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Rebholz D, Liebchen U, Paal M, Vogeser M, Starp J, Gräfe C, Brozat CI, Happich FL, Habler K, Scharf C. Can linezolid be validly measured in endotracheal aspiration in critically ill patients? A proof-of-concept trial. Intensive Care Med Exp 2024; 12:47. [PMID: 38717627 PMCID: PMC11078899 DOI: 10.1186/s40635-024-00630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-infectives such as linezolid is routinely performed in blood of intensive care unit (ICU) patients to optimize target attainment. However, the concentration at the site of infection is considered more important for a successful therapy. Until now, bronchoalveolar lavage (BAL) is the gold standard to measure intrapulmonary concentrations of anti-infective agents. However, it is an invasive method and unsuitable for regular TDM. The aim of this proof-of-concept study was to investigate whether it is possible to reliably determine the intrapulmonary concentration of linezolid from endotracheal aspiration (ENTA). METHODS Intubated ICU patients receiving 600 mg intravenous linezolid twice daily were examined in steady state. First, preliminary experiments were performed in six patients to investigate which patients are suitable for linezolid measurement in ENTA. In a second step, trough and peak linezolid concentrations of plasma and ENTA were determined in nine suitable patients. RESULTS Linezolid can validly be detected in ENTA with viscous texture and > 0.5 mL volume. The mean (SD) linezolid trough concentration was 2.02 (1.27) mg/L in plasma and 1.60 (1.36) mg/L in ENTA, resulting in a median lung penetration rate of 104%. The mean (SD) peak concentration in plasma and ENTA was 10.77 (5.93) and 4.74 (2.66) mg/L. CONCLUSIONS Linezolid can validly be determined in ENTA with an adequate texture and volume. The penetration rate is comparable to already published BAL concentrations. This method might offer a simple and non-invasive method for TDM at the site of infection "lung". Due to promising results of the feasibility study, comparison of ENTA and BAL in the same patient should be investigated in a further trial.
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Affiliation(s)
- Diana Rebholz
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Starp
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Caroline Gräfe
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Clara I Brozat
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Felix L Happich
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Habler
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany.
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Geilen J, Kainz M, Zapletal B, Naka A, Tichy J, Jäger W, Böhmdorfer M, Zeitlinger M, Schultz MJ, Stamm T, Ritschl V, Geleff S, Tschernko E. Antimicrobial Drug Penetration Is Enhanced by Lung Tissue Inflammation and Injury. Am J Respir Crit Care Med 2024; 209:829-839. [PMID: 38099833 DOI: 10.1164/rccm.202306-0974oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/15/2023] [Indexed: 04/04/2024] Open
Abstract
Rationale: Pneumonia is a frequent and feared complication in intubated critically ill patients. Tissue concentrations of antimicrobial drugs need to be sufficiently high to treat the infection and also prevent development of bacterial resistance. It is uncertain whether pulmonary inflammation and injury affect antimicrobial drug penetration into lung tissue.Objectives: To determine and compare tissue and BAL fluid concentrations of ceftaroline fosamil and linezolid in a model of unilateral acute lung injury in pigs and to evaluate whether dose adjustment is necessary to reach sufficient antimicrobial concentrations in injured lung tissue.Methods: After induction of unilateral acute lung injury, ceftaroline fosamil and linezolid were administered intravenously. Drug concentrations were measured in lung tissue through microdialysis and in blood and BAL fluid samples during the following 8 hours. The primary endpoint was the tissue concentration area under the concentration curve in the first 8 hours (AUC0-8 h) of the two antimicrobial drugs.Measurements and Main Results: In 10 pigs, antimicrobial drug concentrations were higher in inflamed and injured lung tissue compared with those in uninflamed and uninjured lung tissue (median ceftaroline fosamil AUC0-8 h [and interquartile range] = 26.7 mg ⋅ h ⋅ L-1 [19.7-39.0] vs. 16.0 mg ⋅ h ⋅ L-1 [13.6-19.9], P = 0.02; median linezolid AUC0-8 h 76.0 mg ⋅ h ⋅ L-1 [68.1-96.0] vs. 54.6 mg ⋅ h ⋅ L-1 [42.7-60.9], P = 0.01), resulting in a longer time above the minimal inhibitory concentration and in higher peak concentrations and dialysate/plasma ratios. Penetration into BAL fluid was excellent for both antimicrobials, but without left-to-right differences (ceftaroline fosamil, P = 0.78; linezolid, P = 1.00).Conclusions: Tissue penetration of two commonly used antimicrobial drugs for pneumonia is enhanced by early lung tissue inflammation and injury, resulting in longer times above the minimal inhibitory concentration. Thus, lung tissue inflammation ameliorates antimicrobial drug penetration during the acute phase.
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Affiliation(s)
- Johannes Geilen
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Matthias Kainz
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Bernhard Zapletal
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Asami Naka
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Johanna Tichy
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Walter Jäger
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Michaela Böhmdorfer
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Clinical Pharmacokinetics/Pharmacogenetics, and Imaging
| | - Marcus J Schultz
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
- Department of Intensive Care, Amsterdam University Medical Centers, location "AMC", University of Amsterdam, Amsterdam, the Netherlands; and
| | - Tanja Stamm
- Institute of Outcomes Research, Center for Medical Data Science, and
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Valentin Ritschl
- Institute of Outcomes Research, Center for Medical Data Science, and
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Silvana Geleff
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Edda Tschernko
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
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Chang J, Tasellari A, Wagner JL, Scheetz MH. Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents. Expert Rev Anti Infect Ther 2023; 21:1309-1325. [PMID: 37876291 DOI: 10.1080/14787210.2023.2275663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades. AREAS COVERED Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations. EXPERT OPINION Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Ardita Tasellari
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Jamie L Wagner
- School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
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El-Kimary EI, Allam AN, Khafagy ES, Hegazy WAH. Analytical Methodologies for the Estimation of Oxazolidinone Antibiotics as Key Members of anti-MRSA Arsenal: A Decade in Review. Crit Rev Anal Chem 2023:1-30. [PMID: 37378883 DOI: 10.1080/10408347.2023.2228902] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Gram-positive bacterial infections are among the most serious diseases related with high mortality rates and huge healthcare costs especially with the rise of antibiotic-resistant strains that limits treatment options. Thus, development of new antibiotics combating these multi-drug resistant bacteria is crucial. Oxazolidinone antibiotics are the only totally synthetic group of antibiotics that showed activity against multi-drug resistant Gram positive bacteria including MRSA because of their unique mechanism of action in targeting protein synthesis. This group include approved marketed members (tedizolid, linezolid and contezolid) or those under development (delpazlolid, radezolid and sutezolid). Due to the significant impact of this class, larger number of analytical methods were required to meet the needs of both clinical and industrial studies. Analyzing these drugs either alone or with other antimicrobial agents commonly used in ICU, in the presence of pharmaceutical or endogenous biological interferences, or in the presence of matrix impurities as metabolites and degradation products poses a big analytical challenge. This review highlights current analytical approaches published in the last decade (2012-2022) that dealt with the determination of these drugs in different matrices and discusses their advantages and disadvantages. Various techniques have been described for their determination including chromatographic, spectroscopic, capillary electrophoretic and electroanalytical methods. The review comprises six sections (one for each drug) with their related tables that depict critical figures of merit and some experimental conditions for the reviewed methods. Furthermore, future perspectives about the analytical methodologies that can be developed in the near future for determination of these drugs are suggested.
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Affiliation(s)
- Eman I El-Kimary
- Faculty of Pharmacy, Department of Pharmaceutical Analytical Chemistry, Alexandria University, Alexandria, Egypt
- Pharmacy Program, Department of Pharmaceutical Sciences (Chemistry), Oman College of Health Sciences, Muscat, Oman
| | - Ahmed N Allam
- Faculty of Pharmacy, Department of Pharmaceutics, Alexandria University, Alexandria, Egypt
- Pharmacy Program, Department of Pharmaceutics, Oman College of Health Sciences, Muscat, Oman
| | - El-Sayed Khafagy
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-kharj, Saudi Arabia
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Wael A H Hegazy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
- Pharmacy Program, Department of Pharmaceutical Sciences (Microbiology and Immunology), Oman College of Health Sciences, Muscat, Oman
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Targeted Therapy of Severe Infections Caused by Staphylococcus aureus in Critically Ill Adult Patients: A Multidisciplinary Proposal of Therapeutic Algorithms Based on Real-World Evidence. Microorganisms 2023; 11:microorganisms11020394. [PMID: 36838359 PMCID: PMC9960997 DOI: 10.3390/microorganisms11020394] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 02/08/2023] Open
Abstract
(1) Introduction: To develop evidence-based algorithms for targeted antibiotic therapy of infections caused by Staphylococcus aureus in critically ill adult patients. (2) Methods: A multidisciplinary team of four experts had several rounds of assessment for developing algorithms concerning targeted antimicrobial therapy of severe infections caused by Staphylococcus aureus in critically ill patients. The literature search was performed by a researcher on PubMed-MEDLINE (until August 2022) to provide evidence for supporting therapeutic choices. Quality and strength of evidence was established according to a hierarchical scale of the study design. Two different algorithms were created, one for methicillin-susceptible Staphylococcus aureus (MSSA) and the other for methicillin-resistant Staphylococcus aureus (MRSA). The therapeutic options were categorized for each different site of infection and were selected also on the basis of pharmacokinetic/pharmacodynamic features. (3) Results: Cefazolin or oxacillin were the agents proposed for all of the different types of severe MSSA infections. The proposed targeted therapies for severe MRSA infections were different according to the infection site: daptomycin plus fosfomycin or ceftaroline or ceftobiprole for bloodstream infections, infective endocarditis, and/or infections associated with intracardiac/intravascular devices; ceftaroline or ceftobiprole for community-acquired pneumonia; linezolid alone or plus fosfomycin for infection-related ventilator-associated complications or for central nervous system infections; daptomycin alone or plus clindamycin for necrotizing skin and soft tissue infections. (4) Conclusions: We are confident that targeted therapies based on scientific evidence and optimization of the pharmacokinetic/pharmacodynamic features of antibiotic monotherapy or combo therapy may represent valuable strategies for treating MSSA and MRSA infections.
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Zoller M, Liebchen U, Scharf C. Authors' response: "Serum linezolid concentrations are reduced in critically ill patients with pulmonary infections: A prospective observational study". J Crit Care 2022; 72:154168. [PMID: 36241467 DOI: 10.1016/j.jcrc.2022.154168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Zoller
- Department of Anesthesiology, LMU Hospital, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Munich, Germany
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Zoller M, Paal M, Greimel A, Kallee S, Vogeser M, Irlbeck M, Schroeder I, Liebchen U, Scharf C. Serum linezolid concentrations are reduced in critically ill patients with pulmonary infections: A prospective observational study. J Crit Care 2022; 71:154100. [PMID: 35780622 DOI: 10.1016/j.jcrc.2022.154100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
RATIONALE The concentration-time profile of linezolid varies considerably in critically ill patients. Question of interest is, if the site of infection influences linezolid serum concentrations. METHODS 68 critically ill patients, treated with linezolid, were included. The concentration-time-profile for linezolid was determined using maximum a-posteriori predictions. A trough concentration (Cmin) between 2 and 10 mg/L was defined as the target. A generalized linear model (GLM) was established to evaluate potential covariates. RESULTS The indications for linezolid therapy were in descending order: peritonitis (38.2%), pneumonia (25.0%), infectious acute respiratory distress syndrome (ARDS) (19.1%), and other non-pulmonary infection (17.7%). 27.2 and 7.9% of Cmin were subtherapeutic and toxic, respectively. In the GLM, ARDS (mean: -2.1 mg/L, CI: -3.0 to -1.2 mg/L) and pneumonia (mean: -2.2 mg/L, CI: -2.8 to -1.6 mg/L) were significant (p < 0.001) determinants of Cmin. Patients with ARDS (mean: 2.3 mg/L, 51.2% subtherapeutic, 0.0% toxic) and pneumonia (mean: 3.5 mg/L, 41.5% subtherapeutic, 7.7% toxic) had significantly (p < 0.001) lower Cmin than those with peritonitis (mean: 5.5 mg/L, 14.4% subtherapeutic, 9.3% toxic) and other non-pulmonary infection (mean: 5.2 mg/L, 3.3% subtherapeutic, 16.5% toxic). CONCLUSION Linezolid serum concentrations are reduced in patients with pulmonary infections. Future studies should investigate if other linezolid thresholds are needed in those patients due to linezolid pooling in patients´ lung.
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Affiliation(s)
- Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Antonia Greimel
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany.
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