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Personalized Piperacillin Dosing for the Critically Ill: A Retrospective Analysis of Clinical Experience with Dosing Software and Therapeutic Drug Monitoring to Optimize Antimicrobial Dosing. Antibiotics (Basel) 2021; 10:antibiotics10060667. [PMID: 34205135 PMCID: PMC8227218 DOI: 10.3390/antibiotics10060667] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022] Open
Abstract
Optimization of antibiotic dosing is a treatment intervention that is likely to improve outcomes in severe infections. The aim of this retrospective study was to describe the therapeutic exposure of steady state piperacillin concentrations (cPIP) and clinical outcome in critically ill patients with sepsis or septic shock who received continuous infusion of piperacillin with dosing personalized through software-guided empiric dosing and therapeutic drug monitoring (TDM). Therapeutic drug exposure was defined as cPIP of 32–64 mg/L (2–4× the ‘MIC breakpoint’ of Pseudomonas aeruginosa). Of the 1544 patients screened, we included 179 patients (335 serum concentrations), of whom 89% achieved the minimum therapeutic exposure of >32 mg/L and 12% achieved potentially harmful cPIP > 96 mg/L within the first 48 h. Therapeutic exposure was achieved in 40% of the patients. Subsequent TDM-guided dose adjustments significantly enhanced therapeutic exposure to 65%, and significantly reduced cPIP > 96 mg/L to 5%. Mortality in patients with cPIP > 96 mg/L (13/21; 62%) (OR 5.257, 95% CI 1.867–14.802, p = 0.001) or 64–96 mg/L (30/76; 45%) (OR 2.696, 95% CI 1.301–5.586, p = 0.007) was significantly higher compared to patients with therapeutic exposure (17/72; 24%). Given the observed variability in critically ill patients, combining the application of dosing software and consecutive TDM increases therapeutic drug exposure of piperacillin in patients with sepsis and septic shock.
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102
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Barreto EF, Webb AJ, Pais GM, Rule AD, Jannetto PJ, Scheetz MH. Setting the Beta-Lactam Therapeutic Range for Critically Ill Patients: Is There a Floor or Even a Ceiling? Crit Care Explor 2021; 3:e0446. [PMID: 34136822 PMCID: PMC8202642 DOI: 10.1097/cce.0000000000000446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Beta-lactam antibiotics exhibit high interindividual variability in drug concentrations in patients with critical illness which led to an interest in the use of therapeutic drug monitoring to improve effectiveness and safety. To implement therapeutic drug monitoring, it is necessary to define the beta-lactam therapeutic range-in essence, what drug concentration would prompt a clinician to make dose adjustments up or down. This objective of this narrative review was to summarize evidence for the "floor" (for effectiveness) and "ceiling" (for toxicity) for the beta-lactam therapeutic range to be used with individualized therapeutic drug monitoring. DATA SOURCES Research articles were sourced from PubMed using search term combinations of "pharmacokinetics," "pharmacodynamics," "toxicity," "neurotoxicity," "therapeutic drug monitoring," "beta-lactam," "cefepime," "meropenem," "piperacillin/tazobactam," "ICU," and "critical illness." STUDY SELECTION Articles were selected if they included preclinical, translational, or clinical data on pharmacokinetic and pharmacodynamic thresholds for effectiveness and safety for beta-lactams in critical illness. DATA SYNTHESIS Experimental data indicate a beta-lactam concentration above the minimum inhibitory concentration of the organism for greater than or equal to 40-60% of the dosing interval is needed, but clinical data indicate that higher concentrations may be preferrable. In the first 48 hours of critical illness, a free beta-lactam concentration at or above the susceptibility breakpoint of the most likely pathogen for 100% of the dosing interval would be reasonable (typically based on Pseudomonas aeruginosa). After 48 hours, the lowest acceptable concentration could be tailored to 1-2× the observed minimum inhibitory concentration of the organism for 100% of the dosing interval (often a more susceptible organism). Neurotoxicity is the primary dose-dependent adverse effect of beta-lactams, but the evidence remains insufficient to link a specific drug concentration to greater risk. CONCLUSIONS As studies advance the understanding of beta-lactam exposure and response in critically ill patients, it is essential to clearly define the acceptable therapeutic range to guide regimen selection and adjustment.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
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103
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Tan WW, Watt KM, Boakye-Agyeman F, Cohen-Wolkowiez M, Mok YH, Yung CF, Chan YH. Optimal Dosing of Meropenem in a Small Cohort of Critically Ill Children Receiving Continuous Renal Replacement Therapy. J Clin Pharmacol 2021; 61:744-754. [PMID: 33314163 PMCID: PMC8089047 DOI: 10.1002/jcph.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
Severe sepsis is an important cause of mortality and morbidity in critically ill children. Meropenem is a broad-spectrum antibiotic commonly used to treat sepsis. Current meropenem dosage recommendations for children on continuous renal replacement therapy are extrapolated from pharmacokinetic (PK) studies done in adults. Our study aims to determine the optimal dosing in critically ill septic children receiving continuous renal replacement therapy. A prospective single-center PK study was performed in 9 children in the intensive care unit on continuous renal replacement therapy. Meropenem concentrations were measured from blood and effluent fluid samples. A population PK model was developed using nonlinear mixed-effects modeling software (NONMEM, AstraZeneca UK Ltd, Cheshire, UK). Monte Carlo simulations were performed. The PK/pharmacodynamic target aimed for plasma concentrations above minimum inhibitory concentration of 4 mg/L for 100% of dosing interval (100%ƒT>MIC ). A 2-compartment model best characterized meropenem PK. Mean (range) clearance and elimination half-life was 0.091 L/h/kg (0.04-0.157) and 3.9 hours (2.1-7.5), respectively. Dosing of 40 mg/kg/dose every 12 hours over 30 minutes achieved PK/PD target in only 32% while 20 mg/kg every 8 hours over 4 hours or 40 mg/kg every 8 hours over 2 hours achieved 100% ƒT>MIC target for at least 90% of simulated patients.
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Affiliation(s)
- Wei Wei Tan
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin M Watt
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Felix Boakye-Agyeman
- Integrated Drug Development, Certara Strategic Consulting, Certara USA, Inc. 100 Overlook Center, Princeton, New Jersey, USA
| | - Michael Cohen-Wolkowiez
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Yee Hui Mok
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chee Fu Yung
- Department of Paediatric Medicine, Infectious Disease Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
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104
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Jang SM, Awdishu L. Drug dosing considerations in continuous renal replacement therapy. Semin Dial 2021; 34:480-488. [PMID: 33939855 DOI: 10.1111/sdi.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, which is associated with increased in-hospital mortality. Delivering effective antibiotics to treat patients with sepsis receiving continuous renal replacement therapy (RRT) is complicated by variability in pharmacokinetics, dialysis delivery, lack of primary literature, and therapeutic drug monitoring. Pharmacokinetic alterations include changes in absorption, distribution, protein binding (PB), metabolism, and renal elimination. Drug absorption may be significantly changed due to alterations in gastric pH, perfusion, gastrointestinal motility, and intestinal atrophy. Volume of distribution for hydrophilic drugs may be increased due to volume overload. Estimation of renal clearance is challenged by the effective delivery of RRT. Drug characteristics such as PB, volume of distribution, and molecular weight impact removal of the drug by RRT. The totality of these alterations leads to reduced exposure. Despite our best knowledge, therapeutic drug monitoring of patients receiving continuous RRT demonstrates wide variability in antimicrobial concentrations, highlighting the need for expanded monitoring of all drugs. This review article will focus on changes in drug pharmacokinetics in AKI and dosing considerations to attain antibiotic pharmacodynamic targets in critically ill patients receiving continuous RRT.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Linda Awdishu
- Clinical Pharmacy, UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
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105
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Cusumano JA, Klinker KP, Huttner A, Luther MK, Roberts JA, LaPlante KL. Towards precision medicine: Therapeutic drug monitoring-guided dosing of vancomycin and β-lactam antibiotics to maximize effectiveness and minimize toxicity. Am J Health Syst Pharm 2021; 77:1104-1112. [PMID: 32537644 DOI: 10.1093/ajhp/zxaa128] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The goal of this review is to explore the role of antimicrobial therapeutic drug monitoring (TDM), especially in critically ill, obese, and older adults, with a specific focus on β-lactams and vancomycin. SUMMARY The continued rise of antimicrobial resistance prompts the need to optimize antimicrobial dosing. The aim of TDM is to individualize antimicrobial dosing to achieve antibiotic exposures associated with improved patient outcomes. Initially, TDM was developed to minimize adverse effects during use of narrow therapeutic index agents. Today, patient and organism complexity are expanding the need for precision dosing through TDM services. Alterations of pharmacokinetics and pharmacodynamics (PK/PD) in the critically ill, obese, and older adult populations, in conjunction with declining organism susceptibility, complicate attainment of therapeutic targets. Over the last decade, antimicrobial TDM has expanded with the emergence of literature supporting β-lactam TDM and a shift from monitoring vancomycin trough concentrations to monitoring of the ratio of area under the concentration (AUC) curve to minimum inhibitory concentration (MIC). PK/PD experts should be at the forefront of implementing precision dosing practices. CONCLUSION Precision dosing through TDM is expanding and is especially important in populations with altered PK/PD, including critically ill, obese, and older adults. Due to wide PK/PD variability in these populations, TDM is vital to maximize antimicrobial effectiveness and decrease adverse event rates. However, there is still a need for studies connecting TDM to patient outcomes. Providing patient-specific care through β-lactam TDM and transitioning to vancomycin AUC/MIC monitoring may be challenging, but with experts at the forefront of this initiative, PK-based optimization of antimicrobial therapy can be achieved.
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Affiliation(s)
- Jaclyn A Cusumano
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | | | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Megan K Luther
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
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106
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Westermann I, Gastine S, Müller C, Rudolph W, Peters F, Bloos F, Pletz M, Hagel S. Population pharmacokinetics and probability of target attainment in patients with sepsis under renal replacement therapy receiving continuous infusion of meropenem: Sustained low-efficiency dialysis and continuous veno-venous haemodialysis. Br J Clin Pharmacol 2021; 87:4293-4303. [PMID: 33818823 DOI: 10.1111/bcp.14846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/16/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS To describe the population pharmacokinetics (PK) and probability of target attainment (PTA) of continuous infusion (CI) of meropenem in septic patients receiving renal replacement therapy (RRT). METHODS Fifteen patients without RRT, 13 patients receiving sustained low-efficiency dialysis and 12 patients receiving continuous veno-venous haemodialysis were included. Population PK analysis with Monte Carlo simulations for different dosing regimens was performed. For minimum inhibitory concentration 2 mg/L was chosen. The target was set as 50% time ≥4× minimum inhibitory concentration. RESULTS The PK of meropenem was best described by a 1-compartment model with linear elimination. Serum creatinine, residual diuresis and time on RRT, with no difference between sustained low-efficiency dialysis and continuous veno-venous haemodialysis, were found to be significant covariates affecting clearance, explaining >20% of the clearance between subject variability. PTA analysis showed that in patients with RRT, 2 g/24 h, meropenem CI achieved a PTA of 95%. In patients without RRT, the target was achieved with 3 g/24 h CI or prolonged infusion of 1 g meropenem over 8 hours but not with bolus application of 1 g meropenem for 8 hours. Only 2 patients (both without RRT) had meropenem concentrations below the target level. However, approximately half of the patients with RRT receiving CI 3 g/24 h meropenem had toxic concentrations. CONCLUSION We found relevant PK variability for meropenem CI in septic patients with or without RRT, leading to a substantial risk for overdosing in patients with RRT. This finding highlights the strong demand for personalized dosing in critically ill patients.
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Affiliation(s)
- Isabella Westermann
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Carsten Müller
- Centre of Pharmacology, Department of Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Wiebke Rudolph
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Peters
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Stefan Hagel
- Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
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107
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Gastine S, Hsia Y, Clements M, Barker CI, Bielicki J, Hartmann C, Sharland M, Standing JF. Variation in Target Attainment of Beta-Lactam Antibiotic Dosing Between International Pediatric Formularies. Clin Pharmacol Ther 2021; 109:958-970. [PMID: 33521971 PMCID: PMC8358626 DOI: 10.1002/cpt.2180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022]
Abstract
As antimicrobial susceptibility of common bacterial pathogens decreases, ensuring optimal dosing may preserve the use of older antibiotics in order to limit the spread of resistance to newer agents. Beta-lactams represent the most widely prescribed antibiotic class, yet most were licensed prior to legislation changes mandating their study in children. As a result, significant heterogeneity persists in the pediatric doses used globally, along with quality of evidence used to inform dosing. This review summarizes dosing recommendations from the major pediatric reference sources and tries to answer the questions: Does beta-lactam dose heterogeneity matter? Does it impact pharmacodynamic target attainment? For three important severe clinical infections-pneumonia, sepsis, and meningitis-pharmacokinetic models were identified for common for beta-lactam antibiotics. Real-world demographics were derived from three multicenter point prevalence surveys. Simulation results were compared with minimum inhibitory concentration distributions to inform appropriateness of recommended doses in targeted and empiric treatment. While cephalosporin dosing regimens are largely adequate for target attainment, they also pose the most risk of neurotoxicity. Our review highlights aminopenicillin, piperacillin, and meropenem doses as potentially requiring review/optimization in order to preserve the use of these agents in future.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Yingfen Hsia
- School of PharmacyQueen’s University BelfastBelfastUK
| | | | - Charlotte I.S. Barker
- Department of Medical & Molecular GeneticsKing’s College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
- Paediatric Pharmacology GroupUniversity of Basel Children’s HospitalBaselSwitzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond Street Hospital for ChildrenLondonUK
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108
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Schießer S, Hitzenbichler F, Kees MG, Kratzer A, Lubnow M, Salzberger B, Kees F, Dorn C. Measurement of Free Plasma Concentrations of Beta-Lactam Antibiotics: An Applicability Study in Intensive Care Unit Patients. Ther Drug Monit 2021; 43:264-270. [PMID: 33086362 DOI: 10.1097/ftd.0000000000000827] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The antibacterial effect of antibiotics is linked to the free drug concentration. This study investigated the applicability of an ultrafiltration method to determine free plasma concentrations of beta-lactam antibiotics in ICU patients. METHODS Eligible patients included adult ICU patients treated with ceftazidime (CAZ), meropenem (MEM), piperacillin (PIP)/tazobactam (TAZ), or flucloxacillin (FXN) by continuous infusion. Up to 2 arterial blood samples were drawn at steady state. Patients could be included more than once if they received another antibiotic. Free drug concentrations were determined by high-performance liquid chromatography with ultraviolet detection after ultrafiltration, using a method that maintained physiological conditions (pH 7.4/37°C). Total drug concentrations were determined to calculate the unbound fraction. In a post-hoc analysis, free concentrations were compared with the target value of 4× the epidemiological cut-off value (ECOFF) for Pseudomonas aeruginosa as a worst-case scenario for empirical therapy with CAZ, MEM or PIP/tazobactam and against methicillin-sensitive Staphylococcus aureus for targeted therapy with FXN. RESULTS Fifty different antibiotic treatment periods in 38 patients were evaluated. The concentrations of the antibiotics showed a wide range because of the fixed dosing regimen in a mixed population with variable kidney function. The mean unbound fractions (fu) of CAZ, MEM, and PIP were 102.5%, 98.4%, and 95.7%, with interpatient variability of <6%. The mean fu of FXN was 11.6%, with interpatient variability of 39%. It was observed that 2 of 12 free concentrations of CAZ, 1 of 40 concentrations of MEM, and 11 of 23 concentrations of PIP were below the applied target concentration of 4 × ECOFF for P. aeruginosa. All concentrations of FXN (9 samples from 6 patients) were >8 × ECOFF for methicillin-sensitive Staphylococcus aureus. CONCLUSIONS For therapeutic drug monitoring purposes, measuring total or free concentrations of CAZ, MEM, or PIP is seemingly adequate. For highly protein-bound beta-lactams such as FXN, free concentrations should be favored in ICU patients with prevalent hypoalbuminemia.
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Affiliation(s)
- Selina Schießer
- Departments of Infection Prevention and Infectious Diseases and
| | | | | | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg
| | | | - Frieder Kees
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
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109
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Fiore M, Peluso L, Taccone FS, Hites M. The impact of continuous renal replacement therapy on antibiotic pharmacokinetics in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:543-554. [PMID: 33733979 DOI: 10.1080/17425255.2021.1902985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Mortality due to severe infections in critically ill patients undergoing continuous renal replacement therapy (CRRT) remains high. Nevertheless, rapid administration of adequate antibiotic therapy can improve survival. Delivering optimized antibiotic therapy can be a challenge, as standard drug regimens often result in insufficient or excessive serum concentrations due to significant changes in the volume of distribution and/or drug clearance in these patients. Insufficient drug concentrations can be responsible for therapeutic failure and death, while excessive concentrations can cause toxic adverse events.Areas covered: We performed a narrative review of the impact of CRRT on the pharmacokinetics of the most frequently used antibiotics in critically ill patients. We have provided explanations for the changes in the PKs of antibiotics observed and suggestions to optimize dosage regimens in these patients.Expert opinion: Despite considerable efforts to identify optimal antibiotic dosage regimens for critically ill patients receiving CRRT, adequate target achievement remains too low for hydrophilic antibiotics in many patients. Whenever possible, individualized therapy based on results from therapeutic drug monitoring must be given to avoid undertreatment or toxicity.
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Affiliation(s)
- Marco Fiore
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | | | - Maya Hites
- Department of Infectious Diseases, Hopital Erasme, Brussels, Belgium
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110
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Merino-Bohórquez V, Docobo-Pérez F, Valiente-Méndez A, Delgado-Valverde M, Cameán M, Hope WW, Pascual Á, Rodríguez-Baño J. Population Pharmacokinetics of Piperacillin in Non-Critically Ill Patients with Bacteremia Caused by Enterobacteriaceae. Antibiotics (Basel) 2021; 10:antibiotics10040348. [PMID: 33805895 PMCID: PMC8064303 DOI: 10.3390/antibiotics10040348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 11/16/2022] Open
Abstract
This study analyzes the pharmacokinetic variability of piperacillin in non-critically ill patients with Enterobacteriaceae bloodstream infections (EBSI) and explores predicted clinical outcomes and piperacillin-related neurotoxicity under different renal conditions. Hospitalized, non-critically ill patients treated with piperacillin–tazobactam for EBSI were included. Four serum samples per patient were collected and analyzed. A population pharmacokinetic model was developed using the Pmetrics package for R. Monte Carlo simulations of various dosage regimens of 4 g piperacillin, administered q8 h or q12 h by short (0.5 h) or long (4 h) infusion, following the different glomerular filtration rate (GFR) categories used to classify chronic kidney disease (Kidney Disease: Improving Global Outcomes, KDIGO) to determine the probability of target attainment (PTA) using a free drug concentrations above the minimal inhibitory concentration (fT > MIC) of 50% for efficacy and targets for piperacillin-associated neurotoxicity. Twenty-seven patients (102 samples) were included. Extended piperacillin infusions reached a PTA > 90% (50%fT > MIC) within the susceptibility range, although a loading dose did not greatly improve the expected outcome. Long infusions reduced the expected toxicity in patients with severe renal impairment. The study supports the use of extended infusions of piperacillin in non-critically ill patients with EBSI. No benefits of a loading dose were expected in our population. Finally, extended infusions may reduce the risk of toxicity in patients with severe renal impairment.
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Affiliation(s)
- Vicente Merino-Bohórquez
- Unidad de Gestión de Farmacia Hospitalaria, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain; (V.M.-B.); (M.C.)
- Departamento de Farmacología, Universidad de Sevilla, 41009 Sevilla, Spain
| | - Fernando Docobo-Pérez
- Departamento de Microbiología, Universidad de Sevilla, 41009 Sevilla, Spain;
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain; (A.V.-M.); (M.D.-V.); (J.R.-B.)
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence:
| | - Adoración Valiente-Méndez
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain; (A.V.-M.); (M.D.-V.); (J.R.-B.)
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Mercedes Delgado-Valverde
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain; (A.V.-M.); (M.D.-V.); (J.R.-B.)
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Manuel Cameán
- Unidad de Gestión de Farmacia Hospitalaria, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain; (V.M.-B.); (M.C.)
| | - William W. Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GE, UK;
- Royal Liverpool and Broadgreen University Hospital Trust, Liverpool L69 3GE, UK
| | - Álvaro Pascual
- Departamento de Microbiología, Universidad de Sevilla, 41009 Sevilla, Spain;
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain; (A.V.-M.); (M.D.-V.); (J.R.-B.)
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Instituto de Biomedicina de Sevilla IBIS, Hospital Universitario Virgen Macarena/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain; (A.V.-M.); (M.D.-V.); (J.R.-B.)
- Red Española de Investigación en Patología Infecciosa (REIPI RD16/0016), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain
- Departamento de Medicina, Universidad de Sevilla, 41009 Sevilla, Spain
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111
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Poor Correlation between Meropenem and Piperacillin Plasma Concentrations and Delivered Dose of Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2021; 65:AAC.02029-20. [PMID: 33495227 DOI: 10.1128/aac.02029-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/17/2021] [Indexed: 12/12/2022] Open
Abstract
There is insufficient data on the relationship between antibiotic dosing and plasma concentrations in patients treated with continuous renal replacement therapy (CRRT). In this prospective observational study, we explored the variability in plasma concentrations of meropenem and piperacillin in critically ill patients treated with CRRT and the correlation between concentrations and CRRT intensity. Antibiotic concentrations were measured at the middle and end of the dosing interval and repeated after 2 to 3 days when feasible. Measured concentrations were compared to the clinical susceptible breakpoints for Pseudomonas aeruginosa, 16 and 2 mg/liter for piperacillin and meropenem, respectively. CRRT intensity was estimated by delivered, time-averaged, total effluent flow (Q eff), corrected for predilution. Concentrations were also compared between patients with different residual diuresis. We included 140 meropenem concentrations from 98 patients and 47 piperacillin concentrations from 37 patients. Concentrations at the middle of the dosing interval were above target at all occasions for both antibiotics. For meropenem, 6.5% of trough concentrations were below target, and for piperacillin, 22%. Correlations between Q eff and antibiotic concentrations or the concentration half-life (t 1/2) were either statistically not significant or weak. Meropenem concentrations and t 1/2 values differed between patients with different residual diuresis. Thus, when treating intensive care patients with CRRT and recommended doses of meropenem or piperacillin, both low, suboptimal plasma concentrations and unnecessarily high, potentially toxic, plasma concentrations are common. Plasma concentrations cannot be predicted from CRRT intensity. Residual diuresis is associated with lower meropenem concentrations, but the correlation is weak. Concentration measurement is probably the most useful approach to avoid suboptimal treatment.
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112
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Alper Öztürk A, Namlı İ, Aygül A. Cefaclor Monohydrate-Loaded Colon-Targeted Nanoparticles for Use in COVID-19 Dependent Coinfections and Intestinal Symptoms: Formulation, Characterization, Release Kinetics, and Antimicrobial Activity. Assay Drug Dev Technol 2021; 19:156-175. [PMID: 33728979 DOI: 10.1089/adt.2020.1014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Corona virus disease-2019 (COVID-19) emerged in Wuhan, China in December 2019 and was declared as a pandemic by the World Health Organization in March 2020. Although there is no complete treatment protocol for COVID-19, studies on this topic are ongoing, and it is known that broad-spectrum antibiotics such as cephalosporins are used for coinfections and symptoms in COVID-19 patients. Studies have shown that Staphylococcus aureus and Escherichia coli bacteria can cause symptoms such as diarrhea and coinfections accompanying COVID-19. Therefore, in this study, colon-targeted cefaclor monohydrate (CEF)-loaded poly(lactic-co-glycolic acid) (PLGA)-Eudragit S100 nanoparticles (NPs) were prepared using a nanoprecipitation technique. The particle sizes of the CEF-loaded NPs were between 171.4 and 198.8 nm. The encapsulation efficiency was in the range of 58.4%-81.2%. With dissolution studies, it has been concluded that formulations prepared with Eudragit S100 (E-coded) and Eudragit S100+PLGA (EP-coded) are pH-sensitive formulations and they are targetable to the colon, whereas the formulation prepared only with PLGA (P-coded) can release a higher CEF rate in the colon owing to the slow release properties of PLGA. The release kinetics were fitted to the Korsmeyer-Peppas and Weibull models. The antibacterial activity of E-, EP-, and P-coded formulations was 16-fold, 16-fold, and 2-fold higher than CEF, respectively, for S. aureus and E. coli according to the microdilution results. As a result of the time killing experiment, all formulations prepared were found to be more effective than the antibiotic itself for long periods. Consequently, all formulations prepared in this study hope to guide researchers/clinicians in treating both gram-positive and gram-negative bacteria-induced infections, as well as COVID-19 associated coinfections and symptoms.
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Affiliation(s)
- A Alper Öztürk
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Anadolu University, Eskişehir, Turkey
| | - İrem Namlı
- Department of Pharmaceutical Technology, Graduate School of Health Sciences, Anadolu University, Eskişehir, Turkey
| | - Abdurrahman Aygül
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, Çukurova University, Adana, Turkey
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113
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Downes KJ, Goldman JL. Too Much of a Good Thing: Defining Antimicrobial Therapeutic Targets to Minimize Toxicity. Clin Pharmacol Ther 2021; 109:905-917. [PMID: 33539569 DOI: 10.1002/cpt.2190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/27/2021] [Indexed: 12/19/2022]
Abstract
Antimicrobials are a common cause of drug toxicity. Understanding the relationship between systemic antimicrobial exposure and toxicity is necessary to enable providers to take a proactive approach to prevent undesired drug effects. When an exposure threshold has been defined that predicts drug toxicity, therapeutic drug monitoring (TDM) can be performed to assure drug exposure does not exceed the defined threshold. Although some antimicrobials have well-defined dose-dependent toxicities, many other exposure-toxicity relationships have either not been well-defined or, in some cases, not been evaluated at all. In this review, we examine the relationship between exposures and toxicities for antibiotic, antifungal, and antiviral agents. Furthermore, we classify these relationships into four categories: known association between drug exposure and toxicity such that clinical implementation of a specific exposure threshold associated with toxicity for TDM is supported (category 1), known association between drug exposure and toxicity but the specific exposure threshold associated with toxicity is undefined (category 2), association between drug exposure and toxicity has been suggested but relationship is poorly defined (category 3), and no known association between drug exposure and toxicity (category 4). Further work to define exposure-toxicity thresholds and integrate effective TDM strategies has the potential to minimize many of the observed antimicrobial toxicities.
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Affiliation(s)
- Kevin J Downes
- The Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer L Goldman
- Divisions of Clinical Pharmacology, Toxicology and Therapeutic Innovation and Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri - Kansas City, Kansas City, Missouri, USA
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114
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Steffens NA, Zimmermann ES, Nichelle SM, Brucker N. Meropenem use and therapeutic drug monitoring in clinical practice: a literature review. J Clin Pharm Ther 2021; 46:610-621. [PMID: 33533509 DOI: 10.1111/jcpt.13369] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/01/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Meropenem, a carbapenem antibiotic, is widely prescribed for the treatment of life-threatening infections. The main parameter associated with its therapeutic success is the percentage of time that the levels remain above the minimum inhibitory concentration. Inadequate levels of meropenem can lead to therapeutic failure and increase the possibility of microbial resistance. The employment of strategies involving dose regimens and drug pharmacodynamics has become increasingly important to optimize therapies. In the present study, we conducted a review with the purpose of assembling information about the clinical use of meropenem and therapeutic drug monitoring. METHODS A literature review emphasizing the application of therapeutic drug monitoring (TDM) of meropenem in clinical practice has been done. To identify articles related to the topic, we performed a standardized search from January 21, 2020 to December 21, 2020, using specific descriptors in PubMed, Lilacs and Embase. RESULTS AND DISCUSSION In total, 35 studies were included in the review. The daily dose of meropenem commonly ranged from 3 to 6 g/day. Critically ill patients and those with impaired renal function appear to be the most suitable patients for the application of meropenem TDM, in order to guide therapy. We observed that most of the studies recommend TDM and that, in nine locations, the TDM of meropenem and of other beta-lactams is a routine practice. TDM data can help to maximize the clinical outcomes of the treatment with meropenem. It can also improve the patient care by providing suitable levels of meropenem, guiding the most appropriate dose regimens, which is the main parameter associated with therapeutic success. WHAT IS NEW AND CONCLUSION The findings from this review suggest that the therapeutic monitoring of meropenem can be beneficial, since it adjusts the treatment and aids clinical outcomes. It does so by indicating the appropriate dosage and preventing failure, toxicity and possible antimicrobial resistance. The multidisciplinary effort, basic knowledge and communication among the medical team are also essential.
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Affiliation(s)
- Nadine A Steffens
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Estevan S Zimmermann
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida at Lake Nona, Orlando, FL, USA
| | - Sabrina M Nichelle
- Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Natália Brucker
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil.,Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
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115
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Abdulla A, Ewoldt TMJ, Purmer IM, Muller AE, Gommers D, Endeman H, Koch BCP. A narrative review of predictors for β-lactam antibiotic exposure during empirical treatment in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:359-368. [PMID: 33463382 DOI: 10.1080/17425255.2021.1879049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION : Emerging studies suggest that antibiotic pharmacokinetics (PK) are difficult to predict in critically ill patients. The high intra- and inter-patient PK variability makes it challenging to accurately predict the appropriate dosage required for a given patient. Identifying patients at risk could help clinicians to consider more individualized dosing regimens and perform therapeutic drug monitoring. We provide an overview of relevant predictors associated with target (non-)attainment of β-lactam antibiotics in critically ill patients. AREAS COVERED : This narrative review summarizes patient and clinical characteristics that can help to predict the attainment of target serum concentrations and to provide guidance on antimicrobial dose optimization. Literature was searched using Embase and Medline database, focusing on β-lactam antibiotics in critically ill patients. EXPERT OPINION : Adequate concentration attainment can be anticipated in critically ill patients prior to initiating empiric β-lactam antibiotic therapy based on readily available demographic and clinical factors. Male gender, younger age, and augmented renal clearance were the most significant predictors for target non-attainment and should be considered in further investigations to develop dosing algorithms for optimal β-lactam therapy.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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116
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Abdulla A, Edwina EE, Flint RB, Allegaert K, Wildschut ED, Koch BCP, de Hoog M. Model-Informed Precision Dosing of Antibiotics in Pediatric Patients: A Narrative Review. Front Pediatr 2021; 9:624639. [PMID: 33708753 PMCID: PMC7940353 DOI: 10.3389/fped.2021.624639] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022] Open
Abstract
Optimal pharmacotherapy in pediatric patients with suspected infections requires understanding and integration of relevant data on the antibiotic, bacterial pathogen, and patient characteristics. Because of age-related physiological maturation and non-maturational covariates (e.g., disease state, inflammation, organ failure, co-morbidity, co-medication and extracorporeal systems), antibiotic pharmacokinetics is highly variable in pediatric patients and difficult to predict without using population pharmacokinetics models. The intra- and inter-individual variability can result in under- or overexposure in a significant proportion of patients. Therapeutic drug monitoring typically covers assessment of pharmacokinetics and pharmacodynamics, and concurrent dose adaptation after initial standard dosing and drug concentration analysis. Model-informed precision dosing (MIPD) captures drug, disease, and patient characteristics in modeling approaches and can be used to perform Bayesian forecasting and dose optimization. Incorporating MIPD in the electronic patient record system brings pharmacometrics to the bedside of the patient, with the aim of a consisted and optimal drug exposure. In this narrative review, we evaluated studies assessing optimization of antibiotic pharmacotherapy using MIPD in pediatric populations. Four eligible studies involving amikacin and vancomycin were identified from 418 records. Key articles, independent of year of publication, were also selected to highlight important attributes of MIPD. Although very little research has been conducted until this moment, the available data on vancomycin indicate that MIPD is superior compared to conventional dosing strategies with respect to target attainment. The utility of MIPD in pediatrics needs to be further confirmed in frequently used antibiotic classes, particularly aminoglycosides and beta-lactams.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elma E Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
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117
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[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:346-360. [PMID: 33309603 DOI: 10.1016/j.pharma.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.
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118
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Mathieu O, Le Souder C, Granet C, Hillaire-Buys D. Incidence des surdosages par pipéracilline, étude rétrospective sur une année. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2020. [DOI: 10.1016/j.toxac.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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119
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Le Souder C, Hillaire-Buys D, Mathieu O. Encéphalopathie au cours d’une hospitalisation pour pneumopathie infectieuse : penser au surdosage à la pipéracilline. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2020. [DOI: 10.1016/j.toxac.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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120
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Scharf C, Liebchen U, Paal M, Taubert M, Vogeser M, Irlbeck M, Zoller M, Schroeder I. The higher the better? Defining the optimal beta-lactam target for critically ill patients to reach infection resolution and improve outcome. J Intensive Care 2020; 8:86. [PMID: 33292582 PMCID: PMC7686672 DOI: 10.1186/s40560-020-00504-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Beta-lactam antibiotics are often subject to therapeutic drug monitoring, but breakpoints of target attainment are mostly based on expert opinions. Studies that show a correlation between target attainment and infection resolution are missing. This analysis investigated whether there is a difference in infection resolution based on two breakpoints of target attainment. METHODS An outcome group out of 1392 critically ill patients treated with meropenem or piperacillin-tazobactam was formed due to different selection criteria. Afterwards, three groups were created: group 1=free drug concentration (f) was < 100% of the time (T) above the minimal inhibitory concentration (MIC) (< 100% fT > MIC), group 2=100% fT > MIC < 4xMIC, and group 3=100% fT > 4xMIC. Parameters for infection control, renal and liver function, and estimated and observed in-hospital mortality were compared between those groups. Statistical analysis was performed with one-way analysis of variance, Tukey post hoc test, U test, and bivariate logistic regression. RESULTS The outcome group consisted of 55 patients (groups 1-3, 17, 24, and 14 patients, respectively). Patients allocated to group 2 or 3 had a significantly faster reduction of the C-reactive protein in contrast to patients allocated to group 1 (p = 0.033 and p = 0.026). Patients allocated to group 3 had a worse renal function, a higher Acute Physiology and Chronic Health Evaluation (APACHE II) score, were older, and had a significantly higher in-hospital mortality compared to group 1 (p = 0.017) and group 2 (p = 0.001). The higher mortality was significantly influenced by worse liver function, higher APACHE II, and higher Sequential Organ Failure Assessment (SOFA) score and norepinephrine therapy. CONCLUSION Achieving the target 100% fT > MIC leads to faster infection resolution in the critically ill. However, there was no benefit for patients who reached the highest target of 100% fT > 4xMIC, although the mortality rate was higher possibly due to confounding effects. In conclusion, we recommend the target 100% fT > MIC < 4xMIC for critically ill patients. TRIAL REGISTRATION NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Max Taubert
- Department I of Pharmacology, Centre for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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121
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Ho V, Tay F, Wu JE, Lum L, Tambyah P. The Case for Intermittent Carbapenem Dosing in Stable Haemodialysis Patients. Antibiotics (Basel) 2020; 9:antibiotics9110815. [PMID: 33207584 PMCID: PMC7696023 DOI: 10.3390/antibiotics9110815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/27/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose: Antimicrobial resistant infections are common in patients on haemodialysis, often needing long courses of carbapenems. This results in a longer hospital stay and risk of iatrogenic complications. However, carbapenems can be given intermittently to allow for earlier discharge. We aim to describe the clinical outcomes of intermittent versus daily meropenem in stable, intermittently haemodialysed patients. Methods: In total, 103 records were examined retrospectively. Data collected include demographics, clinical interventions and outcomes such as hospital length of stay (LOS), 30-day readmission rates and adverse events. Findings: Mean age 61.6 ± 14.2 years, 57.3% male. Most common bacteria cultured were Klebsiella pneumoniae (16.5%). The most common indication was pneumonia (27.2%). Mean duration of therapy on meropenem was 12.4 ± 14.4 days; eight patients needed more than 30 days of meropenem. In total, 55.3% did not have intervention for source control; 86.4% received daily dosing of meropenem; 7.8% patients received intermittent dosing of meropenem only, and 5.8 patients received both types of dosing regimens. LOS of the index admission was shorter for the intermittent arm (15.5 ± 7.6 days versus daily: 30.2 ± 24.5 days), though 30-day readmission was higher (50% versus daily: 38.2%). Implications: We recommend further rigorous randomised controlled trials to investigate the clinical utility of intermittent meropenem dosing in patients on stable haemodialysis.
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Affiliation(s)
- Vanda Ho
- Department of Medicine, National University Hospital, National University Health System, Singapore 119228, Singapore; (L.L.); (P.T.)
- Correspondence: ; Tel.: +65-6779-5555
| | - Felecia Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
| | - Jia En Wu
- Department of Pharmacy, National University Health System, Singapore 119228, Singapore;
| | - Lionel Lum
- Department of Medicine, National University Hospital, National University Health System, Singapore 119228, Singapore; (L.L.); (P.T.)
| | - Paul Tambyah
- Department of Medicine, National University Hospital, National University Health System, Singapore 119228, Singapore; (L.L.); (P.T.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore;
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122
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Abdulla A, Dijkstra A, Hunfeld NGM, Endeman H, Bahmany S, Ewoldt TMJ, Muller AE, van Gelder T, Gommers D, Koch BCP. Failure of target attainment of beta-lactam antibiotics in critically ill patients and associated risk factors: a two-center prospective study (EXPAT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:558. [PMID: 32933574 PMCID: PMC7493358 DOI: 10.1186/s13054-020-03272-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022]
Abstract
Background Early and appropriate antibiotic dosing is associated with improved clinical outcomes in critically ill patients, yet target attainment remains a challenge. Traditional antibiotic dosing is not suitable in critically ill patients, since these patients undergo physiological alterations that strongly affect antibiotic exposure. For beta-lactam antibiotics, the unbound plasma concentrations above at least one to four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval (100%ƒT > 1–4×MIC) have been proposed as pharmacodynamic targets (PDTs) to maximize bacteriological and clinical responses. The objectives of this study are to describe the PDT attainment in critically ill patients and to identify risk factors for target non-attainment. Methods This prospective observational study was performed in two ICUs in the Netherlands. We enrolled adult patients treated with the following beta-lactam antibiotics: amoxicillin (with or without clavulanic acid), cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and meropenem. Based on five samples within a dosing interval at day 2 of therapy, the time unbound concentrations above the epidemiological cut-off (ƒT > MICECOFF and ƒT > 4×MICECOFF) were determined. Secondary endpoints were estimated multivariate binomial and binary logistic regression models, for examining the association of PDT attainment with patient characteristics and clinical outcomes. Results A total of 147 patients were included, of whom 63.3% achieved PDT of 100%ƒT > MICECOFF and 36.7% achieved 100%ƒT > 4×MICECOFF. Regression analysis identified male gender, estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2, and high body mass index (BMI) as risk factors for target non-attainment. Use of continuous renal replacement therapy (CRRT) and high serum urea significantly increased the probability of target attainment. In addition, we found a significant association between the 100%ƒT > MICECOFF target attainment and ICU length of stay (LOS), but no significant correlation was found for the 30-day survival. Conclusions Traditional beta-lactam dosing results in low target attainment in the majority of critically ill patients. Male gender, high BMI, and high eGFR were significant risk factors for target non-attainment. These predictors, together with therapeutic drug monitoring, may help ICU clinicians in optimizing beta-lactam dosing in critically ill patients. Trial registration Netherlands Trial Registry (EXPAT trial), NTR 5632. Registered on 7 December 2015.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Soma Bahmany
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
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123
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Wallenburg E, ter Heine R, Schouten JA, Brüggemann RJ. Personalised antimicrobial dosing: standing on the shoulders of giants. Int J Antimicrob Agents 2020; 56:106062. [DOI: 10.1016/j.ijantimicag.2020.106062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/13/2020] [Indexed: 12/17/2022]
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124
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De Rose DU, Cairoli S, Dionisi M, Santisi A, Massenzi L, Goffredo BM, Dionisi-Vici C, Dotta A, Auriti C. Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age. Int J Mol Sci 2020; 21:E5898. [PMID: 32824472 PMCID: PMC7460644 DOI: 10.3390/ijms21165898] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Sara Cairoli
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Marco Dionisi
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Luca Massenzi
- Neonatal Intensive Care Unit and Neonatal Pathology, Fatebenefratelli Hospital, 00186 Rome, Italy;
| | - Bianca Maria Goffredo
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Carlo Dionisi-Vici
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
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125
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Contejean A, Jaffrelot L, Benaboud S, Tréluyer JM, Grignano E, Willems L, Gauzit R, Bouscary D, Gana I, Boujaafar S, Kernéis S, Hirt D. A meropenem pharmacokinetics model in patients with haematological malignancies. J Antimicrob Chemother 2020; 75:2960-2968. [DOI: 10.1093/jac/dkaa275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Optimal dosing of antibiotics is critical in immunocompromised patients suspected to have an infection. Data on pharmacokinetics (PK) of meropenem in patients with haematological malignancies are scarce.
Objectives
To optimize dosing regimens, we aimed to develop a PK population model for meropenem in this population.
Methods
Patients aged ≥18 years, hospitalized in the haematology department of our 1500 bed university hospital for a malignant haematological disease and who had received at least one dose of meropenem were eligible. Meropenem was quantified by HPLC. PK were described using a non-linear mixed-effect model and external validation performed on a distinct database. Monte Carlo simulations estimated the PTA, depending on renal function, duration of infusion and MIC. Target for free trough concentration was set at >4× MIC.
Results
Overall, 88 patients (181 samples) were included, 66 patients (75%) were in aplasia and median Modification of Diet in Renal Disease (MDRD) CLCR was 117 mL/min/1.73 m2 (range: 35–359). Initial meropenem dosing regimen ranged from 1 g q8h to 2 g q8h over 30 to 60 min. A one-compartment model with first-order elimination adequately described the data. Only MDRD CLCR was found to be significantly associated with CL. Only continuous infusion achieved a PTA of 100% whatever the MIC and MDRD CLCR. Short duration of infusion (<60 min) failed to reach an acceptable PTA, except for bacteria with MIC < 0.25 mg/L in patients with MDRD CLCR below 90 mL/min/1.73 m2.
Conclusions
In patients with malignant haematological diseases, meropenem should be administered at high dose (6 g/day) and on continuous infusion to reach acceptable trough concentrations.
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Affiliation(s)
- A Contejean
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - L Jaffrelot
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Benaboud
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - J -M Tréluyer
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - E Grignano
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - L Willems
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
| | - R Gauzit
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Bouscary
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - I Gana
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Boujaafar
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Kernéis
- Université de Paris, Faculté de Médecine, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Hirt
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- INSERM, U1018, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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Dhaese S, Van Vooren S, Boelens J, De Waele J. Therapeutic drug monitoring of β-lactam antibiotics in the ICU. Expert Rev Anti Infect Ther 2020; 18:1155-1164. [PMID: 32597263 DOI: 10.1080/14787210.2020.1788387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Individualizing antibiotic therapy is paramount to improve clinical outcomes while minimizing the risk of toxicity and antimicrobial therapy. β-lactam antibiotics are amongst the drugs most commonly prescribed in the Intensive Care Unit (ICU). The pharmacokinetics of β-lactam antibiotics are profoundly altered in critically ill patients, leading to the failure of standard drug dosing regimens to result in adequate drug concentrations. Therapeutic Drug Monitoring (TDM) of β-lactam antibiotics is a promising tool to help optimize β-lactam antibiotic therapy. AREAS COVERED The rationale behind TDM for β-lactam antibiotics is explained, as well as some more practical aspects such as when to sample, what concentrations to strive for and how to use it in clinical practice. We also discuss microbiological and analytical considerations, knowledge gaps, and future perspectives of β-lactam antibiotics TDM in ICU patients. EXPERT OPINION TDM of β-lactam antibiotics has been studied intensively in recent years. While TDM may not yet be widely available, and targets need to be further refined, TDM of β-lactam antibiotics will help to optimize antibiotic therapy in the critically ill patient, as an integrated part of an antimicrobial stewardship program.
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Affiliation(s)
- Sofie Dhaese
- Department of Internal Medicine and Pediatrics, Ghent University Hospital , Ghent, Belgium
| | - Sarah Van Vooren
- Department of Diagnostic Sciences, Ghent University Hospital , Ghent, Belgium
| | - Jerina Boelens
- Department of Diagnostic Sciences, Ghent University Hospital , Ghent, Belgium
| | - Jan De Waele
- Department of Internal Medicine and Pediatrics, Ghent University Hospital , Ghent, Belgium
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Chosidow A, Benaboud S, Beranger A, Zheng Y, Moulin F, Dupic L, Renolleau S, Treluyer JM, Oualha M. Are β-lactam concentrations adequate in severe sepsis and septic shock in children? Therapie 2020; 75:633-640. [PMID: 32593420 DOI: 10.1016/j.therap.2020.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/18/2019] [Accepted: 04/02/2020] [Indexed: 01/16/2023]
Abstract
AIM OF THE STUDY Early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock's treatment. We aim to describe the plasma concentration of the most used β-lactams in critically ill children, to describe the rate of patients with suboptimal exposure, and associated clinical and biological factors. METHODS From January 2016 to May 2017, children less than 18 years old with severe sepsis or septic shock were included. Samples were collected in pediatric intensive care unit for children with severe sepsis or septic shock. β-lactam plasma concentrations were analysed using high performance liquid chromatography. RESULTS Among the 37 enrolled patients, 24 (64.9%) had insufficient concentration [cefotaxime 7/14 (43%); piperacillin-tazobactam, 10/13 (77%); amoxicillin 6/7 (86%); meropenem 3/6 (50%), cefazolin 1/4 (25%), imipenem 0/2 (0%); ceftazidime 0/1 (0%)]. Insufficient concentrations were associated with early measurements [<72hours from the sepsis' onset (P=0.035) and an increased creatinine clearance (P=0.01)]. CONCLUSION β-lactams current dosing in critically ill septic children could be suboptimal.
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Affiliation(s)
- Anais Chosidow
- Armand-Trousseau hospital, AP-HP, pediatric department, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France.
| | - Sihem Benaboud
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Agathe Beranger
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Yi Zheng
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Florence Moulin
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Laurent Dupic
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | | | - Jean-Marc Treluyer
- Pharmacology department, Cochin hospital, 75014 Paris, France; Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
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128
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Garber B, Glauser J. Recent Developments in Infectious Disease Chemotherapy: Review for Emergency Department Practitioners 2020. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020; 8:116-121. [PMID: 32837804 PMCID: PMC7296288 DOI: 10.1007/s40138-020-00218-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose of Review We discuss and review new antimicrobials for treatment of bacterial, viral, fungal, and parasitic infections with indications, contraindications, and side effects for each. We will also review new information and indications on older agents that are relevant to clinical practice. Many of them may be unfamiliar to Emergency Physicians given their newness and at times hospital restrictions on their use. We also review some new promising agents that are not yet in the clinical pipeline. Recent Findings As new antibiotics become available for clinicians to use, new information becomes available with respect to the drugs' indications, efficacy, pathogen resistance, drug-drug interactions, and side effects. Summary This article provides Emergency Department clinicians with a useful summary with new information on antibiotic use and recent research into agents which may become available.
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Affiliation(s)
- Boris Garber
- MetroHealth Medical Center, Case Western Reserve School of Medicine, Cleveland, OH USA
| | - Jonathan Glauser
- MetroHealth Medical Center, Case Western Reserve School of Medicine, Cleveland, OH USA
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129
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Abstract
BACKGROUND Cephalexin is used for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) infections in children. Although 4 times daily dosing is recommended, less frequent dosing regimens are often prescribed to improve treatment acceptability and adherence. We developed a population pharmacokinetic model of cephalexin in children to determine a twice-daily (BID) and thrice-daily (TID) cephalexin dosing regimen for MSSA infections. METHODS A population pharmacokinetic model was developed using a nonlinear mixed effects modeling approach. The dataset used was from a prospective open-label pharmacokinetic study of orally administered cephalexin in 12 children 1-16 years of age with bone and joint infections. Simulations were performed to determine a BID and TID dosing regimen so that ≥90% of children in this age group would achieve the pharmacodynamic target for MSSA (ie, time that the free drug concentration exceeds the minimum inhibitory concentration of the bacteria for at least 40% of the dosing interval). RESULTS The final model was 1 compartment with a transit compartment model to account for delay in oral absorption. For BID dosing, doses of 22-45 and 80 mg/kg were required for MSSA with minimum inhibitory concentrations of 1-2 and 4 mg/L, respectively. For TID dosing, the respective required doses were 15-25 and 45 mg/kg. CONCLUSIONS Our study proposes a BID and TID cephalexin dosing regimen that can be prospectively evaluated. Through reducing the dose frequency of this widely prescribed antibiotic, we can reduce the medication burden for children and improve treatment compliance for MSSA infections.
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130
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Antibiotic Exposure Profiles in Trials Comparing Intensity of Continuous Renal Replacement Therapy. Crit Care Med 2020; 47:e863-e871. [PMID: 31397714 DOI: 10.1097/ccm.0000000000003955] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether the probability of target attainment over 72 hours of initial therapy with beta-lactam (cefepime, ceftazidime, piperacillin/tazobactam) and carbapenem (imipenem, meropenem) antibiotics were substantially influenced between intensive and less-intensive continuous renal replacement therapy groups in the Acute Renal Failure Trial Network trial and The RENAL Replacement Therapy Study trial. DESIGN The probability of target attainment was calculated using pharmacodynamic targets of percentage of time that free serum concentrations (fT): 1) were above the target organism's minimum inhibitory concentration (≥ fT > 1 × minimum inhibitory concentration); 2) were above four times the minimum inhibitory concentration (≥ % fT > 4 × minimum inhibitory concentration); and 3) were always above the minimum inhibitory concentration (≥ 100% fT > minimum inhibitory concentration) for the first 72 hours of antibiotic therapy. Demographic data and effluent rates from the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials were used. Optimal doses were defined as the dose achieving greater than or equal to 90% probability of target attainment. SETTING Monte Carlo simulations using demographic data from Acute Renal Failure Trial Network and RENAL Replacement Therapy Study trials. PATIENTS Virtual critically ill patients requiring continuous renal replacement therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The pharmacodynamic target of fT greater than 1 × minimum inhibitory concentration led to similarly high rates of predicted response with antibiotic doses often used in continuous renal replacement therapy. Achieving 100% fT greater than minimum inhibitory concentration is a more stringent benchmark compared with T greater than 4 × minimum inhibitory concentration with standard antibiotic dosing. The intensity of effluent flow rates (less intensive vs intensive) did not substantially influence the probability of target attainment of antibiotic dosing regimens regardless of pharmacodynamic target. CONCLUSIONS Antibiotic pharmacodynamic target attainment rates likely were not meaningfully different in the low- and high-intensity treatment arms of the Acute Renal Failure Trial Network and RENAL Replacement Therapy Study Investigators trials.
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131
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Cattaneo D, Corona A, De Rosa FG, Gervasoni C, Kocic D, Marriott DJ. The management of anti-infective agents in intensive care units: the potential role of a 'fast' pharmacology. Expert Rev Clin Pharmacol 2020; 13:355-366. [PMID: 32320302 DOI: 10.1080/17512433.2020.1759413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of 'fast microbiology.' Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents. AREAS COVERED We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles. EXPERT OPINION Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a 'fast pharmacology' at the bedside.
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Affiliation(s)
- Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Alberto Corona
- Intensive Care Unit, ASST Fatebenefratelli Sacco, University Hospital , Milan, Italy
| | | | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Danijela Kocic
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney , Sydney, Australia
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital , Sydney, Australia
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132
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Grensemann J, Busse D, König C, Roedl K, Jäger W, Jarczak D, Iwersen-Bergmann S, Manthey C, Kluge S, Kloft C, Fuhrmann V. Acute-on-chronic liver failure alters meropenem pharmacokinetics in critically ill patients with continuous hemodialysis: an observational study. Ann Intensive Care 2020; 10:48. [PMID: 32323030 PMCID: PMC7176801 DOI: 10.1186/s13613-020-00666-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infection and sepsis are a main cause of acute-on-chronic liver failure (ACLF). Adequate dosing of antimicrobial therapy is of central importance to improve outcome. Liver failure may alter antibiotic drug concentrations via changes of drug distribution and elimination. We studied the pharmacokinetics of meropenem in critically ill patients with ACLF during continuous veno-venous hemodialysis (CVVHD) and compared it to critically ill patients without concomitant liver failure (NLF). METHODS In this prospective cohort study, patients received meropenem 1 g tid short-term infusion (SI). Meropenem serum samples were analyzed by high-performance liquid chromatography. A population pharmacokinetic analysis was performed followed by Monte Carlo simulations of (A) meropenem 1 g tid SI, (B) 2 g loading plus 1 g prolonged infusion tid (C) 2 g tid SI, and (D) 2 g loading and continuous infusion of 3 g/day on days 1 and 7. Probability of target attainment (PTA) was assessed for 4× the epidemiological cut-off values for Enterobacterales (4 × 0.25 mg/L) and Pseudomonas spp. (4 × 2 mg/L). RESULTS Nineteen patients were included in this study. Of these, 8 patients suffered from ACLF. A two-compartment model with linear clearance from the central compartment described meropenem pharmacokinetics. The peripheral volume of distribution (V2) was significantly higher in ACLF compared to NLF (38.6L versus 19.7L, p = .05). PTA for Enterobacterales was achieved in 100% for all dosing regimens. PTA for Pseudomonas spp. in ACLF on day 1/7 was: A: 18%/80%, B: 94%/88%, C: 85%/98% D: 100%/100% and NLF: A: 48%/65%, B: 91%/83%, C: 91%/93%, D: 100%/100%. CONCLUSION ALCF patients receiving CVVHD had a higher V2 and may require a higher loading dose of meropenem. For Pseudomonas, high doses or continuous infusion are required to reach PTA in ACLF patients.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Walter Jäger
- Department of Pharmaceutical Chemistry, University of Vienna, Althanstraße 14, 1090, Vienna, Austria
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefanie Iwersen-Bergmann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, 22529, Hamburg, Germany
| | - Carolin Manthey
- First Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Medicine B, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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133
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Märtson AG, Sturkenboom MGG, Stojanova J, Cattaneo D, Hope W, Marriott D, Patanwala AE, Peloquin CA, Wicha SG, van der Werf TS, Tängdén T, Roberts JA, Neely MN, Alffenaar JWC. How to design a study to evaluate therapeutic drug monitoring in infectious diseases? Clin Microbiol Infect 2020; 26:1008-1016. [PMID: 32205294 DOI: 10.1016/j.cmi.2020.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is a tool to personalize and optimize dosing by measuring the drug concentration and subsequently adjusting the dose to reach a target concentration or exposure. The evidence to support TDM is however often ranked as expert opinion. Limitations in study design and sample size have hampered definitive conclusions of the potential added value of TDM. OBJECTIVES We aim to give expert opinion and discuss the main points and limitations of available data from antibiotic TDM trials and emphasize key elements for consideration in design of future clinical studies to quantify the benefits of TDM. SOURCES The sources were peer-reviewed publications, guidelines and expert opinions from the field of TDM. CONTENT This review focuses on key aspects of antimicrobial TDM study design: describing the rationale for a TDM study, assessing the exposure of a drug, assessing susceptibility of pathogens and selecting appropriate clinical endpoints. Moreover we provide guidance on appropriate study design. IMPLICATIONS This is an overview of different aspects relevant for the conduct of a TDM study. We believe that this paper will help researchers and clinicians to design and conduct high-quality TDM studies.
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Affiliation(s)
- A-G Märtson
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - M G G Sturkenboom
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands
| | - J Stojanova
- Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Valparaíso, Chile
| | - D Cattaneo
- ASST Fatebenefratelli Sacco University Hospital, Unit of Clinical Pharmacology, Department of Laboratory Medicine, Milan, Italy
| | - W Hope
- University of Liverpool, Antimicrobial Pharmacodynamics and Therapeutics, Liverpool, UK; Royal Liverpool Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - D Marriott
- St Vincent's Hospital, Sydney, Australia
| | - A E Patanwala
- The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Royal Prince Alfred Hospital, Sydney, Australia
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - S G Wicha
- University of Hamburg, Department of Clinical Pharmacy, Institute of Pharmacy, Hamburg, Germany
| | - T S van der Werf
- University of Groningen, University Medical Centre Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands; University of Groningen, University Medical Centre Groningen, Department of Internal Medicine, Groningen, the Netherlands
| | - T Tängdén
- Uppsala University, Department of Medical Sciences, Uppsala, Sweden
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & 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; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - M N Neely
- Children's Hospital of Los Angeles, Laboratory of Applied Pharmacokinetics and Bioinformatics, Los Angeles, CA, USA
| | - J-W C Alffenaar
- University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, the Netherlands; The University of Sydney, Sydney Pharmacy School, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.
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134
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Scharf C, Paal M, Schroeder I, Vogeser M, Draenert R, Irlbeck M, Zoller M, Liebchen U. Therapeutic Drug Monitoring of Meropenem and Piperacillin in Critical Illness-Experience and Recommendations from One Year in Routine Clinical Practice. Antibiotics (Basel) 2020; 9:antibiotics9030131. [PMID: 32245195 PMCID: PMC7148485 DOI: 10.3390/antibiotics9030131] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/19/2022] Open
Abstract
Various studies have reported insufficient beta-lactam concentrations in critically ill patients. The extent to which therapeutic drug monitoring (TDM) in clinical practice can reduce insufficient antibiotic concentrations is an ongoing matter of investigation. We retrospectively evaluated routine meropenem and piperacillin measurements in critically ill patients who received antibiotics as short infusions in the first year after initiating a beta-lactam TDM program. Total trough concentrations above 8.0 mg/L for meropenem and above 22.5 mg/L for piperacillin were defined as the breakpoints for target attainment. We included 1832 meropenem samples and 636 piperacillin samples. We found that 39.3% of meropenem and 33.6% of piperacillin samples did not reach the target concentrations. We observed a clear correlation between renal function and antibiotic concentration (meropenem, r = 0.53; piperacillin, r = 0.63). Patients with renal replacement therapy or creatinine clearance (CrCl) of <70 mL/min had high rates of target attainment with the standard dosing regimens. There was a low number of patients with a CrCl >100 mL/min that achieved the target concentrations with the maximum recommended dosage. Patients with impaired renal function only required TDM if toxic side effects were noted. In contrast, patients with normal renal function required different dosage regimens and TDM-guided therapy to reach the breakpoints of target attainment.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
- Correspondence: ; Fax: +49-89-4400-78886
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Rika Draenert
- Section Clinical Infectious Diseases, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
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135
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Intrapulmonary concentrations of meropenem administered by continuous infusion in critically ill patients with nosocomial pneumonia: a randomized pharmacokinetic trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:55. [PMID: 32066497 PMCID: PMC7026992 DOI: 10.1186/s13054-020-2763-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/06/2020] [Indexed: 12/16/2022]
Abstract
Background Optimal antimicrobial drug exposure in the lung is required for successful treatment outcomes for nosocomial pneumonia. Little is known about the intrapulmonary pharmacokinetics (PK) of meropenem when administered by continuous infusion (CI). The aim of this study was to evaluate the PK of two dosages of meropenem (3 g vs 6 g/day by CI) in the plasma and epithelial lining fluid (ELF) in critically ill patients with nosocomial pneumonia. Methods Thirty-one patients (81% male, median (IQR) age 72 (22) years) were enrolled in a prospective, randomized, clinical trial. Sixteen patients received 1 g/8 h and 15 2 g/8 h by CI (8 h infusion). Plasma and ELF meropenem concentrations were modeled using a population methodology, and Monte Carlo simulations were performed to estimate the probability of attaining (PTA) a free ELF concentration of 50% of time above MIC (50% fT>MIC), which results in logarithmic killing and the suppression of resistance in experimental models of pneumonia. Results The median (IQR) of meropenem AUC0–24 h in the plasma and ELF was 287.6 (190.2) and 84.1 (78.8) mg h/L in the 1 g/8 h group vs 448.1 (231.8) and 163.0 (201.8) mg h/L in the 2 g/8 h group, respectively. The penetration ratio was approximately 30% and was comparable between the dosage groups. In the Monte Carlo simulations, only the highest approved dose of meropenem of 2 g/8 h by CI allowed to achieve an optimal PTA for all isolates with a MIC < 4 mg/L. Conclusions An increase in the dose of meropenem administered by CI achieved a higher exposure in the plasma and ELF. The use of the highest licensed dose of 6 g/day may be necessary to achieve an optimal coverage in ELF for all susceptible isolates (MIC ≤ 2 mg/L) in patients with conserved renal function. An alternative therapy should be considered when the presence of microorganisms with a MIC greater than 2 mg/L is suspected. Trial registration The trial was registered in the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT-no. 2016-002796-10). Registered on 27 December 2016.
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136
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Abdulla A, Ewoldt TMJ, Hunfeld NGM, Muller AE, Rietdijk WJR, Polinder S, van Gelder T, Endeman H, Koch BCP. The effect of therapeutic drug monitoring of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients: the DOLPHIN trial protocol of a multi-centre randomised controlled trial. BMC Infect Dis 2020; 20:57. [PMID: 31952493 PMCID: PMC6969462 DOI: 10.1186/s12879-020-4781-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/08/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Critically ill patients undergo extensive physiological alterations that will have impact on antibiotic pharmacokinetics. Up to 60% of intensive care unit (ICU) patients meet the pharmacodynamic targets of beta-lactam antibiotics, with only 30% in fluoroquinolones. Not reaching these targets might increase the chance of therapeutic failure, resulting in increased mortality and morbidity, and antibiotic resistance. The DOLPHIN trial was designed to demonstrate the added value of therapeutic drug monitoring (TDM) of beta-lactam and fluoroquinolones in critically ill patients in the ICU. METHODS A multi-centre, randomised controlled trial (RCT) was designed to assess the efficacy and cost-effectiveness of model-based TDM of beta-lactam and fluoroquinolones. Four hundred fifty patients will be included within 24 months after start of inclusion. Eligible patients will be randomly allocated to either study group: the intervention group (active TDM) or the control group (non-TDM). In the intervention group dose adjustment of the study antibiotics (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, amoxicillin, amoxicillin with clavulanic acid, flucloxacillin, piperacillin with tazobactam, meropenem, and ciprofloxacin) on day 1, 3, and 5 is performed based upon TDM with a Bayesian model. The primary outcome will be ICU length of stay. Other outcomes amongst all survival, disease severity, safety, quality of life after ICU discharge, and cost effectiveness will be included. DISCUSSION No trial has investigated the effect of early TDM of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients. The findings from the DOLPHIN trial will possibly lead to new insights in clinical management of critically ill patients receiving antibiotics. In short, to TDM or not to TDM? TRIAL REGISTRATION EudraCT number: 2017-004677-14. Sponsor protocol name: DOLPHIN. Registered 6 March 2018 . Protocol Version 6, Protocol date: 27 November 2019.
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Affiliation(s)
- A Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - T M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - N G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
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Erba A, Beuret M, Daly ML, Khanna N, Osthoff M. OPAT in Switzerland: single-center experience of a model to treat complicated infections. Infection 2019; 48:231-240. [PMID: 31828605 DOI: 10.1007/s15010-019-01381-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/03/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Outpatient parenteral antimicrobial therapy (OPAT) programmes are established in the minority of Swiss hospitals. We aimed to study the OPAT programme at the University Hospital Basel during a 3-year period to evaluate safety and outcome. METHODS All patients treated in the OPAT programme between 2015 and 2017 were included in the study. Demographic, clinical and OPAT outcome data were extracted from the hospital information system. Differences between treatment periods were analysed and risk factors for readmission and adverse events identified. RESULTS In total, 462 patients were enrolled from 2015 to 2017. Patient numbers and total treatment days increased by 68% and 116%, respectively. Indications included many complicated infections such as bone and joint (23%) and intravascular infections (13%). Of the identified Gram-negative bacteria, 25% produced extended spectrum beta-lactamases. The percentage of antibiotics administrated with an elastomeric device increased from 11% in 2015 to 29% in 2017, whereas the use of once-daily antimicrobials (such as ceftriaxone) declined. Adverse events were rare (n = 67; 14.6%) including only two severe catheter-related events. Cure was noted in 98% of patients. 30-day unplanned readmission occurred in 46 (10.0%) patients, and intravascular infections and a higher Charlson comorbidity index were identified as independent predictors. CONCLUSION This study demonstrates the successful implementation of a formal OPAT programme in a Swiss tertiary care hospital. Careful selection of patients and monitoring during treatment are crucial to avoid frequent readmissions. Hence, our data call for an expansion of OPAT services in Switzerland in the near future.
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Affiliation(s)
- Andrea Erba
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Michelle Beuret
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Mary-Louise Daly
- Medical Outpatient Clinic, University Hospital Basel, Basel, Switzerland
| | - Nina Khanna
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Department of Clinical Research, University of Basel, Basel, Switzerland.
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138
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Update in antibiotic therapy in intensive care unit: report from the 2019 Nîmes International Symposium. Anaesth Crit Care Pain Med 2019; 38:647-656. [DOI: 10.1016/j.accpm.2019.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/14/2022]
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139
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Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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140
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Carrié C, Chadefaux G, Sauvage N, de Courson H, Petit L, Nouette-Gaulain K, Pereira B, Biais M. Increased β-Lactams dosing regimens improve clinical outcome in critically ill patients with augmented renal clearance treated for a first episode of hospital or ventilator-acquired pneumonia: a before and after study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:379. [PMID: 31775840 PMCID: PMC6881978 DOI: 10.1186/s13054-019-2621-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/23/2019] [Indexed: 01/18/2023]
Abstract
Background Augmented renal clearance (ARC) is recognized as a leading cause of β-lactam subexposure when conventional dosing regimens are used. The main objective was to compare the clinical outcome of ARC patients treated by conventional or increased β-lactam dosing regimens for a first episode of hospital or ventilator-acquired pneumonia (HAP-VAP). Methods In this single-center, retrospective study, every ARC patient treated by β-lactam for a first episode of HAP-VAP was included during two 15-month periods, before (Control period) and after (Treatment period) the modification of a local antibiotic therapy protocol. ARC was defined by a 24-h measured creatinine clearance ≥ 150 ml/min. The primary endpoint was defined as a therapeutic failure of the antimicrobial therapy or a HAP-VAP relapse within 28 days. Inverse probability of treatment weight (IPTW) was derived from a propensity score model. Cox proportional hazard models were used to evaluate the association between treatment period and clinical outcome. Results During the study period, 177 patients were included (control period, N = 88; treatment period, N = 89). Therapeutic failure or HAP-VAP relapse was significantly lower in the treatment period (10 vs. 23%, p = 0.019). The IPTW-adjusted hazard ratio of poor clinical outcome in the treatment period was 0.35 (95% CI 0.15–0.81), p = 0.014. No antibiotic side effect was reported during the treatment period. Conclusions Higher than licensed dosing regimens of β-lactams may be safe and effective in reducing the rate of therapeutic failure and HAP-VAP recurrence in critically ill augmented renal clearance (ARC) patients.
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Affiliation(s)
- Cédric Carrié
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France.
| | - Grégoire Chadefaux
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France
| | - Noémie Sauvage
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France
| | - Hugues de Courson
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France
| | - Laurent Petit
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France
| | - Karine Nouette-Gaulain
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France.,University Bordeaux Segalen, 33000, Bordeaux, France
| | - Bruno Pereira
- Biostatistics Unit, Délégation Recherche Clinique & Innovation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Biais
- Anesthesiology and Critical Care Department, Hôpital Pellegrin, CHU Bordeaux, 33000, Bordeaux, France.,University Bordeaux Segalen, 33000, Bordeaux, France
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141
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Corrigendum to "Early target attainment of continuous infusion piperacillin/tazobactam and meropenem in critically ill patients: A prospective observational study" [Journal of Critical Care 52 (2019) 75-79]. J Crit Care 2019; 56:325. [PMID: 31740024 DOI: 10.1016/j.jcrc.2019.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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142
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Population pharmacokinetics of meropenem in critically ill children with different renal functions. Eur J Clin Pharmacol 2019; 76:61-71. [DOI: 10.1007/s00228-019-02761-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
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143
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Brinkmann A, Röhr AC, Köberer A, Fuchs T, Krüger WA, König C, Richter D, Weigand MA, Frey OR. [Adequate anti-infective treatment : Importance of individual dosing and application]. Anaesthesist 2019; 67:461-476. [PMID: 29766208 DOI: 10.1007/s00101-018-0443-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (Vd) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.
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Affiliation(s)
- A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland.
| | - A C Röhr
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
| | - A Köberer
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - T Fuchs
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Konstanz, Konstanz, Deutschland
| | - C König
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - O R Frey
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
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Pascale R, Giannella M, Bartoletti M, Viale P, Pea F. Use of meropenem in treating carbapenem-resistant Enterobacteriaceae infections. Expert Rev Anti Infect Ther 2019; 17:819-827. [PMID: 31559876 DOI: 10.1080/14787210.2019.1673731] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The epidemiology of carbapenem-resistant Enterobacterales (CRE) is increasingly worldwide. Production of carbapenemases is the most common and efficient mechanism of carbapenem resistance, and could theoretically be overcome by optimizing the pharmacokinetic/pharmacodynamic (PK/PD) behavior of meropenem. Areas covered: This article overviews the available literature concerning the potential role that meropenem may still have in the treatment carbapenem-resistant Enterobacteriaceae infections. Clinical studies published in English language until June 2019 were searched on PubMed database. Expert commentary: High-dose continuous infusion meropenem-based combination regimens could still represent a valuable option for treating CRE infections in specific circumstances. Knowledge of the local prevalent mechanisms of carbapenem resistance, of patient clinical severity, of the site of infection, of an accurate minimum inhibitory concentration (MIC) value, coupled with the possibility of carrying-out a real-time therapeutic drug monitoring (TDM)-based PK/PD optimization of drug exposure must all be considered as fundamental for properly pursuing this goal.
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Affiliation(s)
- Renato Pascale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Federico Pea
- Department of Medicine, University of Udine , Udine , Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine , Udine , Italy
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Therapeutic drug monitoring-guided continuous infusion of piperacillin/tazobactam significantly improves pharmacokinetic target attainment in critically ill patients: a retrospective analysis of four years of clinical experience. Infection 2019; 47:1001-1011. [PMID: 31473974 DOI: 10.1007/s15010-019-01352-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Standard dosing and intermittent bolus application (IB) are important risk factors for pharmacokinetic (PK) target non-attainment during empirical treatment with β-lactams in critically ill patients, particularly in those with sepsis and septic shock. We assessed the effect of therapeutic drug monitoring-guided (TDM), continuous infusion (CI) and individual dosing of piperacillin/tazobactam (PIP) on PK-target attainment in critically ill patients. METHODS This is a retrospective, single-center analysis of a database including 484 patients [933 serum concentrations (SC)] with severe infections, sepsis and septic shock who received TDM-guided CI of PIP in the intensive care unit (ICU) of an academic teaching hospital. The PK-target was defined as a PIP SC between 33 and 64 mg/L [fT > 2-4 times the epidemiological cutoff value (ECOFF) of Pseudomonas aeruginosa (PSA)]. RESULTS PK-target attainment with standard dosing (initial dose) was observed in 166 patients (34.3%), whereas only 49 patients (10.1%) demonstrated target non-attainment. The minimum PK-target of ≥ 33 mg/L was overall realized in 89.9% (n = 435/484) of patients after the first PIP dose including 146 patients (30.2%) with potentially harmful SCs ≥ 100 mg/L. Subsequent TDM-guided dose adjustments significantly enhanced PK-target attainment to 280 patients (62.4%) and significantly reduced the fraction of potentially overdosed (≥ 100 mg/L) patients to 4.5% (n = 20/449). Renal replacement therapy (RRT) resulted in a relevant reduction of PIP clearance (CLPIP): no RRT CLPIP 6.8/6.3 L/h (median/IQR) [SCs n = 752, patients n = 405], continuous veno-venous hemodialysis (CVVHD) CLPIP 4.3/2.6 L/h [SCs n = 160, n = 71 patients], intermittent hemodialysis (iHD) CLPIP 2.6/2.3 L/h [SCs n = 21, n = 8 patients]). A body mass index (BMI) of > 40 kg/m2 significantly increased CLPIP 9.6/7.7 L/h [SC n = 43, n = 18 patients] in these patients. Age was significantly associated with supratherapeutic PIP concentrations (p < 0.0005), whereas high CrCL led to non-target attainment (p < 0.0005). Patients with target attainment (33-64 mg/L) within the first 24 h exhibited the lowest hospital mortality rates (13.9% [n = 23/166], p < 0.005). Those with target non-attainment demonstrated higher mortality rates (≤ 32 mg/L; 20.8% [n = 10/49] ≥ 64 mg/L; 29.4% [n = 79/269]). CONCLUSION TDM-guided CI of PIP is safe in critically ill patients and improves PK-target attainment. Exposure to defined PK-targets impacts patient mortality while lower and higher than intended SCs may influence the outcome of critically ill patients. Renal function and renal replacement therapy are main determinants of PK-target attainment. These results are only valid for CI of PIP and not for prolonged or intermittent bolus administration of PIP.
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146
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Sumi CD, Heffernan AJ, Lipman J, Roberts JA, Sime FB. What Antibiotic Exposures Are Required to Suppress the Emergence of Resistance for Gram-Negative Bacteria? A Systematic Review. Clin Pharmacokinet 2019; 58:1407-1443. [DOI: 10.1007/s40262-019-00791-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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147
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Minichmayr IK, Roberts JA, Frey OR, Roehr AC, Kloft C, Brinkmann A. Development of a dosing nomogram for continuous-infusion meropenem in critically ill patients based on a validated population pharmacokinetic model. J Antimicrob Chemother 2019; 73:1330-1339. [PMID: 29425283 DOI: 10.1093/jac/dkx526] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background Optimal antibiotic exposure is a vital but challenging prerequisite for achieving clinical success in ICU patients. Objectives To develop and externally validate a population pharmacokinetic model for continuous-infusion meropenem in critically ill patients and to establish a nomogram based on a routinely available marker of renal function. Methods A population pharmacokinetic model was developed in NONMEM® 7.3 based on steady-state meropenem concentrations (CSS) collected during therapeutic drug monitoring. Different serum creatinine-based markers of renal function were compared for their influence on meropenem clearance (the Cockcroft-Gault creatinine clearance CLCRCG, the CLCR bedside estimate according to Jelliffe, the Chronic Kidney Disease Epidemiology Collaboration equation and the four-variable Modification of Diet in Renal Disease equation). After validation of the pharmacokinetic model with independent data, a dosing nomogram was developed, relating renal function to the daily doses required to achieve selected target concentrations (4/8/16 mg/L) in 90% of the patients. Probability of target attainment was determined for efficacy (CSS ≥8 mg/L) and potentially increased likelihood of adverse drug reactions (CSS >32 mg/L). Results In total, 433 plasma concentrations (3.20-48.0 mg/L) from 195 patients (median/P0.05 - P0.95 at baseline: weight 77.0/55.0-114 kg, CLCRCG 63.0/19.6-168 mL/min) were used for model building. We found that CLCRCG best described meropenem clearance (CL = 7.71 L/h, CLCRCG = 80 mL/min). The developed model was successfully validated with external data (n = 171, 73 patients). According to the nomogram, daily doses of 910/1480/2050/2800/3940 mg were required to reach a target CSS = 8 mg/L in 90% of patients with CLCRCG = 20/50/80/120/180 mL/min, respectively. A low probability of adverse drug reactions (<0.5%) was associated with these doses. Conclusions A dosing nomogram was developed for continuous-infusion meropenem based on renal function in a critically ill population.
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Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany.,Graduate Research Training program PharMetrX, Freie Universitaet Berlin, Berlin, Germany, and Universitaet Potsdam, Potsdam, Germany
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Otto R Frey
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka C Roehr
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Alexander Brinkmann
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
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148
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Ehmann L, Zoller M, Minichmayr IK, Scharf C, Huisinga W, Zander J, Kloft C. Development of a dosing algorithm for meropenem in critically ill patients based on a population pharmacokinetic/pharmacodynamic analysis. Int J Antimicrob Agents 2019; 54:309-317. [PMID: 31229669 DOI: 10.1016/j.ijantimicag.2019.06.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/30/2019] [Accepted: 06/15/2019] [Indexed: 12/21/2022]
Abstract
Effective antibiotic dosing is vital for therapeutic success in critically ill patients. This work aimed to develop an algorithm to identify appropriate meropenem dosing in critically ill patients. Population pharmacokinetic (PK) modelling was performed in NONMEM®7.3 based on densely sampled meropenem serum samples (npatients = 48; nsamples = 1376) and included a systematic analysis of 27 pre-selected covariates to identify factors influencing meropenem exposure. Using Monte Carlo simulations newly considering the uncertainty of PK parameter estimates, standard meropenem dosing was evaluated with respect to attainment of the pharmacokinetic/pharmacodynamic (PK/PD) target and was compared with alternative infusion regimens (short-term, prolonged, continuous; daily dose, 2000-6000 mg). Subsequently, a dosing algorithm was developed to identify appropriate dosing regimens. The two-compartment population PK model included three factors influencing meropenem pharmacokinetics: the Cockcroft-Gault creatinine clearance (CLCRCG) on meropenem clearance; and body weight and albumin on the central and peripheral volume of distribution, respectively; of these, only CLCRCG was identified as a vital influencing factor on PK/PD target attainment. A three-level dosing algorithm was developed (considering PK parameter uncertainty), suggesting dosing regimens depending on renal function and the level (L) of knowledge about the infecting pathogen (L1, pathogen unknown; L2, pathogen known; L3(-MIC), pathogen and susceptibility known; L3(+MIC), MIC known). Whereas patients with higher CLCRCG and lower pathogen susceptibility required mainly intensified dosing regimens, lower than standard doses appeared sufficient for highly susceptible pathogens. In conclusion, a versatile meropenem dosing algorithm for critically ill patients is proposed, indicating appropriate dosing regimens based on patient- and pathogen-specific information.
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Affiliation(s)
- Lisa Ehmann
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; Graduate Research Training Program PharMetrX
| | - Michael Zoller
- Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; Graduate Research Training Program PharMetrX
| | - Christina Scharf
- Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Johannes Zander
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany.
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149
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Hagel S, Fiedler S, Hohn A, Brinkmann A, Frey OR, Hoyer H, Schlattmann P, Kiehntopf M, Roberts JA, Pletz MW. Therapeutic drug monitoring-based dose optimisation of piperacillin/tazobactam to improve outcome in patients with sepsis (TARGET): a prospective, multi-centre, randomised controlled trial. Trials 2019; 20:330. [PMID: 31171029 PMCID: PMC6554958 DOI: 10.1186/s13063-019-3437-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 05/10/2019] [Indexed: 12/25/2022] Open
Abstract
Background Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection with a hospital mortality in excess of 40%. Along with insufficient and delayed empirical antimicrobial therapy, inappropriate antimicrobial exposure has been identified to negatively affect patient outcomes. Receipt of prolonged infusion (i.e. extended or continuous infusion) of piperacillin/tazobactam (TZP) improves antimicrobial exposure and is associated with reduced mortality in patients with sepsis. Using therapeutic drug monitoring (TDM) with dosing tailored to the altered pharmacokinetics of the individual patient to avoid under- and overdosing may be a further strategy to improve patient outcomes. This current trial will address the question whether a TDM-guided therapy with TZP administered by continuous infusion will result in a greater resolution of organ dysfunction and hence better clinical outcome compared to continuous infusion of the total daily dose of TZP without TDM. Methods The study is an investigator-initiated, multi-centre, parallel-group, single-blinded, randomised controlled trial. The trial will be conducted in several centres across Germany. Adult patients (aged ≥ 18 years) with severe sepsis or septic shock will be eligible for study participation. Participants will be randomly assigned to receive either TZP by continuous infusion guided by daily TDM of piperacillin (experimental group) or by continuous infusion without TDM guidance (total daily dose in normal renal function 13.5 g TZP) (control group). The pharmacokinetic (PK)/pharmacodynamic (PD) target will be 100% f T>4MIC (percentage of time during a dosing interval that the free [f] drug concentration exceeds 4 times the minimum inhibitory concentration). The primary efficacy endpoint is the change in mean total Sequential Organ Failure Assessment score from day 1 after randomisation until day 10 or discharge from the intensive care unit or death, whichever comes first. Secondary outcomes include mortality, clinical cure, microbiological cure, overall antibiotic use, individual components of the primary outcome, adverse events and analysis of PK and (PD) indices. Discussion This trial will assess for the first time whether continuous infusion of TZP guided by daily TDM in patients with sepsis will result in a greater resolution of organ dysfunction and hence better clinical outcome compared to continuous infusion without TDM. Trial registration German Clinical Trials Register (GermanCTR), DRKS00011159. Registered on 10 October 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3437-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany. .,Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.
| | - Sandra Fiedler
- Center for Clinical Studies, Jena University Hospital, Jena, Germany
| | - Andreas Hohn
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto R Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Heike Hoyer
- Institute of Medical Statistics, Computer Sciences and Data Sciences, Jena University Hospital, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Data Sciences, Jena University Hospital, Jena, Germany
| | - Michael Kiehntopf
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany.,Department of Clinical Chemistry and Laboratory Medicine, Jena University Hospital, Jena, Germany.,Integrated Biobank Jena (IBBJ), Jena University Hospital, Jena, Germany
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, and School of Pharmacy, University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Mathias W Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
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150
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Dhaese SAM, Thooft ADJ, Farkas A, Lipman J, Verstraete AG, Stove V, Roberts JA, De Waele JJ. Early target attainment of continuous infusion piperacillin/tazobactam and meropenem in critically ill patients: A prospective observational study. J Crit Care 2019; 52:75-79. [PMID: 30986758 DOI: 10.1016/j.jcrc.2019.04.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate target attainment of empirically dosed continuous infusion piperacillin/tazobactam (TZP) and meropenem (MER) in critically ill patients. PATIENTS AND METHODS Patients were sampled on a daily basis. TZP or MER concentrations were evaluated during the first two days antibiotic therapy. The lower limit of the target range was defined as unbound concentrations equaling 4 times the epidemiological cutoff value of P. aeruginosa. The upper limit of the target range was based on the risk of toxicity, i.e. unbound concentrations >160 mg/L for TZP and > 45 mg/L for MER. Multivariable logistic regression was used to evaluate factors associated with target attainment. RESULTS Data from 253 patients were analyzed. Overall, 76/205 (37.1%) and 36/48 (75%) of the patients receiving TZP or MER respectively, attained target concentrations. In multivariable analysis, estimated creatinine clearance was identified as a risk factor for target non-attainment (OR 0.988, 95%CI [0.982;0.994]). Patients receiving MER were more likely to attain target concentrations compared with patients receiving TZP (OR 6.02, 95%CI [2.12;18.4]). CONCLUSION Target attainment of empiric antibiotic therapy in critically ill patients was low (37%) for TZP and moderate (75%) for MER, despite the use of a loading dose and despite optimization of the mode of infusion.
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Affiliation(s)
- Sofie A M Dhaese
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | | | - Andras Farkas
- Department of Pharmacy, Mount Sinai West Hospital, New York, United States.
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Alain G Verstraete
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
| | - Veronique Stove
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
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