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Damgaard T, Woksepp H, Brudin L, Bonnedahl J, Nielsen EI, Schön T, Hällgren A. Estimated glomerular filtration rate as a tool for early identification of patients with insufficient exposure to beta-lactam antibiotics in intensive care units. Infect Dis (Lond) 2024; 56:451-459. [PMID: 38436273 DOI: 10.1080/23744235.2024.2323002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Only about 50% of intensive care unit (ICU) patients reach a free trough concentration above MIC (100% fT > MIC) of beta-lactam antibiotics. Although dose adjustments based on therapeutic drug monitoring (TDM) could be beneficial, TDM is not widely available. We investigated serum creatinine-based estimated GFR (eGFR) as a rapid screening tool to identify ICU patients at risk of insufficient exposure. METHOD Ninety-three adult patients admitted to four ICUs in southeast Sweden treated with piperacillin/tazobactam, meropenem, or cefotaxime were included. Beta-lactam trough concentrations were measured. The concentration target was set to 100% fT > MICECOFF (2, 4, and 16 mg/L based on calculated free levels for meropenem, cefotaxime, and piperacillin, respectively). eGFR was primarily determined via Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) and compared to three other eGFR equations. Data was analysed using logistic regression and receiver operative characteristic (ROC) curves. RESULTS With intermittent standard dosing, insufficient exposure was common in patients with a relative eGFR ≥48mL/min/1.73m2 [85%, (45/53)], particularly when treated with cefotaxime [96%, (24/25)]. This eGFR cut-off had a sensitivity of 92% and specificity of 82% (AUC 0.871, p < 0.001) in identifying insufficient exposure. In contrast, patients with eGFR <48mL/min/1.73m2 had high target attainment [90%, (36/40)] with a wide variability in drug exposure. There was no difference between the four eGFR equations (AUC 0.866-0.872, cut-offs 44-51 ml/min/1.73m2). CONCLUSION Serum creatinine-based eGFR is a simple and widely available surrogate marker with potential for early identification of ICU patients at risk of insufficient exposure to piperacillin, meropenem, and cefotaxime.
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Affiliation(s)
- Tobias Damgaard
- Pharmaceutical Department in Kalmar, Region Kalmar County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hanna Woksepp
- Department of Research and Department of Clinical Microbiology in Kalmar, Region Kalmar County, and Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
| | - Lars Brudin
- Department of Clinical Physiology in Kalmar, Region Kalmar County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jonas Bonnedahl
- Department of Infectious Diseases in Kalmar, Region Kalmar County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Thomas Schön
- Department of Infectious Diseases in Kalmar, Region Kalmar County, Department of Infectious Diseases in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anita Hällgren
- Department of Infectious Diseases in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Aldardeer NF, Alshreef MM, Alharbi EA, Aljabri AK, Aljawadi MH, Almangour TA, Alobaili S, Alarifi MI, Alomari A, Alhammad AM. Early Versus Late Antipseudomonal β-Lactam Antibiotic Dose Adjustment in Critically Ill Sepsis Patients With Acute Kidney Injury: A Prospective Observational Cohort Study. Open Forum Infect Dis 2024; 11:ofae059. [PMID: 38434610 PMCID: PMC10906704 DOI: 10.1093/ofid/ofae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024] Open
Abstract
Background Acute kidney injury (AKI) is a common complication of sepsis, contributing to an increased mortality rate. However, some studies have demonstrated that renal function improves in sepsis patients with AKI within 48 hours, raising questions about the necessity for early antibiotic adjustment. This study evaluates the association between the timing of antipseudomonal β-lactam dose adjustment and the outcomes of critically ill sepsis patients with AKI. Methods A prospective, multicenter observational study of critically ill patients aged ≥18 years admitted to the intensive care unit with sepsis and AKI and started on antipseudomonal β-lactam therapy. After the initial dose, eligible patients were grouped as early β-lactam antibiotic (E-BLA) or late β-lactam antibiotic (L-BLA) dose adjustments based on the administration of subsequent renally adjusted doses within 24 hours and after 24 hours of sepsis recognition, respectively. The main outcome of interest was in-hospital mortality. Results Among 1185 patients screened, 224 (mean age, 62.7 ± 16.8 years; 62% were male) met inclusion criteria. Eighty-four and 140 patients were included in the E-BLA and L-BLA groups, respectively. Approximately half of the cohort presented with AKI stage II, and piperacillin-tazobactam was prescribed as initial empirical therapy in more than 50% of the cohort. In the multivariable Cox proportional hazards model, L-BLA was associated with a significant reduction in in-hospital mortality compared to E-BLA (hazard ratio, 0.588 [95% confidence interval, .355-.974]). Conclusions In sepsis patients with AKI, L-BLA was associated with in-hospital mortality benefits.
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Affiliation(s)
- Namareq F Aldardeer
- Department of Pharmacy Services, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Maram M Alshreef
- Department of Pharmacy Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Emad A Alharbi
- Department of Pharmacy Services, King Fahad Hospital, Madinah, Saudi Arabia
| | - Ahmad K Aljabri
- Department of Pharmacy Services, King Fahad Hospital, Madinah, Saudi Arabia
| | - Mohammad H Aljawadi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Thamer A Almangour
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Saad Alobaili
- Department of Medicine, Nephrology Unit, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed I Alarifi
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Awad Alomari
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah M Alhammad
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Corporate Department of Pharmacy Services, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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3
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Dejaco A, Dorn C, Paal M, Gruber M, Graf BM, Kees MG. Determination of glomerular filtration rate "en passant" after high doses of iohexol for computed tomography in intensive care medicine-a proof of concept. Front Pharmacol 2024; 15:1346343. [PMID: 38362152 PMCID: PMC10867190 DOI: 10.3389/fphar.2024.1346343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Accurate assessment of renal function is of great clinical and scientific importance, as it is an important pharmacokinetic covariate of pivotal drugs. The iohexol clearance is nearly identical to the glomerular filtration rate, but its determination usually requires an intravenous injection and therefore bears intrinsic risks. This motivates to showcase an "en passant" approach to quantification of renal function without additional risk or blood sampling beyond routine care using real-world data. We enrolled 37 intensive care patients who received high doses of iohexol for computed tomography imaging, and quantified series of iohexol plasma concentrations by high-performance liquid chromatography (HPLC-UV). Iohexol clearance was derived by both log-linear regression and nonlinear least squares fitting and compared to glomerular filtration rate estimated by the CKD-EPI-2021 formulas. Nonlinear fitting not only turned out to be more accurate but also more robust in handling the irregularly timed data points. Concordance of iohexol clearance against estimations based on both creatinine and cystatin C showed a slightly higher bias (-3.44 mL/min/1.73 m2) compared to estimations based on creatinine alone (-0.76 mL/min/1.73 m2), but considerably narrower limits of agreement (±42.8 vs. 56 mL/min/1.73 m2) and higher Lin's correlation (0.84 vs. 0.72). In summary, we have demonstrated the feasibility and performance of the "en passant" variant of the iohexol method in intensive care medicine and described a working protocol for its application in clinical practice and pharmacologic studies.
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Affiliation(s)
- Alexander Dejaco
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Michael Paal
- Institute for Laboratory Medicine, Hospital of the University of Munich (LMU), Munich, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard M. Graf
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Martin G. Kees
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
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Stašek J, Keller F, Kočí V, Klučka J, Klabusayová E, Wiewiorka O, Strašilová Z, Beňovská M, Škardová M, Maláska J. Update on Therapeutic Drug Monitoring of Beta-Lactam Antibiotics in Critically Ill Patients—A Narrative Review. Antibiotics (Basel) 2023; 12:antibiotics12030568. [PMID: 36978435 PMCID: PMC10044408 DOI: 10.3390/antibiotics12030568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Beta-lactam antibiotics remain one of the most preferred groups of antibiotics in critical care due to their excellent safety profiles and their activity against a wide spectrum of pathogens. The cornerstone of appropriate therapy with beta-lactams is to achieve an adequate plasmatic concentration of a given antibiotic, which is derived primarily from the minimum inhibitory concentration (MIC) of the specific pathogen. In a critically ill patient, the plasmatic levels of drugs could be affected by many significant changes in the patient’s physiology, such as hypoalbuminemia, endothelial dysfunction with the leakage of intravascular fluid into interstitial space and acute kidney injury. Predicting antibiotic concentration from models based on non-critically ill populations may be misleading. Therapeutic drug monitoring (TDM) has been shown to be effective in achieving adequate concentrations of many drugs, including beta-lactam antibiotics. Reliable methods, such as high-performance liquid chromatography, provide the accurate testing of a wide range of beta-lactam antibiotics. Long turnaround times remain the main drawback limiting their widespread use, although progress has been made recently in the implementation of different novel methods of antibiotic testing. However, whether the TDM approach can effectively improve clinically relevant patient outcomes must be proved in future clinical trials.
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Affiliation(s)
- Jan Stašek
- Department of Internal Medicine and Cardiology, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Filip Keller
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Veronika Kočí
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Eva Klabusayová
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Ondřej Wiewiorka
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Zuzana Strašilová
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Miroslava Beňovská
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Markéta Škardová
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Jan Maláska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, 620 00 Brno, Czech Republic
- Correspondence:
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Antimicrobial stewardship programs in the Intensive Care Unit in patients with infections caused by multidrug-resistant Gram-negative bacilli. Med Intensiva 2023; 47:99-107. [PMID: 36319534 DOI: 10.1016/j.medine.2022.09.004] [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: 03/01/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 01/20/2023]
Abstract
Antimicrobial stewardship programs (ASPs) have been shown to be effective and safe, contributing to reducing and adjusting antimicrobial use in clinical practice. Such programs not only reduce antibiotic selection pressure and therefore the selection of multidrug-resistant strains, but also reduce the potential deleterious effects for individual patients and even improve the prognosis by adjusting the choice of drug and dosage, and lessening the risk of adverse effects and interactions. Gram-negative bacilli (GNB), particularly multidrug-resistant strains (MDR-GNB), represent the main infectious problem in the Intensive Care Unit (ICU), and are therefore a target for ASPs. The present review provides an update on the relationship between ASPs and MDR-GNB.
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Ruiz Ramos J, Ramírez Galleymore P. Programas de optimización de antibióticos en la unidad de cuidados intensivos en caso de infecciones por bacilos gramnegativos multiresistentes. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sidamo T, Shibeshi W, Yimer G, Aklillu E, Engidawork E. Explorative Analysis of Treatment Outcomes of Levofloxacin- and Moxifloxacin-Based Regimens and Outcome Predictors in Ethiopian MDR-TB Patients: A Prospective Observational Cohort Study. Infect Drug Resist 2022; 14:5473-5489. [PMID: 34984005 PMCID: PMC8703047 DOI: 10.2147/idr.s342964] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 11/30/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose/Background Although Ethiopia is among the thirty high multi-drug resistant tuberculosis (MDR-TB) burden countries in the world, comparative therapeutic efficacy of moxifloxacin and levofloxacin has not been explored, particularly in MDR-TB patients. We therefore aimed to prospectively compare clinical outcomes and determine potential predictors of the outcomes among patients on moxifloxacin or levofloxacin-based MDR-TB drug regimens. Methods We analyzed clinical parameters and laboratory data of eighty MDR-TB patients on moxifloxacin- or levofloxacin-based regimens. The clinical outcomes were compared using the Kaplan–Meier survival functions and the outcome definitions of the 2013 World Health Organization. Monthly sputum culture conversions and a molecular line probe assay results were also assessed. Observed outcomes and patient-related variables between the two groups were compared using chi-square, Wilcoxon Rank and Fisher exact tests. We also determined the potential predictors influencing treatment outcomes of moxifloxacin and levofloxacin using Cox proportional hazard model. Results The levofloxacin-based treatment group had a lower failure rate and adverse drug events as well as better treatment success than the moxifloxacin-based group. Overall treatment success was 65%. Disaggregating the data revealed that 53.8% were cured, 11.2% completed treatment, 10.0% died, 11.2% failed, and 13.8% were lost-to-follow-up. The line probe assay result showed that 11.3% of the clinical isolates were resistant to fluoroquinolones and 3.8% were resistant to both fluoroquinolones and injectable anti-TB agents. Treatment regimen type, culture conversion rate, alcohol use, cavity lesion, serum levels of creatinine and alanine aminotransferase were independent predictors of treatment outcome. Conclusion The levofloxacin-based regimen group has a better overall treatment success than the moxifloxacin-based group among MDR-TB patients. Clinical parameters and substance use history of the patients influenced treatment outcomes. We recommend further broader clinical studies to substantiate our findings as an input to review MDR-TB treatment guidelines.
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Affiliation(s)
- Temesgen Sidamo
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workineh Shibeshi
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Global One Health Initiative, Office of International Affairs, The Ohio State University, Columbus, OH, USA
| | - Eleni Aklillu
- Department of Laboratory of Medicine Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, C-168 141 86, Sweden
| | - Ephrem Engidawork
- Department of Pharmacology & Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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de Vroom SL, van Daalen FV, Zieck SE, Mathôt RAA, van Hest RM, Geerlings SE. Does dose reduction of renally cleared antibiotics in patients with impaired renal function lead to adequate drug exposure? A systematic review. Clin Microbiol Infect 2020; 27:352-363. [PMID: 33290864 DOI: 10.1016/j.cmi.2020.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is inconsistency between many guidelines in the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function. OBJECTIVES This systematic review summarizes the available evidence on the adequacy of the recommended dose reduction in terms of achieving sufficient antibiotic drug exposure or pharmacokinetic/pharmacodynamic target attainment after treatment with these reduced doses. DATA SOURCES We systematically searched Ovid Medline and Embase from inception (respectively 1946 and 1947) through July 2019. STUDY ELIGIBILITY CRITERIA All studies reporting antibiotic drug exposure and/or pharmacokinetic/pharmacodynamic (PK/PD) target attainment after dose reduction of antibiotics in patients with impaired renal function. PARTICIPANTS Adult patients with or without infections. INTERVENTIONS Administration of reduced doses of antibiotics (orally, intravenously or intramuscularly). METHODS The reduced dose was considered adequate when the most relevant parameters of drug exposure or PK/PD target attainment in patients with impaired renal function were within a range of 80% to 125% of that patients with adequate renal function receiving a regular dose (reference) or when PK/PD target attainment was attained in at least 90% of the patients with impaired renal function, regardless of the lack of a reference group. RESULTS Twenty-seven of the 4202 identified studies were included. The quality of 15 of 27 studies was fair, and most studies were of β-lactams (12/27). Best evidence was available for meropenem: four studies were included, of which two studies were of good quality. Drug exposure for meropenem is 158% to 286% higher in patients with impaired renal function receiving reduced doses compared to patients with adequate renal function receiving regular doses. For all other antibiotics, a maximum of one good-quality study could be identified. CONCLUSIONS No good-quality evidence on the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function is present, with the exception of meropenem.
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Affiliation(s)
- Suzanne L de Vroom
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
| | - Frederike V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands
| | - Saskia E Zieck
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
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Abdulla A, Ewoldt TMJ, Hunfeld NGM, Muller AE, Rietdijk WJR, Polinder S, van Gelder T, Endeman H, Koch BCP. The effect of therapeutic drug monitoring of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients: the DOLPHIN trial protocol of a multi-centre randomised controlled trial. BMC Infect Dis 2020; 20:57. [PMID: 31952493 PMCID: PMC6969462 DOI: 10.1186/s12879-020-4781-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/08/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Critically ill patients undergo extensive physiological alterations that will have impact on antibiotic pharmacokinetics. Up to 60% of intensive care unit (ICU) patients meet the pharmacodynamic targets of beta-lactam antibiotics, with only 30% in fluoroquinolones. Not reaching these targets might increase the chance of therapeutic failure, resulting in increased mortality and morbidity, and antibiotic resistance. The DOLPHIN trial was designed to demonstrate the added value of therapeutic drug monitoring (TDM) of beta-lactam and fluoroquinolones in critically ill patients in the ICU. METHODS A multi-centre, randomised controlled trial (RCT) was designed to assess the efficacy and cost-effectiveness of model-based TDM of beta-lactam and fluoroquinolones. Four hundred fifty patients will be included within 24 months after start of inclusion. Eligible patients will be randomly allocated to either study group: the intervention group (active TDM) or the control group (non-TDM). In the intervention group dose adjustment of the study antibiotics (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, amoxicillin, amoxicillin with clavulanic acid, flucloxacillin, piperacillin with tazobactam, meropenem, and ciprofloxacin) on day 1, 3, and 5 is performed based upon TDM with a Bayesian model. The primary outcome will be ICU length of stay. Other outcomes amongst all survival, disease severity, safety, quality of life after ICU discharge, and cost effectiveness will be included. DISCUSSION No trial has investigated the effect of early TDM of beta-lactam and fluoroquinolones on clinical outcome in critically ill patients. The findings from the DOLPHIN trial will possibly lead to new insights in clinical management of critically ill patients receiving antibiotics. In short, to TDM or not to TDM? TRIAL REGISTRATION EudraCT number: 2017-004677-14. Sponsor protocol name: DOLPHIN. Registered 6 March 2018 . Protocol Version 6, Protocol date: 27 November 2019.
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Affiliation(s)
- A Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - T M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - N G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
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