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Nolan J, McCarthy K, Farkas A, Avent ML. Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study. Int J Clin Pharm 2023; 45:1444-1451. [PMID: 37532840 DOI: 10.1007/s11096-023-01618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/24/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L. AIM To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions. METHOD A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data. RESULTS Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L. CONCLUSION Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.
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Affiliation(s)
- J Nolan
- The Royal Brisbane and Women's Hospital, Herston, Australia.
- School of Medicine, University of Queensland, 4029, Herston, Australia.
| | - K McCarthy
- The Royal Brisbane and Women's Hospital, Herston, Australia
- School of Medicine, University of Queensland, 4029, Herston, Australia
| | - A Farkas
- Mount Sinai West Hospital, New York, USA
- Optimum Dosing Strategies, Bloomingdale, New York, USA
| | - M L Avent
- The Royal Brisbane and Women's Hospital, Herston, Australia
- Queensland Statewide Antimicrobial Stewardship Program, University of Queensland Centre for Clinical Research, Herston, Australia
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2
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Alnezary FS, Almutairi MS, Gonzales-Luna AJ, Thabit AK. The Significance of Bayesian Pharmacokinetics in Dosing for Critically Ill Patients: A Primer for Clinicians Using Vancomycin as an Example. Antibiotics (Basel) 2023; 12:1441. [PMID: 37760737 PMCID: PMC10525617 DOI: 10.3390/antibiotics12091441] [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: 08/14/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Antibiotic use is becoming increasingly challenging with the emergence of multidrug-resistant organisms. Pharmacokinetic (PK) alterations result from complex pathophysiologic changes in some patient populations, particularly those with critical illness. Therefore, antibiotic dose individualization in such populations is warranted. Recently, there have been advances in dose optimization strategies to improve the utilization of existing antibiotics. Bayesian-based dosing is one of the novel approaches that could help clinicians achieve target concentrations in a greater percentage of their patients earlier during therapy. This review summarizes the advantages and disadvantages of current approaches to antibiotic dosing, with a focus on critically ill patients, and discusses the use of Bayesian methods to optimize vancomycin dosing. The Bayesian method of antibiotic dosing was developed to provide more precise predictions of drug concentrations and target achievement early in therapy. It has benefits such as the incorporation of personalized PK/PD parameters, improved predictive abilities, and improved patient outcomes. Recent vancomycin dosing guidelines emphasize the importance of using the Bayesian method. The Bayesian method is able to achieve appropriate antibiotic dosing prior to the patient reaching the steady state, allowing the patient to receive the right drug at the right dose earlier in therapy.
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Affiliation(s)
- Faris S. Alnezary
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 41477, Saudi Arabia;
| | - Masaad Saeed Almutairi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim 51452, Saudi Arabia
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX 77204, USA;
| | - Abrar K. Thabit
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah 21589, Saudi Arabia;
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Nguyen TA, Kirubakaran R, Schultz HB, Wong S, Reuter SE, McMullan B, Bolisetty S, Campbell C, Horvath AR, Stocker SL. Analytical and Non-Analytical Variation May Lead to Inappropriate Antimicrobial Dosing in Neonates: An In Silico Study. Clin Chem 2023:7146664. [PMID: 37116191 DOI: 10.1093/clinchem/hvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/01/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of aminoglycosides and vancomycin is used to prevent oto- and nephrotoxicity in neonates. Analytical and nonanalytical factors potentially influence dosing recommendations. This study aimed to determine the impact of analytical variation (imprecision and bias) and nonanalytical factors (accuracy of drug administration time, use of non-trough concentrations, biological variation, and dosing errors) on neonatal antimicrobial dosing recommendations. METHODS Published population pharmacokinetic models and the Australasian Neonatal Medicines Formulary were used to simulate antimicrobial concentration-time profiles in a virtual neonate population. Laboratory quality assurance data were used to quantify analytical variation in antimicrobial measurement methods used in clinical practice. Guideline-informed dosing recommendations based on drug concentrations were applied to compare the impact of analytical variation and nonanalytical factors on antimicrobial dosing. RESULTS Analytical variation caused differences in subsequent guideline-informed dosing recommendations in 9.3-12.1% (amikacin), 16.2-19.0% (tobramycin), 12.2-45.8% (gentamicin), and 9.6-19.5% (vancomycin) of neonates. For vancomycin, inaccuracies in drug administration time (45.6%), use of non-trough concentrations (44.7%), within-subject biological variation (38.2%), and dosing errors (27.5%) were predicted to result in more dosing discrepancies than analytical variation (12.5%). Using current analytical performance specifications, tolerated dosing discrepancies would be up to 14.8% (aminoglycosides) and 23.7% (vancomycin). CONCLUSIONS Although analytical variation can influence neonatal antimicrobial dosing recommendations, nonanalytical factors are more influential. These result in substantial variation in subsequent dosing of antimicrobials, risking inadvertent under- or overexposure. Harmonization of measurement methods and improved patient management systems may reduce the impact of analytical and nonanalytical factors on neonatal antimicrobial dosing.
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Affiliation(s)
- Thi A Nguyen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- Seberang Jaya Hospital, Penang, Malaysia
| | - Hayley B Schultz
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Sherilyn Wong
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Stephanie E Reuter
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Srinivas Bolisetty
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Craig Campbell
- NSW Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Andrea R Horvath
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- NSW Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Sophie L Stocker
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
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4
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Han J, Sauberan J, Tran MT, Adler-Shohet FC, Michalik DE, Tien TH, Tran L, DO DH, Bradley JS, Le J. Implementation of Vancomycin Therapeutic Monitoring Guidelines: Focus on Bayesian Estimation Tools in Neonatal and Pediatric Patients. Ther Drug Monit 2022; 44:241-252. [PMID: 34145165 DOI: 10.1097/ftd.0000000000000910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The 2020 consensus guidelines for vancomycin therapeutic monitoring recommend using Bayesian estimation targeting the ratio of the area under the curve over 24 hours to minimum inhibitory concentration as an optimal approach to individualize therapy in pediatric patients. To support institutional guideline implementation in children, the objective of this study was to comprehensively assess and compare published population-based pharmacokinetic (PK) vancomycin models and available Bayesian estimation tools, specific to neonatal and pediatric patients. METHODS PubMed and Embase databases were searched from January 1994 to December 2020 for studies in which a vancomycin population PK model was developed to determine clearance and volume of distribution in neonatal and pediatric populations. Available Bayesian software programs were identified and assessed from published articles, software program websites, and direct communication with the software company. In the present review, 14 neonatal and 20 pediatric models were included. Six programs (Adult and Pediatric Kinetics, BestDose, DoseMeRx, InsightRx, MwPharm++, and PrecisePK) were evaluated. RESULTS Among neonatal models, Frymoyer et al and Capparelli et al used the largest PK samples to generate their models, which were externally validated. Among the pediatric models, Le et al used the largest sample size, with multiple external validations. Of the Bayesian programs, DoseMeRx, InsightRx, and PrecisePK used clinically validated neonatal and pediatric models. CONCLUSIONS To optimize vancomycin use in neonatal and pediatric patients, clinicians should focus on selecting a model that best fits their patient population and use Bayesian estimation tools for therapeutic area under the -curve-targeted dosing and monitoring.
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Affiliation(s)
- Jihye Han
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | - Jason Sauberan
- Neonatal Research Institute, SHARP Mary Birch Hospital for Women and Newborns, San Diego
| | | | | | - David E Michalik
- MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, California
| | | | - Lan Tran
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | | | - John S Bradley
- Division of Infectious Diseases, University of California at San Diego, Louisiana Jolla; and
- Rady Children's Hospital-San Diego, San Diego, California
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
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Oommen T, Thommandram A, Palanica A, Fossat Y. A Free Open-Source Bayesian Vancomycin Dosing App for Adults: Design and Evaluation Study. JMIR Form Res 2022; 6:e30577. [PMID: 35353046 PMCID: PMC9008526 DOI: 10.2196/30577] [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: 05/20/2021] [Revised: 10/08/2021] [Accepted: 02/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background It has been suggested that Bayesian dosing apps can assist in the therapeutic drug monitoring of patients receiving vancomycin. Unfortunately, Bayesian dosing tools are often unaffordable to resource-limited hospitals. Our aim was to improve vancomycin dosing in adults. We created a free and open-source dose adjustment app, VancoCalc, which uses Bayesian inference to aid clinicians in dosing and monitoring of vancomycin. Objective The aim of this paper is to describe the design, development, usability, and evaluation of a free open-source Bayesian vancomycin dosing app, VancoCalc. Methods The app build and model fitting process were described. Previously published pharmacokinetic models were used as priors. The ability of the app to predict vancomycin concentrations was performed using a small data set comprising of 52 patients, aged 18 years and over, who received at least 1 dose of intravenous vancomycin and had at least 2 vancomycin concentrations drawn between July 2018 and January 2021 at Lakeridge Health Corporation Ontario, Canada. With these estimated and actual concentrations, median prediction error (bias), median absolute error (accuracy), and root mean square error (precision) were calculated to evaluate the accuracy of the Bayesian estimated pharmacokinetic parameters. Results A total of 52 unique patients’ initial vancomycin concentrations were used to predict subsequent concentration; 104 total vancomycin concentrations were assessed. The median prediction error was –0.600 ug/mL (IQR –3.06, 2.95), the median absolute error was 3.05 ug/mL (IQR 1.44, 4.50), and the root mean square error was 5.34. Conclusions We described a free, open-source Bayesian vancomycin dosing calculator based on revisions of currently available calculators. Based on this small retrospective preliminary sample of patients, the app offers reasonable accuracy and bias, which may be used in everyday practice. By offering this free, open-source app, further prospective validation could be implemented in the near future.
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Affiliation(s)
| | | | - Adam Palanica
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
| | - Yan Fossat
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
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Mao W, Lu D, Zhou J, Zhen J, Yan J, Li L. Chinese ICU physicians' knowledge of antibiotic pharmacokinetics/pharmacodynamics (PK/PD): a cross-sectional survey. BMC MEDICAL EDUCATION 2022; 22:173. [PMID: 35287666 PMCID: PMC8920424 DOI: 10.1186/s12909-022-03234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patients with sepsis have a high mortality rate, accumulated evidences suggest that an optimal antibiotic administration strategy based on pharmacokinetics/pharmacodynamics (PK/PD) can improve the prognosis of septic patients. Therefore, we assessed Chinese intensive care unit (ICU) physicians' knowledge about PK/PD. METHODS In December 2019, we designed a questionnaire focused on Chinese ICU physicians' knowledge about PK/PD and collected the questionnaires after 3 months. The questionnaire was distributed via e-mail and WeChat, and was distributed to ICU doctors in 31 administrative regions of China except Hong Kong, Macao and Taiwan. The passing score was corrected by the Angoff method, and the ICU physicians' knowledge about PK/PD was analysed accordingly. RESULTS We received a total of 1,309 questionnaires and retained 1,240 valid questionnaires. The passing score was 90.8, and the overall pass rate was 56.94%. The pass rate for tertiary and secondary hospitals was 59.07% and 37.19%, respectively. ICU physicians with less than 5 years of work experience and resident physician accounted for the highest pass rate, while those with between 5 to 10 years of work experience and attending accounted for the lowest pass rate. The majority of participants in the Chinese Critical Care Certified Course (5C) were from Jiangsu and Henan provinces, and they had the highest average scores (125.8 and 126.5, respectively). For Beijing and Shanghai, the average score was only 79.4 and 90.9, respectively. CONCLUSIONS Chinese ICU physicians' knowledge about PK/PD is unsatisfactory. Therefore, it is essential to strengthen ICU physicians' knowledge about PK/PD.
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Affiliation(s)
- Wenchao Mao
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, China
| | - Difan Lu
- The First Affiliated Hospital of Zhejiang University, Hangzhou, 310003, Zhejiang, China
| | - Jia Zhou
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, China
| | - Junhai Zhen
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, China
| | - Jing Yan
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, China.
| | - Li Li
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, 310013, China.
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7
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Schön K, Koristkova B, Kacirova I, Brozmanova H, Grundmann M. Comparison of Mw\Pharm 3.30 and Mw\Pharm ++, a Windows version of pharmacokinetic software for PK/PD monitoring of vancomycin. Part 1: A-posteriori modelling. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 214:106552. [PMID: 34896687 DOI: 10.1016/j.cmpb.2021.106552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVES For a long time, the Mw\Pharm software suite (MEDI\WARE, Prague, Czech Republic/ Groningen, Netherlands) has been used for PK/PD modelling in therapeutic drug monitoring (TDM). The aim of this study was to find the best model in the newer Windows Mw\Pharm++ 1.3.5.558 version (WIN). METHODS 25 patients were repeatedly examined for vancomycin (mean age 63±14 years, body weight 88±21 kg, median dose 1 g/12 h). Trough concentrations predicted a-posteriori by WIN models "vancomycin_adult_k_C2", "#vancomycin_adult_C2", "vancomycin_adult_C2" were compared with the measured value and "vancomycin adult" DOS 3.30 model (DOS). STATISTICS Percentage prediction error (%PE) calculated as (predicted-measured)/measured values, or WIN-DOS/DOS - data presented as mean±SD, RMSE, Blandt-Altman plot - data presented as bias±SD (95% limits of agreement), Pearson's coefficient of rank correlation (R), Student's t-test. Statistical analysis was performed using GraphPad Prism version 5.00 for Windows. RESULTS The mean%PE in vancomycin predicted values varied from -4.5% ± 33.6 to -8.2% ± 39.3. The%PE between WIN and DOS models varied from -0.2% ± 24.5% to 4.4 ± 21.4%. Model "vancomycin_adult_C2" was closest both to measured vancomycin trough concentration and DOS model:%PE -4.5 ± 33.6% vs +4.2 ± 20.3%, RMSE 33.7 vs 20.6, Blandt-Altman bias +2.19 ± 6.17 (-9.9 - 14.3) vs -0.29 ± 3.25 (-6.7 - 6.1), resp. "#vancomycin_adult_C2" model produced largest%PE (-8.2%), RMSE (40.0) as well as Blandt-Altman bias +2.82 ± 6.76 (-10.4 - 16.1). The Pearson's R of predicted and measured vancomycin concentration, and of values predicted by WIN and DOS models, varied from 0.5135 to 0.5854, P<0.0001 and from 0.7869 to 0.8462, P<0.0001, resp. CONCLUSIONS Three Windows vancomycin models and one DOS model in the Mw\Pharm software were compared. The best outcomes, i.e. lowest%PE, RMSE and highest Pearson's R, were reached with "vancomycin_adult_C2" model.
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Affiliation(s)
- Kristyna Schön
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Czechia
| | - Blanka Koristkova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Czechia; Department of Clinical Pharmacology, Department of Laboratory Medicine, University Hospital Ostrava, Czechia.
| | - Ivana Kacirova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Czechia; Department of Clinical Pharmacology, Department of Laboratory Medicine, University Hospital Ostrava, Czechia
| | - Hana Brozmanova
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Czechia; Department of Clinical Pharmacology, Department of Laboratory Medicine, University Hospital Ostrava, Czechia
| | - Milan Grundmann
- Department of Clinical Pharmacology, Faculty of Medicine, University of Ostrava, Czechia
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Implementation and Comparison of Two Pharmacometric Tools for Model-Based Therapeutic Drug Monitoring and Precision Dosing of Daptomycin. Pharmaceutics 2022; 14:pharmaceutics14010114. [PMID: 35057009 PMCID: PMC8779485 DOI: 10.3390/pharmaceutics14010114] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Daptomycin is a candidate for therapeutic drug monitoring (TDM). The objectives of this work were to implement and compare two pharmacometric tools for daptomycin TDM and precision dosing. A nonparametric population PK model developed from patients with bone and joint infection was implemented into the BestDose software. A published parametric model was imported into Tucuxi. We compared the performance of the two models in a validation dataset based on mean error (ME) and mean absolute percent error (MAPE) of individual predictions, estimated exposure and predicted doses necessary to achieve daptomycin efficacy and safety PK/PD targets. The BestDose model described the data very well in the learning dataset. In the validation dataset (94 patients, 264 concentrations), 21.3% of patients were underexposed (AUC24h < 666 mg.h/L) and 31.9% of patients were overexposed (Cmin > 24.3 mg/L) on the first TDM occasion. The BestDose model performed slightly better than the model in Tucuxi (ME = -0.13 ± 5.16 vs. -1.90 ± 6.99 mg/L, p < 0.001), but overall results were in agreement between the two models. A significant proportion of patients exhibited underexposure or overexposure to daptomycin after the initial dosage, which supports TDM. The two models may be useful for model-informed precision dosing.
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Optimizing antimicrobial use: challenges, advances and opportunities. Nat Rev Microbiol 2021; 19:747-758. [PMID: 34158654 DOI: 10.1038/s41579-021-00578-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
An optimal antimicrobial dose provides enough drug to achieve a clinical response while minimizing toxicity and development of drug resistance. There can be considerable variability in pharmacokinetics, for example, owing to comorbidities or other medications, which affects antimicrobial pharmacodynamics and, thus, treatment success. Although current approaches to antimicrobial dose optimization address fixed variability, better methods to monitor and rapidly adjust antimicrobial dosing are required to understand and react to residual variability that occurs within and between individuals. We review current challenges to the wider implementation of antimicrobial dose optimization and highlight novel solutions, including biosensor-based, real-time therapeutic drug monitoring and computer-controlled, closed-loop control systems. Precision antimicrobial dosing promises to improve patient outcome and is important for antimicrobial stewardship and the prevention of antimicrobial resistance.
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Personalized Antibiotic Therapy for the Critically Ill: Implementation Strategies and Effects on Clinical Outcome of Piperacillin Therapeutic Drug Monitoring-A Descriptive Retrospective Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121452. [PMID: 34943664 PMCID: PMC8698194 DOI: 10.3390/antibiotics10121452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 12/29/2022] Open
Abstract
Therapeutic drug monitoring (TDM) is increasingly relevant for an individualized antibiotic therapy and subsequently a necessary tool to reduce multidrug-resistant pathogens, especially in light of diminishing antimicrobial capabilities. Critical illness is associated with profound pharmacokinetic and pharmacodynamic alterations, which challenge dose finding and the application of particularly hydrophilic drugs such as β-lactam antibiotics. Methods: Implementation strategy, potential benefit, and practicability of the developed standard operating procedures were retrospectively analyzed from January to December 2020. Furthermore, the efficacy of the proposed dosing target of piperacillin in critically ill patients was evaluated. Results: In total, 160 patients received piperacillin/tazobactam therapy and were subsequently included in the study. Of them, 114 patients received piperacillin/tazobactam by continuous infusion and had at least one measurement of piperacillin serum level according to the standard operating procedure. In total, 271 measurements were performed with an average level of 79.0 ± 46.0 mg/L. Seventy-one piperacillin levels exceeded 100 mg/L and six levels were lower than 22.5 mg/L. The high-level and the low-level group differed significantly in infection laboratory parameters (CRP (mg/dL) 20.18 ± 11.71 vs. 5.75 ± 5.33) and renal function [glomerular filtration rate (mL/min/1.75 m2) 40.85 ± 26.74 vs. 120.50 ± 70.48]. Conclusions: Piperacillin levels are unpredictable in critically ill patients. TDM during piperacillin/tazobactam therapy is highly recommended for all patients. Although our implementation strategy was effective, further strategies implemented into the daily clinical workflow might support the health care staff and increase the clinicians' alertness.
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Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
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Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Goutelle S, Alloux C, Bourguignon L, Van Guilder M, Neely M, Maire P. To Estimate or to Forecast? Lessons From a Comparative Analysis of Four Bayesian Fitting Methods Based on Nonparametric Models. Ther Drug Monit 2021; 43:461-471. [PMID: 34250963 DOI: 10.1097/ftd.0000000000000879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/03/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Using pharmacokinetic (PK) models and Bayesian methods in dosing software facilitates the analysis of individual PK data and precision dosing. Several Bayesian methods are available for computing Bayesian posterior distributions using nonparametric population models. The objective of this study was to compare the performance of the maximum a posteriori (MAP) model, multiple model (MM), interacting MM (IMM), and novel hybrid MM(HMM) in estimating past concentrations and predicting future concentrations during therapy. Amikacin and vancomycin PK data were analyzed in older hospitalized patients using 2 strategies. First, the entire data set of each patient was fitted using each of the 4 methods implemented in BestDose software. Then, the 4 methods were used in each therapeutic drug monitoring occasion to estimate the past concentrations available at this time and to predict the subsequent concentrations to be observed on the next occasion. The bias and precision of the model predictions were compared among the methods. A total of 406 amikacin concentrations from 96 patients and 718 vancomycin concentrations from 133 patients were available for analysis. Overall, significant differences were observed in the predictive performance of the 4 Bayesian methods. The IMM method showed the best fit to past concentration data of amikacin and vancomycin, whereas the MM method was the least precise. However, MM best predicted the future concentrations of amikacin. The MAP and HMM methods showed a similar predictive performance and seemed to be more appropriate for the prediction of future vancomycin concentrations than the other models were. The richness of the prior distribution may explain the discrepancies between the results of the 2 drugs. Although further research with other drugs and models is necessary to confirm our findings, these results challenge the widely accepted assumption in PK modeling that a better data fit indicates better forecasting of future observations.
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Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France. Alloux is now with the Assistance Publique-Hôpitaux de Paris, Agence Générale des Equipements et des Produits de Santé (AGEPS), Département Essais Cliniques, Paris, France
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France
- Univ Lyon, Université Lyon 1 UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France ; and
| | - Céline Alloux
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France. Alloux is now with the Assistance Publique-Hôpitaux de Paris, Agence Générale des Equipements et des Produits de Santé (AGEPS), Département Essais Cliniques, Paris, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France. Alloux is now with the Assistance Publique-Hôpitaux de Paris, Agence Générale des Equipements et des Produits de Santé (AGEPS), Département Essais Cliniques, Paris, France
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France
- Univ Lyon, Université Lyon 1 UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France ; and
| | - Michael Van Guilder
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Children's Hospital Los Angeles and the University of Southern California, Los Angeles, California
| | - Michael Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, Children's Hospital Los Angeles and the University of Southern California, Los Angeles, California
| | - Pascal Maire
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France. Alloux is now with the Assistance Publique-Hôpitaux de Paris, Agence Générale des Equipements et des Produits de Santé (AGEPS), Département Essais Cliniques, Paris, France
- Univ Lyon, Université Lyon 1 UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France ; and
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13
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Sandaradura I, Alffenaar JW, Cotta MO, Daveson K, Day RO, Van Hal S, Lau C, Marriott DJE, Penm J, Roberts JA, Tabah A, Williams P, Imani S. Emerging therapeutic drug monitoring of anti-infective agents in Australian hospitals: Availability, performance and barriers to implementation. Br J Clin Pharmacol 2021; 88:669-679. [PMID: 34289135 DOI: 10.1111/bcp.14995] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS The purpose of the study was to assess the status of emerging therapeutic drug monitoring (TDM) of anti-infective agents in Australian hospitals. METHODS A nationwide cross-sectional survey of all Australian hospitals operating in the public and private health sector was conducted between August and September 2019. The survey consisted of questions regarding institutional TDM practice for anti-infective agents and clinical vignettes specific to β-lactam antibiotics. RESULTS Responses were received from 82 unique institutions, representing all Australian states and territories. All 29 (100%) of principal referral (major) hospitals in Australia participated. Five surveys were partially complete. Only 25% (20/80) of hospitals had TDM testing available on-site for any of the eight emerging TDM candidates considered: β-lactam antibiotics, anti-tuberculous agents, flucytosine, fluoroquinolones, ganciclovir, human immunodeficiency virus (HIV) drugs, linezolid and teicoplanin. A considerable time lag was noted between TDM sampling and reporting of results. With respect to β-lactam antibiotic TDM, variable indications, pharmacodynamic targets and sampling times were identified. The three greatest barriers to local TDM performance were found to be (1) lack of timely assays/results, (2) lack of institutional-wide expertise and/or training and (3) lack of guidelines to inform ordering of TDM and interpretation of results. The majority of respondents favoured establishing national TDM guidelines and increasing access to dose prediction software, at rates of 89% and 96%, respectively. CONCLUSION Translating emerging TDM evidence into daily clinical practice is slow. Concerted efforts are required to address the barriers identified and facilitate the implementation of standardised practice.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia.,Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Jan-Willem Alffenaar
- Department of Pharmacy, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia
| | - Menino O Cotta
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases, Canberra Hospital, Canberra, ACT, Australia.,Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD, Australia
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sebastiaan Van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cindy Lau
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, St Vincent's Hospital, Sydney, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Microbiology, SydPath, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Paul Williams
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Sahand Imani
- Northern Sydney Local Health District, Hornsby Ku-ring-gai Hospital, Sydney, NSW, Australia
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14
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Garreau R, Bricca R, Gagnieu MC, Roux S, Conrad A, Bourguignon L, Ferry T, Goutelle S. Population pharmacokinetics of daptomycin in patients with bone and joint infection: minimal effect of rifampicin co-administration and confirmation of a sex difference. J Antimicrob Chemother 2021; 76:1250-1257. [PMID: 33550409 DOI: 10.1093/jac/dkab006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/29/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Daptomycin is increasingly used in the treatment of bone and joint infection (BJI), but its pharmacokinetics (PK) and dosage requirements have not been thoroughly investigated in this indication. Daptomycin may be co-administered with rifampicin, which raises questions about a potential drug interaction. OBJECTIVES To investigate the population PK and dosage requirements of daptomycin in patients with BJI, and examine the influence of rifampicin co-administration. METHODS A population approach was used to analyse PK data from patients who received daptomycin in our regional reference for BJI. We examined the influence of available covariates, including rifampicin co-administration on daptomycin PK. Simulations performed with the final model investigated the influence of dosages and covariates on PTA for both efficacy and safety. RESULTS A total of 1303 daptomycin concentrations from 183 patients were analysed. A two-compartment model best described the data. Significant intra-individual variability was observed. Daptomycin clearance was influenced by renal function and sex, with females having a 26% lower typical clearance than males. Central volume of distribution (V1) was influenced by body weight, age, sex and rifampicin co-administration. Typical V1 was 11% lower in patients who were co-administered rifampicin. In PK/PD simulations, sex influenced the probability of AUC24/MIC target attainment, while rifampicin had a marginal effect. CONCLUSIONS A daptomycin dosage of 8 mg/kg/24 h in women and 10 mg/kg/24 h in men should optimize efficacy but may lead to excessive trough concentrations in many patients, especially in women. Therapeutic drug monitoring appears necessary for precision dosing of daptomycin.
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Affiliation(s)
- Romain Garreau
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
| | - Romain Bricca
- Hôpital Nord-Ouest, Service de médecine interne et des maladies infectieuses, Villefranche Sur Saône, France
| | - Marie-Claude Gagnieu
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie -Toxicologie, Lyon, France
| | - Sandrine Roux
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre interrégional de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
| | - Anne Conrad
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre interrégional de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Facultés de Médecine et de Pharmacie de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université' Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007 Lyon, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Facultés de Médecine et de Pharmacie de Lyon, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre interrégional de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Facultés de Médecine et de Pharmacie de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université' Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, F-69007 Lyon, France
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Facultés de Médecine et de Pharmacie de Lyon, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
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15
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Goutelle S, Conrad A, Pouderoux C, Braun E, Laurent F, Gagnieu MC, Cohen S, Guitton J, Valour F, Ferry T. Pharmacokinetic/Pharmacodynamic Dosage Individualization of Suppressive Beta-Lactam Therapy Administered by Subcutaneous Route in Patients With Prosthetic Joint Infection. Front Med (Lausanne) 2021; 8:583086. [PMID: 33869238 PMCID: PMC8044368 DOI: 10.3389/fmed.2021.583086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Suppressive parenteral antibiotic therapy with beta-lactams may be necessary in patients with Gram-negative bone and joint infection (BJI). Subcutaneous drug administration can facilitate this therapy in outpatient setting, but there is limited information about this practice. We have developed an original approach for drug dosing in this context, based on therapeutic drug monitoring (TDM) and pharmacokinetic/pharmacodynamic (PK/PD) principles. The objective of this study was to describe our approach and its first results in a case series. We analyzed data from patients who received suppressive antibiotic therapy by subcutaneous (SC) route with beta-lactams as salvage therapy for prosthetic joint infection (PJI) and had TDM with PK/PD-based dose adjustment. Ten patients (six women and four men with a mean age of 77 years) were included from January 2017 to May 2020. The drugs administered by SC route were ceftazidime (n = 4), ertapenem (n = 4), and ceftriaxone (n = 2). In each patient, PK/PD-guided dosage individualization was performed based on TDM and minimum inhibitory concentration (MIC) measurements. The dose interval could be prolonged from twice daily to thrice weekly in some patients, while preserving the achievement of PK/PD targets. The infection was totally controlled by the strategy in nine out the 10 patients during a median follow-up of 1,035 days (~3 years). No patient acquired carbapenem-resistant Gram-negative bacteria during the follow-up. One patient presented treatment failure with acquired drug resistance under therapy, which could be explained by late MIC determination and insufficient exposure, retrospectively. To conclude, our innovative approach, based on model-based TDM, MIC determination, and individualized PK/PD goals, facilitates, and optimizes suppressive outpatient beta-lactam therapy administered by SC route for PJI. These encouraging results advocate for larger clinical evaluation.
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Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Anne Conrad
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Cécile Pouderoux
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Evelyne Braun
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France.,Institut des Agents Infectieux, Laboratoire de bactériologie, Centre National de référence des staphylocoques, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Marie-Claude Gagnieu
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Sabine Cohen
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Jérôme Guitton
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Florent Valour
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Tristan Ferry
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
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16
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Osorio C, Garzón L, Jaimes D, Silva E, Bustos RH. Impact on Antibiotic Resistance, Therapeutic Success, and Control of Side Effects in Therapeutic Drug Monitoring (TDM) of Daptomycin: A Scoping Review. Antibiotics (Basel) 2021; 10:antibiotics10030263. [PMID: 33807617 PMCID: PMC8001274 DOI: 10.3390/antibiotics10030263] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance (AR) is a problem that threatens the search for adequate safe and effective antibiotic therapy against multi-resistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococci (VRE) and Clostridium difficile, among others. Daptomycin is the treatment of choice for some infections caused by Gram-positive bacteria, indicated most of the time in patients with special clinical conditions where its high pharmacokinetic variability (PK) does not allow adequate plasma concentrations to be reached. The objective of this review is to describe the data available about the type of therapeutic drug monitoring (TDM) method used and described so far in hospitalized patients with daptomycin and to describe its impact on therapeutic success, suppression of bacterial resistance, and control of side effects. The need to create worldwide strategies for the appropriate use of antibiotics is clear, and one of these is the performance of therapeutic drug monitoring (TDM). TDM helps to achieve a dose adjustment and obtain a favorable clinical outcome for patients by measuring plasma concentrations of an administered drug, making a rational interpretation guided by a predefined concentration range, and, thus, adjusting dosages individually.
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Affiliation(s)
- Carolina Osorio
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (C.O.); (L.G.); (D.J.)
| | - Laura Garzón
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (C.O.); (L.G.); (D.J.)
| | - Diego Jaimes
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (C.O.); (L.G.); (D.J.)
| | - Edwin Silva
- Faculty of Medicine, University of La Sabana, Chía 140013, Colombia;
| | - Rosa-Helena Bustos
- Evidence-Based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia; (C.O.); (L.G.); (D.J.)
- Correspondence: ; Tel.: +57-1-8615555
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17
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Sandaradura I, Wojciechowski J, Marriott DJE, Day RO, Stocker S, Reuter SE. Model-Optimized Fluconazole Dose Selection for Critically Ill Patients Improves Early Pharmacodynamic Target Attainment without the Need for Therapeutic Drug Monitoring. Antimicrob Agents Chemother 2021; 65:e02019-20. [PMID: 33361309 PMCID: PMC8092533 DOI: 10.1128/aac.02019-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/20/2020] [Indexed: 12/19/2022] Open
Abstract
Fluconazole has been associated with higher mortality compared with the echinocandins in patients treated for invasive candida infections. Underexposure from current fluconazole dosing regimens may contribute to these worse outcomes, so alternative dosing strategies require study. The objective of this study was to evaluate fluconazole drug exposure in critically ill patients comparing a novel model-optimized dose selection method with established approaches over a standard 14-day (336-h) treatment course. Target attainment was evaluated in a representative population of 1,000 critically ill adult patients for (i) guideline dosing (800-mg loading and 400-mg maintenance dosing adjusted to renal function), (ii) guideline dosing followed by therapeutic drug monitoring (TDM)-guided dose adjustment, and (iii) model-optimized dose selection based on patient factors (without TDM). Assuming a MIC of 2 mg/liter, free fluconazole 24-h area under the curve (fAUC24) targets of ≥200 mg · h/liter and <800 mg · h/liter were used for assessment of target attainment. Guideline dosing resulted in underexposure in 21% of patients at 48 h and in 23% of patients at 336 h. The TDM-guided strategy did not influence 0- to 48-h target attainment due to inherent procedural delays but resulted in 37% of patients being underexposed at 336 h. Model-optimized dosing resulted in ≥98% of patients meeting efficacy targets throughout the treatment course, while resulting in less overexposure compared with guideline dosing (7% versus 14%) at 336 h. Model-optimized dose selection enables fluconazole dose individualization in critical illness from the outset of therapy and should enable reevaluation of the comparative effectiveness of this drug in patients with severe fungal infections.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- School of Medicine, University of Sydney, NSW, Australia
| | | | - Deborah J E Marriott
- Department of Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Richard O Day
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sophie Stocker
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
- Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stephanie E Reuter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
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18
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Willems J, Hermans E, Schelstraete P, Depuydt P, De Cock P. Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review. Paediatr Drugs 2021; 23:39-53. [PMID: 33174101 PMCID: PMC7654352 DOI: 10.1007/s40272-020-00426-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 02/08/2023]
Abstract
Antibiotics are one of the most prescribed drug classes in the pediatric intensive care unit, yet the incidence of inappropriate antibiotic prescribing remains high in critically ill children. Optimizing the use of antibiotics in this population is imperative to guarantee adequate treatment, avoid toxicity and the occurrence of antibiotic resistance, both on a patient level and on a population level. Antibiotic stewardship encompasses all initiatives to promote responsible antibiotic usage and the PICU represents a major target environment for antibiotic stewardship programs. This narrative review provides a summary of the available knowledge on the optimal selection, duration, dosage, and route of administration of antibiotic treatment in critically ill children. Overall, more scientific evidence on how to optimize antibiotic treatment is warranted in this population. We also give our personal expert opinion on research priorities.
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Affiliation(s)
- Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Eline Hermans
- Department of Pediatrics, Ghent University Hospital, Gent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology, Ghent University Hospital, Gent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Pieter De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium.
- Department of Pharmacy, Ghent University Hospital, Gent, Belgium.
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19
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[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:346-360. [PMID: 33309603 DOI: 10.1016/j.pharma.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.
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Pongchaidecha M, Changpradub D, Bannalung K, Seejuntra K, Thongmee S, Unnual A, Santimaleeworagun W. Vancomycin Area under the Curve and Pharmacokinetic Parameters during the First 24 Hours of Treatment in Critically Ill Patients using Bayesian Forecasting. Infect Chemother 2020; 52:573-582. [PMID: 33263245 PMCID: PMC7779987 DOI: 10.3947/ic.2020.52.4.573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/18/2020] [Indexed: 12/29/2022] Open
Abstract
Background Currently, the achievement of the target area under the curve (AUC)/minimum inhibitory concentration ratio during the first 24 - 48 h of treatment is associated with reduced 30-day mortality and greater microbiological eradication in patients with methicillin-resistant Staphylococcus aureus bacteremia. This study aimed to determine the AUC and pharmacokinetic parameters on the first day of vancomycin administration based on the Bayesian theorem to optimize the dosing regimen in critically ill patients. Materials and Methods This retrospective study included participants meeting the following criteria: 1) ≥18 years old; 2) receipt of at least one dose of vancomycin; 3) measurement of 2 vancomycin serum concentrations during the first 24 h of treatment; and 4) an intensive care unit admission, mechanical ventilator use, or an Acute Physiology and Chronic Health Evaluation II score >15 points. The AUC on day 1 of treatment and the estimated vancomycin pharmacokinetic parameters were measured using PrecisePK software based on the Bayesian theorem. Results We obtained 132 vancomycin concentrations from 66 patients. The vancomycin pharmacokinetic parameters were as follows: AUC0-24, 571.09 (± standard deviation [SD] 188.62) mg/L·h; clearance (CL), 2.97 (± SD 1.81) L/h; volume of distribution (Vd), 50.60 (± SD 13.91) L; elimination rate constant, 0.062 (± SD 0.039) h−1; and half-life, 18.19 (± SD 15.96) h. Focusing on the vancomycin loading dose, AUC0-24 400 - 600 was achieved in 41.7, 46.1, 44.4, and 26.3% of patients with loading doses of <20, 20 – 24.9, 25 – 30, and >30 mg/kg, respectively. Whereas AUC0-24 ≥521 was achieved in 50, 50, 77.8, and 84.2% of patients with loading doses of <20, 20 – 24.9, 25 – 30, and >30 mg/kg, respectively. The CL of vancomycin was correlated with creatinine CL, whereas the Vd of vancomycin was significantly correlated with age and body weight. Conclusion This study revealed that the higher Vd and CL values on the first day of vancomycin therapy were found in critically ill patients. Additionally, a higher vancomycin loading dose (25 – 30 mg/kg) might be required to achieve target of AUC0-24 during early phase of administration for critically ill patients.
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Affiliation(s)
- Manat Pongchaidecha
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Dhitiwat Changpradub
- Division of Infectious Diseases, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Kanjana Bannalung
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Kajeewan Seejuntra
- Department of Pharmacy, Ramathibodi Chakri Naruebodindra Hospital, Samutprakarn, Thailand
| | | | - Aminta Unnual
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Wichai Santimaleeworagun
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.,Antibiotic Optimization and Patient Care Project by Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.
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Chai MG, Cotta MO, Abdul-Aziz MH, Roberts JA. What Are the Current Approaches to Optimising Antimicrobial Dosing in the Intensive Care Unit? Pharmaceutics 2020; 12:pharmaceutics12070638. [PMID: 32645953 PMCID: PMC7407796 DOI: 10.3390/pharmaceutics12070638] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial dosing in the intensive care unit (ICU) can be problematic due to various challenges including unique physiological changes observed in critically ill patients and the presence of pathogens with reduced susceptibility. These challenges result in reduced likelihood of standard antimicrobial dosing regimens achieving target exposures associated with optimal patient outcomes. Therefore, the aim of this review is to explore the various methods for optimisation of antimicrobial dosing in ICU patients. Dosing nomograms developed from pharmacokinetic/statistical models and therapeutic drug monitoring are commonly used. However, recent advances in mathematical and statistical modelling have resulted in the development of novel dosing software that utilise Bayesian forecasting and/or artificial intelligence. These programs utilise therapeutic drug monitoring results to further personalise antimicrobial therapy based on each patient’s clinical characteristics. Studies quantifying the clinical and cost benefits associated with dosing software are required before widespread use as a point-of-care system can be justified.
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Affiliation(s)
- Ming G. Chai
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Menino O. Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Mohd H. Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane 4006, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, 30021 Nimes, France
- Correspondence:
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Cattaneo D, Corona A, De Rosa FG, Gervasoni C, Kocic D, Marriott DJ. The management of anti-infective agents in intensive care units: the potential role of a 'fast' pharmacology. Expert Rev Clin Pharmacol 2020; 13:355-366. [PMID: 32320302 DOI: 10.1080/17512433.2020.1759413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of 'fast microbiology.' Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents. AREAS COVERED We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles. EXPERT OPINION Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a 'fast pharmacology' at the bedside.
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Affiliation(s)
- Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Alberto Corona
- Intensive Care Unit, ASST Fatebenefratelli Sacco, University Hospital , Milan, Italy
| | | | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Danijela Kocic
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney , Sydney, Australia
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital , Sydney, Australia
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Crass RL, Williams P, Roberts JA. The challenge of quantifying and managing pharmacokinetic variability of beta-lactams in the critically ill. Anaesth Crit Care Pain Med 2019; 39:27-29. [PMID: 31899302 DOI: 10.1016/j.accpm.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Ryan L Crass
- Ann Arbor Pharmacometrics Group, Ann Arbor, MI, USA
| | - Paul Williams
- Department of Pharmacy, Sunshine Coast University Hospital, Brisbane, Queensland, Australia; University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France.
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