharmacokinetics of meropenem. Pharmacokinetic analysis was performed using Monolix Suite 2020R1 (Lixoft, France). Results Trough concentrations were highly variable and ranged from <0.5 µg/mL to 39 µg/mL, with a mean ± SD trough concentration of 8.5 ± 8 µg/mL. Only 46% of patients achieved the therapeutic target. The only significant predictor of failing to achieve the PKPD target was augmented renal clearance. Conclusion In conclusion, more than half of our patients did not achieve the PKPD target. Thus, there is a need for better dosing strategies of meropenem in critically ill patients in Saudi Arabia such as extended and continuous infusion.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
- Corresponding author at: Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
| | - Shereen A. Dasuqi
- Department of Pharmacy, King Khalid University Hospital, King Saudi University Medical City, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- Critical Care Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Rasha A. Omran
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, University of Jordan, Amman Jordan
| | - Saeed Ali Syed
- Department of Pharmaceutical; Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Turki AlJaloud
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah AlAhmadi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohammed A. Hamad
- Critical Care Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Maarbjerg SF, Thorsted A, Friberg LE, Nielsen EI, Wang M, Schrøder H, Albertsen BK. Continuous infusion of piperacillin-tazobactam significantly improves target attainment in children with cancer and fever. Cancer Rep (Hoboken) 2021; 5:e1585. [PMID: 34796702 PMCID: PMC9575485 DOI: 10.1002/cnr2.1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/07/2022] Open
Abstract
Background Children with febrile neutropenia commonly exhibit alterations of pharmacokinetic (PK) parameters, leading to decreased β‐lactam concentrations. Aims This study evaluated piperacillin PK and probability of target attainment (PTA) with continuous infusion of piperacillin‐tazobactam, in order to optimize the dosing regimen. Methods This prospective PK study included children with cancer, aged 1–17 years, who were treated with piperacillin‐tazobactam for suspected or verified infection. A piperacillin‐tazobactam loading dose (100 mg/kg) was administered followed by continuous infusion (300 mg/kg/day). The unbound fraction of piperacillin was quantified by high‐performance liquid chromatography and PK were described using population PK modeling. PK data was used to update and extend a previous PK model built on data following intermittent administration. Monte Carlo simulations were performed to assess PTA for targets of 100% time above the minimum inhibitory concentration (100% fT > MIC) and 50% fT > 4xMIC. Results We included 68 fever episodes among 38 children with a median (IQR) age of 6.5 years and body weight of 27.4 kg (15.1–54.0). A three‐compartment model adequately described the concentration‐time data. Median (95% confidence interval) estimates for clearance and piperacillin concentration at steady state were 14.2 L/h/70 kg (13.0; 15.3) and 47.6 mg/L (17.2; 129.5), respectively. Body weight or lean body weight was significantly associated with the PK parameters, and body weight was integrated in the final PK model. Based on piperacillin exposure, continuous infusion was the only dosing regimen to achieve optimal PTA for the P. aeruginosa breakpoint (16 mg/L) with the target of 100% fT > MIC, and a daily dose of 300 mg/kg reached optimal PTA. The strict target of 50% fT > 4xMIC (64 mg/L) was not feasibly attained by any dosing regimen at recommended doses. Conclusion Unlike conventional piperacillin intermittent administration and extended infusion regimens, continuous infusion allows the target of 100% fT > MIC to be reached for children with febrile neutropenia.
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Affiliation(s)
- Sabine F Maarbjerg
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Mikala Wang
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte K Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Winiszewski H, Despres C, Puyraveau M, Lagoutte-Renosi J, Montange D, Besch G, Floury SP, Chaignat C, Labro G, Vettoretti L, Clairet AL, Capellier G, Vivet B, Piton G. β-lactam dosing at the early phase of sepsis: Performance of a pragmatic protocol for target concentration achievement in a prospective cohort study. J Crit Care 2021; 67:141-146. [PMID: 34768176 DOI: 10.1016/j.jcrc.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE We hypothesized that a protocol of standardized fixed dose using prolonged infusion during the early phase of sepsis may avoid insufficient β-lactam concentrations. METHODS In this single center prospective study, patients with sepsis and vasopressors were enrolled if they were treated by either piperacillin-tazobactam, meropenem or cefepime. Βeta-lactams were administered at fixed dose by prolonged infusion. Targeted plasma concentrations for piperacillin, meropenem and cefepime were above 80 mg/L, 8 mg/L and 38 mg/L respectively. Three blood samples were collected per patient over the first 48 h of treatment. Primary endpoint was target concentration achievement during the 48 first hours, defined as all plasma concentrations above the targeted threshold. RESULTS Among the 89 patients completing the three samples, target concentrations were achieved for 61 (69%). Target concentrations were achieved in 20 (53%), 32 (89%), and 9 (60%) of the patients treated with piperacillin, meropenem and cefepime, respectively. By multivariate analysis, lower APACHE 2 score, higher baseline MDRD creatinine clearance, and piperacillin use were independently associated with insufficient β-lactam concentrations. CONCLUSION Despite a fixed dose antibiotic administration protocol with prolonged infusion insufficient β-lactam concentration was frequent at the early phase of sepsis, especially in less severe patients, without renal failure, and treated with piperacillin. In septic patients with vasopressors, piperacillin dosing higher than 16 g may be needed to achieve the recommended target concentration. TRIAL REGISTRATION NCT02820987.
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Affiliation(s)
- Hadrien Winiszewski
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France.
| | - Cyrielle Despres
- Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Marc Puyraveau
- Methodology Unit, Clinical Investigation Center INSERM 1431, Besançon University Hospital, Besançon, France
| | | | - Damien Montange
- Pharmacology Unit, Besançon University Hospital, Besançon, France
| | - Guillaume Besch
- Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | | | | | - Guylaine Labro
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Lucie Vettoretti
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | | | - Gilles Capellier
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia
| | | | - Gael Piton
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
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Polain A, Gorham J, Romeo I, Belliato M, Peluso L, Partipilo F, Njimi H, Brasseur A, Jacobs F, Creteur J, Hites M, Taccone FS. Prediction of Insufficient Beta-Lactam Concentrations in Extracorporeal Membranous Oxygenation Patients. Microorganisms 2021; 9:microorganisms9112219. [PMID: 34835344 PMCID: PMC8625763 DOI: 10.3390/microorganisms9112219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background: The aim of this study was to identify predictors of insufficient beta-lactam concentrations in patients undergoing extracorporeal membrane oxygenation (ECMO). Methods: Retrospective analysis of all patients receiving ECMO support and treated with ceftazidime or cefepime (CEF), piperacillin/tazobactam (TZP), or meropenem (MEM). Trough drug concentrations (Cmin) were measured before the subsequent dose, according to the decision of the attending physician. Insufficient drug concentrations were identified if Cmin was below the clinical breakpoint of Pseudomonas aeruginosa. Results: A total of 222 Cmin (CEF, n = 41; TZP, n = 85; MEM, n = 96) from 110 patients were included; insufficient concentrations were observed in 26 (12%) antibiotic assessments; 21 (81%) of those occurred during MEM therapy. Insufficient Cmin were associated with a shorter time from initiation of antibiotics to measurement, a lower single dose of antibiotic, a higher creatinine clearance (CrCL), lower sequential organ failure assessment (SOFA) scores, and less use of continuous renal replacement therapy (CRRT) when compared to others. Conclusions: Insufficient broad-spectrum beta-lactam concentrations were observed in 12% of drug measurement during ECMO therapy. Higher than recommended drug regimens could be considered in the very early phase of therapy and in those patients with augmented renal clearance and with less severe organ dysfunction.
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Affiliation(s)
- Amandine Polain
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | - Julie Gorham
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | - Immacolata Romeo
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
- UOC Anestesia e Rianimazione 2 Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Mirko Belliato
- UOC Anestesia e Rianimazione 2 Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Lorenzo Peluso
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | | | - Hassane Njimi
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | - Alexandre Brasseur
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | - Frederique Jacobs
- Clinic of Infectious Diseases, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.J.); (M.H.)
| | - Jacques Creteur
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
| | - Maya Hites
- Clinic of Infectious Diseases, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.J.); (M.H.)
| | - Fabio Silvio Taccone
- Deparment of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (A.P.); (J.G.); (I.R.); (L.P.); (H.N.); (A.B.); (J.C.)
- Correspondence: ; Tel.: +32-2555-5587
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Ullah S, Beer R, Fuhr U, Taubert M, Zeitlinger M, Kratzer A, Dorn C, Arshad U, Kofler M, Helbok R. Brain Exposure to Piperacillin in Acute Hemorrhagic Stroke Patients Assessed by Cerebral Microdialysis and Population Pharmacokinetics. Neurocrit Care 2021; 33:740-748. [PMID: 32219679 PMCID: PMC7736006 DOI: 10.1007/s12028-020-00947-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The broad antibacterial spectrum of piperacillin/tazobactam makes the combination suitable for the treatment of nosocomial bacterial central nervous system (CNS) infections. As limited data are available regarding piperacillin CNS exposure in patients without or with low-grade inflammation, a clinical study was conducted (1) to quantify CNS exposure of piperacillin by cerebral microdialysis and (2) to evaluate different dosing regimens in order to improve probability of target attainment (PTA) in brain. METHODS Ten acute hemorrhagic stroke patients (subarachnoid hemorrhage, n = 6; intracerebral hemorrhage, n = 4) undergoing multimodality neuromonitoring received 4 g piperacillin/0.5 g tazobactam every 8 h by 30-min infusions for the management of healthcare-associated pneumonia. Cerebral microdialysis was performed as part of the clinical neuromonitoring routine, and brain interstitial fluid samples were retrospectively analyzed for piperacillin concentrations after the first and after multiple doses for at least 5 days and quantified by high-performance liquid chromatography. Population pharmacokinetic modeling and Monte Carlo simulations with various doses and types of infusions were performed to predict exposure. A T>MIC of 50% was selected as pharmacokinetic/pharmacodynamic target parameter. RESULTS Median peak concentrations of unbound piperacillin in brain interstitial space fluid were 1.16 (range 0.08-3.59) and 2.78 (range 0.47-7.53) mg/L after the first dose and multiple doses, respectively. A one-compartment model with a transit compartment and a lag time (for the first dose) between systemic and brain exposure was appropriate to describe the brain concentrations. Bootstrap median estimates of the parameters were: transfer rate from plasma to brain (0.32 h-1), transfer rate from brain to plasma (7.31 h-1), and lag time [2.70 h (coefficient of variation 19.7%)]. The simulations suggested that PTA would exceed 90% for minimum inhibitory concentrations (MICs) up to 0.5 mg/L and 1 mg/L at a dose of 12-16 and 24 g/day, respectively, regardless of type of infusion. For higher MICs, PTA dropped significantly. CONCLUSION Limited CNS exposure of piperacillin might be an obstacle in treating patients without general meningeal inflammation except for infections with highly susceptible pathogens. Brain exposure of piperacillin did not improve significantly with a prolongation of infusions.
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Affiliation(s)
- Sami Ullah
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Usman Arshad
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, Bonn, Germany
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Urbina T, Razazi K, Ourghanlian C, Woerther PL, Chosidow O, Lepeule R, de Prost N. Antibiotics in Necrotizing Soft Tissue Infections. Antibiotics (Basel) 2021; 10:antibiotics10091104. [PMID: 34572686 PMCID: PMC8466904 DOI: 10.3390/antibiotics10091104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 12/23/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.
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Affiliation(s)
- Tomas Urbina
- Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75571 Paris, France;
- Sorbonne Université, Université Pierre-et-Marie Curie, 75001 Paris, France
| | - Keyvan Razazi
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
| | - Clément Ourghanlian
- Service de Pharmacie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Paul-Louis Woerther
- Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
| | - Olivier Chosidow
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
- Service de Dermatologie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France
| | - Raphaël Lepeule
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Nicolas de Prost
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
- Correspondence: ; Tel.: +33-1-49-81-23-94
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Abstract
OBJECTIVE The first 70 years of critical care can be considered a period of "industrial revolution-like" advancement in terms of progressing the understanding and care of critical illness. Unfortunately, like the industrial revolution's impact on the environment, advancing ICU care of increasingly elderly, immunosuppressed, and debilitated individuals has resulted in a greater overall burden and complexity of nosocomial infections within modern ICUs. Given the rapid evolution of nosocomial infections, the authors provide an updated review. DATA SOURCES AND STUDY SELECTION We searched PubMed and OVID for peer-reviewed literature dealing with nosocomial infections in the critically ill, as well as the websites of government agencies involved with the reporting and prevention of nosocomial infections. Search terms included nosocomial infection, antibiotic resistance, microbiome, antibiotics, and intensive care. DATA EXTRACTION AND DATA SYNTHESIS Nosocomial infections in the ICU setting are evolving in multiple domains including etiologic pathogens plus novel or emerging pathogens, prevalence, host risk factors, antimicrobial resistance, interactions of the host microbiome with nosocomial infection occurrence, and understanding of pathogenesis and prevention strategies. Increasing virulence and antimicrobial resistance of nosocomial infections mandate increasing efforts toward their prevention. CONCLUSIONS Nosocomial infections are an important determinant of outcome for patients in the ICU setting. Systematic research aimed at improving the prevention and treatment of nosocomial infections is still needed.
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Prolonged infusion of beta-lactam antibiotics for Gram-negative infections: rationale and evidence base. Curr Opin Infect Dis 2021; 33:501-510. [PMID: 33009140 DOI: 10.1097/qco.0000000000000681] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the rationale of and current evidence for prolonged beta-lactam infusion in the management of Gram-negative infections. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) data from various in-vitro and in-vivo experimental studies conclusively support prolonged infusion over intermittent infusion in terms of achieving effective beta-lactam exposure for maximal bacterial killing. Superior PK/PD target attainment has been demonstrated with prolonged beta-lactam infusion in patient populations that are more likely to have less susceptible Gram-negative infections. These populations include critically ill patients, cystic fibrosis patients and patients with malignant diseases. The clinical impact of prolonged beta-lactam infusion is likely to be the greatest in these patient groups: critically ill patients with a high level of illness severity who are not receiving renal replacement therapy; patients with nonfermenting Gram-negative bacilli infection and patients with respiratory infection. Critically ill patients with augmented renal clearance may not achieve effective beta-lactam exposure even with the use of prolonged infusion. Maximizing the effectiveness of prolonged beta-lactam infusion via therapeutic drug monitoring is becoming a more common strategy in the management of critically ill patients with Gram-negative infection. SUMMARY Prolonged beta-lactam infusion may not benefit all patients but only for those who are critically ill and/or immunocompromised, who are also more likely to have less susceptible Gram-negative infections.
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Fillâtre P, Lemaitre F, Nesseler N, Schmidt M, Besset S, Launey Y, Maamar A, Daufresne P, Flecher E, Le Tulzo Y, Tadie JM, Tattevin P. Impact of extracorporeal membrane oxygenation (ECMO) support on piperacillin exposure in septic patients: a case-control study. J Antimicrob Chemother 2021; 76:1242-1249. [PMID: 33569597 DOI: 10.1093/jac/dkab031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/14/2021] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To describe the impact of extracorporeal membrane oxygenation (ECMO) devices on piperacillin exposure in ICU patients. METHODS This observational, prospective, multicentre, case-control study was performed in the ICUs of two tertiary care hospitals in France. ECMO patients with sepsis treated with piperacillin/tazobactam were enrolled. Control patients were matched according to SOFA score and creatinine clearance. The pharmacokinetics of piperacillin were described based on a population pharmacokinetic model, calculating the proportion of time the piperacillin plasma concentration was above 64 mg/L (i.e. 4× MIC breakpoint for Pseudomonas aeruginosa). RESULTS Forty-two patients were included. Median (IQR) age was 60 years (49-66), SOFA score was 11 (9-14) and creatinine clearance was 47 mL/min (5-95). There was no significant difference in the proportion of time piperacillin concentrations were ≥64 mg/L in patients treated with ECMO and controls during the first administration (P = 0.184) or at steady state (P = 0.309). Following the first administration, 36/42 (86%) patients had trough piperacillin concentrations <64 mg/L. Trough concentrations at steady state were similar in patients with ECMO and controls (P = 0.535). Creatinine clearance ≥40 mL/min was independently associated with piperacillin trough concentration <64 mg/L at steady state [OR = 4.3 (95% CI 1.1-17.7), P = 0.043], while ECMO support was not [OR = 0.5 (95% CI 0.1-2.1), P = 0.378]. CONCLUSIONS ECMO support has no impact on piperacillin exposure. ICU patients with sepsis are frequently underexposed to piperacillin, which suggests that therapeutic drug monitoring should be strongly recommended for severe infections.
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Affiliation(s)
- P Fillâtre
- St Brieuc Hospital, Réanimation Polyvalente, F-22000 St Brieuc, France
| | - F Lemaitre
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en santé, Environnement et Travail) - UMR_S 1085, F-35000 Rennes, France
| | - N Nesseler
- Rennes University Hospital, Service de Réanimation de Chirurgie Cardiothoracique et de Chirurgie Vasculaire, F-35000 Rennes, France.,Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414, F35000 Rennes, France
| | - M Schmidt
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, APHP, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - S Besset
- Louis Mourier Hospital, Médecine Intensive-Réanimation, AP-HP, F92700 Colombes, France
| | - Y Launey
- Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414, F35000 Rennes, France.,Rennes University Hospital, Surgical Critical Care Unit, Department of Anaesthesia, Critical Care and Perioperative Medicine, F-35033 Rennes, France
| | - A Maamar
- Rennes University Hospital, Infectious Diseases and Intensive Care Unit, F-35033 Rennes, France.,Univ Rennes, Faculté de Médecine, Biosit, F-35043 Rennes, France.,Univ Rennes, Inserm-CIC-1414, IFR 140, F-35033 Rennes, France
| | - P Daufresne
- Rennes University Hospital, Haematology Unit, F-35033 Rennes, France
| | - E Flecher
- Rennes University Hospital, Department of Thoracic and Cardiovascular Surgery, F-35033 Rennes, France.,Univ Rennes, Inserm U1099, Signal and Image Treatment Laboratory (LTSI), F-35033 Rennes, France
| | - Y Le Tulzo
- Rennes University Hospital, Infectious Diseases and Intensive Care Unit, F-35033 Rennes, France.,Univ Rennes, Faculté de Médecine, Biosit, F-35043 Rennes, France.,Univ Rennes, Inserm-CIC-1414, IFR 140, F-35033 Rennes, France
| | - J M Tadie
- Rennes University Hospital, Infectious Diseases and Intensive Care Unit, F-35033 Rennes, France.,Univ Rennes, Faculté de Médecine, Biosit, F-35043 Rennes, France.,Univ Rennes, Inserm-CIC-1414, IFR 140, F-35033 Rennes, France
| | - P Tattevin
- Rennes University Hospital, Infectious Diseases and Intensive Care Unit, F-35033 Rennes, France.,Univ Rennes, Faculté de Médecine, Biosit, F-35043 Rennes, France.,Univ Rennes, Inserm-CIC-1414, IFR 140, F-35033 Rennes, France
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Taccone FS, Bogossian EG, Tironi RM, Antonucci E, Hites M, Knoop C, Etienne I, Jacobs F, Creteur J. Early β-lactam concentrations and infectious complications after lung transplantation. Am J Transplant 2021; 21:2489-2497. [PMID: 33880877 DOI: 10.1111/ajt.16432] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/25/2023]
Abstract
Antibiotic underdosing in prophylactic antibiotic regimes after lung transplantation (LTx) can increase the risk of infection. We aimed to study whether β-lactam concentrations achieved desirable pharmacodynamic targets in the early phase after LTx and the association between drug concentrations and the development of early infections or the acquisition of multidrug-resistant (MDR) strains. We reviewed patients in whom broad-spectrum β-lactam levels were measured after LTx during antibiotic prophylaxis. β-Lactam concentrations were considered "insufficient" if drug levels remained below four times the clinical breakpoint of the minimal inhibitory concentration for Pseudomonas aeruginosa. The primary outcome was the occurrence of an infection and/or acquisition of MDR pathogens in the first 14 days after transplantation. A total of 70 patients were included. "Insufficient" drug concentrations were found in 40% of patients. In 27% of patients, an early MDR pathogen was identified and 49% patients were diagnosed with an early posttransplant infection. Patients with "insufficient" drug concentrations acquired more frequently MDR bacteria and/or developed an infection than others (22/28, 79% vs. 20/42, 48% - p = .01). β-Lactam levels were often found to be below the desired drug targets in the early phase after transplantation and may be associated with the occurrence of early infectious complications.
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Affiliation(s)
- Fabio S Taccone
- Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa G Bogossian
- Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Rafael M Tironi
- Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Elio Antonucci
- Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Christiane Knoop
- Department of Lung Transplantation. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Etienne
- Department of Lung Transplantation. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care. Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
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Jaruratanasirikul S, Boonpeng A, Nawakitrangsan M, Samaeng M. NONMEM population pharmacokinetics and Monte Carlo dosing simulations of imipenem in critically ill patients with life-threatening severe infections during support with or without extracorporeal membrane oxygenation in an intensive care unit. Pharmacotherapy 2021; 41:572-597. [PMID: 34080708 DOI: 10.1002/phar.2597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/05/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVES The objectives of this study were (i) to determine the population pharmacokinetic (PK) of imipenem in critically ill patients with life-threatening severe infections, (ii) to investigate the impact of extracorporeal membrane oxygenation (ECMO) on the population PK of imipenem during support with ECMO compared to those without ECMO support, and (iii) to assess the probability of target attainment (PTA) for finding the optimal dosage regimens of imipenem in critically ill patients with life-threatening severe infections. DESIGN Open-label, PK study. SETTING Academic tertiary care medical center. PATIENTS Fifty critically ill patients with or without ECMO by pooling data from previously published studiesand unpublished data from 14 patients. INTERVENTION AND MEASUREMENTS The population PK of imipenem was determined using NONMEM and a Monte Carlo simulation was performed to determine the PTAs of achieving 40% and 75% exposure times during which the plasma drug concentrations remained above the MIC. MAIN RESULTS The values of volume of distribution and total clearance were 30.5 L and 13.3 L/h, respectively. The ECMO circuit did not show a significant influence on the PK parameters of imipenem. For pathogens with a MIC of 4 mg/L, the PTA target of 75% fT>MIC in patients with normal renal function was achieved when the imipenem was administered by a 4-h infusion of 1 g q6h. CONCLUSION The ECMO circuit had little effect on enhancing the PK changes of imipenem that had already occurred in these patients. A high dosage of imipenem may be required for achieving the PK/pharmacodynamic targets against less susceptible pathogens, however, the dosage regimens in patients with renal impairment may not need to be as high as those required in patients with normal renal function. ClinicalTrials.gov: NCT03858387.
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Affiliation(s)
- Sutep Jaruratanasirikul
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Apinya Boonpeng
- School of Pharmaceutical Sciences, University of Phayao, Muang, Thailand
| | - Monchana Nawakitrangsan
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Maseetoh Samaeng
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Setting the Beta-Lactam Therapeutic Range for Critically Ill Patients: Is There a Floor or Even a Ceiling? Crit Care Explor 2021; 3:e0446. [PMID: 34136822 PMCID: PMC8202642 DOI: 10.1097/cce.0000000000000446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Beta-lactam antibiotics exhibit high interindividual variability in drug concentrations in patients with critical illness which led to an interest in the use of therapeutic drug monitoring to improve effectiveness and safety. To implement therapeutic drug monitoring, it is necessary to define the beta-lactam therapeutic range-in essence, what drug concentration would prompt a clinician to make dose adjustments up or down. This objective of this narrative review was to summarize evidence for the "floor" (for effectiveness) and "ceiling" (for toxicity) for the beta-lactam therapeutic range to be used with individualized therapeutic drug monitoring. DATA SOURCES Research articles were sourced from PubMed using search term combinations of "pharmacokinetics," "pharmacodynamics," "toxicity," "neurotoxicity," "therapeutic drug monitoring," "beta-lactam," "cefepime," "meropenem," "piperacillin/tazobactam," "ICU," and "critical illness." STUDY SELECTION Articles were selected if they included preclinical, translational, or clinical data on pharmacokinetic and pharmacodynamic thresholds for effectiveness and safety for beta-lactams in critical illness. DATA SYNTHESIS Experimental data indicate a beta-lactam concentration above the minimum inhibitory concentration of the organism for greater than or equal to 40-60% of the dosing interval is needed, but clinical data indicate that higher concentrations may be preferrable. In the first 48 hours of critical illness, a free beta-lactam concentration at or above the susceptibility breakpoint of the most likely pathogen for 100% of the dosing interval would be reasonable (typically based on Pseudomonas aeruginosa). After 48 hours, the lowest acceptable concentration could be tailored to 1-2× the observed minimum inhibitory concentration of the organism for 100% of the dosing interval (often a more susceptible organism). Neurotoxicity is the primary dose-dependent adverse effect of beta-lactams, but the evidence remains insufficient to link a specific drug concentration to greater risk. CONCLUSIONS As studies advance the understanding of beta-lactam exposure and response in critically ill patients, it is essential to clearly define the acceptable therapeutic range to guide regimen selection and adjustment.
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Bjergum MW, Barreto EF, Scheetz MH, Rule AD, Jannetto PJ. Stability and Validation of a High-Throughput LC-MS/MS Method for the Quantification of Cefepime, Meropenem, and Piperacillin and Tazobactam in Serum. J Appl Lab Med 2021; 6:1202-1212. [PMID: 34086904 DOI: 10.1093/jalm/jfab036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The class of antibiotics known as β-lactams are a commonly used due to their effectiveness and safety. Therapeutic drug monitoring has been proposed but requires an accurate assay along with well-characterized preanalytic stability, as β-lactams are known to be relatively unstable. METHODS A high-throughput LC-MS/MS assay validation and stability study was performed for cefepime, meropenem, and piperacillin and tazobactam in serum. Patient samples, standards, and QCs were crashed with acetonitrile containing internal standard. Following centrifugation, an aliquot of the supernatant was diluted with clinical laboratory reagent water and analyzed by LC-MS/MS. RESULTS The assay showed linearity between 0.5 and 60 µg/mL for each analyte. The intra- and interassay reproducibility at 3 different concentrations (approximately 2, 25, and 40 µg/mL) was <5% for each analyte. Accuracy studies for each analyte were compared using linear regression and demonstrated: slope = 1.0 ± 0.1; r2 ≥ 0.980; and y intercept 95% CI that included zero. Minimal ion suppression or enhancement was observed, and no significant carryover was observed up to 500 µg/mL of each analyte. Stability studies demonstrated significant loss in serum for each analyte at ambient and refrigerated temperatures (2-8 °C) and at -20 °C over days or weeks. In contrast, when stored at -80 °C, no significant loss was observed. CONCLUSIONS The LC-MS/MS assay showed acceptable performance characteristics for quantitation of β-lactams. With well-characterized stability, this assay can be used with residual specimens for pharmacokinetic modeling, which may lead to individualized dosing and improved patient care.
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Affiliation(s)
- Matthew W Bjergum
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Marc H Scheetz
- Departments of Pharmacy and Pharmacology, Midwestern University, Colleges of Pharmacy and Graduate Studies, Pharmacometrics Center of Excellence, Downers Grove, IL USA.,Northwestern Memorial Hospital, Chicago, IL, USA
| | - Andrew D Rule
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Tan WW, Watt KM, Boakye-Agyeman F, Cohen-Wolkowiez M, Mok YH, Yung CF, Chan YH. Optimal Dosing of Meropenem in a Small Cohort of Critically Ill Children Receiving Continuous Renal Replacement Therapy. J Clin Pharmacol 2021; 61:744-754. [PMID: 33314163 PMCID: PMC8089047 DOI: 10.1002/jcph.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
Severe sepsis is an important cause of mortality and morbidity in critically ill children. Meropenem is a broad-spectrum antibiotic commonly used to treat sepsis. Current meropenem dosage recommendations for children on continuous renal replacement therapy are extrapolated from pharmacokinetic (PK) studies done in adults. Our study aims to determine the optimal dosing in critically ill septic children receiving continuous renal replacement therapy. A prospective single-center PK study was performed in 9 children in the intensive care unit on continuous renal replacement therapy. Meropenem concentrations were measured from blood and effluent fluid samples. A population PK model was developed using nonlinear mixed-effects modeling software (NONMEM, AstraZeneca UK Ltd, Cheshire, UK). Monte Carlo simulations were performed. The PK/pharmacodynamic target aimed for plasma concentrations above minimum inhibitory concentration of 4 mg/L for 100% of dosing interval (100%ƒT>MIC ). A 2-compartment model best characterized meropenem PK. Mean (range) clearance and elimination half-life was 0.091 L/h/kg (0.04-0.157) and 3.9 hours (2.1-7.5), respectively. Dosing of 40 mg/kg/dose every 12 hours over 30 minutes achieved PK/PD target in only 32% while 20 mg/kg every 8 hours over 4 hours or 40 mg/kg every 8 hours over 2 hours achieved 100% ƒT>MIC target for at least 90% of simulated patients.
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Affiliation(s)
- Wei Wei Tan
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin M Watt
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Felix Boakye-Agyeman
- Integrated Drug Development, Certara Strategic Consulting, Certara USA, Inc. 100 Overlook Center, Princeton, New Jersey, USA
| | - Michael Cohen-Wolkowiez
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Yee Hui Mok
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chee Fu Yung
- Department of Paediatric Medicine, Infectious Disease Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
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El-Haffaf I, Caissy JA, Marsot A. Piperacillin-Tazobactam in Intensive Care Units: A Review of Population Pharmacokinetic Analyses. Clin Pharmacokinet 2021; 60:855-875. [PMID: 33876381 DOI: 10.1007/s40262-021-01013-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 12/15/2022]
Abstract
Piperacillin-tazobactam is a potent β-lactam/β-lactamase inhibitor antibiotic commonly prescribed in the intensive care unit setting. Admitted patients often show large variability in treatment response due to multiple pathophysiological changes present in this population that alter the drug's pharmacokinetics. This review summarizes the population pharmacokinetic models developed for piperacillin-tazobactam and provides comprehensive data on current dosing strategies while identifying significant covariates in critically ill patients. A literature search on the PubMed database was conducted, from its inception to July 2020. Relevant articles were retained if they met the defined inclusion/exclusion criteria. A total of ten studies, published between 2009 and 2020, were eligible. One- and two-compartment models were used in two and eight studies, respectively. The lowest estimated piperacillin clearance value was 3.12 L/h, and the highest value was 19.9 L/h. The estimations for volume of distribution varied between 11.2 and 41.2 L. Tazobactam clearance values ranged between 5.1 and 6.78 L/h, and tazobactam volume of distribution values ranged between 17.5 and 76.1 L. The most frequent covariates were creatinine clearance and body weight, each present in four studies. Almost all studies used an exponential approach for the interindividual variability. The highest variability was observed in piperacillin central volume of distribution, at a value of 75.0%. Simulations showed that continuous or extended infusion methods performed better than intermittent administration to achieve appropriate pharmacodynamic targets. This review synthesizes important pharmacokinetic elements for piperacillin-tazobactam in an intensive care unit setting. This will help clinicians better understand changes in the drug's pharmacokinetic parameters in this specific population.
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Affiliation(s)
- Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
| | - Jean-Alexandre Caissy
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.,Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
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Leon L, Guerci P, Pape E, Thilly N, Luc A, Germain A, Butin-Druoton AL, Losser MR, Birckener J, Scala-Bertola J, Novy E. Serum and peritoneal exudate concentrations after high doses of β-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study. J Antimicrob Chemother 2021; 75:156-161. [PMID: 31599951 DOI: 10.1093/jac/dkz407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage. OBJECTIVES To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes. METHODS This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT>4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606). RESULTS Forty-eight patients were included with a median (IQR) age of 64 (53-74) years and a SAPS II of 40 (32-65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64-0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target. CONCLUSIONS In severe IAIs, high doses of β-lactams ensured 100% fT>4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology.
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Affiliation(s)
- Lisa Leon
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
| | - Philippe Guerci
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
| | - Elise Pape
- University of Lorraine, F-54000, Nancy, France.,Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, F-5400, France
| | - Nathalie Thilly
- University of Lorraine, F-54000, Nancy, France.,Plateforme d'aide à la recherche Clinique, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France
| | - Amandine Luc
- University of Lorraine, F-54000, Nancy, France.,Plateforme d'aide à la recherche Clinique, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France
| | - Adeline Germain
- University of Lorraine, F-54000, Nancy, France.,Department of Surgery, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France
| | - Anne-Lise Butin-Druoton
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
| | - Marie-Reine Losser
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
| | - Julien Birckener
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
| | - Julien Scala-Bertola
- University of Lorraine, F-54000, Nancy, France.,Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, Nancy, F-5400, France
| | - Emmanuel Novy
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandœuvre-Lès-Nancy, F-54511, France.,University of Lorraine, F-54000, Nancy, France
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Hites M. Minireview on Novel Anti-infectious Treatment Options and Optimized Drug Regimens for Sepsis. Front Med (Lausanne) 2021; 8:640740. [PMID: 33937283 PMCID: PMC8082150 DOI: 10.3389/fmed.2021.640740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/16/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis, a life-threatening organ dysfunction caused by a dysregulated response to infection is a major public health concern, as it is a leading cause of mortality and critical illness worldwide. Antibiotics are one of the cornerstones of the treatment of sepsis; administering appropriate antibiotics in a rapid fashion to obtain adequate drug concentrations at the site of the infection can improve survival of patients. Nevertheless, it is a challenge for clinicians to do so. Indeed, clinicians today are regularly confronted with infections due to very resistant pathogens, and standard dosage regimens of antibiotics often do not provide adequate antibiotic concentrations at the site of the infection. We provide a narrative minireview of different anti-infectious treatments currently available and suggestions on how to deliver optimized dosage regimens to septic patients. Particular emphasis will be made on newly available anti-infectious therapies.
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Affiliation(s)
- Maya Hites
- Clinic of Infectious Diseases, Cliniques Universitaires de Bruxelles (CUB)-Erasme Hospital, Brussels, Belgium
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70
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Fiore M, Peluso L, Taccone FS, Hites M. The impact of continuous renal replacement therapy on antibiotic pharmacokinetics in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:543-554. [PMID: 33733979 DOI: 10.1080/17425255.2021.1902985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Mortality due to severe infections in critically ill patients undergoing continuous renal replacement therapy (CRRT) remains high. Nevertheless, rapid administration of adequate antibiotic therapy can improve survival. Delivering optimized antibiotic therapy can be a challenge, as standard drug regimens often result in insufficient or excessive serum concentrations due to significant changes in the volume of distribution and/or drug clearance in these patients. Insufficient drug concentrations can be responsible for therapeutic failure and death, while excessive concentrations can cause toxic adverse events.Areas covered: We performed a narrative review of the impact of CRRT on the pharmacokinetics of the most frequently used antibiotics in critically ill patients. We have provided explanations for the changes in the PKs of antibiotics observed and suggestions to optimize dosage regimens in these patients.Expert opinion: Despite considerable efforts to identify optimal antibiotic dosage regimens for critically ill patients receiving CRRT, adequate target achievement remains too low for hydrophilic antibiotics in many patients. Whenever possible, individualized therapy based on results from therapeutic drug monitoring must be given to avoid undertreatment or toxicity.
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Affiliation(s)
- Marco Fiore
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | | | - Maya Hites
- Department of Infectious Diseases, Hopital Erasme, Brussels, Belgium
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71
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Barreto EF, Rule AD, Alshaer MH, Roberts JA, Abdul Aziz MH, Scheetz MH, Mara KC, Jannetto PJ, Gajic O, O'Horo JC, Boehmer KR. Provider perspectives on beta-lactam therapeutic drug monitoring programs in the critically ill: a protocol for a multicenter mixed-methods study. Implement Sci Commun 2021; 2:34. [PMID: 33762025 PMCID: PMC7992791 DOI: 10.1186/s43058-021-00134-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Background Beta-lactams (i.e., penicillins, cephalosporins, carbapenems, monobactams) are the most widely used class of antibiotics in critically ill patients. There is substantial interpatient variability in beta-lactam pharmacokinetics which renders their effectiveness and safety largely unpredictable. One strategy to ensure achievement of therapeutic concentrations is drug level testing (“therapeutic drug monitoring”; TDM). While studies have suggested promise with beta-lactam TDM, it is not yet widely available or implemented. This protocol presents a mixed-methods study designed to examine healthcare practitioners’ perspectives on the use and implementation of beta-lactam TDM in the critically ill. Methods An explanatory sequential mixed-methods design will be used [QUANT → qual]. First, quantitative data will be collected through a web-based questionnaire directed at clinicians at three academic medical centers at different phases of beta-lactam TDM implementation (not yet implemented, partially implemented, fully implemented). The sampling frame will include providers from a variety of disciplines that interact with drug level testing and interpretation in the critical care environment including pharmacists, intensivists, infectious diseases experts, medical/surgical trainees, and advanced practice providers. Second, approximately 30 individuals will be purposively sampled from survey respondents to conduct in-depth qualitative interviews to explain and expand upon the results from the quantitative strand. Normalization Process Theory and the Consolidated Framework for Implementation Science will be used to guide data analysis. Discussion These data will be used to answer two specific questions: “What are ICU practitioners’ perspectives on implementing beta-lactam TDM?” and “What factors contribute to the success of beta-lactam TDM program implementation?” Results of this study will be used to design future implementation strategies for beta-lactam TDM programs in the critically ill. Trial registration NCT04755777. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00134-9.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| | - Andrew D Rule
- Division of Epidemiology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, USA
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Mohd Hafiz Abdul Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, 4029, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA.,Pharmacometrics Center of Excellence, Midwestern University, 555 31st St, Downers Grove, IL, 60515, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - John C O'Horo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.,Division of Infectious Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
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72
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Van Vooren S, Verstraete AG. A sensitive and high-throughput quantitative liquid chromatography high-resolution mass spectrometry method for therapeutic drug monitoring of 10 β-lactam antibiotics, linezolid and two β-lactamase inhibitors in human plasma. Biomed Chromatogr 2021; 35:e5092. [PMID: 33590498 DOI: 10.1002/bmc.5092] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/20/2021] [Accepted: 01/27/2021] [Indexed: 12/19/2022]
Abstract
An ultra-high pressure liquid chromatography high-resolution mass spectrometric (UHPLC-HRMS) method was developed for the simultaneous and sensitive quantification of 10 β-lactam antibiotics (cefepime, meropenem, amoxicillin, cefazolin, benzylpenicillin, ceftazidime, piperacillin, flucloxacillin, cefuroxime and aztreonam), linezolid and β-lactamase inhibitors tazobactam and clavulanic acid in human plasma. Validation according to the EMA guidelines showed excellent within- and between-run accuracy and precision (i.e. between 1.1 and 8.5%) and high sensitivity (i.e. lower limit of quantification between 0.25 and 1 mg/L). The UHPLC-HRMS method enables a short turnaround time and high sensitivity and needs only a small amount of plasma, allowing appropriate routine therapeutic drug monitoring. The short turnaround time is obtained by speeding up the protocol on multiple levels, i.e. fast and workload-efficient sample preparation (i.e. protein precipitation and dilution), short (4 min) instrument run time, simultaneous measurement of all relevant β-lactam antibiotics used in the intensive care unit and the use of the same instrument, column and mobile phases as for the other routine methods in our laboratory.
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Affiliation(s)
- Sarah Van Vooren
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Alain G Verstraete
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.,Department of Laboratory Medicine, Ghent Hospital, Ghent, Belgium
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73
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Abdulla A, Ewoldt TMJ, Purmer IM, Muller AE, Gommers D, Endeman H, Koch BCP. A narrative review of predictors for β-lactam antibiotic exposure during empirical treatment in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:359-368. [PMID: 33463382 DOI: 10.1080/17425255.2021.1879049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION : Emerging studies suggest that antibiotic pharmacokinetics (PK) are difficult to predict in critically ill patients. The high intra- and inter-patient PK variability makes it challenging to accurately predict the appropriate dosage required for a given patient. Identifying patients at risk could help clinicians to consider more individualized dosing regimens and perform therapeutic drug monitoring. We provide an overview of relevant predictors associated with target (non-)attainment of β-lactam antibiotics in critically ill patients. AREAS COVERED : This narrative review summarizes patient and clinical characteristics that can help to predict the attainment of target serum concentrations and to provide guidance on antimicrobial dose optimization. Literature was searched using Embase and Medline database, focusing on β-lactam antibiotics in critically ill patients. EXPERT OPINION : Adequate concentration attainment can be anticipated in critically ill patients prior to initiating empiric β-lactam antibiotic therapy based on readily available demographic and clinical factors. Male gender, younger age, and augmented renal clearance were the most significant predictors for target non-attainment and should be considered in further investigations to develop dosing algorithms for optimal β-lactam therapy.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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74
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Zheng J, Sun Z, Sun L, Zhang X, Hou G, Han Q, Li X, Liu G, Gao Y, Ye M, Wang H, Yu K. Pharmacokinetics and Pharmacodynamics of Linezolid in Patients With Sepsis Receiving Continuous Venovenous Hemofiltration and Extended Daily Hemofiltration. J Infect Dis 2021; 221:S279-S287. [PMID: 32176792 DOI: 10.1093/infdis/jiz566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/25/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This prospective study compared pharmacokinetics (PK) and pharmacodynamics (PD) of linezolid in patients with sepsis receiving continuous venovenous hemofiltration (CVVH) with patients receiving extended daily hemofiltration (EDH). METHODS Patients with sepsis treated with linezolid and CVVH or EDH were included. Serial blood samples were collected and linezolid concentrations measured. PKs were analyzed using Pmetrics. Monte Carlo simulations were used to evaluate PD target achievement. RESULTS From 20 patients, 320 blood samples were collected for PK and PD analysis. PK profiles of linezolid were best described by a 2-compartment model. PK parameters were not significantly different between EDH and CVVH groups and were associated with body weight, renal replacement therapy (RRT) duration, and sequential organ failure assessment score. Monte Carlo simulations showed poor fractional target attainment for a minimum inhibitory concentration (MIC) of 2 mg/L with standard 600 mg intravenous administration every 12 hours. CONCLUSIONS Patients with sepsis receiving RRT exhibited variability in PK/PD parameters for linezolid. PK parameters were not significantly different between CVVH- and EDH-treated patients. Higher probability of target attainment would be achievable at a MIC of 2 mg/L in EDH patients. Higher linezolid doses should be considered for patients on RRT to achieve adequate blood levels.
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Affiliation(s)
- Junbo Zheng
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhidan Sun
- Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Lei Sun
- Department of Intensive Care Medicine, The First Hospital of Harbin, Harbin, Heilongjiang, China
| | - Xing Zhang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Guiying Hou
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Qiuyuan Han
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xianghui Li
- Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Gaofeng Liu
- Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yang Gao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ming Ye
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Hongliang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Kaijiang Yu
- Department of Intensive Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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Thabet P, Joshi A, MacDonald E, Hutton B, Cheng W, Stevens A, Kanji S. Clinical and pharmacokinetic/dynamic outcomes of prolonged infusions of beta-lactam antimicrobials: An overview of systematic reviews. PLoS One 2021; 16:e0244966. [PMID: 33481817 PMCID: PMC7822342 DOI: 10.1371/journal.pone.0244966] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/19/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This overview of reviews aims to map and compare of objectives, methods, and findings of existing systematic reviews to develop a greater understanding of the information available about prolonged beta-lactam infusions in hospitalized patients with infection. DESIGN Overview of systematic reviews. DATA SOURCES Medline, Embase, PROSPERO and the Cochrane Library were systematically searched from January, 1990 to June, 2019 using a peer reviewed search strategy. Grey literature was also searched for relevant reviews. ELIGIBILITY CRITERIA FOR SELECTING REVIEWS Systematic reviews were sought that compared two or more infusion strategies for intravenous beta-lactam antimicrobials and report clinical cure or mortality. Populations of included reviews were restricted to hospitalized patients with infection, without restrictions on age, infection type, or disease. DATA EXTRACTION AND ANALYSIS Abstract screening, data extraction, quality and risk of bias assessment were conducted by two independent reviewers. Overlap between reviews was assessed using a modified corrected covered area. Overview findings are reported in accordance with Cochrane's recommendation for overview conduct. Clinical outcomes extracted included survival, clinical cure, treatment failure, microbiological cure, length of stay, adverse events, cost, and emergence of resistance. RESULTS The search strategy identified 3327 unique citations from which 21 eligible reviews were included. Reviews varied by population, intervention and outcomes studied. Between reviews, overlap of primary studies was generally high, methodologic quality generally low and risk of bias variable. Nine of 14 reviews that quantitatively evaluated mortality and clinical cure identified a benefit with prolonged infusions of beta lactams when compared with intermittent infusions. Evidence of mortality and clinical cure benefit was greater among critically ill patients when compared to less sick patients and lower in randomized controlled trials when compared with observational studies. CONCLUSIONS Findings from our review demonstrate a consistent and reproducible lack of harm with prolonged infusions of beta-lactam antibiotics with variability in effect size and significance of benefits. Despite 21 systematic reviews addressing prolonged infusions of beta-lactams, this overview supports the continued need for a definitive systematic review given variability in populations, interventions and outcomes in the current systematic reviews. Subsequent systematic reviews should have more rigorous and transparent methods, only include RCTs and evaluate the proposed benefits found in various subgroup-analyses-i.e. high risk of mortality. TRIAL REGISTRATION Prospero registry, CRD42019117118.
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Affiliation(s)
| | - Anchal Joshi
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Canada
| | - Wei Cheng
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Salmaan Kanji
- The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Canada
- * E-mail:
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76
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Lonsdale DO, Lipman J. Global personalization of antibiotic therapy in critically ill patients. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1874823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George’s, University of London, London, UK
- Department of Critical Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Evaluation of pharmacokinetic and pharmacodynamic parameters of meropenem in critically ill patients with acute kidney disease. Eur J Clin Pharmacol 2021; 77:831-840. [PMID: 33409684 PMCID: PMC7787627 DOI: 10.1007/s00228-020-03062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
Purpose No study has been evaluated pharmacokinetic (PK) and pharmacodynamic (PD) properties of β-lactam antibiotics in patients with acute kidney injury (AKI), not requiring renal replacement therapy (RRT). We evaluated the time that plasma concentrations remain above four times the MIC (ft > 4MIC) and PK parameters of meropenem in this population. Methods In this prospective, randomized clinical trial (RCT), all patients received standard dose (3 g daily) of meropenem for 48 h, then randomly allocated in standard or adjusted groups. The standard group received meropenem without dose adjustment. In the adjusted group, the meropenem dose was adjusted based on the Cockcroft-Gault(C-G) equation. Meropenem concentrations were measured at the peak and trough times on the 2nd and 5th days of the study. Results On the 2nd day of the study, 3 out of 10 (30%) of patients attained the PD target (≥ 80%ft > 4MIC). In the 5th day of the study, the PD target was attained in 2 out of 10 (20%) and 1 out of 5 (20%) of patients who received standard and adjusted doses of meropenem, respectively (p = 1). In all samples, increased volume of distribution (Vd) (median; IQR) (46.04; 23.06–103.18 L), terminal half-life (T1/2) (4.51; 2.67–8.88 h) and decreased clearance (6.52; 4.43–10.16 L/h) have been shown. Conclusion In critically ill patients with AKI, who not receive RRT, standard doses, and adjusted according to renal function of meropenem failed to achieve PD target of ≥ 80%ft > 4MIC. Higher doses are required for this target. Retrospectively registered The study protocol with registered retrospectively and approved on January 19, 2019, with the number of IRCT20160412027346N5. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-020-03062-0.
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Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021; 25:566-574. [PMID: 34177177 PMCID: PMC8196372 DOI: 10.5005/jp-journals-10071-23810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We live in an era of evolving microbial infections and equally evolving drug resistance among microorganisms. In any healthcare facility, intensivists play the most pivotal role with critically ill patients under their direct care. Majority of the critically ill patients already harbor a microorganism at admission or acquire one in the form of healthcare-associated infections during their course of intensive care unit stay. It is therefore rather imperative for intensivists to possess sound knowledge in clinical microbiology. On a negative note, most clinicians have very meager and remote knowledge acquired during their undergraduate years. This knowledge is rather theoretical than applied and wanes over the years becoming nonbeneficial in intensive patient care. We, therefore, intend to explore important concepts in applied microbiology and infection control that intensivists should know and implement in their clinical practice on a day-to-day basis. How to cite this article: Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021;25(5):566–574.
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Affiliation(s)
- Isabella Princess
- Department of Microbiology, Apollo Speciality Hospitals, Vanagaram Branch, Chennai, Tamil Nadu, India
| | - Rohit Vadala
- Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
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79
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[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:346-360. [PMID: 33309603 DOI: 10.1016/j.pharma.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.
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80
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de Vroom SL, van Daalen FV, Zieck SE, Mathôt RAA, van Hest RM, Geerlings SE. Does dose reduction of renally cleared antibiotics in patients with impaired renal function lead to adequate drug exposure? A systematic review. Clin Microbiol Infect 2020; 27:352-363. [PMID: 33290864 DOI: 10.1016/j.cmi.2020.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is inconsistency between many guidelines in the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function. OBJECTIVES This systematic review summarizes the available evidence on the adequacy of the recommended dose reduction in terms of achieving sufficient antibiotic drug exposure or pharmacokinetic/pharmacodynamic target attainment after treatment with these reduced doses. DATA SOURCES We systematically searched Ovid Medline and Embase from inception (respectively 1946 and 1947) through July 2019. STUDY ELIGIBILITY CRITERIA All studies reporting antibiotic drug exposure and/or pharmacokinetic/pharmacodynamic (PK/PD) target attainment after dose reduction of antibiotics in patients with impaired renal function. PARTICIPANTS Adult patients with or without infections. INTERVENTIONS Administration of reduced doses of antibiotics (orally, intravenously or intramuscularly). METHODS The reduced dose was considered adequate when the most relevant parameters of drug exposure or PK/PD target attainment in patients with impaired renal function were within a range of 80% to 125% of that patients with adequate renal function receiving a regular dose (reference) or when PK/PD target attainment was attained in at least 90% of the patients with impaired renal function, regardless of the lack of a reference group. RESULTS Twenty-seven of the 4202 identified studies were included. The quality of 15 of 27 studies was fair, and most studies were of β-lactams (12/27). Best evidence was available for meropenem: four studies were included, of which two studies were of good quality. Drug exposure for meropenem is 158% to 286% higher in patients with impaired renal function receiving reduced doses compared to patients with adequate renal function receiving regular doses. For all other antibiotics, a maximum of one good-quality study could be identified. CONCLUSIONS No good-quality evidence on the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function is present, with the exception of meropenem.
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Affiliation(s)
- Suzanne L de Vroom
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
| | - Frederike V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands
| | - Saskia E Zieck
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
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81
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Lonsdale DO, Shah RV, Lipman J. Infection, Sepsis and the Inflammatory Response: Mechanisms and Therapy. Front Med (Lausanne) 2020; 7:588863. [PMID: 33344475 PMCID: PMC7738462 DOI: 10.3389/fmed.2020.588863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis secondary to bacterial infection remains a significant cause of morbidity and mortality globally. Recent decades have seen the evolution of international collaborations to improve care for these patients and identify areas for research. In this article we discuss the pathophysiology underlying the condition, review the current recommended management strategies, discuss areas of controversy, and highlight the need for ongoing research, particularly in diagnostics.
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Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Reya V Shah
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, NÎmes University Hospital, University of Montpellier, NÎmes, France
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Pharmacokinetics and Monte Carlo Dosing Simulations of Imipenem in Critically Ill Patients with Life-Threatening Severe Infections During Support with Extracorporeal Membrane Oxygenation. Eur J Drug Metab Pharmacokinet 2020; 45:735-747. [PMID: 32886347 PMCID: PMC7471576 DOI: 10.1007/s13318-020-00643-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO), a cardiopulmonary bypass device, has been found to increase the profound pathophysiological changes associated with life-threatening severe infections in patients with multiple comorbidities, which results in alterations of pharmacokinetic patterns for antibiotics. Objectives The aims of this study were (1) to determine the pharmacokinetics of imipenem and (2) to assess the probability of target attainment (PTA) for imipenem in critically ill patients with life-threatening severe infections during support with ECMO. Methods The pharmacokinetic studies were carried out following administration of 0.5 g of imipenem every 6 h on the 4th dose of drug administration in 10 patients and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the plasma drug concentrations remained above minimum inhibitory concentration (T > MIC) and 80% T > MIC. Results The median values of volume of distribution and total clearance (CL) of imipenem in these patients were 13.98 L and 9.78 L/h, respectively. A high PTA (≥ 90%) for a target of 80% with a MIC of 4 μg/mL in patients with CLCR 60–120 mL/min and flow rate of ECMO circuit 3–5.5 L/min was observed when imipenem was administered by a 4-h infusion of 1 g every 6 h. Conclusions A high dosage regimen such as 1 g every 6 h of imipenem may be required to achieve pharmacodynamic targets against less susceptible pathogens in this patient population. ClinicalTrial.gov Identifier NCT03776305, date of registration: 11 December 2018. Electronic supplementary material The online version of this article (10.1007/s13318-020-00643-3) contains supplementary material, which is available to authorized users.
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83
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Kühn D, Metz C, Seiler F, Wehrfritz H, Roth S, Alqudrah M, Becker A, Bracht H, Wagenpfeil S, Hoffmann M, Bals R, Hübner U, Geisel J, Lepper PM, Becker SL. Antibiotic therapeutic drug monitoring in intensive care patients treated with different modalities of extracorporeal membrane oxygenation (ECMO) and renal replacement therapy: a prospective, observational single-center study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:664. [PMID: 33239110 PMCID: PMC7689974 DOI: 10.1186/s13054-020-03397-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/18/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Effective antimicrobial treatment is key to reduce mortality associated with bacterial sepsis in patients on intensive care units (ICUs). Dose adjustments are often necessary to account for pathophysiological changes or renal replacement therapy. Extracorporeal membrane oxygenation (ECMO) is increasingly being used for the treatment of respiratory and/or cardiac failure. However, it remains unclear whether dose adjustments are necessary to avoid subtherapeutic drug levels in septic patients on ECMO support. Here, we aimed to evaluate and comparatively assess serum concentrations of continuously applied antibiotics in intensive care patients being treated with and without ECMO. METHODS Between October 2018 and December 2019, we prospectively enrolled patients on a pneumological ICU in southwest Germany who received antibiotic treatment with piperacillin/tazobactam, ceftazidime, meropenem, or linezolid. All antibiotics were applied using continuous infusion, and therapeutic drug monitoring of serum concentrations (expressed as mg/L) was carried out using high-performance liquid chromatography. Target concentrations were defined as fourfold above the minimal inhibitory concentration (MIC) of susceptible bacterial isolates, according to EUCAST breakpoints. RESULTS The final cohort comprised 105 ICU patients, of whom 30 were treated with ECMO. ECMO patients were significantly younger (mean age: 47.7 vs. 61.2 years; p < 0.001), required renal replacement therapy more frequently (53.3% vs. 32.0%; p = 0.048) and had an elevated ICU mortality (60.0% vs. 22.7%; p < 0.001). Data on antibiotic serum concentrations derived from 112 measurements among ECMO and 186 measurements from non-ECMO patients showed significantly lower median serum concentrations for piperacillin (32.3 vs. 52.9; p = 0.029) and standard-dose meropenem (15.0 vs. 17.8; p = 0.020) in the ECMO group. We found high rates of insufficient antibiotic serum concentrations below the pre-specified MIC target among ECMO patients (piperacillin: 48% vs. 13% in non-ECMO; linezolid: 35% vs. 15% in non-ECMO), whereas no such difference was observed for ceftazidime and meropenem. CONCLUSIONS ECMO treatment was associated with significantly reduced serum concentrations of specific antibiotics. Future studies are needed to assess the pharmacokinetic characteristics of antibiotics in ICU patients on ECMO support.
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Affiliation(s)
- Dennis Kühn
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany.,Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Carlos Metz
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Holger Wehrfritz
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Sophie Roth
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Mohammad Alqudrah
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - André Becker
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Hendrik Bracht
- Department of Anaesthesiology and Critical Care Medicine, University Hospital of Ulm, Ulm, Germany
| | - Stefan Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Mathias Hoffmann
- Hospital Pharmacy, Saarland University Medical Center, Homburg, Germany
| | - Robert Bals
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany
| | - Ulrich Hübner
- Department of Clinical Chemistry and Laboratory Medicine, Homburg, Germany
| | - Jürgen Geisel
- Department of Clinical Chemistry and Laboratory Medicine, Homburg, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology, Allergology and Intensive Care Medicine, Saarland University Medical Center, Homburg, Germany.
| | - Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany.
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Scharf C, Liebchen U, Paal M, Taubert M, Vogeser M, Irlbeck M, Zoller M, Schroeder I. The higher the better? Defining the optimal beta-lactam target for critically ill patients to reach infection resolution and improve outcome. J Intensive Care 2020; 8:86. [PMID: 33292582 PMCID: PMC7686672 DOI: 10.1186/s40560-020-00504-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Beta-lactam antibiotics are often subject to therapeutic drug monitoring, but breakpoints of target attainment are mostly based on expert opinions. Studies that show a correlation between target attainment and infection resolution are missing. This analysis investigated whether there is a difference in infection resolution based on two breakpoints of target attainment. METHODS An outcome group out of 1392 critically ill patients treated with meropenem or piperacillin-tazobactam was formed due to different selection criteria. Afterwards, three groups were created: group 1=free drug concentration (f) was < 100% of the time (T) above the minimal inhibitory concentration (MIC) (< 100% fT > MIC), group 2=100% fT > MIC < 4xMIC, and group 3=100% fT > 4xMIC. Parameters for infection control, renal and liver function, and estimated and observed in-hospital mortality were compared between those groups. Statistical analysis was performed with one-way analysis of variance, Tukey post hoc test, U test, and bivariate logistic regression. RESULTS The outcome group consisted of 55 patients (groups 1-3, 17, 24, and 14 patients, respectively). Patients allocated to group 2 or 3 had a significantly faster reduction of the C-reactive protein in contrast to patients allocated to group 1 (p = 0.033 and p = 0.026). Patients allocated to group 3 had a worse renal function, a higher Acute Physiology and Chronic Health Evaluation (APACHE II) score, were older, and had a significantly higher in-hospital mortality compared to group 1 (p = 0.017) and group 2 (p = 0.001). The higher mortality was significantly influenced by worse liver function, higher APACHE II, and higher Sequential Organ Failure Assessment (SOFA) score and norepinephrine therapy. CONCLUSION Achieving the target 100% fT > MIC leads to faster infection resolution in the critically ill. However, there was no benefit for patients who reached the highest target of 100% fT > 4xMIC, although the mortality rate was higher possibly due to confounding effects. In conclusion, we recommend the target 100% fT > MIC < 4xMIC for critically ill patients. TRIAL REGISTRATION NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Max Taubert
- Department I of Pharmacology, Centre for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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85
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Tang Girdwood S, Arbough T, Dong M, Mizuno T, Tang P, Vinks AA, Kaplan J. Molecular Adsorbent Recirculating System Therapy with Continuous Renal Replacement Therapy Enhanced Clearance of Piperacillin in a Pediatric Patient and Led to Failure to Attain Pharmacodynamic Targets. Pharmacotherapy 2020; 40:1061-1068. [PMID: 32916003 DOI: 10.1002/phar.2462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Molecular adsorbent recirculating system (MARS), an extracorporeal support device used in patients with liver failure, specifically removes albumin-bound molecules, including antibiotics. Case reports in adult patients showed that MARS enhances the clearance of piperacillin. However, for those patients, pharmacodynamic targets were achieved when piperacillin/tazobactam was administered as extended infusions over 3-4 hours. In contrast, piperacillin/tazobactam is typically given as short intermittent infusions in children. No reports describe the effect of MARS on piperacillin pharmacokinetics or pharmacodynamic target attainment in pediatric patients with liver failure. This case report describes the effects of MARS on piperacillin clearance and target attainment in a child with liver failure. It was noted that MARS, in conjunction with continuous renal replacement therapy (CRRT), enhanced the clearance of piperacillin when compared with CRRT alone (6.4-7.4 L/hr vs 3.0 L/hr). Pharmacodynamic targets were not attained during MARS-CRRT cycles with free piperacillin concentrations being above 64 µg/ml for < 50% of dosing intervals, the goal target. We performed simulation analysis to identify a dosing regimen to optimize target attainment. For this patient, doses 3 times what she received over 3-hour extended infusions and an additional dose within 5 hours of cycle initiation would have led to target attainment throughout the MARS-CRRT cycles.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Trent Arbough
- Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Min Dong
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Peter Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pathology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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86
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Bartoletti M, Giannella M, Lewis RE, Caraceni P, Tedeschi S, Paul M, Schramm C, Bruns T, Merli M, Cobos-Trigueros N, Seminari E, Retamar P, Muñoz P, Tumbarello M, Burra P, Torrani Cerenzia M, Barsic B, Calbo E, Maraolo AE, Petrosillo N, Galan-Ladero MA, D'Offizi G, Zak-Doron Y, Rodriguez-Baño J, Baldassarre M, Verucchi G, Domenicali M, Bernardi M, Viale P. Extended Infusion of β-Lactams for Bloodstream Infection in Patients With Liver Cirrhosis: An Observational Multicenter Study. Clin Infect Dis 2020; 69:1731-1739. [PMID: 30649218 DOI: 10.1093/cid/ciz032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/10/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We analyzed the impact of continuous/extended infusion (C/EI) vs intermittent infusion of piperacillin-tazobactam (TZP) and carbapenems on 30-day mortality of patients with liver cirrhosis and bloodstream infection (BSI). METHODS The BICRHOME study was a prospective, multicenter study that enrolled 312 cirrhotic patients with BSI. In this secondary analysis, we selected patients receiving TZP or carbapenems as adequate empirical treatment. The 30-day mortality of patients receiving C/EI or intermittent infusion of TZP or carbapenems was assessed with Kaplan-Meier curves, Cox-regression model, and estimation of the average treatment effect (ATE) using propensity score matching. RESULTS Overall, 119 patients received TZP or carbapenems as empirical treatment. Patients who received C/EI had a significantly lower mortality rate (16% vs 36%, P = .047). In a Cox-regression model, the administration of C/EI was associated with a significantly lower mortality (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.11-0.936; P = .04) when adjusted for severity of illness and an ATE of 25.6% reduction in 30-day mortality risk (95% CI, 18.9-32.3; P < .0001) estimated with propensity score matching. A significant reduction in 30-day mortality was also observed in the subgroups of patients with sepsis (HR, 0.21; 95% CI, 0.06-0.74), acute-on-chronic liver failure (HR, 0.29; 95% CI, 0.03-0.99), and a model for end-stage liver disease score ≥25 (HR, 0.26; 95% CI, 0.08-0.92). At competing risk analysis, C/EI of beta-lactams was associated with significantly higher rates of hospital discharge (subdistribution hazard [95% CI], 1.62 [1.06-2.47]). CONCLUSIONS C/EI of beta-lactams in cirrhotic patients with BSI may improve outcomes and facilitate earlier discharge.
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Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Russell E Lewis
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Mical Paul
- Unit of Infectious Diseases, Rambam Health Care Campus, HaAliya HaShniya, Israel
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, University Clinic of Cologne, Germany
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Germany
| | - Manuela Merli
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Viale, Italy
| | | | - Elena Seminari
- Department of Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pilar Retamar
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBIS) and Departamento de Medicina, Universidad de Sevilla, Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mario Tumbarello
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padova University Hospital, Italy
| | - Maria Torrani Cerenzia
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, University of Turin, Italy
| | - Bruno Barsic
- Infectious Diseases, University Hospital for Infectious Diseases "Dr Fran Mihaljevic," Zagreb, Croatia
| | - Ester Calbo
- Infectious Disease Unit, Service of Internal Medicine, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II
| | - Nicola Petrosillo
- 2nd Infectious Diseases Division, National Institute for Infectious Diseases L. Spallanzani, Rome
| | | | - Gianpiero D'Offizi
- Hepatology and Infectious Diseases Unit, National Institute for Infectious Diseases L. Spallanzani, Rome
| | - Yael Zak-Doron
- Unit of Infectious Diseases, Rambam Health Care Campus, HaAliya HaShniya, Israel
| | - Jesus Rodriguez-Baño
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBIS) and Departamento de Medicina, Universidad de Sevilla, Madrid, Spain
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, University of Bologna, Italy.,S.Orsola-Malpighi University Hospital, Center for Applied Biomedical Research, Bologna, Italy
| | - Gabriella Verucchi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
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87
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Abdulla A, Dijkstra A, Hunfeld NGM, Endeman H, Bahmany S, Ewoldt TMJ, Muller AE, van Gelder T, Gommers D, Koch BCP. Failure of target attainment of beta-lactam antibiotics in critically ill patients and associated risk factors: a two-center prospective study (EXPAT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:558. [PMID: 32933574 PMCID: PMC7493358 DOI: 10.1186/s13054-020-03272-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022]
Abstract
Background Early and appropriate antibiotic dosing is associated with improved clinical outcomes in critically ill patients, yet target attainment remains a challenge. Traditional antibiotic dosing is not suitable in critically ill patients, since these patients undergo physiological alterations that strongly affect antibiotic exposure. For beta-lactam antibiotics, the unbound plasma concentrations above at least one to four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval (100%ƒT > 1–4×MIC) have been proposed as pharmacodynamic targets (PDTs) to maximize bacteriological and clinical responses. The objectives of this study are to describe the PDT attainment in critically ill patients and to identify risk factors for target non-attainment. Methods This prospective observational study was performed in two ICUs in the Netherlands. We enrolled adult patients treated with the following beta-lactam antibiotics: amoxicillin (with or without clavulanic acid), cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and meropenem. Based on five samples within a dosing interval at day 2 of therapy, the time unbound concentrations above the epidemiological cut-off (ƒT > MICECOFF and ƒT > 4×MICECOFF) were determined. Secondary endpoints were estimated multivariate binomial and binary logistic regression models, for examining the association of PDT attainment with patient characteristics and clinical outcomes. Results A total of 147 patients were included, of whom 63.3% achieved PDT of 100%ƒT > MICECOFF and 36.7% achieved 100%ƒT > 4×MICECOFF. Regression analysis identified male gender, estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2, and high body mass index (BMI) as risk factors for target non-attainment. Use of continuous renal replacement therapy (CRRT) and high serum urea significantly increased the probability of target attainment. In addition, we found a significant association between the 100%ƒT > MICECOFF target attainment and ICU length of stay (LOS), but no significant correlation was found for the 30-day survival. Conclusions Traditional beta-lactam dosing results in low target attainment in the majority of critically ill patients. Male gender, high BMI, and high eGFR were significant risk factors for target non-attainment. These predictors, together with therapeutic drug monitoring, may help ICU clinicians in optimizing beta-lactam dosing in critically ill patients. Trial registration Netherlands Trial Registry (EXPAT trial), NTR 5632. Registered on 7 December 2015.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Soma Bahmany
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
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88
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Population Pharmacokinetics and Target Attainment of Cefepime in Critically Ill Patients and Guidance for Initial Dosing. Antimicrob Agents Chemother 2020; 64:AAC.00745-20. [PMID: 32601155 DOI: 10.1128/aac.00745-20] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/24/2020] [Indexed: 12/25/2022] Open
Abstract
Cefepime is commonly used in the intensive care unit (ICU) to treat bacterial infections. The time during which the free cefepime concentration is above the MIC (fT>MIC) should be optimized to increase the efficacy of the regimen. We aim to optimize the exposure of cefepime in ICU patients by using population pharmacokinetic (PK) modeling and simulations. Two data sets were included in this study. The first was a prospective study of pediatric patients who received cefepime at 50 mg/kg of body weight and had extensive PK sampling. The second study comprised retrospective data for adult ICU patients admitted to UF Health Shands Hospital who received cefepime and had their cefepime concentrations measured. The population PK model was developed, and simulations were performed, using Pmetrics. The target exposures were 100% fT>MIC and 100% fT>4×MIC The studies included a total of 266 patients, and the mean ages were 3.9 years in the pediatric group and 55 years in adult group. More than half of the patients were males. The mean (standard deviation [SD]) creatinine clearance (CrCl) was 125 (93) ml/min. The mean (SD) daily dose for adults was 4.9 (1.6) g. Cefepime was well described by a two-compartment model with weight as a covariate on the volume of distribution and elimination rate constant (k el), and CrCl and age group as covariates on k el At a MIC of 8 mg/liter, a cefepime loading dose of 4 g as an extended infusion followed by a 6-g continuous infusion was needed for good target attainment. In conclusion, prolonged or continuous infusions will be needed to achieve optimal cefepime exposure for ICU patients. Given the observed variability, therapeutic drug monitoring can help individualize therapy.
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89
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Marsot A, Hraiech S, Cassir N, Daviet F, Parzy G, Blin O, Papazian L, Guilhaumou R. Aminoglycosides in critically ill patients: which dosing regimens for which pathogens? Int J Antimicrob Agents 2020; 56:106124. [PMID: 32739478 DOI: 10.1016/j.ijantimicag.2020.106124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 06/17/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Modifications of antibiotic pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We aimed to determine optimised amikacin (AMK), gentamicin (GEN) and tobramycin (TOB) intravenous dosing regimens in this patient population. Patients admitted to the medical ICU and treated with AMK, GEN or TOB were included. Analyses were performed using a parametric population approach. Monte Carlo simulations were performed and the probability of target attainment (PTA) was calculated using Cmax/MIC ≥ 8 and trough concentrations as targets. A total of 117 critically ill hospitalised patients were studied. Median values (interindividual variability, ɷ2) of clearance were 3.51 (0.539), 3.53 (0.297), 2.70 (0.339) and 5.07 (0.339) L/h for AMK, GEN, TOB, and TOB in cystic fibrosis (CF), respectively. Median values (ɷ2) of central volume of distribution were 30.2 (0.215), 20.0 (0.109) and 25.6 (0.177) L for AMK, GEN and TOB, respectively. Simulations showed that doses should be adjusted to actual body weight and creatinine clearance (CLCR) for AMK and GEN, and according to CLCR and presence of CF for TOB. In conclusion, our recommendations for treating Pseudomonas aeruginosa infections in this population include using initial doses of 35 mg/kg for AMK or 10 mg/kg for TOB (CF and non-CF patients). GEN demonstrated the best rates of target attainment against Staphylococcus aureus infections with a dose of 5 mg/kg. As high aminoglycoside doses are required in this population, efficacy and safety targets are conflicting and therapeutic drug monitoring remains an important tool to manage this issue.
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Affiliation(s)
- A Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.
| | - S Hraiech
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - N Cassir
- Aix-Marseille Université, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - F Daviet
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - G Parzy
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - O Blin
- IHU Méditerranée Infection, Marseille, France
| | - L Papazian
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - R Guilhaumou
- Aix-Marseille Univ., APHM, INSERM, CIC CPCET Service de Pharmacologie Clinique et Pharmacovigilance, INS Inst Neurosci Syst, Marseille, France
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90
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Delattre IK, Hites M, Laterre PF, Dugernier T, Spapen H, Wallemacq PE, Jacobs F, Taccone FS. What is the optimal loading dose of broad-spectrum β-lactam antibiotics in septic patients? Results from pharmacokinetic simulation modelling. Int J Antimicrob Agents 2020; 56:106113. [PMID: 32721604 DOI: 10.1016/j.ijantimicag.2020.106113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/25/2020] [Accepted: 07/19/2020] [Indexed: 01/15/2023]
Abstract
Optimal loading doses of β-lactams to rapidly achieve adequate drug concentrations in critically ill patients are unknown. This was a post-hoc analysis of a prospective study that evaluated broad-spectrum β-lactams [piperacillin (PIP), ceftazidime (CAZ), cefepime (FEP) and meropenem (MEM)] pharmacokinetics (PKs) in patients with sepsis or septic shock (n = 88). Monte Carlo simulation was performed for 1000 virtual patients using specific sets of covariates for various dosing regimens and different durations of administration. Pharmacodynamic (PD) targets were considered as drug concentrations exceeding at least 50% of time above four times the minimum inhibitory concentration (T>4 × MIC) of Pseudomonas aeruginosa, according to EUCAST criteria, for PIP, 70%T>4 × MIC for CAZ and FEP and 40%T>4 × MIC for MEM. The probability of target attainment (PTA) was derived by calculating the percentage of patients who attained the PK/PD target at each MIC. The optimal loading dose was defined as the one associated with a ≥90% probability to achieve the PD targets. Our simulation model identified an optimal loading dose for PIP of 8 g given as a 3-h infusion (PTA of 96.2%), for CAZ and FEP of 4 g given as a 3-h infusion (PTA of 96.5% and 98.4%, respectively), and for MEM of 2 g given as a 30-min infusion (PTA of 93.4%), with the following antibiotic dose administered 6 h thereafter regardless of the drug. A higher first dose of broad-spectrum β-lactams should be given to adequately treat less-susceptible pathogens in septic patients. These findings need to be validated in a prospective study.
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Affiliation(s)
- Isabelle K Delattre
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain (UCL), Brussels, Belgium; Louvain Drug Research Institute, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires St Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Thierry Dugernier
- Department of Intensive Care, Clinique St-Pierre, Ottignies, Belgium
| | - Herbert Spapen
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Pierre E Wallemacq
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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91
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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92
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Chosidow A, Benaboud S, Beranger A, Zheng Y, Moulin F, Dupic L, Renolleau S, Treluyer JM, Oualha M. Are β-lactam concentrations adequate in severe sepsis and septic shock in children? Therapie 2020; 75:633-640. [PMID: 32593420 DOI: 10.1016/j.therap.2020.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/18/2019] [Accepted: 04/02/2020] [Indexed: 01/16/2023]
Abstract
AIM OF THE STUDY Early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock's treatment. We aim to describe the plasma concentration of the most used β-lactams in critically ill children, to describe the rate of patients with suboptimal exposure, and associated clinical and biological factors. METHODS From January 2016 to May 2017, children less than 18 years old with severe sepsis or septic shock were included. Samples were collected in pediatric intensive care unit for children with severe sepsis or septic shock. β-lactam plasma concentrations were analysed using high performance liquid chromatography. RESULTS Among the 37 enrolled patients, 24 (64.9%) had insufficient concentration [cefotaxime 7/14 (43%); piperacillin-tazobactam, 10/13 (77%); amoxicillin 6/7 (86%); meropenem 3/6 (50%), cefazolin 1/4 (25%), imipenem 0/2 (0%); ceftazidime 0/1 (0%)]. Insufficient concentrations were associated with early measurements [<72hours from the sepsis' onset (P=0.035) and an increased creatinine clearance (P=0.01)]. CONCLUSION β-lactams current dosing in critically ill septic children could be suboptimal.
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Affiliation(s)
- Anais Chosidow
- Armand-Trousseau hospital, AP-HP, pediatric department, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France.
| | - Sihem Benaboud
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Agathe Beranger
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Yi Zheng
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Florence Moulin
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Laurent Dupic
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | | | - Jean-Marc Treluyer
- Pharmacology department, Cochin hospital, 75014 Paris, France; Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
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93
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Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).
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94
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Caro Y, Cámara M, De Zan M. A review of bioanalytical methods for the therapeutic drug monitoring of β-lactam antibiotics in critically ill patients: Evaluation of the approaches used to develop and validate quality attributes. Talanta 2020; 210:120619. [DOI: 10.1016/j.talanta.2019.120619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022]
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95
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Bodmann KF, Höhl R, Krüger W, Grabein B, Graninger W. Calculated initial parenteral treatment of bacterial infections: Sepsis. GMS INFECTIOUS DISEASES 2020; 8:Doc09. [PMID: 32373434 PMCID: PMC7186805 DOI: 10.3205/id000053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This is the eleventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. Sepsis, defined as a life threatening organ dysfunction caused by a misregulated host response to an infection, is the third leading cause of death in Germany with a lethality rate of 30% to over 50%. An early, effective antimicrobial therapy is, next to infectious source control, the most important causal treatment option. It should be complemented by the mainly supportive measures of general intensive care therapy. Prior antimicrobial therapy, the patient's medical history (e.g. risk factors for multiresistant agents) and small-scale epidemiology are to be considered as part of the therapeutic and practical decisions. A modification of the often needed broad initial calculated combination therapy is desirable. In the future, prompt measurements of plasma concentrations of antiinfectives, especially for the sepsis patient with diverse and partly conflicting pathophysiological changes, will have great importance regarding efficacy, toxicity and resistance development. In order to apply those complex strategies in clinical routine, there is a requirement for a strong interdisciplinary collaboration between the intensive care unit, clinical infectiology, microbiology, and clinical pharmacology, ideally in the framework of a functional antimicrobial stewardship program.
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Affiliation(s)
- Klaus-Friedrich Bodmann
- Klinik für Internistische Intensiv- und Notfallmedizin und Klinische Infektiologie, Klinikum Barnim GmbH, Werner Forßmann Krankenhaus, Eberswalde, Germany
| | - Rainer Höhl
- Institut für Klinikhygiene, Medizinische Mikrobiologie und Klinische Infektiologie, Klinikum Nürnberg, Germany
| | - Wolfgang Krüger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Konstanz, Germany
| | - Beatrice Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Munich, Germany
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96
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. Calculated initial parenteral treatment of bacterial infections: Skin and soft tissue infections. GMS INFECTIOUS DISEASES 2020; 8:Doc11. [PMID: 32373436 PMCID: PMC7186924 DOI: 10.3205/id000055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is the ninth chapter of the guideline "Calculated Parenteral Initial Therapy of Adult Bacterial Disorders - Update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter contains the first German S2k guidelines for bacterial skin and soft tissue infections. They encompass recommendations on diagnosis and treatment of the defined entities erysipelas (caused by beta-hämolytic streptococci), limited superficial cellulitis (S. aureus), severe cellulitis, abscess, complicated skin and soft tissue infections, infections of feet in diabetic patients ("diabetic foot"), necrotizing soft tissue infection and bite injuries.
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Affiliation(s)
- Cord Sunderkötter
- Universitätsklinik und Poliklinik für Dermatologie und Venerologie, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Karsten Becker
- Institut für Med. Mikrobiologie, Universitätsklinikum Münster, Germany
| | - Christian Eckmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Peine, Germany
| | | | - Peter Kujath
- Chirurgische Klinik, Medizinische Universität Lübeck, Germany
| | - Helmut Schöfer
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Frankfurt/Main, Germany
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97
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Scharf C, Paal M, Schroeder I, Vogeser M, Draenert R, Irlbeck M, Zoller M, Liebchen U. Therapeutic Drug Monitoring of Meropenem and Piperacillin in Critical Illness-Experience and Recommendations from One Year in Routine Clinical Practice. Antibiotics (Basel) 2020; 9:antibiotics9030131. [PMID: 32245195 PMCID: PMC7148485 DOI: 10.3390/antibiotics9030131] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/19/2022] Open
Abstract
Various studies have reported insufficient beta-lactam concentrations in critically ill patients. The extent to which therapeutic drug monitoring (TDM) in clinical practice can reduce insufficient antibiotic concentrations is an ongoing matter of investigation. We retrospectively evaluated routine meropenem and piperacillin measurements in critically ill patients who received antibiotics as short infusions in the first year after initiating a beta-lactam TDM program. Total trough concentrations above 8.0 mg/L for meropenem and above 22.5 mg/L for piperacillin were defined as the breakpoints for target attainment. We included 1832 meropenem samples and 636 piperacillin samples. We found that 39.3% of meropenem and 33.6% of piperacillin samples did not reach the target concentrations. We observed a clear correlation between renal function and antibiotic concentration (meropenem, r = 0.53; piperacillin, r = 0.63). Patients with renal replacement therapy or creatinine clearance (CrCl) of <70 mL/min had high rates of target attainment with the standard dosing regimens. There was a low number of patients with a CrCl >100 mL/min that achieved the target concentrations with the maximum recommended dosage. Patients with impaired renal function only required TDM if toxic side effects were noted. In contrast, patients with normal renal function required different dosage regimens and TDM-guided therapy to reach the breakpoints of target attainment.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
- Correspondence: ; Fax: +49-89-4400-78886
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Rika Draenert
- Section Clinical Infectious Diseases, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
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98
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Preanalytical Stability of Piperacillin, Tazobactam, Meropenem, and Ceftazidime in Plasma and Whole Blood Using Liquid Chromatography-Tandem Mass Spectrometry. Ther Drug Monit 2020; 41:538-543. [PMID: 31306394 DOI: 10.1097/ftd.0000000000000650] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is increasingly used to optimize the dosing of beta-lactam antibiotics in critically ill patients. However, beta-lactams are inherently unstable and degrade over time. Hence, patient samples need to be appropriately handled and stored before analysis to generate valid results for TDM. The appropriate handling and storage conditions are not established, with few and conflicting studies on the stability of beta-lactam antibiotics in clinical samples. The aim of this study was to assess the preanalytical stability of piperacillin, tazobactam, meropenem, and ceftazidime in human plasma and whole blood using a liquid chromatography-tandem mass spectrometry method for simultaneous quantification. METHODS A reverse phase liquid chromatography-tandem mass spectrometry method for the quantification of piperacillin, tazobactam, meropenem, and ceftazidime in plasma after protein precipitation was developed and validated. The preanalytical stability of these beta-lactams was assessed in EDTA- and citrate-anticoagulated plasma at 24, 4, and -20°C. The whole blood stability of the analytes in EDTA-anticoagulated tubes was assessed at 24°C. Stability was determined by nonlinear regression analysis defined by the lower limit of the 95th confidence interval of the time to 15% of degradation. RESULTS Based on the lower limit of the 95th confidence interval of the time to 15% of degradation, piperacillin, tazobactam, meropenem, and ceftazidime were stable in EDTA-anticoagulated plasma for at least 6 hours at 24°C, 3 days at 4°C, and 4 days at -20°C. Stability in EDTA- and citrate-anticoagulated plasma was similar. Stability in whole blood was similar to plasma at 24°C. CONCLUSIONS Plasma samples for the TDM of piperacillin, tazobactam, meropenem, and ceftazidime should be processed within 6 hours if kept at room temperature and within 3 days if kept at 4°C. All long-term storage of samples should be at -80°C.
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99
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Martínez ML, Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. An approach to antibiotic treatment in patients with sepsis. J Thorac Dis 2020; 12:1007-1021. [PMID: 32274170 PMCID: PMC7139065 DOI: 10.21037/jtd.2020.01.47] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.
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Affiliation(s)
- María Luisa Martínez
- Department of Intensive Care, Hospital Universitario General de Catalunya, Barcelona, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias, Barcelona, Spain
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100
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Sunderkötter C, Becker K, Eckmann C, Graninger W, Kujath P, Schöfer H. S2k guidelines for skin and soft tissue infections Excerpts from the S2k guidelines for "calculated initial parenteral treatment of bacterial infections in adults - update 2018". J Dtsch Dermatol Ges 2020; 17:345-369. [PMID: 30920735 DOI: 10.1111/ddg.13790] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
These first German S2k guidelines for bacterial skin and soft tissue infections were developed as one chapter of the recommendations for "calculated initial parenteral treatment of bacterial infections" issued under the auspices of the Paul-Ehrlich Society, of which the main part is presented here. Well-calculated antibiotic therapies require precise diagnostic criteria. Erysipelas is defined as non-purulent infection considered to be caused by beta-hemolytic strepto-cocci. It is diagnosed clinically by its bright-red erythema and early fever or chills at disease onset. Penicillin is the treatment of choice. Limited soft tissue infection (cellulitis) is usually caused by Staphylococcus (S.) aureus, frequently originates from chronic wounds and presents with a more violaceous-red hue and only rarely with initial fever or chills. Treatment consists of first- or second--generation cephalosporins or flucloxacillin (IV). Severe cellulitis is a purulent, partially necrotic infection which extends through tissue boundaries to fascias and requires surgical management in addition to antibiotics. Moreover, it frequently fulfills the criteria for "complicated soft tissue infections", as previously defined by the Food and Drug Administration for use in clinical trials (they include comorbidities such as uncontrolled diabetes, peripheral artery disease, neutropenia). It requires antibiotics which besides S. aureus target anaerobic and/or gramnegative bacteria. The rare so-called necrotizing skin and soft tissue infections represent a distinct entity. They are characterized by rapid, life-threatening progression due to special bacterial toxins that cause ischemic necrosis and shock and need rapid and thorough debridement in addition to appropriate antibiotics. For cutaneous abscesses the first-line treatment is adequate drainage. Additional antibiotic therapy is required only under certain circumstances (e.g., involvement of the face, hands, or anogenital region, or if drainage is somehow complicated). The present guidelines also contain consensus-based recommendations for higher doses of antibiotics than those approved or usually given in clinical trials. The goal is to deliver rational antibiotic treatment that is both effective and well-tolerated and that exerts no unnecessary selection pressure in terms of multidrug resistance.
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Affiliation(s)
- Cord Sunderkötter
- Department of Translational Dermatoinfectiology, Medical Faculty of the University of Münster, and Department of Dermatology and Venereology, University Medical Center, Martin Luther University of Halle-Wittenberg, Halle, Germany
| | - Karsten Becker
- Institute of Medical Microbiology, Münster University Medical Center, Münster, Germany
| | - Christian Eckmann
- Department of General, Visceral and Thoracic Surgery, Peine Medical Center, Peine, Germany
| | - Wolfgang Graninger
- Medical University of Vienna, Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Vienna General Hospital, Vienna, Austria
| | - Peter Kujath
- Department of Visceral, Vascular and Thoracic Surgery, Heide Medical Center, Heide, Germany
| | - Helmut Schöfer
- Department of Dermatology, Venereology, and Allergology, University hospital Frankfurt, Goethe-university, Frankfurt am Main, Germany
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