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Laquian L, Efron PA. Antibiotic Use in the Surgical Intensive Care Unit. Adv Surg 2024; 58:203-221. [PMID: 39089778 DOI: 10.1016/j.yasu.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Judicious use of antibiotics in the critically ill starts with the evaluation for suspected infection, including close consideration of the patient's history. If infection is present or strongly suspected, empiric antibiotics should be promptly initiated and selected based on the source of infection, patient factors, and local resistance patterns. If the surgeon decides source control is indicated, they must determine the optimal approach and timing. As soon as culture and sensitivity data are available, de-escalation to narrower spectrum agents is essential to decrease the risks of antibiotic toxicity and resistance. Importantly, surgeons should participate in antibiotic stewardship in their patients.
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Affiliation(s)
- Liza Laquian
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Fu J, Cai W, Pan S, Chen L, Fang X, Shang Y, Xu J. Developments and Trends of Nanotechnology Application in Sepsis: A Comprehensive Review Based on Knowledge Visualization Analysis. ACS NANO 2024; 18:7711-7738. [PMID: 38427687 DOI: 10.1021/acsnano.3c10458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Sepsis, a common life-threatening clinical condition, continues to have high morbidity and mortality rates, despite advancements in management. In response, significant research efforts have been directed toward developing effective strategies. Within this scope, nanotechnology has emerged as a particularly promising field, attracting significant interest for its potential to enhance disease diagnosis and treatment. While several reviews have highlighted the use of nanoparticles in sepsis, comprehensive studies that summarize and analyze the hotspots and research trends are lacking. To identify and further promote the development of nanotechnology in sepsis, a bibliometric analysis was conducted on the relevant literature, assessing research trends and hotspots in the application of nanomaterials for sepsis. Next, a comprehensive review of the subjectively recognized research hotspots in sepsis, including nanotechnology-enhanced biosensors and nanoscale imaging for sepsis diagnostics, and nanoplatforms designed for antimicrobial, immunomodulatory, and detoxification strategies in sepsis therapy, is elucidated, while the potential side effects and toxicity risks of these nanomaterials were discussed. Particular attention is given to biomimetic nanoparticles, which mimic the biological functions of source cells like erythrocytes, immune cells, and platelets to evade immune responses and effectively deliver therapeutic agents, demonstrating substantial translational potential. Finally, current challenges and future perspectives of nanotechnology applications in sepsis with a view to maximizing their great potential in the research of translational medicine are also discussed.
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Affiliation(s)
- Jiaji Fu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
- Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430023, China
| | - Wentai Cai
- The First Clinical College, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shangwen Pan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lang Chen
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiaowei Fang
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui 230001, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Wuhan Jinyintan Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430023, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Chastain DB, White BP, Tu PJ, Chan S, Jackson BT, Kubbs KA, Bandali A, McDougal S, Henao-Martínez AF, Cluck DB. Candidemia in Adult Patients in the ICU: A Reappraisal of Susceptibility Testing and Antifungal Therapy. Ann Pharmacother 2024; 58:305-321. [PMID: 37272474 DOI: 10.1177/10600280231175201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
OBJECTIVE To provide updates on the epidemiology and recommendations for management of candidemia in patients with critical illness. DATA SOURCES A literature search using the PubMed database (inception to March 2023) was conducted using the search terms "invasive candidiasis," "candidemia," "critically ill," "azoles," "echinocandin," "antifungal agents," "rapid diagnostics," "antifungal susceptibility testing," "therapeutic drug monitoring," "antifungal dosing," "persistent candidemia," and "Candida biofilm." STUDY SELECTION/DATA EXTRACTION Clinical data were limited to those published in the English language. Ongoing trials were identified through ClinicalTrials.gov. DATA SYNTHESIS A total of 109 articles were reviewed including 25 pharmacokinetic/pharmacodynamic studies and 30 studies including patient data, 13 of which were randomized controlled clinical trials. The remaining 54 articles included fungal surveillance data, in vitro studies, review articles, and survey data. The current 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Management of Candidiasis provides recommendations for selecting empiric and definitive antifungal therapies for candidemia, but data are limited regarding optimized dosing strategies in critically ill patients with dynamic pharmacokinetic changes or persistent candidemia complicated. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Outcomes due to candidemia remain poor despite improved diagnostic platforms, antifungal susceptibility testing, and antifungal therapy selection for candidemia in critically ill patients. Earlier detection and identification of the species causing candidemia combined with recognition of patient-specific factors leading to dosing discrepancies are crucial to improving outcomes in critically ill patients with candidemia. CONCLUSIONS Treatment of candidemia in critically ill patients must account for the incidence of non-albicans Candida species and trends in antifungal resistance as well as overcome the complex pathophysiologic changes to avoid suboptimal antifungal exposure.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
| | - Bryan P White
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Patrick J Tu
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Sophea Chan
- Department of Clinical & Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA
- Department of Pharmacy, Phoebe Putney Memorial Hospital, Albany, GA, USA
| | | | - Kara A Kubbs
- University of Oklahoma Health Medical Center, Oklahoma City, OK, USA
| | - Aiman Bandali
- Overlook Medical Center, Atlantic Health System, Summit, NJ, USA
| | | | - Andrés F Henao-Martínez
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David B Cluck
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
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Jiang X, Qin Y, Lei R, Han Y, Yang J, Zhang G, Liu J. A rapid and simple HPLC-MS/MS method for the therapeutic drug monitoring of six special-grade antimicrobials in pediatric patients. Heliyon 2024; 10:e24198. [PMID: 38226205 PMCID: PMC10788798 DOI: 10.1016/j.heliyon.2024.e24198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/17/2024] Open
Abstract
Meropenem, linezolid, fluconazole, voriconazole, posaconazole, and vancomycin are six important antimicrobials used for severe infections in critically ill patients listed in special-grade antimicrobials in China. The six antimicrobials' highly variable pharmacodynamics and pharmacokinetics in critically ill pediatric patients present significant challenges to clinicians in ensuring optimal therapeutic targets. Therefore, therapeutic drug monitoring of these antimicrobials in human plasma is necessary to obtain their plasma concentration. A rapid, simple, and sample-saving high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method was developed, which could simultaneously determine all six antimicrobials. It required only 10 μL of plasma and a one-step protein precipitation process. Chromatographic separation was achieved on a reversed-phase column (C18, 30 × 2.1 mm, 2.6 μm) via gradient elution using water and acetonitrile containing 0.1 % formic acid as mobile phase. The injection volume was 2 μL, and the total run time was only 2.5 min. Detection was done using a Triple Quad™ 4500MD tandem mass spectrometer coupled with an electrospray ionization (ESI) source in positive mode. The calibration curves ranged from 0.5 to 64 μg/mL for meropenem and fluconazole, 0.2-25.6 μg/mL for linezolid and voriconazole, 0.1-12.8 μg/mL for posaconazole and 1-128 μg/mL for vancomycin, with the coefficients of correlation all greater than 0.996. Furthermore, the method was validated rigorously according to the European Medicines Agency (EMA) guidelines, demonstrating excellent accuracy (from 93.0 % to 110.6 %) and precision (from 2.0 % to 12.8 %). Moreover, its applicability to various matrices (including serum, hemolytic plasma, and hyperlipidemic plasma) was evaluated. Thus, this method was successfully applied to routine therapeutic drug monitoring for critically ill pediatric patients and other patients in need.
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Affiliation(s)
- Xijuan Jiang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Yabin Qin
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Rong Lei
- Hebei Key Laboratory of Traditional Chinese Medicine Quality Evaluation and Standard Research, Hebei Institute for Drug and Medical Device Control, Shijiazhuang, Hebei, 050227, China
| | - Yu Han
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Jing Yang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Guying Zhang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Jianfang Liu
- Office of Clinical Trial Center, The First Affiliated Hospital of Hebei University of Chinese Medicine, Shijiazhuang, Hebei, 050017, China
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Salehi M, Rezazade-Moayed F, Khalili H, Hemati H, Aghdami N, Dashtkoohi M, Dashtkoohi M, Beig-Mohammadi MT, Ramezani M, Hajiabdolbaghi M, Fattah-Ghazi S. Safety of megadose meropenem in the empirical treatment of nosocomial sepsis: a pilot randomized clinical trial. Future Microbiol 2023; 18:335-342. [PMID: 37140270 DOI: 10.2217/fmb-2022-0170] [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: 05/05/2023] Open
Abstract
Objective: To evaluate the safety of megadose meropenem as empirical treatment of nosocomial sepsis. Materials & methods: Critically ill patients diagnosed with sepsis received either high-dose (2 g every 8 h) or megadose (4 g every 8 h) meropenem as an intravenous infusion over 3 h. Results: A total of 23 patients with nosocomial sepsis were eligible and included in the megadose (n = 11) or high-dose (n = 12) group. No treatment-related adverse events were observed during a 14-day follow-up. Clinical response was also comparable between the groups. Conclusion: Megadose meropenem may be considered for empirical treatment of nosocomial sepsis without serious concern regarding its safety.
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Affiliation(s)
- Mohammadreza Salehi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Farah Rezazade-Moayed
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Hemati
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Aghdami
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology & Technology, Academic Center for Education, Culture & Research, Tehran, Iran
| | - Mohadese Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoud Ramezani
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Hajiabdolbaghi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Samrand Fattah-Ghazi
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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C/MIC > 4: A Potential Instrument to Predict the Efficacy of Meropenem. Antibiotics (Basel) 2022; 11:antibiotics11050670. [PMID: 35625314 PMCID: PMC9137711 DOI: 10.3390/antibiotics11050670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
This prospective study aimed to explore the determinants of meropenem trough concentration (Ctrough) in patients with bacterial pneumonia and to investigate the association between its concentration and efficacy. From January 2019 to December 2019, patients with pulmonary infections were prospectively enrolled from the intensive care unit. Factors affecting the meropenem trough concentration were analyzed, and a multiple linear regression model was constructed. Logistic regression analyses were used to investigate the relationship between Ctrough and clinical efficacy. A total of 64 patients were enrolled, in whom 210 meropenem concentrations were measured. Of the total, 60.9% (39/64) were considered clinically successful after treatment. Ctrough may increase with increased blood urea nitrogen, albumin, and concomitant antifungal use. By contrast, concentration may decrease with increased endogenous creatinine clearance rate. Six variables, including Ctrough/minimum inhibitory concentration (MIC) > 4, were associated with the efficacy of meropenem. There was an independent correlation between Ctrough/MIC > 4 and efficacy after fully adjusting for confounding factors. Based upon renal function indexes, it is possible to predict changes in meropenem concentration and adjust the dosage precisely and individually. Ctrough/MIC > 4 is a potential instrument to predict successful treatment with meropenem.
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Selig DJ, Akers KS, Chung KK, Kress AT, Livezey JR, Por ED, Pruskowski KA, DeLuca JP. Comparison of Piperacillin and Tazobactam Pharmacokinetics in Critically Ill Patients with Trauma or with Burn. Antibiotics (Basel) 2022; 11:618. [PMID: 35625262 PMCID: PMC9138153 DOI: 10.3390/antibiotics11050618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/10/2022] Open
Abstract
Critical illness caused by burn and sepsis is associated with pathophysiologic changes that may result in the alteration of pharmacokinetics (PK) of antibiotics. However, it is unclear if one mechanism of critical illness alters PK more significantly than another. We developed a population PK model for piperacillin and tazobactam (pip-tazo) using data from 19 critically ill patients (14 non-burn trauma and 5 burn) treated in the Military Health System. A two-compartment model best described pip-tazo data. There were no significant differences found in the volume of distribution or clearance of pip-tazo in burn and non-burn patients. Although exploratory in nature, our data suggest that after accounting for creatinine clearance (CrCl), doses would not need to be increased for burn patients compared to trauma patients on consideration of PK alone. However, there is a high reported incidence of augmented renal clearance (ARC) in burn patients and pharmacodynamic (PD) considerations may lead clinicians to choose higher doses. For critically ill patients with normal kidney function, continuous infusions of 13.5-18 g pip-tazo per day are preferable. If ARC is suspected or the most stringent PD targets are desired, then continuous infusions of 31.5 g pip-tazo or higher may be required. This approach may be reasonable provided that therapeutic drug monitoring is enacted to ensure pip-tazo levels are not supra-therapeutic.
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Affiliation(s)
- Daniel J. Selig
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, MD 20910, USA; (A.T.K.); (E.D.P.); (J.P.D.)
| | - Kevin S. Akers
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA; (K.S.A.); (K.A.P.)
| | - Kevin K. Chung
- Department of Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (K.K.C.); (J.R.L.)
| | - Adrian T. Kress
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, MD 20910, USA; (A.T.K.); (E.D.P.); (J.P.D.)
| | - Jeffrey R. Livezey
- Department of Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (K.K.C.); (J.R.L.)
| | - Elaine D. Por
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, MD 20910, USA; (A.T.K.); (E.D.P.); (J.P.D.)
| | - Kaitlin A. Pruskowski
- United States Army Institute of Surgical Research, San Antonio, TX 78234, USA; (K.S.A.); (K.A.P.)
- Department of Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA; (K.K.C.); (J.R.L.)
| | - Jesse P. DeLuca
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, MD 20910, USA; (A.T.K.); (E.D.P.); (J.P.D.)
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Chang JL, Pearson JC, Rhee C. Early Empirical Use of Broad-Spectrum Antibiotics in Sepsis. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00777-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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10
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OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1424-1431. [DOI: 10.1093/jac/dkac039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/14/2022] [Indexed: 11/13/2022] Open
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Kim YK, Kim HS, Park S, Kim HI, Lee SH, Lee DH. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1353-1364. [PMID: 35224630 PMCID: PMC9047688 DOI: 10.1093/jac/dkac059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/05/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hwan-il Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Dong-Hwan Lee
- Department of Clinical Pharmacology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
- Corresponding author. E-mail:
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Munir MM, Rasheed H, Khokhar MI, Khan RR, Saeed HA, Abbas M, Ali M, Bilal R, Nawaz HA, Khan AM, Qamar S, Anjum SM, Usman M. Dose Tailoring of Vancomycin Through Population Pharmacokinetic Modeling Among Surgical Patients in Pakistan. Front Pharmacol 2021; 12:721819. [PMID: 34858169 PMCID: PMC8632000 DOI: 10.3389/fphar.2021.721819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Vancomycin is a narrow therapeutic agent, and it is necessary to optimize the dose to achieve safe therapeutic outcomes. The purpose of this study was to identify the significant covariates for vancomycin clearance and to optimize the dose among surgical patients in Pakistan. Methods: Plasma concentration data of 176 samples collected from 58 surgical patients treated with vancomycin were used in this study. A population pharmacokinetic model was developed on NONMEM® using plasma concentration-time data. The effect of all available covariates was evaluated on the pharmacokinetic parameters of vancomycin by stepwise covariate modeling. The final model was evaluated using bootstrap, goodness-of-fit plots, and visual predictive checks. Results: The pharmacokinetics of vancomycin followed a one-compartment model with first-order elimination. The vancomycin clearance (CL) and volume of distribution (Vd) were 2.45 L/h and 22.6 l, respectively. Vancomycin CL was influenced by creatinine clearance (CRCL) and body weight of the patients; however, no covariate was significant for its effect on the volume of distribution. Dose tailoring was performed by simulating dosage regimens at a steady state based on the CRCL of the patients. The tailored doses were 400, 600, 800, and 1,000 mg for patients with a CRCL of 20, 60, 100, and 140 ml/min, respectively. Conclusion: Vancomycin CL is influenced by CRCL and body weight of the patient. This model can be helpful for the dose tailoring of vancomycin based on renal status in Pakistani patients.
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Affiliation(s)
- Muhammad Muaaz Munir
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Huma Rasheed
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Muhammad Imran Khokhar
- Ameer-ud-Din Medical College, Post-Graduate Medical Institute (PGMI), Lahore General Hospital, Lahore, Pakistan
| | - Rizwan Rasul Khan
- Department of Medicine, Aziz Fatima Medical and Dental College, Faisalabad, Pakistan
| | | | - Mateen Abbas
- Quality Operation Laboratory, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Mohsin Ali
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Govt College University, Faisalabad, Pakistan
| | - Rabiea Bilal
- CMH Lahore Medical College and IOD, NUMS, Lahore, Pakistan
| | - Hafiz Awais Nawaz
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Abdul Muqeet Khan
- Quality Operation Laboratory, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Shaista Qamar
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Syed Muneeb Anjum
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Muhammad Usman
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
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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.
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Jaruratanasirikul S, Boonpeng A, Nawakitrangsan M, Samaeng M. NONMEM population pharmacokinetics and Monte Carlo dosing simulations of imipenem in critically ill patients with life-threatening severe infections during support with or without extracorporeal membrane oxygenation in an intensive care unit. Pharmacotherapy 2021; 41:572-597. [PMID: 34080708 DOI: 10.1002/phar.2597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/05/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVES The objectives of this study were (i) to determine the population pharmacokinetic (PK) of imipenem in critically ill patients with life-threatening severe infections, (ii) to investigate the impact of extracorporeal membrane oxygenation (ECMO) on the population PK of imipenem during support with ECMO compared to those without ECMO support, and (iii) to assess the probability of target attainment (PTA) for finding the optimal dosage regimens of imipenem in critically ill patients with life-threatening severe infections. DESIGN Open-label, PK study. SETTING Academic tertiary care medical center. PATIENTS Fifty critically ill patients with or without ECMO by pooling data from previously published studiesand unpublished data from 14 patients. INTERVENTION AND MEASUREMENTS The population PK of imipenem was determined using NONMEM and a Monte Carlo simulation was performed to determine the PTAs of achieving 40% and 75% exposure times during which the plasma drug concentrations remained above the MIC. MAIN RESULTS The values of volume of distribution and total clearance were 30.5 L and 13.3 L/h, respectively. The ECMO circuit did not show a significant influence on the PK parameters of imipenem. For pathogens with a MIC of 4 mg/L, the PTA target of 75% fT>MIC in patients with normal renal function was achieved when the imipenem was administered by a 4-h infusion of 1 g q6h. CONCLUSION The ECMO circuit had little effect on enhancing the PK changes of imipenem that had already occurred in these patients. A high dosage of imipenem may be required for achieving the PK/pharmacodynamic targets against less susceptible pathogens, however, the dosage regimens in patients with renal impairment may not need to be as high as those required in patients with normal renal function. ClinicalTrials.gov: NCT03858387.
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Affiliation(s)
- Sutep Jaruratanasirikul
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Apinya Boonpeng
- School of Pharmaceutical Sciences, University of Phayao, Muang, Thailand
| | - Monchana Nawakitrangsan
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Maseetoh Samaeng
- Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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15
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Tan WW, Watt KM, Boakye-Agyeman F, Cohen-Wolkowiez M, Mok YH, Yung CF, Chan YH. Optimal Dosing of Meropenem in a Small Cohort of Critically Ill Children Receiving Continuous Renal Replacement Therapy. J Clin Pharmacol 2021; 61:744-754. [PMID: 33314163 PMCID: PMC8089047 DOI: 10.1002/jcph.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
Severe sepsis is an important cause of mortality and morbidity in critically ill children. Meropenem is a broad-spectrum antibiotic commonly used to treat sepsis. Current meropenem dosage recommendations for children on continuous renal replacement therapy are extrapolated from pharmacokinetic (PK) studies done in adults. Our study aims to determine the optimal dosing in critically ill septic children receiving continuous renal replacement therapy. A prospective single-center PK study was performed in 9 children in the intensive care unit on continuous renal replacement therapy. Meropenem concentrations were measured from blood and effluent fluid samples. A population PK model was developed using nonlinear mixed-effects modeling software (NONMEM, AstraZeneca UK Ltd, Cheshire, UK). Monte Carlo simulations were performed. The PK/pharmacodynamic target aimed for plasma concentrations above minimum inhibitory concentration of 4 mg/L for 100% of dosing interval (100%ƒT>MIC ). A 2-compartment model best characterized meropenem PK. Mean (range) clearance and elimination half-life was 0.091 L/h/kg (0.04-0.157) and 3.9 hours (2.1-7.5), respectively. Dosing of 40 mg/kg/dose every 12 hours over 30 minutes achieved PK/PD target in only 32% while 20 mg/kg every 8 hours over 4 hours or 40 mg/kg every 8 hours over 2 hours achieved 100% ƒT>MIC target for at least 90% of simulated patients.
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Affiliation(s)
- Wei Wei Tan
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin M Watt
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Felix Boakye-Agyeman
- Integrated Drug Development, Certara Strategic Consulting, Certara USA, Inc. 100 Overlook Center, Princeton, New Jersey, USA
| | - Michael Cohen-Wolkowiez
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Yee Hui Mok
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chee Fu Yung
- Department of Paediatric Medicine, Infectious Disease Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
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16
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Roberts JA, Joynt GM, Lee A, Choi G, Bellomo R, Kanji S, Mudaliar MY, Peake SL, Stephens D, Taccone FS, Ulldemolins M, Valkonen MM, Agbeve J, Baptista JP, Bekos V, Boidin C, Brinkmann A, Buizen L, Castro P, Cole CL, Creteur J, De Waele JJ, Deans R, Eastwood GM, Escobar L, Gomersall C, Gresham R, Jamal JA, Kluge S, König C, Koulouras VP, Lassig-Smith M, Laterre PF, Lei K, Leung P, Lefrant JY, Llauradó-Serra M, Martin-Loeches I, Mat Nor MB, Ostermann M, Parker SL, Rello J, Roberts DM, Roberts MS, Richards B, Rodríguez A, Roehr AC, Roger C, Seoane L, Sinnollareddy M, Sousa E, Soy D, Spring A, Starr T, Thomas J, Turnidge J, Wallis SC, Williams T, Wittebole X, Zikou XT, Paul SK, Lipman J. The Effect of Renal Replacement Therapy and Antibiotic Dose on Antibiotic Concentrations in Critically Ill Patients: Data From the Multinational Sampling Antibiotics in Renal Replacement Therapy Study. Clin Infect Dis 2021; 72:1369-1378. [PMID: 32150603 DOI: 10.1093/cid/ciaa224] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The optimal dosing of antibiotics in critically ill patients receiving renal replacement therapy (RRT) remains unclear. In this study, we describe the variability in RRT techniques and antibiotic dosing in critically ill patients receiving RRT and relate observed trough antibiotic concentrations to optimal targets. METHODS We performed a prospective, observational, multinational, pharmacokinetic study in 29 intensive care units from 14 countries. We collected demographic, clinical, and RRT data. We measured trough antibiotic concentrations of meropenem, piperacillin-tazobactam, and vancomycin and related them to high- and low-target trough concentrations. RESULTS We studied 381 patients and obtained 508 trough antibiotic concentrations. There was wide variability (4-8-fold) in antibiotic dosing regimens, RRT prescription, and estimated endogenous renal function. The overall median estimated total renal clearance (eTRCL) was 50 mL/minute (interquartile range [IQR], 35-65) and higher eTRCL was associated with lower trough concentrations for all antibiotics (P < .05). The median (IQR) trough concentration for meropenem was 12.1 mg/L (7.9-18.8), piperacillin was 78.6 mg/L (49.5-127.3), tazobactam was 9.5 mg/L (6.3-14.2), and vancomycin was 14.3 mg/L (11.6-21.8). Trough concentrations failed to meet optimal higher limits in 26%, 36%, and 72% and optimal lower limits in 4%, 4%, and 55% of patients for meropenem, piperacillin, and vancomycin, respectively. CONCLUSIONS In critically ill patients treated with RRT, antibiotic dosing regimens, RRT prescription, and eTRCL varied markedly and resulted in highly variable antibiotic concentrations that failed to meet therapeutic targets in many patients.
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Affiliation(s)
- Jason A Roberts
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Gavin M Joynt
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anna Lee
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gordon Choi
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg and School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - M Yugan Mudaliar
- Intensive Care Unit, Westmead Hospital, Sydney, Australia.,Medical School, University of Sydney, Sydney, Australia
| | - Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dianne Stephens
- Intensive Care Unit, Royal Darwin Hospital, Darwin, Australia.,Flinders University, Adelaide, Australia.,National Critical Care and Trauma Response Centre, Darwin, Australia
| | | | - Marta Ulldemolins
- Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain.,Infectious Diseases-Internal Medicine Departments, Bellvitge University Hospital, l'Hospitalet de Llobregat, Spain
| | - Miia Maaria Valkonen
- Intensive Care Medicine, Department of Perioperative, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Julius Agbeve
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Herston, Australia
| | - João P Baptista
- Intensive Care Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Vasileios Bekos
- Intensive Care Unit, Naval and Veterans Hospital of Athens, Athens, Greece
| | - Clement Boidin
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Lyon, France.,Hôpital Pierre Garraud, Hospices Civils de Lyon, Lyon, France
| | - Alexander Brinkmann
- Department of Anesthesia and Critical Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Luke Buizen
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
| | - Pedro Castro
- Medical Intensive Care Unit, ICMiD. Hospital Clínic de Barcelona, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain
| | - C Louise Cole
- Medical School, University of Sydney, Sydney, Australia.,Intensive Care Unit, Nepean Hospital, Sydney, Australia
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Brussels, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine; Ghent University Hospital, Ghent, Belgium
| | - Renae Deans
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg and School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Leslie Escobar
- Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Charles Gomersall
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Janattul Ain Jamal
- Department of Pharmacy, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Vasilios P Koulouras
- Intensive Care Unit Department, University Hospital of Ioannina, Ioannina, Greece
| | - Melissa Lassig-Smith
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Katie Lei
- Guy's and St Thomas Hospital, London, United Kingdom
| | - Patricia Leung
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jean-Yves Lefrant
- Intensive Care Unit, Nîmes University Hospital (Centre Hospitalo Universitaire Nimes), Nimes, France
| | - Mireia Llauradó-Serra
- Department of Nursing, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ignacio Martin-Loeches
- Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Multidisciplinary Intensive Care Research Organization (MICRO), St James Hospital, Dublin, Ireland
| | - Mohd Basri Mat Nor
- Department of Anesthesiology and Intensive Care, School of Medicine, International Islamic University Malaysia, Selangor, Malaysia
| | | | - Suzanne L Parker
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jordi Rello
- CIBERES, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Darren M Roberts
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia.,Translational Research Institute, The University of Queensland, Buranda, Australia
| | - Brent Richards
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Australia
| | - Alejandro Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Tarragona, Spain.,Rovira i Virgili University, IISPV/CIBERES, Tarragona, Spain
| | - Anka C Roehr
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Claire Roger
- Intensive Care Unit, Nîmes University Hospital (Centre Hospitalo Universitaire Nimes), Nimes, France
| | - Leonardo Seoane
- Faculty of Medicine, An University of Queensland, New Orleans, Louisiana, USA.,Intensive Care Unit, Ochsner Health System, New Orleans, Louisiana, USA
| | - Mahipal Sinnollareddy
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Eduardo Sousa
- Intensive Care Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dolors Soy
- IDIBAPS, University of Barcelona, Barcelona, Spain.,Pharmacy Department, Division of Medicines. Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Spring
- Intensive Care Unit, Naval and Veterans Hospital of Athens, Athens, Greece
| | - Therese Starr
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jane Thomas
- Intensive Care Unit, Royal Darwin Hospital, Darwin, Australia
| | - John Turnidge
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Steven C Wallis
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Tricia Williams
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Xavier Wittebole
- Intensive Care Unit, Clinique Universitaire St Luc UCL, Brussels, Belgium
| | - Xanthi T Zikou
- Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Sanjoy K Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
| | - Jeffrey Lipman
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Papafilippou L, Claxton A, Dark P, Kostarelos K, Hadjidemetriou M. Nanotools for Sepsis Diagnosis and Treatment. Adv Healthc Mater 2021; 10:e2001378. [PMID: 33236524 DOI: 10.1002/adhm.202001378] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/07/2020] [Indexed: 12/12/2022]
Abstract
Sepsis is one of the leading causes of death worldwide with high mortality rates and a pathological complexity hindering early and accurate diagnosis. Today, laboratory culture tests are the epitome of pathogen recognition in sepsis. However, their consistency remains an issue of controversy with false negative results often observed. Clinically used blood markers, C reactive protein (CRP) and procalcitonin (PCT) are indicators of an acute-phase response and thus lack specificity, offering limited diagnostic efficacy. In addition to poor diagnosis, inefficient drug delivery and the increasing prevalence of antibiotic-resistant microorganisms constitute significant barriers in antibiotic stewardship and impede effective therapy. These challenges have prompted the exploration for alternative strategies that pursue accurate diagnosis and effective treatment. Nanomaterials are examined for both diagnostic and therapeutic purposes in sepsis. The nanoparticle (NP)-enabled capture of sepsis causative agents and/or sepsis biomarkers in biofluids can revolutionize sepsis diagnosis. From the therapeutic point of view, currently existing nanoscale drug delivery systems have proven to be excellent allies in targeted therapy, while many other nanotherapeutic applications are envisioned. Herein, the most relevant applications of nanomedicine for the diagnosis, prognosis, and treatment of sepsis is reviewed, providing a critical assessment of their potentiality for clinical translation.
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Affiliation(s)
- Lana Papafilippou
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
| | - Andrew Claxton
- Department of Critical Care Salford Royal Foundation Trust Stott Lane Salford M6 8HD UK
| | - Paul Dark
- Manchester NIHR Biomedical Research Centre Division of Infection Immunity and Respiratory Medicine University of Manchester Manchester M13 9PT UK
| | - Kostas Kostarelos
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
- Catalan Institute of Nanoscience and Nanotechnology (ICN2) Campus UAB Bellaterra Barcelona 08193 Spain
| | - Marilena Hadjidemetriou
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
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18
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Pharmacokinetics and Monte Carlo Dosing Simulations of Imipenem in Critically Ill Patients with Life-Threatening Severe Infections During Support with Extracorporeal Membrane Oxygenation. Eur J Drug Metab Pharmacokinet 2020; 45:735-747. [PMID: 32886347 PMCID: PMC7471576 DOI: 10.1007/s13318-020-00643-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO), a cardiopulmonary bypass device, has been found to increase the profound pathophysiological changes associated with life-threatening severe infections in patients with multiple comorbidities, which results in alterations of pharmacokinetic patterns for antibiotics. Objectives The aims of this study were (1) to determine the pharmacokinetics of imipenem and (2) to assess the probability of target attainment (PTA) for imipenem in critically ill patients with life-threatening severe infections during support with ECMO. Methods The pharmacokinetic studies were carried out following administration of 0.5 g of imipenem every 6 h on the 4th dose of drug administration in 10 patients and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the plasma drug concentrations remained above minimum inhibitory concentration (T > MIC) and 80% T > MIC. Results The median values of volume of distribution and total clearance (CL) of imipenem in these patients were 13.98 L and 9.78 L/h, respectively. A high PTA (≥ 90%) for a target of 80% with a MIC of 4 μg/mL in patients with CLCR 60–120 mL/min and flow rate of ECMO circuit 3–5.5 L/min was observed when imipenem was administered by a 4-h infusion of 1 g every 6 h. Conclusions A high dosage regimen such as 1 g every 6 h of imipenem may be required to achieve pharmacodynamic targets against less susceptible pathogens in this patient population. ClinicalTrial.gov Identifier NCT03776305, date of registration: 11 December 2018. Electronic supplementary material The online version of this article (10.1007/s13318-020-00643-3) contains supplementary material, which is available to authorized users.
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19
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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20
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Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers. ASAIO J 2020; 66:707-721. [PMID: 32604322 PMCID: PMC7228451 DOI: 10.1097/mat.0000000000001193] [Citation(s) in RCA: 249] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
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21
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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.
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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
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22
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Brunsdon P, Saluja B, Sahajwalla C. Clinical Pharmacology Considerations for Developing Small-Molecule Treatments for COVID-19. J Clin Pharmacol 2020; 60:1147-1154. [PMID: 32579707 PMCID: PMC7361784 DOI: 10.1002/jcph.1697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
Numerous drugs are being investigated for the treatment of COVID‐19, including antivirals and therapies targeting complications related to COVID‐19. The clinical presentation of COVID‐19 varies from mild fever, cough, and dyspnea in the early stages of disease to severe complications such as acute respiratory distress syndrome, systemic hyperinflammation, and sepsis. A thorough understanding of the disease pathogenesis and the disease complications is essential to developing effective therapies to treat this potentially life‐threatening disease. This review offers key clinical pharmacology considerations involved in the development of small molecules for the treatment of COVID‐19. They are based on the major observed disease complications that impact drug absorption, distribution, metabolism, and elimination. We also address considerations regarding potential drug interactions, alternative routes and methods of administration, and dosing in patients on hemodialysis.
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Affiliation(s)
- Priya Brunsdon
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bhawana Saluja
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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23
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Fujii M, Karumai T, Yamamoto R, Kobayashi E, Ogawa K, Tounai M, Lipman J, Hayashi Y. Pharmacokinetic and pharmacodynamic considerations in antimicrobial therapy for sepsis. Expert Opin Drug Metab Toxicol 2020; 16:415-430. [DOI: 10.1080/17425255.2020.1750597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Motoki Fujii
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Infectious Disease, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Toshiyuki Karumai
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryohei Yamamoto
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Eri Kobayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Kenta Ogawa
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Mayuko Tounai
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
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Saran S, Rao NS, Azim A. Drug Dosing in Critically Ill Patients with Acute Kidney Injury and on Renal Replacement Therapy. Indian J Crit Care Med 2020; 24:S129-S134. [PMID: 32704220 PMCID: PMC7347056 DOI: 10.5005/jp-journals-10071-23392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) complicates in around 40-50% of patients in intensive care units (ICUs), and this can account for up to 80% mortality, especially in those patients requiring renal replacement therapy (RRT). Appropriate drug dosing in such patients is a challenge to the intensivists due to various factors such as patient related (appropriate body weight, organ clearance, serum protein concentration), drug related [molecular weight (MW), protein binding, volume of distribution (V d), hydrophilicity, or hydrophobicity], and RRT related (type, modality of solute removal, filter characteristics, dose, and duration). Therapeutic drug monitoring (TDM) of drugs can be a promising solution to this complex scenario to titrate a drug to its clinical response, but it is available only for a few drugs. In this review, we discussed drug dosing aspects of antimicrobials, sedatives, and antiepileptics in critically ill patients with AKI on RRT. HOW TO CITE THIS ARTICLE Saran S, Rao NS, Azim A. Drug Dosing in Critically Ill Patients with Acute Kidney Injury and on Renal Replacement Therapy. Indian J Crit Care Med 2020;24(Suppl 3):S129-S134.
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Affiliation(s)
- Sai Saran
- Department of Critical Care Medicine, Super Speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India
| | - Namrata S Rao
- Department of Nephrology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Adembri C, Villa G, Rosi E, Tofani L, Fallani S, De Gaudio AR, Novelli A. Caspofungin PK in critically ill patients after the first and fourth doses: suggestions for therapeutic drug monitoring? J Chemother 2020; 32:124-131. [PMID: 32202224 DOI: 10.1080/1120009x.2020.1737783] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We describe caspofungin pharmacokinetics (PK) after the first and fourth doses in 20 critically ill septic patients. Monte Carlo simulation was used to analyze the probability of target attainment (PTA) (AUC/MIC > 865) for Candida spp. Caspofungin concentrations were analyzed by HPLC in plasma and urine. A great variability in PK parameters was observed after both doses. Patients were divided in two groups according to their AUC values (AUC ≤ 75 mg h/L cut-off). In the low-AUC group Cmax, Cmin and AUC were lower, while Vd and Cl were higher than in the high-AUC group (p < 0.05, both at day 1 and 4). The mean 24-h urinary recovery of the drug was 8 ± 6.3% (day1) and 9.8 ± 6.3 (day4). Monte Carlo simulation analysis (0.03-1 mg/L MIC-range) showed that PTA was guaranteed only for MICs ≤ 0.03 mg/L in the low-AUC group, and for MICs ≤ 0.06 mg/L in the high-AUC group. No group had a PTA ≥ 90% for 0.125 mg/L MIC (the epidemiological cut-off). Mortality was higher in low-AUC group (p < 0.01). In our 'real-world' population, no clinical data can predict which patient will have lower, suboptimal caspofungin exposure, therefore we suggest TDM to optimize caspofungin therapy and reduce the risk of selecting resistances (CEAVC, 32366/2015; OSS.15.114, NCT03798600).
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Affiliation(s)
- C Adembri
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - G Villa
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - E Rosi
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Florence, Italy
| | - L Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - S Fallani
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Florence, Italy
| | - A R De Gaudio
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - A Novelli
- Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Florence, Italy
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Coskun D, Corum O, Yazar E. Effect of supportive therapy on the pharmacokinetics of intravenous marbofloxacin in endotoxemic sheep. J Vet Pharmacol Ther 2020; 43:288-296. [PMID: 32133667 DOI: 10.1111/jvp.12849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/28/2020] [Accepted: 02/13/2020] [Indexed: 12/26/2022]
Abstract
The purpose of this study was to determine the influences of supportive therapy (ST) on the pharmacokinetics (PK) of marbofloxacin in lipopolysaccharide (LPS)-induced endotoxemic sheep. Furthermore, minimum inhibitory concentration (MIC) of marbofloxacin against Escherichia coli, Mannheimia haemolytica, Pasteurella multocida, Klebsiella pneumoniae, Salmonella spp., and Staphylococcus aureus was determined. The study was performed using a three-period cross PK design following a 15-day washout period. In the first period, marbofloxacin (10 mg/kg) was administered by an intravenous (IV) injection. In the second and third periods, marbofloxacin was co-administered with ST (lactated ringer + 5% dextrose + 0.45% sodium chloride, IV, 20 ml/kg, dexamethasone 0.5 mg/kg, SC) and ST + LPS (E. coli O55:B5, 10 µg/kg), respectively. Plasma marbofloxacin concentration was measured using HPLC-UV. Following IV administration of marbofloxacin alone, the t 1 / 2 λ z , AUC0-∞ , ClT , and Vdss were 2.87 hr, 34.73 hr × µg/ml, 0.29 L hr-1 kg-1 , and 0.87 L/kg, respectively. While no change was found in the MBX + ST group in terms of the PK parameters of marbofloxacin, it was determined that the ClT of marbofloxacin decreased, AUC0-∞ increased, and t 1 / 2 λ z and MRT prolonged in the MBX + ST + LPS group. MIC values of marbofloxacin were 0.031 to >16 µg/ml for E. coli, 0.016 to >16 µg/ml for M. haemolytica, 0.016-1 µg/ml for P. multocida, 0.016-0.25 µg/ml for K. pneumoniae, 0.031-0.063 µg/ml for Salmonella spp., and 0.031-1 µg/ml for S. aureus. The study results show the necessity to make a dose adjustment of marbofloxacin following concomitant administration of ST in endotoxemic sheep. Also, the PK and pharmacodynamic effect of marbofloxacin needs to be determined in naturally infected septicemic sheep following concomitant administration of single and ST.
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Affiliation(s)
- Devran Coskun
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Siirt, Siirt, Turkey
| | - Orhan Corum
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Kastamonu, Kastamonu, Turkey
| | - Enver Yazar
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkey
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Branick K, Taylor MJ, Trump MW, Wall GC. Apparent interference with extracorporeal membrane oxygenation by liposomal amphotericin B in a patient with disseminated blastomycosis receiving continuous renal replacement therapy. Am J Health Syst Pharm 2020; 76:810-813. [PMID: 30994894 DOI: 10.1093/ajhp/zxz054] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We describe the use of liposomal amphotericin B and amphotericin B deoxycholate in a critically ill patient with pulmonary blastomycosis receiving both venovenous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). SUMMARY A 50-year-old African American man presented for dyspnea and cough and was noted to have blastomycosis on bronchoscopy. He developed respiratory failure and acute kidney injury, requiring mechanical ventilation, ECMO, and CRRT. After 4 days of liposomal amphotericin, the transmembrane pressure gradient on the membrane oxygenator increased dramatically without visualization of a clot, requiring a circuit exchange. A trough amphotericin B level taken the day before the exchange was undetectable for amphotericin B. After the circuit exchange, the patient was switched to amphotericin B deoxycholate. A subsequent trough level was 3.8 μg/mL. The patient improved and was able to be decannulated. However, he did require tracheostomy and long-term hemodialysis. CONCLUSION In our case we believe that liposomal amphotericin B was significantly removed by ECMO and was responsible for the failure of the ECMO circuit. We would suggest amphotericin B deoxycholate be used in such patients preferentially and that serum levels of the drug be assessed when possible.
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Affiliation(s)
- Kaitlin Branick
- Department of Internal Medicine, Iowa Methodist Medical Center, Des Moines, IA
| | - Matthew J Taylor
- Department of Internal Medicine, Iowa Methodist Medical Center, Des Moines, IA
| | - Matthew W Trump
- Department of Pulmonary and Critical Care Medicine, The Iowa Clinic PC, and Department of Pulmonary and Critical Care Medicine-Unity Point Health, Des Moines, IA
| | - Geoffrey C Wall
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA
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Raffaeli G, Cavallaro G, Allegaert K, Koch BCP, Mosca F, Tibboel D, Wildschut ED. Sequestration of Voriconazole and Vancomycin Into Contemporary Extracorporeal Membrane Oxygenation Circuits: An in vitro Study. Front Pediatr 2020; 8:468. [PMID: 32974242 PMCID: PMC7481439 DOI: 10.3389/fped.2020.00468] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Bacterial and fungal infections are common and often contribute to death in patients undergoing extracorporeal membrane oxygenation (ECMO). Drug disposition is altered during ECMO, and adsorption in the circuit is an established causative factor. Vancomycin and voriconazole are widely used, despite the lack of evidence-based prescription guidelines. Objective: The objective of this study was to determine the extraction of voriconazole and vancomycin by the Xenios/Novalung ECMO circuits. Methods: We have set up nine closed-loop ECMO circuits, consisting of four different iLAActivve ® kits for neonatal, pediatric, and adult support: three iLA-ActivveMiniLung ® petite kits, two iLA-ActivveMiniLung ® kits, two iLA-ActivveiLA ® kits, and two iLA-Activve X-lung ® kits. The circuits were primed with whole blood and maintained at physiologic conditions for 24 h. Voriconazole and vancomycin were injected as a single-bolus age-related dose into the circuits. Pre-membrane (P2) blood samples were obtained at baseline and after drug injection at 2, 10, 30, 180, 360 min, and 24 h. A control sample at 2 min was collected for spontaneous drug degradation testing at 24 h. Results: Seventy-two samples were analyzed in triplicate. The mean percentage of drug recovery at 24 h was 20% for voriconazole and 62% for vancomycin. Conclusions: The extraction of voriconazole and vancomycin by contemporary ECMO circuits is clinically relevant across all age-related circuit sizes and may result in reduced drug exposure in vivo.
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Affiliation(s)
- Genny Raffaeli
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Karel Allegaert
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | | | - Fabio Mosca
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enno D Wildschut
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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Jaruratanasirikul S, Vattanavanit V, Samaeng M, Nawakitrangsan M, Sriwiriyajan S. Pharmacokinetics of Imipenem in Critically Ill Patients with Life-threatening Severe Infections During Support with Extracorporeal Membrane Oxygenation. Clin Drug Investig 2019; 39:787-798. [PMID: 31124013 DOI: 10.1007/s40261-019-00796-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has become increasingly used for lifesaving respiratory and/or cardiac failure support in critically ill patients, including those with life-threatening severe infections. This cardiopulmonary bypass device has been shown to enhance the profound pathophysiological changes in this patient population, resulting in an alteration of the pharmacokinetics of antimicrobial agents. OBJECTIVE The aim of this study was to determine the effect of ECMO on the pharmacokinetics of imipenem in critically ill patients supported by this cardiopulmonary bypass device. METHODS The study was conducted in critically ill patients with respiratory and/or cardiac failure and severe infections who were supported by ECMO. All patients received a 1-h infusion of 0.5 g of imipenem every 6 h and imipenem pharmacokinetics studies were carried out on the fourth dose of drug administration. RESULTS Ten patients were enrolled in this study. The pharmacokinetics parameters of imipenem were found to be highly variable. The volume of distribution, total clearance, elimination half-life and the area under the concentration-time curve between 0 and 6 h were 33.38 ± 13.89 L, 9.99 ± 10.47 L/h, 12.01 ± 29.63 h and 88.93 ± 54.07 mg∙h/L, respectively. CONCLUSIONS Pathophysiological changes in critically ill patients with severe infections during support with ECMO had a greater impact on altered pharmacokinetic patterns of imipenem than those that occur in critically ill patients without ECMO support. Therefore, the largest licensed dose, 1 g every 6 h, of imipenem, may be required to maintain adequate drug concentrations to achieve the pharmacokinetic/pharmacodynamic targets for effective antimicrobial therapy in this patient population.
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Affiliation(s)
- Sutep Jaruratanasirikul
- Department of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand.
| | - Veerapong Vattanavanit
- Department of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand
| | - Maseetoh Samaeng
- Department of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand
| | - Monchana Nawakitrangsan
- Department of Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand
| | - Somchai Sriwiriyajan
- Department of Pharmacology, Faculty of Science, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand
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Raffaeli G, Pokorna P, Allegaert K, Mosca F, Cavallaro G, Wildschut ED, Tibboel D. Drug Disposition and Pharmacotherapy in Neonatal ECMO: From Fragmented Data to Integrated Knowledge. Front Pediatr 2019; 7:360. [PMID: 31552205 PMCID: PMC6733981 DOI: 10.3389/fped.2019.00360] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. As the survival and the overall outcome of patients rely on the treatment and reversal of the underlying disease, effective and preferentially evidence-based pharmacotherapy is crucial to target recovery. Currently limited data exist to support the clinicians in their every-day intensive care prescribing practice with the contemporary ECMO technology. Indeed, drug dosing to optimize pharmacotherapy during neonatal ECMO is a major challenge. The impact of the maturational changes of the organ function on both pharmacokinetics (PK) and pharmacodynamics (PD) has been widely established over the last decades. Next to the developmental pharmacology, additional non-maturational factors have been recognized as key-determinants of PK/PD variability. The dynamically changing state of critical illness during the ECMO course impairs the achievement of optimal drug exposure, as a result of single or multi-organ failure, capillary leak, altered protein binding, and sometimes a hyperdynamic state, with a variable effect on both the volume of distribution (Vd) and the clearance (Cl) of drugs. Extracorporeal membrane oxygenation introduces further PK/PD perturbation due to drug sequestration and hemodilution, thus increasing the Vd and clearance (sequestration). Drug disposition depends on the characteristics of the compounds (hydrophilic vs. lipophilic, protein binding), patients (age, comorbidities, surgery, co-medications, genetic variations), and circuits (roller vs. centrifugal-based systems; silicone vs. hollow-fiber oxygenators; renal replacement therapy). Based on the potential combination of the above-mentioned drug PK/PD determinants, an integrated approach in clinical drug prescription is pivotal to limit the risks of over- and under-dosing. The understanding of the dose-exposure-response relationship in critically-ill neonates on ECMO will enable the optimization of dosing strategies to ensure safety and efficacy for the individual patient. Next to in vitro and clinical PK data collection, physiologically-based pharmacokinetic modeling (PBPK) are emerging as alternative approaches to provide bedside dosing guidance. This article provides an overview of the available evidence in the field of neonatal pharmacology during ECMO. We will identify the main determinants of altered PK and PD, elaborate on evidence-based recommendations on pharmacotherapy and highlight areas for further research.
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Affiliation(s)
- Genny Raffaeli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Pavla Pokorna
- Department of Pediatrics—ICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Enno D. Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Jaruratanasirikul S, Nitchot W, Wongpoowarak W, Samaeng M, Nawakitrangsan M. Population pharmacokinetics and Monte Carlo simulations of sulbactam to optimize dosage regimens in patients with ventilator-associated pneumonia caused by Acinetobacter baumannii. Eur J Pharm Sci 2019; 136:104940. [DOI: 10.1016/j.ejps.2019.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 05/08/2019] [Accepted: 05/23/2019] [Indexed: 11/29/2022]
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Marvin JL, Levine BJ, Papas M, Rosini JM. An Evaluation of the Incidence of Nephrotoxicity After a Loading Dose of Vancomycin in Patients With Severe Renal Impairment. J Emerg Med 2019; 56:701-708. [PMID: 31029400 DOI: 10.1016/j.jemermed.2019.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/09/2019] [Accepted: 03/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Loading doses of vancomycin assist in the rapid achievement of target trough concentrations. Patients with renal dysfunction have been excluded from studies evaluating loading doses. OBJECTIVE The purpose of this study was to investigate nephrotoxicity related to initial vancomycin dose in patients with severe renal dysfunction. METHODS A retrospective cohort study was approved by the Institutional Review Board of a large, academic health system. Adults were included if they received intravenous vancomycin in the emergency department and presented with creatinine clearance < 30 mL/min. Chronic dialysis patients were excluded. The primary outcome was incidence of nephrotoxicity after an initial high (>20 mg/kg) vs. low (≤20 mg/kg) dose of vancomycin. Secondary outcomes included dialysis, vancomycin concentrations, length of stay, in-hospital mortality, and a composite outcome of nephrotoxicity or dialysis. RESULTS Of the 927 patients included in the analysis, nephrotoxicity occurred in 7.2% and 13.8% of patients in the high- and low-dose groups, respectively (p < 0.01). Patients in the high-dose group had a reduced risk of nephrotoxicity (relative risk 0.53; 95% confidence interval 0.35-0.78). The reduction in risk remained after fitting a generalized linear model adjusting for weight, age, sex, initial serum creatinine, diabetes, and chronic kidney disease (relative risk 0.61; 95% confidence interval 0.39-0.93). Limitations of this study include its retrospective design and single-center population. CONCLUSION These data suggest that vancomycin loading doses do not increase nephrotoxicity compared with lower doses in patients with severe renal dysfunction. These patients should be included in future studies relating to vancomycin loading doses.
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Affiliation(s)
- Jennifer L Marvin
- Department of Pharmacy, Christiana Care Health System, Newark, Delaware
| | - Brian J Levine
- Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware
| | - Mia Papas
- Value Institute, Christiana Care Health System, Newark, Delaware
| | - Jamie M Rosini
- Department of Pharmacy, Christiana Care Health System, Newark, Delaware
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35
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Jamal JA, Roger C, Roberts JA. Understanding the impact of pathophysiological alterations during critical illness on drug pharmacokinetics. Anaesth Crit Care Pain Med 2018; 37:515-517. [PMID: 30359771 DOI: 10.1016/j.accpm.2018.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Janattul-Ain Jamal
- Department of Pharmacy, Hospital Tengku Ampuan Afzan, 25100 Kuantan, Pahang, Malaysia
| | - Claire Roger
- Department of Anaesthesiology, Emergency and Critical Care Medicine, Intensive Care Unit, Nîmes University Hospital, place du Professeur Debré, 30029 Nîmes, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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Kovacevic MP, Szumita PM, Dube KM, DeGrado JR. Transition From Continuous Infusion Fentanyl to Hydromorphone in Critically Ill Patients. J Pharm Pract 2018; 33:129-135. [PMID: 29996718 DOI: 10.1177/0897190018786832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The 2013 Society of Critical Care Medicine guidelines for the management of pain, agitation, and delirium in adult intensive care unit (ICU) patients recommend intravenous opioids as first-line therapy to treat nonneuropathic pain. There is a paucity of literature describing possible benefits of utilizing specific opioids over others in ICU patients. OBJECTIVE The objective was to identify rationales for the transition from continuous infusion fentanyl to continuous infusion hydromorphone in critically ill patients. METHODS This was a single-center, prospective, observational analysis of adult ICU patients who were transitioned from fentanyl to hydromorphone. The major end point was to characterize the primary reason for transition. Minor end points included secondary reason(s) for transition, transition dosing, changes in continuous sedative requirements, and level of sedation. RESULTS Forty-six patients were included in the analysis. The primary rationale for transition was ventilator compliance (28.3%), followed by tachyphylaxis or better pain control (19.6%), and reduction in sedatives (13.0%). The most common secondary reason(s) for transition included reduction in sedatives (47.8%), opioid rotation (32.6%), and obesity (30.4). Median fentanyl rate of 100 µg/h was transitioned to 1 mg/h of hydromorphone. The percentage of patients requiring the use of continuous sedatives was decreased in the 24 hours following transition (P = .005); however, patients were more deeply sedated (P = .02). CONCLUSION Rationales for transition were to improve ventilator compliance, optimize patient-specific pharmacokinetics, and limit overall sedative exposure.
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Affiliation(s)
- Mary P Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin M Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
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Hoo GSR, Liew YX, Kwa ALH. Optimisation of antimicrobial dosing based on pharmacokinetic and pharmacodynamic principles. Indian J Med Microbiol 2018; 35:340-346. [PMID: 29063877 DOI: 10.4103/ijmm.ijmm_17_278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
While suboptimal dosing of antimicrobials has been attributed to poorer clinical outcomes, clinical cure and mortality advantages have been demonstrated when target pharmacokinetic (PK) and pharmacodynamic (PD) indices for various classes of antimicrobials were achieved to maximise antibiotic activity. Dosing optimisation requires a good knowledge of PK/PD principles. This review serves to provide a foundation in PK/PD principles for the commonly prescribed antibiotics (β-lactams, vancomycin, fluoroquinolones and aminoglycosides), as well as dosing considerations in special populations (critically ill and obese patients). PK principles determine whether an appropriate dose of antimicrobial reaches the intended pathogen(s). It involves the fundamental processes of absorption, distribution, metabolism and elimination, and is affected by the antimicrobial's physicochemical properties. Antimicrobial pharmacodynamics define the relationship between the drug concentration and its observed effect on the pathogen. The major indicator of the effect of the antibiotics is the minimum inhibitory concentration. The quantitative relationship between a PK and microbiological parameter is known as a PK/PD index, which describes the relationship between dose administered and the rate and extent of bacterial killing. Improvements in clinical outcomes have been observed when antimicrobial agents are dosed optimally to achieve their respective PK/PD targets. With the rising rates of antimicrobial resistance and a limited drug development pipeline, PK/PD concepts can foster more rational and individualised dosing regimens, improving outcomes while simultaneously limiting the toxicity of antimicrobials.
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Affiliation(s)
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital; Emerging Infectious Diseases, Duke-National University of Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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Pharmacokinetic and Pharmacodynamic Considerations of Antibiotics of Last Resort in Treating Gram-Negative Infections in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:10. [PMID: 29623443 DOI: 10.1007/s11908-018-0614-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW We provide an overview of antimicrobials that are considered last resort for the treatment of resistant gram-negative infections in adult critically ill patients. The role in therapy, pharmacodynamic (PD) goals, and pharmacokinetic (PK) changes in critical illness for aminoglycosides, polymyxins, tigecycline, fosfomycin, and fluoroquinolones are summarized. RECENT FINDINGS Altered PK in septic patients in the intensive care unit (ICU) is observed with many of our agents of last resort. Based on the available literature, dosage adjustments may be required to optimize PK parameters and meet PD targets for most effective bacterial killing. Data is limited, studies are conducted in heterogeneous patient populations, and conclusions are frequently conflicting. Strategic dosing regimens such as high-dose extended interval dosing of aminoglycosides or loading doses with colistin and polymyxin B are examples of ways to optimize antibiotic PK in critically ill patients. Benefits of these strategies must be balanced with risks of increased toxicity. Patients with resistant gram-negative infections may present with septic shock in the ICU. Sepsis can significantly alter the PK of antibiotics and require dosage adjustments to attain optimal drug levels. An understanding of PK and PD properties of these agents of last resort will help to maximize therapeutic efficacy while minimizing toxic effects.
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Importance of Site of Infection and Antibiotic Selection in the Treatment of Carbapenem-Resistant Pseudomonas aeruginosa Sepsis. Antimicrob Agents Chemother 2018; 62:AAC.02400-17. [PMID: 29378722 DOI: 10.1128/aac.02400-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/19/2018] [Indexed: 02/01/2023] Open
Abstract
In a retrospective analysis of 215 patients with carbapenem-resistant Pseudomonas aeruginosa sepsis, we observed a significantly higher risk of mortality associated with respiratory tract infection (risk ratio [RR], 1.20; 95% confidence interval [CI], 1.04 to 1.39; P = 0.010) and lower risk with urinary tract infection (RR, 0.80; 95% CI, 0.71 to 0.90; P = 0.004). Aminoglycoside monotherapy was associated with increased mortality, even after adjusting for confounders (adjusted RR, 1.72; 95% CI, 1.03 to 2.85; P = 0.037), consistent across multiple sites of infection.
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Droege ME, Van Fleet SL, Mueller EW. Application of Antibiotic Pharmacodynamics and Dosing Principles in Patients With Sepsis. Crit Care Nurse 2018; 36:22-32. [PMID: 27037336 DOI: 10.4037/ccn2016881] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Sepsis is associated with marked mortality, which may be reduced by prompt initiation of adequate, appropriate doses of antibiotic. Critically ill patients often have physiological changes that reduce blood and tissue concentrations of antibiotic and high rates of multidrug-resistant pathogens, which may affect patients' outcomes. All critical care professionals, including critical care nurses, should understand antibiotic pharmacokinetics and pharmacodynamics to ensure sound antibiotic dosing and administration strategies for optimal microbial killing and patients' outcomes. Effective pathogen eradication occurs when the dose of antibiotic reaches or maintains optimal concentrations relative to the minimum inhibitory concentration for the pathogen. Time-dependent antibiotics, such as β-lactams, can be given as extended or continuous infusions. Concentration-dependent antibiotics such as aminoglycosides are optimized by using high, once-daily dosing strategies with serum concentration monitoring. Vancomycin and fluoroquinolones are dependent on both time and concentration above the minimum inhibitory concentration.
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Affiliation(s)
- Molly E Droege
- Molly E. Droege is a clinical pharmacy specialist, trauma, surgery, orthopedics, UC Health-University of Cincinnati Medical Center, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing University of Cincinnati, Cincinnati, Ohio.Suzanne L. Van Fleet is a clinical pharmacy specialist, critical care, UC Health-West Chester Hospital, West Chester, Ohio, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing, University of Cincinnati.Eric W. Mueller is an assistant director, clinical services and research, and a clinical pharmacy specialist, critical care, Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center. He is also an adjunct associate professor of pharmacy practice and an adjunct instructor of advanced clinical nursing, University of Cincinnati
| | - Suzanne L Van Fleet
- Molly E. Droege is a clinical pharmacy specialist, trauma, surgery, orthopedics, UC Health-University of Cincinnati Medical Center, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing University of Cincinnati, Cincinnati, Ohio.Suzanne L. Van Fleet is a clinical pharmacy specialist, critical care, UC Health-West Chester Hospital, West Chester, Ohio, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing, University of Cincinnati.Eric W. Mueller is an assistant director, clinical services and research, and a clinical pharmacy specialist, critical care, Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center. He is also an adjunct associate professor of pharmacy practice and an adjunct instructor of advanced clinical nursing, University of Cincinnati
| | - Eric W Mueller
- Molly E. Droege is a clinical pharmacy specialist, trauma, surgery, orthopedics, UC Health-University of Cincinnati Medical Center, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing University of Cincinnati, Cincinnati, Ohio.Suzanne L. Van Fleet is a clinical pharmacy specialist, critical care, UC Health-West Chester Hospital, West Chester, Ohio, and an assistant professor of clinical pharmacy and an adjunct instructor of advanced clinical nursing, University of Cincinnati.Eric W. Mueller is an assistant director, clinical services and research, and a clinical pharmacy specialist, critical care, Department of Pharmacy Services, UC Health-University of Cincinnati Medical Center. He is also an adjunct associate professor of pharmacy practice and an adjunct instructor of advanced clinical nursing, University of Cincinnati.
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Abstract
Sepsis is a leading cause of maternal morbidity and mortality in developed and developing nations. Obstetric practitioners should be familiar with guidelines that promote the safe and expeditious recovery of those affected. This article will provide the reader with rational steps to aid in the recovery of such a patient.
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Affiliation(s)
- Arthur Jason Vaught
- John Hopkins School of Medicine, 600 N. Wolfe St, Phipps 228, Baltimore, MD 21287.
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König C, Braune S, Roberts JA, Nierhaus A, Steinmetz OM, Baehr M, Frey OR, Langebrake C, Kluge S. Population pharmacokinetics and dosing simulations of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis. J Antimicrob Chemother 2018; 72:1433-1440. [PMID: 28175308 DOI: 10.1093/jac/dkw592] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 12/29/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives To describe the population PKs of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis (SLED). Patients and methods This study was performed in ICUs of a university hospital. We collected blood samples during three consecutive days of SLED sessions in patients receiving ceftazidime. Concentration versus time curves were analysed using a population PKs approach with Pmetrics ® . Monte Carlo simulation for the first 24 h including a 6 h SLED session was performed with the final model. The fractional target attainment against the MIC of Pseudomonas aeruginosa was executed using targets of 50 and 100% fT > MIC . Results In total, 211 blood samples of 16 critically ill patients under SLED were collected. SLED treatments were 299.3 (68.4) min in duration. A two-compartment linear population PK model was most appropriate. The mean (SD) CL of ceftazidime on SLED, and off SLED were 5.32 (3.2), 1.06 (1.0) L/h respectively. The PTA for 50% fT > MIC for a dose of 1 g intravenously every 8 h was 98%. Assuming a target of 100% fT > MIC a dose of 2 g every 12 h covers isolates with MIC ≤8 mg/L with a PTA of 96%. Conclusion In critically ill patients receiving SLED, ceftazidime 1 g every 8 h and ceftazidime 2 g every 12 h appear to be sufficient for achieving traditional (50% fT > MIC ) and aggressive PD targets (100% fT > MIC ) for susceptible isolates (MIC ≤8 mg/L), respectively.
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Affiliation(s)
- Christina König
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Braune
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jason A Roberts
- Burns, Trauma, and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver M Steinmetz
- University Medical Center Hamburg-Eppendorf, Department of Internal Medicine III. (Nephrology/Rheumatology with Section Endocrinology), Hamburg, Germany
| | - Michael Baehr
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Otto R Frey
- Hospital Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Owen EJ, Gibson GA, Buckman SA. Pharmacokinetics and Pharmacodynamics of Antimicrobials in Critically Ill Patients. Surg Infect (Larchmt) 2017; 19:155-162. [PMID: 29272204 DOI: 10.1089/sur.2017.262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Critically ill patients with severe infections often have altered pharmacokinetic and pharmacodynamic variables that lead to challenging treatment decisions. These altered variables can often lead to inadequate dosing and poor treatment outcomes. The pharmacokinetic parameters include absorption, distribution, metabolism, and excretion. Pharmacodynamics is the relationship between drug serum concentrations and pharmacologic and toxicologic properties of the medication. In addition to these altered parameters, these critically ill patients frequently are receiving organ support in the forms of continuous renal replacement therapy or extra-corporeal membrane oxygenation. Altered pharmacodynamics can lead to decreased end-organ perfusion, which can ultimately lead to treatment failure or exposure-related toxicity. The most common antimicrobials utilized in the intensive care unit are classified by the pharmacodynamic principles of time-dependent, concentration-dependent, and concentration dependent with time-dependence. Thus, the aim of this review is to outline pharmacokinetic and pharmacodynamic changes of critically ill patients with severe infections and provide strategies for optimal antibiotic agent dosing in these patients.
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Affiliation(s)
| | | | - Sara A Buckman
- 2 Washington University School of Medicine in St. Louis , St. Louis, Missouri
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Continuous Infusion Versus Intermittent Bolus of Beta-Lactams in Critically Ill Patients with Respiratory Infections: A Systematic Review and Meta-analysis. Eur J Drug Metab Pharmacokinet 2017; 43:155-170. [DOI: 10.1007/s13318-017-0439-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Bellmann R. [Personalised pharmacotherapy in intensive care unit patients]. Med Klin Intensivmed Notfmed 2017; 112:289-294. [PMID: 28466289 DOI: 10.1007/s00063-017-0284-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 01/10/2023]
Abstract
Critically ill patients need fast, effective and safe pharmacotherapy. The pharmacokinetics and pharmacodynamics of the administered drugs are influenced by numerous individual conditions. Genetic factors mainly determines drug metabolism. However, therapeutic decisions are not yet guided by genetic analyses. In elderly patients, the volume of distribution can be altered and renal elimination may be delayed. Drug-drug interactions involving current medications can increase the incidence of adverse effects from treatment in the intensive care unit. In early severe sepsis, plasma levels of water-soluble drugs can be decreased because of enhanced volume of distribution and increased renal clearance. Later on, drug elimination can be impaired by deterioration of liver and renal function. Furthermore, the pharmacokinetic effects of continuous renal replacement therapy have to be considered. Plasma levels of critically ill patients show increased variability in comparison with healthy subjects or other patient groups. The therapeutic effect of antibiotics and of many other drugs cannot be assessed immediately. As dosage of these medications cannot be guided by their clinical efficacy, insufficient exposure or overdosage accompanied by toxic side effects may result. Standard dose recommendations that were developed in healthy volunteers or noncritically ill patients must be adapted to individual conditions and requirements of critically ill patients.
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Affiliation(s)
- R Bellmann
- Arbeitsgruppe Klinische Pharmakokinetik, Labor für Inflammationsforschung, Gemeinsame Einrichtung Internistische Notfall- und Intensivmedizin, Department Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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Usman M, Frey OR, Hempel G. Population pharmacokinetics of meropenem in elderly patients: dosing simulations based on renal function. Eur J Clin Pharmacol 2016; 73:333-342. [PMID: 27966034 DOI: 10.1007/s00228-016-2172-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate different dosage regimens of meropenem in elderly patients in relation with renal function using a population pharmacokinetic (popPK) model. METHODS The data of 178 elderly patients treated with meropenem was collected from different sources. A popPK model was developed by using NONMEM® and the influence of different covariates on meropenem CL and V1 was observed. Monte Carlo dosing simulations were performed at steady state to observe the % T > MIC for targets of 40, 60 and 80% of dosage intervals at different levels of creatinine clearance (CLCR). RESULTS The data was described by a two-compartment model and the values of parameter estimates for CL, V1, Q and V2 were 5.27 L/h, 17.2 L, 9.92 L/h and 10.6 L, respectively. The CLCR, body weight and centre had a significant influence on meropenem CL while no direct influence of age was observed. Extended infusions had pharmacokinetic and pharmacodynamic (PK/PD) breakpoint one dilution greater than corresponding short infusion regimens for each target of % T > MIC. CONCLUSION Meropenem CL was significantly lower in the elderly compared to CL reported in younger patients due to the reduced renal function. An extended infusion of 1000 mg q8h can be considered for empirical treatment of infections in elderly patients when CLCR is ≤ 50 mL/min. A continuous infusion of 3000 mg daily dose is preferred if CLCR > 50 mL/min. However, a higher daily dose of meropenem would be required for resistant strains (MIC >8 mg/L) of bacteria if CLCR is >100 mL/min.
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Affiliation(s)
- Muhammad Usman
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Otto R Frey
- Department of Pharmacy, Hospital of Heidenheim, Heidenheim, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.
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Population Pharmacokinetics and Pharmacodynamics Modeling To Optimize Dosage Regimens of Sulbactam in Critically Ill Patients with Severe Sepsis Caused by Acinetobacter baumannii. Antimicrob Agents Chemother 2016; 60:7236-7244. [PMID: 27671056 DOI: 10.1128/aac.01669-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/12/2016] [Indexed: 01/02/2023] Open
Abstract
Sulbactam is being considered as an alternative concomitant medication with other effective antibiotics for the treatment of multidrug-resistant (MDR) Acinetobacter baumannii infections. Pathophysiological changes in critically ill patients with severe sepsis, resulting in altered pharmacokinetic (PK) patterns for antibiotics, are important factors in determining therapeutic success. The aims of this study were (i) to examine the population PK parameters and (ii) to assess the probability of target attainment (PTA) for sulbactam in patients with severe sepsis caused by A. baumannii PK studies were carried out following administration of 2 g of sulbactam every 12 h on the 4th day of drug administration in 27 patients, and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the plasma drug concentration remained above the MIC (T>MIC) and 60% T>MIC The central and peripheral volumes of distribution were 14.56 and 9.55 liters, respectively, and total clearances of sulbactam were 2.26 liters/h and 7.64 liters/h in patients aged >65 years and ≤65 years, respectively. The high PTAs (≥90%) for targets of 40% T>MIC and 60% T>MIC with a MIC of 4 μg/ml were observed when sulbactam was administered by a 4-h infusion of 1 g every 12 h and 1 g every 8 h, respectively. Sulbactam would be an alternative antibiotic option to coadminister with colistin for the treatment of infections caused by MDR A. baumannii However, for pathogens with MICs of >4 μg/ml, higher dosage regimens of sulbactam are required.
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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50
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Veillette JJ, Winans SA, Forland SC, Maskiewicz VK. A simple and rapid RP-HPLC method for the simultaneous determination of piperacillin and tazobactam in human plasma. J Pharm Biomed Anal 2016; 131:80-86. [DOI: 10.1016/j.jpba.2016.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/08/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
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