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Are Standard Dosing Regimens of Ceftriaxone Adapted for Critically Ill Patients with Augmented Creatinine Clearance? Antimicrob Agents Chemother 2019; 63:AAC.02134-18. [PMID: 30602511 DOI: 10.1128/aac.02134-18] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/11/2018] [Indexed: 01/21/2023] Open
Abstract
The objective of the present study was to determine whether augmented renal clearance (ARC) impacts negatively on ceftriaxone pharmacokinetic (PK)/pharmacodynamic (PD) target attainment in critically ill patients. Over a 9-month period, all critically ill patients treated with ceftriaxone were eligible. During the first 3 days of antimicrobial therapy, every patient underwent 24-h creatinine clearance (CLCR) measurements and therapeutic drug monitoring of unbound ceftriaxone. ARC was defined by a CLCR of ≥150 ml/min. Empirical underdosing was defined by a trough unbound ceftriaxone concentration under 2 mg/liter (percentage of the time that the concentration of the free fraction of drug remained greater than the MIC [fT >MIC], 100%). Monte Carlo simulation (MCS) was performed to determine the probability of target attainment (PTA) of different dosing regimens for various MICs and three groups of CLCR (<150, 150 to 200, and >200 ml/min). Twenty-one patients were included. The rate of empirical ceftriaxone underdosing was 62% (39/63). A CLCR of ≥150 ml/min was associated with empirical target underdosing with an odds ratio (OR) of 8.8 (95% confidence interval [CI] = 2.5 to 30.7; P < 0.01). Ceftriaxone PK concentrations were best described by a two-compartment model. CLCR was associated with unbound ceftriaxone clearance (P = 0.02). In the MCS, the proportion of patients who would have failed to achieve a 100% fT >MIC was significantly higher in ARC patients for each dosage regimen (OR = 2.96; 95% CI = 2.74 to 3.19; P < 0.01). A dose of 2 g twice a day was best suited to achieve a 100% fT >MIC When targeting a 100% fT >MIC for the less susceptible pathogens, patients with a CLCR of ≥150 ml/min remained at risk of empirical ceftriaxone underdosing. These data emphasize the need for therapeutic drug monitoring in ARC patients.
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102
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Affiliation(s)
- Renaud Prevel
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Driss Berdaï
- Service de Pharmacologie Médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Alexandre Boyer
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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103
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Corum O, Corum DD, Er A, Uney K. Pharmacokinetics of cefquinome after single and repeated subcutaneous administrations in sheep. J Vet Pharmacol Ther 2019; 42:647-653. [PMID: 30719732 DOI: 10.1111/jvp.12750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to determine the pharmacokinetics of cefquinome (CFQ) following single and repeated subcutaneous (SC) administrations in sheep. Six clinically healthy, 1.5 ± 0.2 years sheep were used for the study. In pharmacokinetic study, the crossover design in three periods was performed. The withdrawal interval between the study periods was 15 days. In first period, CFQ (Cobactan, 2.5%) was administered by an intravenous (IV) bolus (3 sheep) and SC (3 sheep) injections at 2.5 mg/kg dose. In second period, the treatment administration was repeated via the opposite administration route. In third period, CFQ was administrated subcutaneously to each sheep (n = 6) at a dose of 2.5 mg/kg q. 24 hr for 5 days. Plasma concentrations of CFQ were measured using the HPLC-UV method. Pharmacokinetic parameters were calculated using non-compartmental methods. The elimination half-life and mean residence time of CFQ after the single SC administration were longer than IV administration (p < 0.05). Bioavailability (F%) of CFQ following the single SC administration was 123.51 ± 11.54%. The area under the curve (AUC0-∞ ) and peak concentration following repeated doses (last dose) were higher than those observed after the first dose (p < 0.05). CFQ accumulated after repeated SC doses. CFQ can be given via SC at a dose of 2.5 mg/kg every 24 hr for the treatment of infections caused by susceptible pathogens, which minimum inhibitory concentration is ≤1.0 μg/ml in sheep.
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Affiliation(s)
- Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Duygu Durna Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Ayse Er
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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104
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Part III: Minimum Quality Threshold in Preclinical Sepsis Studies (MQTiPSS) for Fluid Resuscitation and Antimicrobial Therapy Endpoints. Shock 2019; 51:33-43. [DOI: 10.1097/shk.0000000000001209] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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105
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Corum DD, Corum O, Altan F, Eser Faki H, Bahcivan E, Er A, Uney K. Pharmacokinetics of ceftriaxone following single ascending intravenous doses in sheep. Small Rumin Res 2018. [DOI: 10.1016/j.smallrumres.2018.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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106
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Pilmis B, Zahar JR. Ventilator-associated pneumonia related to ESBL-producing gram negative bacilli. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:424. [PMID: 30581832 DOI: 10.21037/atm.2018.09.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent cause of intensive care unit (ICU) acquired infections. The worldwide spreading of extended spectrum beta-lactamase producing enterobacteriaceae (ESBL-PE) represents a major problem encountered more and more frequently in ICU. Among ICU patients, between 5% to 25% are ESBL-PE carriers. Whereas, previous carriage is the major risk factors associated with VAP related to ESBL-PE, among carriers, only 5% to 20% will develop a VAP related to ESBL-PE. Also, diagnosis and therapeutic delay are associated with length of stay and higher morbidity, and mortality, therefore, early identification of patients at risk of ESBL-PE related infections is crucial for early implementation of effective antibiotic therapy. VAP related to ESBL-PE should be considered in: previous colonized patients in case of late onset pneumonia and/or when several antibiotic courses precede the infectious episode or even in patients with shock. Among non-colonized patients, if VAP occurs, the risk being related to ESBL-PE is less than 1%. In the future, new rapid microbiological diagnostic tests will allow an early diagnosis. According to recent data, empirical antibiotic therapy should be based on carbapenems. Other alternative antibiotic classes could be used for de-escalation. However, several pharmacodynamic and pharmacokinetics precautions should be taken to achieve drug concentrations at site of infection and except to cure the infected patient.
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Affiliation(s)
- Benoit Pilmis
- Antimicrobial Stewardship Team, Hospital Paris Saint Joseph, 185 rue Raymond Losserand, 75014 Paris, France
| | - Jean-Ralph Zahar
- Department of Microbiology, Hospital Paris Seine Saint Denis, 125 rue de Stalingrad 93000 Bobigny, France.,UMR 1137, IAME Team 5, DeSCID: Decision SCiences in Infectious Diseases, Control and Care, INSERM, UFR SMBH, Paris 13, Paris Cité University, Paris, France
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107
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Olbrisch K, Kisch T, Thern J, Kramme E, Rupp J, Graf T, Wicha SG, Mailänder P, Raasch W. After standard dosage of piperacillin plasma concentrations of drug are subtherapeutic in burn patients. Naunyn Schmiedebergs Arch Pharmacol 2018; 392:229-241. [PMID: 30368548 DOI: 10.1007/s00210-018-1573-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/19/2018] [Indexed: 12/21/2022]
Abstract
Infections are a major problem in patients with burn diseases. Mortality is high despite antibiotic therapy as studies are controversial concerning drug underdosing. The aims of this prospective, observational study were to monitor plasma concentrations of piperacillin during standard piperacillin/tazobactam treatment in 20 burn patients and 16 controls from the intensive care unit (ICU) and to optimize doses by in silico analyses. Piperacillin/tazobactam (4/0.5 g, tid) was administered over 0.5 h. Blood samples were taken at 1, 4, and 7.5 h after the end of the infusion. Free piperacillin plasma concentrations were determined. Pharmacokinetic parameters and in silico analysis results were calculated using the freeware TDMx. The primary target was defined as percentage of the day (fT>1xMIC; fT>4xMIC) when piperacillin concentrations exceeded 1xMIC/4xMIC (minimum inhibitory concentration), considering a MIC breakpoint of 16 mg/L for Pseudomonas aeruginosa. In an off-label approach, two burn patients were treated with 8/1 g piperacillin/tazobactam, 3 h qid. fT>1xMIC (55 ± 22% vs. 77 ± 24%) and fT>4xMIC (17 ± 11% vs. 30 ± 11%) were lower in burn than in ICU patients after 4/0.5 g, 0.5 h, tid. In silico analyses indicated that fT>1xMIC (93 ± 12% burn, 97 ± 4% ICU) and fT>4xMIC (62 ± 23% burn, 84 ± 19% ICU) values increase by raising the piperacillin dosage to 8/1 g qid and prolonging the infusion time to 3 h. Off-label treatment results were similar to in silico data for burn patients (84%fT>1xMIC and 47%fT>4xMIC). Standard dosage regimens for piperacillin/tazobactam resulted in subtherapeutic piperacillin concentrations in burn and ICU patients. Dose adjustments via in silico analyses can help to optimize antibiotic therapy and to predict respective concentrations in vivo. Trial registration: NCT03335137, registered 07.11.2017, retrospectively.
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Affiliation(s)
- Katharina Olbrisch
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
- Department of Pharmacy, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Kisch
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Julia Thern
- Department of Pharmacy, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Evelyn Kramme
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Graf
- University Heart Centre Lübeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Sebastian G Wicha
- Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Peter Mailänder
- Clinic of Plastic Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Walter Raasch
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany.
- CBBM (Center of Brain, Behavior and Metabolism), University of Lübeck, Lübeck, Germany.
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108
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Meropenem Combined with Ciprofloxacin Combats Hypermutable Pseudomonas aeruginosa from Respiratory Infections of Cystic Fibrosis Patients. Antimicrob Agents Chemother 2018; 62:AAC.01150-18. [PMID: 30104278 DOI: 10.1128/aac.01150-18] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022] Open
Abstract
Hypermutable Pseudomonas aeruginosa organisms are prevalent in chronic respiratory infections and have been associated with reduced lung function in cystic fibrosis (CF); these isolates can become resistant to all antibiotics in monotherapy. This study aimed to evaluate the time course of bacterial killing and resistance of meropenem and ciprofloxacin in combination against hypermutable and nonhypermutable P. aeruginosa Static concentration time-kill experiments over 72 h assessed meropenem and ciprofloxacin in mono- and combination therapies against PAO1 (nonhypermutable), PAOΔmutS (hypermutable), and hypermutable isolates CW8, CW35, and CW44 obtained from CF patients with chronic respiratory infections. Meropenem (1 or 2 g every 8 h [q8h] as 3-h infusions and 3 g/day as a continuous infusion) and ciprofloxacin (400 mg q8h as 1-h infusions) in monotherapies and combinations were further evaluated in an 8-day hollow-fiber infection model study (HFIM) against CW44. Concentration-time profiles in lung epithelial lining fluid reflecting the pharmacokinetics in CF patients were simulated and counts of total and resistant bacteria determined. All data were analyzed by mechanism-based modeling (MBM). In the HFIM, all monotherapies resulted in rapid regrowth with resistance at 48 h. The maximum daily doses of 6 g meropenem (T>MIC of 80% to 88%) and 1.2 g ciprofloxacin (area under the concentration-time curve over 24 h in the steady state divided by the MIC [AUC/MIC], 176), both given intermittently, in monotherapy failed to suppress regrowth and resulted in substantial emergence of resistance (≥7.6 log10 CFU/ml resistant populations). The combination of these regimens achieved synergistic killing and suppressed resistance. MBM with subpopulation and mechanistic synergy yielded unbiased and precise curve fits. Thus, the combination of 6 g/day meropenem plus ciprofloxacin holds promise for future clinical evaluation against infections by susceptible hypermutable P. aeruginosa.
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109
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Jamal JA, Roger C, Roberts JA. Understanding the impact of pathophysiological alterations during critical illness on drug pharmacokinetics. Anaesth Crit Care Pain Med 2018; 37:515-517. [PMID: 30359771 DOI: 10.1016/j.accpm.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Janattul-Ain Jamal
- Department of Pharmacy, Hospital Tengku Ampuan Afzan, 25100 Kuantan, Pahang, Malaysia
| | - Claire Roger
- Department of Anaesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Professeur Debré, 30029 Nîmes, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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110
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Lee JM, Lee JW, Jeong TS, Bang ES, Kim SH. Single-Center Pharmacokinetic Study and Simulation of a Low Meropenem Concentration in Brain-Dead Organ Donors. Antimicrob Agents Chemother 2018; 62:e00542-18. [PMID: 30061281 PMCID: PMC6153783 DOI: 10.1128/aac.00542-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/25/2018] [Indexed: 11/20/2022] Open
Abstract
Meropenem is an ultrabroad-spectrum antibiotic of the carbapenem family. In brain-dead organ donors, administration of standard meropenem dosages does not reach therapeutic levels. Our objectives were to determine the plasma concentration of meropenem after the administration of standard meropenem dose and to estimate an improved dosage regimen for these patients. One gram of meropenem was administered as a 1-h infusion every 8 h for 1 to 3 days, and blood samples were collected. The plasma concentration of meropenem was measured and subjected to pharmacokinetic analysis. Simcyp simulation was performed to predict the optimum plasma levels and dosage based on the patients' individual pharmacokinetic parameters. The maximum plasma concentration of meropenem was 3.29 μg/ml, which was lower than four times the MIC of 8 μg/ml. Although the mean creatinine clearance of patients was moderately low (67.5 ml/min), the apparent volume of distribution at steady state (Vss) and time-averaged total body clearance (CL) of meropenem were markedly elevated (4.97 liters/kg and 2.06 liters/h/kg, respectively), owing to massive fluid loading to decrease the high sodium levels and to treat shock or dehydration. The simulation revealed that dose and infusion time of meropenem should be increased based on patients' Vss and CL, and a loading dose is recommended to reach rapidly the target concentration. In conclusion, a standard meropenem regimen is insufficient to achieve optimal drug levels in brain-dead patients, and an increase in dose and extended or continuous infusion with intravenous bolus administration of a loading dose are recommended for these patients.
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Affiliation(s)
- Jae-Myeong Lee
- Department of Surgery, Ajou University School of Medicine, Yeongtong-gu, Suwon, Republic of Korea
| | - Joo Won Lee
- College of Pharmacy and Research Institute of Pharmaceutical Science and Technology, Ajou University, Yeongtong-gu, Suwon, Republic of Korea
| | - Tae Seok Jeong
- College of Pharmacy and Research Institute of Pharmaceutical Science and Technology, Ajou University, Yeongtong-gu, Suwon, Republic of Korea
| | - Eun Sook Bang
- Office of Pharmacy, Ajou University Hospital, Yeongtong-gu, Suwon, Republic of Korea
| | - So Hee Kim
- College of Pharmacy and Research Institute of Pharmaceutical Science and Technology, Ajou University, Yeongtong-gu, Suwon, Republic of Korea
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111
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Reply to Sorooshian and Snow, "Is Alternate-Day Therapeutic Drug Monitoring in the Intensive Care Unit Not Intensive Enough?". Antimicrob Agents Chemother 2018; 62:62/10/e01343-18. [PMID: 30249716 DOI: 10.1128/aac.01343-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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112
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Veiga RP, Paiva JA. Pharmacokinetics-pharmacodynamics issues relevant for the clinical use of beta-lactam antibiotics in critically ill patients. Crit Care 2018; 22:233. [PMID: 30244674 PMCID: PMC6151903 DOI: 10.1186/s13054-018-2155-1] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/08/2018] [Indexed: 12/15/2022] Open
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients and beta-lactams are the most common antibiotic class used. Critically ill patient's pathophysiological factors lead to altered pharmacokinetics and pharmacodynamics of beta-lactams.A comprehensive bibliographic search in PubMed database of all English language articles published from January 2000 to December 2017 was performed, allowing the selection of articles addressing the pharmacokinetics or pharmacodynamics of beta-lactam antibiotics in critically ill patients.In critically ill patients, several factors may increase volume of distribution and enhance renal clearance, inducing high intra- and inter-patient variability in beta-lactam concentration and promoting the risk of antibiotic underdosing. The duration of infusion of beta-lactams has been shown to influence the fT > minimal inhibitory concentration and an improved beta-lactam pharmacodynamics profile may be obtained by longer exposure with more frequent dosing, extended infusions, or continuous infusions.The use of extracorporeal support techniques in the critically ill may further contribute to this problem and we recommend not reducing standard antibiotic dosage since no drug accumulation was found in the available literature and to maintain continuous or prolonged infusion, especially for the treatment of infections caused by multidrug-resistant bacteria.Prediction of outcome based on concentrations in plasma results in overestimation of antimicrobial activity at the site of infection, namely in cerebrospinal fluid and the lung. Therefore, although no studies have assessed clinical outcome, we recommend using higher than standard dosing, preferably with continuous or prolonged infusions, especially when treating less susceptible bacterial strains at these sites, as the pharmacodynamics profile may improve with no apparent increase in toxicity.A therapeutic drug monitoring-guided approach could be particularly useful in critically ill patients in whom achieving target concentrations is more difficult, such as obese patients, immunocompromised patients, those infected by highly resistant bacterial strains, patients with augmented renal clearance, and those undergoing extracorporeal support techniques.
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Affiliation(s)
- Rui Pedro Veiga
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
| | - José-Artur Paiva
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
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113
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Quantification of Cefepime, Meropenem, Piperacillin, and Tazobactam in Human Plasma Using a Sensitive and Robust Liquid Chromatography-Tandem Mass Spectrometry Method, Part 1: Assay Development and Validation. Antimicrob Agents Chemother 2018; 62:AAC.00859-18. [PMID: 29941654 DOI: 10.1128/aac.00859-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/20/2018] [Indexed: 11/20/2022] Open
Abstract
The highly variable pharmacokinetics of β-lactam antibiotics and β-lactamase inhibitors poses a significant challenge to clinicians in ensuring appropriate antibiotic doses in critically ill patients. Therefore, routine monitoring of plasma concentrations is important for individualization of antimicrobial therapy. Accordingly, a simple and robust analytical method for the simultaneous measurement of multiple β-lactam antibiotics and β-lactamase inhibitors is highly desirable to ensure quick decisions on dose adjustments. In this study, a sensitive, simple, and robust method for the simultaneous quantification of cefepime, meropenem, piperacillin, and tazobactam in human plasma was developed and rigorously validated according to FDA guidance. Sample extraction was accomplished by simple protein precipitation. Chromatographic separation of analytes was achieved using stepwise gradient elution. Analytes were monitored using tandem mass spectrometry (MS/MS) with a turbo ion spray source in positive multiple-reaction-monitoring mode. The calibration curve ranged from 0.5 to 150 μg/ml for cefepime, 0.1 to 150 μg/ml for meropenem and piperacillin, and 0.25 to 150 μg/ml for tazobactam. Inter- and intraday precision and accuracy, sensitivity, selectivity, dilution integrity, matrix effect, extraction recovery, and hemolysis effect were investigated for all four analytes, and the results met the acceptance criteria. Compared to other reported methods, our method is more robust because of the combination of the following features: (i) a simple sample extraction procedure, (ii) a short sample run time, (iii) a wide dynamic range, and (iv) the small plasma sample volume needed. Since our method already covers β-lactams and a β-lactamase inhibitor with highly heterogeneous physicochemical properties, further antibiotic candidates may easily be incorporated into this multianalyte method.
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114
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Quantification of Cefepime, Meropenem, Piperacillin, and Tazobactam in Human Plasma Using a Sensitive and Robust Liquid Chromatography-Tandem Mass Spectrometry Method, Part 2: Stability Evaluation. Antimicrob Agents Chemother 2018; 62:AAC.00861-18. [PMID: 29941653 DOI: 10.1128/aac.00861-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/20/2018] [Indexed: 11/20/2022] Open
Abstract
Although the stability of β-lactam antibiotics is a known issue, none of the previously reported bioanalytical methods had an adequate evaluation of the stability of these drugs. In the current study, the stability of cefepime, meropenem, piperacillin, and tazobactam under various conditions was comprehensively evaluated. The evaluated parameters included stock solution stability, short-term stability, long-term stability, freeze-thaw stability, processed sample stability, and whole-blood stability. When stored at -20°C, the stock solution of meropenem in methanol was stable for up to 3 weeks, and the stock solutions of cefepime, piperacillin, and tazobactam were stable for up to 6 weeks. All four antibiotics were stable in human plasma for up to 3 months when stored at -80°C and were stable in whole blood for up to 4 h at room temperature. Short-term stability results indicated that all four β-lactams were stable at room temperature for 2 h, but substantial degradation was observed when the plasma samples were stored at room temperature for 24 h, with the degradation rates for cefepime, meropenem, piperacillin, and tazobactam being 30.1%, 75.6%, 49.0%, and 37.7%, respectively. Because the stability information is method independent, our stability results can be used as a reference by other research groups that work with these antibiotics.
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115
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Pharmacodynamic Target Attainment for Cefepime, Meropenem, and Piperacillin-Tazobactam Using a Pharmacokinetic/Pharmacodynamic-Based Dosing Calculator in Critically Ill Patients. Antimicrob Agents Chemother 2018; 62:AAC.01008-18. [PMID: 29967022 DOI: 10.1128/aac.01008-18] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/25/2018] [Indexed: 01/19/2023] Open
Abstract
This was a prospective study to determine if pharmacokinetic/pharmacodynamic (PK/PD)-based antibiotic dosing software aids in achieving concentration targets in critically ill patients receiving cefepime (n = 10), meropenem (n = 20), or piperacillin-tazobactam (n = 19). Antibiotic calculator doses targeting a >90% probability of target attainment (PTA) differed from package insert doses for 22.4% (11/49) of patients. Target attainment was achieved for 98% of patients (48/49). A PK/PD-based antibiotic dosing calculator provides beta-lactam doses with a high PTA in critically ill patients.
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116
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de Velde F, Mouton JW, de Winter BCM, van Gelder T, Koch BCP. Clinical applications of population pharmacokinetic models of antibiotics: Challenges and perspectives. Pharmacol Res 2018; 134:280-288. [PMID: 30033398 DOI: 10.1016/j.phrs.2018.07.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 11/26/2022]
Abstract
Because of increasing antimicrobial resistance and the shortage of new antibiotics, there is a growing need to optimize the use of old and new antibiotics. Modelling of the pharmacokinetic/pharmacodynamic (PK/PD) characteristics of antibiotics can support the optimization of dosing regimens. Antimicrobial efficacy is determined by susceptibility of the drug to the microorganism and exposure to the drug, which relies on the PK and the dose. Population PK models describe relationships between patients characteristics and drug exposure. This article highlights three clinical applications of these models applied to antibiotics: 1) dosing evaluation of old antibiotics, 2) setting clinical breakpoints and 3) dosing individualization using therapeutic drug monitoring (TDM). For each clinical application, challenges regarding interpretation are discussed. An important challenge is to improve the understanding of the interpretation of modelling results for good implementation of the dosing recommendations, clinical breakpoints and TDM advices. Therefore, also background information on PK/PD principles and approaches to analyse PK/PD data are provided.
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Affiliation(s)
- Femke de Velde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands.
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands; Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
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Andersen MG, Thorsted A, Storgaard M, Kristoffersson AN, Friberg LE, Öbrink-Hansen K. Population Pharmacokinetics of Piperacillin in Sepsis Patients: Should Alternative Dosing Strategies Be Considered? Antimicrob Agents Chemother 2018; 62:e02306-17. [PMID: 29507062 PMCID: PMC5923116 DOI: 10.1128/aac.02306-17] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/17/2018] [Indexed: 12/11/2022] Open
Abstract
Sufficient antibiotic dosing in septic patients is essential for reducing mortality. Piperacillin-tazobactam is often used for empirical treatment, but due to the pharmacokinetic (PK) variability seen in septic patients, optimal dosing may be a challenge. We determined the PK profile for piperacillin given at 4 g every 8 h in 22 septic patients admitted to a medical ward. Piperacillin concentrations were compared to the clinical breakpoint MIC for Pseudomonas aeruginosa (16 mg/liter), and the following PK/pharmacodynamic (PD) targets were evaluated: the percentage of the dosing interval that the free drug concentration is maintained above the MIC (fTMIC) of 50% and 100%. A two-compartment population PK model described the data well, with clearance being divided into renal and nonrenal components. The renal component was proportional to the estimated creatinine clearance (eCLCR) and constituted 74% of the total clearance in a typical individual (eCLCR, 83.9 ml/min). Patients with a high eCLCR (>130 ml/min) were at risk of subtherapeutic concentrations for the current regimen, with a 90% probability of target attainment being reached at MICs of 2.0 (50% fTMIC) and 0.125 mg/liter (100% fTMIC). Simulations of alternative dosing regimens and modes of administration showed that dose increment and prolonged infusion increased the chance of achieving predefined PK/PD targets. Alternative dosing strategies may therefore be needed to optimize piperacillin exposure in septic patients. (This study has been registered at ClinicalTrials.gov under identifier NCT02569086.).
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Affiliation(s)
- Maria Goul Andersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Thorsted
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Population Pharmacokinetics of Meropenem in Plasma and Subcutis from Patients on Extracorporeal Membrane Oxygenation Treatment. Antimicrob Agents Chemother 2018. [PMID: 29530848 DOI: 10.1128/aac.02390-17] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The objectives of this study were to describe meropenem pharmacokinetics (PK) in plasma and/or subcutaneous adipose tissue (SCT) in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) treatment and to develop a population PK model to simulate alternative dosing regimens and modes of administration. We conducted a prospective observational study. Ten patients on ECMO treatment received meropenem (1 or 2 g) intravenously over 5 min every 8 h. Serial SCT concentrations were determined using microdialysis and compared with plasma concentrations. A population PK model of SCT and plasma data was developed using NONMEM. Time above clinical breakpoint MIC for Pseudomonas aeruginosa (8 mg/liter) was predicted for each patient. The following targets were evaluated: time for which the free (unbound) concentration is maintained above the MIC of at least 40% (40% fT>MIC), 100% fT>MIC, and 100% fT>4×MIC. For all dosing regimens simulated in both plasma and SCT, 40% fT>MIC was attained. However, prolonged meropenem infusion would be needed for 100% fT>MIC and 100% fT>4×MIC to be obtained. Meropenem plasma and SCT concentrations were associated with estimated creatinine clearance (eCLCr). Simulations showed that in patients with increased eCLCr, dose increment or continuous infusion may be needed to obtain therapeutic meropenem concentrations. In conclusion, our results show that using traditional targets of 40% fT>MIC for standard meropenem dosing of 1 g intravenously every 8 h is likely to provide sufficient meropenem concentration to treat the problematic pathogen P. aeruginosa for patients receiving ECMO treatment. However, for patients with an increased eCLCr, or if more aggressive targets, like 100% fT>MIC or 100% fT>4×MIC, are adopted, incremental dosing or continuous infusion may be needed.
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119
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Popowicz ND, O'Halloran SJ, Fitzgerald D, Lee YG, Joyce DA. A rapid, LC-MS/MS assay for quantification of piperacillin and tazobactam in human plasma and pleural fluid; application to a clinical pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1081-1082:58-66. [DOI: 10.1016/j.jchromb.2018.02.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 01/24/2018] [Accepted: 02/18/2018] [Indexed: 12/01/2022]
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120
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Kaska M, Havel E, Selke-Krulichova I, Safranek P, Bezouska J, Martinkova J. Covariate determinants of effective dosing regimens for time-dependent beta-lactam antibiotics for critically ill patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:219-226. [PMID: 29582860 DOI: 10.5507/bp.2018.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 03/21/2018] [Indexed: 11/23/2022] Open
Abstract
AIMS Critically ill patients undergoing aggressive fluid resuscitation and treated empirically with hydrosoluble time-dependent beta-lactam antibiotics are at risk for sub-therapeutic plasma concentrations. The aim of this study was to assess the impact of two covariates - creatinine clearance (Clcr) and cumulative fluid balance (CFB) on pharmacokinetics/pharmacodynamics (PK/PD) target attainment within a week of treatment with meropenem (ME) or piperacillin/tazobactam (PIP/TZB). METHODS In this prospective observational pharmacokinetic (PK) study, 18 critically ill patients admitted to a surgical Intensive Care Unit (ICU) were enrolled. The primary PK/PD target was free antibiotic concentrations above MIC at 100% of the dosing interval (100%fT>MIC) to obtain maximum bactericidal activity. Drug concentration was measured using liquid chromatography-tandem mass spectrometry. RESULTS The treatment of both 8 septic patients with IV extended ME dosing 2 g/3 h q8 h and 10 polytraumatized patients with IV intermittent PIP/TZB dosing 4.0/0.5 g q8 h was monitored. 8/18 patients (44%) manifested augmented renal clearence (ARC) where Clcr ≥130 mL/min/1.73 m2. Maximum changes were reported on days 2-3: the median positive CFB followed by the large median volume of distribution: Vdme=70.3 L (41.9-101.5), Vdpip = 46.8 L (39.7-60.0). 100%fTme>MIC was achieved in all patients on ME (aged ≥60 years), and only in two patients (non-ARC, aged ≥65 years) out of 10 on PIP/TZB. A mixed model analysis revealed positive relationship of CFBpip with Vdpip (P=0.021). CONCLUSION Assuming that the positive correlation between CFB and Vd exists for piperacillin in the setting of the pathological state, then CFB should predict Vdpip across subjects at each and every time point.
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Affiliation(s)
- Milan Kaska
- Department of Surgery, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic.,Academic Department of Surgery, Faculty of Medicine in Hradec Kralove, Charles University and Department of Surgery, University Hospital, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Eduard Havel
- Department of Surgery, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic.,Academic Department of Surgery, Faculty of Medicine in Hradec Kralove, Charles University and Department of Surgery, University Hospital, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Iva Selke-Krulichova
- Academic Department of Surgery, Faculty of Medicine in Hradec Kralove, Charles University and Department of Surgery, University Hospital, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Petr Safranek
- Department of Surgery, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Jan Bezouska
- Academic Department of Surgery, Faculty of Medicine in Hradec Kralove, Charles University and Department of Surgery, University Hospital, Sokolska 581, 50005 Hradec Kralove, Czech Republic
| | - Jirina Martinkova
- Department of Surgery, University Hospital Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
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Simultaneous quantification of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin in human serum using an isotope-dilution HPLC-MS/MS method. J Pharm Biomed Anal 2018; 152:102-110. [PMID: 29414000 DOI: 10.1016/j.jpba.2018.01.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 01/08/2023]
Abstract
The aim of the current study was to develop and validate a robust multi-analyte high performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS) method for simultaneous quantification of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin, which are the most commonly used antibiotics in intensive care units. Sample clean-up included a protein precipitation protocol, followed by chromatographic separation on a C8 reverse phase HPLC column within 4 min, using a formic acid-ammonium formiate methanol step-elution gradient. All compounds were detected with electrospray ionization (ESI+) mass spectrometry in multiple reaction time monitoring. The method was validated according to the protocol from the European Medicines Agency and was thoroughly evaluated for interferences and quantification linearity. Linear relationships between peak area responses and drug concentrations were obtained in the range of 0.25-200 mg/l for cefepime, 0.25-120 mg/l for meropenem, 0.05-10 mg/l for ciprofloxacin, 0.125-10 mg/l for moxifloxacin, 0.125-50 mg/l for linezolid and 0.5-400 mg/l for piperacillin with an R2 > 0.997. Imprecision and inaccuracy values (both intra- and inter-assay) were ≤ 6.8% and ≤10.9% for all analytes in quality control samples, respectively. The assay proved to be selective for the study antibiotics, and the internal standards consistently compensated for matrix effects. The described simple and reliable HPLC-MS/MS assay is a powerful tool for routine TDM of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin in human serum in clinical laboratories. With a total process time of approximately 30 min, it allows for accurate and selective quantification up to the expected pharmacokinetic peak concentrations.
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123
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Udy AA, Roberts JA, Lipman J, Blot S. The effects of major burn related pathophysiological changes on the pharmacokinetics and pharmacodynamics of drug use: An appraisal utilizing antibiotics. Adv Drug Deliv Rev 2018; 123:65-74. [PMID: 28964882 DOI: 10.1016/j.addr.2017.09.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/31/2017] [Accepted: 09/22/2017] [Indexed: 12/13/2022]
Abstract
Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.
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124
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Wu XJ, Huang X, Shi HY, Chen XK, Dong Q, Hao GX, Li Y, Zheng Y, Zhao W. Determination of cefoperazone and sulbactam in serum by HPLC-MS/MS: An adapted method for therapeutic drug monitoring in children. Biomed Chromatogr 2017; 32. [PMID: 29148595 DOI: 10.1002/bmc.4143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/25/2017] [Accepted: 11/03/2017] [Indexed: 11/09/2022]
Abstract
A rapid, accurate and specific high-performance liquid chromatography-tandem mass spectrometry method has been validated for the simultaneous determination of cefoperazone and sulbactam in a small volume sample for children. A Shim-pack XR-ODS C18 column with gradient elution of water (0.1% formic acid) and acetonitrile (0.1% formic acid) solution was used for separation at a flow rate of 0.3 mL/min. The calibration curves of two analytes in serum showed excellent linearity over the concentration ranges of 0.03-10 μg/mL for cefoperazone, and 0.01-3 μg/mL for sulbactam, respectively. This method involves simple sample preparation steps and was validated according to standard US Food and Drug Administration and European Medicines Agency guidelines in terms of selectivity, linearity, detection limits, matrix effects, accuracy, precision, recovery and stability. This assay can be easily implemented in clinical practice to determine concentrations of cefoperazone and sulbactam in children.
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Affiliation(s)
- Xiu-Jun Wu
- Laboratory of Clinical Pharmacokinetic of TCM, Affiliated Hospital of Liaoning University of Traditional Medicine, Shenyang, China
| | - Xin Huang
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
| | - Hai-Yan Shi
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xing-Kai Chen
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Qian Dong
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Yan Li
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
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125
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Carrié C, Petit L, d'Houdain N, Sauvage N, Cottenceau V, Lafitte M, Foumenteze C, Hisz Q, Menu D, Legeron R, Breilh D, Sztark F. Association between augmented renal clearance, antibiotic exposure and clinical outcome in critically ill septic patients receiving high doses of β-lactams administered by continuous infusion: a prospective observational study. Int J Antimicrob Agents 2017; 51:443-449. [PMID: 29180280 DOI: 10.1016/j.ijantimicag.2017.11.013] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/07/2017] [Accepted: 11/18/2017] [Indexed: 11/18/2022]
Abstract
This study assessed whether augmented renal clearance (ARC) impacts negatively on antibiotic concentrations and clinical outcomes in patients treated by high-dose β-lactams administered continuously. Over a 9-month period, all critically ill patients without renal impairment treated by one of the monitored β-lactams for a documented infection were eligible. During the first 3 days of antibiotic therapy, every patient underwent 24-h CLCr measurements and therapeutic drug monitoring. The main outcome was the rate of β-lactam underdosing, defined as a free drug concentration <4 × MIC of the known pathogen. Secondary outcomes were rates of subexposure for β-lactams and therapeutic failure. The performance of CLCr in predicting underdosing was assessed by a ROC curve, and multivariable logistic regression was performed to determine risk factors for subexposure and therapeutic failure. A total of 79 patients were included and 235 samples were analysed. The rate of underdosing<4×MIC was 12%, with a significant association with CLCr (P <0.0001). A threshold of CLCr ≥ 170 mL/min had a sensitivity and specificity of 0.93 (95% CI 0.77-0.99) and 0.65 (95% CI 0.58-0.71) for predicting β-lactam underdosing<4×MIC. Mean CLCr values ≥170 mL/min were significantly associated with subexposure<4xMIC [OR = 10.1 (2.4-41.6); P = 0.001]. Patients with subexposure<4×MIC presented higher rates of therapeutic failure [OR = 6.3 (1.2-33.2); P = 0.03]. Mean CLCr values ≥170 mL/min remain a risk factor for subexposure to β-lactams despite high doses of β-lactams administered continuously. β-Lactam subexposure was associated with higher rates of therapeutic failure in septic critically ill patients.
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Affiliation(s)
- Cédric Carrié
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France.
| | - Laurent Petit
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | | | - Noemie Sauvage
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Vincent Cottenceau
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Melanie Lafitte
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Cecile Foumenteze
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Quentin Hisz
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Deborah Menu
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Rachel Legeron
- Pharmacology Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Dominique Breilh
- Pharmacology Department, CHU Bordeaux, 33000, Bordeaux, France; Université Bordeaux Segalen, 33000 Bordeaux, France
| | - Francois Sztark
- Anesthesiology and Critical Care Department, CHU Bordeaux, 33000, Bordeaux, France; Université Bordeaux Segalen, 33000 Bordeaux, France
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Pilmis B, Jullien V, Tabah A, Zahar JR, Brun-Buisson C. Piperacillin-tazobactam as alternative to carbapenems for ICU patients. Ann Intensive Care 2017; 7:113. [PMID: 29127502 PMCID: PMC5681454 DOI: 10.1186/s13613-017-0334-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/26/2017] [Indexed: 12/19/2022] Open
Abstract
Several studies suggest that alternatives to carbapenems, and particulary beta-lactam/beta-lactamase inhibitor combinations, can be used for therapy of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE)-related infections in non-ICU patients. Little is known concerning ICU patients in whom achieving the desired plasmatic pharmacokinetic/pharmacodynamic (PK/PD) target may be difficult. Also, in vitro susceptibility to beta-lactamase inhibitors might not translate into clinical efficacy. We reviewed the recent clinical studies examining the use of BL/BLI as alternatives to carbapenems for therapy of bloodstream infection, PK/PD data and discuss potential ecological benefit from avoiding the use of carbapenems. With the lack of prospective randomized studies, treating ICU patients with ESBL-PE-related infections using piperacillin-tazobactam should be done with caution. Current data suggest that BL/BLI empirical use should be avoided for therapy of ESBL-PE-related infection. Also, definitive therapy should be reserved to patients in clinical stable condition, after microbial documentation and results of susceptibility tests. Optimization of administration and higher dosage should be used in order to reach pharmacological targets.
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Affiliation(s)
- Benoit Pilmis
- Service de maladies infectieuses et tropicales, Hôpital Necker Enfants malades, Service de maladies infectieuses et tropicales, Université Paris Descartes, Paris, France.,Equipe mobile de microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Vincent Jullien
- Service de Pharmacologie, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France.,INSERM U1129, Paris, France
| | - Alexis Tabah
- Intensive Care Unit, The Redcliffe Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - Jean-Ralph Zahar
- Département de Microbiologie Clinique, Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, CHU Avicenne, 125 rue de Stalingrad, 9300, Bobigny, France. .,Infection Control Unit, IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France.
| | - Christian Brun-Buisson
- Réanimation médicale, Hôpital Henri Mondor, Université Paris Est Créteil (UPEC), Créteil, France
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127
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Hecht M, Evard H, Takkis K, Veigure RT, Aro R, Lohmus R, Herodes K, Leito I, Kipper K. Sponge Spray-Reaching New Dimensions of Direct Sampling and Analysis by MS. Anal Chem 2017; 89:11592-11597. [PMID: 29028329 DOI: 10.1021/acs.analchem.7b02957] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sample preparation for the analysis of clinical samples with the mass spectrometer (MS) can be extensive and expensive. Simplifying and speeding up the process would be very beneficial. This paper reports sponge spray-a novel sampling and direct MS analysis approach-attempting exactly that. It enables direct analysis without any sample preparation from dried blood, plasma, and urine. The tip of a volumetric absorptive microsampling device is used to collect an exact amount of sample and from that same tip an electrospray can be directed into a mass spectrometer. We demonstrate here that, although with significant matrix effects, quantitation of penicillin G, a common antimicrobial, is possible in plasma and in urine, with essentially no sample preparation.
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Affiliation(s)
- Max Hecht
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Hanno Evard
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia.,Faculty of Pharmacy, Division of Pharmaceutical Chemistry and Technology, University of Helsinki , Viikinkaari 5, 00790 Helsinki, Finland
| | - Kalev Takkis
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Ru Ta Veigure
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Rudolf Aro
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Rynno Lohmus
- University of Tartu , Institute of Physics, W. Ostwaldi Street 1, 50411 Tartu, Estonia
| | - Koit Herodes
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Ivo Leito
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia
| | - Karin Kipper
- University of Tartu , Institute of Chemistry, 14a Ravila Street, 50411 Tartu, Estonia.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London , Cranmer Terrace, London SW17 0RE, United Kingdom.,Analytical Services International, St George's University of London , Cranmer Terrace, London SW17 0RE, United Kingdom
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128
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Continuous Infusion Versus Intermittent Bolus of Beta-Lactams in Critically Ill Patients with Respiratory Infections: A Systematic Review and Meta-analysis. Eur J Drug Metab Pharmacokinet 2017; 43:155-170. [DOI: 10.1007/s13318-017-0439-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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129
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Toullec L, Dupouey J, Vigne C, Marsot A, Allanioux L, Blin O, Leone M, Guilhaumou R. Analytical interference during cefepime therapeutic drug monitoring in intensive care patient: About a case report. Therapie 2017; 72:587-592. [DOI: 10.1016/j.therap.2017.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/07/2017] [Indexed: 11/16/2022]
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130
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Lefeuvre S, Bois-Maublanc J, Hocqueloux L, Bret L, Francia T, Eleout-Da Violante C, Billaud EM, Barbier F, Got L. A simple ultra-high-performance liquid chromatography-high resolution mass spectrometry assay for the simultaneous quantification of 15 antibiotics in plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1065-1066:50-58. [PMID: 28946125 DOI: 10.1016/j.jchromb.2017.09.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 09/05/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
Abstract
Antibiotic (ATB) treatment of critically ill patients with pathophysiological injuries remains a challenge due to the constant increase in antimicrobial resistance. Therapeutic drug monitoring (TDM) is advised for ATB dose adjustments to avoid suboptimal concentrations and dose-related adverse effects. Therefore, a single and reliable analytical method for a broad selection of ATBs was developed using a high-resolution mass spectrometry (HRMS) platform for frequent use in intensive care units. An UHPLC assay coupled to high resolution accurate mass acquisition has been developed for the quantification of penicillins (amoxicillin, oxacillin, piperacillin, and ticarcillin), cephalosporines (cefepime, cefotaxime, ceftazidime, and ceftriaxone), carbapenems (ertapenem, imipenem, and meropenem), lincosamide (clindamycin), quinolones (ofloxacin and ciprofloxacin) and tazobactam. Plasma samples (100μL) were spiked with an internal standard solution followed by protein precipitation. Separation was achieved on an Accucore C18 column, which enabled sample analysis every 9min. All compounds were detected in electrospray positive ion mode and quantified with a linear regression between 0.5 and 32mg/L (r2>0.998). Overall precision and accuracy did not exceed 15%. No significant matrix effect was observed for the studied ATBs. Stored stock solutions at -20°C were stable for 6 months, except for amoxicillin and imipenem. Analytes in plasma were stable for 24h under ambient conditions as well as in post-preparation in an autosampler, except for amoxicillin and imipenem. This HRMS assay provides the simultaneous quantification of 15 ATB; it fulfills the usual quality criteria and was successfully applied for routine TDM of ATBs. The method is based on a full scan acquisition, and it would be easy to add other compounds to the present panel in the future, as this assay has already been proven to be efficient for different classes of compounds.
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Affiliation(s)
- S Lefeuvre
- Laboratory of Biochemistry, CHR Orléans, France.
| | | | - L Hocqueloux
- Tropical and Infectious Deseases Department, CHR Orléans, France
| | - L Bret
- Laboratory de Microbiology-Virology, CHR Orléans, France
| | - T Francia
- Laboratory of Biochemistry, CHR Orléans, France
| | | | - E M Billaud
- Pharmacology Department, AP-HP, Hôpital Européen Georges Pompidou, Paris Descartes University, Paris, France
| | - F Barbier
- Intensive care Department, CHR Orléans, France
| | - L Got
- Laboratory of Biochemistry, CHR Orléans, France
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Rawson TM, Sharma S, Georgiou P, Holmes A, Cass A, O'Hare D. Towards a minimally invasive device for beta-lactam monitoring in humans. Electrochem commun 2017; 82:1-5. [PMID: 31031564 PMCID: PMC6485621 DOI: 10.1016/j.elecom.2017.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Antimicrobial resistance is a leading patient safety issue. There is a need to develop novel mechanisms for monitoring and subsequently improving the precision of how we use antibiotics. A surface modified microneedle array was developed for monitoring beta-lactam antibiotic levels in human interstitial fluid. The sensor was fabricated by anodically electrodepositing iridium oxide (AEIROF) onto a platinum surface on the microneedle followed by fixation of beta-lactamase enzyme within a hydrogel. Calibration of the sensor was performed to penicillin-G in buffer solution (PBS) and artificial interstitial fluid (ISF). Further calibration of a platinum disc electrode was undertaken using amoxicillin and ceftriaxone. Open-circuit potentials were performed and data analysed using the Hill equation and log(concentration [M]) plots. The microneedle sensor demonstrated high reproducibility between penicillin-G runs in PBS with mean Km (±1SD) = 0.0044 ± 0.0013 M and mean slope function of log(concentration plots) 29 ± 1.80 mV/decade (r2=0.933). Response was reproducible after 28 days storage at 4°C. In artificial ISF, the sensors response was Km (±1SD) = 0.0077 ± 0.0187 M and a slope function of 34 ± 1.85 mv/decade (r2=0.995). Our results suggest that microneedle array based beta-lactam sensing may be a future application of this AEIROF based enzymatic sensor.
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Affiliation(s)
- Timothy Miles Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United Kingdom
| | - Sanjiv Sharma
- Department of Chemistry & Institute of Biomedical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London. W12 0NN. United Kingdom
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, W12 0NN, United Kingdom
| | - Anthony Cass
- Department of Chemistry & Institute of Biomedical Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Danny O'Hare
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom
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Delattre IK, Taccone FS, Jacobs F, Hites M, Dugernier T, Spapen H, Laterre PF, Wallemacq PE, Van Bambeke F, Tulkens PM. Optimizing β-lactams treatment in critically-ill patients using pharmacokinetics/pharmacodynamics targets: are first conventional doses effective? Expert Rev Anti Infect Ther 2017; 15:677-688. [PMID: 28571493 DOI: 10.1080/14787210.2017.1338139] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The pharmacokinetic/pharmacodynamic index determining β-lactam activity is the percentage of the dosing interval (%T) during which their free serum concentration remains above a critical threshold over the minimum inhibitory concentration (MIC). Regrettably, neither the value of %T nor that of the threshold are clearly defined for critically-ill patients. Areas covered: We review and assess the targets proposed for β-lactams in critical illness by screening the literature since 1997. Depending on the study intention (clinical cure vs. suppression of resistance), targets proposed range from 20%T > 1xMIC to 100%T > 5xMIC. Assessment and comparative analysis of their respective clinical efficacy suggest that a value of 100%T > 4xMIC may be needed. Simulation studies, however, show that this target will not be reached at first dose for the majority of critically-ill patients if using the most commonly recommended doses. Expert commentary: Considering that critically-ill patients are highly vulnerable and likely to experience antibiotic underexposure, and because effective initial treatment is a key determinant of clinical outcome, we support the use of a target of 100%T > 4xMIC, which could not only maximize efficacy but also minimize emergence of resistance. Clinical and microbiological studies are needed to test for the feasibility and effectiveness of reaching such a demanding target.
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Affiliation(s)
- Isabelle K Delattre
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium.,b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Fabio S Taccone
- c Department of Intensive Care , Hôpital Erasme , Brussels , Belgium
| | - Frédérique Jacobs
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Maya Hites
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Thierry Dugernier
- e Department of Intensive Care , Clinique St-Pierre , Ottignies , Belgium
| | - Herbert Spapen
- f Department of Intensive Care , Universitair Ziekenhuis Brussel , Brussels , Belgium
| | | | - Pierre E Wallemacq
- b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Françoise Van Bambeke
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
| | - Paul M Tulkens
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
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133
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Bruch R, Chatelle C, Kling A, Rebmann B, Wirth S, Schumann S, Weber W, Dincer C, Urban G. Clinical on-site monitoring of ß-lactam antibiotics for a personalized antibiotherapy. Sci Rep 2017; 7:3127. [PMID: 28600499 PMCID: PMC5466632 DOI: 10.1038/s41598-017-03338-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/26/2017] [Indexed: 01/07/2023] Open
Abstract
An appropriate antibiotherapy is crucial for the safety and recovery of patients. Depending on the clinical conditions of patients, the required dose to effectively eradicate an infection may vary. An inadequate dosing not only reduces the efficacy of the antibiotic, but also promotes the emergence of antimicrobial resistances. Therefore, a personalized therapy is of great interest for improved patients' outcome and will reduce in long-term the prevalence of multidrug-resistances. In this context, on-site monitoring of the antibiotic blood concentration is fundamental to facilitate an individual adjustment of the antibiotherapy. Herein, we present a bioinspired approach for the bedside monitoring of free accessible ß-lactam antibiotics, including penicillins (piperacillin) and cephalosporins (cefuroxime and cefazolin) in untreated plasma samples. The introduced system combines a disposable microfluidic chip with a naturally occurring penicillin-binding protein, resulting in a high-performance platform, capable of gauging very low antibiotic concentrations (less than 6 ng ml-1) from only 1 µl of serum. The system's applicability to a personalized antibiotherapy was successfully demonstrated by monitoring the pharmacokinetics of patients, treated with ß-lactam antibiotics, undergoing surgery.
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Affiliation(s)
- R Bruch
- Department of Microsystems Engineering, University of Freiburg, 79110, Freiburg, Germany
| | - C Chatelle
- Faculty of Biology, University of Freiburg, 79104, Freiburg, Germany.,BIOSS Centre for Biological Signalling Studies, University of Freiburg, 79104, Freiburg, Germany
| | - A Kling
- Department of Biosystems Science and Engineering, ETH Zurich, 4058, Basel, Switzerland
| | - B Rebmann
- Faculty of Biology, University of Freiburg, 79104, Freiburg, Germany.,BIOSS Centre for Biological Signalling Studies, University of Freiburg, 79104, Freiburg, Germany
| | - S Wirth
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - S Schumann
- Department of Anaesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - W Weber
- Faculty of Biology, University of Freiburg, 79104, Freiburg, Germany.,BIOSS Centre for Biological Signalling Studies, University of Freiburg, 79104, Freiburg, Germany
| | - C Dincer
- Department of Microsystems Engineering, University of Freiburg, 79110, Freiburg, Germany. .,Freiburg Materials Research Center, University of Freiburg, 79104, Freiburg, Germany.
| | - G Urban
- Department of Microsystems Engineering, University of Freiburg, 79110, Freiburg, Germany.,Freiburg Materials Research Center, University of Freiburg, 79104, Freiburg, Germany
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134
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Simultaneous determination of nine β-lactam antibiotics in human plasma by an ultrafast hydrophilic-interaction chromatography-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1060:138-143. [PMID: 28618388 DOI: 10.1016/j.jchromb.2017.06.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 06/04/2017] [Accepted: 06/06/2017] [Indexed: 12/29/2022]
Abstract
Contemporary β-lactam antibiotic dosing is debatable in severely ill patients, since the occurrence of pathophysiological changes in critical illness can result in great inter-individual variability. Therapeutic drug monitoring (TDM) is a commonly used dosing strategy to optimize exposure and thereby minimize toxicity and maximize the efficacy. Currently, TDM of β-lactam antibiotics is rarely performed, due to poor availability in clinical practice. We describe an ultrafast Hydrophilic-Interaction Chromatography (HILIC) based UPLC-MS/MS method for the determination of amoxicillin, benzylpenicillin, cefotaxime, cefuroxime, ceftazidime, flucloxacillin, imipenem, meropenem and piperacillin in human plasma. This method involves simple sample preparation steps and was comprehensively validated according to standard FDA guidelines. For all analytes, mean accuracy and precision values were within the acceptance value. The lower and upper limits of quantification were found to be sufficient to cover the therapeutic range for all antibiotics. Finally, the method was successfully applied in a large pharmacokinetic study performed in the intensive care setting, and the feasibility of the analytical procedure was demonstrated in routine clinical practice. To the best of our knowledge, we report here the first HILIC-based UPLC-MS/MS assay for the determination of β-lactam antibiotics in human plasma. This simple, sensitive and ultrafast assay requires small-volume samples and can easily be implemented in clinical laboratories to promote the TDM of β-lactam antibiotics.
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135
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Altan F, Uney K, Er A, Cetin G, Dik B, Yazar E, Elmas M. Pharmacokinetics of ceftiofur in healthy and lipopolysaccharide-induced endotoxemic newborn calves treated with single and combined therapy. J Vet Med Sci 2017; 79:1245-1252. [PMID: 28579597 PMCID: PMC5559372 DOI: 10.1292/jvms.16-0641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this research was to compare plasma pharmacokinetics of ceftiofur sodium (CS) in healthy calves, and in calves with experimentally induced endotoxemia. Six calves received CS (2.2 mg/kg, IM) 2 hr after intravenous
administration of 0.9% NaCl (Ceft group). After a washout period, the same 6 calves received CS 2 hr after intravenous injection of lipopolysaccharide (LPS+Ceft group). Another group of 6 calves received a combination of drug
therapies that included CS 2 hr after administration of 0.9% NaCl (Comb group). A third group of 6 calves received the same combination therapy regimen 2 hr after intravenous injection of lipopolysaccharide (LPS+Comb group).
Plasma concentrations of CS and all desfuroylceftiofur-related metabolites were determined using HPLC, and its pharmacokinetic properties were determined based on a two-compartment model. The peak concentration of CS in the
LPS+Comb group occurred the earliest, and the clearance rate of CS was the highest in the Comb and LPS+Comb groups (P<0.05). The elimination half-life of CS in the LPS+Ceft group was longer than that in the
Ceft and Comb groups (P<0.05). The results of this study indicate that combined therapies and endotoxemic status may alter the plasma pharmacokinetics of CS in calves.
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Affiliation(s)
- Feray Altan
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Dicle, Diyarbakir 21280, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya 42031, Turkey
| | - Ayse Er
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya 42031, Turkey
| | - Gul Cetin
- Department of Biochemistry, Faculty of Pharmacy, University of Erzincan, 24100, Turkey
| | - Burak Dik
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya 42031, Turkey
| | - Enver Yazar
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya 42031, Turkey
| | - Muammer Elmas
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya 42031, Turkey
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Abstract
Drugs are key weapons that clinicians have to battle against the profound pathologies encountered in critically ill patients. Antibiotics in particular are commonly used and can improve patient outcomes dramatically. Despite this, there are strong opportunities for further reducing the persisting poor outcomes for infected critically ill patients. However, taking these next steps for improving patient care requires a new approach to antibiotic therapy. Giving the right dose is highly likely to increase the probability of clinical cure from infection and suppress the emergence of resistant pathogens. Furthermore, in some patients with higher levels of sickness severity, reduced mortality from an optimized approach to antibiotic use could also occur. To enable optimized dosing, the use of customized dosing regimens through either evidence-based dosing nomograms or preferably through the use of dosing software supplemented by therapeutic drug monitoring data should be embedded into daily practice. These customized dosing regimens should also be given as soon as practicable as reduced time to initiation of therapy has been shown to improve patient survival, particularly in the presence of septic shock. However, robust data supporting these logical approaches to therapy, which may deliver the next step change improvement for treatment of infections in critically ill patients, are lacking. Large prospective studies of patient survival and health system costs are now required to determine the value of customized antibiotic dosing, that is, giving the right dose at the right time.
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137
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Aardema H, Nannan Panday P, Wessels M, van Hateren K, Dieperink W, Kosterink JGW, Alffenaar JW, Zijlstra JG. Target attainment with continuous dosing of piperacillin/tazobactam in critical illness: a prospective observational study. Int J Antimicrob Agents 2017; 50:68-73. [PMID: 28501674 DOI: 10.1016/j.ijantimicag.2017.02.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/14/2017] [Accepted: 02/22/2017] [Indexed: 12/31/2022]
Abstract
Optimal dosing of β-lactam antibiotics in critically ill patients is a challenge given the unpredictable pharmacokinetic profile of this patient population. Several studies have shown intermittent dosing to often yield inadequate drug concentrations. Continuous dosing is an attractive alternative from a pharmacodynamic point of view. This study evaluated whether, during continuous dosing, piperacillin concentrations reached and maintained a pre-defined target in critically ill patients. Adult patients treated with piperacillin by continuous dosing in the intensive care unit of a university medical centre in The Netherlands were prospectively studied. Total and unbound piperacillin concentrations drawn at fixed time points throughout the entire treatment course were determined by liquid chromatography-tandem mass spectrometry. A pharmacokinetic combined target of a piperacillin concentration ≥80 mg/L, reached within 1 h of starting study treatment and maintained throughout the treatment course, was set. Eighteen patients were analysed. The median duration of monitored piperacillin treatment was 60 h (interquartile range, 33-96 h). Of the 18 patients, 5 (27.8%) reached the combined target; 15 (83.3%) reached and maintained a less strict target of >16 mg/L. In this patient cohort, this dosing schedule was insufficient to reach the pre-defined target. Depending on which target is to be met, a larger initial cumulative dose is desirable, combined with therapeutic drug monitoring.
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Affiliation(s)
- Heleen Aardema
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands.
| | - Prashant Nannan Panday
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mireille Wessels
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kay van Hateren
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Jos G W Kosterink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Section of Pharmacotherapy and Pharmaceutical Care, Department of Pharmacy, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan-Willem Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands
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138
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Substantial Impact of Altered Pharmacokinetics in Critically Ill Patients on the Antibacterial Effects of Meropenem Evaluated via the Dynamic Hollow-Fiber Infection Model. Antimicrob Agents Chemother 2017; 61:AAC.02642-16. [PMID: 28264846 DOI: 10.1128/aac.02642-16] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022] Open
Abstract
Critically ill patients frequently have substantially altered pharmacokinetics compared to non-critically ill patients. We investigated the impact of pharmacokinetic alterations on bacterial killing and resistance for commonly used meropenem dosing regimens. A Pseudomonas aeruginosa isolate (MICmeropenem 0.25 mg/liter) was studied in the hollow-fiber infection model (inoculum ∼107.5 CFU/ml; 10 days). Pharmacokinetic profiles representing critically ill patients with augmented renal clearance (ARC), normal, or impaired renal function (creatinine clearances of 285, 120, or ∼10 ml/min, respectively) were generated for three meropenem regimens (2, 1, and 0.5 g administered as 8-hourly 30-min infusions), plus 1 g given 12 hourly with impaired renal function. The time course of total and less-susceptible populations and MICs were determined. Mechanism-based modeling (MBM) was performed using S-ADAPT. All dosing regimens across all renal functions produced similar initial bacterial killing (≤∼2.5 log10). For all regimens subjected to ARC, regrowth occurred after 7 h. For normal and impaired renal function, bacterial killing continued until 23 to 47 h; regrowth then occurred with 0.5- and 1-g regimens with normal renal function (fT>5×MIC = 56 and 69%, fCmin/MIC < 2); the emergence of less-susceptible populations (≥32-fold increases in MIC) accompanied all regrowth. Bacterial counts remained suppressed across 10 days with normal (2-g 8-hourly regimen) and impaired (all regimens) renal function (fT>5×MIC ≥ 82%, fCmin/MIC ≥ 2). The MBM successfully described bacterial killing and regrowth for all renal functions and regimens simultaneously. Optimized dosing regimens, including extended infusions and/or combinations, supported by MBM and Monte Carlo simulations, should be evaluated in the context of ARC to maximize bacterial killing and suppress resistance emergence.
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139
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Continuous and Prolonged Intravenous β-Lactam Dosing: Implications for the Clinical Laboratory. Clin Microbiol Rev 2017; 29:759-72. [PMID: 27413094 DOI: 10.1128/cmr.00022-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Beta-lactam antibiotics serve as a cornerstone in the management of bacterial infections because of their wide spectrum of activity and low toxicity. Since resistance rates among bacteria are continuously on the rise and the pipeline for new antibiotics does not meet this trend, an optimization of current beta-lactam treatment is needed. This review provides an overview of optimization through use of prolonged- and continuous-infusion dosing strategies compared with more traditional intermittent infusions. Included is an overview of the scientific basis for using these nontraditional prolonged- and continuous-infusion-based regimens, with a focus on major areas in which the clinical laboratory can support the clinical use of these regimens.
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140
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Neuville M, El-Helali N, Magalhaes E, Radjou A, Smonig R, Soubirou JF, Voiriot G, Le Monnier A, Ruckly S, Bouadma L, Sonneville R, Timsit JF, Mourvillier B. Systematic overdosing of oxa- and cloxacillin in severe infections treated in ICU: risk factors and side effects. Ann Intensive Care 2017; 7:34. [PMID: 28332157 PMCID: PMC5362565 DOI: 10.1186/s13613-017-0255-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 03/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background Oxacillin and cloxacillin are the most frequently used penicillins for the treatment of severe methicillin-susceptible Staphylococcus aureus infections in intensive care units (ICUs), especially endocarditis. International recommendations do not suggest any adaptation of the dosage in case of renal impairment. We wanted to assess the risk factors for overdosing in ICU and the related observed side effects. Methods All patients with a therapeutic drug monitoring of oxa- or cloxacillin between 2008 and 2014 were included. The target range of trough concentration for total antibiotic activity was considered to be 20–50 mg/L. Data concerning the infection, the given treatment, the renal function, and the attributed side effects of overdosing were collected. A logistic regression model was used to compute the measured trough concentrations. Results Sixty-two patients were included in this study. We found a median trough plasma concentration of 134.3 mg/L (IQR 65.3–201 mg/L). Ten patients (16.1%) reached the target concentration; all other patients (83.9%) were overdosed. Eleven patients (17.7%) experienced neurological side effects attributed to a high antibiotic concentration, i.e. persistent coma and delirium. When adjusted on the dosage used, the risk of overdosing was significantly associated with a creatinine clearance <10 mL/min (with or without hemodialysis). Conclusion With the suggested dose of 12 g/day for cloxacillin treatment in case of endocarditis and severe infections occurring in ICU, 83.9% of patients are largely overdosed. Considering the observed side effects, doses should be accurately monitored and reduced, particularly when renal replacement therapy is needed. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0255-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathilde Neuville
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.
| | - Najoua El-Helali
- Unité de Microbiologie clinique et dosages des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
| | - Eric Magalhaes
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Aguila Radjou
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Roland Smonig
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Jean-François Soubirou
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Guillaume Voiriot
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Alban Le Monnier
- Unité de Microbiologie clinique et dosages des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75014, Paris, France
| | - Stéphane Ruckly
- UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, INSERM, Paris Diderot University, 75018, Paris, France
| | - Lila Bouadma
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.,UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, INSERM, Paris Diderot University, 75018, Paris, France
| | - Romain Sonneville
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France
| | - Jean-François Timsit
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.,UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, INSERM, Paris Diderot University, 75018, Paris, France
| | - Bruno Mourvillier
- Service de Réanimation médicale et Infectieuse, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.,UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care, INSERM, Paris Diderot University, 75018, Paris, France
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141
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Economou CJP, Wong G, McWhinney B, Ungerer JPJ, Lipman J, Roberts JA. Impact of β-lactam antibiotic therapeutic drug monitoring on dose adjustments in critically ill patients undergoing continuous renal replacement therapy. Int J Antimicrob Agents 2017; 49:589-594. [PMID: 28341612 DOI: 10.1016/j.ijantimicag.2017.01.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/29/2022]
Abstract
The objective of this study was to describe the effect of therapeutic drug monitoring (TDM) and dose adjustments of β-lactam antibiotics administered to critically ill patients undergoing continuous renal replacement therapy (CRRT) in a 30-bed tertiary intensive care unit (ICU). β-Lactam TDM data in our tertiary referral ICU were retrospectively reviewed. Clinical, demographic and dosing data were collected for patients administered β-lactam antibiotics while undergoing CRRT. The target trough concentration range was 1-10× the minimum inhibitory concentration (MIC). A total of 111 TDM samples from 76 patients (46 male) with a mean ± standard deviation age of 56.6 ± 15.9 years and weight of 89.1 ± 25.8 kg were identified. The duration of antibiotic therapy was between 2 days and 42 days. TDM identified a need for dose modification of β-lactam antibiotics in 39 (35%) instances; in 27 (24%) samples, TDM values resulted in decreasing the prescribed dose of β-lactam antibiotic whereas an increase in the prescribed dose occurred in 12 (11%) cases. In patients treated for hospital-acquired pneumonia and primary or secondary bacteraemia, the dose was required to be decreased in 10/25 (40%) and 7/46 (15%) cases, respectively, to attain target concentrations. β-Lactam TDM is a useful tool for guiding drug dosing in complex patients such as those receiving CRRT. Although over one-third of patients manifested concentrations outside the therapeutic range, most of these CRRT patients had excessive β-lactam concentrations.
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Affiliation(s)
- Caleb J P Economou
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Research, ICON Cancer Foundation, Brisbane, QLD, Australia
| | - Gloria Wong
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, QLD, Australia.
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Ropski MK, Guillaumin J, Monnig AA, Townsend K, McLoughlin MA. Use of cryopoor plasma for albumin replacement and continuous antimicrobial infusion for treatment of septic peritonitis in a dog. J Vet Emerg Crit Care (San Antonio) 2017; 27:348-356. [PMID: 28135411 DOI: 10.1111/vec.12583] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 02/17/2015] [Accepted: 04/12/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report the successful management of a dog with septic peritonitis and septic shock secondary to enterectomy dehiscence using novel techniques for identification of intestinal dehiscence and for septic shock treatment. CASE SUMMARY A 5-year-old castrated male Bernese Mountain Dog presented for lethargy 6 days following enterotomy for foreign body obstruction. Septic peritonitis was identified due to dehiscence of the enterotomy site, and resection and anastomosis were performed using a gastrointestinal anastomosis and thoracoabdominal stapling device. Postoperatively the patient experienced severe hypotension, which responded to norepinephrine constant rate infusion (CRI) after failing to improve with fluid therapy or dopamine CRI. Further treatment included antimicrobial CRI and supportive care including careful fluid therapy. Due to low effective circulating volume paired with intersititial fluid overload and large volume abdominal effusion, fluid therapy consisted of a combination of human serum albumin, canine albumin, synthetic colloids, and isotonic crystalloids. Cryopoor plasma (CPP) was used as a source of canine albumin and intravascular volume. On Day 4, food dye was given through a nasogastric tube due to suspicion of dehiscence of the anastomosis site. Dehiscence was confirmed during abdominal exploratory, and a second resection and anastomosis was performed. Abdominal partial closure with vacuum-assisted closure device was performed. Supportive care was continued with CPP CRI and imipenem CRI. Planned relaparotomy to change the vacuum-assisted closure device was performed 48 hours later, with abdominal closure 96 hours after anastomosis. The patient was discharged on Day 15. Recheck 12 months later was normal. NEW OR UNIQUE INFORMATION PROVIDED This case includes novel techniques such food dye via nasogastric tube to identify anastomosis dehiscence, use of CPP as a source of canine albumin, and antimicrobial CRI in a dog with septic peritonitis.
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Affiliation(s)
- Meaghan K Ropski
- Department of Clinical Sciences, Ohio State University, Columbus, OH, 43210
| | - Julien Guillaumin
- Department of Clinical Sciences, Ohio State University, Columbus, OH, 43210
| | - Andrea A Monnig
- Department of Clinical Sciences, Ohio State University, Columbus, OH, 43210
| | - Katy Townsend
- Department of Clinical Sciences, Ohio State University, Columbus, OH, 43210
| | - Mary A McLoughlin
- Department of Clinical Sciences, Ohio State University, Columbus, OH, 43210
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143
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Principles of Anti-infective Therapy and Surgical Prophylaxis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00136-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] Open
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144
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Chung EK, Fleming MR, Cheatham SC, Kays MB. Population Pharmacokinetics and Pharmacodynamics of Doripenem in Obese, Hospitalized Patients. Ann Pharmacother 2016; 51:209-218. [DOI: 10.1177/1060028016676831] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Doripenem population pharmacokinetics and dosing recommendations are limited in obesity. Objective: To evaluate the population pharmacokinetics and pharmacodynamics of doripenem in obese patients. Methods: Hospitalized adults with a body mass index (BMI) ≥ 40 kg/m2 or total body weight (TBW) ≥45.5 kg over their ideal body weight received doripenem 500 mg every 8 hours, infused over 1 hour. Population pharmacokinetic analyses were performed using NONMEM, and Monte Carlo simulations were performed for 5 intermittent and prolonged infusion dosing regimens to calculate probability of target attainment (PTA) at 40% and 100% fT>MIC (free drug concentrations above the minimum inhibitory concentration). Results: A total of 20 patients were studied: 10 in an intensive care unit (ICU) and 10 in a non-ICU. A 2-compartment model with first-order elimination best described the serum concentration-time data. Doripenem clearance (CL) was significantly associated with creatinine CL (CRCL), volume of the central compartment with TBW and ICU residence, and volume of the peripheral compartment with TBW ( P < 0.05). Using 40% fT>MIC, PTA was >90% for all simulated dosing regimens at MICs ≤2 mg/L. Using 100% fT>MIC, prolonged infusions of 1 g every 6 hours and 2 g every 8 hours achieved >90% PTA at MICs ≤2 mg/L. Conclusions: CRCL, ICU residence, and TBW are significantly associated with doripenem pharmacokinetics. Currently approved dosing regimens provide adequate pharmacodynamic exposures at 40% fT>MIC for susceptible bacteria in obese patients. However, prolonged infusions of larger doses are needed if a higher pharmacodynamic target is desired.
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Affiliation(s)
- Eun Kyoung Chung
- Kyung Hee University College of Pharmacy, Dongdaemun-gu, Seoul, South Korea
| | | | | | - Michael B. Kays
- Purdue University College of Pharmacy, Indianapolis and West Lafayette, IN, USA
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145
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Chung EK, Cheatham SC, Fleming MR, Healy DP, Kays MB. Population Pharmacokinetics and Pharmacodynamics of Meropenem in Nonobese, Obese, and Morbidly Obese Patients. J Clin Pharmacol 2016; 57:356-368. [PMID: 27530916 DOI: 10.1002/jcph.812] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/11/2016] [Indexed: 01/21/2023]
Abstract
The study objective was to evaluate meropenem population pharmacokinetics and pharmacodynamics in nonobese, obese, and morbidly obese patients. Forty adult patients-11 nonobese (body mass index [BMI] < 30 kg/m2 ), 9 obese (30 kg/m2 ≤ BMI < 40 kg/m2 ), and 20 morbidly obese (BMI ≥ 40 kg/m2 )-received meropenem 500 mg every 6 hours (q6h), q8h, or q12h or 1 g q6h or q8h, infused over 0.5 hour. Population pharmacokinetic modeling was performed using NONMEM, and 5000-patient Monte-Carlo simulations were performed to calculate probability of target attainment (PTA) for 5 dosing regimens, infused over 0.5 and 3 hours, using fT>MIC of 40%, 54%, and 100% of the dosing interval. A 2-compartment linear-elimination model best described the serum concentration-time data, and creatinine clearance was significantly associated with systemic clearance. Pharmacokinetic parameters were not significantly different among patient groups. In patients with creatinine clearances ≥50 mL/min, all simulated dosing regimens achieved >90% PTA at 40% fT>MIC in all patient groups at MICs ≤2 mg/L. Only 500 mg q8h, infused over 0.5 hour, did not achieve >90% PTA at 54% fT>MIC in nonobese and morbidly obese patients. At 100% fT>MIC, 1 g q6h and 2 g q8h, infused over 3 hours, reliably achieved >90% PTA in all patient groups. Meropenem pharmacokinetics are comparable among nonobese, obese, and morbidly obese patients. Standard dosing regimens provide adequate pharmacodynamic exposures for susceptible pathogens at 40% and 54% fT>MIC, but prolonged infusions of larger doses are needed for adequate exposures at 100% fT>MIC. Dosage adjustments based solely on body weight are unnecessary.
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Affiliation(s)
- Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul, South Korea
| | | | - Megan R Fleming
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Daniel P Healy
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Michael B Kays
- Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis and West Lafayette, IN, USA
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146
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Uney K, Altan F, Altan S, Erol H, Arican M, Elmas M. Plasma and synovial fluid pharmacokinetics of cefquinome following the administration of multiple doses in horses. J Vet Pharmacol Ther 2016; 40:239-247. [PMID: 27641837 DOI: 10.1111/jvp.12362] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 08/11/2016] [Indexed: 11/26/2022]
Abstract
The plasma and synovial fluid pharmacokinetics and safety of cefquinome, a 2-amino-5-thiazolyl cephalosporin, were determined after multiple intravenous administrations in sixteen healthy horses. Cefquinome was administered to each horse through a slow i.v. injection over 20 min at 1, 2, 4, and 6 mg/kg (n = 4 horses per dose) every 12 h for 7 days (a total of 13 injections). Serial blood and synovial fluid samples were collected during the 12 h after the administration of the first and last doses and were analyzed by a high-performance liquid chromatography assay. The data were evaluated using noncompartmental pharmacokinetic analyses. The estimated plasma pharmacokinetic parameters were compared with the hypothetical minimum inhibitory concentration (MIC) values (0.125-2 μg/mL). The plasma and synovial fluid concentrations and area under the concentration-time curves (AUC) of cefquinome showed a dose-dependent increase. After a first dose of cefquinome, the ranges for the mean plasma half-life values (2.30-2.41 h), the mean residence time (1.77-2.25 h), the systemic clearance (158-241 mL/h/kg), and the volume of distribution at steady-state (355-431 mL/kg) were consistent across dose levels and similar to those observed after multiple doses. Cefquinome did not accumulate after multiple doses. Cefquinome penetrated the synovial fluid with AUCsynovial fluid /AUCplasma ratios ranging from 0.57 to 1.37 after first and thirteenth doses, respectively. Cefquinome is well tolerated, with no adverse effects. The percentage of time for which the plasma concentrations were above the MIC was >45% for bacteria, with MIC values of ≤0.25, ≤0.5, and ≤1 μg/mL after the administration of 1, 2, and 4 or 6 mg/kg doses of CFQ at 12-h intervals, respectively. Further studies are needed to determine the optimal dosage regimes in critically ill patients.
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Affiliation(s)
- K Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - F Altan
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Dicle, Diyarbakir, Turkey
| | - S Altan
- Department of Surgery, Faculty of Veterinary Medicine, University of Dicle, Diyarbakir, Turkey
| | - H Erol
- Department of Surgery, Faculty of Veterinary Medicine, University of Erciyes, Kayseri, Turkey
| | - M Arican
- Department of Surgery, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
| | - M Elmas
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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147
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Kim YK, Jung JA, Choi HK, Bae IG, Choi WS, Hur J, Jin SJ, Kim SW, Kwon KT, Lee SR, Shin JG, Kiem S. Population Pharmacokinetic Analysis of Piperacillin/Tazobactam in Korean Patients with Acute Infections. Infect Chemother 2016; 48:209-215. [PMID: 27659435 PMCID: PMC5048002 DOI: 10.3947/ic.2016.48.3.209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/30/2016] [Accepted: 07/16/2016] [Indexed: 11/24/2022] Open
Abstract
Background For more effective and safer usage of antibiotics, the dosing strategy should be individualized based on the patients’ characteristics, including race. The aim of this study was to investigate the population pharmacokinetic (PK) profiles of piperacillin and tazobactam in Korean patients with acute infections. Materials and Methods At least four consecutive 2/0.25 g or 4/0.5 g doses of piperacillin/tazobactam (TZP) were intravenously infused over 1 h every 8 h for patients with creatinine clearance (CLcr) ≤50 ml/min or CLcr >50 mL/min, respectively. Blood samples from 33 patients at a steady-state were taken pre-dose and at 0 min, 30 min, and 4-6 h after the fourth infusion. The population PK analysis was conducted using a non-linear mixed-effects method. A likelihood ratio test was used to select significant covariates, with significance levels of P <0.05 for selection and P <0.01 for elimination. Results Both piperacillin PK and tazobactam PK were well described by a two-compartment model with first-order elimination. Creatinine clearance and body weight, as covariates on clearance (CL) and volume of central compartment (V1), were selected among the covariates possibly affecting PK parameters of both drugs. CL was defined as CL = 2.9 + 4.03 × CLcr /47 for piperacillin and CL = 1.76 + 4.81 × CLcr /47 for tazobactam. V1 was defined as V1 = 19.5 × weight/60 for piperacillin and V1 = 22.6 × weight/60 for tazobactam. Conclusion The PK profiles of TZP at a steady-state in Korean patients with acute infections were well described by a two-compartment model with first-order elimination. Both piperacillin and tazobactam clearances were significantly influenced by creatinine clearance.
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Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Ah Jung
- Department of Clinical Pharmacology, Inje University College of Medicine, Busan, Korea
| | - Hyang Ki Choi
- Department of Clinical Pharmacology, Inje University College of Medicine, Busan, Korea
| | - In Gyu Bae
- Department of Internal Medicine, School of Medicine, Gyeongsang National University, Jinju, Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Sung Joon Jin
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Ki Tae Kwon
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Sang Rok Lee
- Division of Allergy and Infectious Diseases, Department of Internal Medicine, Cheongju St. Mary's Hospital, Cheongju, Korea
| | - Jae Gook Shin
- Department of Clinical Pharmacology, Inje University College of Medicine, Busan, Korea
| | - Sungmin Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
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148
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Legrand T, Vodovar D, Tournier N, Khoudour N, Hulin A. Simultaneous Determination of Eight β-Lactam Antibiotics, Amoxicillin, Cefazolin, Cefepime, Cefotaxime, Ceftazidime, Cloxacillin, Oxacillin, and Piperacillin, in Human Plasma by Using Ultra-High-Performance Liquid Chromatography with Ultraviolet Detection. Antimicrob Agents Chemother 2016; 60:4734-42. [PMID: 27216076 PMCID: PMC4958196 DOI: 10.1128/aac.00176-16] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/19/2016] [Indexed: 12/18/2022] Open
Abstract
A simple and rapid ultra-high-performance liquid chromatography (UHPLC) method using UV detection was developed for the simultaneous determination of eight β-lactam antibiotics in human plasma, including four penicillins, amoxicillin (AMX), cloxacillin (CLX), oxacillin (OXA), and piperacillin (PIP), and four cephalosporins, cefazolin (CFZ), cefepime (FEP), cefotaxime (CTX), and ceftazidime (CAZ). One hundred-microliter samples were spiked with thiopental as an internal standard, and proteins were precipitated by acetonitrile containing 0.1% formic acid. Separation was achieved on a pentafluorophenyl (PFP) column with a mobile phase composed of phosphoric acid (10 mM) and acetonitrile in gradient elution mode at a flow rate of 500 μl/min. Detection was performed at 230 nm for AMX, CLX, OXA, and PIP and 260 nm for CFZ, FEP, CTX, and CAZ. The total analysis time did not exceed 13 min. The method was found to be linear at concentrations ranging from 2 to 100 mg/liter for each compound, and all validation parameters fulfilled international requirements. Between- and within-run accuracy errors ranged from -5.2% to 11.4%, and precision was lower than 14.2%. This simple method requires small-volume samples and can easily be implemented in most clinical laboratories to promote the therapeutic drug monitoring of β-lactam antibiotics. The simultaneous determination of several antibiotics considerably reduces the time to results for clinicians, which may improve treatment efficiency, especially in critically ill patients.
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Affiliation(s)
- Tiphaine Legrand
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Dominique Vodovar
- Service d'Anesthésie et des Réanimations Chirurgicales, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France IMIV, CEA, INSERM, CNRS, Université Paris-Sud, Université Paris Saclay, CEA-SHFJ, Orsay, France
| | - Nicolas Tournier
- IMIV, CEA, INSERM, CNRS, Université Paris-Sud, Université Paris Saclay, CEA-SHFJ, Orsay, France
| | - Nihel Khoudour
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Anne Hulin
- Laboratoire de Pharmacologie-Toxicologie, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
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149
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Abstract
PURPOSE OF REVIEW To highlight the importance of escalating pathogen resistance in ventilator-associated pneumonia (VAP) along with diagnostic and treatment implications. RECENT FINDINGS In a period of rising bacterial resistance, VAP remains an important infection occurring in critically ill patients. Risk factors for multidrug-resistant pathogens depend on both local epidemiology and host factors. New diagnostic techniques and antimicrobials can help with rapid bacterial identification and timely and appropriate treatment while avoiding emergence of bacterial resistance. SUMMARY Clinicians should be aware of risk factors for multidrug-resistant pathogens causing VAP and also of particularities of diagnosis and treatment of this important clinical entity.
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150
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Bergen PJ, Bulitta JB, Kirkpatrick CMJ, Rogers KE, McGregor MJ, Wallis SC, Paterson DL, Lipman J, Roberts JA, Landersdorfer CB. Effect of different renal function on antibacterial effects of piperacillin against Pseudomonas aeruginosa evaluated via the hollow-fibre infection model and mechanism-based modelling. J Antimicrob Chemother 2016; 71:2509-20. [PMID: 27231278 DOI: 10.1093/jac/dkw153] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/05/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pathophysiological changes in critically ill patients can cause severely altered pharmacokinetics and widely varying antibiotic exposures. The impact of altered pharmacokinetics on bacterial killing and resistance has not been characterized in the dynamic hollow-fibre in vitro infection model (HFIM). METHODS A clinical Pseudomonas aeruginosa isolate (piperacillin MIC 4 mg/L) was studied in the HFIM (inoculum ∼10(7) cfu/mL). Pharmacokinetic profiles of three piperacillin dosing regimens (4 g 8-, 6- and 4-hourly, 30 min intravenous infusion) as observed in critically ill patients with augmented renal clearance (ARC), normal renal function or impaired renal function (creatinine clearances of 250, 110 or 30 mL/min, respectively) were simulated over 7 days. The time courses of total and less-susceptible populations and MICs were determined. Mechanism-based modelling was performed in S-ADAPT. RESULTS For all regimens with ARC and regimens with 8- or 6-hourly dosing with normal renal function, initial killing of ≤∼2 log10 was followed by regrowth to 10(8)-10(9) cfu/mL at 48 h. For 8- and 6-hourly dosing at normal renal function, the proportion of less-susceptible colonies increased ∼10-100-fold above those in ARC and control arms. Regimens achieving an fCmin of ≥5× MIC resulted in bacterial killing of 3-4 log10 without regrowth and suppressed less-susceptible populations to ≤∼2 log10. The mechanism-based model successfully quantified the time course of bacterial growth, killing and regrowth. CONCLUSIONS Only high piperacillin concentrations prevented regrowth of P. aeruginosa. Individualized dosing regimens that account for altered pharmacokinetics and aim for higher-than-standard antibiotic exposures to achieve an fCmin of ≥5× MIC were required to maximize bacterial killing and suppress emergence of resistance.
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Affiliation(s)
- Phillip J Bergen
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jürgen B Bulitta
- Center for Pharmacometrics and Systems Pharmacology, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Carl M J Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kate E Rogers
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Megan J McGregor
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - David L Paterson
- The University of Queensland Center for Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Cornelia B Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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