1
|
Zhang X, Wang Y, Li S, Xie F, Yi H. Simulated drug disposition in critically ill patients to evaluate effective PK/PD targets for combating Pseudomonas aeruginosa resistance to meropenem. Antimicrob Agents Chemother 2024; 68:e0154123. [PMID: 38319075 PMCID: PMC10916391 DOI: 10.1128/aac.01541-23] [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: 11/22/2023] [Accepted: 01/13/2024] [Indexed: 02/07/2024] Open
Abstract
Bacterial infections, including those caused by Pseudomonas aeruginosa, often lead to sepsis, necessitating effective antibiotic treatment like carbapenems. The key pharmacokinetic/pharmacodynamic (PK/PD) index correlated to carbapenem efficacy is the fraction time of unbound plasma concentration above the minimum inhibitory concentration (MIC) of the pathogen (%fT > MIC). While multiple targets exist, determining the most effective one for critically ill patients remains a matter of debate. This study evaluated meropenem's bactericidal potency and its ability to combat drug resistance in Pseudomonas aeruginosa under three representative PK/PD targets: 40% fT > MIC, 100% fT > MIC, and 100% fT > 4× MIC. The hollow fiber infection model (HFIM) was constructed, validated, and subsequently inoculated with a substantial Pseudomonas aeruginosa load (1 × 108 CFU/mL). Different meropenem regimens were administered to achieve the specified PK/PD targets. At specified intervals, samples were collected from the HFIM system and subjected to centrifugation. The resulting supernatant was utilized to determine drug concentrations, while the precipitates were used to track changes in both total and drug-resistant bacterial populations over time by the spread plate method. The HFIM accurately reproduced meropenem's pharmacokinetics in critically ill patients. All three PK/PD target groups exhibited a rapid bactericidal response within 6 h of the initial treatment. However, the 40% fT > MIC and 100% fT > MIC groups subsequently showed bacterial resurgence and resistance, whereas the 100% fT > 4× MIC group displayed sustained bactericidal activity with no evidence of drug resistance. The HFIM system revealed that maintaining 100% fT > 4× MIC offers a desirable microbiological response for critically ill patients, demonstrating strong bactericidal capacity and effective prevention of drug resistance.
Collapse
Affiliation(s)
- Xiaonan Zhang
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yan Wang
- Yueyang Inspection and Testing Center, Yueyang, China
| | - Sanwang Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Hanxi Yi
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, China
| |
Collapse
|
2
|
Dräger S, Ewoldt TMJ, Abdulla A, Rietdijk WJR, Verkaik N, Ramakers C, de Jong E, Osthoff M, Koch BCP, Endeman H. Exploring the Impact of Model-Informed Precision Dosing on Procalcitonin Concentrations in Critically Ill Patients: A Secondary Analysis of the DOLPHIN Trial. Pharmaceutics 2024; 16:270. [PMID: 38399324 PMCID: PMC10891837 DOI: 10.3390/pharmaceutics16020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Model-informed precision dosing (MIPD) might be used to optimize antibiotic treatment. Procalcitonin (PCT) is a biomarker for severity of infection and response to antibiotic treatment. The aim of this study was to assess the impact of MIPD on the course of PCT and to investigate the association of PCT with pharmacodynamic target (PDT) attainment in critically ill patients. This is a secondary analysis of the DOLPHIN trial, a multicentre, open-label, randomised controlled trial. Patients with a PCT value available at day 1 (T1), day 3 (T3), or day 5 (T5) after randomisation were included. The primary outcome was the absolute difference in PCT concentration at T1, T3, and T5 between the MIPD and the standard dosing group. In total, 662 PCT concentrations from 351 critically ill patients were analysed. There was no statistically significant difference in PCT concentration between the trial arms at T1, T3, or T5. The median PCT concentration was highest in patients who exceeded 10× PDT at T1 [13.15 ng/mL (IQR 5.43-22.75)]. In 28-day non-survivors and in patients that exceeded PDT at T1, PCT decreased significantly between T1 and T3, but plateaued between T3 and T5. PCT concentrations were not significantly different between patients receiving antibiotic treatment with or without MIPD guidance. The potential of PCT to guide antibiotic dosing merits further investigation.
Collapse
Affiliation(s)
- Sarah Dräger
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Tim M. J. Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Wim J. R. Rietdijk
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Institutional Affairs, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Nelianne Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Christian Ramakers
- Department of Clinical Chemistry, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Rode Kruis Ziekenhuis, 1942 LE Beverwijk, The Netherlands
| | - Michael Osthoff
- Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Birgit C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| |
Collapse
|
3
|
Maranchick NF, Webber J, Alshaer MH, Felton TW, Peloquin CA. Impact of Beta-Lactam Target Attainment on Resistance Development in Patients with Gram-Negative Infections. Antibiotics (Basel) 2023; 12:1696. [PMID: 38136730 PMCID: PMC10740680 DOI: 10.3390/antibiotics12121696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND The objective was to identify associations between beta-lactam pharmacokinetic/pharmacodynamic (PK/PD) targets and Gram-negative bacteria resistance emergence in patients. METHODS Retrospective data were collected between 2016 to 2019 at the University of Florida Health-Shands Hospital in Gainesville, FL. Adult patients with two Gram-negative isolates receiving cefepime, meropenem, or piperacillin-tazobactam and who had plasma beta-lactam concentrations were included. Beta-lactam exposures and time free drug concentrations that exceeded minimum inhibitory concentrations (ƒT > MIC), four multiples of MIC (ƒT > 4× MIC), and free area under the time concentration curve to MIC (ƒAUC/MIC) were generated. Resistance emergence was defined as any increase in MIC or two-fold increase in MIC. Multiple regression analysis assessed the PK/PD parameter impact on resistance emergence. RESULTS Two hundred fifty-six patients with 628 isolates were included. The median age was 58 years, and 59% were males. Cefepime was the most common beta-lactam (65%) and Pseudomonas aeruginosa the most common isolate (43%). The mean daily ƒAUC/MIC ≥ 494 was associated with any increase in MIC (p = 0.002) and two-fold increase in MIC (p = 0.004). The daily ƒAUC/MIC ≥ 494 was associated with decreased time on antibiotics (p = 0.008). P. aeruginosa was associated with any increase in MIC (OR: 6.41, 95% CI [3.34-12.28]) or 2× increase in MIC (7.08, 95% CI [3.56-14.07]). CONCLUSIONS ƒAUC/MIC ≥ 494 may be associated with decreased Gram-negative resistance emergence.
Collapse
Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
| | - Jessica Webber
- College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
| | - Timothy W. Felton
- North West Ventilation Unit, Manchester University NHS Foundation Trust, Manchester M23 9LT, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9NT, UK
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA
- Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA
| |
Collapse
|
4
|
Gatti M, Rinaldi M, Laici C, Siniscalchi A, Viale P, Pea F. Role of a Real-Time TDM-Based Expert Clinical Pharmacological Advice Program in Optimizing the Early Pharmacokinetic/Pharmacodynamic Target Attainment of Continuous Infusion Beta-Lactams among Orthotopic Liver Transplant Recipients with Documented or Suspected Gram-Negative Infections. Antibiotics (Basel) 2023; 12:1599. [PMID: 37998801 PMCID: PMC10668725 DOI: 10.3390/antibiotics12111599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 10/31/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
(1) Objectives: To describe the attainment of optimal pharmacokinetic/pharmacodynamic (PK/PD) targets in orthotopic liver transplant (OLT) recipients treated with continuous infusion (CI) beta-lactams optimized using a real-time therapeutic drug monitoring (TDM)-guided expert clinical pharmacological advice (ECPA) program during the early post-surgical period. (2) Methods: OLT recipients admitted to the post-transplant intensive care unit over the period of July 2021-September 2023, receiving empirical or targeted therapy with CI meropenem, piperacillin-tazobactam, meropenem-vaborbactam, or ceftazidime-avibactam optimized using a real-time TDM-guided ECPA program, were retrospectively retrieved. Steady-state beta-lactam (BL) and/or beta-lactamase inhibitor (BLI) plasma concentrations (Css) were measured, and the Css/MIC ratio was selected as the best PK/PD target for beta-lactam efficacy. The PK/PD target of meropenem was defined as being optimal when attaining a fCss/MIC ratio > 4. The joint PK/PD target of the BL/BLI combinations (namely piperacillin-tazobactam, ceftazidime-avibactam, and meropenem-vaborbactam) was defined as being optimal when the fCss/MIC ratio > 4 of the BL and the fCss/target concentration (CT) ratio > 1 of tazobactam or avibactam, or the fAUC/CT ratio > 24 of vaborbactam were simultaneously attained. Multivariate logistic regression analysis was performed for testing potential variables that were associated with a failure in attaining early (i.e., at first TDM assessment) optimal PK/PD targets. (3) Results: Overall, 77 critically ill OLT recipients (median age, 57 years; male, 63.6%; median MELD score at transplantation, 17 points) receiving a total of 100 beta-lactam treatment courses, were included. Beta-lactam therapy was targeted in 43% of cases. Beta-lactam dosing adjustments were provided in 76 out of 100 first TDM assessments (76.0%; 69.0% decreases and 7.0% increases), and overall, in 134 out of 245 total ECPAs (54.7%). Optimal PK/PD target was attained early in 88% of treatment courses, and throughout beta-lactam therapy in 89% of cases. Augmented renal clearance (ARC; OR 7.64; 95%CI 1.32-44.13) and MIC values above the EUCAST clinical breakpoint (OR 91.55; 95%CI 7.12-1177.12) emerged as independent predictors of failure in attaining early optimal beta-lactam PK/PD targets. (4) Conclusion: A real-time TDM-guided ECPA program allowed for the attainment of optimal beta-lactam PK/PD targets in approximately 90% of critically ill OLT recipients treated with CI beta-lactams during the early post-transplant period. OLT recipients having ARC or being affected by pathogens with MIC values above the EUCAST clinical breakpoint were at high risk for failure in attaining early optimal beta-lactam PK/PD targets. Larger prospective studies are warranted for confirming our findings.
Collapse
Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.R.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria of Bologna, 40138 Bologna, Italy
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.R.); (P.V.); (F.P.)
- Infectious Disease Unit, Department for integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria of Bologna, 40138 Bologna, Italy
| | - Cristiana Laici
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.L.); (A.S.)
| | - Antonio Siniscalchi
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.L.); (A.S.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.R.); (P.V.); (F.P.)
- Infectious Disease Unit, Department for integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria of Bologna, 40138 Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy; (M.R.); (P.V.); (F.P.)
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria of Bologna, 40138 Bologna, Italy
| |
Collapse
|
5
|
Alshaer MH, Williams R, Mousa MJ, Alexander KM, Maguigan KL, Manigaba K, Maranchick N, Shoulders BR, Felton TW, Mathew SK, Peloquin CA. Cefepime Daily Exposure and the Associated Impact on the Change in Sequential Organ Failure Assessment Scores and Vasopressors Requirement in Critically Ill Patients Using Repeated-Measures Mixed-Effect Modeling. Crit Care Explor 2023; 5:e0993. [PMID: 38304706 PMCID: PMC10833631 DOI: 10.1097/cce.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
IMPORTANCE Sepsis and septic shock are major healthcare problems that need early and appropriate management. OBJECTIVES To evaluate the association of daily cefepime pharmacokinetic/pharmacodynamic (PK/PD) parameters with change in Sequential Organ Failure Assessment (SOFA) score and vasopressors requirement. DESIGN SETTING AND PARTICIPANTS This is a retrospective study. Adult ICU patients who received cefepime for Gram-negative pneumonia or bloodstream infection (BSI) and had cefepime concentrations measured were included. Daily cefepime exposure was generated and PK/PD parameters calculated for patients. Repeated-measures mixed-effect modeling was used to evaluate the impact of PK/PD on the outcomes. MAIN OUTCOMES AND MEASURES Change in daily SOFA score and vasopressors requirement. RESULTS A total of 394 and 207 patients were included in the SOFA and vasopressors analyses, respectively. The mean (±sd) age was 55 years (19) and weight 81 kg (29). For the change in SOFA score, daily SOFA score, mechanical ventilation, renal replacement therapy, and number of vasopressors were included. In the vasopressors analysis, daily SOFA score, day of therapy, and hydrocortisone dose were significant covariates in the final model. Achieving cefepime concentrations above the minimum inhibitory concentration (MIC) (T>MIC) for 100% of the dosing interval was associated with 0.006 µg/kg/min decrease in norepinephrine-equivalent dose. Cefepime PK/PD did not have an impact on the daily change in SOFA score. CONCLUSIONS AND RELEVANCE Achieving 100% T>MIC was associated with negligible decrease in vasopressors requirement in ICU patients with Gram-negative pneumonia and BSI. There was no impact on the change in SOFA score.
Collapse
Affiliation(s)
- Mohammad H Alshaer
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Roy Williams
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Mays J Mousa
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Kaitlin M Alexander
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Kelly L Maguigan
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Kayihura Manigaba
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Nicole Maranchick
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| | - Bethany R Shoulders
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
- Department of Pharmacy, UF Health Shands Hospital, Gainesville, FL
| | - Timothy W Felton
- North West Ventilation Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Sumith K Mathew
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- Emerging Pathogens Institute, University of Florida, Gainesville, FL
| |
Collapse
|
6
|
Tilanus A, Drusano G. Optimizing the Use of Beta-Lactam Antibiotics in Clinical Practice: A Test of Time. Open Forum Infect Dis 2023; 10:ofad305. [PMID: 37416756 PMCID: PMC10319623 DOI: 10.1093/ofid/ofad305] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/03/2023] [Indexed: 07/08/2023] Open
Abstract
Despite their limitations, the pharmacokinetics (PK) and pharmacodynamics (PD) indices form the basis for our current understanding regarding antibiotic development, selection, and dose optimization. Application of PK-PD in medicine has been associated with better clinical outcome, suppression of resistance, and optimization of antibiotic consumption. Beta-lactam antibiotics remain the cornerstone for empirical and directed therapy in many patients. The percentage of time of the dosing interval that the free (unbound) drug concentration remains above the minimal inhibitory concentration (MIC) (%fT > MIC) has been considered the PK-PD index that best predicts the relationship between antibiotic exposure and killing for the beta-lactam antibiotics. Time dependence of beta-lactam antibiotics has its origin in the acylation process of the serine active site of penicillin-binding proteins, which subsequently results in bacteriostatic and bactericidal effects during the dosing interval. To enhance the likelihood of target attainment, higher doses, and prolonged infusion strategies, with/or without loading doses, have been applied to compensate for subtherapeutic levels of antibiotics related to PK-PD changes, especially in the early phase of severe sepsis. To minimize resistance and maximize clinical outcome, empirical therapy with a meropenem loading dose followed by high-dose-prolonged infusion should be considered in patients with high inoculum infections presenting as severe (Gram negative) sepsis. Subsequent de-escalation and dosing of beta-lactam antibiotics should be considered as an individualized dynamic process that requires dose adjustments throughout the time course of the disease process mediated by clinical parameters that indirectly assess PK-PD alterations.
Collapse
Affiliation(s)
- Alwin Tilanus
- Correspondence: Alwin Tilanus, MD, MSc, Internist—Infectious Disease Specialist, Department of Infectious Diseases, Clinica Los Nogales, Calle 95 # 23-61, Bogotá, Colombia, ()
| | | |
Collapse
|
7
|
Venuti F, Trunfio M, Martson AG, Lipani F, Audagnotto S, Di Perri G, Calcagno A. Extended and Continuous Infusion of Novel Protected β-Lactam Antibiotics: A Narrative Review. Drugs 2023:10.1007/s40265-023-01893-6. [PMID: 37314633 DOI: 10.1007/s40265-023-01893-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
Consolidated data from pharmacokinetic and pharmacodynamic studies support the administration of β-lactam antibiotics in prolonged infusion (i.e., extended or continuous) to optimize therapeutic efficacy by increasing the probability of attaining maximal bactericidal activity. This is the longest possible time during which the free drug concentrations are approximately four-fold the minimum inhibitory concentration between dosing intervals. In the context of antimicrobial stewardship strategies, achieving aggressive pharmacokinetic and pharmacodynamic targets is an important tool in the management of multi-drug resistant (MDR) bacterial infections and in the attainment of mutant preventing concentrations. However, prolonged infusion remains an unexploited resource. Novel β-lactam/β-lactamase inhibitor (βL/βLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-cilastatin-relebactam) have been released in recent years to face the emerging challenge of MDR Gram-negative bacteria. Pre-clinical and real-life evidence has confirmed the promising role of prolonged infusion of these molecules in specific settings and clinical populations. In this narrative review we have summarized available pharmacological and clinical data, future perspectives, and current limitations of prolonged infusion of the novel protected β-lactams, their application in hospital settings and in the context of outpatient parenteral antimicrobial therapy.
Collapse
Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy.
| | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Anne-Grete Martson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Filippo Lipani
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| |
Collapse
|
8
|
Chaira T, Subramani C, Barman TK. ADME, Pharmacokinetic Scaling, Pharmacodynamic and Prediction of Human Dose and Regimen of Novel Antiviral Drugs. Pharmaceutics 2023; 15:pharmaceutics15041212. [PMID: 37111697 PMCID: PMC10146820 DOI: 10.3390/pharmaceutics15041212] [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: 01/23/2023] [Revised: 03/29/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
The search for new drugs is an extremely time-consuming and expensive endeavour. Much of that time and money go into generating predictive human pharmacokinetic profiles from preclinical efficacy and safety animal data. These pharmacokinetic profiles are used to prioritize or minimize the attrition at later stages of the drug discovery process. In the area of antiviral drug research, these pharmacokinetic profiles are equally important for the optimization, estimation of half-life, determination of effective dose, and dosing regimen, in humans. In this article we have highlighted three important aspects of these profiles. First, the impact of plasma protein binding on two primary pharmacokinetic parameters-volume of distribution and clearance. Second, interdependence of primary parameters on unbound fraction of the drug. Third, the ability to extrapolate human pharmacokinetic parameters and concentration time profiles from animal profiles.
Collapse
Affiliation(s)
- Tridib Chaira
- Department of Pharmacology, SGT University, Gurugram 122505, Haryana, India
| | - Chandru Subramani
- Department of Pathology, Galveston National Laboratory, University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Tarani Kanta Barman
- Department of Pathology, Galveston National Laboratory, University of Texas Medical Branch, Galveston, TX 77550, USA
| |
Collapse
|
9
|
Kula C, Arga KY. Systems Biomarkers, Artificial Intelligence, and One Health Vision Can Help Fight Antimicrobial Resistance. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2023; 27:191-192. [PMID: 36848246 DOI: 10.1089/omi.2023.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Affiliation(s)
- Ceyda Kula
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
- Health Biotechnology Joint Research and Application Center of Excellence, Istanbul, Turkey
| | - Kazım Yalçın Arga
- Department of Bioengineering, Faculty of Engineering, Marmara University, Istanbul, Turkey
- Health Biotechnology Joint Research and Application Center of Excellence, Istanbul, Turkey
- Genetic and Metabolic Diseases Research and Investigation Center, Marmara University, Istanbul, Turkey
| |
Collapse
|
10
|
Beta-lactam target attainment and associated outcomes in patients with bloodstream infections. Int J Antimicrob Agents 2023; 61:106727. [PMID: 36646230 DOI: 10.1016/j.ijantimicag.2023.106727] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To evaluate the association between early and cumulative beta-lactam pharmacokinetic/pharmacodynamic (PK/PD) parameters and therapy outcomes in bloodstream infection (BSI). METHODS Adult patients who received cefepime, meropenem, or piperacillin/tazobactam for BSI and had concentrations measured were included. Beta-lactam exposure was generated and the time that free concentration remained above the minimum inhibitory concentration (fT>MIC) and four multiples of MIC (fT>4 × MIC) were calculated for times 0-24 h and 0-7 days of therapy. Multiple regression analysis was performed to evaluate the impact of PK/PD on microbiological and clinical outcomes. RESULTS A total of 204 patients and 213 BSI episodes were included. The mean age was 58 years and weight 83 kg. Age, Sequential Organ Failure Assessment (SOFA) score, haemodialysis, Pitt bacteraemia score, and hours of empiric antibiotic therapy were significantly associated with certain outcomes and retained in the final model. In multiple regression analysis, fT>4 × MIC at 0-24 h and 0-7 days was a significant predictor of negative blood culture on day 7 (P=0.0161 and 0.0068, respectively). In the time-to-event analysis, patients who achieved 100% fT>4 × MIC at 0-24 h and 0-7 days had a shorter time to negative blood culture compared with those who did not (log-rank P=0.0004 and 0.0014, respectively). No significant associations were identified between PK/PD parameters and other outcomes, including improvement in symptoms at day 7 and 30-day mortality. CONCLUSION Early and cumulative achievement of fT>4 × MIC was a significant predictor of microbiological outcome in patients with BSI.
Collapse
|
11
|
Effectiveness and Safety of Beta-Lactam Antibiotics with and without Therapeutic Drug Monitoring in Patients with Pseudomonas aeruginosa Pneumonia or Bloodstream Infection. Antimicrob Agents Chemother 2022; 66:e0064622. [PMID: 36073943 PMCID: PMC9578394 DOI: 10.1128/aac.00646-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This objective of this study was to compare clinical outcomes in hospitalized patients with Pseudomonas aeruginosa pneumonia (PNA) or bloodstream infection (BSI) receiving beta-lactam antibiotic (BLA) infusions with and without the guidance of therapeutic drug monitoring (TDM). A retrospective, parallel cohort study was conducted at two academic medical centers between December 2015 and January 2020, UF Shands Gainesville, which uses BLA TDM for select patients (BLA TDM), and UF Health Jacksonville, which does not use BLA TDM (No-BLA TDM). All hospitalized adult patients with respiratory or blood culture positive for P. aeruginosa who met diagnosis criteria for lower respiratory tract infection with a positive P. aeruginosa respiratory culture and who received ≥48 h of intravenous BLA with in vitro susceptibility within 72 h of positive culture collection were included. The primary outcome was a composite of presumed treatment failure defined as the presence of any of the following from index-positive P. aeruginosa culture collection to the end of BLA therapy: all-cause mortality, escalation of and/or additional antimicrobial therapy for P. aeruginosa infection after 48 h of treatment with susceptible BLA due to worsening clinical status, or transfer to a higher level of care (i.e., the intensive care unit [ICU]). Analyses were adjusted for possible confounding with inverse probability of treatment weighting (IPTW). Two-hundred patients were included (BLA TDM, n = 95; No-BLA TDM, n = 105). In IPTW-adjusted analysis of the primary composite endpoint, BLA TDM demonstrated a significant decrease in presumed treatment failure compared to No-BLA TDM (adjusted odds ratio [aOR] 0.037, 95% confidence interval [CI] [0.013 to 0.107]; P < 0.001). BLA TDM had more 30-, 60- and 90-day infection-related readmissions ([aOR], 11.301, 95% CI (3.595 to 35.516); aOR 10.389, 95% CI [2.496 to 43.239], and aOR 24.970, 95% CI [6.703 to 93.028]) in IPTW analyses. For both unadjusted and IPTW-adjusted cohorts, there was no significant difference in hospital and ICU length of stay, adverse effects while on BLA, or microbiological eradication between BLA TDM and No-BLA TDM. In hospitalized adult patients with P. aeruginosa PNA or BSI, the use of TDM-guided BLA infusions decreased the odds of presumed treatment failure compared to patients receiving BLA infusions without TDM guidance. Future studies should evaluate BLA TDM impact on readmission.
Collapse
|
12
|
Using Machine Learning To Define the Impact of Beta-Lactam Early and Cumulative Target Attainment on Outcomes in Intensive Care Unit Patients with Hospital-Acquired and Ventilator-Associated Pneumonia. Antimicrob Agents Chemother 2022; 66:e0056322. [PMID: 35699444 PMCID: PMC9295596 DOI: 10.1128/aac.00563-22] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are the most common intensive care unit (ICU) infections. We aimed to evaluate the association of early and cumulative beta-lactam pharmacokinetic/pharmacodynamic (PK/PD) parameters with therapy outcomes in pneumonia. Adult ICU patients who received cefepime, meropenem, or piperacillin-tazobactam for HAP or VAP and had its concentration measured were included. Beta-lactam exposure was generated for every patient for the entire duration of therapy, and the time free concentration remained above the MIC (fT>MIC) and the time free concentration remained above four multiples of the MIC (fT>4×MIC) were calculated for time frames of 0 to 24 h, 0 to 10 days, and day 0 to end of therapy. Regression analyses and machine learning were performed to evaluate the impact of PK/PD on therapy outcomes. A total of 735 patients and 840 HAP/VAP episodes (47% HAP) were included. The mean age was 56 years, and the mean weight was 80 kg. Sequential organ failure assessment (SOFA), hemodialysis, age, and weight were significantly associated with the clinical outcomes and kept in the final model. In the full cohort including all pneumonia episodes, PK/PD parameters at different time windows were associated with a favorable composite outcome, clinical cure, and mechanical ventilation (MV)-free days. In patients who had positive cultures and reported MICs, almost all PK/PD parameters were significant predictors of therapy outcomes. In the machine learning analysis, PK/PD parameters ranked high and were the primary overall predictors of clinical cure. Early target attainment and cumulative target attainment have a great impact on pneumonia outcomes. Beta-lactam exposure should be optimized early and maintained through therapy duration.
Collapse
|
13
|
Jauregizar N, Quindós G, Gil-Alonso S, Suárez E, Sevillano E, Eraso E. Postantifungal Effect of Antifungal Drugs against Candida: What Do We Know and How Can We Apply This Knowledge in the Clinical Setting? J Fungi (Basel) 2022; 8:jof8070727. [PMID: 35887482 PMCID: PMC9317160 DOI: 10.3390/jof8070727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 02/07/2023] Open
Abstract
The study of the pharmacological properties of an antifungal agent integrates the drug pharmacokinetics, the fungal growth inhibition, the fungicidal effect and the postantifungal activity, laying the basis to guide optimal dosing regimen selection. The current manuscript reviews concepts regarding the postantifungal effect (PAFE) of the main classes of drugs used to treat Candida infections or candidiasis. The existence of PAFE and its magnitude are highly dependent on both the fungal species and the class of the antifungal agent. Therefore, the aim of this article was to compile the information described in the literature concerning the PAFE of polyenes, azoles and echinocandins against the Candida species of medical interest. In addition, the mechanisms involved in these phenomena, methods of study, and finally, the clinical applicability of these studies relating to the design of dosing regimens were reviewed and discussed. Additionally, different factors that could determine the variability in the PAFE were described. Most PAFE studies were conducted in vitro, and a scarcity of PAFE studies in animal models was observed. It can be stated that the echinocandins cause the most prolonged PAFE, followed by polyenes and azoles. In the case of the triazoles, it is worth noting the inconsistency found between in vitro and in vivo studies.
Collapse
Affiliation(s)
- Nerea Jauregizar
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain;
- Correspondence:
| | - Guillermo Quindós
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Sandra Gil-Alonso
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Elena Suárez
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain;
| | - Elena Sevillano
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| | - Elena Eraso
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Bilbao, Spain; (G.Q.); (S.G.-A.); (E.S.); (E.E.)
| |
Collapse
|
14
|
Zhou J, Jiang L, Zhang ZL, Wang ZR, Zhang YX, Lin X, Tang BH, Yao BF, Guo ZX, Yang JJ, Van Den Anker J, Wu YE, Zhao W. Population pharmacokinetics and dosing optimization of mezlocillin in neonates and young infants. J Antimicrob Chemother 2022; 77:2238-2244. [PMID: 35662337 DOI: 10.1093/jac/dkac176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/07/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Mezlocillin is used in the treatment of neonatal infectious diseases. However, due to the absence of population pharmacokinetic studies in neonates and young infants, dosing regimens differ considerably in clinical practice. Hence, this study aimed to describe the pharmacokinetic characteristics of mezlocillin in neonates and young infants, and propose the optimal dosing regimen based on the population pharmacokinetic model of mezlocillin. METHODS A prospective, open-label pharmacokinetic study of mezlocillin was carried out in newborns. Blood samples were collected using an opportunistic sampling method. HPLC was used to measure the plasma drug concentrations. A population pharmacokinetic model was developed using NONMEM software. RESULTS Ninety-five blood samples from 48 neonates and young infants were included. The ranges of postmenstrual age and birth weight were 29-40 weeks and 1200-4000 g, respectively, including term and preterm infants. A two-compartment model with first-order elimination was developed to describe the population pharmacokinetics of mezlocillin. Postmenstrual age, current weight and serum creatinine concentration were the most important covariates. Monte Carlo simulation results indicated that the current dose of 50 mg/kg q12h resulted in 89.2% of patients achieving the therapeutic target, when the MIC of 4 mg/L was used as the breakpoint. When increasing the dosing frequency to q8h, a dose of 20 mg/kg resulted in 74.3% of patients achieving the therapeutic target. CONCLUSIONS A population pharmacokinetic model of mezlocillin in neonates and young infants was established. Optimal dosing regimens based on this model were provided for use in neonatal infections.
Collapse
Affiliation(s)
- Jing Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Li Jiang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhi-Ling Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhao-Rui Wang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Yan-Xiu Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Xu Lin
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zi-Xuan Guo
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing-Jing Yang
- Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - John Van Den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| |
Collapse
|
15
|
Estradé O, Vozmediano V, Carral N, Isla A, González M, Poole R, Suarez E. Key Factors in Effective Patient-Tailored Dosing of Fluoroquinolones in Urological Infections: Interindividual Pharmacokinetic and Pharmacodynamic Variability. Antibiotics (Basel) 2022; 11:antibiotics11050641. [PMID: 35625285 PMCID: PMC9137891 DOI: 10.3390/antibiotics11050641] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Fluoroquinolones (FQs) are a critical group of antimicrobials prescribed in urological infections as they have a broad antimicrobial spectrum of activity and a favorable tissue penetration at the site of infection. However, their clinical practice is not problem-free of treatment failure, risk of emergence of resistance, and rare but important adverse effects. Due to their critical role in clinical improvement, understanding the dose-response relation is necessary to optimize the effectiveness of FQs therapy, as it is essential to select the right antibiotic at the right dose for the right duration in urological infections. The aim of this study was to review the published literature about inter-individual variability in pharmacological processes that can be responsible for the clinical response after empiric dose for the most commonly prescribed urological FQs: ciprofloxacin, levofloxacin, and moxifloxacin. Interindividual pharmacokinetic (PK) variability, particularly in elimination, may contribute to treatment failure. Clearance related to creatinine clearance should be specifically considered for ciprofloxacin and levofloxacin. Likewise, today, undesired interregional variability in FQs antimicrobial activity against certain microorganisms exists. FQs pharmacology, patient-specific characteristics, and the identity of the local infecting organism are key factors in determining clinical outcomes in FQs use.
Collapse
Affiliation(s)
- Oskar Estradé
- Department of Urology, Cruces University Hospital, 48903 Barakaldo, Spain;
| | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Nerea Carral
- Department of Pharmacology, Faculty of Medicine and Nursey, University of Basque Country UPV/EHU, 48940 Leioa, Spain;
- Biocruces Health Research Institute, 48903 Barakaldo, Spain
| | - Arantxa Isla
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain;
- Instituto de Investigación Sanitaria Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, 01006 Vitoria-Gasteiz, Spain
| | - Margarita González
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Rachel Poole
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Elena Suarez
- Department of Pharmacology, Faculty of Medicine and Nursey, University of Basque Country UPV/EHU, 48940 Leioa, Spain;
- Biocruces Health Research Institute, 48903 Barakaldo, Spain
- Correspondence:
| |
Collapse
|
16
|
Smith HG, Bean DC, Clarke RH, Loyn R, Larkins JA, Hassell C, Greenhill AR. Presence and antimicrobial resistance profiles of Escherichia coli, Enterococcusspp. and Salmonellasp. in 12 species of Australian shorebirds and terns. Zoonoses Public Health 2022; 69:615-624. [PMID: 35460193 PMCID: PMC9544147 DOI: 10.1111/zph.12950] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 03/13/2022] [Accepted: 04/05/2022] [Indexed: 11/27/2022]
Abstract
Antibiotic resistance is an ongoing threat to both human and animal health. Migratory birds are a potential vector for the spread of novel pathogens and antibiotic resistance genes. To date, there has been no comprehensive study investigating the presence of antibiotic resistance (AMR) in the bacteria of Australian shorebirds or terns. In the current study, 1022 individual birds representing 12 species were sampled across three states of Australia (Victoria, South Australia, and Western Australia) and tested for the presence of phenotypically resistant strains of three bacteria with potential to be zoonotic pathogens; Escherichia coli, Enterococcusspp., and Salmonellasp. In total, 206 E. coli, 266 Enterococcusspp., and 20 Salmonellasp. isolates were recovered, with AMR detected in 42% of E. coli, 85% of Enterococcusspp., and 10% of Salmonellasp. Phenotypic resistance was commonly detected to erythromycin (79% of Enterococcusspp.), ciprofloxacin (31% of Enterococcusspp.) and streptomycin (21% of E. coli). Resident birds were more likely to carry AMR bacteria than migratory birds (p ≤ .001). Bacteria isolated from shorebirds and terns are commonly resistant to at least one antibiotic, suggesting that wild bird populations serve as a potential reservoir and vector for AMR bacteria. However, globally emerging phenotypes of multidrug‐resistant bacteria were not detected in Australian shorebirds. This study provides baseline data of the carriage of AMR bacteria in Australian shorebirds and terns.
Collapse
Affiliation(s)
- Hannah G Smith
- Institute of Innovation, Science and Sustainability, Federation University, Churchill, Australia
| | - David C Bean
- Institute of Innovation, Science and Sustainability, Federation University, Churchill, Australia
| | - Rohan H Clarke
- School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Richard Loyn
- School of Life Sciences, Centre for Freshwater Ecosystems, La Trobe University, Wodonga, Victoria, Australia.,Institute for Land, Water and Society, Charles Sturt University, Albury, New South Wales, Australia
| | - Jo-Ann Larkins
- Institute of Innovation, Science and Sustainability, Federation University, Churchill, Australia.,School of Science, Engineering and Information Technology, Federation University, Ballarat, Victoria, Australia
| | - Chris Hassell
- Global Flyway Network, Broome, Western Australia, Australia.,Australasian Wader Studies Group, Broome, Western Australia, Australia
| | - Andrew R Greenhill
- Institute of Innovation, Science and Sustainability, Federation University, Churchill, Australia
| |
Collapse
|
17
|
Therapeutic drug monitoring of meropenem and piperacillin-tazobactam in the Singapore critically ill population - A prospective, multi-center, observational study (BLAST 1). J Crit Care 2022; 68:107-113. [PMID: 34999376 DOI: 10.1016/j.jcrc.2021.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To determine percentage of patients with sub-therapeutic beta-lactam exposure in our intensive care units (ICU) and to correlate target attainment with clinical outcomes. MATERIALS AND METHODS Multi-centre, prospective, observational study was conducted in ICUs from three hospitals in Singapore from July 2016 to May 2018. Adult patients (≥21 years) receiving meropenem or piperacillin-tazobactam were included. Four blood samples were obtained during a dosing interval to measure and determine attainment of therapeutic targets: unbound beta-lactam concentration above (i) minimum inhibitory concentration (MIC) at 40% (meropenem) or 50% (piperacillin) of dosing interval (40-50%fT > MIC) and (ii) 5 × MIC at 100% of dosing interval (100%fT > 5 × MIC). Correlation to clinical outcomes was evaluated using Cox regression. RESULTS Beta-lactam levels were highly variable among 61 patients, with trough meropenem and piperacillin levels at 21.5 ± 16.8 mg/L and 101.6 ± 81.1 mg/L respectively. Among 85 sets of blood samples, current dosing practices were able to achieve 94% success for 40-50%fT > MIC and 44% for 100%fT > 5 × MIC. Failure to achieve 40-50%fT > MIC within 48 h was significantly associated with all-cause mortality (HR: 9.0, 95% CI: 1.8-45.0), after adjustment for APACHE II score. Achievement of 100%fT > 5 × MIC within 48 h was significantly associated with shorter length of hospital stay. CONCLUSION Current dosing practices may be suboptimal for ICU patients. Beta-lactam TDM may be useful.
Collapse
|
18
|
Luxton T, King N, Wälti C, Jeuken L, Sandoe J. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1532-1541. [PMID: 35355067 PMCID: PMC9155611 DOI: 10.1093/jac/dkac101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Dosing regimens guided by therapeutic drug monitoring (TDM) may be able to improve penicillin exposure in patients, which could result in improved patient health outcomes. Objectives This systematic review aims to describe the impact penicillin TDM has on health outcomes, including antimicrobial resistance (AMR). Methods Studies measuring penicillins in patient samples that adjusted regimens according to the result, and reported health outcomes were selected. Study bias was assessed according to study type. Included study characteristics were tabulated and described by narrative synthesis. Results Three randomized controlled trials (RCTs), 16 cohort studies, and 9 case studies were included. No RCTs showed statistically significant improvements in health outcomes. Five cohort studies showed improvement in at least one health outcome associated with target attainment. However, there was a high risk of bias in all studies for health outcomes. One study assessed the impact of penicillin TDM on AMR and found that improved target attainment was associated with suppression of resistance. No studies found a detrimental effect of penicillin TDM. Conclusions There is little evidence to suggest that TDM improves health outcomes, however neither health outcomes nor impact on AMR were adequately addressed. Variations in TDM implementation meant that a meta-analysis was not suitable. Penicillin TDM needs standardization, however there is currently no clear evidence of optimal conditions. Suitably powered studies are required to resolve the ambiguity surrounding the impact of TDM on clinical outcomes, including AMR. Further, standardized protocols and concentration targets need to be identified for TDM to be implemented successfully.
Collapse
Affiliation(s)
- Timothy Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
- Corresponding author. E-mail:
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars Jeuken
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
- Leiden Institute of Chemistry, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
| | | |
Collapse
|
19
|
Continuous versus intermittent infusion of antibiotics in Gram-negative multidrug-resistant infections. Curr Opin Infect Dis 2021; 34:737-747. [PMID: 34261906 DOI: 10.1097/qco.0000000000000755] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review was to perform a critical reappraisal of the real-world evidence supporting administration by prolonged infusion of novel beta-lactams for the management of multidrug-resistant Gram-negative infections. RECENT FINDINGS Real-world evidence support the use of novel beta-lactams by prolonged infusion over intermittent infusion in terms of achieving aggressive pharmacokinetic/pharmacodynamic (PK/PD) target for either maximizing efficacy and clinical outcome or suppressing the emergence of resistance development. Continuous infusion of ceftolozane-tazobactam showed a marked superiority toward both intermittent and extended infusion (EI) in achieving a PK/PD target of 100%fT> 4 X MIC in infections caused by less-susceptible Pseudomonas aeruginosa isolates. No resistance development was found in critically ill or immunocompromised patients treated with EI ceftolozane-tazobactam compared to intermittent infusion. Prolonged infusion of ceftazidime-avibactam was negatively associated with mortality in patients affected by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae infections. Different challenging scenarios (patients showing augmented renal clearance of affected by deep-seated infections) could benefit from prolonged infusion to optimize the efficacy of novel agents. SUMMARY Although available data are still limited, real-world evidence regarding mainly ceftolozane-tazobactam and ceftazidime-avibactam could support the administration of novel beta-lactams by prolonged infusion in some specific scenarios in which achievement of aggressive PK/PD target is quite challenging.
Collapse
|
20
|
Pseudomonas aeruginosa Susceptibility in Spain: Antimicrobial Activity and Resistance Suppression Evaluation by PK/PD Analysis. Pharmaceutics 2021; 13:pharmaceutics13111899. [PMID: 34834314 PMCID: PMC8620410 DOI: 10.3390/pharmaceutics13111899] [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: 09/27/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Pseudomonas aeruginosa remains one of the major causes of healthcare-associated infection in Europe; in 2019, 12.5% of invasive isolates of P. aeruginosa in Spain presented combined resistance to ≥3 antimicrobial groups. The Spanish nationwide survey on P. aeruginosa antimicrobial resistance mechanisms and molecular epidemiology was published in 2019. Based on the information from this survey, the objective of this work was to analyze the overall antimicrobial activity of the antipseudomonal antibiotics considering pharmacokinetic/pharmacodynamic (PK/PD) analysis. The role of PK/PD to prevent or minimize resistance emergence was also evaluated. A 10,000-subject Monte Carlo simulation was executed to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR) considering the minimum inhibitory concentration (MIC) distribution of bacteria isolated in ICU or medical wards, and distinguishing between sample types (respiratory and non-respiratory). Ceftazidime/avibactam followed by ceftolozane/tazobactam and colistin, categorized as the Reserve by the Access, Watch, Reserve (AWaRe) classification of the World Health Organization, were the most active antimicrobials, with differences depending on the admission service, sample type, and dose regimen. Discrepancies between EUCAST-susceptibility breakpoints for P. aeruginosa and those estimated by PK/PD analysis were detected. Only standard doses of ceftazidime/avibactam and ceftolozane/tazobactam provided drug concentrations associated with resistance suppression.
Collapse
|
21
|
Assessment of a PK/PD Target of Continuous Infusion Beta-Lactams Useful for Preventing Microbiological Failure and/or Resistance Development in Critically Ill Patients Affected by Documented Gram-Negative Infections. Antibiotics (Basel) 2021; 10:antibiotics10111311. [PMID: 34827249 PMCID: PMC8615220 DOI: 10.3390/antibiotics10111311] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/25/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Emerging data suggest that more aggressive beta-lactam PK/PD targets could minimize the occurrence of microbiological failure and/or resistance development. This study aims to assess whether a PK/PD target threshold of continuous infusion (CI) beta-lactams may be useful in preventing microbiological failure and/or resistance development in critically ill patients affected by documented Gram-negative infections. METHODS Patients admitted to intensive care units from December 2020 to July 2021 receiving continuous infusion beta-lactams for documented Gram-negative infections and having at least one therapeutic drug monitoring in the first 72 h of treatment were included. A receiver operating characteristic (ROC) curve analysis was performed using the ratio between steady-state concentration and minimum inhibitory concentration (Css/MIC) ratio as the test variable and occurrence of microbiological failure as the state variable. Area under the curve (AUC) and 95% confidence interval (CI) were calculated. Independent risk factors for the occurrence of microbiological failure were investigated using logistic regression. RESULTS Overall, 116 patients were included. Microbiological failure occurred in 26 cases (22.4%). A Css/MIC ratio ≤ 5 was identified as PK/PD target cut-off with sensitivity of 80.8% (CI 60.6-93.4%) and specificity of 90.5% (CI 74.2-94.4%), and with an AUC of 0.868 (95%CI 0.793-0.924; p < 0.001). At multivariate regression, independent predictors of microbiological failure were Css/MIC ratio ≤ 5 (odds ratio [OR] 34.54; 95%CI 7.45-160.11; p < 0.001) and Pseudomonas aeruginosa infection (OR 4.79; 95%CI 1.11-20.79; p = 0.036). CONCLUSIONS Early targeting of CI beta-lactams at Css/MIC ratio > 5 during the treatment of documented Gram-negative infections may be helpful in preventing microbiological failure and/or resistance development in critically ill patients.
Collapse
|
22
|
Suboptimal drug exposure leads to selection of different subpopulations of ceftazidime-avibactam-resistant Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae in a critically ill patient. Int J Infect Dis 2021; 113:213-217. [PMID: 34656787 DOI: 10.1016/j.ijid.2021.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ceftazidime-avibactam (CAZ-AVI) is a promising novel agent with activity against carbapenem-resistant Enterobacteriaceae. Here, we describe the dynamic evolution of a Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) infection in a critically ill patient treated with CAZ-AVI-tigecycline combination therapy. METHODS Whole-genome sequencing was performed on longitudinal intrapatient KPC-Kp strains isolated from different sites during CAZ-AVI treatment. The pharmacokinetic/pharmacodynamic (PK/PD) analysis was performed on the basis of therapeutic drug monitoring of ceftazidime. RESULTS The development of resistance due to mutations in the blaKPC gene was observed in KPC-Kp strains isolated from bronchoalveolar lavage and blood during CAZ-AVI treatment. PK/PD analysis demonstrated that during the first days of treatment CAZ- AVI blood exposure was suboptimal (steady-state concentration/minimum inhibitory concentration ratio 2.85). Of note, the low antibiotic pressure may have selected hybrid subpopulations harboring blaKPC-3 and T243M mutation in KPC-Kp isolated from bronchoalveolar lavage and D179Y mutation in those isolated from blood. CONCLUSION These results suggest the high adaptability of KPC to CAZ-AVI due to the rapid evolution of resistance and highlight the importance of identifying the optimal PK/PD target to prevent such an event from occurring again in a critically ill patient with pneumonia due to KPC-Kp.
Collapse
|
23
|
Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
Collapse
|
24
|
Al-Shaer MH, Rubido E, Cherabuddi K, Venugopalan V, Klinker K, Peloquin C. Early therapeutic monitoring of β-lactams and associated therapy outcomes in critically ill patients. J Antimicrob Chemother 2021; 75:3644-3651. [PMID: 32910809 DOI: 10.1093/jac/dkaa359] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/17/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In the ICU, early and appropriate antimicrobial therapy is important to lower infection-related mortality. OBJECTIVES Assess whether achieving early β-lactam free concentration above the MIC 100% of the time (fT>MIC) is associated with positive outcomes in the ICU. METHODS This retrospective study was conducted in ICU patients admitted to UF Health Shands Hospital between 2016 and 2018. Adult patients who received β-lactam therapy and had drug concentration measured were included. Data collected included demographics, β-lactam regimens and concentrations, sources of infection, cultures and susceptibilities, mortality, length of stay, resistance acquisition for 30 days and clinical outcome at end of therapy. Multiple regression and time-to-event (TTE) analyses were performed. RESULTS Two-hundred and six patients were included. Clinical cure occurred in 71%, microbial eradication occurred in 58% and new resistance to the β-lactam received developed in 8% of patients. Hospital and 30 day mortalities were 17% and 14%, respectively. fT>MIC and fT>4×MIC were associated with clinical cure (P = 0.0303), microbial eradication (P = 0.0476) and suppression of resistance (P = 0.0043). Delay in measuring β-lactam concentration was associated with clinical failure (P = 0.0072), longer ICU stay (P < 0.0001) and higher mortality (P = 0.0387). In the TTE analysis, patients with 100% fT>MIC had a significantly shorter ICU stay (P = 0.0297). Patients who had clinical cure and microbial eradication had drug concentrations measured earlier (P = 0.0025 and 0.0254, respectively). CONCLUSIONS This study highlights the importance of early measurement of β-lactam concentration and confirms the association between fT>MIC and clinical cure, microbial eradication and emergence of resistance.
Collapse
Affiliation(s)
- Mohammad H Al-Shaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Eric Rubido
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kenneth Klinker
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| |
Collapse
|
25
|
Pharmacokinetics and pharmacodynamics of antibiotics in cystic fibrosis: a narrative review. Int J Antimicrob Agents 2021; 58:106381. [PMID: 34157401 DOI: 10.1016/j.ijantimicag.2021.106381] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/21/2021] [Accepted: 06/10/2021] [Indexed: 12/22/2022]
Abstract
Cystic fibrosis affects several organs, predisposing patients to severe bacterial respiratory infections, including those caused by methicillin-resistant Staphylococcus aureus. Cystic fibrosis is also associated with a wide spectrum of pathological changes that can significantly affect the absorption, distribution, metabolism, and/or elimination of several drugs, including antibacterial agents. Therefore, awareness of the pharmacokinetic derangements in patients with cystic fibrosis is mandatory for the optimisation of antibiotic therapy. This review discusses the basic principles of pharmacokinetics and the pathophysiology of the pharmacokinetics changes associated with cystic fibrosis; it also provides an update of available data for the most widely used antibiotics. Evidence accumulated in the last few years has clearly shown that a significant number of cystic fibrosis patients treated with conventional dosing schemes have sub-therapeutic antibiotic concentrations, increasing their risk of therapeutic failure and/or the emergence of resistant pathogens. Some proposals to optimise antibiotic therapies in this clinical setting based on therapeutic drug monitoring are also discussed.
Collapse
|
26
|
The Role of PK/PD Analysis in the Development and Evaluation of Antimicrobials. Pharmaceutics 2021; 13:pharmaceutics13060833. [PMID: 34205113 PMCID: PMC8230268 DOI: 10.3390/pharmaceutics13060833] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/27/2021] [Accepted: 05/31/2021] [Indexed: 12/13/2022] Open
Abstract
Pharmacokinetic/pharmacodynamic (PK/PD) analysis has proved to be very useful to establish rational dosage regimens of antimicrobial agents in human and veterinary medicine. Actually, PK/PD studies are included in the European Medicines Agency (EMA) guidelines for the evaluation of medicinal products. The PK/PD approach implies the use of in vitro, ex vivo, and in vivo models, as well as mathematical models to describe the relationship between the kinetics and the dynamic to determine the optimal dosing regimens of antimicrobials, but also to establish susceptibility breakpoints, and prevention of resistance. The final goal is to optimize therapy in order to maximize efficacy and minimize side effects and emergence of resistance. In this review, we revise the PK/PD principles and the models to investigate the relationship between the PK and the PD of antibiotics. Additionally, we highlight the outstanding role of the PK/PD analysis at different levels, from the development and evaluation of new antibiotics to the optimization of the dosage regimens of currently available drugs, both for human and animal use.
Collapse
|
27
|
Population Pharmacokinetics and Dosage Optimization of Linezolid in Critically Ill Pediatric Patients. Antimicrob Agents Chemother 2021; 95:AAC.02504-20. [PMID: 33558298 PMCID: PMC8092909 DOI: 10.1128/aac.02504-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Linezolid is an oxazolidinone antibiotic exhibiting efficacy against multidrug-resistant (MDR) Gram-positive-related infections. However, its population pharmacokinetic (PopPK) profile in Chinese critically ill children has not been characterized. Optimal dosing regimens should be established according to the PopPK/pharmacodynamic(PD) properties of linezolid in the specific population. This work aims to describe the pharmacokinetic (PK) properties of linezolid, assess the factors affecting interpatient variability, and establish an optimized regimen for children in pediatric intensive care unit (PICU). A single-center, prospective, open-labeled PK study was performed. Ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) was applied to measure the plasma levels during linezolid treatment. PopPK analysis was conducted using Phoenix NLME software. Sixty-three critically ill pediatric patients were included. The data showed good fit for a two-compartment model with linear elimination. Body weight and aspartate aminotransferase (AST) were the most significant covariates explaining variabilities in linezolid PK for the pediatric population. Therapeutic target was defined as the ratio of the area under drug plasma concentration-time curve over 24 h to minimum inhibitory concentration (AUC/MIC) of >80. Different dosing regimens were evaluated using Monte Carlo simulation to determine the optimal dosage strategy for linezolid. Although the probability of target attainment (PTA) was high (>96%) for 10 mg/kg every 8 h at MIC≤1 mg/L, it was lower than 70% at MIC>1 mg/L. Thus, the dosing regimen required adjustment. When the dosing regimen was adjusted to 15 mg/kg every 6 h, the PTA increased from 63.6% to 94.6% at MIC=2 mg/L, thereby indicating higher treatment success. Children with AST of >40 U/L had significant higher AUC than those with AST of ≤40 U/L (205.45 vs. 159.96). Therefore, dosage adjustment was required according to the AST levels. The PopPK characteristics of linezolid in critically ill children were evaluated, and an optimal dosage regimen was constructed based on developmental PopPK/PD model and simulation. (This study has been registered in the Chinese Clinical Trial Registry under no. ChiCTR1900021386.).
Collapse
|
28
|
The Minimum Inhibitory Concentration of Antibiotics: Methods, Interpretation, Clinical Relevance. Pathogens 2021; 10:pathogens10020165. [PMID: 33557078 PMCID: PMC7913839 DOI: 10.3390/pathogens10020165] [Citation(s) in RCA: 237] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 12/19/2022] Open
Abstract
Inefficiency of medical therapies used in order to cure patients with bacterial infections requires not only to actively look for new therapeutic strategies but also to carefully select antibiotics based on variety of parameters, including microbiological. Minimal inhibitory concentration (MIC) defines in vitro levels of susceptibility or resistance of specific bacterial strains to applied antibiotic. Reliable assessment of MIC has a significant impact on the choice of a therapeutic strategy, which affects efficiency of an infection therapy. In order to obtain credible MIC, many elements must be considered, such as proper method choice, adherence to labeling rules, and competent interpretation of the results. In this paper, two methods have been discussed: dilution and gradient used for MIC estimation. Factors which affect MIC results along with the interpretation guidelines have been described. Furthermore, opportunities to utilize MIC in clinical practice, with pharmacokinetic /pharmacodynamic parameters taken into consideration, have been investigated. Due to problems related to PK determination in individual patients, statistical estimation of the possibility of achievement of the PK/PD index, based on the Monte Carlo, was discussed. In order to provide comprehensive insights, the possible limitations of MIC, which scientists are aware of, have been outlined.
Collapse
|
29
|
Eisert A, Lanckohr C, Frey J, Frey O, Wicha SG, Horn D, Ellger B, Schuerholz T, Marx G, Simon TP. Comparison of two empirical prolonged infusion dosing regimens for meropenem in patients with septic shock: A two-center pilot study. Int J Antimicrob Agents 2021; 57:106289. [PMID: 33515688 DOI: 10.1016/j.ijantimicag.2021.106289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Due to high pharmacokinetic variability, standard doses of meropenem are frequently inadequate in septic patients. Therapeutic drug monitoring of meropenem is not widely available; therefore, improved empiric dosing recommendations are needed. OBJECTIVES This study aimed to compare the attainment of pharmacologic targets for two common empirical dosing regimens for meropenem in patients with septic shock. METHODS Two empiric dosing schemes for meropenem were compared using extended infusions (120 minutes) in 32 patients with septic shock in the intensive care units at two different hospitals. One regimen was 3 × 2 g meropenem/24 h for two days, followed by 3 × 1 g meropenem/24 h; the other regimen was 4 × 1 g meropenem/24 h. Serum meropenem concentrations were measured for the first 72 h of therapy, and pharmacokinetic modelling was performed to define the percentage of time the free drug concentration was above various target MICs for each regimen (%fT>MIC). RESULTS Both regimens led to a sufficiently high %fT>MIC for pathogens with target MICs < 4 mg/L. When higher MICs were targeted, the %fT>MIC of 4 × 1 g meropenem decreased faster than that of 3 × 2 g meropenem. At high MICs of 32 mg/L, both dosing regimens failed to provide appropriate drug concentrations. Renal function was a significant covariate of target attainment. CONCLUSIONS The results of this study can guide clinicians in their choice of an empirical dosing regimen for meropenem. If pathogens with low MICs (< 4 mg/L) are targeted, both dosing regimens are adequate, whereas more resistant strains require higher doses.
Collapse
Affiliation(s)
- Albrecht Eisert
- Department of Pharmacy, University Hospital Aachen RWTH Aachen, Aachen, Germany; Institute of Clinical Pharmacology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Janina Frey
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital Muenster, Muenster, Germany
| | - Bjoern Ellger
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Tobias Schuerholz
- Department of Anaesthesia and Intensive Care, University of Rostock, Rostock, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany.
| |
Collapse
|
30
|
de Vroom SL, van Daalen FV, Zieck SE, Mathôt RAA, van Hest RM, Geerlings SE. Does dose reduction of renally cleared antibiotics in patients with impaired renal function lead to adequate drug exposure? A systematic review. Clin Microbiol Infect 2020; 27:352-363. [PMID: 33290864 DOI: 10.1016/j.cmi.2020.11.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is inconsistency between many guidelines in the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function. OBJECTIVES This systematic review summarizes the available evidence on the adequacy of the recommended dose reduction in terms of achieving sufficient antibiotic drug exposure or pharmacokinetic/pharmacodynamic target attainment after treatment with these reduced doses. DATA SOURCES We systematically searched Ovid Medline and Embase from inception (respectively 1946 and 1947) through July 2019. STUDY ELIGIBILITY CRITERIA All studies reporting antibiotic drug exposure and/or pharmacokinetic/pharmacodynamic (PK/PD) target attainment after dose reduction of antibiotics in patients with impaired renal function. PARTICIPANTS Adult patients with or without infections. INTERVENTIONS Administration of reduced doses of antibiotics (orally, intravenously or intramuscularly). METHODS The reduced dose was considered adequate when the most relevant parameters of drug exposure or PK/PD target attainment in patients with impaired renal function were within a range of 80% to 125% of that patients with adequate renal function receiving a regular dose (reference) or when PK/PD target attainment was attained in at least 90% of the patients with impaired renal function, regardless of the lack of a reference group. RESULTS Twenty-seven of the 4202 identified studies were included. The quality of 15 of 27 studies was fair, and most studies were of β-lactams (12/27). Best evidence was available for meropenem: four studies were included, of which two studies were of good quality. Drug exposure for meropenem is 158% to 286% higher in patients with impaired renal function receiving reduced doses compared to patients with adequate renal function receiving regular doses. For all other antibiotics, a maximum of one good-quality study could be identified. CONCLUSIONS No good-quality evidence on the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function is present, with the exception of meropenem.
Collapse
Affiliation(s)
- Suzanne L de Vroom
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
| | - Frederike V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands
| | - Saskia E Zieck
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam Infection and Immunity (AI&II), Amsterdam, the Netherlands.
| |
Collapse
|
31
|
Nguyen TK, Peyrusson F, Dodémont M, Pham NH, Nguyen HA, Tulkens PM, Van Bambeke F. The Persister Character of Clinical Isolates of Staphylococcus aureus Contributes to Faster Evolution to Resistance and Higher Survival in THP-1 Monocytes: A Study With Moxifloxacin. Front Microbiol 2020; 11:587364. [PMID: 33329458 PMCID: PMC7719683 DOI: 10.3389/fmicb.2020.587364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/16/2020] [Indexed: 12/26/2022] Open
Abstract
Staphylococcus aureus may cause relapsing infections. We previously showed that S. aureus SH1000 surviving intracellularly to bactericidal antibiotics are persisters. Here, we used 54 non-duplicate clinical isolates to assess links between persistence, resistance evolution, and intracellular survival, using moxifloxacin throughout as test bactericidal antibiotic. The relative persister fraction (RPF: percentage of inoculum surviving to 100× MIC moxifloxacin in stationary phase culture for each isolate relative to ATCC 25923) was determined to categorize isolates with low (≤10) or high (>10) RPF. Evolution to resistance (moxifloxacin MIC ≥ 0.5 mg/L) was triggered by serial passages at 0.5× MIC (with daily concentration readjustments). Intracellular moxifloxacin maximal efficacy (Emax) was determined by 24 h concentration-response experiments [pharmacodynamic model (Hill-Langmuir)] with infected THP-1 monocytes exposed to moxifloxacin (0.01 to 100× MIC) after phagocytosis. Division of intracellular survivors was followed by green fluorescence protein dilution (FACS). Most (30/36) moxifloxacin-susceptible isolates showed low RPF but all moxifloxacin-resistant (n = 18) isolates harbored high RPF. Evolution to resistance of susceptible isolates was faster for those with high vs. low RPF (with SOS response and topoisomerase-encoding genes overexpression). Intracellularly, moxifloxacin Emax was decreased (less negative) for isolates with high vs. low RPF, independently from resistance. Moxifloxacin intracellular survivors were non-dividing. The data demonstrate and quantitate persisters in clinical isolates of S. aureus, and show that this phenotype accelerates resistance evolution and is associated with intracellular survival in spite of high antibiotic concentrations. Isolates with high RPF may represent a possible cause of treatment failure not directly related to resistance in patients receiving active antibiotics.
Collapse
Affiliation(s)
- Tiep K Nguyen
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium.,Department of Pharmaceutical Industry, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Frédéric Peyrusson
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Magali Dodémont
- Centre National de Référence des Staphylocoques, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB) Site Anderlecht, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Nhung H Pham
- Department of Microbiology, Bach Mai Hospital, Hanoi, Vietnam.,Microbiology Department, Hanoi Medical University, Hanoi, Vietnam
| | - Hoang A Nguyen
- The National Center for Drug Information and Adverse Drug Reactions Monitoring, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Paul M Tulkens
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Françoise Van Bambeke
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| |
Collapse
|
32
|
Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [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: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
Collapse
Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| |
Collapse
|
33
|
Adembri C, Novelli A, Nobili S. Some Suggestions from PK/PD Principles to Contain Resistance in the Clinical Setting-Focus on ICU Patients and Gram-Negative Strains. Antibiotics (Basel) 2020; 9:E676. [PMID: 33036190 PMCID: PMC7601871 DOI: 10.3390/antibiotics9100676] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022] Open
Abstract
The containment of the phenomenon of resistance towards antimicrobials is a priority, especially in preserving molecules acting against Gram-negative pathogens, which represent the isolates more frequently found in the fragile population of patients admitted to Intensive Care Units. Antimicrobial therapy aims to prevent resistance through several actions, which are collectively known as "antimicrobial stewardship", to be taken together, including the application of pharmacokinetic/pharmacodynamic (PK/PD) principles. PK/PD application has been shown to prevent the emergence of resistance in numerous experimental studies, although a straight translation to the clinical setting is not possible. Individualized antibiotic dosing and duration should be pursued in all patients, and even more especially when treating intensive care unit (ICU) septic patients in whom optimal exposure is both difficult to achieve and necessary. In this review, we report on the available data that support the application of PK/PD parameters to contain the development of resistance and we give some practical suggestions that can help to translate the benefit of PK/PD application to the bedside.
Collapse
Affiliation(s)
- Chiara Adembri
- Department of Health Sciences, Section of Anesthesiology and IC, University of Florence, 50134 Firenze, Italy;
| | - Andrea Novelli
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, 50139 Firenze, Italy;
| | - Stefania Nobili
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, 50139 Firenze, Italy;
| |
Collapse
|
34
|
Abstract
Antimicrobial susceptibility testing (AST) is now, more than ever, a critical role of the microbiology laboratory. Several factors limit its application for patient care and antimicrobial resistance epidemiology, including time to results, requirements for pure cultures, and high starting concentration of bacteria. This review discusses the global status of AST and new phenotypic and genotypic methods in late-stage development or that are new to market.
Collapse
Affiliation(s)
- Romney M Humphries
- Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South C-3322 MCN, Nashville, TN 37232-2561, USA.
| |
Collapse
|
35
|
Wallenburg E, ter Heine R, Schouten JA, Brüggemann RJ. Personalised antimicrobial dosing: standing on the shoulders of giants. Int J Antimicrob Agents 2020; 56:106062. [DOI: 10.1016/j.ijantimicag.2020.106062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/13/2020] [Indexed: 12/17/2022]
|
36
|
Dhaese S, Van Vooren S, Boelens J, De Waele J. Therapeutic drug monitoring of β-lactam antibiotics in the ICU. Expert Rev Anti Infect Ther 2020; 18:1155-1164. [PMID: 32597263 DOI: 10.1080/14787210.2020.1788387] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Individualizing antibiotic therapy is paramount to improve clinical outcomes while minimizing the risk of toxicity and antimicrobial therapy. β-lactam antibiotics are amongst the drugs most commonly prescribed in the Intensive Care Unit (ICU). The pharmacokinetics of β-lactam antibiotics are profoundly altered in critically ill patients, leading to the failure of standard drug dosing regimens to result in adequate drug concentrations. Therapeutic Drug Monitoring (TDM) of β-lactam antibiotics is a promising tool to help optimize β-lactam antibiotic therapy. AREAS COVERED The rationale behind TDM for β-lactam antibiotics is explained, as well as some more practical aspects such as when to sample, what concentrations to strive for and how to use it in clinical practice. We also discuss microbiological and analytical considerations, knowledge gaps, and future perspectives of β-lactam antibiotics TDM in ICU patients. EXPERT OPINION TDM of β-lactam antibiotics has been studied intensively in recent years. While TDM may not yet be widely available, and targets need to be further refined, TDM of β-lactam antibiotics will help to optimize antibiotic therapy in the critically ill patient, as an integrated part of an antimicrobial stewardship program.
Collapse
Affiliation(s)
- Sofie Dhaese
- Department of Internal Medicine and Pediatrics, Ghent University Hospital , Ghent, Belgium
| | - Sarah Van Vooren
- Department of Diagnostic Sciences, Ghent University Hospital , Ghent, Belgium
| | - Jerina Boelens
- Department of Diagnostic Sciences, Ghent University Hospital , Ghent, Belgium
| | - Jan De Waele
- Department of Internal Medicine and Pediatrics, Ghent University Hospital , Ghent, Belgium
| |
Collapse
|
37
|
Soraluce A, Barrasa H, Asín-Prieto E, Sánchez-Izquierdo JÁ, Maynar J, Isla A, Rodríguez-Gascón A. Novel Population Pharmacokinetic Model for Linezolid in Critically Ill Patients and Evaluation of the Adequacy of the Current Dosing Recommendation. Pharmaceutics 2020; 12:pharmaceutics12010054. [PMID: 31936614 PMCID: PMC7023070 DOI: 10.3390/pharmaceutics12010054] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/30/2019] [Indexed: 12/30/2022] Open
Abstract
Antimicrobial treatment in critically ill patients remains challenging. The aim of this study was to develop a population pharmacokinetic model for linezolid in critically ill patients and to evaluate the adequacy of current dosing recommendation (600 mg/12 h). Forty inpatients were included, 23 of whom were subjected to continuous renal replacement therapies (CRRT). Blood and effluent samples were drawn after linezolid administration at defined time points, and linezolid levels were measured. A population pharmacokinetic model was developed, using NONMEM 7.3. The percentage of patients that achieved the pharmacokinetic/pharmacodynamic (PK/PD) targets was calculated (AUC24/MIC > 80 and 100% T>MIC). A two-compartment model best described the pharmacokinetics of linezolid. Elimination was conditioned by the creatinine clearance and by the extra-corporeal clearance if the patient was subjected to CRRT. For most patients, the standard dose of linezolid did not cover infections caused by pathogens with MIC ≥ 2 mg/L. Continuous infusion may be an alternative, especially when renal function is preserved.
Collapse
Affiliation(s)
- Amaia Soraluce
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Helena Barrasa
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Eduardo Asín-Prieto
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
| | | | - Javier Maynar
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
- Correspondence: ; Tel.: +34-945-01-3094
| |
Collapse
|
38
|
Rimmler C, Lanckohr C, Akamp C, Horn D, Fobker M, Wiebe K, Redwan B, Ellger B, Koeck R, Hempel G. Physiologically based pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis. Br J Clin Pharmacol 2019; 85:2864-2877. [PMID: 31487057 PMCID: PMC6955413 DOI: 10.1111/bcp.14121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 12/18/2022] Open
Abstract
Aims Adequate plasma concentrations of antibiotics during surgery are essential for the prevention of surgical site infections. We examined the pharmacokinetics of 1.5 g cefuroxime administered during induction of anaesthesia with follow‐up doses every 2.5 hours until the end of surgery. We built a physiologically based pharmacokinetic model with the aim to ensure adequate antibiotic plasma concentrations in a heterogeneous population. Methods A physiologically based pharmacokinetic model (PK‐Sim®/MoBi®) was developed to investigate unbound plasma concentrations of cefuroxime. Blood samples from 25 thoracic surgical patients were analysed with high‐performance liquid chromatography. To evaluate optimized dosing regimens, physiologically based pharmacokinetic model simulations were conducted. Results Dosing simulations revealed that a standard dosing regimen of 1.5 g every 2.5 hours reached the pharmacokinetic/pharmacodynamic target for Staphylococcus aureus. However, for Escherichia coli, >50% of the study participants did not reach predefined targets. Effectiveness of cefuroxime against E. coli can be improved by administering a 1.5 g bolus immediately followed by a continuous infusion of 3 g cefuroxime over 3 hours. Conclusion The use of cefuroxime for perioperative antibiotic prophylaxis to prevent staphylococcal surgical site infections appears to be effective with standard dosing of 1.5 g preoperatively and follow‐up doses every 2.5 hours. In contrast, if E. coli is relevant in surgeries, this dosing regimen appears insufficient. With our derived dose recommendations, we provide a solution for this issue.
Collapse
Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Ceren Akamp
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery and Lung Transplantation, University Hospital Muenster, Muenster, Germany
| | - Bassam Redwan
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery and Lung Transplantation, University Hospital Muenster, Muenster, Germany
| | - Bjoern Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Robin Koeck
- Institute of Hygiene, DRK Kliniken Berlin Westend, Berlin, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| |
Collapse
|
39
|
Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
Collapse
Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
40
|
Thémans P, Marquet P, Winkin JJ, Musuamba FT. Towards a Generic Tool for Prediction of Meropenem Systemic and Infection-Site Exposure: A Physiologically Based Pharmacokinetic Model for Adult Patients with Pneumonia. Drugs R D 2019; 19:177-189. [PMID: 31090024 PMCID: PMC6544603 DOI: 10.1007/s40268-019-0268-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The objective of this study was to develop a physiologically based pharmacokinetic model for meropenem using a retrograde approach, which could serve as a basis for prediction of the systemic and infection-site drug exposures in different populations and indications. We intended this model to be a useful tool to inform (local) pharmacokinetic-based optimal dosing of meropenem in different settings. METHODS We developed a reduced physiologically based pharmacokinetic model with NONMEM software using a top-down approach. We used historical (previously published) data for model development and qualification. We used steady-state systemic and infection-site concentrations from 60 adult patients diagnosed with severe lung infection for model development and internal evaluation. The data included rich plasma and sparse epithelial lining fluid samples. We based the internal validation of the model on successful numerical convergence, adequate precision in parameter estimation, acceptable goodness-of-fit plot with no indication of bias, and acceptable performance of visual predictive checks. We performed external validation by fitting the model to independent data from five previously published studies: four studies in patients with pneumonia, with different grades of renal impairment, and one study in morbidly obese patients. RESULTS We successfully fitted a reduced physiologically based pharmacokinetic model with six compartments (arterial and venous pools, infection site [lungs], liver, kidneys and rest of the body) to the data and adequately estimated model parameters. We successfully qualified the model (internally and externally) using established methods. Estimated values for tissue-to-plasma partition coefficients were 0.2629 and 0.1946 for lungs and non-fat tissues (kidneys and liver), respectively. Estimated total clearance was 8.174 L/h for a typical patient with a glomerular filtration rate of 65 mL/min. Consistent with the known mechanism of meropenem elimination and previously published models, renal clearance accounted for 70% of total clearance. The model had good predictive performances on data from five different sources including populations with different characteristics with regard to body size, renal function and morbidity. CONCLUSIONS We successfully developed a physiologically based pharmacokinetic model for meropenem in adult patients to be used as a basis for prediction of concentrations in different groups of patients, and eventually for effective dose individualisation in different subgroups of the population.
Collapse
Affiliation(s)
- Pauline Thémans
- Department of Mathematics, Namur Institute for Complex Systems (naXys), University of Namur, Namur, Belgium
| | | | - Joseph J Winkin
- Department of Mathematics, Namur Institute for Complex Systems (naXys), University of Namur, Namur, Belgium
| | - Flora T Musuamba
- INSERM UMR 1248, Université de Limoges, Limoges, France.
- Federal Agency for Medicines and Health Products, Place Victor Horta 40/40, 1060, Brussels, Belgium.
- Faculty of Pharmacy, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo.
| |
Collapse
|
41
|
How to optimize antibiotic pharmacokinetic/pharmacodynamics for Gram-negative infections in critically ill patients. Curr Opin Infect Dis 2018; 31:555-565. [DOI: 10.1097/qco.0000000000000494] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Simeone P, Lagier D, Mokart D, Montravers P, Esposito-Farèse M, Lasocki S, Dupont H. Impact of combined antibiotic treatment on multidrug-resistant bacteria emergence after postoperative intra-abdominal infections : Discussion on the DURAPOP randomised clinical trial. Intensive Care Med 2018; 44:1000-1001. [PMID: 29754311 DOI: 10.1007/s00134-018-5215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Pierre Simeone
- Department of Anesthesia and Critical Care, La Timone, Teaching Hospital, APHM, Marseille, France. .,Aix Marseille Univ, CNRS, INT, Inst Neurosci Timone, Marseille, France.
| | - David Lagier
- Department of Anesthesia and Critical Care, La Timone, Teaching Hospital, APHM, Marseille, France
| | - Djamel Mokart
- Department of Anesthesia and Intensive Care, Institut Paoli-Calmettes, 13009, Marseille, France
| | - Philippe Montravers
- Paris Diderot Sorbonne Cite University, and Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP, INSERM, UMR 1152, Paris, France
| | - Marina Esposito-Farèse
- INSERM CIC-EC 1425, Unité de Recherche Clinique, HUPNVS, CHU Bichat-Claude Bernard, APHP, Paris, France
| | - Sigismond Lasocki
- L'UBL, Université d'Angers, Département d'Anesthésie Réanimation, CHU Angers, Angers, France
| | - Herve Dupont
- Critical Care Medicine Department, Amiens University Hospital, and INSERM U1088, University of Picardy Jules Verne, Amiens, France
| |
Collapse
|