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Suna J, Moloney G, Marathe SP, Bierbach B, Roberts JA, Parker S, Ungerer JPJ, Mcwhinney B, Dorofaeff T, Venugopal P, Alphonso N. Perioperative cefazolin prophylaxis in paediatric cardiac surgery: a prospective, cohort study. Ann Thorac Surg 2022; 114:1434-1440. [PMID: 35292260 DOI: 10.1016/j.athoracsur.2022.02.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study's objective was to determine the effect of age, prolonged bypass, and hypothermia on serum cefazolin concentrations in children undergoing cardiac surgery. METHODS A prospective, single-centre, observational study was conducted. Children undergoing cardiac surgery were examined. Participants received cefazolin intravenously approximately 1 hour before skin incision, 3 hourly intraoperatively and 8 hourly postoperatively. Blood samples were collected at 6-8 timepoints intraoperatively and 6-time points in the first 24 hours postoperatively. Target unbound serum cefazolin concentrations were of 2 mg/L. RESULTS Sixty-eight patients were enrolled in the study, and 64 included in the analysis. All maintained concentrations ≥ 2 mg/L throughout the operation. Nineteen patients (30%) did not maintain concentrations ≥ 2 mg/L in the first 24 hours following surgery. Older, larger children (p < 0.0001) were significantly less likely to achieve target unbound serum cefazolin concentrations. CONCLUSIONS Intraoperative cefazolin concentrations reached the target concentration in all paediatric cardiac surgical cases. Postoperative cefazolin dosing appears insufficient to achieve minimum inhibitory concentrations in many patients.
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Affiliation(s)
- Jessica Suna
- Industry Fellow, University of Queensland, Brisbane, Australia; Deputy Director, Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.
| | - Gregory Moloney
- Senior Medical Officer, Department of Anaesthetics, Queensland Children's Hospital, Brisbane, Australia
| | - Supreet P Marathe
- Lecturer, University of Queensland Clinical School, Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Cardiac Surgery Fellow, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Benjamin Bierbach
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Germany
| | - Jason A Roberts
- NHMRC Practitioner Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Consultant Pharmacist, Pharmacy Department and Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Scientific Consultant, Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Suzanne Parker
- NHMRC Early Career Research Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jacobus P J Ungerer
- Director Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane Australia; School of Biomedical Sciences, University of Queensland, Brisbane Australia
| | - Brett Mcwhinney
- Supervising Scientist, Pathology Queensland, Queensland Health, Brisbane Australia
| | - Tavey Dorofaeff
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Medical Officer, Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia
| | - Prem Venugopal
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Associate Professor, Child Health Research Centre, University of Queensland, Brisbane, Australia; Deputy Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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Dosing antibiotic prophylaxis during cardiopulmonary bypass-a higher level of complexity? A structured review. Int J Antimicrob Agents 2017; 49:395-402. [PMID: 28254373 DOI: 10.1016/j.ijantimicag.2016.12.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/01/2016] [Accepted: 12/17/2016] [Indexed: 12/30/2022]
Abstract
In highly invasive procedures such as open heart surgery, the risk of post-operative infection is particularly high due to exposure of the surgical field to multiple foreign devices. Adequate antibiotic prophylaxis is an essential intervention to minimise post-operative morbidity and mortality. However, there is a lack of clear understanding on the adequacy of traditional prophylactic dosing regimens, which are rarely supported by data. The aim of this structured review is to describe the relevant pharmacokinetic/pharmacodynamic (PK/PD) considerations for optimal antibiotic prophylaxis for major cardiac surgery including cardiopulmonary bypass (CPB). A structured review of the relevant published literature was performed and 45 relevant studies describing antibiotic pharmacokinetics in patients receiving extracorporeal CPB as part of major cardiac surgery were identified. Some of the studies suggested marked PK alterations in the peri-operative period with increases in volume of distribution (Vd) by up to 58% and altered drug clearances of up to 20%. Mechanisms proposed as causing the PK changes included haemodilution, hypothermia, retention of the antibiotic within the extracorporeal circuit, altered physiology related to a systemic inflammatory response, and maldistribution of blood flow. Of note, some studies reported no or minimal impact of the CPB procedure on antibiotic pharmacokinetics. Given the inconsistent data, ongoing research should focus on clarifying the influence of CPB procedure and related clinical covariates on the pharmacokinetics of different antibiotics during cardiac surgery. Traditional prophylactic dosing regimens may need to be re-assessed to ensure sufficient drug exposures that will minimise the risk of surgical site infections.
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