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Bassetti M, Luyt CE, Nicolau DP, Pugin J. Characteristics of an ideal nebulized antibiotic for the treatment of pneumonia in the intubated patient. Ann Intensive Care 2016; 6:35. [PMID: 27090532 PMCID: PMC4835402 DOI: 10.1186/s13613-016-0140-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 02/06/2023] Open
Abstract
Gram-negative pneumonia in patients who are intubated and mechanically ventilated is associated with increased morbidity and mortality as well as higher healthcare costs compared with those who do not have the disease. Intravenous antibiotics are currently the standard of care for pneumonia; however, increasing rates of multidrug resistance and limited penetration of some classes of antimicrobials into the lungs reduce the effectiveness of this treatment option, and current clinical cure rates are variable, while recurrence rates remain high. Inhaled antibiotics may have the potential to improve outcomes in this patient population, but their use is currently restricted by a lack of specifically formulated solutions for inhalation and a limited number of devices designed for the nebulization of antibiotics. In this article, we review the challenges clinicians face in the treatment of pneumonia and discuss the characteristics that would constitute an ideal inhaled drug/device combination. We also review inhaled antibiotic options currently in development for the treatment of pneumonia in patients who are intubated and mechanically ventilated.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Santa Maria Misericordia University Hospital, Udine, Italy.
| | - Charles-Edouard Luyt
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, USA
| | - Jérôme Pugin
- Service des Soins Intensifs, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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103
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O’Donnell JN, Miglis CM, Lee JY, Tuvell M, Lertharakul T, Scheetz MH. Carbapenem susceptibility breakpoints, clinical implications with the moving target. Expert Rev Anti Infect Ther 2016; 14:389-401. [DOI: 10.1586/14787210.2016.1159131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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104
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Yatera K, Naito K, Noguchi S, Akata K, Yamasaki K, Nishida C, Kawanami T, Sakamoto N, Kido T, Ishimoto H, Mukae H. Clinical efficacy and safety of high-dose doripenem in Japanese patients with pneumonia. J Infect Chemother 2016; 22:137-42. [DOI: 10.1016/j.jiac.2015.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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Kollef MH, Micek ST. Editorial Commentary: Antimicrobial De-escalation: What's in a Name? Clin Infect Dis 2015; 62:1018-20. [PMID: 26703859 DOI: 10.1093/cid/civ1201] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine
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Population Pharmacokinetics of Doripenem in Critically Ill Patients with Sepsis in a Malaysian Intensive Care Unit. Antimicrob Agents Chemother 2015; 60:206-14. [PMID: 26482304 DOI: 10.1128/aac.01543-15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 10/13/2015] [Indexed: 01/28/2023] Open
Abstract
Doripenem has been recently introduced in Malaysia and is used for severe infections in the intensive care unit. However, limited data currently exist to guide optimal dosing in this scenario. We aimed to describe the population pharmacokinetics of doripenem in Malaysian critically ill patients with sepsis and use Monte Carlo dosing simulations to develop clinically relevant dosing guidelines for these patients. In this pharmacokinetic study, 12 critically ill adult patients with sepsis receiving 500 mg of doripenem every 8 h as a 1-hour infusion were enrolled. Serial blood samples were collected on 2 different days, and population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling approach. A two-compartment linear model with between-subject and between-occasion variability on clearance was adequate in describing the data. The typical volume of distribution and clearance of doripenem in this cohort were 0.47 liters/kg and 0.14 liters/kg/h, respectively. Doripenem clearance was significantly influenced by patients' creatinine clearance (CL(CR)), such that a 30-ml/min increase in the estimated CL(CR) would increase doripenem CL by 52%. Monte Carlo dosing simulations suggested that, for pathogens with a MIC of 8 mg/liter, a dose of 1,000 mg every 8 h as a 4-h infusion is optimal for patients with a CL(CR) of 30 to 100 ml/min, while a dose of 2,000 mg every 8 h as a 4-h infusion is best for patients manifesting a CL(CR) of >100 ml/min. Findings from this study suggest that, for doripenem usage in Malaysian critically ill patients, an alternative dosing approach may be meritorious, particularly when multidrug resistance pathogens are involved.
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Andruska A, Micek ST, Shindo Y, Hampton N, Colona B, McCormick S, Kollef MH. Pneumonia Pathogen Characterization Is an Independent Determinant of Hospital Readmission. Chest 2015; 148:103-111. [PMID: 25429607 PMCID: PMC7127757 DOI: 10.1378/chest.14-2129] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hospital readmissions for pneumonia occur often and are difficult to predict. For fiscal year 2013, the Centers for Medicare & Medicaid Services readmission penalties have been applied to acute myocardial infarction, heart failure, and pneumonia. However, the overall impact of pneumonia pathogen characterization on hospital readmission is undefined. METHODS This was a retrospective 6-year cohort study (August 2007 to September 2013). RESULTS We evaluated 9,624 patients with a discharge diagnosis of pneumonia. Among these patients, 4,432 (46.1%) were classified as having culture-negative pneumonia, 1,940 (20.2%) as having pneumonia caused by antibiotic-susceptible bacteria, 2,991 (31.1%) as having pneumonia caused by potentially antibiotic-resistant bacteria, and 261 (2.7%) as having viral pneumonia. The 90-day hospital readmission rate for survivors (n = 7,637, 79.4%) was greatest for patients with pneumonia attributed to potentially antibiotic-resistant bacteria (11.4%) followed by viral pneumonia (8.3%), pneumonia attributed to antibiotic-susceptible bacteria (6.6%), and culture-negative pneumonia (5.8%) (P < .001). Multiple logistic regression analysis identified pneumonia attributed to potentially antibiotic-resistant bacteria to be independently associated with 90-day readmission (OR, 1.75; 95% CI, 1.56-1.97; P < .001). Other independent predictors of 90-day readmission were Charlson comorbidity score > 4, cirrhosis, and chronic kidney disease. Culture-negative pneumonia was independently associated with lower risk for 90-day readmission. CONCLUSIONS Readmission after hospitalization for pneumonia is relatively common and is related to pneumonia pathogen characterization. Pneumonia attributed to potentially antibiotic-resistant bacteria is associated with an increased risk for 90-day readmission, whereas culture-negative pneumonia is associated with lower risk for 90-day readmission.
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Affiliation(s)
- Adam Andruska
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Yuichiro Shindo
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO; Institute for Advanced Research, Nagoya University, Nagoya, Japan
| | - Nicholas Hampton
- BJC Healthcare (Dr Hampton, Mr Colona, and Ms McCormick), Center for Clinical Excellence, St. Louis, MO
| | - Brian Colona
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Sandra McCormick
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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Pugh R, Grant C, Cooke RPD, Dempsey G. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev 2015; 2015:CD007577. [PMID: 26301604 PMCID: PMC7025798 DOI: 10.1002/14651858.cd007577.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pneumonia is the most common hospital-acquired infection affecting patients in the intensive care unit (ICU). However, current national guidelines for the treatment of hospital-acquired pneumonia (HAP) are several years old and the diagnosis of pneumonia in mechanically ventilated patients (VAP) has been subject to considerable recent attention. The optimal duration of antibiotic therapy for HAP in the critically ill is uncertain. OBJECTIVES To assess the effectiveness of short versus prolonged-course antibiotics for HAP in critically ill adults, including patients with VAP. SEARCH METHODS We searched CENTRAL (2015, Issue 5), MEDLINE (1946 to June 2015), MEDLINE in-process and other non-indexed citations (5 June 2015), EMBASE (2010 to June 2015), LILACS (1982 to June 2015) and Web of Science (1955 to June 2015). SELECTION CRITERIA We considered all randomised controlled trials (RCTs) comparing a fixed 'short' duration of antibiotic therapy with a 'prolonged' course for HAP (including patients with VAP) in critically ill adults. DATA COLLECTION AND ANALYSIS Two review authors conducted data extraction and assessment of risk of bias. We contacted trial authors for additional information. MAIN RESULTS We identified six relevant studies involving 1088 participants. This included two new studies published after the date of our previous review (2011). There was substantial variation in participants, in the diagnostic criteria used to define an episode of pneumonia, in the interventions and in the reported outcomes. We found no evidence relating to patients with a high probability of HAP who were not mechanically ventilated. For patients with VAP, overall a short seven- or eight-day course of antibiotics compared with a prolonged 10- to 15-day course increased 28-day antibiotic-free days (two studies; N = 431; mean difference (MD) 4.02 days; 95% confidence interval (CI) 2.26 to 5.78) and reduced recurrence of VAP due to multi-resistant organisms (one study; N = 110; odds ratio (OR) 0.44; 95% CI 0.21 to 0.95), without adversely affecting mortality and other recurrence outcomes. However, for cases of VAP specifically due to non-fermenting Gram-negative bacilli (NF-GNB), recurrence was greater after short-course therapy (two studies, N = 176; OR 2.18; 95% CI 1.14 to 4.16), though mortality outcomes were not significantly different. One study found that a three-day course of antibiotic therapy for patients with suspected HAP but a low Clinical Pulmonary Infection Score (CPIS) was associated with a significantly lower risk of superinfection or emergence of antimicrobial resistance, compared with standard (prolonged) course therapy. AUTHORS' CONCLUSIONS On the basis of a small number of studies and appreciating the lack of uniform definition of pneumonia, we conclude that for patients with VAP not due to NF-GNB a short, fixed course (seven or eight days) of antibiotic therapy appears not to increase the risk of adverse clinical outcomes, and may reduce the emergence of resistant organisms, compared with a prolonged course (10 to 15 days). However, for patients with VAP due to NF-GNB, there appears to be a higher risk of recurrence following short-course therapy. These findings do not differ from those of our previous review and are broadly consistent with current guidelines. There are few data from RCTs comparing durations of therapy in non-ventilated patients with HAP, but on the basis of a single study, short-course (three-day) therapy for HAP appears not to be associated with worse clinical outcome, and may reduce the risk of subsequent infection or the emergence of resistant organisms when there is low probability of pneumonia according to the CPIS.
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Affiliation(s)
- Richard Pugh
- Glan Clwyd HospitalDepartment of AnaestheticsRhylDenbighshireUKLL18 5UJ
| | - Chris Grant
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
| | - Richard PD Cooke
- Alder Hey Children's NHS Foundation TrustDepartment of MicrobiologyEaton RoadWest DerbyLiverpoolMerseysideUKL12 2AP
| | - Ged Dempsey
- University Hospital AintreeDepartment of Critical CareLower LaneLiverpoolMerseysideUKL9 7AL
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110
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Pseudomonas aeruginosa nosocomial pneumonia: impact of pneumonia classification. Infect Control Hosp Epidemiol 2015; 36:1190-7. [PMID: 26190444 DOI: 10.1017/ice.2015.167] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe and compare the mortality associated with nosocomial pneumonia due to Pseudomonas aeruginosa (Pa-NP) according to pneumonia classification (community-onset pneumonia [COP], hospital-acquired pneumonia [(HAP], and ventilator-associated pneumonia [VAP]). DESIGN We conducted a retrospective cohort study of adults with Pa-NP. We compared mortality for Pa-NP among patients with COP, HAP, and VAP and used logistic regression to identify risk factors for hospital mortality and inappropriate initial antibiotic therapy (IIAT). SETTING Twelve acute care hospitals in 5 countries (United States, 3; France, 2; Germany, 2; Italy, 2; and Spain, 3). PATIENTS/PARTICIPANTS A total of 742 patients with Pa-NP. RESULTS Hospital mortality was greater for those with VAP (41.9%) and HAP (40.1%) compared with COP (24.5%) (P<.001). In multivariate analyses, independent predictors of hospital mortality differed by pneumonia classification (COP: need for mechanical ventilation and intensive care; HAP: multidrug-resistant isolate; VAP: IIAT, increasing age, increasing Charlson comorbidity score, bacteremia, and use of vasopressors). Presence of multidrug resistance was identified as an independent predictor of IIAT for patients with COP and HAP, whereas recent antibiotic administration was protective in patients with VAP. CONCLUSIONS Among patients with Pa-NP, pneumonia classification identified patients with different risks for hospital mortality. Specific risk factors for hospital mortality also differed by pneumonia classification and multidrug resistance appeared to be an important risk factor for IIAT. These findings suggest that pneumonia classification for P. aeruginosa identifies patients with different mortality risks and specific risk factors for outcome and IIAT.
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Abstract
PURPOSE OF REVIEW To highlight the clinical importance of ventilator-associated pneumonia (VAP) in an era of escalating antimicrobial resistance. RECENT FINDINGS VAP continues to be an important infection in the critically ill. The development of rapid microbiologic diagnostics and new antimicrobial agents offer opportunities for improved treatment strategies for VAP balancing the need to treat effectively in a timely manner and antimicrobial stewardship. Additionally, the new surveillance definitions for assessing the quality of care in critically ill patients (ventilator-associated events, ventilator-associated conditions, and infection-related ventilator-associated conditions) do not appear to be adequate surrogates for the identification of VAP. SUMMARY Clinicians caring for critically ill patients should be aware of the importance of correctly treating VAP. As new diagnostic technologies and antimicrobials become available for VAP, their incorporation into routine patient management should occur in a way that optimizes patient outcomes wherein minimizing further emergence of antimicrobial resistance.
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112
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Bailey KL, Kalil AC. Ventilator-Associated Pneumonia (VAP) with Multidrug-Resistant (MDR) Pathogens: Optimal Treatment? Curr Infect Dis Rep 2015; 17:494. [PMID: 26092246 DOI: 10.1007/s11908-015-0494-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ventilator-associated pneumonia (VAP) due to multidrug-resistant bacteria (MDR) is an emerging problem worldwide. Both gram-negative and gram-positive microorganisms are associated with VAP. We first describe the magnitude of the problem of MDR VAP followed by its clinical impact on survival outcomes, with the primary aim to review the optimal antibiotic choices to treat patients with MDR VAP. We discuss the challenges of intravenous and inhaled antibiotic treatments, as well as of monotherapy and combination antimicrobial therapies.
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Affiliation(s)
- Kristina L Bailey
- Pulmonary, Critical Care Allergy and Sleep Medicine Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric). Intensive Care Med 2015; 41:1181-96. [PMID: 26077053 DOI: 10.1007/s00134-015-3853-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/28/2015] [Indexed: 02/07/2023]
Abstract
Emerging resistance to antibiotics shows no signs of decline. At the same time, few new antibacterials are being discovered. There is a worldwide recognition regarding the danger of this situation. The urgency of the situation and the conviction that practices should change led the Société de Réanimation de Langue Française (SRLF) and the Société Française d'Anesthésie et de Réanimation (SFAR) to set up a panel of experts from various disciplines. These experts met for the first time at the end of 2012 and have since met regularly to issue the following 67 recommendations, according to the rigorous GRADE methodology. Five fields were explored: i) the link between the resistance of bacteria and the use of antibiotics in intensive care; ii) which microbiological data and how to use them to reduce antibiotic consumption; iii) how should antibiotic therapy be chosen to limit consumption of antibiotics; iv) how can antibiotic administration be optimized; v) review and duration of antibiotic treatments. In each institution, the appropriation of these recommendations should arouse multidisciplinary discussions resulting in better knowledge of local epidemiology, rate of antibiotic use, and finally protocols for improving the stewardship of antibiotics. These efforts should contribute to limit the emergence of resistant bacteria.
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115
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Kamata K, Suzuki H, Kanemoto K, Tokuda Y, Shiotani S, Hirose Y, Suzuki M, Ishikawa H. Clinical evaluation of the need for carbapenems to treat community-acquired and healthcare-associated pneumonia. J Infect Chemother 2015; 21:596-603. [PMID: 26070781 DOI: 10.1016/j.jiac.2015.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 05/10/2015] [Accepted: 05/11/2015] [Indexed: 12/15/2022]
Abstract
Carbapenems have an overall broad antibacterial spectrum and should be protected against from the acquisition of drug resistance. The clinical advantages of carbapenem in cases of pneumonia have not been certified and the need for antipseudomonal antimicrobial agents to treat healthcare-associated pneumonia (HCAP) remains controversial. We introduced an antimicrobial stewardship program for carbapenem and tazobactam/piperacillin use and investigated the effects of this program on the clinical outcomes of 591 pneumonia cases that did not require intensive care unit management, mechanical ventilation or treatment with vasopressor agents [221 patients with community-acquired pneumonia (CAP) and 370 patients with HCAP]. Compared with the pre-intervention period, age, comorbidities and the severity and etiology of pneumonia did not differ during the intervention period. Carbapenems were rarely used during the intervention period in cases of pneumonia (CAP: 12% vs. 1%, HCAP: 13% vs. 1%), while antipseudomonal beta-lactam use was reduced from 33% to 8% among cases with HCAP. This reduction in the rate of carbapenem administration did not have an impact on the prognosis in the cases of CAP, and the in-hospital mortality was lower among the patients with HCAP during the intervention period (15% vs. 5%, p = 0.013). The causes of death in the cases of HCAP were not directly related to pneumonia during the intervention period. The current study shows that carbapenem use can be avoided in cases of CAP or HCAP that are not in a critical condition. The frequent use of antipseudomonal beta-lactams does not improve the clinical outcomes of HCAP.
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Affiliation(s)
- Kazuhiro Kamata
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan.
| | - Koji Kanemoto
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | | | - Seiji Shiotani
- Department of Radiology, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Yumi Hirose
- Department of General Medicine and Primary Care, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Masatsune Suzuki
- Department of General Medicine and Primary Care, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Hiroichi Ishikawa
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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An international multicenter retrospective study of Pseudomonas aeruginosa nosocomial pneumonia: impact of multidrug resistance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:219. [PMID: 25944081 PMCID: PMC4446947 DOI: 10.1186/s13054-015-0926-5] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/15/2015] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Pseudomonas aeruginosa nosocomial pneumonia (Pa-NP) is associated with considerable morbidity, prolonged hospitalization, increased costs, and mortality. METHODS We conducted a retrospective cohort study of adult patients with Pa-NP to determine 1) risk factors for multidrug-resistant (MDR) strains and 2) whether MDR increases the risk for hospital death. Twelve hospitals in 5 countries (United States, n = 3; France, n = 2; Germany, n = 2; Italy, n = 2; and Spain, n = 3) participated. We compared characteristics of patients who had MDR strains to those who did not and derived regression models to identify predictors of MDR and hospital mortality. RESULTS Of 740 patients with Pa-NP, 226 patients (30.5%) were infected with MDR strains. In multivariable analyses, independent predictors of multidrug-resistance included decreasing age (adjusted odds ratio [AOR] 0.91, 95% confidence interval [CI] 0.96-0.98), diabetes mellitus (AOR 1.90, 95% CI 1.21-3.00) and ICU admission (AOR 1.73, 95% CI 1.06-2.81). Multidrug-resistance, heart failure, increasing age, mechanical ventilation, and bacteremia were independently associated with in-hospital mortality in the Cox Proportional Hazards Model analysis. CONCLUSIONS Among patients with Pa-NP the presence of infection with a MDR strain is associated with increased in-hospital mortality. Identification of patients at risk of MDR Pa-NP could facilitate appropriate empiric antibiotic decisions that in turn could lead to improved hospital survival.
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Avni T, Shiver-Ofer S, Leibovici L, Tacconelli E, DeAngelis G, Cookson B, Pagani L, Paul M. Participation of elderly adults in randomized controlled trials addressing antibiotic treatment of pneumonia. J Am Geriatr Soc 2015; 63:233-43. [PMID: 25688601 DOI: 10.1111/jgs.13250] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine how relevant current evidence on antibiotic treatment of pneumonia is for elderly adults. DESIGN Systematic review. SETTING Randomized controlled trials (RCTs; N = 43) comparing different antibiotics and prospective observational studies (N = 182) published since 2005. PARTICIPANTS Adults with community-acquired (CAP), healthcare-associated (HCAP), hospital-acquired (HAP), or ventilator-associated (VAP) pneumonia. MEASUREMENTS Exclusion criteria that could preferentially limit participation of elderly adults were examined, subgroup or other adjusted analyses were searched for according to age, and treatment effects in participants younger than 65 in RCTs were compared with those in participants aged 65 and older. Mean participant ages in RCTs and observational studies were compared. Risk ratios (RRs) with 95% confidence intervals (CIs) for differences between older and younger adults were pooled using a fixed effect metaanalysis. RESULTS No RCT reported exclusion based on an upper age limit; 100% of community CAP trials, 90% of hospitalized CAP trials, and 76% of HAP and VAP trials excluded individuals based on comorbidities. None of the RCTs reported a subgroup analysis for mortality according to age. The RR for the pooled difference in treatment failure rates between participants younger than 65 and those aged 65 and older was 1.25 (95% CI = 0.94-1.65, 12 RCTs) and between participants younger than 75 and aged 75 and older was 1.43 (95% CI = 0.98-2.09, 7 RCTs). RCT participants were significantly younger (54.0 ± 9.6) than those in observational studies of CAP (66.2 ± 8.1, P < .001). Age differences were not significant for HCAP, HAP, and VAP. CONCLUSION Elderly adults are often excluded from RCTs of bacterial pneumonia. No data were found on the comparative efficacy of antibiotic treatment in elderly adults and the general population.
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Affiliation(s)
- Tomer Avni
- Department of Internal Medicine E, Rabin Medical Center, Beilinson Hospital and Sackler Faculty of Medicine, Tel-Aviv University, Israel
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Qu XY, Hu TT, Zhou W. A meta-analysis of efficacy and safety of doripenem for treating bacterial infections. Braz J Infect Dis 2015; 19:156-62. [PMID: 25636188 PMCID: PMC9425342 DOI: 10.1016/j.bjid.2014.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/29/2014] [Indexed: 11/25/2022] Open
Abstract
Objective Methods Results Conclusion
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119
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Nair GB, Niederman MS. Ventilator-associated pneumonia: present understanding and ongoing debates. Intensive Care Med 2015; 41:34-48. [PMID: 25427866 PMCID: PMC7095124 DOI: 10.1007/s00134-014-3564-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 11/11/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention. RESULTS Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a 'ventilator bundle' can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies. CONCLUSION The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.
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Affiliation(s)
- Girish B. Nair
- Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
| | - Michael S. Niederman
- Department of Medicine, Winthrop-University Hospital, 222 Station Plaza N., Suite 509, Mineola, NY 11501 USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
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120
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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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Garnacho-Montero J, Corcia-Palomo Y, Amaya-Villar R, Martin-Villen L. How to treat VAP due to MDR pathogens in ICU patients. BMC Infect Dis 2014; 14:135. [PMID: 25430700 PMCID: PMC4289192 DOI: 10.1186/1471-2334-14-135] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 03/10/2014] [Indexed: 11/22/2022] Open
Abstract
Background The increasing occurrence of multidrug resistant (MDR) bacteria arises at a time when there is a lack of antibiotics active against these pathogens and few new antimicrobials are in the pipelines of the pharmaceutical industry. Treatment of ventilator-associated pneumonia (VAP) caused especially by MDR Gram-negative bacilli (GNB) represents a real challenge due to the dearth of treatment options. Methods We searched the medical literature relevant about management of ventilator-associated pneumonia caused by multi-drug resistant pathogens including GNB and methicillin-resistant S. aureus. Results Empirical therapy should be prescribed based on the local pattern of susceptibilities. Colistin and tigecycline are in many cases the unique options for the treatment of many episodes of VAP caused by MDR-GNB. Tigecyline (not licensed for treatment of pneumonia) should be used with an initial bolus of 200 mg followed by 100 mg every 12 h. The need for a loading dose and the administration of high doses of colistin (9 million IU/day in two or three doses) is currently accepted. Vancomycin has been considered the treatment of choice for pneumonia due to MRSA although linezolid may provide higher rate of clinical cure for MRSA VAP with a good safety profile. The initial antibiotic treatment must be reassessed and simplify in accordance of culture results. Conclusions Empirical treatment of VAP due to MDR pathogens should be based on knowledge of local ecology. A strategy combining early high doses of effective agents with subsequent simplification in the light of microbiologic information is recommended.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Wieczorek A, Tokarz A, Gaszynski W, Gaszynski T. The doripenem serum concentrations in intensive care patients suffering from acute kidney injury, sepsis, and multi organ dysfunction syndrome undergoing continuous renal replacement therapy slow low-efficiency dialysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2039-44. [PMID: 25364230 PMCID: PMC4211861 DOI: 10.2147/dddt.s64942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Doripenem is a novel wide-spectrum antibiotic, and a derivate of carbapenems. It is an ideal antibiotic for treatment of serious nosocomial infections and severe sepsis for its exceptionally high efficiency and broad antibacterial spectrum of action. Doripenem is eliminated mainly by the kidneys. In cases of acute kidney injury, dosing of doripenem depends on creatinine clearance and requires adjustments. Doripenem is eliminated during hemodialysis because its molecular weight is 300–400 Da. The aim of this study was to establish the impact of continuous renal replacement therapy (CRRT) slow low-efficiency dialysis (SLED) on doripenem serum concentrations in a population of intensive-therapy patients with life-threatening infections and severe sepsis. Ten patients were enrolled in this observational study. Twelve blood samples were collected during the first administration of doripenem in a 1-hour continuous infusion while CRRT SLED was provided. Fluid chromatography was used for measurement of the concentration of doripenem in serum. In all collected samples, concentration of doripenem was above the minimum inhibition concentration of this antibiotic. Based on these results, we can draw the conclusion that doripenem concentration is above the minimum inhibition concentration throughout all of CRRT. The dosing pattern proposed by the manufacturer can be used in patients receiving CRRT SLED without necessary modifications.
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Affiliation(s)
- Andrzej Wieczorek
- Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
| | - Andrzej Tokarz
- Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
| | - Wojciech Gaszynski
- Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
| | - Tomasz Gaszynski
- Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
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Stratégies de réduction de l’utilisation des antibiotiques à visée curative en réanimation (adulte et pédiatrique). MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0916-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:480. [PMID: 25405992 PMCID: PMC4281952 DOI: 10.1186/s13054-014-0480-6] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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Garnacho-Montero J, Ferrándiz-Millón C. High dose of tigecycline for extremely resistant Gram-negative pneumonia: yes, we can. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:157. [PMID: 25043402 PMCID: PMC4075419 DOI: 10.1186/cc13942] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Few antimicrobials are currently active to treat infections caused by extremely resistant Gram-negative bacilli (ERGNB), which represent a serious global public health concern. Tigecycline, which covers the majority of these ERGNB (with the exception of Pseudomonas aeruginosa), is not currently approved for hospital-acquired pneumonia, and several meta-analyses have suggested an increased risk of death in patients receiving this antibiotic. Other studies suggest that the use of high-dose tigecycline may represent an alternative in daily practice. De Pascale and colleagues report that the clinical cure rate in patients with ventilator-associated pneumonia is significantly higher with a high dose of tigecycline than with the conventional dose, although mortality was unaffected. This high dose is safe; no patients required discontinuation or dose reduction.
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Bowers DR, Hunter AS, Jacobs DM, Kuper KM, Musick WL, Perez KK, Shah DN, Schilling AN. Significant publications on infectious diseases pharmacotherapy in 2012. Am J Health Syst Pharm 2014; 70:1930-40. [PMID: 24128968 DOI: 10.2146/ajhp130129] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The most important articles pertaining to infectious diseases (ID) pharmacotherapy published in 2012, as nominated and ranked by panels of pharmacists and physicians with ID expertise, are summarized. SUMMARY Members of the Houston Infectious Diseases Network were asked to nominate articles on ID research published in prominent peer-reviewed journals during the period January 1-December 31, 2012, with a major impact in the field of ID pharmacotherapy. A list of 42 nominated articles on general ID-related topics and 8 articles pertaining to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) was compiled. In a survey conducted in January 2013, members of the Society of Infectious Diseases Pharmacists (SIDP) were asked to select from the list 10 general ID articles and 1 HIV/AIDS-related article that they considered to be the most important. Of the 180 SIDP members surveyed, 100 (55%) and 44 (24%) participated in ranking the general ID and HIV/AIDS-related articles, respectively. Summaries of the highest-ranked articles in both categories are presented here. CONCLUSION With the volume of published ID-related research growing each year, both ID specialists and nonspecialists are challenged to stay current with the literature. Key ID-related publications in 2012 included updated recommendations on management of diabetic foot infections, articles on promising approaches to prevention and early treatment of HIV disease, and reports on developments in research on pharmacotherapies for methicillin-resistant Staphylococcus aureus bacteremia and Klebsiella pneumoniae infections.
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Affiliation(s)
- Dana R Bowers
- Dana R. Bowers, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, TX. Andrew S. Hunter, Pharm.D., BCPS, is Clinical Specialist-Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston. David M. Jacobs, Pharm.D., BCPS, is Postgraduate Year 2 Infectious Diseases Resident, Cardinal Health, Houston, and Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston. Kristi M. Kuper, Pharm.D., BCPS, GSPC, is Clinical Pharmacy Manager, VHA Performance Services, Houston. William L. Musick, Pharm.D., BCPS, is Clinical Specialist-Infectious Diseases; and Katherine K. Perez, Pharm.D., BCPS, is Clinical Specialist-Infectious Diseases, The Methodist Hospital, Houston. Dhara N. Shah, Pharm.D., BCPS, is Research Assistant Professor, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston. Amy N. Schilling, Pharm.D., BCPS, is Clinical Practice Specialist-Internal Medicine/Infectious Diseases, University of Texas Medical Branch, Galveston
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Roberts JA, Udy AA, Bulitta JB, Stuart J, Jarrett P, Starr T, Lassig-Smith M, Roberts NA, Dunlop R, Hayashi Y, Wallis SC, Lipman J. Doripenem population pharmacokinetics and dosing requirements for critically ill patients receiving continuous venovenous haemodiafiltration. J Antimicrob Chemother 2014; 69:2508-16. [PMID: 24879665 DOI: 10.1093/jac/dku177] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Doripenem is a newer carbapenem with little data available to guide effective dosing during renal replacement therapy in critically ill patients. The objective of this study was to determine the population pharmacokinetics of doripenem in critically ill patients undergoing continuous venovenous haemodiafiltration (CVVHDF) for acute kidney injury (AKI). METHODS This was an observational pharmacokinetic study in 12 infected critically ill adult patients with AKI undergoing CVVHDF and receiving 500 mg of doripenem intravenously every 8 h as a 60 min infusion. Serial blood samples were taken on 2 days of treatment and used for population pharmacokinetic analysis with S-ADAPT. RESULTS The median (IQR) age was 62 (53-71) years, the median (IQR) weight was 77 (67-96) kg and the median (IQR) APACHE II score was 29 (19-32). The median blood, dialysate and replacement fluid rates were 200, 1000 and 1000 mL/h, respectively. A two-compartment linear model with doripenem clearance described by CVVHDF, renal or non-renal mechanisms was most appropriate. The mean value for total doripenem clearance was 4.46 L/h and volume of distribution was 38.0 L. Doripenem clearance by CVVHDF was significantly correlated with the replacement fluid flow rate and accounted for ∼30%-37% of total clearance. A dose of 500 mg intravenously every 8 h achieved favourable pharmacokinetic/pharmacodynamics for all patients up to an MIC of 4 mg/L. CONCLUSIONS This is the first paper describing the pharmacokinetics/pharmacodynamics of doripenem in critically ill patients with AKI receiving CVVHDF. A dose of 500 mg intravenously every 8 h was appropriate for our CVVHDF settings for infections caused by susceptible bacteria.
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Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew A Udy
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Juergen B Bulitta
- Centre for Medicine Use and Safety, Monash University (Parkville Campus), Parkville, Australia
| | - Janine Stuart
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Paul Jarrett
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Therese Starr
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | | | - Rachel Dunlop
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yoshiro Hayashi
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia Royal Brisbane and Women's Hospital, Brisbane, Australia
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Roberts JA, Paul SK, Akova M, Bassetti M, De Waele JJ, Dimopoulos G, Kaukonen KM, Koulenti D, Martin C, Montravers P, Rello J, Rhodes A, Starr T, Wallis SC, Lipman J. Reply to Rhodes et al. Clin Infect Dis 2014; 59:907-8. [PMID: 24867785 DOI: 10.1093/cid/ciu403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jason A Roberts
- Burns Trauma and Critical Care Research Centre, University of Queensland Royal Brisbane and Women's Hospital, Australia Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Sanjoy K Paul
- Clinical Trials and Biostatistics Unit, Queensland Institute for Medical Research Berghofer Medical Research Institute, Australia Queensland Clinical Trials and Biostatistics Centre, School of Population Health, University of Queensland, Brisbane, Australia
| | - Murat Akova
- Hacettepe University, School of Medicine, Ankara, Turkey
| | - Matteo Bassetti
- Azienda Ospedaliera Universitaria Santa Maria della Misericordia, Udine, Italy
| | | | | | | | - Despoina Koulenti
- Burns Trauma and Critical Care Research Centre, University of Queensland Attikon University Hospital, Athens, Greece
| | - Claude Martin
- Hospital Nord, Marseille, France AzuRea Group, France
| | - Philippe Montravers
- Centre Hospitalier Universitaire Bichat-Claude Bernard, Assistance Publique Hopitaux de Paris, Université Paris VII, France
| | - Jordi Rello
- Centro de Investigacion Biomedica en Red, Vall d'Hebron Institut of Research, Universitat Autonoma de Barcelona, Spain
| | - Andrew Rhodes
- St George's Healthcare National Health Service Trust and St George's University of London, United Kingdom
| | | | - Steven C Wallis
- Burns Trauma and Critical Care Research Centre, University of Queensland
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, University of Queensland Royal Brisbane and Women's Hospital, Australia
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Augmented renal clearance: an augmented definition of appropriate antibiotic therapy?*. Crit Care Med 2014; 42:728-9. [PMID: 24534959 DOI: 10.1097/ccm.0000000000000081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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130
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Cannon JP, Lee TA, Clark NM, Setlak P, Grim SA. The risk of seizures among the carbapenems: a meta-analysis. J Antimicrob Chemother 2014; 69:2043-55. [PMID: 24744302 DOI: 10.1093/jac/dku111] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES A consensus exists among clinicians that imipenem/cilastatin is the most epileptogenic carbapenem, despite inconsistencies in the literature. METHODS We conducted a meta-analysis of all randomized controlled trials comparing carbapenems with each other or with non-carbapenem antibiotics to assess the risk of seizures for imipenem, meropenem, ertapenem and doripenem. RESULTS In the risk difference (RD) analysis, there were increased patients with seizure (2 per 1000 persons, 95% CI 0.001, 0.004) among recipients of carbapenems versus non-carbapenem antibiotics. This difference was largely attributed to imipenem as its use was associated with an additional 4 patients per 1000 with seizure (95% CI 0.002, 0.007) compared with non-carbapenem antibiotics, whereas none of the other carbapenems was associated with increased seizure. Similarly, in the pooled OR analysis, carbapenems were associated with a significant increase in the risk of seizures relative to non-carbapenem comparator antibiotics (OR 1.87, 95% CI 1.35, 2.59). The ORs for risk of seizures from imipenem, meropenem, ertapenem and doripenem compared with other antibiotics were 3.50 (95% CI 2.23, 5.49), 1.04 (95% CI 0.61, 1.77), 1.32 (95% CI 0.22, 7.74) and 0.44 (95% CI 0.13, 1.53), respectively. In studies directly comparing imipenem and meropenem, there was no difference in epileptogenicity in either RD or pooled OR analyses. CONCLUSIONS The absolute risk of seizures with carbapenems was low, albeit higher than with non-carbapenem antibiotics. Although imipenem was more epileptogenic than non-carbapenem antibiotics, there was no statistically significant difference in the imipenem versus meropenem head-to-head comparison.
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Affiliation(s)
- Joan P Cannon
- Pharmacy Services, Hines VA Hospital, Hines, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Nina M Clark
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago, Maywood, IL, USA
| | | | - Shellee A Grim
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago, Maywood, IL, USA Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Cotta MO, Roberts JA, Tabah A, Lipman J, Vogelaers D, Blot S. Antimicrobial stewardship of β-lactams in intensive care units. Expert Rev Anti Infect Ther 2014; 12:581-95. [DOI: 10.1586/14787210.2014.902308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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132
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Dimopoulos G, Poulakou G, Pneumatikos IA, Armaganidis A, Kollef MH, Matthaiou DK. Short- vs long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest 2014; 144:1759-1767. [PMID: 23788274 DOI: 10.1378/chest.13-0076] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND We performed a systematic review and meta-analysis of short- vs long-duration antibiotic regimens for ventilator-associated pneumonia (VAP). METHODS We searched PubMed and Cochrane Central Registry of Controlled Trials. Four randomized controlled trials (RCTs) comparing short (7-8 days) with long (10-15 days) regimens were identified. Primary outcomes included mortality, antibiotic-free days, and clinical and microbiologic relapses. Secondary outcomes included mechanical ventilation-free days, duration of mechanical ventilation, and length of ICU stay. RESULTS All RCTs included mortality data, whereas data on relapse and antibiotic-free days were provided in three and two out of four RCTs, respectively. No difference in mortality was found between the compared arms (fixed effect model [FEM]: OR = 1.20; 95% CI, 0.84-1.72; P = .32). There was an increase in antibiotic-free days in favor of the short-course treatment with a pooled weighted mean difference of 3.40 days (random effects model: 95% CI, 1.43-5.37; P < .001). There was no difference in relapses between the compared arms, although a strong trend to lower relapses in the long-course treatment was observed (FEM: OR = 1.67; 95% CI, 0.99-2.83; P = .06). No difference was found between the two arms regarding the remaining outcomes. Sensitivity analyses yielded similar results. CONCLUSIONS Short-course treatment of VAP was associated with more antibiotic-free days. No difference was found regarding mortality and relapses; however, a strong trend for fewer relapses was observed in favor of the long-course treatment, being mostly driven by one study in which the observed relapses were probably more microbiologic than clinical. Additional research is required to elucidate the issue.
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Affiliation(s)
- George Dimopoulos
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Garyphallia Poulakou
- 4th Department of Internal Medicine, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Ioannis A Pneumatikos
- The Department of Intensive Care, Medical School, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupoli, Greece
| | - Apostolos Armaganidis
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Dimitrios K Matthaiou
- Department of Critical Care, Medical School, University of Athens, "Attikon" University Hospital, Athens, Greece.
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Liapikou A, Rosales-Mayor E, Torres A. Pharmacotherapy for hospital-acquired pneumonia. Expert Opin Pharmacother 2014; 15:775-86. [DOI: 10.1517/14656566.2014.889115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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134
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Imipenem, meropenem, or doripenem to treat patients with Pseudomonas aeruginosa ventilator-associated pneumonia. Antimicrob Agents Chemother 2013; 58:1372-80. [PMID: 24342638 DOI: 10.1128/aac.02109-13] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Only limited data exist on Pseudomonas aeruginosa ventilator-associated pneumonia (VAP) treated with imipenem, meropenem, or doripenem. Therefore, we conducted a prospective observational study in 169 patients who developed Pseudomonas aeruginosa VAP. Imipenem, meropenem, and doripenem MICs for Pseudomonas aeruginosa isolates were determined using Etests and compared according to the carbapenem received. Among the 169 isolates responsible for the first VAP episode, doripenem MICs were lower (P<0.0001) than those of imipenem and meropenem (MIC50s, 0.25, 2, and 0.38, respectively); 61%, 64%, and 70% were susceptible to imipenem, meropenem, and doripenem, respectively (P was not statistically significant). Factors independently associated with carbapenem resistance were previous carbapenem use (within 15 days) and mechanical ventilation duration before VAP onset. Fifty-six (33%) patients had at least one VAP recurrence, and 56 (33%) died. Factors independently associated with an unfavorable outcome (recurrence or death) were a high day 7 sequential organ failure assessment score and mechanical ventilation dependency on day 7. Physicians freely prescribed a carbapenem to 88 patients: imipenem for 32, meropenem for 24, and doripenem for 32. The remaining 81 patients were treated with various antibiotics. Imipenem-, meropenem-, and doripenem-treated patients had similar VAP recurrence rates (41%, 25%, and 22%, respectively; P=0.15) and mortality rates (47%, 25%, and 22%, respectively; P=0.07). Carbapenem resistance emerged similarly among patients treated with any carbapenem. No carbapenem was superior to another for preventing carbapenem resistance emergence.
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135
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Klompas M. Set a Short Course But Follow the Patient's Course for Ventilator-Associated Pneumonia. Chest 2013; 144:1745-1747. [DOI: 10.1378/chest.13-1744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Chant C, Leung A, Friedrich JO. Optimal dosing of antibiotics in critically ill patients by using continuous/extended infusions: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R279. [PMID: 24289230 PMCID: PMC4056781 DOI: 10.1186/cc13134] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
Introduction The aim of this study was to determine whether using pharmacodynamic-based dosing of antimicrobials, such as extended/continuous infusions, in critically ill patients is associated with improved outcomes as compared with traditional dosing methods. Methods We searched Medline, HealthStar, EMBASE, Cochrane Clinical Trial Registry, and CINAHL from inception to September 2013 without language restrictions for studies comparing the use of extended/continuous infusions with traditional dosing. Two authors independently selected studies, extracted data on methodology and outcomes, and performed quality assessment. Meta-analyses were performed by using random-effects models. Results Of 1,319 citations, 13 randomized controlled trials (RCTs) (n = 782 patients) and 13 cohort studies (n = 2,117 patients) met the inclusion criteria. Compared with traditional non-pharmacodynamic-based dosing, RCTs of continuous/extended infusions significantly reduced clinical failure rates (relative risk (RR) 0.68; 95% confidence interval (CI) 0.49 to 0.94, P = 0.02) and intensive care unit length of stay (mean difference, −1.5; 95% CI, −2.8 to −0.2 days, P = 0.02), but not mortality (RR, 0.87; 95% CI, 0.64 to 1.19; P = 0.38). No significant between-trial heterogeneity was found for these analyses (I2 = 0). Reduced mortality rates almost achieved statistical significance when the results of all included studies (RCTs and cohort studies) were pooled (RR, 0.83; 95% CI, 0.69 to 1.00; P = 0.054). Conclusions Pooled results from small RCTs suggest reduced clinical failure rates and intensive care unit length-of-stay when using continuous/extended infusions of antibiotics in critically ill patients. Reduced mortality rates almost achieved statistical significance when the results of RCTs were combined with cohort studies. These results support the conduct of adequately powered RCTs to define better the utility of continuous/extended infusions in the era of antibiotic resistance.
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137
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MacVane SH, Kuti JL, Nicolau DP. Prolonging β-lactam infusion: a review of the rationale and evidence, and guidance for implementation. Int J Antimicrob Agents 2013; 43:105-13. [PMID: 24359838 DOI: 10.1016/j.ijantimicag.2013.10.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/25/2013] [Accepted: 10/28/2013] [Indexed: 10/26/2022]
Abstract
Given the sparse antibiotic pipeline and the increasing prevalence of resistant organisms, efforts should be made to optimise the pharmacodynamic exposure of currently available agents. Prolonging the infusion duration is a strategy used to increase the percentage of the dosing interval that free drug concentrations remain above the minimum inhibitory concentration (fT>MIC), the pharmacodynamic efficacy driver for time-dependent antibiotics such as β-lactams. β-Lactams, the most commonly prescribed class of antibiotics owing to their efficacy and safety profile, have been the mainstay of therapy since the discovery of penicillin over 60 years ago. Mounting evidence, including the use of population pharmacokinetic modelling and Monte Carlo simulation, suggests that prolonging the infusion time of β-lactam antibiotics may have advantages over standard infusion techniques, including an enhanced probability of achieving requisite fT>MIC exposures, lower mortality and potentially reductions in infection/antibiotic-related costs. As a result of these favourable attributes, clinical practice guidelines support the use of prolonged-infusion β-lactams in the treatment of many severe infections. This article discusses the rationale and evidence for prolonging the infusion of β-lactam antibiotics and provides guidance for the implementation of a prolonged-infusion programme.
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Affiliation(s)
- Shawn H MacVane
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA.
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138
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Nair GB, Niederman MS. Year in review 2012: Critical Care--respiratory infections. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:251. [PMID: 24438847 PMCID: PMC4057239 DOI: 10.1186/cc12773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Over the last two decades, considerable progress has been made in the understanding of disease mechanisms and infection control strategies related to infections, particularly pneumonia, in critically ill patients. Patient-centered and preventative strategies assume paramount importance in this era of limited health-care resources, in which effective targeted therapy is required to achieve the best outcomes. Risk stratification using severity scores and inflammatory biomarkers is a promising strategy for identifying sick patients early during their hospital stay. The emergence of multidrug-resistant pathogens is becoming a major hurdle in intensive care units. Cooperation, education, and interaction between multiple disciplines in the intensive care unit are required to limit the spread of resistant pathogens and to improve care. In this review, we summarize findings from major publications over the last year in the field of respiratory infections in critically ill patients, putting an emphasis on a newer understanding of pathogenesis, use of biomarkers, and antibiotic stewardship and examining new treatment options and preventive strategies.
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139
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Kumar A. An alternate pathophysiologic paradigm of sepsis and septic shock: implications for optimizing antimicrobial therapy. Virulence 2013; 5:80-97. [PMID: 24184742 PMCID: PMC3916387 DOI: 10.4161/viru.26913] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role.
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Affiliation(s)
- Anand Kumar
- Section of Critical Care Medicine; Section of Infectious Diseases; Health Sciences Centre; Winnipeg, MB Canada
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140
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Kollef MH. Ventilator-associated tracheobronchitis and ventilator-associated pneumonia: truth vs myth. Chest 2013; 144:3-5. [PMID: 23880669 DOI: 10.1378/chest.12-3015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Marin H Kollef
- From the Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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141
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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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142
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Garazzino S, Lutsar I, Bertaina C, Tovo PA, Sharland M. New antibiotics for paediatric use: A review of a decade of regulatory trials submitted to the European Medicines Agency from 2000—Why aren’t we doing better? Int J Antimicrob Agents 2013; 42:99-118. [DOI: 10.1016/j.ijantimicag.2013.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 05/04/2013] [Indexed: 10/26/2022]
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143
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Skrupky LP, Tellor BR, Mazuski JE. Current strategies for the treatment of complicated intraabdominal infections. Expert Opin Pharmacother 2013; 14:1933-47. [DOI: 10.1517/14656566.2013.821109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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144
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Affiliation(s)
- Jordi Rello
- Critical Care Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, CIBERES, Universitat Autonoma de Barcelona, Barcelona, Spain
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145
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Hsaiky L, Murray KP, Kokoska L, Desai N, Cha R. Standard Versus Prolonged Doripenem Infusion for Treatment of Gram-Negative Infections. Ann Pharmacother 2013; 47:999-1006. [DOI: 10.1345/aph.1s032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Doripenem is the most recently introduced carbapenem, with a broad spectrum of antimicrobial activity. Preliminary data indicated that activity is optimized by maximizing the time that serum concentration remains above the minimum inhibitory concentration; however, limited clinical data are available to support this approach. OBJECTIVE To compare clinical outcomes before and after implementation of a hospital-wide initiative extending the duration of infusion for doripenem from 1 hour (standard) to 4 hours (prolonged). METHODS This retrospective, quasi-experimental study compared clinical outcomes associated with doripenem administered as a 1-hour infusion versus a 4-hour infusion for treatment of suspected or documented infections caused by gram-negative organisms. Outcomes were assessed for the entire cohort, as well as for the subpopulation of patients admitted to the intensive care unit. RESULTS Two hundred patients were included; 106 patients received doripenem via standard infusion and 94 patients via prolonged infusion. No significant differences were noted between the treatment groups in clinical success, length of stay, or duration of treatment when the entire cohort was evaluated. In the critically ill subgroup, pneumonia, standard-infusion doripenem, and concomitant bacteremia were independent predictors of clinical failure (adjusted odds ratio [95% CI] 7.8 [2.4–25.6], 5.5 [1.6–18.7], and 7.0 [1.6–31.3], respectively). Additionally, critically ill patients who received doripenem via standard infusion were significantly more likely to experience recurrence of infection or death within 90 days. No significant differences were noted in length of stay or duration of bacteremia. CONCLUSIONS The duration of infusion did not significantly impact outcomes when the entire cohort was compared; however, prolonged infusion of doripenem was associated with significantly improved clinical outcomes among critically ill patients. These findings support the use of prolonged infusion of doripenem for critically ill patients.
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Affiliation(s)
- Lama Hsaiky
- Lama Hsaiky PharmD BCPS, Clinical Pharmacy Specialist–Infectious Diseases, Department of Pharmacy, Oakwood Hospital and Medical Center, Dearborn, MI
| | - Kyle P Murray
- Kyle P Murray PharmD BCPS, Clinical Pharmacist Specialist–Infectious Diseases/Critical Care Huron Valley Sinai Hospital, Commerce, MI
| | - Lianne Kokoska
- Lianne Kokoska PharmD, PGY-1 Pharmacy Practice Resident, Harper University Hospital, Detroit, MI
| | - Neha Desai
- Neha Desai PharmD, Clinical Pharmacy Manager, Oakwood Hospital and Medical Center
| | - Raymond Cha
- Raymond Cha BS PharmD, Assistant Professor of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit
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146
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Kollef MH. Antibiotics for the critically ill: more than just selecting appropriate initial therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:146. [PMID: 23714588 PMCID: PMC3707008 DOI: 10.1186/cc12698] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Critically ill patients with infection provide a number of challenges to clinicians in terms of optimizing their antimicrobial treatment. Of foremost importance, initial antibiotic treatment should be selected as to provide coverage for the causative pathogens. However, the administration of those antibiotics (dosing, interval of administration, duration of infusion, route of administration) should be prescribed in a manner to ensure optimal drug delivery to the site of infection. This is a challenge given the characteristics of many infected critically ill patients (shock, elevated cardiac output in the resuscitated state, supranormal creatinine clearance, increased volume of distribution). Intensive care unit practitioners should utilize treatment strategies that strive to deliver antibiotics in an individualized manner aimed at attaining desired pharmacokinetic/pharmacodynamic targets. The goal of such a treatment strategy is to maximize the likelihood of curing the infection and allowing the critically ill patient the best opportunity for recovery. Effective implementation of antimicrobial optimization delivery strategies will likely require a multi-disciplinary approach including intensivists, pharmacists, and infectious disease specialists.
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147
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Roux D, Ricard JD. Nouveautés et perspectives thérapeutiques des pneumonies acquises sous ventilation mécanique à Pseudomonas aeruginosa. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0679-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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148
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Huang W, Wan X. Overview of progresses in critical care medicine 2012. J Thorac Dis 2013; 5:184-92. [PMID: 23585947 DOI: 10.3978/j.issn.2072-1439.2013.02.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/21/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Wei Huang
- Department of critical care medicine, 1 hospital of Dalian medical university, Dalian 116011, China
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149
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Bhalodi AA, Keel RA, Quintiliani R, Lodise TP, Nicolau DP, Kuti JL. Pharmacokinetics of Doripenem in Infected Patients Treated Within and Outside the Intensive Care Unit. Ann Pharmacother 2013; 47:617-27. [DOI: 10.1345/aph.1r789] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Doripenem often is used in the intensive care unit (ICU) to treat serious infections. However, pharmacokinetics in this population often are altered by various physiologic changes. Current pharmacokinetic data in critically ill patients receiving doripenem are limited. OBJECTIVE To determine the pharmacokinetics of doripenem in patients treated in the ICU versus outside the ICU. METHODS A total of 3–4 serum samples were collected from 25 infected patients receiving doripenem. A 2-compartment model was fit to serum pharmacokinetic data with nonparametric adaptive grid with adaptive γ. In the structural pharmacokinetic model, clearance (Cl) was made proportional to creatinine clearance (CrCl) and an intercept term. Bayesian pharmacokinetic parameters were compared between the 2 populations. A 5000-patient Monte Carlo simulation was performed for various CrCl ranges. The probability of pharmacodynamic target attainment was calculated over a range of minimum inhibitory concentrations (MICs), assuming a target of 35% of the dosing interval that unbound drug concentrations remain above the MIC. RESULTS Mean (range) age, body mass index, and CrCl were 61 (31–90) years, 31.2 (15.1–55.5) kg/m2, and 86 (15–221) mL/min, respectively. After the Bayesian step, r2, bias, and precision were 0.97, 0.04, and 1.44 μg/mL, respectively. Mean (SD) parameters for ICU (n = 13) and non-ICU (n = 12) patients were not significantly different (p > 0.05): volume of central compartment (17.3 [11.2] vs 18.5 [11.7] L), Cl (10.1 [10.2] vs 15.5 [16.9] L/h), k12 (4.7 [4.7] vs 4.7 [4.8] h−1), and k21 (7.1 [5.5] vs 5.7 [5.3] h−1), respectively. Optimal target attainments were obtained for patients with normal renal function up to MICs of 2 μg/mL with a dose of 500 mg every 8 hours as 1-hour and 4-hour infusions. CONCLUSIONS Doripenem pharmacokinetics were similar between ICU and non-ICU patients in this population. Optimal dosing regimens should be selected based on underlying renal function and suspected MIC of the infecting pathogen.
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Affiliation(s)
- Amira A Bhalodi
- Amira A Bhalodi PharmD, Research Fellow, Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - Rebecca A Keel
- Rebecca A Keel PharmD, Research Fellow, Center for Anti-Infective Research and Development, Hartford Hospital
| | - Richard Quintiliani
- Richard Quintiliani MD, Infectious Diseases Physician, Division of Infectious Diseases, Hartford Hospital and Connecticut Multi-Specialty Group
| | - Thomas P Lodise
- Thomas P Lodise PharmD, Associate Professor, Albany College of Pharmacy and Health Sciences, Albany, NY
| | - David P Nicolau
- David P Nicolau PharmD, Director, Center for Anti-Infective Research and Development and Division of Infectious Diseases, Hartford Hospital
| | - Joseph L Kuti
- Joseph L Kuti PharmD, Associate Director, Center for Anti-Infective Research and Development, Hartford Hospital
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150
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Martin-Loeches I, Torres A. A week seems to be weak: tailoring duration of antibiotic treatment in Gram-negative ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:106. [PMID: 23336300 PMCID: PMC4057223 DOI: 10.1186/cc11899] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The optimal length of antimicrobial therapy has not been extensively studied for a great majority of infections and, in critically ill patients affected by ventilator-associated pneumonia, is a persisting and unsolved issue confronting clinicians. The integration of biomarkers, clinical judgment, and microbiologic eradication might help to define a shorter duration for some ventilator-associated pneumonia episodes due to non-fermenting Gram-negative bacilli, but until these strategies are implemented in clinical practice for individualizing antibiotic treatment, a short-course duration does not seem to tailor a long benefit.
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