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Zhao Y, Zang B, Wang Q. Prolonged versus intermittent β-lactam infusion in sepsis: a systematic review and meta-analysis of randomized controlled trials. Ann Intensive Care 2024; 14:30. [PMID: 38368588 PMCID: PMC10874917 DOI: 10.1186/s13613-024-01263-9] [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: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND The two latest studies on prolonged versus intermittent use of β-lactam antibiotics in patients with sepsis did not reach consistent conclusions, further contributing to the controversy surrounding the effectiveness of the prolonged β-lactam antibiotics infusion strategy. We conducted a systemic review and meta-analysis to evaluate the efficacy and safety of prolonged and intermittent β-lactam infusion in adult patients with sepsis. METHODS We systematically searched PubMed, EMBASE, and Cochrane Library databases for original randomized controlled trials comparing prolonged and intermittent β-lactam infusion in sepsis patients. A random-effects model was used to evaluate mortality, clinical success, microbiological success, and adverse events. We also conducted subgroup analyses to explore the impact of various factors on the mortality rates. Relative risk (RR) and corresponding 95% confidence intervals (CIs) were used to calculate the overall effect sizes for dichotomous outcomes. This meta-analysis was registered in PROSPERO (CRD42023463905). RESULTS We assessed 15 studies involving 2130 patients. In our comprehensive assessment, we found a significant reduction in all-cause mortality (RR, 0.83; 95% CI 0.72-0.97; P = 0.02) and a notable improvement in clinical success (RR, 1.16; 95% CI 1.03-1.31; P = 0.02) in the prolonged infusion group compared to the intermittent infusion group, whereas microbiological success did not yield statistically significant results (RR, 1.10; 95% CI 0.98-1.23; P = 0.11). No significant differences in adverse events were observed between the two groups (RR, 0.91; 95% CI 0.64-1.29; P = 0.60). Additionally, remarkable conclusions were drawn from subgroup analyses including studies with sample sizes exceeding 20 individuals per group (RR, 0.84; 95%CI 0.72-0.98; P = 0.03), research conducted post-2010 (RR, 0.84; 95%CI 0.72-0.98; P = 0.03), cases involving infections predominantly caused by Gram-negative bacteria (RR, 0.81; 95%CI 0.68-0.96; P = 0.02), as well as the administration of a loading dose (RR, 0.84; 95% CI 0.72-0.97; P = 0.02) and the use of penicillin (RR, 0.61; 95% CI 0.38-0.98; P = 0.04). CONCLUSIONS Compared to intermittent infusion, prolonged infusion of β-lactam antibiotics significantly decreases all-cause mortality among patients with sepsis and enhances clinical success without increasing adverse events.
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Affiliation(s)
- Yang Zhao
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110000, China
| | - Bin Zang
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110000, China.
| | - Qian Wang
- Department of Emergency, The Fourth Affiliated Hospital of China Medical University, 4 Chongshan East Road, Shenyang, 110000, China.
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Li X, Long Y, Wu G, Li R, Zhou M, He A, Jiang Z. Prolonged vs intermittent intravenous infusion of β-lactam antibiotics for patients with sepsis: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. Ann Intensive Care 2023; 13:121. [PMID: 38051467 DOI: 10.1186/s13613-023-01222-w] [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: 09/13/2023] [Accepted: 11/26/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The prolonged β-lactam antibiotics infusion has been an attractive strategy in severe infections, because it provides a more stable free drug concentration and a longer duration of free drug concentration above the minimum inhibitory concentration (MIC). We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of prolonged vs intermittent intravenous infusion of β-lactam antibiotics for patients with sepsis. METHODS This study was prospectively registered on PROSPERO database (CRD42023447692). We searched EMBASE, PubMed, and Cochrane Library to identify eligible studies (up to July 6, 2023). Any study meeting the inclusion and exclusion criteria would be included. The primary outcome was all-cause mortality within 30 days. Two authors independently screened studies and extracted data. When the I2 values < 50%, we used fixed-effect mode. Otherwise, the random effects model was used. TSA was also performed to search for the possibility of false-positive (type I error) or false-negative (type II error) results. RESULTS A total of 4355 studies were identified in our search, and nine studies with 1762 patients were finally included. The pooled results showed that, compared with intermittent intravenous infusion, prolonged intravenous infusion of beta-lactam antibiotics resulted in a significant reduction in all-cause mortality within 30 days in patients with sepsis (RR 0.82; 95%CI 0.70-0.96; P = 0.01; TSA-adjusted CI 0.62-1.07). However, the certainty of the evidence was rated as low, and the TSA results suggested that more studies were needed to further confirm our conclusion. In addition, it is associated with lower hospital mortality, ICU mortality, and higher clinical cure. No significant reduction in 90-day mortality or the emergence of resistance bacteria was detected between the two groups. CONCLUSIONS Prolonged intravenous infusion of beta-lactam antibiotics in patients with sepsis was associated with short-term survival benefits and higher clinical cure. However, the TSA results suggested that more studies are needed to reach a definitive conclusion. In terms of long-term survival benefits, we could not show an improvement.
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Affiliation(s)
- Xiaoming Li
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Yi Long
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Guixin Wu
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Rui Li
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Mingming Zhou
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Aiting He
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China
| | - Zhengying Jiang
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, 181 Han-Yu Road, Chongqing, 400030, China.
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Fernández-Rubio B, Herrera-Hidalgo L, de Alarcón A, Luque-Márquez R, López-Cortés LE, Luque S, Gutiérrez-Urbón JM, Fernández-Polo A, Gutiérrez-Valencia A, Gil-Navarro MV. Stability Studies of Antipseudomonal Beta Lactam Agents for Outpatient Therapy. Pharmaceutics 2023; 15:2705. [PMID: 38140046 PMCID: PMC10747133 DOI: 10.3390/pharmaceutics15122705] [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: 11/04/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) is a useful treatment strategy against Pseudomonas aeruginosa and other multidrug-resistant bacteria. However, it is hindered by the lack of stability data for the administration of antibiotics under OPAT conditions. Our objective was to investigate the stability of nine antipseudomonal and broad-spectrum beta lactam antibiotics (aztreonam, cefepime, cefiderocol, ceftazidime, ceftazidime/avibactam, ceftolozane/tazobactam, meropenem, meropenem/vaborbactam, and piperacillin/tazobactam) to allow the spread of OPAT programs. All the antibiotics were diluted in 500 mL 0.9% sodium chloride and stored at 4, 25, 32, and 37 °C for 72 h in two different devices (infusion bags and elastomeric pumps). The solutions were considered stable if the color, clearness, and pH remained unchanged and if the percentage of intact drug was ≥90%. All the antimicrobials remained stable 72 h under refrigerated conditions and at least 30 h at 25 °C. At 32 °C, all the antibiotics except for meropenem and meropenem/vaborbactam remained stable for 24 h or more. At 37 °C, only aztreonam, piperacillin/tazobactam, cefepime, cefiderocol, and ceftolozane/tazobactam were stable for at least 24 h. The stability results were the same in the two devices tested. All the antibiotics studied are actual alternatives for the treatment of antipseudomonal or multidrug-resistant infections in OPAT programs, although the temperature of the devices is crucial to ensure antibiotic stability.
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Affiliation(s)
- Beatriz Fernández-Rubio
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Arístides de Alarcón
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Rafael Luque-Márquez
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
| | - Luis E. López-Cortés
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena/Department of Medicine, School of Medicine, University of Sevilla/Biomedicine Institute of Sevilla (IBiS)/CSIC, 41009 Seville, Spain
| | - Sònia Luque
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, 08003 Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d’Investigacions Mèdiques (IMIM), 08003 Barcelona, Spain
| | - José María Gutiérrez-Urbón
- Unidad de Gestión Clínica de Farmacia, Complexo Hospitalario Universitario de A Coruña, 15006 A Coruña, Spain;
| | - Aurora Fernández-Polo
- Unidad de Gestión Clínica de Farmacia, Hospital Universitari Vall d’Hebron, Institut de Recerca Vall d’Hebron, 08035 Barcelona, Spain;
| | - Alicia Gutiérrez-Valencia
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
| | - María V. Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (B.F.-R.); (M.V.G.-N.)
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Parasitologia, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBiS), 41013 Seville, Spain; (A.d.A.); (R.L.-M.); (A.G.-V.)
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; (L.E.L.-C.); (S.L.)
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Venuti F, Gaviraghi A, De Nicolò A, Stroffolini G, Longo BM, Di Vincenzo A, Ranzani FA, Quaranta M, Romano F, Catellani E, Marchiaro C, Cinnirella G, D'Avolio A, Bonora S, Calcagno A. Real-Life Experience of Continuously Infused Ceftolozane/Tazobactam in Patients with Bronchiectasis and Multidrug-Resistant Pseudomonas aeruginosa Infection in the Outpatient Setting. Antibiotics (Basel) 2023; 12:1214. [PMID: 37508309 PMCID: PMC10376517 DOI: 10.3390/antibiotics12071214] [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: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Ceftolozane/tazobactam (C/T) is a novel β-lactam/β-lactamase inhibitor with excellent activity against the multidrug-resistant (MDR) P. aeruginosa. Continuous infusion (CI) dosing allows the optimization of pharmacokinetic and pharmacodynamic (PK/PD) properties of β-lactam antibiotics and may support patients' treatment as outpatients. (2) Methods: Adult patients receiving their entire course of C/T as a CI in the outpatient setting were retrospectively included in the study. The primary outcome evaluated was clinical resolution. The secondary outcomes evaluated were PK/PD target attainment (ƒT > 4 × MIC) and microbiologic clearance at the end of treatment. Therapeutic drug monitoring to assess C/T concentration was performed. (3) Results: Three patients were enrolled in the study and received 9 g of C/T in CI every 24 h. One patient received an additional course of antimicrobial therapy due to disease exacerbation six months after initial treatment, accounting for four evaluated treatments. The primary outcome was achieved in 3/4 treatments and the secondary outcome was achieved in 4/4 and 3/3, respectively. In all patients, free ceftolozane concentrations were >10 times higher than the EUCAST breakpoint (4 mg/L). (4) Conclusions: Elastomeric infusion of C/T delivered in CI can be an effective and convenient way to treat acute diseases caused by MDR-P. aeruginosa, avoid hospital admission, and contribute to infection control strategies. Despite the small number of enrolled patients, clinical and microbiological results support this strategy.
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Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Alberto Gaviraghi
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Amedeo De Nicolò
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, 10149 Turin, Italy
| | - Giacomo Stroffolini
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, 5, 37024 Verona, Italy
| | - Bianca Maria Longo
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Alessia Di Vincenzo
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, 10149 Turin, Italy
| | - Fabio Antonino Ranzani
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Matilde Quaranta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Francesca Romano
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Eleonora Catellani
- ASL Città di Torino, Amedeo di Savoia Hospital, Corso Svizzera 164, 10149 Torino, Italy
| | - Carlotta Marchiaro
- ASL Città di Torino, Amedeo di Savoia Hospital, Corso Svizzera 164, 10149 Torino, Italy
| | - Giacoma Cinnirella
- ASL Città di Torino, Amedeo di Savoia Hospital, Corso Svizzera 164, 10149 Torino, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin, 10149 Turin, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino at the Amedeo di Savoia Hospital, ASL Città di Torino, Corso Svizzera 164, 10149 Torino, Italy
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