101
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Awissi DK, Beauchamp A, Hébert E, Lavigne V, Munoz DL, Lebrun G, Savoie M, Fagnan M, Amyot J, Tétreault N, Robitaille R, Varin F, Lavallée C, Pichette V, Leblanc M. Pharmacokinetics of an extended 4-hour infusion of piperacillin-tazobactam in critically ill patients undergoing continuous renal replacement therapy. Pharmacotherapy 2016; 35:600-7. [PMID: 26095008 DOI: 10.1002/phar.1604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the pharmacokinetic and pharmacodynamic profiles of piperacillin-tazobactam administered as a 4-hour infusion in critically ill patients undergoing continuous renal replacement therapy (CRRT). DESIGN Prospective, observational, pharmacokinetic study. SETTING Intensive care unit of a tertiary care hospital in Montréal, Canada. PATIENTS Twenty critically ill adults who were undergoing continuous venovenous hemodiafiltration and receiving a 4-hour infusion of piperacillin 4 g-tazobactam 0.5 g every 8 hours for a documented or suspected infection. INTERVENTION Blood samples were collected every hour over an 8-hour dosing interval. Prefilter and postfilter blood samples, and effluent and urine samples were also collected. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion of patients who achieved an unbound piperacillin plasma concentration above a target minimum inhibitory concentration (MIC) of 64 mg/L (MIC that inhibits 90% of isolates for Pseudomonas aeruginosa) for at least 50% of the dosing interval; 18 (90%) of the 20 patients achieved this outcome. In all patients, the free piperacillin concentrations were above the Pseudomonas aeruginosa breakpoint of 16 mg/L for the entire time interval. Regarding piperacillin pharmacokinetic parameters, the median (interquartile range) minimum unbound plasma concentration was 65.15 mg/L (51.30-89.30), maximum unbound plasma concentration was 141.3 mg/L (116.75-173.90), sieving coefficient was 0.809 (0.738-0.938), total clearance was 65.82 ml/minute (53.79-102.87), and renal clearance was 0.16 ml/minute (0.05-3.04). The median CRRT dose was 32.0 ml/kg/h (25.0-39.8). CONCLUSIONS Administration of a 4-hour infusion of piperacillin-tazobactam was associated with a favorable pharmacodynamic profile in patients undergoing CRRT. Concentrations associated with maximal activity were attained in our patients.
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Affiliation(s)
- Don-Kelena Awissi
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Annie Beauchamp
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Elisabeth Hébert
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Viviane Lavigne
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Danya Lucia Munoz
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Geneviève Lebrun
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Michel Savoie
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Mylène Fagnan
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Julie Amyot
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Nicolas Tétreault
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Robert Robitaille
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - France Varin
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Christian Lavallée
- Department of Infectious Diseases and Medical Microbioloy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Vincent Pichette
- Department of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Martine Leblanc
- Department of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.,Intensive Care Unit, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
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102
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Honore PM, Spapen HD. Cefepime-induced neurotoxicity in critically ill patients undergoing continuous renal replacement therapy: beware of dose reduction! CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:455. [PMID: 26718619 PMCID: PMC4699351 DOI: 10.1186/s13054-015-1179-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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103
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Wong WT, Choi G, Gomersall CD, Lipman J. To increase or decrease dosage of antimicrobials in septic patients during continuous renal replacement therapy: the eternal doubt. Curr Opin Pharmacol 2015; 24:68-78. [PMID: 26667969 DOI: 10.1016/j.coph.2015.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 02/04/2023]
Abstract
Critical illness, acute renal failure and continuous renal replacement therapy (CRRT) are associated with changes in pharmacokinetics. Initial antibiotic dose should be based on published volume of distribution and generally be at least the standard dose, as volume of distribution is usually unchanged or increased. Subsequent doses should be based on total clearance. Total clearance varies with the CRRT clearance which mainly depends on effluent flow rate, sieving coefficient/saturation coefficient. As antibiotic clearance by healthy kidneys is usually higher than clearance by CRRT, except for colistin, subsequent doses should generally be lower than given to patients without renal dysfunction. In the future therapeutic drug monitoring, together with sophisticated pharmacokinetic models taking into account the pharmacokinetic variability, may enable more appropriate individualized dosing.
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Affiliation(s)
- Wai-Tat Wong
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gordon Choi
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles D Gomersall
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Jeffrey Lipman
- Academic Discipline of Anaesthesiology & Critical Care, The University of Queensland and Queensland University of Technology, Queensland, Australia
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104
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Cotta MO, Roberts JA, Lipman J. Antibiotic dose optimization in critically ill patients. Med Intensiva 2015; 39:563-72. [PMID: 26415688 DOI: 10.1016/j.medin.2015.07.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/10/2015] [Accepted: 07/21/2015] [Indexed: 12/19/2022]
Abstract
The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.
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Affiliation(s)
- M O Cotta
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - J Lipman
- Burns Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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105
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Nehus EJ, Mizuno T, Cox S, Goldstein SL, Vinks AA. Pharmacokinetics of meropenem in children receiving continuous renal replacement therapy: Validation of clinical trial simulations. J Clin Pharmacol 2015. [PMID: 26222329 DOI: 10.1002/jcph.601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Meropenem is frequently prescribed in critically ill children receiving continuous renal replacement therapy (CRRT). We previously used clinical trial simulations to evaluate dosing regimens of meropenem in this population and reported that a dose of 20 mg/kg every 12 hours optimizes target attainment. Meropenem pharmacokinetics were investigated in this prospective, open-label study to validate our previous in silico predictions. Seven patients received meropenem (13.8-22 mg/kg) administered intravenously every 12 hours as part of standard care. A mean dose of 18.6 mg/kg of meropenem was administered, resulting in a mean peak concentration of 80.1 μg/mL. Meropenem volume of distribution was 0.35 ± 0.085 L/kg. CRRT clearance was 40.2 ± 6.6 mL/(min · 1.73 m(2) ) and accounted for 63.4% of the total clearance of 74.8 ± 36.9 mL/(min · 1.73 m(2) ). Simulations demonstrated that a dose of 20 mg/kg every 12 hours resulted in a time above the minimum inhibitory concentration (%fT > MIC) of 100% in 5 out of 7 subjects, with a %fT > MIC of 93% and 43% in the remaining 2 subjects. We conclude that CRRT contributed significantly to the total clearance of meropenem. A dosing regimen of 20 mg/kg achieved good target attainment in critically ill children receiving CRRT, which is consistent with our previously published in silico predictions.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shareen Cox
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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106
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Ulldemolins M, Soy D, Llaurado-Serra M, Vaquer S, Castro P, Rodríguez AH, Pontes C, Calvo G, Torres A, Martín-Loeches I. Meropenem population pharmacokinetics in critically ill patients with septic shock and continuous renal replacement therapy: influence of residual diuresis on dose requirements. Antimicrob Agents Chemother 2015; 59:5520-8. [PMID: 26124172 PMCID: PMC4538468 DOI: 10.1128/aac.00712-15] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/20/2015] [Indexed: 12/29/2022] Open
Abstract
Meropenem dosing in critically ill patients with septic shock and continuous renal replacement therapy (CRRT) is complex, with the recommended maintenance doses being 500 mg to 1,000 mg every 8 h (q8h) to every 12 h. This multicenter study aimed to describe the pharmacokinetics (PKs) of meropenem in this population to identify the sources of PK variability and to evaluate different dosing regimens to develop recommendations based on clinical parameters. Thirty patients with septic shock and CRRT receiving meropenem were enrolled (153 plasma samples were tested). A population PK model was developed with data from 24 patients and subsequently validated with data from 6 patients using NONMEM software (v.7.3). The final model was characterized by CL = 3.68 + 0.22 · (residual diuresis/100) and V = 33.00 · (weight/73)(2.07), where CL is total body clearance (in liters per hour), residual diuresis is the volume of residual diuresis (in milliliters per 24 h), and V is the apparent volume of distribution (in liters). CRRT intensity was not identified to be a CL modifier. Monte Carlo simulations showed that to maintain concentrations of the unbound fraction (fu ) of drug above the MIC of the bacteria for 40% of dosing interval T (referred to as 40% of the ƒ uT >MIC), a meropenem dose of 500 mg q8h as a bolus over 30 min would be sufficient regardless of the residual diuresis. If 100% of the ƒ uT >MIC was chosen as the target, oligoanuric patients would require 500 mg q8h as a bolus over 30 min for the treatment of susceptible bacteria (MIC < 2 mg/liter), while patients with preserved diuresis would require the same dose given as an infusion over 3 h. If bacteria with MICs close to the resistance breakpoint (2 to 4 mg/liter) were to be treated with meropenem, a dose of 500 mg every 6 h would be necessary: a bolus over 30 min for oligoanuric patients and an infusion over 3 h for patients with preserved diuresis. Our results suggest that residual diuresis may be an easy and inexpensive tool to help with titration of the meropenem dose and infusion time in this challenging population.
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Affiliation(s)
- Marta Ulldemolins
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Critical Care Department, Sabadell Hospital, University Institute Parc Taulí-Universitat Autònoma de Barcelona (UAB), Sabadell, Spain Universitat de Barcelona (UB), Barcelona, Spain
| | - Dolors Soy
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Universitat de Barcelona (UB), Barcelona, Spain Pharmacy Department, Hospital Clínic de Barcelona, Barcelona, Spain Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mireia Llaurado-Serra
- Nursing Department, Universitat Rovira i Virgili (URV), Tarragona, Spain Critical Care Department, Joan XXIII University Hospital, Institut d'Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, Tarragona, Spain
| | - Sergi Vaquer
- Critical Care Department, Sabadell Hospital, University Institute Parc Taulí-Universitat Autònoma de Barcelona (UAB), Sabadell, Spain
| | - Pedro Castro
- Universitat de Barcelona (UB), Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Medical Critical Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alejandro H Rodríguez
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Critical Care Department, Joan XXIII University Hospital, Institut d'Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, Tarragona, Spain
| | - Caridad Pontes
- Department of Clinical Pharmacology, Sabadell Hospital, Institut Universitari Parc Taulí-Universitat Autònoma de Barcelona (UAB), Sabadell, Spain Pharmacology, Therapeutics and Toxicology Department, Universitat Autònoma de Barcelona (UAB), Sabadell, Spain
| | - Gonzalo Calvo
- Universitat de Barcelona (UB), Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Department of Clinical Pharmacology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antoni Torres
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Universitat de Barcelona (UB), Barcelona, Spain Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Respiratory Critical Care Unit, Pneumology Department, Institut Clínic del Tòrax, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ignacio Martín-Loeches
- Critical Care Department, Sabadell Hospital, University Institute Parc Taulí-Universitat Autònoma de Barcelona (UAB), Sabadell, Spain Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Multidisciplinary Intensive Care Research Organization (MICRO), Critical Care Department, St. James University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
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107
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Leventhal TM, Liu KD. What a Nephrologist Needs to Know About Acute Liver Failure. Adv Chronic Kidney Dis 2015; 22:376-81. [PMID: 26311599 DOI: 10.1053/j.ackd.2015.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/16/2015] [Accepted: 06/16/2015] [Indexed: 12/30/2022]
Abstract
Although relatively rare in the United States, acute liver failure (ALF) is associated with very high rates of morbidity and mortality. A leading cause of morbidity and mortality is cerebral edema and intracranial hypertension. Hypothermia, osmotic diuretics, and hyperosmolar therapy are commonly used to manage these complications; however, when these are ineffective, renal replacement therapy may be needed for volume management. Acute kidney injury is a common complication of ALF and may arise from a number of etiologies, including hepatorenal syndrome and acute tubular necrosis. Acute kidney injury is most common in patients who develop ALF because of acetaminophen toxicity or ischemia. With regard to renal replacement therapy, we will review specific considerations relevant to the management of the patient with ALF.
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108
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Can we use an ex vivo continuous hemofiltration model to describe the adsorption and elimination of meropenem and piperacillin? Int J Artif Organs 2015; 38:419-24. [PMID: 26349527 DOI: 10.5301/ijao.5000422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine the adsorption and elimination characteristics of meropenem and piperacillin during simulated continuous renal replacement therapy (CRRT), and to compare the observed data from this ex vivo study with previous data from clinical studies. METHOD This was an experimental study utilizing a modified CRRT circuit and polysulfone membrane (1.2 m2), circulated with a blood-crystalloid mixture. Adsorption onto the CRRT circuit was tested over a 4-h period, and clearance was assessed separately using variable continuous hemofiltration settings. RESULTS A rapid 9% reduction in circulating meropenem and piperacillin concentrations was observed at approximately 0.5 and 1.0 h for each antibiotic, respectively. The post-dilution setting was associated with a significantly higher sieving coefficient (Sc) and filter clearance (CLfilter) (mean ± SD) (Sc 1.14 ± 0.10 versus 1.06 ± 0.04; CLfilter 19.05 ± 1.63 versus 17.59 ± 0.62 ml/min, P values < 0.05) for meropenem. No significant differences were observed for piperacillin pharmacokinetics. Clinically comparable Sc data were observed between data obtained from the ex vivo study and data from previous clinical studies, for both antibiotics. CONCLUSIONS Meropenem and piperacillin appear to be rapidly adsorbed into the CRRT circuit, and the delivery site of fluid replacement significantly influences meropenem pharmacokinetics. However, these findings are likely to be clinically insignificant and not affect dosing requirements. This ex vivo method could be a surrogate for future clinical pharmacokinetic studies of CRRT. Further research is required to explore the applicability of the ex vivo method to further characterize antibiotic pharmacokinetics during CRRT.
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109
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Gharbi M, Moore LSP, Gilchrist M, Thomas CP, Bamford K, Brannigan ET, Holmes AH. Forecasting carbapenem resistance from antimicrobial consumption surveillance: Lessons learnt from an OXA-48-producing Klebsiella pneumoniae outbreak in a West London renal unit. Int J Antimicrob Agents 2015; 46:150-6. [PMID: 25979640 PMCID: PMC4526541 DOI: 10.1016/j.ijantimicag.2015.03.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 11/28/2022]
Abstract
This study aimed to forecast the incidence rate of carbapenem resistance and to assess the impact of an antimicrobial stewardship intervention using routine antimicrobial consumption surveillance data. Following an outbreak of OXA-48-producing Klebsiella pneumoniae (January 2008-April 2010) in a renal cohort in London, a forecasting ARIMA model was derived using meropenem consumption data [defined daily dose per 100 occupied bed-days (DDD/100OBD)] from 2005-2014 as a predictor of the incidence rate of OXA-48-producing organisms (number of new cases/year/100,000OBD). Interrupted times series assessed the impact of meropenem consumption restriction as part of the outbreak control. Meropenem consumption at lag -1 year (the preceding year), highly correlated with the incidence of OXA-48-producing organisms (r=0.71; P=0.005), was included as a predictor within the forecasting model. The number of cases/100,000OBD for 2014-2015 was estimated to be 4.96 (95% CI 2.53-7.39). Analysis of meropenem consumption pre- and post-intervention demonstrated an increase of 7.12 DDD/100OBD/year (95% CI 2.97-11.27; P<0.001) in the 4 years preceding the intervention, but a decrease thereafter. The change in slope was -9.11 DDD/100OBD/year (95% CI -13.82 to -4.39). Analysis of alternative antimicrobials showed a significant increase in amikacin consumption post-intervention from 0.54 to 3.41 DDD/100OBD/year (slope +0.72, 95% CI 0.29-1.15; P=0.01). Total antimicrobials significantly decreased from 176.21 to 126.24 DDD/100OBD/year (P=0.05). Surveillance of routinely collected antimicrobial consumption data may provide a key warning indicator to anticipate increased incidence of carbapenem-resistant organisms. Further validation using real-time data is needed.
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Affiliation(s)
- M Gharbi
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK.
| | - L S P Moore
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
| | - M Gilchrist
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
| | - C P Thomas
- Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
| | - K Bamford
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
| | - E T Brannigan
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
| | - A H Holmes
- The National Centre for Infection Prevention and Management, Imperial College London, Du Cane Road, London W12 ONN, UK; Imperial College Healthcare NHS Trust, Du Cane Road, London W12 OHS, UK
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110
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Carlier M, Taccone FS, Beumier M, Seyler L, Cotton F, Jacobs F, Roberts JA. Population pharmacokinetics and dosing simulations of cefepime in septic shock patients receiving continuous renal replacement therapy. Int J Antimicrob Agents 2015. [PMID: 26208469 DOI: 10.1016/j.ijantimicag.2015.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The aim of this study was to describe the population pharmacokinetics of cefepime in septic shock patients requiring continuous renal replacement therapy and to determine whether current or alternative dosing regimens can achieve PK/PD targets. In this observational PK study, 62 samples from 13 patients were analysed using non-linear mixed-effects modelling. Different dosing regimens were evaluated using Monte Carlo simulations with ultrafiltration flow rates (UFRs) of 1000, 1500 and 2000 mL/h. The probability of target attainment was calculated against a conservative (60% T(>MIC)) and a higher PK/PD target (100% T(>MIC)) against an MIC of 8 mg/L, the clinical susceptibility breakpoint for Pseudomonas aeruginosa. A one-compartment model with between-subject variability (BSV) on clearance and volume of distribution (V(d)) described the data adequately. UFR was supported as a covariate on both parameters. Typical values for clearance and V(d) were 4.4L/h (BSV 37%) and 40.9L (BSV 20%), respectively. Dosing simulations showed failure to achieve both a conservative and a higher PK/PD target using a dose of 1g q12h for patients treated with a high UFR (≥1500 mL/h). The dose of 2g q8h or 1g q6h leads to optimal target attainment for high UFR. One gram q8h is optimal for low UFR (≤1000 mL/h). We found important variability in PK parameters. Dosing simulations show that a dose of 2g q8h or 1g q6h is needed to ensure rapid achievement of adequate levels if the UFR is ≥1500 mL/h and 1g q8h for low UFR (≤1000 mL/h).
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Affiliation(s)
- Mieke Carlier
- Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium; Department of Critical Care, Ghent University, Ghent, Belgium.
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Majorie Beumier
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lucie Seyler
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Frédéric Cotton
- Department of Clinical Chemistry, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Herston, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia; Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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111
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Keller F, Schröppel B, Ludwig U. Pharmacokinetic and pharmacodynamic considerations of antimicrobial drug therapy in cancer patients with kidney dysfunction. World J Nephrol 2015; 4:330-344. [PMID: 26167456 PMCID: PMC4491923 DOI: 10.5527/wjn.v4.i3.330] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/12/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Patients with cancer have a high inherent risk of infectious complications. In addition, the incidence of acute and chronic kidney dysfunction rises in this population. Anti-infective drugs often require dosing modifications based on an estimate of kidney function, usually the glomerular filtration rate (GFR). However, there is still no preferential GFR formula to be used, and in acute kidney injury there is always a considerable time delay between true kidney function and estimated GFR. In most cases, the anti-infective therapy should start with an immediate and high loading dose. Pharmacokinetic as well as pharmacodynamic principles must be applied for further dose adjustment. Anti-infective drugs with time-dependent action should be given with the target of high trough concentrations (e.g., beta lactam antibiotics, penems, vancomycin, antiviral drugs). Anti-infective drugs with concentration-dependent action should be given with the target of high peak concentrations (e.g., aminoglycosides, daptomycin, colistin, quinolones). Our group created a pharmacokinetic database, called NEPharm, hat serves as a reference to obtain reliable dosing regimens of anti-infective drugs in kidney dysfunction as well as renal replacement therapy. To avoid the risk of either too low or too infrequent peak concentrations, we prefer the eliminated fraction rule for dose adjustment calculations.
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Ronco C, Ricci Z, De Backer D, Kellum JA, Taccone FS, Joannidis M, Pickkers P, Cantaluppi V, Turani F, Saudan P, Bellomo R, Joannes-Boyau O, Antonelli M, Payen D, Prowle JR, Vincent JL. Renal replacement therapy in acute kidney injury: controversy and consensus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:146. [PMID: 25887923 PMCID: PMC4386097 DOI: 10.1186/s13054-015-0850-8] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Renal replacement therapies (RRTs) represent a cornerstone in the management of severe acute kidney injury. This area of intensive care and nephrology has undergone significant improvement and evolution in recent years. Continuous RRTs have been a major focus of new technological and treatment strategies. RRT is being used increasingly in the intensive care unit, not only for renal indications but also for other organ-supportive strategies. Several aspects related to RRT are now well established, but others remain controversial. In this review, we review the available RRT modalities, covering technical and clinical aspects. We discuss several controversial issues, provide some practical recommendations, and where possible suggest a research agenda for the future.
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Affiliation(s)
- Claudio Ronco
- Department Nephrology Dialysis & Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Viale Rodolfi, 36100, Vicenza, Italy.
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Daniel De Backer
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Michael Joannidis
- Division of Emergency and Intensive Care Medicine, Department of Internal Medicine, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Centre, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, University of Torino, Azienda Ospedaliera Universitaria 'Città della Salute e della Scienza di Torino Presidio Molinette', Corso Bramante 88, 10126, Turin, Italy.
| | - Franco Turani
- Department of Intensive Care, Aurelia Hospital and European Hospital, Via Portuense 694, 00416, Rome, Italy.
| | - Patrick Saudan
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, 4 rue Gabrielle Perret-Gentil, CH 1211, Geneva, Switzerland.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.
| | - Olivier Joannes-Boyau
- Centre Hospitalier Universitaire (CHU) de Bordeaux, Service d'Anesthésie-Réanimation 2, Avenue de Magellan, F-33600, Pessac, France.
| | - Massimo Antonelli
- Università Cattolica del Sacro Cuore - Policlinico Universitario A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris, 7 Denis Diderot, 75475, Paris, Cedex 10, France.
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health, Whitechapel Road, London, E1 1BB, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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Jamal JA, Roberts DM, Udy AA, Mat-Nor MB, Mohamad-Nor FS, Wallis SC, Lipman J, Roberts JA. Pharmacokinetics of piperacillin in critically ill patients receiving continuous venovenous haemofiltration: A randomised controlled trial of continuous infusion versus intermittent bolus administration. Int J Antimicrob Agents 2015; 46:39-44. [PMID: 25881872 DOI: 10.1016/j.ijantimicag.2015.02.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/26/2022]
Abstract
Here we describe the pharmacokinetics of piperacillin administered by continuous infusion (CI) versus intermittent bolus (IB) dosing in critically ill patients receiving continuous venovenous haemofiltration (CVVH) and compare the frequency of pharmacodynamic/pharmacokinetic (PK/PD) target attainment with each dosing strategy. This was a prospective pharmacokinetic trial in 16 critically ill patients with severe sepsis or septic shock undergoing CVVH and randomised to receive either CI or IB administration of a standard daily dose of piperacillin/tazobactam (11.25g/day on Day 1 followed by 9g/day). Serial blood samples were measured on two occasions. Piperacillin pharmacokinetics were calculated using a non-compartmental approach. Blood concentrations were compared with established PK/PD targets. On occasion 1 (Days 1-3 of therapy), IB administration resulted in significantly higher piperacillin peak concentrations (169 vs. 89mg/L; P=0.002), whereas significantly higher steady-state concentrations were observed in CI patients (83 vs. 57mg/L; P=0.04). Total clearance and clearance not mediated by CVVH were significantly higher with CI administration [median (interquartile range), 1.0 (0.7-1.1) and 0.8 (0.6-1.0)mL/kg/min; P=0.001 and 0.001, respectively]. The estimated unbound piperacillin concentrations were four times above the target susceptibility breakpoint (16mg/L) for the entire dosing interval (100%fT>4xMIC) in 87.5% of patients receiving CI administration (sampling occasion 1), compared with 62.5% of IB patients achieving the desired target (50%fT>4xMIC). Compared with IB dosing, and despite similar CVVH settings, CI administration of piperacillin results in a pharmacokinetic profile that may optimise outcomes for less susceptible pathogens.
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Affiliation(s)
- Janattul-Ain Jamal
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Darren M Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew A Udy
- Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
| | - Mohd-Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, Kulliyyah of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | | | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Pharmacy, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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114
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Roberts DM, Liu X, Roberts JA, Nair P, Cole L, Roberts MS, Lipman J, Bellomo R. A multicenter study on the effect of continuous hemodiafiltration intensity on antibiotic pharmacokinetics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:84. [PMID: 25881576 PMCID: PMC4404619 DOI: 10.1186/s13054-015-0818-8] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/17/2015] [Indexed: 12/02/2022]
Abstract
Introduction Continuous renal replacement therapy (CRRT) may alter antibiotic pharmacokinetics and increase the risk of incorrect dosing. In a nested cohort within a large randomized controlled trial, we assessed the effect of higher (40 mL/kg per hour) and lower (25 mL/kg per hour) intensity CRRT on antibiotic pharmacokinetics. Methods We collected serial blood samples to measure ciprofloxacin, meropenem, piperacillin-tazobactam, and vancomycin levels. We calculated extracorporeal clearance (CL), systemic CL, and volume of distribution (Vd) by non-linear mixed-effects modelling. We assessed the influence of CRRT intensity and other patient factors on antibiotic pharmacokinetics. Results We studied 24 patients who provided 179 pairs of samples. Extracorporeal CL increased with higher-intensity CRRT but the increase was significant for vancomycin only (mean 28 versus 22 mL/minute; P = 0.0003). At any given prescribed CRRT effluent rate, extracorporeal CL of individual antibiotics varied widely, and the effluent-to-plasma concentration ratio decreased with increasing effluent flow. Overall, systemic CL varied to a greater extent than Vd, particularly for meropenem, piperacillin, and tazobactam, and large intra-individual differences were also observed. CRRT dose did not influence overall (systemic) CL, Vd, or half-life. The proportion of systemic CL due to CRRT varied widely and was high in some cases. Conclusions In patients receiving CRRT, there is great variability in antibiotic pharmacokinetics, which complicates an empiric approach to dosing and suggests the need for therapeutic drug monitoring. More research is required to investigate the apparent relative decrease in clearance at higher CRRT effluent rates. Trial registration ClinicalTrials.gov NCT00221013. Registered 14 September 2005. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0818-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Darren M Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Xin Liu
- Therapeutics Research Centre, School of Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland, 4102, Australia. .,University of South Australia, City East Campus, GPO Box 2471, Adelaide, South Australia, 5000, Australia. .,The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia. .,Department of Intensive Care Medicine, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital, Victoria Street, Darlinghurst, NSW, 2010, Australia.
| | - Louise Cole
- Intensive Care Unit, Nepean Hospital, Derby Street, Kingswood, NSW, 2747, Australia.
| | - Michael S Roberts
- Therapeutics Research Centre, School of Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland, 4102, Australia. .,University of South Australia, City East Campus, GPO Box 2471, Adelaide, South Australia, 5000, Australia. .,The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia.
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia. .,Department of Intensive Care Medicine, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
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115
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How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy? Diagn Microbiol Infect Dis 2015; 82:92-103. [PMID: 25698632 DOI: 10.1016/j.diagmicrobio.2015.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 12/28/2014] [Accepted: 01/25/2015] [Indexed: 12/30/2022]
Abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
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116
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Anti-infective drugs during continuous hemodialysis - using the bench to learn what to do at the bedside. Int J Artif Organs 2015; 38:17-22. [PMID: 25633891 DOI: 10.5301/ijao.5000377] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE The main objective of this study was to investigate the clearance of 11 selected anti-infectives in an in vitro model of continuous veno-venous hemodialysis (CVVHD), in order to suggest rational dosing strategies for clinical practice. METHODS Ceftazidime, ciprofloxacin, flucloxacillin, gentamicin, linezolid, meropenem, metronidazole, piperacillin, rifampicin, vancomycin and voriconazole were studied in two different solvents (sodium chloride 0.9% and HSA 5%) using a multifiltrate dialysis device by Fresenius Medical Care (Bad Homburg, Germany). For each solution, prefilter, postfilter, and dialysate samples were drawn simultaneously during one hour of dialysis and were assayed. RESULTS The clearance of all drugs except rifampicin in sodium chloride 0.9% was comparable (mean 1.76 ± 0.11 l/h). The clearance of these agents in human serum albumin solution 5% was reduced by between 5.3% and 72.2%. The unbound drug fraction correlated with a lower clearance in HSA 5% (Pearson correlation coefficient r = 0.933; p = 0.00008). No correlation between clearance in HSA 5% and the drugs' molecular weight was found (Pearson correlation coefficient r = 0.388; p = 0.268). Rifampicin was detected to bind to the surface of the polysulfone filter used. Dialysis clearance of ceftazidime, gentamicin, linezolid, meropenem, metronidazole, piperacillin and vancomycin during CVVHD accounted for over 25% of the total body clearance of population pharmacokinetic data for renally impaired patients. CONCLUSIONS The results from this study highlight that dose adaptations are needed for most of the drugs under investigation for patients undergoing CVVHD. In combination with polysulfone filters, rifampicin should be used with care in this setting.
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Jamal JA, Mat-Nor MB, Mohamad-Nor FS, Udy AA, Wallis SC, Lipman J, Roberts JA. Pharmacokinetics of meropenem in critically ill patients receiving continuous venovenous haemofiltration: A randomised controlled trial of continuous infusion versus intermittent bolus administration. Int J Antimicrob Agents 2015; 45:41-5. [DOI: 10.1016/j.ijantimicag.2014.09.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/04/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
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Donadello K, Antonucci E, Cristallini S, Roberts JA, Beumier M, Scolletta S, Jacobs F, Rondelet B, de Backer D, Vincent JL, Taccone FS. β-Lactam pharmacokinetics during extracorporeal membrane oxygenation therapy: A case-control study. Int J Antimicrob Agents 2014; 45:278-82. [PMID: 25542059 DOI: 10.1016/j.ijantimicag.2014.11.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/03/2014] [Indexed: 11/19/2022]
Abstract
Most adult patients receiving extracorporeal membrane oxygenation (ECMO) require antibiotic therapy, however the pharmacokinetics of β-lactams have not been well studied in these conditions. In this study, data from all patients receiving ECMO support and meropenem (MEM) or piperacillin/tazobactam (TZP) were reviewed. Drug concentrations were measured 2h after the start of a 30-min infusion and just before the subsequent dose. Therapeutic drug monitoring (TDM) results in ECMO patients were matched with those in non-ECMO patients for (i) drug regimen, (ii) renal function, (iii) total body weight, (iv) severity of organ dysfunction and (v) age. Drug concentrations were considered adequate if they remained 4-8× the clinical MIC breakpoint for Pseudomonas aeruginosa for 50% (TZP) or 40% (MEM) of the dosing interval. A total of 41 TDM results (27 MEM; 14 TZP) were obtained in 26 ECMO patients, with 41 matched controls. There were no significant differences in serum concentrations or pharmacokinetic parameters between ECMO and non-ECMO patients, including Vd [0.38 (0.27-0.68) vs. 0.46 (0.33-0.79)L/kg; P=0.37], half-life [2.6 (1.8-4.4) vs. 2.9 (1.7-3.7)h; P=0.96] and clearance [132 (66-200) vs. 141 (93-197)mL/min; P=0.52]. The proportion of insufficient (13/41 vs. 12/41), adequate (15/41 vs. 19/41) and excessive (13/41 vs. 10/41) drug concentrations was similar in ECMO and non-ECMO patients. Achievement of target concentrations of these β-lactams was poor in ECMO and non-ECMO patients. The influence of ECMO on MEM and TZP pharmacokinetics does not appear to be significant.
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Affiliation(s)
- Katia Donadello
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Elio Antonucci
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Stefano Cristallini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marjorie Beumier
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Sabino Scolletta
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Benoit Rondelet
- Department of Thoracic Surgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Daniel de Backer
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.
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Jiang SP, Xu YY, Wu WF, Zhang XG, Lu XY, Xiao YH, Liang WF, Chen J. Improving antimicrobial dosing in critically ill patients receiving continuous venovenous hemofiltration and the effect of pharmacist dosing adjustment. Eur J Intern Med 2014; 25:930-5. [PMID: 25153537 DOI: 10.1016/j.ejim.2014.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/28/2014] [Accepted: 08/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Appropriate antimicrobial dosing for patients receiving continuous venovenous hemofiltration (CVVH) is complex. Pharmacist participation in antimicrobial dosing adjustment for patients receiving CVVH may be advantageous. METHODS A comparative study was performed in a China hospital intensive care unit (ICU).Patients receiving CVVH in the intervention group received antimicrobial dosing adjustment service by pharmacists from January 2012 to June 2012, whereas patients in the control group received routine medical care between July 2012 and December 2012. The primary outcomes including patients' length of ICU stay, mortality in ICU, ICU hospitalization costs, and the occurrence of adverse drug events (ADEs) were then compared. RESULTS 87 and 93 patients were included in the control and intervention groups. During the intervention period, pharmacists made 256 antimicrobial dosing adjustment recommendations for 93 enrolled patients receiving CVVH, of which 224 (87.5%) recommendations were accepted by physicians. Changing in CVVH-related variables (175, 68.4%) were the most common risk factors for dosing errors, whereas β-lactams (131, 51.2%) were the most frequency of antimicrobials associated with dosing errors. Compared with the control group, pharmacist dosing adjustment resulted in £1637.7 cost savings per patient, and 2.36 times reduction of antimicrobial-related adverse drug events (ADEs) (11 vs 26, P=0.002), while length of ICU stay and mortality in ICU showed no significant difference (P>0.05). CONCLUSIONS The involvement of pharmacist to participate in the ICU team rounds for patients receiving CVVH is associated with cost savings and reduction of ADEs. Hospital may consider employing ICU pharmacists.
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Affiliation(s)
- Sai-Ping Jiang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Yan-Yan Xu
- Department of Pharmacy, Lishui central Hospital, 289 Kuocang Road, Lishui 323000, P.R. China
| | - Wei-Fang Wu
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Xing-Guo Zhang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Xiao-Yang Lu
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Yong-Hong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, P.R. China
| | - Wei-Feng Liang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, P.R. China
| | - Jian Chen
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China.
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Timsit JF, Soubirou JF, Voiriot G, Chemam S, Neuville M, Mourvillier B, Sonneville R, Mariotte E, Bouadma L, Wolff M. Treatment of bloodstream infections in ICUs. BMC Infect Dis 2014; 14:489. [PMID: 25431091 PMCID: PMC4289315 DOI: 10.1186/1471-2334-14-489] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022] Open
Abstract
Bloodstream infections (BSIs) are frequent in ICU and is a prognostic factor of severe sepsis. Community acquired BSIs usually due to susceptible bacteria should be clearly differentiated from healthcare associated BSIs frequently due to resistant hospital strains. Early adequate treatment is key and should use guidelines and direct examination of samples performed from the infectious source. Previous antibiotic therapy knowledge, history of multi-drug resistant organism (MDRO) carriage are other major determinants of first choice antimicrobials in heathcare-associated and nosocomial BSIs. Initial antimicrobial dose should be adapted to pharmacokinetic knowledge. In general, a high dose is recommended at the beginning of treatment. If MDRO is suspected combination antibiotic therapy is mandatory because it increase the spectrum of treatment. Most of time, combination should be pursued no more than 2 to 5 days. Given the negative impact of useless antimicrobials, maximal effort should be done to decrease the antibiotic selection pressure. De-escalation from a broad spectrum to a narrow spectrum antimicrobial decreases the antibiotic selection pressure without negative impact on mortality. Duration of therapy should be shortened as often as possible especially when organism is susceptible, when the infection source has been totally controlled.
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121
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Wong G, Sime FB, Lipman J, Roberts JA. How do we use therapeutic drug monitoring to improve outcomes from severe infections in critically ill patients? BMC Infect Dis 2014; 14:288. [PMID: 25430961 PMCID: PMC4289211 DOI: 10.1186/1471-2334-14-288] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/23/2014] [Indexed: 11/16/2022] Open
Abstract
High mortality and morbidity rates associated with severe infections in the critically ill continue to be a significant issue for the healthcare system. In view of the diverse and unique pharmacokinetic profile of drugs in this patient population, there is increasing use of therapeutic drug monitoring (TDM) in attempt to optimize the exposure of antibiotics, improve clinical outcome and minimize the emergence of antibiotic resistance. Despite this, a beneficial clinical outcome for TDM of antibiotics has only been demonstrated for aminoglycosides in a general hospital patient population. Clinical outcome studies for other antibiotics remain elusive. Further, there is significant variability among institutions with respect to the practice of TDM including the selection of patients, sampling time for concentration monitoring, methodologies of antibiotic assay, selection of PK/PD targets as well as dose optimisation strategies. The aim of this paper is to review the available evidence relating to practices of antibiotic TDM, and describe how TDM can be applied to potentially improve outcomes from severe infections in the critically ill.
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Affiliation(s)
| | | | | | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
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Hites M, Dell'Anna AM, Scolletta S, Taccone FS. The challenges of multiple organ dysfunction syndrome and extra-corporeal circuits for drug delivery in critically ill patients. Adv Drug Deliv Rev 2014; 77:12-21. [PMID: 24842474 DOI: 10.1016/j.addr.2014.05.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/01/2014] [Accepted: 05/07/2014] [Indexed: 12/25/2022]
Abstract
The multiple organ dysfunction syndrome (MODS) is characterized by more than one organ system failing, especially during critical illness. MODS is the leading cause of morbidity and mortality in current ICU practice; moreover, multiple organ dysfunction, especially liver and kidneys, may significantly affect the pharmacokinetics (PKs) of different drugs that are currently administered in critically ill patients. These PK alterations may either result in insufficient drug concentrations to achieve the desired effects or in blood and tissue accumulation, with the development of serious adverse events. The use of extra-corporeal circuits, such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), may further contribute to PKs changes in this patients' population. In this review, we have described the main PK changes occurring in all these conditions and how drug concentrations may potentially be affected. The lack of prospective studies on large cohorts of patients makes impossible any specific recommendation on drug regimen adjustment in ICU patients. Nevertheless, the clinicians should be aware of these abnormalities in order to better understand some unexpected therapeutic issues occurring in such patients.
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Affiliation(s)
- Maya Hites
- Department of Infectious Diseases, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium
| | - Antonio Maria Dell'Anna
- Department of Intensive Care, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme - Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels Belgium.
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123
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Antibiothérapie au cours de l’épuration extrarénale continue en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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124
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Clark EG, Bagshaw SM. Unnecessary Renal Replacement Therapy for Acute Kidney Injury is Harmful for Renal Recovery. Semin Dial 2014; 28:6-11. [DOI: 10.1111/sdi.12300] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Edward G. Clark
- Kidney Research Centre; Ottawa Hospital Research Institute; University of Ottawa and Division of Nephrology; The Ottawa Hospital; Ottawa Ontario Canada
| | - Sean M. Bagshaw
- Division of Critical Care Medicine; Faculty of Medicine and Dentistry; University of Alberta; Edmonton Canada
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125
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Vitrat V, Hautefeuille S, Janssen C, Bougon D, Sirodot M, Pagani L. Optimizing antimicrobial therapy in critically ill patients. Infect Drug Resist 2014; 7:261-71. [PMID: 25349478 PMCID: PMC4208492 DOI: 10.2147/idr.s44357] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future.
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Affiliation(s)
- Virginie Vitrat
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France
| | - Serge Hautefeuille
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Cécile Janssen
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France
| | - David Bougon
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Michel Sirodot
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Leonardo Pagani
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France ; Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
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126
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Lewis SJ, Mueller BA. Antibiotic Dosing in Patients With Acute Kidney Injury: "Enough But Not Too Much". J Intensive Care Med 2014; 31:164-76. [PMID: 25326429 DOI: 10.1177/0885066614555490] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 08/25/2014] [Indexed: 12/21/2022]
Abstract
Increasing evidence suggests that antibiotic dosing in critically ill patients with acute kidney injury (AKI) often does not achieve pharmacodynamic goals, and the continued high mortality rate due to infectious causes appears to confirm these findings. Although there are compelling reasons why clinicians should use more aggressive antibiotic dosing, particularly in patients receiving aggressive renal replacement therapies, concerns for toxicity associated with higher doses are real. The presence of multisystem organ failure and polypharmacy predispose these patients to drug toxicity. This article examines the pharmacokinetic and pharmacodynamic consequences of critical illness, AKI, and renal replacement therapy and describes potential solutions to help clinicians give "enough but not too much" in these very complicated patients.
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Affiliation(s)
- Susan J Lewis
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Bruce A Mueller
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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127
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Vincent JL, Pereira AJ, Gleeson J, Backer DD. Early management of sepsis. Clin Exp Emerg Med 2014; 1:3-7. [PMID: 27752546 PMCID: PMC5052825 DOI: 10.15441/ceem.14.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 07/15/2014] [Accepted: 08/11/2014] [Indexed: 02/07/2023] Open
Abstract
Increased awareness of the signs and symptoms of sepsis and an emphasis on the importance of early treatment have helped to improve survival rates from this serious and frequent condition in recent years. With no specific, effective anti-sepsis therapies available, management focuses on early source control with adequate and appropriate antibiotics and removal of any source of infection, rapid resuscitation, hemodynamic stabilization and organ support. Use of dedicated teams to care for patients with sepsis can help optimize early management.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Adriano José Pereira
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - James Gleeson
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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128
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Lewis SJ, Mueller BA. Antibiotic Dosing in Critically Ill Patients Receiving CRRT: Underdosing is Overprevalent. Semin Dial 2014; 27:441-5. [DOI: 10.1111/sdi.12203] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Susan J. Lewis
- Department of Clinical Social and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
| | - Bruce A. Mueller
- Department of Clinical Social and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
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129
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In vivo antibiotic removal during coupled plasma filtration adsorption: a retrospective study. ASAIO J 2014; 60:70-5. [PMID: 24270228 DOI: 10.1097/mat.0000000000000009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coupled plasma filtration adsorption (CPFA) is a blood purification therapy aimed at modulating the host inflammatory response involved in sepsis pathogenesis. One potential drawback of this technique is the unexpected elimination of antibiotics. The aim of this study was to assess the elimination of several antibiotics with CPFA. We performed a retrospective analysis of the serum and ultrafiltrate concentrations of different antibiotics routinely measured during CPFA sessions in five patients experiencing septic shock. The adsorbent extraction ratio (AER) for piperacillin and vancomycin 2 h into the CPFA session were high: 95.4 ± 6.9% and 99.6 ± 0.9%, respectively. These AER decreased significantly by 8 h (at 8 h: 6.3 ± 51.8% and -30.2 ± 25.6%, respectively), suggesting saturation of the resin cartridge. Conversely, the tazobactam AER was low (7.2 ± 15% after 2 h of CPFA). No significant changes in the mean serum concentrations of piperacillin, tazobactam, and vancomycin were observed. Thus, as opposed to tazobactam, we report high adsorption of piperacillin and vancomycin on the CPFA resin but with no reduction in serum concentrations.
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130
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Abstract
PURPOSE OF REVIEW This review highlights the principal advances in critical care over the past year, and discusses the impact of these advances on the diagnosis and management of acute kidney injury (AKI). RECENT FINDINGS Recent literature has focused on assessment of volume status and fluid management, particularly in the setting of respiratory and cardiac failure. Other critical care topics are reviewed using a system-based approach. SUMMARY The incidence of AKI appears to be increasing, and despite advances in the provision of critical care and renal replacement therapies, there has been little improvement in its associated morbidity and mortality. Nonetheless, recent advances in critical care will impact the diagnosis and management of AKI, as well as shape the future research agenda. Continued work in the fields of critical care and nephrology will undoubtedly be centered on improved biomarkers for the detection of AKI, specific therapies to mitigate or reverse AKI, and techniques to prevent the development of AKI in the critically ill population.
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131
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Nehus EJ, Mouksassi S, Vinks AA, Goldstein S. Meropenem in children receiving continuous renal replacement therapy: clinical trial simulations using realistic covariates. J Clin Pharmacol 2014; 54:1421-8. [PMID: 25042683 DOI: 10.1002/jcph.360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/03/2014] [Indexed: 11/06/2022]
Abstract
Meropenem is frequently prescribed in children receiving continuous renal replacement therapy (CRRT). Fluid overload is often present in critically ill children and affects drug disposition. The purpose of this study was to develop a pharmacokinetic model to (1) evaluate target attainment of meropenem dosing regimens against P. aeruginosa in children receiving CRRT and (2) estimate the effect of fluid overload on target attainment. Clinical trial simulations were employed to evaluate target attainment of meropenem in various age groups and degrees of fluid overload in children receiving CRRT. Pharmacokinetic parameters were extracted from published literature, and 287 patients from the prospective pediatric CRRT registry database provided realistic clinical covariates including patient weight, fluid overload, and CRRT prescription characteristics. Target attainment at 40% and 75% time above the minimum inhibitory concentration was evaluated. Clinical trial simulations demonstrated that children greater than 5 years of age achieved acceptable target attainment with a dosing regimen of 20 mg/kg every 12 hours. In children less than 5, however, increased dosing of 20 mg/kg every 8 hours was needed to optimize target attainment. Fluid overload did not affect target attainment. These in silico model predictions will need to be verified in vivo in children receiving meropenem and CRRT.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio
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The Impact of Variation in Renal Replacement Therapy Settings on Piperacillin, Meropenem, and Vancomycin Drug Clearance in the Critically Ill. Crit Care Med 2014; 42:1640-50. [DOI: 10.1097/ccm.0000000000000317] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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133
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De Waele JJ, Carlier M. Beta-lactam antibiotic dosing during continuous renal replacement therapy: how can we optimize therapy? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:158. [PMID: 25043643 PMCID: PMC4075247 DOI: 10.1186/cc13945] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Correct antibiotic treatment is of utmost importance to treat infections in critically ill patients, not only in terms of spectrum and timing but also in terms of dosing. However, this is a real challenge for the clinician because the pathophysiology (such as shock, augmented renal clearance, and multiple organ dysfunction) has a major impact on the pharmacokinetics of hydrophilic antibiotics. The presence of extra-corporal circuits, such as continuous renal replacement therapy, may further complicate this difficult exercise. Standard dosing may result in inadequate concentrations, but unadjusted dosing regimens may lead to toxicity. Recent studies confirm the variability in concentrations, and the wide variation in dialysis techniques used certainly contributes to these findings. Well-designed clinical studies are needed to provide the data from which robust dosing guidance can be developed. In the meantime, non-adjusted dosing in the first 1 to 2 days of antibiotic therapy during continuous renal replacement therapy followed by dose reduction later on seems to be a prudent approach.
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134
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Ulldemolins M, Vaquer S, Llauradó-Serra M, Pontes C, Calvo G, Soy D, Martín-Loeches I. Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:227. [PMID: 25042938 PMCID: PMC4075152 DOI: 10.1186/cc13938] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required to compensate the increased volume of distribution, regardless of impaired organ function. An additional loading dose may be required when CRRT is initiated due to steady-state equilibrium breakage driven by clearance variation. From day 2, dosing must be adjusted to CRRT settings and residual renal function. Therapeutic drug monitoring of beta-lactams may be regarded as a useful tool to daily individualize dosing and to ensure optimal antibiotic exposure.
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135
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Roberts JA, Roberts DM. Antibiotic dosing in critically ill patients with septic shock and on continuous renal replacement therapy: can we resolve this problem with pharmacokinetic studies and dosing guidelines? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:156. [PMID: 25043141 PMCID: PMC4075254 DOI: 10.1186/cc13939] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Dosing antibiotics in critically ill patients to achieve therapeutic concentrations is a significant challenge. The presence of septic shock and prescription of continuous renal replacement therapy introduces further complexities for the clinician. Unfortunately, this is a dilemma encountered daily by intensivists. Although small pharmacokinetic studies are emerging to provide data to help address this problem, the variability in results from these studies is profound. As such, effective antibiotic dosing guidelines for critically ill patients who have septic shock and who receive continuous renal replacement therapy are not available. Dosing flowcharts and therapeutic drug monitoring represent the best available options for clinicians to optimize antibiotic dosing.
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136
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Jiang SP, Zhu ZY, Wu XL, Lu XY, Zhang XG, Wu BH. Effectiveness of pharmacist dosing adjustment for critically ill patients receiving continuous renal replacement therapy: a comparative study. Ther Clin Risk Manag 2014; 10:405-12. [PMID: 24940066 PMCID: PMC4051794 DOI: 10.2147/tcrm.s59187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background The impact of continuous renal replacement therapy (CRRT) on drug removal is complicated; pharmacist dosing adjustment for these patients may be advantageous. This study aims to describe the development and implementation of pharmacist dosing adjustment for critically ill patients receiving CRRT and to examine the effectiveness of pharmacist interventions. Methods A comparative study was conducted in an intensive care unit (ICU) of a university-affiliated hospital. Patients receiving CRRT in the intervention group received specialized pharmacy dosing service from pharmacists, whereas patients in the no-intervention group received routine medical care without pharmacist involvement. The two phases were compared to evaluate the outcome of pharmacist dosing adjustment. Results The pharmacist carried out 233 dosing adjustment recommendations for patients receiving CRRT, and 212 (90.98%) of the recommendations were well accepted by the physicians. Changes in CRRT-related variables (n=144, 61.81%) were the most common risk factors for dosing errors, whereas antibiotics (n=168, 72.10%) were the medications most commonly associated with dosing errors. Pharmacist dosing adjustment resulted in a US$2,345.98 ICU cost savings per critically ill patient receiving CRRT. Suspected adverse drug events in the intervention group were significantly lower than those in the preintervention group (35 in 27 patients versus [vs] 18 in eleven patients, P<0.001). However, there was no significant difference between length of ICU stay and mortality after pharmacist dosing adjustment, which was 8.93 days vs 7.68 days (P=0.26) and 30.10% vs 27.36% (P=0.39), respectively. Conclusion Pharmacist dosing adjustment for patients receiving CRRT was well accepted by physicians, and was related with lower adverse drug event rates and ICU cost savings. These results may support the development of strategies to include a pharmacist in the multidisciplinary ICU team.
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Affiliation(s)
- Sai-Ping Jiang
- Department of Pharmacy, the First Affiliated Hospital, Hangzhou, People's Republic of China
| | - Zheng-Yi Zhu
- Department of Pharmacy, Children's Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao-Liang Wu
- Intensive Care Unit, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao-Yang Lu
- Department of Pharmacy, the First Affiliated Hospital, Hangzhou, People's Republic of China
| | - Xing-Guo Zhang
- Department of Pharmacy, the First Affiliated Hospital, Hangzhou, People's Republic of China
| | - Bao-Hua Wu
- Department of Pharmacy, the First Affiliated Hospital, Hangzhou, People's Republic of China
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137
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Beumier M, Casu GS, Hites M, Seyler L, Cotton F, Vincent JL, Jacobs F, Taccone FS. β-lactam antibiotic concentrations during continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R105. [PMID: 24886826 PMCID: PMC4075122 DOI: 10.1186/cc13886] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 05/07/2014] [Indexed: 01/05/2023]
Abstract
Introduction The use of standard doses of β-lactam antibiotics during continuous renal replacement therapy (CRRT) may result in inadequate serum concentrations. The aim of this study was to evaluate the adequacy of unadjusted drug regimens (i.e., similar to those used in patients with normal renal function) in patients treated with CRRT and the influence of CRRT intensity on drug clearance. Methods We reviewed data from 50 consecutive adult patients admitted to our Department of Intensive Care in whom routine therapeutic drug monitoring (TDM) of broad-spectrum β-lactam antibiotics (ceftazidime or cefepime, CEF; piperacillin/tazobactam; TZP; meropenem, MEM) was performed using unadjusted β-lactam antibiotics regimens (CEF = 2 g q8h; TZP = 4 g q6h; MEM = 1 g q8h). Serum drug concentrations were measured twice during the elimination phase by high-performance liquid chromatography (HPLC-UV). We considered therapy was adequate when serum drug concentrations were between 4 and 8 times the minimal inhibitory concentration (MIC) of Pseudomonas aeruginosa during optimal periods of time for each drug (≥70% for CEF; ≥ 50% for TZP; ≥ 40% for MEM). Therapy was considered as early (ET) or late (LT) phase if TDM was performed within 48 hours of antibiotic initiation or later on, respectively. Results We collected 73 serum samples from 50 patients (age 58 ± 13 years; Acute Physiology and Chronic Health Evaluation II (APACHE II) score on admission 21 (17–25)), 35 during ET and 38 during LT. Drug concentrations were above 4 times the MIC in 63 (90%), but above 8 times the MIC in 39 (53%) samples. The proportions of patients with adequate drug concentrations during ET and LT were quite similar. We found a weak but significant correlation between β-lactam antibiotics clearance and CRRT intensity. Conclusions In septic patients undergoing CRRT, doses of β-lactam antibiotics similar to those given to patients with normal renal function achieved drug levels above the target threshold in 90% of samples. Nevertheless, 53% of samples were associated with very high drug levels and daily drug regimens may need to be adapted accordingly.
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138
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Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, Hope WW, Farkas A, Neely MN, Schentag JJ, Drusano G, Frey OR, Theuretzbacher U, Kuti JL. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. THE LANCET. INFECTIOUS DISEASES 2014; 14:498-509. [PMID: 24768475 DOI: 10.1016/s1473-3099(14)70036-2] [Citation(s) in RCA: 660] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness.
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Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Johan W Mouton
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Alexander A Vinks
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andras Farkas
- Department of Pharmacy, Nyack Hospital, Nyack, NY, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, CA, USA
| | | | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Otto R Frey
- Department of Pharmacy, Heidenheim Hospital, Heidenheim, Germany
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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139
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Continuous renal replacement therapy with regional citrate anticoagulation: do we really know the details? Curr Opin Anaesthesiol 2014; 26:428-37. [PMID: 23673990 DOI: 10.1097/aco.0b013e3283620224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW A significant proportion of critically ill patients with acute kidney injury require continuous renal replacement therapy (CRRT). This article summarizes current evidence on the diagnosis and treatment of acute kidney injury. Regional citrate anticoagulation (RCA) is an emerging but complex technique. A variety of solutions and systems are currently used for RCA. Descriptions of the dosage and methods differ significantly and may cause confusion in everyday practice. This article reviews important scientific findings and highlights pharmacological and pathophysiological aspects of RCA, with a special emphasis on practical clinical issues regarding dosage and available citrate solutions. RECENT FINDINGS RCA provides a similar or even longer circuit run, with manageable metabolic complications. Although large-scale multicentre trials are needed, there is increasing evidence for the benefits of citrate solutions in CRRT. International guidelines recommend using citrate anticoagulation rather than heparin in patients without contraindications against citrate. SUMMARY RCA-CRRT is a technique that can be safely used in the majority of intensive care patients with severe multiple-organ failure. The range of citrate solutions available, the different methods in use--continuous venovenous haemofiltration, continuous venovenous haemodialysis and continuous venovenous haemodiafiltration--and the lack of a generally accepted complete CRRT 'set' have impeded implementation of the technique in clinical practice. Unresolved questions regarding dosage and assessment preclude evidence-based comparison in prospective, multicentre studies. For the moment, each institution has to develop a local working protocol. In clinical practice, detailed staff training and monitoring of possible metabolic disturbances for this complex intervention is essential.
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140
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Varghese JM, Jarrett P, Boots RJ, Kirkpatrick CMJ, Lipman J, Roberts JA. Pharmacokinetics of piperacillin and tazobactam in plasma and subcutaneous interstitial fluid in critically ill patients receiving continuous venovenous haemodiafiltration. Int J Antimicrob Agents 2014; 43:343-8. [PMID: 24612982 DOI: 10.1016/j.ijantimicag.2014.01.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
This prospective pharmacokinetic study aimed to describe plasma and interstitial fluid (ISF) pharmacokinetics of piperacillin and tazobactam in critically ill patients on continuous venovenous haemodiafiltration (CVVHDF). Piperacillin/tazobactam (4g/0.5g) was administered every 8h and CVVHDF was performed as a 3-3.5L/h exchange using a polyacrylonitrile filter with a surface area of 1.05m(2). Serial blood (pre- and post-filter), filtrate/dialysate, urine and ISF concentrations were measured. Subcutaneous tissue ISF concentrations were determined using microdialysis. A total of 407 samples were collected. Median peak plasma concentrations were 210.5 (interquartile range=161.5-229.0) and 29.4 (27.9-32.0) mg/L and median trough plasma concentrations were 64.3 (49.0-68.9) and 12.3 (7.7-13.7) mg/L for piperacillin and tazobactam, respectively. The plasma elimination half-life was 6.4 (4.6-8.7) and 7.3 (4.6-11.8) h, volume of distribution 0.42 (0.29-0.49) and 0.32 (0.24-0.36) L/kg, total clearance 5.1 (4.2-6.2) and 3.8 (3.3-4.2) L/h and CVVHDF clearance 2.5 (2.3-3.1) and 2.5 (2.3-3.2) L/h for piperacillin and tazobactam, respectively. The tissue penetration ratio or ratio of area under the concentration-time curve of the unbound drug in ISF to plasma (unbound AUCISF/AUCplasma) was ca. 1 for both piperacillin and tazobactam. This is the first report of concurrent plasma and ISF concentrations of piperacillin and tazobactam during CVVHDF. For the CVVHDF settings used in this study, a dose of 4.5g piperacillin/tazobactam administered evry 8h resulted in piperacillin concentrations in plasma and ISF >32mg/L throughout most of the dosing interval.
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Affiliation(s)
- Julie M Varghese
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia.
| | - Paul Jarrett
- Department of Intensive Care Medicine, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia
| | - Robert J Boots
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia; Department of Intensive Care Medicine, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia
| | - Carl M J Kirkpatrick
- Centre for Medicine Use and Safety, Monash University, 381 Royal Parade, Melbourne, VIC 3052, Australia
| | - Jeffrey Lipman
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia; Department of Intensive Care Medicine, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia
| | - Jason A Roberts
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Level 7, Block 6, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia; Department of Intensive Care Medicine, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia; Pharmacy Department, Level 1, Ned Hanlon Building, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia
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141
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Fedorenko M, Lam SW, Harinstein LM, Neuner EA, Demirjian S, Bauer SR. Compliance With Institutional Antimicrobial Dosing Guidelines in Patients Receiving Continuous Venovenous Hemodialysis. J Pharm Pract 2014; 28:380-6. [DOI: 10.1177/0897190013519679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Describe the rate of compliance with institutional antimicrobial dosing guidelines in patients on concomitant continuous venovenous hemodialysis (CVVHD). Methods: This single-center retrospective chart review evaluated adult patients receiving concomitant intravenous antimicrobials and CVVHD for at least 24 hours over a 2-month period. Results: A total of 42 patients, 76 antimicrobial courses, and 208 study days (24 hours of concomitant therapy) were evaluated. Overall, antimicrobials were dosed according to the institutional guidelines on 162 (78%) of 208 study days. All nonconcordant doses were below recommendations. The recommended dose was never received prior to antibiotic or CVVHD discontinuation in 22% of the cases. In cases where antimicrobials were initiated when the patient was already on CVVHD, 74% of the initial doses met guideline criteria. Pharmacist recommendation was associated with increased dosing compliance (94% vs 73% of study days, P = .001). During transition from CVVHD to intermittent hemodialysis (IHD), only 62% of antimicrobial doses were decreased by the first IHD day. Conclusions: Antimicrobial dosing in patients on CVVHD was below institutional guideline recommendations in many cases. Pharmacist recommendation was associated with compliance. Centers should evaluate their own compliance rate with institutional guideline recommendations for CVVHD and implement initiatives to improve dosing practices.
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Affiliation(s)
| | - Simon W. Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Sevag Demirjian
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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142
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Pharmacokinetics of ertapenem in critically ill patients receiving continuous venovenous hemodialysis or hemodiafiltration. Antimicrob Agents Chemother 2013; 58:1320-6. [PMID: 24323468 DOI: 10.1128/aac.02090-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study characterizes the pharmacokinetics of ertapenem, a carbapenem antibiotic, in critically ill adult subjects receiving continuous renal replacement therapy (CRRT). Eight critically ill patients with suspected/known Gram-negative infections receiving continuous venovenous hemodialysis (CVVHD) or continuous venovenous hemodiafiltration (CVVHDF) and ertapenem were enrolled. One gram of ertapenem was infused over 30 min. Predialyzer blood samples were drawn with the first dose of ertapenem from the hemodialysis tubing at time zero, 30 min, and 1, 2, 4, 8, 12, 18, and 24 h after the start of the ertapenem infusion. Effluent was collected at the same time points. Ertapenem total serum, unbound serum, and effluent concentrations from all eight subjects were used simultaneously to perform a population compartmental pharmacokinetic modeling procedure using NONMEM. Monte Carlo simulations were performed to evaluate the ability of several ertapenem dosing regimens (500 mg once daily, 750 mg once daily, 500 mg twice daily, and 1,000 mg once daily) to obtain effective unbound serum concentrations above 0.5, 1, and 2 μg/ml. For our simulated patients, all regimens produced unbound ertapenem concentrations above 2 μg/ml for 40% of the dosing interval for at least 96% of simulated patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT00877370.).
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143
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Patterns of medication exposures in hospitalized pediatric patients with acute renal failure requiring intermittent or continuous hemodialysis. Pediatr Crit Care Med 2013; 14:e394-403. [PMID: 23965636 DOI: 10.1097/pcc.0b013e31829f5bc8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications. STUDY DESIGN Retrospective cohort using the Pediatric Health Information System database. SETTING Forty freestanding children's hospitals throughout the United States. PATIENTS Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011. INTERVENTION A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database. MAIN RESULTS Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure. CONCLUSIONS Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.
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144
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Ceftazidime dosage recommendations in burn patients: from a population pharmacokinetic approach to clinical practice via Monte Carlo simulations. Clin Ther 2013; 35:1603-12. [PMID: 24094465 DOI: 10.1016/j.clinthera.2013.08.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/29/2013] [Accepted: 08/23/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ceftazidime dosage regimen recommendations based on pharmacokinetic/pharmacodynamic approaches are not available for burn patients. OBJECTIVE The goal of this study was to propose a continuous dosage regimen of ceftazidime in burn patients, taking into account different MICs and pharmacokinetic covariates. METHODS The population pharmacokinetic analysis was conducted by using software dedicated to the analysis of nonlinear mixed effects models. The population pharmacokinetic model was first developed and validated in 70 adult burn patients. Taking into account various MICs of pathogens, 3 Monte Carlo simulation trials were conducted by using target concentration intervals (10-100, 20-100, and 40-100 mg/L). The recommended dosages were defined as the minimum dose leading to the highest percentage of patients whose ceftazidime concentrations were included in the target interval. RESULTS Serum creatinine and age were identified as covariates of ceftazidime clearance. Age was also involved in volume of distribution. The simulations showed that a dose of 6 g/d did not allow achievement of the target interval in most patients. Regardless of dosage regimen, age, and serum creatinine, the mean percentage of patients reaching the 10- to 100-mg/L and the 20- to 100-mg/L target intervals were 99.4% (0.3%) and 96.1% (0.8%), respectively. For the 40- to 100-mg/L target interval, this percentage was only 76.4% (2.1%) (range, 65%-80%). CONCLUSIONS Age and serum creatinine level can be used at the bedside to determine the initial doses of ceftazidime. These Monte Carlo simulations highlight the need of a reappraisal of ceftazidime's use in burn patients. Doses between 3 and 16 g/d are proposed, taking into account the pathogens' MICs. However, for sepsis caused by a pathogen with an MIC ≥ 8 mg/L, an insufficient percentage of burn patients will reach the therapeutic target with the recommended dosages.
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145
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Udy AA, Roberts JA, Lipman J. Clinical implications of antibiotic pharmacokinetic principles in the critically ill. Intensive Care Med 2013; 39:2070-82. [DOI: 10.1007/s00134-013-3088-4] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/23/2013] [Indexed: 12/21/2022]
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146
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Jiang SP, Zhu ZY, Ma KF, Zheng X, Lu XY. Impact of pharmacist antimicrobial dosing adjustments in septic patients on continuous renal replacement therapy in an intensive care unit. ACTA ACUST UNITED AC 2013; 45:891-9. [PMID: 24024759 DOI: 10.3109/00365548.2013.827338] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Correct dosing of antimicrobial drugs in septic patients receiving continuous renal replacement therapy (CRRT) is complex. This study aimed to evaluate the effects of dosing adjustments performed by pharmacists on the length of intensive care unit (ICU) stay, ICU cost, and antimicrobial adverse drug events (ADEs). METHODS A single-center, 2-phase (pre-/post-intervention) study was performed in an ICU of a university-affiliated hospital. Septic patients receiving CRRT in the post-intervention phase received a specialized antimicrobial dosing service from critical care pharmacists, whereas patients in the pre-intervention phase received routine medical care without involving pharmacists. The 2 phases were compared to evaluate the outcomes of pharmacist interventions. RESULTS Pharmacists made 183 antimicrobial dosing adjustment recommendations for septic patients receiving CRRT. Changes in CRRT-related variables (116, 63.4%) were the most common risk factors for dosing errors, and β-lactams (101, 55.2%) were the antimicrobials most commonly associated with dosing errors. Dosing adjustments were related to a reduced length of ICU stay from 10.7 ± 11.1 days to 7.7 ± 8.3 days (p = 0.037) in the intervention group, and to cost savings of $3525 (13,463 ± 12,045 vs. 9938 ± 8811, p = 0.038) per septic patient receiving CRRT in the ICU. Suspected antimicrobial adverse drug events in the intervention group were significantly fewer than in the pre-intervention group (19 events vs. 8 events, p = 0.048). CONCLUSIONS The involvement of pharmacists in antimicrobial dosing adjustments in septic patients receiving CRRT is associated with a reduced length of ICU stay, lower ICU costs, and fewer ADEs. Hospitals may consider employing clinical pharmacists in ICUs.
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Affiliation(s)
- Sai-Ping Jiang
- From the Department of Pharmacy, the First Affiliated Hospital
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Casu GS, Hites M, Jacobs F, Cotton F, Wolff F, Beumier M, De Backer D, Vincent JL, Taccone FS. Can changes in renal function predict variations in β-lactam concentrations in septic patients? Int J Antimicrob Agents 2013; 42:422-8. [PMID: 23993066 DOI: 10.1016/j.ijantimicag.2013.06.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/23/2013] [Accepted: 06/27/2013] [Indexed: 12/31/2022]
Abstract
This study investigated whether variations in creatinine clearance (CLCr) are correlated with changes in β-lactam concentrations or pharmacokinetics in septic patients. Data for 56 adult patients admitted to the ICU in whom routine therapeutic drug monitoring (TDM) of broad-spectrum β-lactams (ceftazidime, cefepime, piperacillin or meropenem) was performed were reviewed. Patients were included if they had at least two TDM during their ICU stay for the same antibiotic and were not concomitantly treated with any extracorporeal replacement therapy. Serum drug concentrations were measured by HPLC-UV. Antibiotic pharmacokinetics were calculated using a one-compartment model and the percentage of time spent above four times the MIC (%T>4×MIC) for Pseudomonas aeruginosa and the antibiotic clearance (ATB-CL) were obtained. CLCr was measured on the same day as the TDM using 24-h urine collection. The %T>4×MIC and ATB-CL were significantly correlated with CLCr at the first (r=-0.41, P=0.002; r=0.56, P<0.001, respectively) and second (r=-0.61, P<0.001; r=0.63, P<0.001, respectively) TDM. However, changes in ATB-CL were only weakly correlated with changes in CLCr (r=0.34, P=0.01). The proportion of patients with insufficient β-lactam concentrations at the first and second TDM were 39% and 30%, respectively, and increased proportionally to CLCr. Although CLCr was significantly correlated with concentrations and clearance of broad-spectrum β-lactams, changes in CLCr did not reliably predict variations in drug pharmacokinetics/pharmacodynamics. Routine TDM should be considered to adapt β-lactam doses in this setting.
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Affiliation(s)
- Giuseppe Stefano Casu
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, route de Lennik 808, 1070 Brussels, Belgium
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Petrosillo N, Giannella M, Lewis R, Viale P. Treatment of carbapenem-resistant Klebsiella pneumoniae: the state of the art. Expert Rev Anti Infect Ther 2013; 11:159-77. [PMID: 23409822 DOI: 10.1586/eri.12.162] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The increasing incidence of carbapenem-resistant Klebsiella pneumoniae (CR-KP) fundamentally alters the management of patients at risk to be colonized or infected by such microorganisms. Owing to the limitation in efficacy and potential for toxicity of the alternative agents, many experts recommend using combination therapy instead of monotherapy in CR-KP-infected patients. However, in the absence of well-designed comparative studies, the best combination for each infection type, the continued role for carbapenems in combination therapy and when combination therapy should be started remain open questions. Herein, the authors revise current microbiological and clinical evidences supporting combination therapy for CR-KP infections to address some of these issues.
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Affiliation(s)
- Nicola Petrosillo
- 2nd Division of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome, Italy
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Abstract
PURPOSE OF REVIEW Febrile neutropenia presents a clinical challenge in which timely and appropriate antibiotic exposure is crucial. In the context of altered pharmacokinetics and rising bacterial resistance, standard antibiotic doses are unlikely to be sufficient. This review explores the potential utility of altered dosing approaches of β-lactam antibiotics to optimize treatment in febrile neutropenia. RECENT FINDINGS There is a dynamic relationship between the antibiotic, the infecting pathogen, and the host. Great advancements have been made in the understanding of the pharmacokinetic changes in critical illness and the pharmacodynamic relationships of antibiotics in these settings. SUMMARY Antibiotic treatment in febrile neutropenia is becoming increasingly difficult. Patients are of higher acuity, receive more intensive chemotherapy regimens leading to prolonged neutropenia, and are often exposed to multiple antibiotic courses. These patients display significant variability in antibiotic clearances and increases in volume of distribution compared with standard ward-based patients. Rising antibiotic resistance and a lack of new antibiotics in production have prompted alternative dosing strategies based on pharmacokinetic/pharmacodynamic data, such as extended or continuous infusions of β-lactam antibiotics, to maximize the likelihood of treatment success. A definitive study that describes a mortality benefit of such dosing regimens remains elusive and the theoretical advantages require testing in well designed clinical trials.
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150
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Scoville BA, Mueller BA. Medication Dosing in Critically Ill Patients With Acute Kidney Injury Treated With Renal Replacement Therapy. Am J Kidney Dis 2013; 61:490-500. [DOI: 10.1053/j.ajkd.2012.08.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 08/28/2012] [Indexed: 12/20/2022]
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