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Ferre A, Giglio A, Zylbersztajn B, Valenzuela R, Van Sint Jan N, Fajardo C, Reccius A, Dreyse J, Hasbun P. Analysis of Vancomycin Dosage and Plasma Levels in Critically Ill Adult Patients Requiring Extracorporeal Membrane Oxygenation (ECMO). J Intensive Care Med 2024; 39:909-915. [PMID: 38557265 DOI: 10.1177/08850666241243306] [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] [Indexed: 04/04/2024]
Abstract
Introduction: Critically ill patients undergoing extracorporeal membrane oxygenation (ECMO) exhibit unique pharmacokinetics. This study aimed to assess the achievement of vancomycin therapeutic targets in these patients. Methods: This retrospective cohort study included patients on ECMO treated with vancomycin between January 2010 and December 2018. Ninety patients were analyzed based on ECMO connection modality, baseline creatinine levels, estimated glomerular filtration rate (eGFR), renal replacement therapy (RRT) requirements, and vancomycin loading dose administration. Results: Twenty-three percent of the patients achieved the therapeutic range defined by baseline levels. No significant differences in meeting the therapeutic goal were found in multivariate analysis considering ECMO cannulation modality, initial creatinine level, initial eGFR, RRT requirement, or loading dose use. All trough levels between 15 and 20 mcg/mL achieved an estimated area under the curve/minimum inhibitory concentration (AUC/MIC) between 400 and 600, almost all trough levels over 10 mcg/mL predicted an AUC/MIC >400. Discussion: Achieving therapeutic plasma levels in these patients remains challenging, potentially due to factors such as individual pharmacokinetics and pathophysiology. A trough plasma level between 12 and 20 estimated the therapeutic AUC/MIC for all models, proposing a possible lower target, maintaining exposure, and potentially avoiding adverse effects. Despite being one of the largest cohorts of vancomycin use in ECMO patients studied, its retrospective nature and single-center focus limits its broad applicability.
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Affiliation(s)
- Andrés Ferre
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | - Andrés Giglio
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | | | | | - Nicolette Van Sint Jan
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | | | - Andres Reccius
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
- Neurology Department, Clinica Las Condes, Santiago, Chile
| | - Jorge Dreyse
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | - Pablo Hasbun
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
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2
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Roger C. Understanding antimicrobial pharmacokinetics in critically ill patients to optimize antimicrobial therapy: A narrative review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:287-298. [PMID: 39035618 PMCID: PMC11258509 DOI: 10.1016/j.jointm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 07/23/2024]
Abstract
Effective treatment of sepsis not only demands prompt administration of appropriate antimicrobials but also requires precise dosing to enhance the likelihood of patient survival. Adequate dosing refers to the administration of doses that yield therapeutic drug concentrations at the infection site. This ensures a favorable clinical and microbiological response while avoiding antibiotic-related toxicity. Therapeutic drug monitoring (TDM) is the recommended approach for attaining these goals. However, TDM is not universally available in all intensive care units (ICUs) and for all antimicrobial agents. In the absence of TDM, healthcare practitioners need to rely on several factors to make informed dosing decisions. These include the patient's clinical condition, causative pathogen, impact of organ dysfunction (requiring extracorporeal therapies), and physicochemical properties of the antimicrobials. In this context, the pharmacokinetics of antimicrobials vary considerably between different critically ill patients and within the same patient over the course of ICU stay. This variability underscores the need for individualized dosing. This review aimed to describe the main pathophysiological changes observed in critically ill patients and their impact on antimicrobial drug dosing decisions. It also aimed to provide essential practical recommendations that may aid clinicians in optimizing antimicrobial therapy among critically ill patients.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Nîmes, France
- UR UM 103 IMAGINE (Initial Management and prévention of orGan failures IN critically ill patiEnts), Faculty of Medicine, Montpellier University, Montpellier, France
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3
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Fratoni AJ, Kois AK, Gluck JA, Nicolau DP, Kuti JL. Imipenem/relebactam pharmacokinetics in critically ill patients supported on extracorporeal membrane oxygenation. J Antimicrob Chemother 2024; 79:1118-1125. [PMID: 38517465 DOI: 10.1093/jac/dkae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a life-saving modality but has the potential to alter the pharmacokinetics (PK) of antimicrobials. Imipenem/cilastatin/relebactam is an antibiotic with utility in treating certain multi-drug resistant Gram-negative infections. Herein, we describe the population pharmacokinetics of imipenem and relebactam in critically ill patients supported on ECMO. METHODS Patients with infection supported on ECMO received 4-6 doses of imipenem/cilastatin/relebactam per current prescribing information based on estimated creatinine clearance. Blood samples were collected following the final dose of the antibiotic. Concentrations were determined via LC-MS/MS. Population PK models were fit with and without covariates using Pmetrics. Monte Carlo simulations of 1000 patients assessed joint PTA of fAUC0-24/MIC ≥ 8 for relebactam, and ≥40% fT > MIC for imipenem for each approved dosing regimen. RESULTS Seven patients supported on ECMO were included in PK analyses. A two-compartment model with creatinine clearance as a covariate on clearance for both imipenem and relebactam fitted the data best. The mean ± standard deviation parameters were: CL0, 15.21 ± 6.52 L/h; Vc, 10.13 ± 2.26 L; K12, 2.45 ± 1.16 h-1 and K21, 1.76 ± 0.49 h-1 for imipenem, and 6.95 ± 1.34 L/h, 9.81 ± 2.69 L, 2.43 ± 1.13 h-1 and 1.52 ± 0.67 h-1 for relebactam. Simulating each approved dose of imipenem/cilastatin/relebactam according to creatinine clearance yielded PTAs of ≥90% up to an MIC of 2 mg/L. CONCLUSIONS Imipenem/cilastatin/relebactam dosed according to package insert in patients supported on ECMO is predicted to achieve exposures sufficient to treat susceptible Gram-negative isolates, including Pseudomonas aeruginosa.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Abigail K Kois
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Jason A Gluck
- Heart & Vascular Institute, Hartford HealthCare, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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Dillies T, Perinel-Ragey S, Correia P, Morel J, Thiery G, Launay M. Dosing Regimen for Cefotaxime Should Be Adapted to the Stage of Renal Dysfunction in Critically Ill Adult Patients-A Retrospective Study. Antibiotics (Basel) 2024; 13:313. [PMID: 38666989 PMCID: PMC11047316 DOI: 10.3390/antibiotics13040313] [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: 02/26/2024] [Revised: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
Cefotaxime administration is recommended in doses of 3-12 g/day in adults with a Glomerular Filtration Rate (GFR) > 5 mL/min. This study aimed to assess the impact of renal function and obesity on cefotaxime concentrations in intensive care unit (ICU) patients. A retrospective cohort study was conducted on consecutive ICU patients receiving continuous cefotaxime infusion between 2020 and 2022 [IRBN992021/CHUSTE]. Doses were not constant; consequently, a concentration-to-dose ratio (C/D) was considered. Statistical analysis was performed to assess the relationship between cefotaxime concentrations, renal function, and obesity. A total of 70 patients, median age 61 years, were included, with no significant difference in cefotaxime concentrations between obese and non-obese patients. However, concentrations varied significantly by GFR, with underdosing prevalent in patients with normal to increased renal function and overdosing in those with severely impaired renal function. Adjustment of cefotaxime dosing according to GFR was associated with improved target attainment. Cefotaxime dosing in critically ill patients should consider renal function, with higher initial doses required in patients with normal to increased GFR and lower doses in those with severely impaired renal function. Therapeutic drug monitoring may aid in optimising dosing regimens. Prospective studies are warranted to validate these findings and inform clinical practice.
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Affiliation(s)
- Théo Dillies
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
| | - Sophie Perinel-Ragey
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- SAINBIOSE U1059, Université Jean Monnet, INSERM, F-42023 Saint Etienne, France
| | - Patricia Correia
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
| | - Jérôme Morel
- Service de Réanimation Polyvalente B, CHU de Saint-Etienne, F-42055 Saint Etienne, France
| | - Guillaume Thiery
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon, F-69008 Lyon, France
| | - Manon Launay
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- Centre Régional de Pharmacovigilance, CHU de Saint-Etienne, F-42055 Saint Etienne, France
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Zhang H, Xu Y, Huang X, Yang S, Li R, Wu Y, Zou X, Yu Y, Shang Y. Extracorporeal membrane oxygenation in adult patients with sepsis and septic shock: Why, how, when, and for whom. JOURNAL OF INTENSIVE MEDICINE 2024; 4:62-72. [PMID: 38263962 PMCID: PMC10800772 DOI: 10.1016/j.jointm.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/19/2023] [Accepted: 07/07/2023] [Indexed: 01/25/2024]
Abstract
Sepsis and septic shock remain the leading causes of death in intensive care units. Some patients with sepsis fail to respond to routine treatment and rapidly progress to refractory respiratory and circulatory failure, necessitating extracorporeal membrane oxygenation (ECMO). However, the role of ECMO in adult patients with sepsis has not been fully established. According to existing studies, ECMO may be a viable salvage therapy in carefully selected adult patients with sepsis. The choice of venovenous, venoarterial, or hybrid ECMO modes is primarily determined by the patient's oxygenation and hemodynamics (distributive shock with preserved cardiac output, septic cardiomyopathy (left, right, or biventricular heart failure), or right ventricular failure caused by acute respiratory distress syndrome). Veno-venous ECMO can be used in patients with sepsis and severe acute respiratory distress syndrome when conventional mechanical ventilation fails, and early application of veno-arterial ECMO in patients with sepsis-induced refractory cardiogenic shock may be critical in improving their chances of survival. When ECMO is indicated, the choice of an appropriate mode and determination of the optimal timing of initiation and weaning are critical, particularly in an experienced ECMO center. Furthermore, some special issues, such as ECMO flow, anticoagulation, and antibiotic therapy, should be noted during the management of ECMO support.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Youdong Xu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Xin Huang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Shunyin Yang
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, Anhui, 237000, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430022, China
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Cervantes FC, Mizuno T, Dong M, Tang P, Arbough T, Vinks AA, Kaplan JM, Girdwood SCT. Ceftriaxone Pharmacokinetics and Pharmacodynamics in 2 Pediatric Patients on Extracorporeal Membrane Oxygenation Therapy. Ther Drug Monit 2023; 45:832-836. [PMID: 37725684 PMCID: PMC10840633 DOI: 10.1097/ftd.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/13/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Critically ill patients with cardiac or respiratory failure may require extracorporeal membrane oxygenation (ECMO). Antibiotics are frequently administered when the suspected cause of organ failure is an infection. Ceftriaxone, a β-lactam antibiotic, is commonly used in patients who are critically ill. Although studies in adults on ECMO have suggested minimal impact on ceftriaxone pharmacokinetics, limited research exists on ceftriaxone pharmacokinetics/pharmacodynamics (PK/PD) in pediatric ECMO patients. We report the PK profiles and target attainment of 2 pediatric patients on ECMO who received ceftriaxone. METHODS Ceftriaxone concentrations were measured in 2 pediatric patients on ECMO using scavenged opportunistic sampling. PK profiles were generated and individual PK parameters were estimated using measured free ceftriaxone concentrations and a published population PK model in children who are critically ill, using Bayesian estimation. RESULTS Patient 1, an 11-year-old boy on venovenous ECMO for respiratory failure received 2 doses of 52 mg/kg ceftriaxone 12 hours apart while on ECMO and additional doses every 12 hours off ECMO. On ECMO, ceftriaxone clearance was 13.0 L/h/70 kg compared with 7.6 L/h/70 kg off ECMO, whereas the model-predicted mean clearance in children who are critically ill without ECMO support was 6.54 L/h/70 kg. Patient 2, a 2-year-old boy on venoarterial ECMO due to cardiac arrest received 50 mg/kg ceftriaxone every 12 hours while on ECMO for >7 days. Only clearance while on ECMO could be estimated (9.1 L/h/70 kg). Trough concentrations in both patients were >1 mg/L (the breakpoint for Streptococcus pneumoniae ) while on ECMO. CONCLUSIONS ECMO increased ceftriaxone clearance above the model-predicted clearances in the 2 pediatric patients studied. Twelve-hour dosing allowed concentrations to remain above the breakpoint for commonly targeted bacteria but not 4 times the breakpoint in one patient, suggesting that precision dosing may be beneficial to ensure target attainment in children on ECMO.
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Affiliation(s)
- Francisco C. Cervantes
- Department of Medical Education, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Min Dong
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Peter Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Trent Arbough
- Department of Medical Education, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
| | - Alexander A. Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Jennifer M. Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Sonya C. Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
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Tang Girdwood S, Pavia K, Paice K, Hambrick HR, Kaplan J, Vinks AA. β-lactam precision dosing in critically ill children: Current state and knowledge gaps. Front Pharmacol 2022; 13:1044683. [PMID: 36532752 PMCID: PMC9752101 DOI: 10.3389/fphar.2022.1044683] [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: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Sonya Tang Girdwood,
| | - Kathryn Pavia
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kelli Paice
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - H. Rhodes Hambrick
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Kang S, Yang S, Hahn J, Jang JY, Min KL, Wi J, Chang MJ. Dose Optimization of Meropenem in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Cardiac Patients: Pharmacokinetic/Pharmacodynamic Modeling. J Clin Med 2022; 11:jcm11226621. [PMID: 36431106 PMCID: PMC9693387 DOI: 10.3390/jcm11226621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/23/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Our objective was to determine an optimal dosage regimen of meropenem in patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) by developing a pharmacokinetic/pharmacodynamic (PK/PD) model. Methods: This was a prospective cohort study. Blood samples were collected during ECMO (ECMO-ON) and after ECMO (ECMO-OFF). The population pharmacokinetic model was developed using nonlinear mixed-effects modeling. A Monte Carlo simulation was used (n = 10,000) to assess the probability of target attainment. Results: Thirteen adult patients on ECMO receiving meropenem were included. Meropenem pharmacokinetics was best fitted by a two-compartment model. The final pharmacokinetic model was: CL (L/h) = 3.79 × 0.44CRRT, central volume of distribution (L) = 2.4, peripheral volume of distribution (L) = 8.56, and intercompartmental clearance (L/h) = 21.3. According to the simulation results, if more aggressive treatment is needed (100% fT > MIC target), dose increment or extended infusion is recommended. Conclusions: We established a population pharmacokinetic model for meropenem in patients receiving V-A ECMO and revealed that it is not necessary to adjust the dosage depending on V-A ECMO. Instead, more aggressive treatment is needed than that of standard treatment, and higher dosage is required without continuous renal replacement therapy (CRRT). Also, extended infusion could lead to better target attainment, and we could provide updated nomograms of the meropenem dosage regimen.
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Affiliation(s)
- Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- School of Pharmacy, Jeonbuk National University, Jeonju 54896, Korea
| | - June Young Jang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
| | - Min Jung Chang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
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Guerra Valero YC, Dorofaeff T, Coulthard MG, Sparkes L, Lipman J, Wallis SC, Roberts JA, Parker SL. Optimal dosing of cefotaxime and desacetylcefotaxime for critically ill paediatric patients. Can we use microsampling? J Antimicrob Chemother 2022; 77:2227-2237. [PMID: 35678266 PMCID: PMC9333413 DOI: 10.1093/jac/dkac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To describe the population pharmacokinetics of cefotaxime and desacetylcefotaxime in critically ill paediatric patients and provide dosing recommendations. We also sought to evaluate the use of capillary microsampling to facilitate data-rich blood sampling. Methods Patients were recruited into a pharmacokinetic study, with cefotaxime and desacetylcefotaxime concentrations from plasma samples collected at 0, 0.5, 2, 4 and 6 h used to develop a population pharmacokinetic model using Pmetrics. Monte Carlo dosing simulations were tested using a range of estimated glomerular filtration rates (60, 100, 170 and 200 mL/min/1.73 m2) and body weights (4, 10, 15, 20 and 40 kg) to achieve pharmacokinetic/pharmacodynamic (PK/PD) targets, including 100% ƒT>MIC with an MIC breakpoint of 1 mg/L. Results Thirty-six patients (0.2–12 years) provided 160 conventional samples for inclusion in the model. The pharmacokinetics of cefotaxime and desacetylcefotaxime were best described using one-compartmental model with first-order elimination. The clearance and volume of distribution for cefotaxime were 12.8 L/h and 39.4 L, respectively. The clearance for desacetylcefotaxime was 10.5 L/h. Standard dosing of 50 mg/kg q6h was only able to achieve the PK/PD target of 100% ƒT>MIC in patients >10 kg and with impaired renal function or patients of 40 kg with normal renal function. Conclusions Dosing recommendations support the use of extended or continuous infusion to achieve cefotaxime exposure suitable for bacterial killing in critically ill paediatric patients, including those with severe or deep-seated infection. An external validation of capillary microsampling demonstrated skin-prick sampling can facilitate data-rich pharmacokinetic studies.
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Affiliation(s)
| | - Tavey Dorofaeff
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Mark G Coulthard
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia.,Mayne Academy of Paediatrics, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Louise Sparkes
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Jamieson Trauma Institute, Royal Brisbane & Women's Hospital, Herston, QLD 4029, Australia
| | - Steven C Wallis
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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Roberts JA, Bellomo R, Cotta MO, Koch BCP, Lyster H, Ostermann M, Roger C, Shekar K, Watt K, Abdul-Aziz MH. Machines that help machines to help patients: optimising antimicrobial dosing in patients receiving extracorporeal membrane oxygenation and renal replacement therapy using dosing software. Intensive Care Med 2022; 48:1338-1351. [PMID: 35997793 PMCID: PMC9467945 DOI: 10.1007/s00134-022-06847-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Intensive care unit (ICU) patients with end-organ failure will require specialised machines or extracorporeal therapies to support the failing organs that would otherwise lead to death. ICU patients with severe acute kidney injury may require renal replacement therapy (RRT) to remove fluid and wastes from the body, and patients with severe cardiorespiratory failure will require extracorporeal membrane oxygenation (ECMO) to maintain adequate oxygen delivery whilst the underlying pathology is evaluated and managed. The presence of ECMO and RRT machines can further augment the existing pharmacokinetic (PK) alterations during critical illness. Significant changes in the apparent volume of distribution (Vd) and drug clearance (CL) for many important drugs have been reported during ECMO and RRT. Conventional antimicrobial dosing regimens rarely consider the impact of these changes and consequently, are unlikely to achieve effective antimicrobial exposures in critically ill patients receiving ECMO and/or RRT. Therefore, an in-depth understanding on potential PK changes during ECMO and/or RRT is required to inform antimicrobial dosing strategies in patients receiving ECMO and/or RRT. In this narrative review, we aim to discuss the potential impact of ECMO and RRT on the PK of antimicrobials and antimicrobial dosing requirements whilst receiving these extracorporeal therapies. The potential benefits of therapeutic drug monitoring (TDM) and dosing software to facilitate antimicrobial therapy for critically ill patients receiving ECMO and/or RRT are also reviewed and highlighted.
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Affiliation(s)
- Jason A. Roberts
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia ,Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD Australia ,grid.416100.20000 0001 0688 4634Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD Australia ,grid.121334.60000 0001 2097 0141Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, The University of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Menino O. Cotta
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
| | - Birgit C. P. Koch
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Haifa Lyster
- Pharmacy Department, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK ,Cardiothoracic Transplant Unit, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK
| | - Marlies Ostermann
- grid.425213.3Department of Critical Care, King’s College London, Guy’s and St Thomas Hospital, London, SE1 7EH UK
| | - Claire Roger
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, 30 029 Nîmes cedex 9, France ,grid.121334.60000 0001 2097 0141UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| | - Kiran Shekar
- grid.415184.d0000 0004 0614 0266Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537Faculty of Medicine, The University of Queensland, Brisbane, QLD Australia ,grid.1024.70000000089150953Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia ,grid.1033.10000 0004 0405 3820Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD Australia
| | - Kevin Watt
- grid.46078.3d0000 0000 8644 1405School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON N2G 1C5 Canada ,grid.223827.e0000 0001 2193 0096Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Mohd H. Abdul-Aziz
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
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