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Palmer R, Telang S, Ball JR, Chung BC, Hong K, Lieberman JR, Heckmann ND. Super-Obesity is Associated with an Increased Risk of Complications Following Primary Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00624-7. [PMID: 38889806 DOI: 10.1016/j.arth.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Obesity, defined as a body mass index (BMI) ≥ 30, is an ever-growing epidemic, with > 35% of adults in the United States currently classified as obese. Super-obese individuals, defined as those who have a BMI ≥ 50, are the fastest-growing portion of this group. This study sought to quantify the infection risk as well as the incidence of surgical, medical, and thromboembolic complications among super-obese patients undergoing total knee arthroplasty (TKA). METHODS An all-payer claims database was used to identify patients who underwent elective, primary TKA between 2016 and 2021. Patients who had a BMI ≥ 50 were compared to those who had a normal BMI of 18 to 25. Demographics and the incidence of 90-day postoperative complications were compared between the two groups. Univariate analysis and multivariable regression were used to assess differences between groups. RESULTS In total, 3,376 super-obese TKA patients were identified and compared to 17,659 patients who had a normal BMI. Multivariable analysis indicated that the super-obese cohort was at an increased postoperative risk of periprosthetic joint infection (PJI) (adjusted odds ratio [aOR] 3.7, 95% confidence interval [CI]: 2.1 to 6.4, P < 0.001), pulmonary embolism (aOR 2.2, 95%-CI: 1.0 to 5.0, P = 0.047), acute respiratory failure (aOR 4.1, 95%-CI: 2.7 to 6.1, P < 0.001), myocardial infarction (aOR 2.5, 95%-CI: 1.1 to 5.8, P = 0.026), wound dehiscence (aOR 2.3, 95%-CI: 1.4 to 3.8, P = 0.001), and acute renal failure (aOR 3.2, 95%-CI: 2.4 to 4.2, P < 0.001) relative to patients who have normal BMI. CONCLUSION Super-obese TKA patients are at an elevated risk of postoperative infectious, surgical, medical, and thromboembolic complications. As such, risk stratification, as well as appropriate medical management and optimization, is of utmost importance for this high-risk group.
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Affiliation(s)
- Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sagar Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jacob R Ball
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brian C Chung
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kurt Hong
- Center for Clinical Nutrition, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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2
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Liu S, Matvekas A, Naimi T, Ghanem A, Li R, Rajanayake K, Derstine B, Ross B, Sullivan J, Yun HG, Regenbogen S, Byrn J, Su G, Wang S, Pai MP. Morphomics-informed population pharmacokinetic and physiologically-based pharmacokinetic modeling to optimize cefazolin surgical prophylaxis. Pharmacotherapy 2024; 44:77-86. [PMID: 37728152 PMCID: PMC10841046 DOI: 10.1002/phar.2878] [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: 04/14/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Cefazolin is the leading antibiotic used to prevent surgical site infections worldwide. Consensus guidelines recommend adjustment of the cefazolin dose above and below 120 kg without regard to body composition. Algorithms exist to repurpose radiologic data into body composition (morphomics) and inform dosing decisions in obesity. OBJECTIVES To compare the current standard of body weight to morphomic measurements as covariates of cefazolin pharmacokinetics and aid dose stratification of cefazolin in patients with obesity undergoing colorectal surgery. METHODS This prospective study measured cefazolin plasma, fat, and colon tissue concentrations in colorectal surgery patients in order to develop a morphomics-informed population pharmacokinetic (PopPK) model to guide dose adjustments. A physiologically-based pharmacokinetic (PBPK) model was also constructed to inform tissue partitioning in morbidly obese patients (n = 21, body mass index ≥35 kg/m2 with one or more co-morbid conditions). RESULTS Morphomics and pharmacokinetic data were available in 58 patients with a median [min, max] weight and age of 95.9 [68.5, 148.8] kg and 55 [25, 79] years, respectively. The plasma-to-subcutaneous fat partition coefficient was predicted to be 0.072 and 0.060 by the PopPK and PBPK models, respectively. The estimated creatinine clearance (eCLcr ) and body depth at the third lumbar vertebra (body depth_L3) were identified as covariates of cefazolin exposure. The probability of maintaining subcutaneous fat concentrations above 2 μg/mL for 100% of a 4-h surgical period was below 90% when eCLcr ≥105 mL/min and body depth_L3 ≥ 300 mm and less sensitive to the rate of infusion between 5 and 60 min. CONCLUSIONS Kidney function and morphomics were more informative than body weight as covariates of cefazolin target site exposure. Data from more diverse populations, consensus on target cefazolin exposure, and comparative studies are needed before a change in practice can be implemented.
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Affiliation(s)
- Shuhan Liu
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aleksas Matvekas
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Tamara Naimi
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Aws Ghanem
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Ruiting Li
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | | | - Brian Derstine
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Brian Ross
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - June Sullivan
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Hyun Gi Yun
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
| | - Scott Regenbogen
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John Byrn
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Grace Su
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Stewart Wang
- University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Manjunath P. Pai
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan, USA
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Kominiarek MA, Cassimatis I, Peace J, Premkumar A, Toledo P, O'Dwyer L. Peripartum care of persons with obesity: a scoping review of recommendations and practical tools for implementation. BMJ Open 2022; 12:e061430. [PMID: 36123084 PMCID: PMC9486274 DOI: 10.1136/bmjopen-2022-061430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Despite the growing prevalence of obesity among reproductive aged persons in the USA, evidence-based guidelines for peripartum care are lacking. The objective of this scoping review is to identify obesity-related recommendations for peripartum care, evaluate grades of evidence for each recommendation, and identify practical tools (eg, checklists, toolkits, care pathways and bundles) to support their implementation in clinical practice. DATA SOURCES We searched MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov from inception to December 2020 for eligible studies addressing peripartum care in persons with obesity. STUDY ELIGIBILITY CRITERIA Inclusion criteria were published evidence-rated recommendations and practical tools for peripartum care of persons with obesity. STUDY APPRAISAL AND SYNTHESIS METHODS Pairs of independent reviewers extracted data (source, publication year, content and number of recommendations, level and grade of evidence, description of tool) and identified similarities and differences among the articles. RESULTS Of 18 315 screened articles, 18 were included including 7 articles with evidence-rated recommendations and 11 practical tools (3 checklists, 3 guidelines, 1 care bundle, 1 flowchart, 1 care pathway, 1 care map and 1 protocol). Thirteen of 39 evidence-rated recommendations were based on expert opinion. Recommendations related to surgical antibiotic prophylaxis and subcutaneous tissue closure at caesarean delivery received the highest grade of evidence. Some of the practical tools included a checklist from the USA regarding anticoagulation after caesarean delivery (evidence-supported recommendation), a bundle for surgical site infections after caesarean delivery in Australia (evidence did not support recommendation) and a checklist with content for several aspects of peripartum care from Canada (evidence supported seven of nine definitive recommendations). CONCLUSION The recommendations for peripartum care for persons with obesity are based on limited evidence and few practical tools for implementation exist. Future work should focus on developing practical tools based on high-quality studies.
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Affiliation(s)
- Michelle A Kominiarek
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irina Cassimatis
- Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jack Peace
- Anesthesiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ashish Premkumar
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Obstetrics and Gynecology, John H Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Paloma Toledo
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Linda O'Dwyer
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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4
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Timing of Adjunctive Azithromycin for Unscheduled Cesarean Delivery and Postdelivery Infection. Obstet Gynecol 2022; 139:1043-1049. [DOI: 10.1097/aog.0000000000004788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
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Abduljalil K, Ning J, Pansari A, Pan X, Jamei M. Prediction of Maternal and Fetoplacental Concentrations of Cefazolin, Cefuroxime and Amoxicillin during Pregnancy using bottom-up Physiologically based Pharmacokinetic Models. Drug Metab Dispos 2022; 50:386-400. [DOI: 10.1124/dmd.121.000711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
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6
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Elkayal O, Allegaert K, Spriet I, Smits A, Seghaye MC, Charlier C, Dreesen E. Population pharmacokinetics of cefazolin in maternal and umbilical cord plasma, and simulated exposure in term neonates. J Antimicrob Chemother 2021; 76:3229-3236. [PMID: 34499720 DOI: 10.1093/jac/dkab329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/14/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intra-partum cefazolin is used to prevent group B Streptococcus (GBS) vertical transmission in mothers allergic to penicillin without a history of anaphylaxis. OBJECTIVES To investigate the maternal cefazolin dose-exposure relationship and subsequent maternal and neonatal target attainment at delivery. METHODS Data were obtained from 24 healthy, GBS-colonized pregnant women (20-41 years), undergoing vaginal delivery (gestational age ≥37 weeks). During labour, all women received a 2 g cefazolin IV infusion. Eight hours later, eight women received another 1 g in the event of delayed (>8 h) delivery. Next to maternal plasma concentrations (up to 10 per dosing interval, until delivery), venous and arterial umbilical cord concentrations were determined at delivery. Target attainment in maternal/neonatal plasma was set at 1 mg/L for 60% of the dosing interval (unbound cefazolin, worst-case clinical breakpoint). A population pharmacokinetic (popPK) model was built (NONMEM 7.4). ClinicalTrials.gov Identifier: NCT01295606. RESULTS At delivery, maternal blood and arterial umbilical cord unbound cefazolin concentrations were >1 mg/L in 23/24 (95.8%) and 11/12 (91.7%), respectively. The popPK of cefazolin in pregnant women was described by a two-compartment model with first-order elimination. Two additional compartments described the venous and arterial umbilical cord concentration data. Cefazolin target attainment was adequate in the studied cohort, where delivery occurred no later than 6.5 h after either the first or the second dose. PopPK simulations showed adequate maternal and umbilical cord exposure for 12 h following the first dose. CONCLUSIONS PopPK simulations showed that standard pre-delivery maternal cefazolin dosing provided adequate target attainment up to the time of delivery.
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Affiliation(s)
- Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | | | - Corinne Charlier
- Department of Toxicology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
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7
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Lavie M, Lavie I, Cohen A, Levin I, Many A, Fouks Y. Cefazolin prophylaxis in minimally invasive gynecologic surgery - are dosage and timing appropriate? Prospective study using resampling simulation. J Gynecol Obstet Hum Reprod 2021; 50:102154. [PMID: 33905919 DOI: 10.1016/j.jogoh.2021.102154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/20/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Cefazolin is a widely used antimicrobial prophylactic agent, however the appropriate dosage, timing, pharmacology and microbial coverage have not been well-established for gynecologic procedures. We aimed to describe serum concentrations and pharmacokinetics of Intravenous cefazolin given to women prior to scheduled minimally invasive gynecologic surgeries, and to determine whether appropriate antimicrobial coverage had been achieved in short time from prophylactic administration to surgical start time. METHODS A prospective cohort analysis study, using a resampled dataset, of women undergoing scheduled gynecological surgeries in a university affiliated tertiary medical center. IV cefazolin (1 or 2 gr) was administered prior to incision to women weighing <80 kg (Group A) and ≥80 kg (Group B), respectively. Cefazolin serum levels were obtained at the time of skin incision (Time 0) and 30 min later (Time 30), measured by high-pressure liquid chromatography (HPLC). Appropriate antimicrobial coverage was defined when cefazolin serum levels were above minimal inhibitory concentrations (MIC) for Enterobacteriaceae. RESULTS Overall, 21 women were included. The mean time interval between drug administration and incision did not differ between the two groups (18 ± 10 min vs. 11 ± 10 min, respectively, p = .0.25). A hierarchical mixed linear regression model, using a simulation of multiple random bootstrap resampling (n = 1,000), revealed that cefazolin serum levels exceeded MIC, regardless of the timing of administration in the sampling intervals. Mean cefazolin serum levels in time 0 and time 30 min were not affected by BMI in patients receiving 1 gr. CONCLUSION A single dose of IV cefazolin given shortly prior to skin incision provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled minimally invasive gynecologic surgery.
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Affiliation(s)
- Michael Lavie
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Inbar Lavie
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviad Cohen
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ishai Levin
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuval Fouks
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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8
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Maggio L. Medications for Pregnant Women With Obesity: Special Considerations. Clin Obstet Gynecol 2021; 64:214-225. [PMID: 33306496 DOI: 10.1097/grf.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pregnant women with obesity are at increased risk of a multitude of complications of pregnancy and adverse perinatal outcomes. The risk of some of these complications, such as neural tube defects or preeclampsia, may be mitigated by some medications. Other complications, such as diabetes, venous thromboembolism, and infections, require treatment with medications. Given the changes in pharmacokinetics and pharmacodynamics during pregnancy, which is further enhanced by obesity, the optimal medication and its dose is often researched. This chapter further explores the different complications and common medications that women with obesity are likely to require.
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Affiliation(s)
- Lindsay Maggio
- Division of Maternal Fetal Medicine, Nemours Children's Hospital, Orlando, Florida
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9
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A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women. J Clin Med 2021; 10:jcm10040675. [PMID: 33578671 PMCID: PMC7916387 DOI: 10.3390/jcm10040675] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 12/16/2022] Open
Abstract
(1) Background: Caesarean sections in obese patients are associated with an increased risk of surgical wound complications, including hematomas, seromas, abscesses, dehiscence, and surgical site infections. The aim of the present study is to perform a meta-analysis and systematic review of the current literature focusing on the strategies available to decrease wound complications in this population. (2) Methods: We reviewed the data available from the PubMed and the Science Direct databases concerning wound complications after caesarean sections in obese women. The following key words were used: “caesarean section”, “cesarean section”, “wound complication”, “wound morbidity”, and “wound infection”. A total of 540 papers were retrieved, 40 of which were selected for the final systematic review and whereas 21 articles provided data for meta-analysis. (3) Results: The conducted meta-analyses revealed that the use of prophylactic drainage does not increase the risk of wound complications in obese women after a caesarean sections (pooled OR = 1.32; 95% CI 0.64–2.70, p = 0.45) and that vertical skin incisions increase wound complications (pooled OR = 2.48; 95% CI 1.85–3.32, p < 0.01) in obese women, including extremely obese women. (4) Conclusions: Subcutaneous drainage does not reduce the risk of a wound complications, wound infections, and fever in obese women after caesarean sections. Negative prophylactic pressure wound therapy (NPWT) may reduce the risk of surgical site infections. The evidence of using a prophylactic dose of an antibiotic before the caesarean section is still lacking.
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10
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Fouks Y, Ashwal E, Yogev Y, Amit S, Ben Mayor Bashi T, Sinai N, Firsow A, Hasson E, Gamzu R, Many A. Calculating the appropriate prophylactic dose of cefazolin in women undergoing cesarean delivery. J Matern Fetal Neonatal Med 2020; 35:2518-2523. [PMID: 32662688 DOI: 10.1080/14767058.2020.1786529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical site infection and other postoperative complications are relatively common in obstetrical procedures, and they are associated with morbidity, prolonged hospital stay, and readmissions. Appropriate levels of antimicrobial agents given directly before skin incision can prevent the establishment of surgical-related infection caused by endogenous microorganisms present on the woman's skin. We aimed to determine serum concentrations of cefazolin given to pregnant women prior to scheduled cesarean delivery and to compare their drug concentrations and pharmacokinetics in 2 weight groups. STUDY DESIGN We conducted a prospective cohort analysis of the pharmacokinetics of cefazolin in women undergoing cesarean delivery (August 2017 to September 2018). One or two grams of intravenous cefazolin was administered within 30 min prior to skin incision to women weighing <80 kg and ≥80 kg, respectively. Maternal serum samples were obtained at skin incision and 30 min later. The serum concentration of cefazolin was measured by high-pressure liquid chromatography. Antimicrobial coverage was defined as being appropriate when the cefazolin levels were above the minimal inhibitory concentration. Pharmacokinetic parameters were estimated using a one-compartment model. RESULTS A total of 61 women were enrolled, of whom 47 underwent cesarean delivery (study group). The mean time that had elapsed between drug administration to incision was 13 ± 6.9 min (95% confidence interval 10.6-16.2 min). The drug levels after 30 min in women who weighed >80 kg and in women who received 2 g cefazolin, after 30 min from incision differed significantly (87.0 ± 26.0 vs 55.4 ± 16.6 μg/ml, p = .0001). CONCLUSION A single 1- or 2-g dose of cefazolin provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled cesarean delivery.
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Affiliation(s)
- Yuval Fouks
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Sharon Amit
- The Department of Clinical Microbiology and Infectious Diseases, Hadassah University Hospital, Jerusalem, Israel
| | - Tali Ben Mayor Bashi
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Noa Sinai
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Anastasia Firsow
- The Clinical Biochemistry Laboratory, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Hasson
- The Clinical Biochemistry Laboratory, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronni Gamzu
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
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11
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Villamor E, Norman M, Johansson S, Cnattingius S. Maternal Obesity and Risk of Early-onset Neonatal Bacterial Sepsis: Nationwide Cohort and Sibling-controlled Studies. Clin Infect Dis 2020; 73:e2656-e2664. [PMID: 32770206 DOI: 10.1093/cid/ciaa783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/11/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Maternal overweight and obesity are related to risks of pregnancy and delivery complications that, in turn, are associated with newborn infections. We examined the associations between early pregnancy body mass index (BMI; kg/m2) and risk of early-onset neonatal bacterial sepsis (EOS). METHODS We conducted a nationwide population-based retrospective cohort study of 1 971 346 live singleton infants born in Sweden between 1997 and 2016. Outcome was a culture-confirmed EOS diagnosis. We estimated hazard ratios (HR) of EOS according to BMI using proportional hazard models, and identified potential mediators. Among term infants, we conducted sibling-controlled analyses. RESULTS EOS risk per 1000 live births was 1.48; 0.76 in term and 15.52 in preterm infants. Compared with infants of normal-weight mothers (BMI, 18.5-24.9), the adjusted HR (95% confidence interval [CI]) of EOS for BMI categories <18.5, 25.0-29.9, 30.0-34.9, 35.0-39.9, and ≥40.0 were, respectively, 1.07 (.83-1.40), 1.19 (1.08-1.32), 1.70 (1.49-1.94), 2.11 (1.73-2.58), and 2.50 (1.86-3.38). Maternal overweight and obesity increased the risk of EOS by group B Streptococcus, Staphylococcus aureus, and Escherichia coli. Half of the association was mediated through preeclampsia, cesarean section delivery, and preterm delivery. A dose-response association was consistently apparent in term infants only. In sibling-controlled analyses, every kilogram per meter squared interpregnancy BMI change was associated with a mean 8.3% increase in EOS risk (95% CI, 1.7%-15.3%; P = .01). CONCLUSIONS Risk of EOS increases with maternal overweight and obesity severity, particularly in term infants.
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Affiliation(s)
- Eduardo Villamor
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Mikael Norman
- Department of Clinical Science, Intervention, and Technology, Division of Pediatrics, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Johansson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Sven Cnattingius
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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12
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Allegaert K, Muller AE, Russo F, Schoenmakers S, Deprest J, Koch BCP. Pregnancy-related pharmacokinetics and antimicrobial prophylaxis during fetal surgery, cefazolin and clindamycin as examples. Prenat Diagn 2020; 40:1178-1184. [PMID: 32441341 DOI: 10.1002/pd.5753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 11/09/2022]
Abstract
Antimicrobial prophylaxis during surgery aims to prevent post-operative site infections. For fetal surgery, this includes the fetal and amniotic compartments. Both are deep compartments as drug equilibrium with maternal blood is achieved relatively late. Despite prophylaxis, chorio-amnionitis or endometritis following ex utero intrapartum treatment or fetoscopy occur in 4.13% and 1.45% respectively of the interventions. This review summarizes the observations on two commonly administered antimicrobials (cefazolin, clindamycin) for surgical prophylaxis during pregnancy, with emphasis on the deep compartments. For both compounds, antimicrobial exposure is on target when we consider the maternal and fetal plasma compartment. In contrast, amniotic fluid concentrations-time profiles display a delayed and much more blunted pattern, behaving as deep compartment. For cefazolin, there are data that document further dilution in the setting of polyhydramnios. Along this deep compartment concept, there is some accumulation during repeated administration, modeled for cefazolin and observed for clindamycin. The relative underexposure to antimicrobials in amniotic fluid may be reflected in the pattern of maternal-fetal complications after fetal surgery, and suggest that antimicrobial prophylaxis practices for fetal surgery should be reconsidered. Further studies should be designed by a multidisciplinary team (fetal surgeons, clinical pharmacologists and microbiologists) to facilitate efficient evaluation of antimicrobial prophylaxis.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden MC, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Woman's Health, University College London, London, UK
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Eley VA, Christensen R, Ryan R, Jackson D, Parker SL, Smith M, van Zundert AA, Wallis SC, Lipman J, Roberts JA. Prophylactic Cefazolin Dosing in Women With Body Mass Index >35 kg·m−2 Undergoing Cesarean Delivery: A Pharmacokinetic Study of Plasma and Interstitial Fluid. Anesth Analg 2020; 131:199-207. [DOI: 10.1213/ane.0000000000004766] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Antibiotics for the Prevention and Treatment of Postsurgical Obstetric Infections. Obstet Gynecol Surv 2019; 73:475-485. [PMID: 30169886 DOI: 10.1097/ogx.0000000000000590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Douville SE, Callaway LK, Amoako A, Roberts JA, Eley VA. Reducing post-caesarean delivery surgical site infections: a narrative review. Int J Obstet Anesth 2019; 42:76-86. [PMID: 31606251 DOI: 10.1016/j.ijoa.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/22/2019] [Accepted: 08/28/2019] [Indexed: 01/15/2023]
Abstract
Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.
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Affiliation(s)
- S E Douville
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - L K Callaway
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Obstetrics and Gynaecology/Obstetric Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - A Amoako
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Obstetrics and Gynaecology/Obstetric Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - J A Roberts
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Herston, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy and Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - V A Eley
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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16
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Löwik CAM, Zijlstra WP, Knobben BAS, Ploegmakers JJW, Dijkstra B, de Vries AJ, Kampinga GA, Mithoe G, Al Moujahid A, Jutte PC, Wouthuyzen-Bakker M. Obese patients have higher rates of polymicrobial and Gram-negative early periprosthetic joint infections of the hip than non-obese patients. PLoS One 2019; 14:e0215035. [PMID: 30958847 PMCID: PMC6453483 DOI: 10.1371/journal.pone.0215035] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/25/2019] [Indexed: 02/02/2023] Open
Abstract
Background Obese patients are more likely to develop periprosthetic joint infection (PJI) after primary total joint arthroplasty. This study compared the clinical and microbiological characteristics of non-obese, obese and severely obese patients with early PJI, in order to ultimately optimize antibiotic prophylaxis and other prevention measures for this specific patient category. Methods We retrospectively evaluated patients with early PJI of the hip and knee treated with debridement, antibiotics and implant retention (DAIR) between 2006 and 2016 in three Dutch hospitals. Only patients with primary arthroplasties indicated for osteoarthritis were included. Early PJI was defined as an infection that developed within 90 days after index surgery. Obesity was defined as a BMI ≥30kg/m2 and severe obesity as a BMI ≥35kg/m2. Results A total of 237 patients were analyzed, including 64 obese patients (27.0%) and 62 severely obese patients (26.2%). Compared with non-obese patients, obese patients had higher rates of polymicrobial infections (60.3% vs 33.3%, p<0.001) with more often involvement of Enterococcus species (27.0% vs 11.7%, p = 0.003). Moreover, severely obese patients had more Gram-negative infections, especially with Proteus species (12.9% vs 2.3%, p = 0.001). These results were only found in periprosthetic hip infections, comprising Gram-negative PJIs in 34.2% of severely obese patients compared with 24.7% in obese patients and 12.7% in non-obese patients (p = 0.018). Conclusions Our results demonstrate that obese patients with early periprosthetic hip infections have higher rates of polymicrobial infections with enterococci and Gram-negative rods, which stresses the importance of improving preventive strategies in this specific patient category, by adjusting antibiotic prophylaxis regimens, improving disinfection strategies and optimizing postoperative wound care.
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Affiliation(s)
- Claudia A. M. Löwik
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Wierd P. Zijlstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Bas A. S. Knobben
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Joris J. W. Ploegmakers
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Baukje Dijkstra
- Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Astrid J. de Vries
- Department of Orthopaedic Surgery, Martini Hospital, Groningen, The Netherlands
| | - Greetje A. Kampinga
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Glen Mithoe
- Department of Medical Microbiology, Certe Medical Diagnostics and Advice, Groningen, the Netherlands
| | - Aziz Al Moujahid
- Center for Infectious Diseases Friesland, Izore, Leeuwarden, the Netherlands
| | - Paul C. Jutte
- Department of Orthopaedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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17
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Hip and Knee Section, Prevention, Antimicrobials (Systemic): Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S279-S288. [PMID: 30348572 DOI: 10.1016/j.arth.2018.09.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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18
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ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2018; 132:e103-e119. [DOI: 10.1097/aog.0000000000002833] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Palma EC, Laureano JV, de Araújo BV, Meinhardt NG, Stein AT, Dalla Costa T. Fast and sensitive HPLC/UV method for cefazolin quantification in plasma and subcutaneous tissue microdialysate of humans and rodents applied to pharmacokinetic studies in obese individuals. Biomed Chromatogr 2018; 32:e4254. [PMID: 29656496 DOI: 10.1002/bmc.4254] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 11/05/2022]
Abstract
Antimicrobial prophylactic dosing of morbidly obese patients may differ from normal weighted individuals owing to alterations in drug tissue distribution. Drug subcutaneous tissue distribution can be investigated by microdialysis patients and animals. The need for cefazolin prophylactic dose adjustment in obese patients remains under discussion. The paper describes the validation of an HPLC-UV method for cefazolin quantification in plasma and microdialysate samples from clinical and pre-clinical studies. A C18 column with an isocratic mobile phase was used for drug separation, with detection at 272 nm. Total and unbound cefazolin lower limit of quantitation was 5 μg/mL in human plasma, 2 μg/mL in rat plasma, and 0.5 and 0.025 μg/mL in human and rat microdialysate samples, respectively. The maximum intra- and inter-day imprecisions were 10.7 and 8.1%, respectively. The inaccuracy was <9.7%. The limit of quantitation imprecision and inaccuracy were < 15%. Cefazolin stability in the experimental conditions was confirmed. Cefazolin plasma concentrations and subcutaneous tissue penetration were determined by microdialysis in morbidly obese patients (2 g i.v. bolus) and diet-induced obese rats (30 mg/kg i.v. bolus) using the method. This method has the main advantages of easy plasma clean-up and practicability and has proven to be useful in cefazolin clinical and pre-clinical pharmacokinetic investigations.
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Affiliation(s)
- Eduardo Celia Palma
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - João Victor Laureano
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Bibiana Verlindo de Araújo
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Airton Tetelbom Stein
- Center for Obese Class III Care, Nossa Senhora Conceição Hospital (HNSC), Porto Alegre, RS, Brazil
| | - Teresa Dalla Costa
- Pharmacokinetics and PK/PD Modeling Laboratory, Pharmaceutical Sciences Graduate Program, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
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20
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Prophylactic cefazolin concentrations in morbidly obese patients undergoing sleeve gastrectomy: do we achieve targets? Int J Antimicrob Agents 2018; 52:28-34. [PMID: 29501602 DOI: 10.1016/j.ijantimicag.2018.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/17/2018] [Accepted: 02/24/2018] [Indexed: 12/31/2022]
Abstract
Morbid obesity is known to increase the risk of surgical site infections. Optimal concentrations of prophylactic antibacterial drugs are required. Using Monte Carlo simulations, the aim of this work was to build a population pharmacokinetics model for a morbidly obese population to assess a 4000-mg dose of cefazolin recommended by the guidelines and to propose new administration schemes. One hundred and seventeen morbidly obese patients (mean body mass index, 46.95 kg/m2) received 4000 mg of cefazolin intravenously before sleeve gastrectomy. Using population pharmacokinetics modelling and Monte Carlo simulations, probabilities of target attainment (PTAs) (subcutaneous tissue concentration of cefazolin above the minimum inhibitory concentration (MIC) throughout the surgical procedure was targeted) were determined. For Staphylococcus spp. and Streptococcus spp., which are the most frequent species isolated from post-surgical infections in bariatric surgery (MIC usually ≤2 mg/L), PTA remains greater than 0.9 until 2 h after administration of 4000 mg of cefazolin. For MIC up to 4 mg/L, efficient prophylaxis was checked until 1 h after the initial administration. A 3000-mg regimen followed by a continuous infusion (1000 mg/h) achieves these two targets until 4 h after the loading dose. A 2000-mg and a 3000-mg regimen do not achieve sufficient concentrations. According to the duration of surgery and MIC values, an initial administration of 4000 mg should be sufficient, but for extended surgeries continuous infusion can be considered.
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21
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Scheck SM, Blackmore T, Maharaj D, Langdana F, Elder RE. Caesarean section wound infection surveillance: Information for action. Aust N Z J Obstet Gynaecol 2017; 58:518-524. [DOI: 10.1111/ajo.12755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/06/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Simon M. Scheck
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
| | - Timothy Blackmore
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
| | - Dushyant Maharaj
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
- School of Medicine; University of Otago; Otago New Zealand
| | - Fali Langdana
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
- School of Medicine; University of Otago; Otago New Zealand
| | - Rosalie E. Elder
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
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22
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Collins JW, Heyward Hull J, Dumond JB. Comparison of tenofovir plasma and tissue exposure using a population pharmacokinetic model and bootstrap: a simulation study from observed data. J Pharmacokinet Pharmacodyn 2017; 44:631-640. [PMID: 29119381 DOI: 10.1007/s10928-017-9554-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
Sparse tissue sampling with intensive plasma sampling creates a unique data analysis problem in determining drug exposure in clinically relevant tissues. Tissue exposure may govern drug efficacy, as many drugs exert their actions in tissues. We compared tissue area-under-the-curve (AUC) generated from bootstrapped noncompartmental analysis (NCA) methods and compartmental nonlinear mixed effect (NLME) modeling. A model of observed data after single-dose tenofovir disoproxil fumarate was used to simulate plasma and tissue concentrations for two destructive tissue sampling schemes. Two groups of 100 data sets with densely-sampled plasma and one tissue sample per individual were created. The bootstrapped NCA (SAS 9.3) used a trapezoidal method to calculate geometric mean tissue AUC per dataset. For NLME, individual post hoc estimates of tissue AUC were determined, and the geometric mean from each dataset calculated. Median normalized prediction error (NPE) and absolute normalized prediction error (ANPE) were calculated for each method from the true values of the modeled concentrations. Both methods produced similar tissue AUC estimates close to true values. Although the NLME-generated AUC estimates had larger NPEs, it had smaller ANPEs. Overall, NLME NPEs showed AUC under-prediction but improved precision and fewer outliers. The bootstrapped NCA method produced more accurate estimates but with some NPEs > 100%. In general, NLME is preferred, as it accommodates less intensive tissue sampling with reasonable results, and provides simulation capabilities for optimizing tissue distribution. However, if the main goal is an accurate AUC for the studied scenario, and relatively intense tissue sampling is feasible, the NCA bootstrap method is a reasonable, and potentially less time-intensive solution.
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Affiliation(s)
- Jon W Collins
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 1093 Genetic Medicine Building, 120 Mason Farm Rd, CB 7361, Chapel Hill, NC, 27599-7361, USA
| | - J Heyward Hull
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 1093 Genetic Medicine Building, 120 Mason Farm Rd, CB 7361, Chapel Hill, NC, 27599-7361, USA
| | - Julie B Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 1093 Genetic Medicine Building, 120 Mason Farm Rd, CB 7361, Chapel Hill, NC, 27599-7361, USA.
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