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Caubergs V, Van den Broucke E, Mertens B, Gijsen M, Peetermans WE, Van Wijngaerden E, Desmet S, Lagrou K, Declercq P, Quintens C, Spriet I. Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients. Infection 2024:10.1007/s15010-024-02279-w. [PMID: 38967768 DOI: 10.1007/s15010-024-02279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/21/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing. METHODS A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48 h. RESULTS First, 41% of 15.896 hospitalized patients received antimicrobials over 20 days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94). CONCLUSION After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.
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Affiliation(s)
| | - Evelyne Van den Broucke
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium.
| | - Beatrijs Mertens
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
| | - Matthias Gijsen
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of General Internal Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Eric Van Wijngaerden
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of General Internal Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Stefanie Desmet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Clinical Department of Laboratory Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Clinical Department of Laboratory Medicine, UZ Leuven, 3000, Leuven, Belgium
| | | | | | - Isabel Spriet
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
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2
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Najar H, Joas E, Jonsson V, Pålsson E, Landén M. Recent Secular Trends of Body Mass Index in Individuals With Bipolar Disorders and in the General Population. Am J Psychiatry 2024; 181:39-46. [PMID: 37727097 DOI: 10.1176/appi.ajp.20230012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
OBJECTIVE The aims of this study were to investigate secular trends and distribution of body mass index (BMI) among individuals with bipolar disorders and the general population between 2008 and 2019. METHODS Data were from the Swedish National Quality Register for Bipolar Disorder, where 24,423 adults with bipolar disorders were identified, and from the national Swedish Living Conditions Surveys, where 77,485 adults from the general population were identified. Quantile regression was used to compare the 15th, 50th, and 85th percentiles of BMI across age and study years. RESULTS The study sample included 22,127 individuals with bipolar disorders (mean age, 48 years; 63% women) and 71,894 individuals from the general population (mean age, 52 years; 51% women). BMI percentiles were higher among individuals with bipolar disorders. At the 50th percentile, the BMI group differences were 1.1 (95% CI=0.8-1.14) for men and 1.8 (95% CI=1.5-2.1) for women. The gap was widest at the 85th BMI percentile: men, 2.3 (95% CI=1.8-2.8); women, 4.1 (95% CI=3.7-4.6). BMI increased over time in both study groups, but more in the group with bipolar disorders. The changes per decade in mean BMI were 0.4 (95% CI=0.3-0.5) among men in the general population, 1.1 (95% CI=0.7-1.4) among men with bipolar disorders, 0.6 (95% CI=0.5-0.7) among women in the general population, and 1.4 (95% CI=1.1-1.7) among women with bipolar disorders. Women with bipolar disorders had the highest prevalence and the greatest rate of increase of obesity. In 2019, the obesity prevalence was 33% among women and 29% among men with bipolar disorders, compared with 13% and 15%, respectively, among women and men in the general population. CONCLUSIONS Adults with bipolar disorders had a higher BMI and a higher prevalence of obesity than the general population, indicating a higher cardiometabolic risk. Annually, BMI increased more in the group with bipolar disorders than in the general population, particularly among women and among those with high BMI.
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Affiliation(s)
- Hemen Najar
- Institute of Neuroscience and Physiology, Section of Psychiatry and Neurochemistry (Najar, Joas, Pålsson, Landén) and Institute of Medicine, School of Public Health and Community Medicine (Jonsson), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Landén)
| | - Erik Joas
- Institute of Neuroscience and Physiology, Section of Psychiatry and Neurochemistry (Najar, Joas, Pålsson, Landén) and Institute of Medicine, School of Public Health and Community Medicine (Jonsson), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Landén)
| | - Viktor Jonsson
- Institute of Neuroscience and Physiology, Section of Psychiatry and Neurochemistry (Najar, Joas, Pålsson, Landén) and Institute of Medicine, School of Public Health and Community Medicine (Jonsson), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Landén)
| | - Erik Pålsson
- Institute of Neuroscience and Physiology, Section of Psychiatry and Neurochemistry (Najar, Joas, Pålsson, Landén) and Institute of Medicine, School of Public Health and Community Medicine (Jonsson), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Landén)
| | - Mikael Landén
- Institute of Neuroscience and Physiology, Section of Psychiatry and Neurochemistry (Najar, Joas, Pålsson, Landén) and Institute of Medicine, School of Public Health and Community Medicine (Jonsson), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm (Landén)
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3
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Meng L, Mui E, Ha DR, Stave C, Deresinski SC, Holubar M. Comprehensive guidance for antibiotic dosing in obese adults: 2022 update. Pharmacotherapy 2023; 43:226-246. [PMID: 36703246 DOI: 10.1002/phar.2769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 01/28/2023]
Abstract
Drug dosing in obese patients continues to be challenging due to a lack of high-quality evidence to guide dosing recommendations. We first published guidance for antibiotic dosing in obese adults in 2017, in which we critically reviewed articles identified from a broad search strategy to develop dosing recommendations for 35 antimicrobials. In this updated narrative review, we searched Pubmed, Web of Science, and the Cochrane Library using Medical Subject Headings including anti-infectives, specific generic antimicrobial names, obese, pharmacokinetics, and others. We reviewed 393 articles, cross-referenced select cited references, and when applicable, referenced drug databases, package inserts, and clinical trial data to update dosing recommendations for 41 antimicrobials. Most included articles were pharmacokinetic studies, other less frequently included articles were clinical studies (mostly small, retrospective), case reports, and very rarely, guidelines. Pharmacokinetic changes are frequently reported, can be variable, and sometimes conflicting in this population, and do not always translate to a documented difference in clinical outcomes, yet are used to inform dosing strategies. Extended infusions, high doses, and therapeutic drug monitoring remain important strategies to optimize dosing in this population. Additional studies are needed to clinically validate proposed dosing strategies, clarify optimal body size descriptors, dosing weight scalars, and estimation method of renal function in obese patients.
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Affiliation(s)
- Lina Meng
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Emily Mui
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - David R Ha
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Christopher Stave
- Lane Medical Library, Stanford University School of Medicine, Stanford, California, USA
| | - Stan C Deresinski
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | - Marisa Holubar
- Department of Quality, Stanford Health Care, Stanford, California, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
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Population pharmacokinetics and pharmacodynamics of cefazolin using total and unbound serum concentrations in patients with high body weight. Int J Antimicrob Agents 2023; 61:106751. [PMID: 36758780 DOI: 10.1016/j.ijantimicag.2023.106751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 01/04/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
The objective of this study was to evaluate the steady state pharmacokinetics and pharmacodynamics of cefazolin in patients with a high body weight. Cefazolin was administered by 0.5-h infusions to 11 patients with total body weight (TBW) ≥120 kg receiving 3 g q8h, and 12 patients with TBW <120 kg receiving 2 g q8h. Total and unbound serum concentration-time data obtained from serial blood samples were analysed simultaneously by population pharmacokinetic modelling using NONMEM. Probability of target attainment (PTA) was calculated for various dosing regimens through Monte Carlo simulations based on the cumulative percentage of the dosing interval that the unbound concentration exceeds the minimum inhibitory concentration (MIC) value for the pathogen at steady state (fTMIC) ≥40%, ≥60% and 100%. A two-compartment model with non-linear protein binding and allometric scaling of the central volume of distribution using TBW best characterized both total and unbound concentration-time data. Unbound clearance was significantly associated with creatinine clearance, and maximum protein binding constant was significantly associated with serum albumin concentration and body mass index (P <0.05). Based on unbound concentration-time profiles, all simulated regimens achieved PTA >90% at MIC values ≤2 mg/L using fTMIC ≥40%, at MIC values ≤1 mg/L using fTMIC ≥60%, and at MIC values ≤0.5 mg/L using fTMIC of 100%. At fTMIC ≥60%, 0.5-h infusion of cefazolin 1 g q8h achieved PTA <90% at MIC values ≥2 mg/L in patients with TBW≥120 kg; however, prolonged-infusion and higher-dose regimens improved PTA to >90%. Overall, cefazolin pharmacokinetics are altered considerably in obese patients. Higher-dose and/or prolonged-infusion cefazolin regimens should be considered in patients with TBW ≥120 kg, particularly those with less-susceptible Gram-negative infections.
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5
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Hama EY, Uchiyama K, Nagasaka T, Kusahana E, Nakayama T, Yasuda I, Morimoto K, Washida N, Itoh H. High body mass index is a risk factor for transition to hemodialysis or hybrid therapy and peritoneal dialysis-related infection in Japanese patients undergoing peritoneal dialysis. Int Urol Nephrol 2022; 54:3193-3202. [PMID: 35759207 DOI: 10.1007/s11255-022-03252-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Obesity may negatively impact the clinical outcomes of patients undergoing peritoneal dialysis (PD). However, the impact of obesity on PD-related outcomes remains unclear. We herein examined the association of high body mass index (BMI) with complete hemodialysis (HD) transfer, transition to HD and PD/HD hybrid therapy, peritonitis, catheter exit-site and tunnel infection (ESI/TI), and heart failure-related hospitalization. METHODS This retrospective cohort study included 120 patients who underwent PD-catheter insertion between January 2008 and June 2018. BMI ≥ 25 kg/m2 at the time of PD-catheter insertion was defined as high BMI, and its association with outcomes was analyzed using the log-rank test and Cox proportional hazards models. RESULTS The follow-up duration was 46.2 (23.3-75.3) months. The time until transfer to HD and hybrid therapy was significantly shorter in the high BMI group than that in the low BMI group, whereas the time until HD transfer was not significantly different between the two groups (P < 0.001 and 0.18, respectively). Peritonitis-free and ESI/TI-free survivals were significantly shorter in the high BMI group than those in the low BMI group (P = 0.006 and 0.03, respectively). After adjusting for age, sex, diabetes mellitus, and estimated glomerular filtration rate, high BMI remained a significant risk factor for transferring to HD and hybrid therapy, peritonitis, and ESI/TI (hazard ratio [HR] 2.60, P < 0.001; HR 2.08, P = 0.01; HR 2.64, P = 0.02, respectively). CONCLUSION BMI ≥ 25 kg/m2 is a risk factor for transition to HD and hybrid therapy, peritonitis, and ESI/TI, but not for complete HD transfer in Japanese patients with PD.
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Affiliation(s)
- Eriko Yoshida Hama
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Kiyotaka Uchiyama
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
| | - Tomoki Nagasaka
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Ei Kusahana
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Takashin Nakayama
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Itaru Yasuda
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
| | - Kohkichi Morimoto
- Apheresis and Dialysis Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, Japan
| | - Naoki Washida
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.,Department of Nephrology, International University of Health and Welfare School of Medicine, 4-3, Kozunomori, Narita, Chiba, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Tøstesen SK, Hanberg P, Bue M, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen MB, Schmedes AV, Stilling M. Weight-based cefuroxime dosing provides comparable orthopedic target tissue concentrations between weight groups - a microdialysis porcine study. APMIS 2021; 130:111-118. [PMID: 34862642 DOI: 10.1111/apm.13198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Antibiotic prophylaxis is a key element in prevention of surgical site infections. For the majority of orthopedic procedures, antibiotic administration follows fixed dosing regimens irrespective of weight. However, this may result in insufficient antibiotic target tissue concentrations and higher risk of surgical site infections in obese individuals. The aim of this study was to investigate the effect of weight-based cefuroxime dosing on plasma and target tissue concentrations. Eighteen female pigs were allocated into three groups differentiated by weight: 53-57 kg, 73-77 kg, and 93-97 kg. Microdialysis catheters were placed for continuous sampling in bone, muscle, and subcutaneous tissue during an 8h sampling interval. Blood samples were collected as reference. Cefuroxime was administered intravenously as a bolus according to weight (20 mg/kg). The primary endpoint was the time above the cefuroxime minimal inhibitory concentration for Staphylococcus aureus (T > MIC (4 μg/mL)). Comparable target tissue T > MICs (4 μg/mL) were found between weight groups. Mean T > MIC ranged between 116-137 min for plasma, 118-154 min for bone, 109-146 min for the skeletal muscle, and 117-165 min for subcutaneous tissue across the groups. Weight-based cefuroxime (20 mg/kg) dosing approach provides comparable perioperative plasma and target tissue T > MIC (4 μg/mL) in animals between 50-100 kg body weight, and thus a comparable prophylaxis of surgical site infections.
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Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Mikkel Tøttrup
- Department of Orthopedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Maiken Stilling
- Aarhus Microdialysis Research Group, Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Jang SM, Shaw AR, Mueller BA. Size Matters: The Influence of Patient Size on Antibiotics Exposure Profiles in Critically Ill Patients on Continuous Renal Replacement Therapy. Antibiotics (Basel) 2021; 10:antibiotics10111390. [PMID: 34827327 PMCID: PMC8615189 DOI: 10.3390/antibiotics10111390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/20/2022] Open
Abstract
(1) Purpose of this study: To determine whether patient weight influences the probability of target attainment (PTA) over 72 h of initial therapy with beta-lactam (cefepime, ceftazidime, piperacillin/tazobactam) and carbapenem (imipenem, ertapenem, meropenem) antibiotics in the critical care setting. This is the first paper to address the question of whether patient size affects antibiotic PTA in the ICU. (2) Methods: We performed a post hoc analysis of Monte Carlo simulations conducted in virtual critically ill patients receiving antibiotics and continuous renal replacement therapy. The PTA was calculated for each antibiotic on the following pharmacodynamic (PD) targets: (a) were above the target organism’s minimum inhibitory concentration (≥%fT≥1×MIC), (b) were above four times the MIC (≥%fT≥4×MIC), and (c) were always above the MIC (≥100%fT≥MIC) for the first 72 h of antibiotic therapy. The PTA was analyzed in patient weight quartiles [Q1 (lightest)-Q4 (heaviest)]. Optimal doses were defined as the lowest dose achieving ≥90% PTA. (3) Results: The PTA for fT≥1×MIC led to similarly high rates regardless of weight quartiles. Yet, patient weight influenced the PTA for higher PD targets (100%fT≥MIC and fT≥4×MIC) with commonly used beta-lactams and carbapenems. Reaching the optimal PTA was more difficult with a PD target of 100%fT≥MIC compared to fT≥4×MIC. (4) Conclusions: The Monte Carlo simulations showed patients in lower weight quartiles tended to achieve higher antibiotic pharmacodynamic target attainment compared to heavier patients.
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Affiliation(s)
- Soo-Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA 92350, USA
- Correspondence:
| | - Alex R. Shaw
- Medical Strategist, Ironwood Pharmaceuticals, Boston, MA 02110, USA;
| | - Bruce A. Mueller
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA;
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Impact of Underlying Comorbidities on Outcomes of Patients Treated with Ceftaroline Fosamil for Complicated Skin and Soft Tissue Infections: Pooled Results from Three Phase III Randomized Clinical Trials. Infect Dis Ther 2021; 11:217-230. [PMID: 34741280 PMCID: PMC8847533 DOI: 10.1007/s40121-021-00557-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/21/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction In three phase III randomized controlled trials, ceftaroline fosamil was shown to be non-inferior to vancomycin plus aztreonam for the treatment of complicated skin and soft tissue infections (cSSTIs). This exploratory analysis evaluated the impact of underlying comorbidities on clinical outcomes in patients with cSSTI pooled from these three studies. Methods CANVAS 1 and 2 and COVERS evaluated ceftaroline fosamil (600 mg every 12 h [q12h]; 600 mg every 8 h [q8h; COVERS]) versus vancomycin plus aztreonam (1 g q12h each [CANVAS 1 and 2]; vancomycin 15 mg/kg q12h and aztreonam 1 g q8h [COVERS]) in hospitalized adults with cSSTI. The primary efficacy variable in each trial was clinical response at the test-of-cure (TOC) visit. Subgroup analyses were performed on the pooled clinically evaluable (CE) population, exploring the impact of age and various baseline comorbidities. Results Overall, 1808 patients were included in the CE population (1005 ceftaroline fosamil; 803 vancomycin plus aztreonam). Clinical cure rates at TOC were 89.7% (ceftaroline fosamil) and 90.8% (vancomycin plus aztreonam) (difference [95% confidence interval] − 1.13 [− 3.87, 1.67]). Clinical response rates were similar between treatment groups, regardless of age (≤ 65 years or > 65 years), and in subgroups of patients with and without diabetes mellitus, peripheral vascular disease, cancer/malignancy, renal impairment, and obesity; within these subgroups, efficacy and safety results were generally consistent with those of the overall cSSTI population. Conclusions This analysis provides supportive evidence of the efficacy of ceftaroline fosamil in patients with cSSTI and underlying comorbidities. Trial Registration CANVAS 1, NCT00424190 and CANVAS 2, NCT00423657 (both trials first posted on ClinicalTrials.gov 18/01/2007); COVERS, NCT01499277 (first posted on ClinicalTrials.gov 26/12/2011). Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00557-w.
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10
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Lapi F, Marconi E, Pecchioli S, Lagolio E, Rossi A, Concia E, Cricelli C. Reduced effectiveness among β-lactam antibiotics: a population-based cohort study in primary care in Italy. J Antimicrob Chemother 2021; 76:2186-2194. [PMID: 33963363 DOI: 10.1093/jac/dkab128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There are few data comparing the relative effectiveness of the individual β-lactams. OBJECTIVES To quantify the reduced effectiveness, defined as switching to a different antibiotic being prescribed for the same indication, among new users of β-lactam antibiotics in primary care. METHODS A retrospective cohort study was conducted using the Health Search Database, an Italian primary care data source. Patients newly prescribed with β-lactams for a specific indication between 1 January 2013 and 31 December 2017 were identified. A switch to a different antibiotic for the same indication occurring during a 30day follow-up was the study outcome. Cox regression was adopted to assess the risk of switching between the different β-lactams. RESULTS Among 178 256 patients newly treated with β-lactam antibiotics, 1172 (0.65%) switched to a different antibiotic. Amoxicillin/clavulanate (co-amoxiclav: n = 104 891) and amoxicillin (n = 21 699) were the most frequently prescribed β-lactams. The other antibiotics showed significantly higher risk of switching when compared with co-amoxiclav for lower respiratory tract [e.g. ceftriaxone, hazard ratio (HR): 1.6, 95% CI: 1.2-2.0], dental [e.g. amoxicillin, HR: 4.2, 95% CI: 2.9-5.9], and middle ear infections [e.g. amoxicillin, HR: 1.8, 95% CI: 1.1-2.7]. The same results were gathered when parenteral formulations were excluded. CONCLUSIONS The prevalence of reduced effectiveness of newly prescribed β-lactam antibiotics was lower than 1%. Specifically, the rate of switch to another antibiotic, when it was prescribed to treat low respiratory tract, dental, and middle ear infections, was lower among users of co-amoxiclav than those prescribed with other β-lactams.
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Affiliation(s)
- Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Ettore Marconi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Serena Pecchioli
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Erik Lagolio
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Alessandro Rossi
- Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Ercole Concia
- Infectious Diseases Section, Diagnostic and Public Health Department, University of Verona, Policlinico 'G. B. Rossi', Verona, Italy
| | - Claudio Cricelli
- Italian College of General Practitioners and Primary Care, Florence, Italy
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11
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Narayanan N, Lin T, Vinarov D, Bucek T, Johnson L, Mathew C, Chaudhry S, Brunetti L. Relationship Between Multidrug-Resistant Enterobacterales and Obesity in Older Adults. Infect Drug Resist 2021; 14:2527-2532. [PMID: 34234480 PMCID: PMC8255648 DOI: 10.2147/idr.s317014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/01/2021] [Indexed: 01/23/2023] Open
Abstract
Purpose The objective of our study was to determine if obesity is associated with the presence of multidrug-resistant (MDR) bacteria among Enterobacterales. Patients and Methods This two-center cohort study included adult hospitalized patients with at least one specimen sampled from any site for bacterial culture yielding an Enterobacterales bacterial species from November 2016 to May 2017. Study groups were stratified by obesity status based on body mass index <30 kg/m2 (non-obese) and ≥30 kg/m2 (obese). The primary outcome was the presence of gram-negative MDR bacteria defined as presumptive extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales (ceftriaxone resistance) or carbapenem-resistant Enterobacterales (CRE). A multivariable logistic regression model was fit to estimate the adjusted odds ratio while controlling for potential confounders. Results A total of 366 patients, 238 non-obese and 128 obese, were included. The most common gram-negative bacterial species identified was Escherichia coli (64.2%). There was a higher proportion of gram-negative MDR bacteria in obese versus non-obese patients (18.8 versus 11.3%, P=0.057). Obesity was independently associated with gram-negative MDR bacteria after controlling for confounders (adjusted odds ratio, 1.92; 95% CI 1.03–3.60). The association did not significantly vary by diabetes status (interaction term P=0.792). Conclusion Among older adult hospitalized patients, obesity was independently associated with the presence of a gram-negative MDR bacteria (presumptive ESBL or CRE) in a culture.
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Affiliation(s)
- Navaneeth Narayanan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA.,Division of Infectious Diseases, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Tiffany Lin
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - David Vinarov
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Thomas Bucek
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Liya Johnson
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Cheryl Mathew
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | | | - Luigi Brunetti
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA.,Center of Excellence in Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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12
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Tokunaga K, Suzuki C, Hasegawa M, Fujimori I. Cost Analysis in Helicobacter pylori Eradication Therapy Based on a Database of Health Insurance Claims in Japan. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:241-250. [PMID: 33889000 PMCID: PMC8057805 DOI: 10.2147/ceor.s297680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/10/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Cost-benefit is an important consideration for Helicobacter pylori (H. pylori) eradication in Japan, where 1.5 million patients were reported to receive first-line eradication annually. This study aimed to identify the optimal cost-saving triple therapy regimen for H. pylori eradication in Japan. Materials and Methods This retrospective observational study used data from a large-scale, nationwide health insurance claims database (2015‒2018). Using success rates of first-line eradication, mean total costs of first-line and second-line eradications per patient were compared between regimens including a potassium-competitive acid blocker (P-CAB) or a proton pump inhibitor (PPI), and between two clarithromycin (CAM) doses (400 and 800 mg/day). Subgroup analyses by smoking habit or body mass index (BMI) were performed. Results Among propensity score (age, gender, CAM dose, disease name)-matched patients (P-CAB regimen, n=22,002; PPI regimen, n=22,002), total costs were lower with the P-CAB than the PPI regimen (Japanese yen [JPY] 12,952 vs 13,146) owing to significantly higher first-line eradication rates with the P-CAB regimen (93.6% vs 79.7%; p<0.001). For both regimens, even among current smokers or patients with BMI ≥25 kg/m2, eradication rates did not differ by CAM dose, and total costs were approximately JPY1000 lower with CAM 400 mg/day than with CAM 800 mg/day. Conclusion High success rate of first-line eradication contributes to saving in total eradication costs by reducing costs of subsequent therapy, irrespective of patients' smoking status or BMI class. The combination of more potent acid-inhibitory medicine and low-dose CAM may be the optimal regimen in terms of efficacy and cost-benefit in Japan.
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Affiliation(s)
- Kengo Tokunaga
- Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Chihiro Suzuki
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Miyuki Hasegawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Ikuo Fujimori
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
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13
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Pai MP, Wilcox MH, Chitra S, McGovern PC. Safety and efficacy of omadacycline by BMI categories and diabetes history in two Phase III randomized studies of patients with acute bacterial skin and skin structure infections. J Antimicrob Chemother 2021; 76:1315-1322. [PMID: 33458763 PMCID: PMC8050767 DOI: 10.1093/jac/dkaa558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/10/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The objectives of this post-hoc analysis were to examine the safety and efficacy of omadacycline by BMI categories and diabetes history in adults with acute bacterial skin and skin structure infections (ABSSSI) from two pivotal Phase III studies. PATIENTS AND METHODS OASIS-1 (ClinicalTrials.gov identifier NCT02378480): patients were randomized 1:1 to IV omadacycline or linezolid for 7-14 days, with optional transition to oral medication. OASIS-2 (ClinicalTrials.gov identifier NCT02877927): patients received once-daily oral omadacycline or twice-daily oral linezolid for 7-14 days. Early clinical response (ECR) was defined as ≥20% reduction in lesion size 48-72 h after the first dose. Clinical success at post-treatment evaluation (PTE; 7-14 days after the last dose) was defined as symptom resolution such that antibacterial therapy was unnecessary. Safety was assessed by treatment-emergent adverse events and laboratory measures. Between-treatment comparisons were made with regard to WHO BMI categories and diabetes history. RESULTS Patients were evenly distributed among healthy weight, overweight and obese groups. Clinical success for omadacycline-treated patients at ECR and PTE was similar across BMI categories. Outcomes by diabetes status were similar in omadacycline- and linezolid-treated patients: at ECR, clinical success rates were lower for those with diabetes; at PTE, clinical success was similar between treatment groups regardless of diabetes history. The safety of omadacycline and linezolid was largely similar across BMI groups and by diabetes history. CONCLUSIONS Omadacycline efficacy in patients with higher BMI and in patients with diabetes was consistent with results from two pivotal Phase III ABSSSI trials. Fixed-dose omadacycline is an appropriate treatment for ABSSSI in adults regardless of BMI.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mark H Wilcox
- University of Leeds & Leeds Teaching Hospitals, Leeds LS2 9JT, UK
| | - Surya Chitra
- Paratek Pharmaceuticals, Inc., King of Prussia, PA 19406, USA
| | - Paul C McGovern
- Paratek Pharmaceuticals, Inc., King of Prussia, PA 19406, USA
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14
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Veillette JJ, Winans SA, Maskiewicz VK, Truong J, Jones RN, Forland SC. Pharmacokinetics and Pharmacodynamics of High-Dose Piperacillin-Tazobactam in Obese Patients. Eur J Drug Metab Pharmacokinet 2021; 46:385-394. [PMID: 33743171 PMCID: PMC8093170 DOI: 10.1007/s13318-021-00677-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/09/2022]
Abstract
Background and Objective Standard piperacillin–tazobactam (P-T) dosing may be suboptimal in obesity, but high-dose regimens have not been studied. We prospectively evaluated the pharmacokinetics and pharmacodynamics of standard- and high-dose P-T in obese adult inpatients. Methods Those receiving standard-dose P-T with BMI ≥ 30 kg/m2 weighing 105–139 kg or ≥ 140 kg were given up to 6.75 g or 9 g every 6 h, respectively. Patients were monitored closely for safety. Elimination phase blood samples were drawn for 28 patients on standard and high doses to calculate the pharmacokinetic values using a one-compartment model. The likelihood of pharmacodynamic target attainment (100% fT > 16/4 mg/L) on various P-T regimens was calculated using each patient’s own pharmacokinetic values. Results Piperacillin and tazobactam half-lives ranged from 0.5–10.6 to 0.9–15.0 h, while volumes of distribution ranged from 13.6–54.8 to 11.5–60.1 L, respectively. Predicted dose requirements for target attainment ranged from 2.25 g every 6 h in hemodialysis patients to a 27 g/24-h continuous infusion in a patient with a short P-T half-life. An amount of 4.5 g every 6 h would have met the target for only 1/12 (8%) patients with creatinine clearance ≥ 80 mL/min and 13/28 (46%) for all enrolled patients. One patient (3%) experienced an adverse event deemed probably related to high-dose P-T. Conclusion Some patients required high P-T doses for target attainment, but dosing requirements were highly variable. Doses up to 6.75 g or 9 g every 6 h may be tolerable; however, studies are needed to see if high dosing, prolonged infusions, or real-time therapeutic drug monitoring improves outcomes in obese patients. Clinical trial registration (clinicaltrials.gov) NCT01923363. Supplementary Information The online version contains supplementary material available at 10.1007/s13318-021-00677-1.
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Affiliation(s)
- John J Veillette
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.
| | - S Alexander Winans
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Victoria K Maskiewicz
- Department of Pharmaceutical and Administrative Sciences, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - James Truong
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | | | - Steven C Forland
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.,Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA, USA.,Loma Linda University School of Medicine, Loma Linda, CA, USA
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15
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Pai MP. Antimicrobial Dosing in Specific Populations and Novel Clinical Methodologies: Obesity. Clin Pharmacol Ther 2021; 109:942-951. [PMID: 33523485 DOI: 10.1002/cpt.2181] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/16/2021] [Indexed: 12/17/2022]
Abstract
Obesity and its related comorbidities can negatively influence the outcomes of certain infectious diseases. Specific dosing recommendations are often lacking in the product label for patients with obesity that leads to unclear guidance in practice. Higher rates of therapeutic failure have been reported with some fixed dose antibiotics and pragmatic approaches to dose modification are limited for orally administered agents. For i.v. antimicrobials dosed on weight, alternate body size descriptors (ABSDs) have been used to reduce the risk of overdosing. These ABSDs are mathematical transformations of height and weight that represent fat-free weight and follow the same principles as body surface area (BSA)-based dosing of cancer chemotherapy. However, ABSDs are rarely studied in pivotal phase III studies and so can risk the underdosing of antimicrobials in patients with obesity when incorrectly applied in the real-world setting. Specific case examples are presented to highlight these risks. Although general principles may be considered by clinicians, a universal approach to dose modification in obesity is unlikely. Studies that can better distinguish human body phenotypes may help reduce our reliance on height and weight to define dosing. Simple and complex technologies exist to quantify individual body composition that could improve upon our current approach. Early evidence suggests that body composition parameters repurposed from medical imaging data may improve upon height and weight as covariates of drug clearance and distribution. Clinical trials that can integrate human body phenotyping may help us identify new approaches to optimal dose selection of antimicrobials in patients with obesity.
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Affiliation(s)
- Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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16
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Soares ALPPDP, Montanha MC, Alcantara CDS, Silva SRB, Kuroda CM, Yamada SS, Nicacio AE, Maldaner L, Visentainer JV, Simões CF, Locatelli JC, Lopes WA, Mazucheli J, Diniz A, Paixão PJPA, Kimura E. Pharmacokinetics of amoxicillin in obese and nonobese subjects. Br J Clin Pharmacol 2021; 87:3227-3233. [PMID: 33474776 DOI: 10.1111/bcp.14739] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS To compare the pharmacokinetics of amoxicillin (AMX) in obese and nonobese subjects, given as single dose 875-mg tablets. METHODS A prospective, single-centre, open-label, clinical study was carried out involving 10 nonobese and 20 obese subjects given a dose of an AMX 875-mg tablet. Serial blood samples were collected between 0 and 8 hours after administration of AMX and plasma levels were quantified by liquid chromatography-tandem mass spectrometry. The pharmacokinetic parameters (PK) were calculated by noncompartmental analysis and means of the 2 groups were compared using Student t-test. Analysis of correlation between covariates and PK was performed using Pearson's correlation coefficient. RESULTS Ten nonobese subjects (mean age 30.6 ± 7.12 y; body mass index 21.56 ± 1.95 kg/m2 ) and 20 obese subjects (mean age 34.47 ± 7.03 y; body mass index 33.17 ± 2.38 kg/m2 ) participated in the study. Both maximum concentration (Cmax ; 12.12 ± 4.06 vs. 9.66 ± 2.93 mg/L) and area under the curve (AUC)0-inf (34.18 ± 12.94 mg.h/L vs. 26.88 ± 9.24 mg.h/L) were slightly higher in nonobese than in obese subjects, respectively, but differences were not significant. The volume of distribution (V/F) parameter was statistically significantly higher in obese compared to nonobese patients (44.20 ± 17.85 L vs. 27.57 ± 12.96 L). Statistically significant correlations were observed for several weight metrics vs. AUC, Cmax , V/F and clearance, and for creatinine clearance vs. AUC, Cmax and clearance. CONCLUSION In obese subjects, the main altered PK was V/F as a consequence of greater body weight. This may result in antibiotic treatment failure if standard therapeutic regimens are administered.
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Affiliation(s)
- Ana Luiza P P D P Soares
- Postgraduate Program in Biosciences and Physiopathology (PBF), Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Maiara C Montanha
- Research Associate Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Conrado D S Alcantara
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Sandra R B Silva
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Cristina M Kuroda
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Sérgio S Yamada
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Antônio E Nicacio
- Postgraduate Program in Chemistry, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Liane Maldaner
- Departament of Chemistry, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Jesui V Visentainer
- Departament of Chemistry, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Caroline F Simões
- Postgraduate Program in Physical Education, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - João Carlos Locatelli
- Postgraduate Program in Physical Education, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Wendell A Lopes
- Department of Physical Education, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Josmar Mazucheli
- Department of Statistics, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Andrea Diniz
- Department of Pharmacy, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
| | - Paulo J P A Paixão
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Elza Kimura
- Clinical Research Centre and Bioequivalence Studies, Universidade Estadual de Maringá, Maringá, Paraná, Brazil.,Department of Pharmacy, Universidade Estadual de Maringá, Maringá, Paraná, Brazil
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Sirard S, Abou Chakra CN, Langlois MF, Perron J, Carignan A, Valiquette L. Is Antimicrobial Dosing Adjustment Associated with Better Outcomes in Patients with Severe Obesity and Bloodstream Infections? An Exploratory Study. Antibiotics (Basel) 2020; 9:antibiotics9100707. [PMID: 33081192 PMCID: PMC7602836 DOI: 10.3390/antibiotics9100707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 01/21/2023] Open
Abstract
The impact of adjusted treatment on clinical outcomes in patients with severe obesity is unclear. This study included adults with severe obesity admitted for bloodstream infections between 2005 and 2015. The patients were grouped according to the percentage of the appropriateness of the dosage of their antimicrobial treatment: 80–100% = good, 20–79% = moderate, and 0–19% = poor. The association between antimicrobial adjustment and a composite of unfavourable outcomes [intensive care unit stay ≥72 h, duration of sepsis >3 days, length of stay ≥7 days or all-cause 30-day mortality] was assessed using logistic regression. Of 110 included episodes, the adjustment was rated good in 47 (43%) episodes, moderate in 31 (28%), and poor in 32 (29%). Older age, Pitt bacteremia score ≥2, sepsis on day 1, and infection site were independent risk factors for unfavourable outcomes. The level of appropriateness was not associated with unfavourable outcomes. The number of antimicrobials, consultation with an infectious disease specialist, blood urea nitrogen 7–10.9 mmol/L, and hemodialysis were significantly associated with adjusted antimicrobial dosing. While the severity of the infection had a substantial impact on the measured outcomes, we did not find an association between dosing optimization and better outcomes.
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Affiliation(s)
- Stéphanie Sirard
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (S.S.); (C.N.A.C.); (A.C.)
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (S.S.); (C.N.A.C.); (A.C.)
| | - Marie-France Langlois
- Department of Medicine, Division of Endocrinology, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada;
| | - Julie Perron
- Department of Pharmacy, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Granby, QC J2G 1T7, Canada;
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (S.S.); (C.N.A.C.); (A.C.)
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (S.S.); (C.N.A.C.); (A.C.)
- Correspondence: ; Tel.: +1-819-821-8000 (ext. 72568)
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Αntoniadou M, Varzakas T. Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly. Crit Rev Food Sci Nutr 2020; 61:3233-3255. [PMID: 32686465 DOI: 10.1080/10408398.2020.1793729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aging impairs senses, mastication, oral status and function, causing nutritional needs and diet insufficiencies. The present needs of independent older adults suggest that health research and oral health care should shift from reductionist disease management to integral and personal treatment plans, including lifestyle, psychological, nutritional and oral health coaching approaches. Dentists and other medical professionals that work in the field of gerodontology should be educated on the macro and micronutrient needs of the elderly and incorporate certain nutritional plans early in the life of their patients with their approval and cooperation, in order to postpone tooth loss and masticatory impairment. Old recipes such as the Mediterranean diet should be kept as a base for all the elderly and be enriched in a customized interpersonal way from the dentist as well as the medical professional according to the specific needs of one's oral and general health status. In this nonsystematic review paper, the basic aspects of the vicious cycle of nutrition and oral health status are discussed and suggestions of major nutrients' influence and needs for independent elders are reported. Based on the scientific data collected, suggestions are made for the food industry for better quality and dosage of foods for this category of individuals. Such strategies can be a whole new area of interest for the food industry in order to obtain better quality of food packaging for the independent OA with accepted texture, odor, colors, macronutrients and micronutrients' consistency and in specific portions.
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Affiliation(s)
- Maria Αntoniadou
- Dental School, National and Kapodistrian University of Athens, Greece
| | - Theodoros Varzakas
- Dept. Food Science and Technology, University of the Peloponnese, Kalamata, Greece
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Tarricone R, Rognoni C, Arnoldo L, Mazzacane S, Caselli E. A Probiotic-Based Sanitation System for the Reduction of Healthcare Associated Infections and Antimicrobial Resistances: A Budget Impact Analysis. Pathogens 2020; 9:pathogens9060502. [PMID: 32585922 PMCID: PMC7350316 DOI: 10.3390/pathogens9060502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/17/2020] [Accepted: 06/18/2020] [Indexed: 12/28/2022] Open
Abstract
Healthcare associated infections (HAIs) and antibiotic resistance have high social and economic burdens. Healthcare environments play an important role in the transmission of HAIs. The Probiotic Cleaning Hygiene System (PCHS) has been shown to decrease hospital surface pathogens up to 90% vs. conventional chemical cleaning (CCC). This study compares PCHS to CCC as to reduction of HAIs and their severity, related antibiotic resistances, and costs. Incidence rates of HAIs/antibiotic resistances were estimated from a previously conducted multicenter pre-post (6 months CCC + 6 months PCHS) intervention study, after applying the propensity score matching technique. A budget impact analysis compared the current scenario of use of CCC with future scenarios considering increasing utilization of PCHS, from 5% to 50% in the next five years, from a hospital perspective in Italy. The cumulative incidence of HAI was 4.6% and 2.4% (p < 0.0001) for CCC (N = 4160) and PCHS (N = 4160) (OR = 0.47, CI 95% 0.37–0.60), with severe HAIs of 1.57% vs. 1% and antibiotic resistances of 1.13% vs. 0.53%, respectively. Increased use of PCHS over CCC in Italian internal medicine/geriatrics and neurology departments in the next 5 years is expected to avert at least about 31,000 HAIs and 8500 antibiotic resistances, and save at least 14 million euros, of which 11.6 for the treatment of resistant HAIs. Innovative, environmentally sustainable sanitation systems, like PCHS, might substantially reduce antibiotic resistance and increase protection of health worldwide.
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Affiliation(s)
- Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milano, Italy;
- Department of Social and Political Sciences, Bocconi University, 20136 Milano, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milano, Italy;
- Correspondence:
| | - Luca Arnoldo
- Department of Medicine, University of Udine, 33100 Udine, Italy;
| | - Sante Mazzacane
- CIAS Interdepartmental Research Centre, Department of Architecture, Department of Chemical and Pharmaceutical Sciences, University of Ferrara, 44122 Ferrara, Italy; (S.M.); (E.C.)
| | - Elisabetta Caselli
- CIAS Interdepartmental Research Centre, Department of Architecture, Department of Chemical and Pharmaceutical Sciences, University of Ferrara, 44122 Ferrara, Italy; (S.M.); (E.C.)
- Section of Microbiology, Department of Chemical & Pharmaceutical Sciences, University of Ferrara, 44121 Ferrara, Italy
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Drug Dose Selection in Pediatric Obesity: Available Information for the Most Commonly Prescribed Drugs to Children. Paediatr Drugs 2019; 21:357-369. [PMID: 31432433 PMCID: PMC7681556 DOI: 10.1007/s40272-019-00352-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Obesity rates continue to rise in children, and little guidance exists regarding the need for adjustment away from total body weight-based doses for those prescribing drugs to this population of children. A majority of drugs prescribed to children with obesity result in either sub-therapeutic or supra-therapeutic concentrations, placing these children at risk for treatment failure and drug toxicities. In this review, we highlight available obesity-specific pharmacokinetic and dosing information for the most frequently prescribed drugs to children in the inpatient and outpatient clinical settings. We also comment on available dosing recommendations for drugs prescribed to treat common pediatric obesity-related comorbidities. This review highlights that there is no safe or proven 'rule of thumb,' for dosing drugs for children with obesity, and a striking lack of pharmacokinetic data to support the creation of dosing guidelines for children with obesity for the most commonly prescribed drugs. It is important that those prescribing for children with obesity are aware of these gaps in knowledge and of potential drug treatment failure or adverse events related to drug toxicity as a result of these knowledge gaps. Until more data are available, we recommend close monitoring of drug response and adverse events in children with obesity receiving commonly prescribed drugs.
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Narayanan N, Adams CD, Kubiak DW, Cheng S, Stoianovici R, Kagan L, Brunetti L. Evaluation of treatment options for methicillin-resistant Staphylococcus aureus infections in the obese patient. Infect Drug Resist 2019; 12:877-891. [PMID: 31114267 PMCID: PMC6490236 DOI: 10.2147/idr.s196264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/12/2019] [Indexed: 12/30/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major cause of infection in both the hospital and community setting. Obesity is a risk factor for infection, and the prevalence of this disease has reached epidemic proportions worldwide. Treatment of infections in this special population is a challenge given the lack of data on the optimal antibiotic choice and dosing strategies, particularly for treatment of MRSA infections. Obesity is associated with various physiological changes that may lead to altered pharmacokinetic parameters. These changes include altered drug biodistribution, elimination, and absorption. This review provides clinicians with a summary of the literature pertaining to the pharmacokinetic and pharmacodynamic considerations when selecting antibiotic therapy for the treatment of MRSA infections in obese patients.
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Affiliation(s)
- Navaneeth Narayanan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Division of Infectious Diseases, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christopher D Adams
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | - Serena Cheng
- Department of Pharmacy, VA San Diego Healthcare System, San Diego, CA, USA
| | - Robyn Stoianovici
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Leonid Kagan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Department of Pharmaceutics, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Department of Pharmaceutics, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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Diagnostic Stewardship: A Clinical Decision Rule for Blood Cultures in Community-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections. Infect Dis Ther 2019; 8:229-242. [PMID: 30783995 PMCID: PMC6522577 DOI: 10.1007/s40121-019-0238-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Indexed: 01/02/2023] Open
Abstract
Introduction The emergence, spread and persistence of methicillin-resistant Staphylococcus aureus (MRSA) as a causative pathogen in community-onset (CO) skin and soft tissue infections (SSTIs) have resulted in substantial changes in the management of these infections. The indications for obtaining blood cultures in patients with CO-MRSA SSTIs remain poorly defined. The objectives of this study were to derive and validate a clinical decision rule that predicts the probability of MRSA bacteremia in CO-MRSA SSTIs and to identify a low-risk population for whom blood cultures may be safely omitted. Methods This was a retrospective, case-control study with an internal temporal validation cohort conducted at two large urban academic medical centers. Hospitalized adults with CO-MRSA SSTI between 2010 and 2018 were included. Independent predictors of MRSA bacteremia were identified through multivariable logistic regression. A decision rule was derived using weighted coefficient-based scoring. The decision rule was validated in an internal temporal validation cohort. Results A total of 307 patients (155 cases and 152 controls) were included in the derivation cohort. A decision rule was created with a “major criterion” defined as purulent cellulitis and “minor criteria” defined as abnormal temperature, intravenous drug use, leukocytosis, tachycardia, body mass index < 25 kg/m2 and non-upper extremity infection site. A blood culture is indicated by this rule for patients with one major or at least two minor criteria. Otherwise patients are classified as low risk, and blood cultures may be omitted. The sensitivity of the decision rule in the derivation and validation cohorts was 98.71% (95% CI 95.42%, 99.84%) and 95.65% (78.05%, 99.89%), respectively. The specificity was 23.03% (95% CI 16.59%, 30.54%) and 30.77% (95% CI 24.15%, 38.02%), respectively. Conclusion The decision rule developed and validated in this study provides a standardized, evidenced-based approach to determine the need for blood cultures based on bacteremia risk.
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Kim M, Basharat A, Santosh R, Mehdi SF, Razvi Z, Yoo SK, Lowell B, Kumar A, Brima W, Danoff A, Dankner R, Bergman M, Pavlov VA, Yang H, Roth J. Reuniting overnutrition and undernutrition, macronutrients, and micronutrients. Diabetes Metab Res Rev 2019; 35:e3072. [PMID: 30171821 DOI: 10.1002/dmrr.3072] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/20/2018] [Accepted: 08/26/2018] [Indexed: 12/15/2022]
Abstract
Over-nutrition and its late consequences are a dominant theme in medicine today. In addition to the health hazards brought on by over-nutrition, the medical community has recently accumulated a roster of health benefits with obesity, grouped under "obesity paradox." Throughout the world and throughout history until the 20th century, under-nutrition was a dominant evolutionary force. Under-nutrition brings with it a mix of benefits and detriments that are opposite to and continuous with those of over-nutrition. This continuum yields J-shaped or U-shaped curves relating body mass index to mortality. The overweight have an elevated risk of dying in middle age of degenerative diseases while the underweight are at increased risk of premature death from infectious conditions. Micronutrient deficiencies, major concerns of nutritional science in the 20th century, are being neglected. This "hidden hunger" is now surprisingly prevalent in all weight groups, even among the overweight. Because micronutrient replacement is safe, inexpensive, and predictably effective, it is now an exceptionally attractive target for therapy across the spectrum of weight and age. Nutrition-related conditions worthy of special attention from caregivers include excess vitamin A, excess vitamin D, and deficiency of magnesium.
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Affiliation(s)
- Miji Kim
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Anam Basharat
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Ramchandani Santosh
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Syed F Mehdi
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Zanali Razvi
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Sun K Yoo
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Barbara Lowell
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Amrat Kumar
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Wunnie Brima
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, New York, USA
| | - Ann Danoff
- Department of Medicine, Cpl. Michael J Crescenz Veterans Administration Medical Center, Philadelphia, PA, USA
| | - Rachel Dankner
- Department of Epidemiology and Preventive Medicine, School of Public Health, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Bergman
- Department of Medicine, Division of Endocrinology, NYU School of Medicine, New York, NY, USA
| | - Valentin A Pavlov
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
- Center for Biomedical Science and Center for Bioelectric Medicine, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Huan Yang
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
- Center for Biomedical Science and Center for Bioelectric Medicine, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
| | - Jesse Roth
- Laboratory of Diabetes and Diabetes-Related Disorders, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, New York, USA
- Center for Biomedical Science and Center for Bioelectric Medicine, The Feinstein Institute for Medical Research, Northwell Health, New York, USA
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25
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Mirkov S, Lyseng-Williamson KA. Appropriate drug dosages in obese patients. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Thorpe KE, Joski P, Johnston KJ. Antibiotic-Resistant Infection Treatment Costs Have Doubled Since 2002, Now Exceeding $2 Billion Annually. Health Aff (Millwood) 2018; 37:662-669. [PMID: 29561692 DOI: 10.1377/hlthaff.2017.1153] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antibiotic-resistant infections are a global health care concern. The Centers for Disease Control and Prevention estimates that 23,000 Americans with these infections die each year. Rising infection rates add to the costs of health care and compromise the quality of medical and surgical procedures provided. Little is known about the national health care costs attributable to treating the infections. Using data from the Medical Expenditure Panel Survey, we estimated the incremental health care costs of treating a resistant infection as well as the total national costs of treating such infections. To our knowledge, this is the first national estimate of the costs for treating the infections. We found that antibiotic resistance added $1,383 to the cost of treating a patient with a bacterial infection. Using our estimate of the number of such infections in 2014, this amounts to a national cost of $2.2 billion annually. The need for innovative new infection prevention programs, antibiotics, and vaccines to prevent and treat antibiotic-resistant infections is an international priority.
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Affiliation(s)
- Kenneth E Thorpe
- Kenneth E. Thorpe ( ) is the Robert W. Woodruff Professor and chair of the Department of Health Policy and Management, Rollins School of Public Health, Emory University, in Atlanta, Georgia
| | - Peter Joski
- Peter Joski is a senior associate in the Department of Health Policy and Management, Rollins School of Public Health, Emory University
| | - Kenton J Johnston
- Kenton J. Johnston is an assistant professor of health management and policy at Saint Louis University, in Missouri
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27
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Holmes NE, Robinson JO, van Hal SJ, Munckhof WJ, Athan E, Korman TM, Cheng AC, Turnidge JD, Johnson PDR, Howden BP. Morbidity from in-hospital complications is greater than treatment failure in patients with Staphylococcus aureus bacteraemia. BMC Infect Dis 2018; 18:107. [PMID: 29506483 PMCID: PMC5838938 DOI: 10.1186/s12879-018-3011-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 02/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Various studies have identified numerous factors associated with poor clinical outcomes in patients with Staphylococcus aureus bacteraemia (SAB). A new study was created to provide deeper insight into in-hospital complications and risk factors for treatment failure. METHODS Adult patients hospitalised with Staphylococcus aureus bacteraemia (SAB) were recruited prospectively into a multi-centre cohort. The primary outcome was treatment failure at 30 days (composite of all-cause mortality, persistent bacteraemia, or recurrent bacteraemia), and secondary measures included in-hospital complications and mortality at 6- and 12-months. Data were available for 222 patients recruited from February 2011 to December 2012. RESULTS Treatment failure at 30-days was recorded in 14.4% of patients (30-day mortality 9.5%). Multivariable analysis predictors of treatment failure included age > 70 years, Pitt bacteraemia score ≥ 2, CRP at onset of SAB > 250 mg/L, and persistent fevers after SAB onset; serum albumin at onset of SAB, receipt of appropriate empiric treatment, recent healthcare attendance, and performing echocardiography were protective. 6-month and 12-month mortality were 19.1% and 24.2% respectively. 45% experienced at least one in-hospital complication, including nephrotoxicity in 19.5%. CONCLUSIONS This study demonstrates significant improvements in 30-day outcomes in SAB in Australia. However, we have identified important areas to improve outcomes from SAB, particularly reducing renal dysfunction and in-hospital treatment-related complications.
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Affiliation(s)
- Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Austin Centre for Infection Research, PO Box 5555, Heidelberg, VIC, 3084, Australia. .,Department of Microbiology and Immunology, University of Melbourne, Melbourne, VIC, Australia.
| | - J Owen Robinson
- Department of Microbiology and Infectious Diseases, PathWest Laboratory Medicine-WA, Royal Perth Hospital, 197 Wellington Street, Perth, WA, 6000, Australia.,Australian Collaborating Centre for Enterococcus and Staphylococcus Species (ACCESS) Typing and Research, School of Biomedical Sciences, Curtin University, Perth, WA, Australia
| | - Sebastiaan J van Hal
- Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.,Department of Medicine, University of Western Sydney, Sydney, NSW, Australia
| | - Wendy J Munckhof
- Infection Management Services, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD, 4102, Australia.,Department of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Eugene Athan
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, VIC, 3220, Australia.,Department of Medicine, Deakin University, Geelong, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Tony M Korman
- Department of Infectious Diseases, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Hospital, 55 Commercial Road, Prahran, VIC, 3181, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Prahran, VIC, Australia
| | - John D Turnidge
- Australian Commission on Safety and Quality in Health Care, Level 5, 255 Elizabeth Street, Sydney, NSW, 2000, Australia.,Department of Paediatrics, University of Adelaide, Adelaide, SA, Australia
| | - Paul D R Johnson
- Department of Infectious Diseases, Austin Health, Austin Centre for Infection Research, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia.,Department of Microbiology, Monash University, Clayton, VIC, Australia
| | - Benjamin P Howden
- Department of Infectious Diseases, Austin Health, Austin Centre for Infection Research, PO Box 5555, Heidelberg, VIC, 3084, Australia.,Department of Microbiology and Immunology, University of Melbourne, Melbourne, VIC, Australia.,Department of Microbiology, Monash University, Clayton, VIC, Australia.,Microbiological Diagnostic Unit, Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, VIC, 3000, Australia
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Does Regular Exercise Counter T Cell Immunosenescence Reducing the Risk of Developing Cancer and Promoting Successful Treatment of Malignancies? OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:4234765. [PMID: 28751932 PMCID: PMC5511671 DOI: 10.1155/2017/4234765] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/11/2017] [Accepted: 06/01/2017] [Indexed: 12/15/2022]
Abstract
Moderate intensity aerobic exercise training or regular physical activity is beneficial for immune function. For example, some evidence shows that individuals with an active lifestyle exhibit stronger immune responses to vaccination compared to those who are inactive. Encouragingly, poor vaccine responses, which are characteristic of an ageing immune system, can be improved by single or repeated bouts of exercise. In addition, exercise-induced lymphocytosis, and the subsequent lymphocytopenia, is thought to facilitate immune surveillance, whereby lymphocytes search tissues for antigens derived from viruses, bacteria, or malignant transformation. Aerobic exercise training is anti-inflammatory and is linked to lower morbidity and mortality from diseases with infectious, immunological, and inflammatory aetiologies, including cancer. These observations have led to the view that aerobic exercise training might counter the age-associated decline in immune function, referred to as immunosenescence. This article summarises the aspects of immune function that are sensitive to exercise-induced change, highlighting the observations which have stimulated the idea that aerobic exercise training could prevent, limit, or delay immunosenescence, perhaps even restoring aged immune profiles. These potential exercise-induced anti-immunosenescence effects might contribute to the mechanisms by which active lifestyles reduce the risk of developing cancer and perhaps benefit patients undergoing cancer therapy.
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Flanagan S, Minassian SL, Passarell JA, Fiedler-Kelly J, Prokocimer P. Pharmacokinetics of Tedizolid in Obese and Nonobese Subjects. J Clin Pharmacol 2017; 57:1290-1294. [PMID: 28510339 DOI: 10.1002/jcph.928] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/28/2017] [Indexed: 01/21/2023]
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Obesity and Heart Failure as Predictors of Failure in Outpatient Skin and Soft Tissue Infections. Antimicrob Agents Chemother 2017; 61:AAC.02389-16. [PMID: 28069657 DOI: 10.1128/aac.02389-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 12/30/2016] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to evaluate risk factors for failure of antibiotic treatment within 30 days for uncomplicated skin infections of outpatients treated in a Veterans Affairs hospital. A retrospective chart review of outpatients between January 2006 and July 2015 with an ICD-9 (International Statistical Classification of Diseases and Related Health Problems) code of cellulitis or abscess was included in the analysis. The primary outcome was success versus failure of the antibiotic, with failure defined as another antibiotic prescribed or hospitalization within 30 days for the original indication. A total of 293 patients were included in the final analysis, 24% of whom failed within 30 days. Obesity/overweight (body mass index [BMI] of >25 kg/m2) was identified in 83% of the overall population, with 16% of that population having a BMI greater than 40 kg/m2 An elevated mean BMI of 34.2 kg/m2 (P = 0.0098) was found in the subset of patients who failed oral antibiotics compared to a BMI of 31.32 kg/m2 in patients who were treated successfully. Additionally, the patients who failed had an increased prevalence of heart failure at 16% (P = 0.027). Using multivariate logistic regression, BMI and heart failure were determined to be significant predictors of antibiotic prescription failure. Each 10-kg/m2 unit increase in BMI was associated with a 1.62-fold-greater odds of failure. A diagnosis of heart failure increased the odds of failure by 2.6-fold (range, 1.1- to 5.8-fold). Outpatients with uncomplicated skin infections with an elevated BMI and heart failure were found to have increased odds of failure, defined as hospitalization or additional antibiotics within 30 days.
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Chung EK, Cheatham SC, Fleming MR, Healy DP, Kays MB. Population Pharmacokinetics and Pharmacodynamics of Meropenem in Nonobese, Obese, and Morbidly Obese Patients. J Clin Pharmacol 2016; 57:356-368. [PMID: 27530916 DOI: 10.1002/jcph.812] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/11/2016] [Indexed: 01/21/2023]
Abstract
The study objective was to evaluate meropenem population pharmacokinetics and pharmacodynamics in nonobese, obese, and morbidly obese patients. Forty adult patients-11 nonobese (body mass index [BMI] < 30 kg/m2 ), 9 obese (30 kg/m2 ≤ BMI < 40 kg/m2 ), and 20 morbidly obese (BMI ≥ 40 kg/m2 )-received meropenem 500 mg every 6 hours (q6h), q8h, or q12h or 1 g q6h or q8h, infused over 0.5 hour. Population pharmacokinetic modeling was performed using NONMEM, and 5000-patient Monte-Carlo simulations were performed to calculate probability of target attainment (PTA) for 5 dosing regimens, infused over 0.5 and 3 hours, using fT>MIC of 40%, 54%, and 100% of the dosing interval. A 2-compartment linear-elimination model best described the serum concentration-time data, and creatinine clearance was significantly associated with systemic clearance. Pharmacokinetic parameters were not significantly different among patient groups. In patients with creatinine clearances ≥50 mL/min, all simulated dosing regimens achieved >90% PTA at 40% fT>MIC in all patient groups at MICs ≤2 mg/L. Only 500 mg q8h, infused over 0.5 hour, did not achieve >90% PTA at 54% fT>MIC in nonobese and morbidly obese patients. At 100% fT>MIC, 1 g q6h and 2 g q8h, infused over 3 hours, reliably achieved >90% PTA in all patient groups. Meropenem pharmacokinetics are comparable among nonobese, obese, and morbidly obese patients. Standard dosing regimens provide adequate pharmacodynamic exposures for susceptible pathogens at 40% and 54% fT>MIC, but prolonged infusions of larger doses are needed for adequate exposures at 100% fT>MIC. Dosage adjustments based solely on body weight are unnecessary.
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Affiliation(s)
- Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul, South Korea
| | | | - Megan R Fleming
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Daniel P Healy
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Michael B Kays
- Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis and West Lafayette, IN, USA
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Russell JM, Nick-Dart RL, Nornhold BD. Development of a pharmacist-driven protocol for automatic medication dosage adjustments in obese patients. Am J Health Syst Pharm 2016; 72:1656-63. [PMID: 26386107 DOI: 10.2146/ajhp140315] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE A hospital protocol utilizing automatic dosage adjustments and pharmacist consultations to optimize the use of certain medications in obese patients is described. SUMMARY After conducting a literature search focused on medication dosing in obese patients, pharmacists at a large community hospital developed a list of commonly ordered medications appropriate for inclusion in a pharmacy-driven institutional protocol for automatic medication dosage adjustment in adult patients with obesity. Evidence-based recommendations on initial dosing of eight antimicrobials and two anticoagulant agents according to weight and renal function were formulated. Under the protocol, pharmacists receive electronic alerts regarding protocol-eligible patients during initial order verification and automatically adjust medication dosages as appropriate. For patients prescribed anticoagulants at specified dosage levels, clinical pharmacists consult with prescribers to help ensure safe and effective initial and ongoing therapy. Multidisciplinary educational initiatives were conducted prior to protocol implementation. During two designated three-week postimplementation data collection periods, pharmacists received a total of 372 protocol-eligible medication orders. Pharmacists adjusted a total of 149 dosages and verified an additional 183 dosages consistent with the protocol as originally ordered. Clinical pharmacy consults were completed for 10-15% of patients, with laboratory monitoring ordered in 25-30% of those cases (all patients were found to have appropriate test values). There have been no documented adverse drug reactions in patients whose medication dosages were adjusted per protocol. CONCLUSION Pharmacists implemented weight- and renal function-based dosage adjustments for obese patients in 40% of evaluated protocol-eligible cases to achieve 89% compliance with the protocol. Heparin and cefazolin were the medications most likely to require obesity-related dosage adjustments.
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Affiliation(s)
- Justine M Russell
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA.
| | - Rebecca L Nick-Dart
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA
| | - Brandon D Nornhold
- Justine M. Russell, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Emergency Department; Rebecca L. Nick-Dart, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Internal Medicine; and Brandon D. Nornhold, Pharm. D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Saint Vincent Hospital, Erie, PA
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Turner JE. Is immunosenescence influenced by our lifetime "dose" of exercise? Biogerontology 2016; 17:581-602. [PMID: 27023222 PMCID: PMC4889625 DOI: 10.1007/s10522-016-9642-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 03/03/2016] [Indexed: 02/06/2023]
Abstract
The age-associated decline in immune function, referred to as immunosenescence, is well characterised within the adaptive immune system, and in particular, among T cells. Hallmarks of immunosenescence measured in the T cell pool, include low numbers and proportions of naïve cells, high numbers and proportions of late-stage differentiated effector memory cells, poor proliferative responses to mitogens, and a CD4:CD8 ratio <1.0. These changes are largely driven by infection with Cytomegalovirus, which has been directly linked with increased inflammatory activity, poor responses to vaccination, frailty, accelerated cognitive decline, and early mortality. It has been suggested however, that exercise might exert an anti-immunosenescence effect, perhaps delaying the onset of immunological ageing or even rejuvenating aged immune profiles. This theory has been developed on the basis of evidence that exercise is a powerful stimulus of immune function. For example, in vivo antibody responses to novel antigens can be improved with just minutes of exercise undertaken at the time of vaccination. Further, lymphocyte immune-surveillance, whereby cells search tissues for antigens derived from viruses, bacteria, or malignant transformation, is thought to be facilitated by the transient lymphocytosis and subsequent lymphocytopenia induced by exercise bouts. Moreover, some forms of exercise are anti-inflammatory, and if repeated regularly over the lifespan, there is a lower morbidity and mortality from diseases with an immunological and inflammatory aetiology. The aim of this article is to discuss recent theories for how exercise might influence T cell immunosenescence, exploring themes in the context of hotly debated issues in immunology.
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Affiliation(s)
- James E Turner
- Department for Health, University of Bath, Claverton Down, Bath, BA2 7AY, UK.
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Wu G, Zhang C, Wang J, Zhang F, Wang R, Shen J, Wang L, Pang X, Zhang X, Zhao L, Zhang M. Diminution of the gut resistome after a gut microbiota-targeted dietary intervention in obese children. Sci Rep 2016; 6:24030. [PMID: 27044409 PMCID: PMC4820771 DOI: 10.1038/srep24030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/18/2016] [Indexed: 12/30/2022] Open
Abstract
The gut microbiome represents an important reservoir of antibiotic resistance genes (ARGs). Effective methods are urgently needed for managing the gut resistome to fight against the antibiotic resistance threat. In this study, we show that a gut microbiota-targeted dietary intervention, which shifts the dominant fermentation of gut bacteria from protein to carbohydrate, significantly diminished the gut resistome and alleviated metabolic syndrome in obese children. Of the non-redundant metagenomic gene catalog of ~2 × 106 microbial genes, 399 ARGs were identified in 131 gene types and conferred resistance to 47 antibiotics. Both the richness and diversity of the gut resistome were significantly reduced after the intervention. A total of 201 of the 399 ARGs were carried in 120 co-abundance gene groups (CAGs) directly binned from the gene catalog across both pre-and post-intervention samples. The intervention significantly reduced several CAGs in Klebsiella, Enterobacter and Escherichia, which were the major hubs for multiple resistance gene types. Thus, dietary intervention may become a potentially effective method for diminishing the gut resistome.
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Affiliation(s)
- Guojun Wu
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Chenhong Zhang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Jing Wang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Feng Zhang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Ruirui Wang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Jian Shen
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Linghua Wang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Xiaoyan Pang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Xiaojun Zhang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Liping Zhao
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
| | - Menghui Zhang
- State Key Laboratory of Microbial Metabolism, Joint International Research Laboratory of Metabolic &Developmental Sciences, and School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, P.R. China
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Dietch ZC, Duane TM, Cook CH, O'Neill PJ, Askari R, Napolitano LM, Namias N, Watson CM, Dent DL, Edwards BL, Shah PM, Guidry CA, Davies SW, Willis RN, Sawyer RG. Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection. Surg Infect (Larchmt) 2016; 17:412-21. [PMID: 27027416 DOI: 10.1089/sur.2015.213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.
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Affiliation(s)
- Zachary C Dietch
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Therese M Duane
- 3 Department of Surgery, Virginia Commonwealth University , Richmond, Virginia
| | - Charles H Cook
- 4 Department of Surgery, Beth Israel Deaconess Medical Center , Boston, Massachusetts
| | - Patrick J O'Neill
- 5 Department of Surgery, Maricopa Integrated Health System , Phoenix, Arizona
| | - Reza Askari
- 6 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Lena M Napolitano
- 7 Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Nicholas Namias
- 8 Department of Surgery, University of Miami Miller School of Medicine , Miami, Florida
| | - Christopher M Watson
- 9 Department of Surgery, University of South Carolina , Columbia, South Carolina
| | - Daniel L Dent
- 10 Department of Surgery, University of Texas Health Science Center at San Antonio , San Antonio, Texas
| | - Brandy L Edwards
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Puja M Shah
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Christopher A Guidry
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Stephen W Davies
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Rhett N Willis
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia
| | - Robert G Sawyer
- 1 Department of Surgery, The University of Virginia Health System , Charlottesville, Virginia.,2 Division of Patient Outcomes, Policy and Population Research, Department of Public Health Sciences, The University of Virginia Health System , Charlottesville, Virginia
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Alobaid AS, Brinkmann A, Frey OR, Roehr AC, Luque S, Grau S, Wong G, Abdul-Aziz MH, Roberts MS, Lipman J, Roberts JA. What is the effect of obesity on piperacillin and meropenem trough concentrations in critically ill patients? J Antimicrob Chemother 2015; 71:696-702. [PMID: 26702922 DOI: 10.1093/jac/dkv412] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/05/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The objectives of this study were to determine the effects of obesity on unbound trough concentrations and on the achievement of pharmacokinetic (PK)/pharmacodynamic (PD) targets of piperacillin and meropenem in critically ill patients. METHODS This study retrospectively analysed therapeutic-drug-monitoring data from ICU databases in Australia, Germany and Spain, as well as from a large PK study. The presence of obesity was defined as a BMI ≥30 kg/m(2), and patients were also categorized based on level of renal function. The presence of obesity was compared with unbound piperacillin and meropenem trough concentrations. We also used logistic regression to describe factors associated with the achievement of the PK/PD targets, an unbound concentration maintained above the MIC breakpoint (100% fT>MIC and 100% fT>4×MIC) of Pseudomonas aeruginosa. RESULTS In all, 1400 patients were eligible for inclusion in the study. The median age and weight were 67 years (IQR 52-76 years) and 79 kg (69-90 kg), respectively, and 65% of participants were male. Significantly lower median piperacillin trough concentrations [29.4 mg/L (IQR 17.0-58.0 mg/L)] were found in obese patients compared with non-obese patients [42.0 mg/L (21.5-73.5 mg/L)] (P = 0.001). There was no difference for meropenem trough concentrations [obese 10.3 mg/L (IQR 4.8-16.0 mg/L) versus non-obese 11.0 mg/L (4.3-18.5 mg/L); P = 0.296]. Using logistic regression, we found that the presence of obesity was not associated with achievement of 100% fT>MIC, but the use of prolonged infusion, a creatinine clearance ≤100 mL/min, increasing age and female gender were for various PK/PD targets for both piperacillin and meropenem (P < 0.05). CONCLUSIONS This large dataset has shown that the presence of obesity in critically ill patients may affect piperacillin, but not meropenem, unbound trough concentrations.
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Affiliation(s)
- Abdulaziz S Alobaid
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Alexander Brinkmann
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto R Frey
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka C Roehr
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sonia Luque
- Pharmacy Department, Hospital del Mar, Institut Municipal d'Investigacions Biomèdiques, Parc de Salut Mar, Barcelona, Spain Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Institut Municipal d'Investigacions Biomèdiques, Parc de Salut Mar, Barcelona, Spain Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Gloria Wong
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Mohd-Hafiz Abdul-Aziz
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Michael S Roberts
- Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
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Ross EL, Heizer J, Mixon MA, Jorgensen J, Valdez CA, Czaja AS, Reiter PD. Development of recommendations for dosing of commonly prescribed medications in critically ill obese children. Am J Health Syst Pharm 2015; 72:542-56. [PMID: 25788508 DOI: 10.2146/ajhp140280] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The development and use of a decision support tool to help formulate recommendations for dosing of commonly prescribed medications in critically ill obese children are described. METHODS Medications prescribed in 2010 to critically ill infants and children (younger than 18 years) were identified from the Pediatric Health Information System. The most commonly prescribed and therapeutically monitored medications were extracted. Supportive evidence for obesity dosing was identified through a standardized computerized search involving medical subject heading terminology and age filters using PubMed and Ovid. A usefulness scoring system was developed to rate the strength and applicability of the literature to critically ill obese children. A decision supporttool was then created to aid in the formulation of a dosing weight for each medication based on the usefulness score, published pharmacokinetic properties, clinical studies available in the primary literature, and consideration of clinical consequences of underdosing or overdosing. RESULTS A total of 113 medications were evaluated, and 122 discrete citations, supporting 66 medications, were reviewed. Seventy-two percent of citations had general obesity dosing information, and 13% had pediatric-specific information. The overall mean usefulness score was 5.1±4.7 (median, 7). The decision support tool was incorporated to make final dosing weight recommendations for obese children. Ultimately, total body weight was recommended for 52 medications, adjusted weight for 43 medications, and ideal body weight for 18 medications. CONCLUSION The inadequacy of obesity dosing information for most medications commonly ordered for children admitted to a pediatric intensive care unit led to the development of a decision support tool to aid in formulating dosing recommendations.
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Affiliation(s)
- Emma L Ross
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC.
| | - Justin Heizer
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Mark A Mixon
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Jennifer Jorgensen
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Connie A Valdez
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Angela S Czaja
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
| | - Pamela D Reiter
- Emma L. Ross, Pharm.D., is Pediatric Clinical Pharmacist, American Family Children's Hospital, UW Hospital and Clinics, Madison, WI; at the time of writing she was Pharmacy Practice Resident, Department of Pharmacy, Children's Hospital Colorado, Aurora. Justin Heizer, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident; and Mark A. Mixon, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado (UC), Aurora. Jennifer Jorgensen, Pharm.D., is Clinical Pharmacist, General Medicine, Department of Pharmacy, Children's Hospital Colorado. Connie A. Valdez, Pharm.D., M.S.Ed., BCPS, is Associate Professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Angela S. Czaja, M.D., M.Sc., is Associate Professor and Associate Fellowship Director, Division of Critical Care, Department of Pediatrics, School of Medicine, and Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC. Pamela D. Reiter, Pharm.D., is Clinical Pharmacy Specialist, Pediatric Intensive Unit, Department of Pharmacy, Children's Hospital Colorado, and Clinical Associate Professor of Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC
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Dhurandhar NV, Bailey D, Thomas D. Interaction of obesity and infections. Obes Rev 2015; 16:1017-29. [PMID: 26354800 DOI: 10.1111/obr.12320] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/20/2015] [Accepted: 08/03/2015] [Indexed: 12/11/2022]
Abstract
There is evidence that certain infections may induce obesity. Obese persons may also have more severe infections and have compromised response to therapies. The objective of this study is to review the available literature identifying infections that potentially contribute to greater body mass index (BMI) and differential responses of overweight and obese persons to infections. A systematic literature review of human studies examining associations between infections and weight gain, differential susceptibility, severity, and response to prevention and treatment of infection according to BMI status (January 1980-July 2014) was conducted. Three hundred and forty-three studies were eligible for inclusion. Evidence indicated that viral infection by human adenovirus Ad36 and antibiotic eradication of Helicobacter pylori were followed by weight gain. People who were overweight or obese had higher susceptibility to developing post-surgical infections, H1N1 influenza and periodontal disease. More severe infections tended to be present in people with a larger BMI. People with a higher BMI had a reduced response to vaccinations and antimicrobial drugs. Higher doses of antibiotics were more effective in obese patients. Infections may influence BMI, and BMI status may influence response to certain infections, as well as to preventive and treatment measures. These observations have potential clinical implications.
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Affiliation(s)
- N V Dhurandhar
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA
| | - D Bailey
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA
| | - D Thomas
- Center for Quantitative Obesity Research, Department of Mathematical Sciences, Montclair State University, Montclair, NJ, USA
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Rowe S, Siegel D, Benjamin DK. Gaps in Drug Dosing for Obese Children: A Systematic Review of Commonly Prescribed Emergency Care Medications. Clin Ther 2015; 37:1924-32. [PMID: 26323523 PMCID: PMC4586086 DOI: 10.1016/j.clinthera.2015.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 08/13/2015] [Indexed: 01/19/2023]
Abstract
PURPOSE Approximately 1 of 6 children in the United States is obese. This has important implications for drug dosing and safety because pharmacokinetic (PK) changes are known to occur in obesity due to altered body composition and physiologic mechanisms. Inappropriate drug dosing in an emergency setting can limit therapeutic efficacy and increase drug-related toxic effects for obese children. Few systematic reviews examining PK properties and drug dosing in obese children have been performed. METHODS We identified 25 emergency care drugs from the Strategic National Stockpile and Acute Care Supportive Drugs List and performed a systematic review for each drug in 3 study populations: obese children (2-18 years of age), normal weight children, and obese adults (aged >18 years). For each study population, we first reviewed a drug's Food and Drug Administration label and then performed a systematic literature review. From the literature, we extracted drug PK data, biochemical properties, and dosing information. We then reviewed data in 3 age subpopulations (2-7 years, 8-12 years, and 13-18 years) for obese and normal weight children and by route of drug administration (intramuscular, intravenous, oral, and inhaled). If sufficient PK data were not available by age and route of administration, a data gap was identified. FINDINGS Only 2 of 25 emergency care drugs (8%) contained dosing information on the Food and Drug Administration label for obese children and adults compared with 22 of 25 (88%) for normal weight children. We found no sufficient PK data in the literature for any of the emergency care drugs in obese children. Sufficient PK data were found for 7 of 25 emergency care drugs (28%) in normal weight children and 3 of 25 (12%) in obese adults. IMPLICATIONS Insufficient information exists to guide dosing in obese children for any of the emergency care drugs reviewed. This knowledge gap is alarming, given the known PK changes that occur in the setting of obesity. Future clinical trials examining the PK properties of emergency care medications in obese children should be prioritized.
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Affiliation(s)
- Stevie Rowe
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - David Siegel
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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Justo JA, Mayer SM, Pai MP, Soriano MM, Danziger LH, Novak RM, Rodvold KA. Pharmacokinetics of ceftaroline in normal body weight and obese (classes I, II, and III) healthy adult subjects. Antimicrob Agents Chemother 2015; 59:3956-65. [PMID: 25896707 PMCID: PMC4468711 DOI: 10.1128/aac.00498-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/13/2015] [Indexed: 11/20/2022] Open
Abstract
The pharmacokinetic profile of ceftaroline has not been well characterized in obese adults. The purpose of this study was to evaluate the pharmacokinetics of ceftaroline in 32 healthy adult volunteers aged 18 to 50 years in the normal, overweight, and obese body size ranges. Subjects were evenly assigned to 1 of 4 groups based on their body mass index (BMI) and total body weight (TBW) (ranges, 22.1 to 63.5 kg/m(2) and 50.1 to 179.5 kg, respectively). Subjects in the lower-TBW groups were matched by age, sex, race/ethnicity, and serum creatinine to the upper-BMI groups. Serial plasma and urine samples were collected over 12 h after the start of the infusion, and the concentrations of ceftaroline fosamil (prodrug), ceftaroline, and ceftaroline M-1 (inactive metabolite) were assayed. Noncompartmental and population pharmacokinetic analyses were used to evaluate the data. The mean plasma ceftaroline maximum concentration and area under the curve were ca. 30% lower in subjects with a BMI of ≥40 kg/m(2) compared to those <30 kg/m(2). A five-compartment pharmacokinetic model with zero-order infusion and first-order elimination optimally described the plasma concentration-time profiles of the prodrug and ceftaroline. Estimated creatinine clearance (eCLCR) and TBW best explained ceftaroline clearance and volume of distribution, respectively. Although lower ceftaroline plasma concentrations were observed in obese subjects, Monte Carlo simulations suggest the probability of target attainment is ≥90% when the MIC is ≤1 μg/ml irrespective of TBW or eCLCR. No dosage adjustment for ceftaroline appears to be necessary based on TBW alone in adults with comparable eCLCR. Confirmation of these findings in infected obese patients is necessary to validate these findings in healthy volunteers. (This study has been registered at ClinicalTrials.gov under registration no. NCT01648127.).
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Affiliation(s)
- Julie Ann Justo
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Stockton M Mayer
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Manjunath P Pai
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Melinda M Soriano
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Richard M Novak
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Keith A Rodvold
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Asín-Prieto E, Rodríguez-Gascón A, Isla A. Applications of the pharmacokinetic/pharmacodynamic (PK/PD) analysis of antimicrobial agents. J Infect Chemother 2015; 21:319-29. [PMID: 25737147 DOI: 10.1016/j.jiac.2015.02.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/20/2015] [Accepted: 02/02/2015] [Indexed: 12/15/2022]
Abstract
The alarming increase of resistance against multiple currently available antibiotics is leading to a rapid lose of treatment options against infectious diseases. Since the antibiotic resistance is partially due to a misuse or abuse of the antibiotics, this situation can be reverted when improving their use. One strategy is the optimization of the antimicrobial dosing regimens. In fact, inappropriate drug choice and suboptimal dosing are two major factors that should be considered because they lead to the emergence of drug resistance and consequently, poorer clinical outcomes. Pharmacokinetic/pharmacodynamic (PK/PD) analysis in combination with Monte Carlo simulation allows to optimize dosing regimens of the antibiotic agents in order to conserve their therapeutic value. Therefore, the aim of this review is to explain the basis of the PK/PD analysis and associated techniques, and provide a brief revision of the applications of PK/PD analysis from a therapeutic point-of-view. The establishment and reevaluation of clinical breakpoints is the sticking point in antibiotic therapy as the clinical use of the antibiotics depends on them. Two methodologies are described to establish the PK/PD breakpoints, which are a big part of the clinical breakpoint setting machine. Furthermore, the main subpopulations of patients with altered characteristics that can condition the PK/PD behavior (such as critically ill, elderly, pediatric or obese patients) and therefore, the outcome of the antibiotic therapy, are reviewed. Finally, some recommendations are provided from a PK/PD point of view to enhance the efficacy of prophylaxis protocols used in surgery.
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Affiliation(s)
- Eduardo Asín-Prieto
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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42
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Trivedi V, Bavishi C, Jean R. Impact of obesity on sepsis mortality: A systematic review. J Crit Care 2014; 30:518-24. [PMID: 25575851 DOI: 10.1016/j.jcrc.2014.12.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/25/2014] [Accepted: 12/15/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Sepsis and severe sepsis are the most common cause of death among critically ill patients admitted in medical intensive care units. As more than one-third of the adult population of the United States is obese; we undertook a systematic review of the association between obesity and mortality among patients admitted with sepsis, severe sepsis, or septic shock. MATERIALS AND METHODS A systematic review was conducted to identify pertinent studies using a comprehensive search strategy. Studies reporting mortality in obese patients admitted with sepsis were identified. RESULTS Our initial search identified 183 studies of which 7 studies met our inclusion criteria. Three studies reported no significant association between obesity and mortality, 1 study observed increased mortality among obese patients, whereas 3 studies found lower mortality among obese patients. CONCLUSION Our review of the current clinical evidence of association of obesity with sepsis mortality revealed mixed results. Clinicians are faced with a number of challenges while managing obese patients with sepsis and should be mindful of the impact of obesity on antibiotics administration, fluid resuscitation, and ventilator management. Further studies are needed to elicit the impact of obesity on mortality in patients with sepsis.
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Affiliation(s)
| | | | - Raymonde Jean
- Mount Sinai St Luke's Roosevelt Hospital, New York, NY.
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Abstract
Purpose of review Obesity has been shown to be associated with antibiotic underdosing and treatment failure. This article reviews the recent literature on antibiotic dosing in obese patients with pneumonia. Recent findings Obesity is associated with several alterations in antibiotic pharmacokinetics and pharmacodynamics, including increases in the antibiotic volume of distribution and clearance. These alterations necessitate changes in the dosing of certain antibiotics. However, data on antibiotic dosing for pneumonia in obese patients are limited and come mainly from observational studies. Additionally, dosing recommendations are often extrapolated from healthy obese volunteers and from the studies of antibiotics given for other indications. Summary Recognizing obesity-related pharmacokinetic and pharmacodynamic alterations is important in treating obese patients with pneumonia. Studies that evaluate such alterations and assess the impact of antibiotic dosing and delivery on the clinical outcomes of this patient population are needed.
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Lewis SJ, Mueller BA. Antibiotic Dosing in Critically Ill Patients Receiving CRRT: Underdosing is Overprevalent. Semin Dial 2014; 27:441-5. [DOI: 10.1111/sdi.12203] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Susan J. Lewis
- Department of Clinical Social and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
| | - Bruce A. Mueller
- Department of Clinical Social and Administrative Sciences; University of Michigan College of Pharmacy; Ann Arbor Michigan
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Evans JD, Udeani G, Cole P, Friedland HD. Ceftaroline fosamil for the treatment of acute bacterial skin and skin structure infections in obese patients. Postgrad Med 2014; 126:128-34. [PMID: 25295657 DOI: 10.3810/pgm.2014.09.2807] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Ceftaroline fosamil is a broad-spectrum antibiotic approved by the US Food and Drug Administration (FDA) for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) and community-acquired bacterial pneumonia. The Clinical Assessment Program and Teflaro Utilization Registry (CAPTURE) is a multicenter registry study of patients treated with ceftaroline fosamil in the United States for ABSSSI or community-acquired bacterial pneumonia. OBJECTIVE To describe the clinical effectiveness of ceftaroline fosamil in the treatment of ABSSSI in obese patients [body mass index (BMI) ≥ 30] compared with patients with a normal BMI (18.5 to ≤ 24.9). METHODS Data were collected at US study centers by randomly ordered chart review. RESULTS Data from 261 patients with a normal BMI and 690 patients with an obese BMI were collected. The percentage of males was higher in the normal BMI than in the obese category (58.2% and 49.0%, respectively). The mean and median ages at baseline were similar. Most patients (91%) were treated on a general hospital ward, and the mean and median lengths of stay were similar between the 2 groups (approximately 11 days and 7 days, respectively). A total of 73.2% of normal BMI patients and 77.5% of obese patients were discharged to home. Rates of diabetes mellitus were 26.4% in the normal BMI group and 55.1% in the obese group. Methicillin-resistant Staphylococcus aureus was isolated from 26.1% of normal BMI patients and 20.5% of obese patients (16.4% morbidly obese subset). Mean treatment duration for all patients was 5.9 days. Of patients with a normal BMI, 57.5% received ceftaroline fosamil as monotherapy as did 63.3% of obese patients. Clinical success was high in both the normal BMI (85.1%) and the obese (89.0%) groups. CONCLUSION Ceftaroline fosamil is an effective treatment option for obese patients with ABSSSI with a similar clinical success rate, mean and median length of stay, and discharge destination to home when compared with normal BMI patients.
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Affiliation(s)
- John D Evans
- Director of Pharmacy Services, CHRISTUS Spohn Hospital-Alice, Alice, TX.
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Ross EL, Jorgensen J, DeWitt PE, Okada C, Porter R, Haemer M, Reiter PD. Comparison of 3 body size descriptors in critically ill obese children and adolescents: implications for medication dosing. J Pediatr Pharmacol Ther 2014; 19:103-10. [PMID: 25024670 DOI: 10.5863/1551-6776-19.2.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare 3 methods of weight determination for medication dose calculations in obese children and to discuss feasibility for use in routine care. METHODS This was a patient safety and quality improvement study evaluating patients (2-19 years old) admitted to the pediatric intensive care unit during a 13-month period (July 2010-July 2011). Patients identified as obese (≥95th percentile body mass index [BMI] for age), including severely obese (≥99th percentile BMI for age), were included in the weight method comparison portion of this study. Lean body mass estimations, using equations derived by the Peters and Foster methods, were compared to ideal body weight estimates by using the BMI method. Absolute differences between values generated by the 3 methods, intraclass correlation (ICC), and Bland-Altman plots were calculated. RESULTS A total of 1369 patients met initial criteria; 176 met criteria for the dosing weight comparison (age ± SD = 9.28 ± 5 years; actual weight ± SD = 55.5 ± 33.9 kg; 46% female). Sixty were severely obese and 116 were obese. Mean ICC between methods was 0.968 (95% Confidence interval (CI): 0.959, 0.975). The Peters method estimated higher weights than the Foster or BMI method. Bland-Altman plots illustrated good agreement between methods in children with weight below 50 kg, but decreased agreement above 50 kg, which was influenced by sex. CONCLUSIONS All methods demonstrated strong correlation and acceptable agreement in children below 50 kg. Systematic biases were identified in children above 50 kg where variance was higher. The BMI method was least complex to calculate and the most feasible method for daily use.
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Affiliation(s)
- Emma L Ross
- Department of Clinical Pharmacy, Children's Hospital Colorado, Aurora, Colorado
| | - Jennifer Jorgensen
- Department of Clinical Pharmacy, Children's Hospital Colorado, Aurora, Colorado
| | - Peter E DeWitt
- Colorado School of Public Health, Biostatistics and Informatics, Colorado Biostatistics Consortium, Research Consulting Lab, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Carol Okada
- Pediatric Intensive Care Unit, Section of Critical Care Medicine
| | - Renee Porter
- Department of Pediatrics, Section of Nutrition Children's Hospital Colorado, Aurora, Colorado
| | - Matthew Haemer
- Department of Pediatrics, Section of Nutrition Children's Hospital Colorado, Aurora, Colorado
| | - Pamela D Reiter
- Department of Clinical Pharmacy, Children's Hospital Colorado, Aurora, Colorado
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Pai MP, Cojutti P, Pea F. Levofloxacin Dosing Regimen in Severely Morbidly Obese Patients (BMI ≥40 kg/m2) Should Be Guided by Creatinine Clearance Estimates Based on Ideal Body Weight and Optimized by Therapeutic Drug Monitoring. Clin Pharmacokinet 2014; 53:753-62. [DOI: 10.1007/s40262-014-0154-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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A real-world, multicenter assessment of drugs requiring weight-based calculations in overweight, adult critically ill patients. ScientificWorldJournal 2013; 2013:909135. [PMID: 24363625 PMCID: PMC3864136 DOI: 10.1155/2013/909135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 09/24/2013] [Indexed: 11/18/2022] Open
Abstract
Prescribing appropriate doses of drugs requiring weight-based dosing is challenging in overweight patients due to a lack of data. With 68% of the US population considered overweight and these patients being at an increased risk for hospitalization, clinicians need guidance on dosing weight-based drugs. The purpose of this study was to identify “real-world” dose ranges of high-risk medications administered via continuous infusion requiring weight-based dosing and determine the reasons for dosing changes (ineffectiveness or adverse drug reactions). A prospective, multicenter, observational study was conducted in four intensive care units at three institutions. A total of 857 medication orders representing 11 different high-risk medications in 173 patients were reviewed. It was noted that dosing did not increase in proportion to weight classification. Overall, 14 adverse drug reactions occurred in nine patients with more in overweight patients (9 of 14). A total of 75% of orders were discontinued due to ineffectiveness in groups with higher body mass indexes. Ineffectiveness leads to dosing adjustments resulting in the opportunity for medication errors. Also, the frequent dosing changes further demonstrate our lack of knowledge of appropriate dosing for this population. Given the medications' increased propensity to cause harm, institutions should aggressively monitor these medications in overweight patients.
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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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