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Gandéga H, Poujol H, Mezzarobba M, Muller L, Boyer JC, Lefrant JY, Leguelinel G, Roger C. Determinants of beta-lactam PK/PD target attainment in critically ill patients: A single center retrospective study. J Crit Care 2024; 83:154828. [PMID: 38759580 DOI: 10.1016/j.jcrc.2024.154828] [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] [Received: 01/22/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE We aimed to identify factors associated with achieving target BL plasma concentrations and describe real world data for therapeutic drug monitoring (TDM). METHODS A retrospective single center study was conducted. We collected data from patients admitted to ICU with at least one BL TDM. We assessed the proportion of patients attaining the recommended plasma concentrations (i.e 100%fT > 4 to 8 MIC). Univariate and multivariate analyses was performed to identify the determinants of BL target attainment. RESULTS 156 patients were included. At the first dosing, 34% achieved target BL plasma concentrations, 50% were overdosed, and 16% were underdosed. Median time for 1st TDM were 4 (SD = 2.9) days. Multivariate analysis revealed that CKD-EPI estimated glomerular filtration rate (OR = 1.02; CI [1.01; 1.03]; p < 0.0001) and total body weight (OR = 1.03; CI [1.01; 1.04]; p = 0.0048) were the main determinant of BL target attainment. Conversely, Continuous Renal Replacement Therapy (OR = 0.28; CI [0.09; 0.89]; p = 0.0318) and meropenem use (OR = 0.31; CI [0.14; 0.69]; p = 0.0041) were identified as risk factors for overdosing. No factor was associated with underdosing. CONCLUSION Achieving target BL plasma concentrations remains challenging in ICUs. Identifying predictive factors of BL target attainment would favor implementing rapid dosing optimization strategies in both under and overdosing high risk patients.
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Affiliation(s)
- H Gandéga
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France
| | - H Poujol
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - M Mezzarobba
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University of Montpellier, Nîmes, France
| | - L Muller
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - J C Boyer
- Department of toxicity and biochemistry, Nimes University Hospital, Nimes, France
| | - J Y Lefrant
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - G Leguelinel
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES, EA 2415, University of Montpellier, Montpellier, France
| | - C Roger
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France.
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2
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Brenkman M, Cartau T, Pape E, Kolodziej A, Charmillon A, Novy E, Jouzeau JY, Gambier N, Scala-Bertola J. In vitro stability study of 10 beta-lactam antibiotics in human plasma samples. Fundam Clin Pharmacol 2024; 38:502-510. [PMID: 37985813 DOI: 10.1111/fcp.12969] [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] [Received: 10/06/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Beta-lactam antibiotics are reported for some of them to be subject to a rapid degradation in infusion solutions and in human blood samples. However, the current data of stability available in blood samples are limited to a few number of beta-lactam antibiotics, and the methodology of the corresponding studies may be discussed. The objective of the present study is to evaluate the stability of 10 beta-lactam antibiotics in human plasma samples. METHODS Stability of amoxicillin, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, imipenem, meropenem, and piperacillin was evaluated at low and high concentrations at 20°C, 4°C, -20°C, and -80°C for 1, 7, 60, and 90 days, respectively. RESULTS Amoxicillin, cefepime, meropenem, and piperacillin were the least stable antibiotics. The maximum durations allowing the stability for all the evaluated beta-lactams at both tested concentrations were estimated at 3 h, 23 h, 10 days, and 35 days at 20°C, 4°C, -20°C, and -80°C, respectively. CONCLUSION We recommend to transport antibiotic plasma samples in ice at 4°C and even at -20°C if these samples come from external hospitals. Ideally, plasma samples should be stored at -80°C if possible; if not, the analysis of the samples should be performed as soon as possible in the limit of 10 days after a storage at -20°C.
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Affiliation(s)
- Matthieu Brenkman
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
| | - Tom Cartau
- Department of Infectious and Tropical Diseases, CHU-Caen, Caen, France
| | - Elise Pape
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
- CNRS, IMoPA, Université de Lorraine, Nancy, France
| | - Allan Kolodziej
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
| | | | - Emmanuel Novy
- CHRU-Nancy, Intensive Care Units, Université de Lorraine, Nancy, France
- SIMPA, Université de Lorraine, Nancy, France
| | - Jean-Yves Jouzeau
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
- CNRS, IMoPA, Université de Lorraine, Nancy, France
| | - Nicolas Gambier
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
- CNRS, IMoPA, Université de Lorraine, Nancy, France
| | - Julien Scala-Bertola
- CHRU-Nancy, Department of Clinical Pharmacology and Toxicology, Université de Lorraine, Nancy, France
- CNRS, IMoPA, Université de Lorraine, Nancy, France
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3
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Pai Mangalore R, Udy AA, Peel TN, Peleg AY, Ayton D. Implementation Strategies Addressing Stakeholder-Perceived Barriers and Enablers to the Establishment of a Beta-Lactam Antibiotic Therapeutic Drug Monitoring Program: A Qualitative Analysis. Ther Drug Monit 2024; 46:351-362. [PMID: 38018820 DOI: 10.1097/ftd.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of beta-lactam antibiotics (beta-lactams) is increasingly recommended for optimizing antibiotic exposure in intensive care patients with sepsis. However, limited data are available on the implementation of beta-lactam TDM in complex health care settings. Theory-based approaches were used to systematically explore barriers and enablers perceived by key stakeholders in the implementation of beta-lactam TDM in the intensive care unit. METHODS In this qualitative descriptive study, the authors interviewed key stakeholders (n = 40): infectious disease physicians, intensive care unit physicians, pharmacists, clinical leaders, scientists, and nurses. The data were thematically analyzed and coded using the theoretical domains framework, and the codes and themes were mapped to the relevant domains of the capability, opportunity, and motivation behavior-change wheel model. RESULTS Barriers included a lack of knowledge, experience, evidence, and confidence, which led to concerns about capability, lack of resources, and harm in straying from standard practice. Access to education and guidelines, on-site assays with short turnaround times, communication among teams, and workflow integration were identified as enablers. A focus on patient care, trust in colleagues, and endorsement by hospital leaders were strong motivators. Pharmacist and nursing stakeholder groups emerged as key targets in the implementation of strategies. CONCLUSIONS Using theory-based approaches, the authors identified the key barriers and enablers to establishing beta-lactam TDM. These data were used to identify strategies, policies, and key target groups for the implementation of interventions.
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Affiliation(s)
- Rekha Pai Mangalore
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Alexander Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and
| | - Trisha Nicole Peel
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anton Yariv Peleg
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and
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4
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Monti G, Bradić N, Marzaroli M, Konkayev A, Fominskiy E, Kotani Y, Likhvantsev VV, Momesso E, Nogtev P, Lobreglio R, Redkin I, Toffoletto F, Bruni A, Baiardo Redaelli M, D’Andrea N, Paternoster G, Scandroglio AM, Gallicchio F, Ballestra M, Calabrò MG, Cotoia A, Perone R, Cuffaro R, Montrucchio G, Pota V, Ananiadou S, Lembo R, Musu M, Rauch S, Galbiati C, Pinelli F, Pasin L, Guarracino F, Santarpino G, Agrò FE, Bove T, Corradi F, Forfori F, Longhini F, Cecconi M, Landoni G, Bellomo R, Zangrillo A. Continuous vs Intermittent Meropenem Administration in Critically Ill Patients With Sepsis: The MERCY Randomized Clinical Trial. JAMA 2023; 330:141-151. [PMID: 37326473 PMCID: PMC10276329 DOI: 10.1001/jama.2023.10598] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
Importance Meropenem is a widely prescribed β-lactam antibiotic. Meropenem exhibits maximum pharmacodynamic efficacy when given by continuous infusion to deliver constant drug levels above the minimal inhibitory concentration. Compared with intermittent administration, continuous administration of meropenem may improve clinical outcomes. Objective To determine whether continuous administration of meropenem reduces a composite of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria compared with intermittent administration in critically ill patients with sepsis. Design, Setting, and Participants A double-blind, randomized clinical trial enrolling critically ill patients with sepsis or septic shock who had been prescribed meropenem by their treating clinicians at 31 intensive care units of 26 hospitals in 4 countries (Croatia, Italy, Kazakhstan, and Russia). Patients were enrolled between June 5, 2018, and August 9, 2022, and the final 90-day follow-up was completed in November 2022. Interventions Patients were randomized to receive an equal dose of the antibiotic meropenem by either continuous administration (n = 303) or intermittent administration (n = 304). Main Outcomes and Measures The primary outcome was a composite of all-cause mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. There were 4 secondary outcomes, including days alive and free from antibiotics at day 28, days alive and free from the intensive care unit at day 28, and all-cause mortality at day 90. Seizures, allergic reactions, and mortality were recorded as adverse events. Results All 607 patients (mean age, 64 [SD, 15] years; 203 were women [33%]) were included in the measurement of the 28-day primary outcome and completed the 90-day mortality follow-up. The majority (369 patients, 61%) had septic shock. The median time from hospital admission to randomization was 9 days (IQR, 3-17 days) and the median duration of meropenem therapy was 11 days (IQR, 6-17 days). Only 1 crossover event was recorded. The primary outcome occurred in 142 patients (47%) in the continuous administration group and in 149 patients (49%) in the intermittent administration group (relative risk, 0.96 [95% CI, 0.81-1.13], P = .60). Of the 4 secondary outcomes, none was statistically significant. No adverse events of seizures or allergic reactions related to the study drug were reported. At 90 days, mortality was 42% both in the continuous administration group (127 of 303 patients) and in the intermittent administration group (127 of 304 patients). Conclusions and Relevance In critically ill patients with sepsis, compared with intermittent administration, the continuous administration of meropenem did not improve the composite outcome of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. Trial Registration ClinicalTrials.gov Identifier: NCT03452839.
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Affiliation(s)
- Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Nikola Bradić
- Clinical Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
- University North, Varazdin, Croatia
| | - Matteo Marzaroli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aidos Konkayev
- National Scientific Center of Traumatology and Orthopedia named acad NBatpenov, Astana Medical University, Astana, Kazakhstan
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Kameda Medical Center, Kamogawa, Japan
| | | | - Elena Momesso
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Pavel Nogtev
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Ivan Redkin
- Federal Research and Clinical Center of Resuscitation and Rehabilitation, Moscow, Russia
| | - Fabio Toffoletto
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Natascia D’Andrea
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | | | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Romina Perone
- Department of Cardio Thoracic and Vascular Surgery, Pineta Grande Hospital, Pineta Grande, Italy
| | - Raffaele Cuffaro
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgia Montrucchio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Vincenzo Pota
- Università della Campania L. Vanvitelli, Napoli, Italy
| | | | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Musu
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy
- Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Simon Rauch
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of Merano, Merano, Italy
| | - Carola Galbiati
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fulvio Pinelli
- Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Laura Pasin
- Azienda Ospedale Università Padova, Padua, Italy
| | - Fabio Guarracino
- Dipartimento Anestesia e Rianimazione, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giuseppe Santarpino
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
- GVM Care and Research, Department of Cardiac Surgery, Città di Lecce Hospital, Lecce, Italy
- Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Felice Eugenio Agrò
- Research Unit of Anesthesia and Intensive Care, Department of Medicine and Surgery, Università Campus Bio-Medico, Rome, Italy
- Operative Research Unit of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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5
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Novy E, Martinière H, Roger C. The Current Status and Future Perspectives of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12040681. [PMID: 37107043 PMCID: PMC10135361 DOI: 10.3390/antibiotics12040681] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Beta-lactams (BL) are the first line agents for the antibiotic management of critically ill patients with sepsis or septic shock. BL are hydrophilic antibiotics particularly subject to unpredictable concentrations in the context of critical illness because of pharmacokinetic (PK) and pharmacodynamics (PD) alterations. Thus, during the last decade, the literature focusing on the interest of BL therapeutic drug monitoring (TDM) in the intensive care unit (ICU) setting has been exponential. Moreover, recent guidelines strongly encourage to optimize BL therapy using a PK/PD approach with TDM. Unfortunately, several barriers exist regarding TDM access and interpretation. Consequently, adherence to routine TDM in ICU remains quite low. Lastly, recent clinical studies failed to demonstrate any improvement in mortality with the use of TDM in ICU patients. This review will first aim at explaining the value and complexity of the TDM process when translating it to critically ill patient bedside management, interpretating the results of clinical studies and discussion of the points which need to be addressed before conducting further TDM studies on clinical outcomes. In a second time, this review will focus on the future aspects of TDM integrating toxicodynamics, model informed precision dosing (MIPD) and “at risk” ICU populations that deserve further investigations to demonstrate positive clinical outcomes.
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Affiliation(s)
- Emmanuel Novy
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur Et Des Vaisseaux, University Hospital of Nancy, Rue du Morvan, 54511 Vandoeuvre-les Nancy, France
- SIMPA, UR 7300, Faculté de Médecine, Maïeutique et Métiers de la Santé, Campus Brabois Santé, University of Lorraine, 54000 Nancy, France
| | - Hugo Martinière
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 30029 Nimes, France
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6
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Zhou P, Cheng Y, Cao G, Xing Y, Zhai S, Tong X, Yang K. The OBTAINS study: A nationwide cross-sectional survey on the implementation of extended or continuous infusion of β-lactams and vancomycin among neonatal sepsis patients in China. Front Pharmacol 2022; 13:1001924. [PMID: 36299905 PMCID: PMC9589050 DOI: 10.3389/fphar.2022.1001924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/23/2022] [Indexed: 01/03/2023] Open
Abstract
Background: Dosing strategies of β-lactams and vancomycin should be optimized according to pharmacokinetic/pharmacodynamic principles. However, there is no available data indicating the implementation of extended infusion (EI) or continuous infusion (CI) administration in the management of neonatal sepsis. Methods: A nationwide cross-sectional survey was conducted and the pediatricians from 31 provinces in China were enrolled. A multidisciplinary team created the questionnaire, which had three sections and a total of 21 questions with open- and closed-ended responses. The survey was then conducted using an internet platform in an anonymous way. The data was eventually gathered, compiled, and examined. To identify the risk factors associated with the implementation of EI/CI, logistic regression was carried out. Results: A total of 1501 respondents answered the questionnaires. The implementation of EI/CI of β-lactams and vancomycin were only available to one-third of the respondents, and the prolonged strategy was primarily supported by guidelines (71.25%) and advice from medical specialists (55.18%). A significant fraction (72.94%-94.71%) lacked a strong understanding of the infusions' stability. Additionally, it was discovered that more frequent MDT discussions about antibiotic use and the appropriate time pediatricians worked in the neonatal ward were associated with an increase in the use of the EI/CI strategy. Conclusion: The EI/CI strategy in neonatal sepsis was not well recognized in China, and it is necessary to establish a solid MDT team with regularly collaborates. In the near future, guidelines regarding prolonged infusion management in neonatal sepsis should be developed.
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Affiliation(s)
- Pengxiang Zhou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yinchu Cheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Guangna Cao
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
| | - Kehu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China,*Correspondence: Kehu Yang, ; Xiaomei Tong,
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7
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Tritscher P, Delannoy M, Agrinier N, Charmillon A, Degand N, Dellamonica J, Roger C, Leone M, Scala-Bertola J, Novy E. Assessment of current practice for β-lactam therapeutic drug monitoring in French ICUs in 2021: a nationwide cross-sectional survey. J Antimicrob Chemother 2022; 77:2650-2657. [PMID: 36059108 DOI: 10.1093/jac/dkac291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current guidelines and literature support the use of therapeutic drug monitoring (TDM) to optimize β-lactam treatment in adult ICU patients. OBJECTIVES To describe the current practice of β-lactam monitoring in French ICUs. METHODS A nationwide cross-sectional survey was conducted from February 2021 to July 2021 utilizing an online questionnaire that was sent as an email link to ICU specialists (one questionnaire per ICU). RESULTS Overall, 119 of 221 (53.8%) French ICUs participated. Eighty-seven (75%) respondents reported having access to β-lactam TDM, including 52 (59.8%) with on-site access. β-Lactam concentrations were available in 24-48 h and after 48 h for 36 (41.4%) and 26 (29.9%) respondents, respectively. Most respondents (n = 61; 70.1%) reported not knowing whether the β-lactam concentrations in the TDM results were expressed as unbound fractions or total concentrations. The 100% unbound fraction of the β-lactam above the MIC was the most frequent pharmacokinetic and pharmacodynamic target used (n = 62; 73.0%). CONCLUSIONS Despite the publication of international guidelines, β-lactam TDM is not optimally used in French ICUs. The two major barriers are β-lactam TDM interpretation and the required time for results.
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Affiliation(s)
- Perrine Tritscher
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France
| | - Matthieu Delannoy
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France
| | - Nelly Agrinier
- Université de Lorraine, APEMAC, F-54000 Nancy, France.,CHRU-Nancy, INSERM, Université de Lorraine, CIC, Épidémiologie Clinique, F-54000 Nancy, France
| | - Alexandre Charmillon
- Université de Lorraine, CHRU-Nancy, Service de maladies infectieuses, coordonnateur équipe transversale en infectiologie, F-54000 Nancy, France
| | - Nicolas Degand
- Centre Hospitalier d'Antibes Juan les Pins, Service de Biologie, F-06600 Antibes, France
| | - Jean Dellamonica
- Université de Nice Cote d'Azur, CHU de Nice, Service de médecine intensive et réanimation, F-06202 Nice, France.,UR2CA Unité de Recherche Clinique Côte d'Azur, Université Cote d'Azur, F-06202 Nice, France
| | - Claire Roger
- CHU Nîmes, Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, F-30000 Nîmes, France.,UR UM 103 IMAGINE, Université de Montpellier, F-34090 Montpellier, France
| | - Marc Leone
- Aix Marseille Université, APHM, Hôpital Nord, Service d'anesthésie et de Réanimation, F-13015 Marseille, France
| | - Julien Scala-Bertola
- Université de Lorraine, CHRU-Nancy, Service de pharmacologie Clinique et toxicologie, F-54000 Nancy, France.,Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France
| | - Emmanuel Novy
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France.,Université de Lorraine, SIMPA, F-54000 Nancy, France
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8
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Ewoldt TMJ, Abdulla A, van den Broek P, Hunfeld N, Bahmany S, Muller AE, Gommers D, Polinder S, Endeman H, Spronk I, Koch BCP. Barriers and facilitators for therapeutic drug monitoring of beta-lactams and ciprofloxacin in the ICU: a nationwide cross-sectional study. BMC Infect Dis 2022; 22:611. [PMID: 35831793 PMCID: PMC9277596 DOI: 10.1186/s12879-022-07587-w] [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: 12/29/2021] [Accepted: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
Background Recent studies demonstrated that failure of achieving pharmacodynamic targets of commonly used antibiotics is common in critically ill patients. Therapeutic drug monitoring (TDM) can contribute to optimize the exposure of beta-lactams and ciprofloxacin. While evidence for TDM of these antibiotics is growing, translation into clinical implementation remains limited. Therefore, perceived barriers and facilitators are important for implementing TDM in this population. The primary aim of this study was to identify healthcare professionals’ barriers and facilitators for the implementation of TDM of beta-lactams and ciprofloxacin in Dutch intensive care units (ICU). Methods We conducted a nationwide cross-sectional online survey among healthcare professionals (HCPs) involved in antibiotic treatment of ICU patients. An adapted version of the Measurement Instrument for Determinants of Innovations was sent out. Items were considered barriers when ≥ 20% of participants responded with a negative answer. If ≥ 80% of the participants responded with a positive answer, the item was considered a facilitator. Results Sixty-four HCPs completed the survey, of which 14 were from academic hospitals, 25 from general hospitals, and 25 from teaching hospitals. Most participants were hospital pharmacists (59%) or medical specialists (23%). Eleven barriers and four facilitators for implementation of TDM of beta-lactams were identified; 17 barriers for TDM of ciprofloxacin and no facilitators. The most important barriers were a lack of conclusive evidence, organizational support, and low availability of assays. Additional barriers were a lack of consensus on which specific patients to apply TDM and which pharmacodynamic targets to use. Identified facilitators for beta-lactam TDM implementation are low complexity and high task perception, combined with the perception that TDM is important to prevent side effects and to adequately treat infections. Twenty-eight percent of participants reported that flucloxacillin could be analyzed in their hospital. Assay availability of other beta-lactams and ciprofloxacin was lower (3–17%). Conclusion Several barriers were identified that could obstruct the implementation of TDM of beta-lactams and ciprofloxacin in the ICU. In particular, education, clear guidelines, and organizational support should be considered when creating tailored implementation strategies. Finally, evidence of beneficial clinical outcomes on TDM of beta-lactams and ciprofloxacin can enhance further implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07587-w.
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Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands. .,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Nicole Hunfeld
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Soma Bahmany
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Inge Spronk
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part I: focused on acute kidney injury. Expert Rev Clin Pharmacol 2022; 15:551-561. [PMID: 35734940 DOI: 10.1080/17512433.2022.2093713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article, we searched PubMed, Scopus, and Google Scholar for estimating renal function in acute kidney injury, nephrotoxicity of commonly used antibiotics, and nephrotoxin stewardship in intensive care units. EXPERT OPINION Early estimation of kidney function with an accurate method may be helpful to optimize antimicrobial treatment in critically ill patients. Different antibiotic dosing regimens may be required for patients with acute kidney injury. In many low-resource settings, therapeutic drug monitoring is not available for antibiotics. Acute kidney injury may influence treatment effectiveness and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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10
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Seraissol P, Lanot T, Baklouti S, Mané C, Ruiz S, Lavit M, De Riols P, Garrigues JC, Gandia P. Evaluation of 4 quantification methods for monitoring 16 antibiotics and 1 beta-lactamase inhibitor in human serum by high-performance liquid chromatography with tandem mass spectrometry detection. J Pharm Biomed Anal 2022; 219:114900. [PMID: 35752026 DOI: 10.1016/j.jpba.2022.114900] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Antibiotic (ATB) prescription in an intensive care unit (ICU) requires continuous monitoring of serum dosages due to the patient's pathophysiological condition. Dosing adjustment is necessary to achieve effective targeted concentrations. Since ICUs routinely use a large number of ATBs, global monitoring needs to be developed. In the present study, we developed a global analytical method for extracting, separating and quantifying the most widely used ATBs in ICUs: amoxicillin, piperacillin, cefazolin, cefepime, cefotaxime, ceftazidime, ceftolozane, ceftriaxone, ertapenem, meropenem, ciprofloxacin, moxifloxacin, levofloxacin, daptomycin, dalbavancin, linezolid and a beta-lactamase inhibitor: tazobactam. To guarantee the robustness of the quantification, we differentiated the 16 ATBs and the beta lactamase inhibitor into 4 pools (ATB1 to ATB4), taking into account prescription frequency in the ICU, the physicochemical properties and the calibration ranges of the ATBs selected. The whole ATB was then separated with two LC columns in reversed phase: Kinetex Polar-C18 100 Å and Polar-RP-80 synergy, in less than 6.5 min. Detection was carried out by electrospray in positive ion mode, by tandem mass spectrometry (LC-MS/MS. The four quantification methods were validated according to the European guidelines on bioanalytical method validation (EMEA guide), after determining the extraction yields, matrix effects, recovery, precision, accuracy, within-run precision and between-run precision. For all analyses, bias is < 15% and is comparable to the literature and LOQs vary from 0.05 mg.L-1 for ciprofloxacin to 1.00 mg.L-1 for ceftriaxone and dalbavancin. The stability time of cefepime and piperacillin is 3 hrs and for the other ATBs 6 hrs in serum at room temperature. For long-term stability, freezing at - 80 °C guarantees 3 months of stability for ceftriaxone and dalbavancin and more than 6 months for the other ATBs.
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Affiliation(s)
- Patrick Seraissol
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France; Laboratoire Départemental 31, Eau - Vétérinaire - Air, 76 chemin de Boudou, CS 50013, 31140 Launaguet, France
| | - Thomas Lanot
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Sarah Baklouti
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Camille Mané
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Stéphanie Ruiz
- Service de Réanimation Polyvalente Adulte, Hôpital Rangueil, 1 avenue du Professeur Jean Poulhès, 31059 Toulouse Cedex 9, France
| | - Michel Lavit
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Pascale De Riols
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Jean-Christophe Garrigues
- Laboratoire des IMRCP, Université de Toulouse, UMR 5623, 118 Route de Narbonne, 31062 Toulouse Cedex 9, France.
| | - Peggy Gandia
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France; INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, 31 076 Toulouse Cedex 3, France
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11
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Sember AM, LoFaso ME, Lewis SJ. Author response: "An optimal extended-infusion dosing of cefepime and ceftazidime in critically ill patients with continuous renal replacement therapy". J Crit Care 2022; 70:154059. [PMID: 35568021 DOI: 10.1016/j.jcrc.2022.154059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Affiliation(s)
| | - Megan E LoFaso
- University of Findlay College of Pharmacy, Findlay, OH, USA
| | - Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA; Department of Pharmacy, Mercy Health - St. Anne Hospital, Toledo, OH, USA.
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12
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Marti C, Stirnemann J, Lescuyer P, Tonoli D, von Dach E, Huttner A. Therapeutic drug monitoring and clinical outcomes in severely ill patients receiving amoxicillin: a single-center prospective cohort study. Int J Antimicrob Agents 2022; 59:106601. [DOI: 10.1016/j.ijantimicag.2022.106601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/07/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022]
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13
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Chen C, Seabury RW, Steele JM, Parsels KA, Darko W, Miller CD, Kufel WD. Evaluation of β-lactam therapeutic drug monitoring among US health systems with postgraduate year 2 infectious diseases pharmacy residency programs. Am J Health Syst Pharm 2022; 79:1273-1280. [PMID: 35439284 DOI: 10.1093/ajhp/zxac117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE While some guidelines recognize the need for β-lactam therapeutic drug monitoring (TDM), there is still a paucity of data regarding the prevalence of and barriers to performing β-lactam TDM in the United States. We sought to estimate the prevalence of β-lactam TDM, describe monitoring practices, and identify actual and perceived barriers to implementation among health systems in the US. METHODS A multicenter, cross-sectional, 40-item electronic survey was distributed to all postgraduate year 2 (PGY2) infectious diseases (ID) pharmacy residency program directors (RPDs) listed in the American Society of Health-System Pharmacists pharmacy residency directory. The primary outcome was the percentage of institutions with established β-lactam TDM. Secondary outcomes included assessing β-lactam TDM methods and identifying potential barriers to implementation. RESULTS The survey was distributed to 126 PGY2 ID RPDs, with a response rate of 31.7% (40 of 126). Only 7.7% of respondents (3 of 39) performed β-lactam TDM. Patient populations, therapeutic targets, and frequency and timing of obtaining repeat β-lactam concentration measurements varied among institutions. The greatest barrier to implementation was lack of access to testing with a rapid turnaround time. Institutions were unlikely to implement β-lactam TDM within the next year but were significantly more inclined to do so within 5 years (P < 0.001). CONCLUSION Β-lactam TDM was infrequently performed at the surveyed US health systems. Lack of access to serum concentration testing with rapid turnaround and lack of US-specific guidelines appear to be considerable barriers to implementing β-lactam TDM. Among institutions that have implemented β-lactam TDM, there is considerable variation in monitoring approaches.
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Affiliation(s)
- Chieh Chen
- State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Robert W Seabury
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Katie A Parsels
- State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - William Darko
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Christopher D Miller
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Wesley D Kufel
- State University of New York Upstate University Hospital, Syracuse, NY, State University of New York Upstate Medical University, Syracuse, NY, and Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
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14
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Abdulla A, van den Broek P, Ewoldt TMJ, Muller AE, Endeman H, Koch BCP. Barriers and Facilitators in the Clinical Implementation of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: A Critical Review. Ther Drug Monit 2022; 44:112-120. [PMID: 34798631 DOI: 10.1097/ftd.0000000000000937] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increasing knowledge of beta-lactam pharmacodynamics and interpatient and intrapatient variability in pharmacokinetics, the usefulness of therapeutic drug monitoring (TDM) is becoming increasingly clear. However, little research has been conducted to identify potential barriers and facilitators in the clinical implementation of beta-lactam TDM. This study provides an overview of the current practices of beta-lactam TDM and barriers and facilitators in its implementation. METHODS A systematic search was conducted using the Ovid MEDLINE database in April 2021, without restrictions on the publication date. All studies reporting the implementation of beta-lactam antibiotic TDM in critically ill patients through questionnaires or surveys were included in this review. RESULTS Six eligible studies were identified from 215 records, all of which were cross-sectional. All studies identified barriers and facilitators in the implementation of beta-lactam TDM in critically ill patients. The main barriers were insufficient knowledge about various aspects regarding the implementation of beta-lactam TDM and the unavailability of assays. Furthermore, a delay in the acquisition of TDM results reduces the probability of physicians altering drug dosages. Finally, doubts about the cost-effectiveness and clinical effectiveness of beta-lactam TDM in critically ill patients hinder broad implementation. Moreover, to improve the willingness of physicians to use beta-lactam TDM, collaboration between physicians and clinical pharmacists and clinical microbiologists should be strengthened. CONCLUSIONS Although the evidence for application of beta-lactam TDM continues to grow, its clinical implementation remains limited. To enable optimal implementation of these antibiotics in critically ill patients, several barriers need to be overcome regarding logistics, equipment availability, clinical evidence, and proof of cost-effectiveness.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Puck van den Broek
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Adult Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, the Netherlands; and
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Henrik Endeman
- Department of Adult Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
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15
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Matusik E, Lemtiri J, Wabont G, Lambiotte F. Beta-lactam dosing during continuous renal replacement therapy: a survey of practices in french intensive care units. BMC Nephrol 2022; 23:48. [PMID: 35093011 PMCID: PMC8800323 DOI: 10.1186/s12882-022-02678-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/15/2022] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Little information is available on current practice in beta-lactam dosing during continuous renal replacement therapy (CRRT). Optimized dosing is essential for improving outcomes, and there is no consensus on the appropriate dose regimens. The objective of the present study was to describe current practice for beta-lactam dosing during CRRT in intensive care units (ICUs).
Methods
We conducted a nationwide survey by e-mailing an online questionnaire to physicians working in ICUs in France. The questionnaire included three sections: demographic characteristics, CRRT practices, and beta-lactam dosing regimens during CRRT.
Results
157 intensivists completed the questionnaire. Continuous venovenous hemofiltration was the most frequently used CRRT technique, and citrate was the most regularly used anticoagulant. The median prescribed dose at baseline was 30 mL/kg/h. The majority of prescribers (57%) did not reduce beta-lactam dosing during CRRT. The tools were used to adapt dosing regimens during CRRT included guidelines, therapeutic drug monitoring (TDM), and data from the literature. When TDM was used, 100% T > 4 time the MIC was the most common mentioned pharmacokinetic/pharmacodynamic target (53%). Pharmacokinetic software tools were rarely used. Prolonged or continuous infusions were widely used during CRRT (88%). Institutional guidelines on beta-lactam dosing during CRRT were rare. 41% of physicians sometimes consulted another specialist before adapting the dose of antibiotic during CRRT.
Conclusions
Our present results highlight the wide range of beta-lactam dosing practices adopted during CRRT. Personalized TDM and the implementation of Bayesian software appear to be essential for optimizing beta-lactam dosing regimens and improving patient outcomes.
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Quantitative Determination of Unbound Piperacillin and Imipenem in Biological Material from Critically Ill Using Thin-Film Microextraction-Liquid Chromatography-Mass Spectrometry. Molecules 2022; 27:molecules27030926. [PMID: 35164191 PMCID: PMC8839241 DOI: 10.3390/molecules27030926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
β-Lactam antibiotics are most commonly used in the critically ill, but their effective dosing is challenging and may result in sub-therapeutic concentrations that can lead to therapy failure and even promote antimicrobial resistance. In this study, we present the analytical tool enabling specific and sensitive determination of the sole biologically active fraction of piperacillin and imipenem in biological material from the critically ill. Thin-film microextraction sampling technique, followed by rapid liquid chromatography–tandem mass spectrometry (LC-MS/MS) analysis, was optimized and validated for the quantitative determination of antibiotics in blood and bronchoalveolar lavage (BAL) specimens collected from intensive care unit (ICU) patients suffering from ventilation-associated pneumonia (n = 18 and n = 9, respectively). The method was optimized and proved to meet the criteria of US Food and Drug Administration (FDA) guidelines for bioanalytical method validation. Highly selective, sensitive, accurate and precise analysis by means of thin-film microextraction–LC-MS/MS, which is not affected by matrix-related factors, was successfully applied in clinical settings, revealing poor penetration of piperacillin and imipenem from blood into BAL fluid (reflecting the site of bacterial infection), nonlinearity in antibiotic binding to plasma-proteins and drug-specific dependence on creatinine clearance. This work demonstrates that only a small fraction of biologically active antibiotics reach the site of infection, providing clinicians with a high-throughput analytical tool for future studies on personalized therapeutic drug monitoring when tailoring the dosing strategy to an individual patient.
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Winiszewski H, Despres C, Puyraveau M, Lagoutte-Renosi J, Montange D, Besch G, Floury SP, Chaignat C, Labro G, Vettoretti L, Clairet AL, Capellier G, Vivet B, Piton G. β-lactam dosing at the early phase of sepsis: Performance of a pragmatic protocol for target concentration achievement in a prospective cohort study. J Crit Care 2021; 67:141-146. [PMID: 34768176 DOI: 10.1016/j.jcrc.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE We hypothesized that a protocol of standardized fixed dose using prolonged infusion during the early phase of sepsis may avoid insufficient β-lactam concentrations. METHODS In this single center prospective study, patients with sepsis and vasopressors were enrolled if they were treated by either piperacillin-tazobactam, meropenem or cefepime. Βeta-lactams were administered at fixed dose by prolonged infusion. Targeted plasma concentrations for piperacillin, meropenem and cefepime were above 80 mg/L, 8 mg/L and 38 mg/L respectively. Three blood samples were collected per patient over the first 48 h of treatment. Primary endpoint was target concentration achievement during the 48 first hours, defined as all plasma concentrations above the targeted threshold. RESULTS Among the 89 patients completing the three samples, target concentrations were achieved for 61 (69%). Target concentrations were achieved in 20 (53%), 32 (89%), and 9 (60%) of the patients treated with piperacillin, meropenem and cefepime, respectively. By multivariate analysis, lower APACHE 2 score, higher baseline MDRD creatinine clearance, and piperacillin use were independently associated with insufficient β-lactam concentrations. CONCLUSION Despite a fixed dose antibiotic administration protocol with prolonged infusion insufficient β-lactam concentration was frequent at the early phase of sepsis, especially in less severe patients, without renal failure, and treated with piperacillin. In septic patients with vasopressors, piperacillin dosing higher than 16 g may be needed to achieve the recommended target concentration. TRIAL REGISTRATION NCT02820987.
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Affiliation(s)
- Hadrien Winiszewski
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France.
| | - Cyrielle Despres
- Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Marc Puyraveau
- Methodology Unit, Clinical Investigation Center INSERM 1431, Besançon University Hospital, Besançon, France
| | | | - Damien Montange
- Pharmacology Unit, Besançon University Hospital, Besançon, France
| | - Guillaume Besch
- Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | | | | | - Guylaine Labro
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | - Lucie Vettoretti
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
| | | | - Gilles Capellier
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia
| | | | - Gael Piton
- Medical Intensive Care Unit, Besançon University Hospital, Besançon, France
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Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
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Administration and Therapeutic Drug Monitoring of β-lactams and Vancomycin in Critical Care Units in Colombia: The ANTIBIOCOL Study. Pharmaceutics 2021; 13:pharmaceutics13101577. [PMID: 34683870 PMCID: PMC8537979 DOI: 10.3390/pharmaceutics13101577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Therapeutic drug monitoring (TDM) and continuous infusion strategies are effective interventions in clinical practice, but these practices are still largely unknown in Colombia, especially in the critical care setting. This study aims to describe the practices involved in the administration and TDM of β-lactams and vancomycin reported by specialists in critical care in Colombia and to explore the factors that are related to the use of extended infusion. An online nationwide survey was applied to 153 specialists, who were selected randomly. A descriptive, bivariate analysis and a logistic regression model were undertaken. In total, 88.9% of the specialists reported TDM availability and 21.57% reported access to results within 6 h. TDM was available mainly for vancomycin. We found that 85.62% of the intensivists had some type of institutional protocol; however, only 39.22% had a complete and socialized protocol. The odds of preferring extended infusions among those who did not have institutional protocols were 80% lower than those with complete protocols, OR 0.2 (95% CI: 0.06−0.61). The most important perceived barriers to performing continuous infusions and TDM were the lack of training and technologies. This pioneering study in Colombia could impact the quality of care and outcomes of critically ill patients in relation to the threat of antimicrobial resistance.
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Sandaradura I, Alffenaar JW, Cotta MO, Daveson K, Day RO, Van Hal S, Lau C, Marriott DJE, Penm J, Roberts JA, Tabah A, Williams P, Imani S. Emerging therapeutic drug monitoring of anti-infective agents in Australian hospitals: Availability, performance and barriers to implementation. Br J Clin Pharmacol 2021; 88:669-679. [PMID: 34289135 DOI: 10.1111/bcp.14995] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS The purpose of the study was to assess the status of emerging therapeutic drug monitoring (TDM) of anti-infective agents in Australian hospitals. METHODS A nationwide cross-sectional survey of all Australian hospitals operating in the public and private health sector was conducted between August and September 2019. The survey consisted of questions regarding institutional TDM practice for anti-infective agents and clinical vignettes specific to β-lactam antibiotics. RESULTS Responses were received from 82 unique institutions, representing all Australian states and territories. All 29 (100%) of principal referral (major) hospitals in Australia participated. Five surveys were partially complete. Only 25% (20/80) of hospitals had TDM testing available on-site for any of the eight emerging TDM candidates considered: β-lactam antibiotics, anti-tuberculous agents, flucytosine, fluoroquinolones, ganciclovir, human immunodeficiency virus (HIV) drugs, linezolid and teicoplanin. A considerable time lag was noted between TDM sampling and reporting of results. With respect to β-lactam antibiotic TDM, variable indications, pharmacodynamic targets and sampling times were identified. The three greatest barriers to local TDM performance were found to be (1) lack of timely assays/results, (2) lack of institutional-wide expertise and/or training and (3) lack of guidelines to inform ordering of TDM and interpretation of results. The majority of respondents favoured establishing national TDM guidelines and increasing access to dose prediction software, at rates of 89% and 96%, respectively. CONCLUSION Translating emerging TDM evidence into daily clinical practice is slow. Concerted efforts are required to address the barriers identified and facilitate the implementation of standardised practice.
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Affiliation(s)
- Indy Sandaradura
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia.,Institute of Clinical Pathology and Medical Research, New South Wales Health Pathology, Westmead Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
| | - Jan-Willem Alffenaar
- Department of Pharmacy, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, NSW, Australia
| | - Menino O Cotta
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Kathryn Daveson
- Department of Infectious Diseases, Canberra Hospital, Canberra, ACT, Australia.,Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD, Australia
| | - Richard O Day
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sebastiaan Van Hal
- Department of Infectious Diseases and Microbiology, New South Wales Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cindy Lau
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, St Vincent's Hospital, Sydney, NSW, Australia
| | - Deborah J E Marriott
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Microbiology, SydPath, St Vincent's Hospital, Sydney, NSW, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Paul Williams
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Sahand Imani
- Northern Sydney Local Health District, Hornsby Ku-ring-gai Hospital, Sydney, NSW, Australia
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21
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Cusumano JA, Klinker KP, Huttner A, Luther MK, Roberts JA, LaPlante KL. Towards precision medicine: Therapeutic drug monitoring-guided dosing of vancomycin and β-lactam antibiotics to maximize effectiveness and minimize toxicity. Am J Health Syst Pharm 2021; 77:1104-1112. [PMID: 32537644 DOI: 10.1093/ajhp/zxaa128] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The goal of this review is to explore the role of antimicrobial therapeutic drug monitoring (TDM), especially in critically ill, obese, and older adults, with a specific focus on β-lactams and vancomycin. SUMMARY The continued rise of antimicrobial resistance prompts the need to optimize antimicrobial dosing. The aim of TDM is to individualize antimicrobial dosing to achieve antibiotic exposures associated with improved patient outcomes. Initially, TDM was developed to minimize adverse effects during use of narrow therapeutic index agents. Today, patient and organism complexity are expanding the need for precision dosing through TDM services. Alterations of pharmacokinetics and pharmacodynamics (PK/PD) in the critically ill, obese, and older adult populations, in conjunction with declining organism susceptibility, complicate attainment of therapeutic targets. Over the last decade, antimicrobial TDM has expanded with the emergence of literature supporting β-lactam TDM and a shift from monitoring vancomycin trough concentrations to monitoring of the ratio of area under the concentration (AUC) curve to minimum inhibitory concentration (MIC). PK/PD experts should be at the forefront of implementing precision dosing practices. CONCLUSION Precision dosing through TDM is expanding and is especially important in populations with altered PK/PD, including critically ill, obese, and older adults. Due to wide PK/PD variability in these populations, TDM is vital to maximize antimicrobial effectiveness and decrease adverse event rates. However, there is still a need for studies connecting TDM to patient outcomes. Providing patient-specific care through β-lactam TDM and transitioning to vancomycin AUC/MIC monitoring may be challenging, but with experts at the forefront of this initiative, PK-based optimization of antimicrobial therapy can be achieved.
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Affiliation(s)
- Jaclyn A Cusumano
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | | | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Megan K Luther
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
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22
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Liebchen U, Klose M, Paal M, Vogeser M, Zoller M, Schroeder I, Schmitt L, Huisinga W, Michelet R, Zander J, Scharf C, Weinelt FA, Kloft C. Evaluation of the MeroRisk Calculator, A User-Friendly Tool to Predict the Risk of Meropenem Target Non-Attainment in Critically Ill Patients. Antibiotics (Basel) 2021; 10:468. [PMID: 33924047 PMCID: PMC8074046 DOI: 10.3390/antibiotics10040468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The MeroRisk-calculator, an easy-to-use tool to determine the risk of meropenem target non-attainment after standard dosing (1000 mg; q8h), uses a patient's creatinine clearance and the minimum inhibitory concentration (MIC) of the pathogen. In clinical practice, however, the MIC is rarely available. The objectives were to evaluate the MeroRisk-calculator and to extend risk assessment by including general pathogen sensitivity data. METHODS Using a clinical routine dataset (155 patients, 891 samples), a direct data-based evaluation was not feasible. Thus, in step 1, the performance of a pharmacokinetic model was determined for predicting the measured concentrations. In step 2, the PK model was used for a model-based evaluation of the MeroRisk-calculator: risk of target non-attainment was calculated using the PK model and agreement with the MeroRisk-calculator was determined by a visual and statistical (Lin's concordance correlation coefficient (CCC)) analysis for MIC values 0.125-16 mg/L. The MeroRisk-calculator was extended to include risk assessment based on EUCAST-MIC distributions and cumulative-fraction-of-response analysis. RESULTS Step 1 showed a negligible bias of the PK model to underpredict concentrations (-0.84 mg/L). Step 2 revealed a high level of agreement between risk of target non-attainment predictions for creatinine clearances >50 mL/min (CCC = 0.990), but considerable deviations for patients <50 mL/min. For 27% of EUCAST-listed pathogens the median cumulative-fraction-of-response for the observed patients receiving standard dosing was < 90%. CONCLUSIONS The MeroRisk-calculator was successfully evaluated: For patients with maintained renal function it allows a reliable and user-friendly risk assessment. The integration of pathogen-based risk assessment substantially increases the applicability of the tool.
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Affiliation(s)
- Uwe Liebchen
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Marian Klose
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Graduate Research Training Program PharMetrX, Freie Universität Berlin, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Universität Potsdam, 14476 Potsdam, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
| | - Johannes Zander
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
- Laboratory Dr. Brunner, Luisenstr. 7e, 78464 Konstanz, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Ferdinand A. Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Graduate Research Training Program PharMetrX, Freie Universität Berlin, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Universität Potsdam, 14476 Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
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23
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Rozali MA, Abd Rahman NS, Sulaiman H, Abd Rahman AN, Atiya N, Wan Mat WR, Jamaluddin MF, Mazlan MZ, Mat Nor MB, Hasan MS, Abdul-Aziz MH. Knowledge, Perception, and Antibiotic Prescribing Practice in the Intensive Care Unit: Findings from the Malaysian Public Setting. J Pharm Bioallied Sci 2021; 12:S804-S809. [PMID: 33828380 PMCID: PMC8021041 DOI: 10.4103/jpbs.jpbs_266_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/16/2020] [Accepted: 04/01/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction: Approach to managing infection in the intensive care unit (ICU) often varies between institutions and not many readily adapt to available local guidelines despite it was constructed to suite local clinical scenario. Malaysia already has two published guidelines on managing infection in the ICU but data on its compliance are largely unknown. Objectives: A cross-sectional survey was carried out and sent to a total of 868 specialists working primarily in the ICU. The aim of this study was to explore knowledge, perception, and the antibiotic prescribing practice among specialists and advanced trainees in Malaysian ICU. Materials and Methods: A cross-sectional survey was used, consisted of three sections: knowledge, perception, and antibiotic prescribing practice in ICU. Three case vignettes on hospital-acquired pneumonia (HAP), infected necrotizing pancreatitis (INP), and catheter-related bloodstream infection (CRBSI) were used to explore antibiotic prescribing practice. Results: A total of 868 eligible subjects were approached with 104 responded to the survey. Three hundred eighty-nine antibiotics were chosen from seven different classes in the case vignettes. All respondents acknowledged the importance of pharmacokinetic/pharmacodynamic (PK/PD) in antibiotic optimization and majority (97.2%) perceived that current dosing is inadequate to achieve optimal PK/PD target in ICU patients. Majority (85.6%) believed that antibiotic dose should be streamlined to the organisms’ minimum inhibitory concentration (MIC). In terms of knowledge, only 64.4% provided the correct correlations between antibiotics and their respective PK/PD targets. Compliance rates in terms of antibiotic choices were at 79.8%, 77.8%, and 27.9% for HAI, INP, and CRBSI, respectively. Conclusion: Malaysian physicians are receptive to use PK/PD approach to optimize antibiotic dosing in ICU patients. Nonetheless, there are still gaps in the knowledge of antibiotic PK/PD as well as its application in the critically ill, especially for β-lactams.
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Affiliation(s)
- Muhammad Azrai Rozali
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia.,Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
| | - Norny Syafinaz Abd Rahman
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Helmi Sulaiman
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Nadia Atiya
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Rahiza Wan Mat
- Department of Anesthesiology and Intensive Care, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Muhd Zulfakar Mazlan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Mohd Basri Mat Nor
- Department of Intensive Care, International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
| | | | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Queensland, Australia
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24
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Liu J, Zhang S, Huang S, Chen Y, Zhang L, Du H, Wang T, Liu Y, Xu Y, Chen D. Rationality of Time-Dependent Antimicrobial Use in Intensive Care Units in China: A Nationwide Cross-Sectional Survey. Front Med (Lausanne) 2021; 8:584813. [PMID: 33681240 PMCID: PMC7925833 DOI: 10.3389/fmed.2021.584813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/07/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Extended/continuous infusion and therapeutic drug monitoring (TDM) of time-dependent antimicrobials are recommended for optimizing drug exposure for patients in intensive care units (ICUs), although practical application of these measures remains uncertain. We surveyed current practices in infusion and monitoring of commonly prescribed time-dependent antimicrobials in ICUs across China. Methods: From December 2019 to January 2020, we sent online questionnaires about various aspects of infusion and monitoring of time-dependent antimicrobials to intensivists across China. Responses from clinicians were matched with their professional titles using the Sankey diagram. Univariate and multivariate logistic regression analyses were performed to find factors associated with TDM. Results: A total of 3,687 ICU specialists from 31 provincial administrative regions of China responded to our questionnaires. Antibiotic stewardship (ABS) teams were available in hospitals as reported by 3,243 (88.0%) intensivists, including 1,308 (35.5%) who were ABS team members. Although most intensivists (3,490, 94.7%) were acquainted with the concept of prolonged/continuous infusion, nearly half of them (1,634, 44.3%) commonly administered β-lactam antibiotics intermittently. Nearly two-thirds of the respondents reported that their hospitals could not perform TDM. Our multivariable logistic regression analysis revealed that at the hospital level, knowledge of drug sample timing and attitude toward monitoring treatment effects, and drug trough or peak concentration influenced the decision to conduct TDM. Conclusions: We found great variability in prescribing practices, from drug administration to TDM, for several time-dependent antibiotics commonly used for patients with severe infections. Further studies are necessary to effectively evaluate strategies to promote consistent prescribing behavior.
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Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sisi Huang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yizhu Chen
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lidi Zhang
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hangxiang Du
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongan Liu
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Xu
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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25
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Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy 2021; 41:220-233. [PMID: 33480024 DOI: 10.1002/phar.2505] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/13/2022]
Abstract
Therapeutic drug monitoring (TDM) opens the door to personalized medicine, yet it is infrequently applied to β-lactam antibiotics, one of the most commonly prescribed drug classes in the hospital setting. As we continue to understand more about β-lactam pharmacodynamics (PD) and wide inter- and intra-patient variability in pharmacokinetics (PK), the utility of TDM has become increasingly apparent. For β-lactams, the time that free concentrations remain above the minimum inhibitory concentration (MIC) as a function of the dosing interval (%fT>MIC) has been shown to best predict antibacterial effect. Many studies have shown that β-lactam %fT>MIC exposures are often suboptimal across a wide variety of disease states and clinical settings. A limitation to implementing this practice is the general lack of understanding on how to best operationalize this intervention and interpret the results. The instrumentation and expertise needed to quantify β-lactams for TDM is rarely available locally, but certain laboratories advertise these services and perform them regularly. Familiarity with the modalities and nuances of antimicrobial susceptibility testing is crucial to establishing β-lactam concentration targets that meet the relevant exposure thresholds. Evaluation of these concentrations is best accomplished using population PK software and Bayesian modeling, for which a multitude of programs are available. While TDM of β-lactams has shown an ability to increase the rate of target attainment, there is currently limited evidence to suggest that it leads to improved clinical outcomes. Although consensus guidelines for β-lactam TDM do not exist in the United States, guidance would help to promote this important practice and better standardize the approach across institutions. Herein, we discuss the basis for β-lactam TDM, review supporting evidence, and provide guidance for implementation in specific patient populations.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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26
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Therapeutic drug monitoring of commonly used anti-infective agents: A nationwide cross-sectional survey of Australian hospital practices. Int J Antimicrob Agents 2020; 56:106180. [PMID: 32987102 DOI: 10.1016/j.ijantimicag.2020.106180] [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: 06/13/2020] [Revised: 09/01/2020] [Accepted: 09/19/2020] [Indexed: 12/20/2022]
Abstract
When performed according to best-practice principles, therapeutic drug monitoring (TDM) can optimise anti-infective treatment and directly benefit clinical outcomes. We evaluated TDM performance and clinical decision-making for established anti-infective agents amongst Australian hospitals. A nationwide cross-sectional survey was conducted between August and September 2019. The survey consisted of multiple-choice questions regarding TDM of anti-infective agents in general as well as clinical vignettes specific to vancomycin, gentamicin and voriconazole. We sought to survey all Australian hospitals operating both in the public and private health sectors. Responses were captured from 85 unique institutions, from all Australian states and territories. Regarding guidelines, 26% of hospitals did not have endorsed guidelines to advise on the ordering, sampling and interpretation of TDM for any anti-infective agent. Admitting teams were predominantly responsible for ordering TDM (85%) and interpreting results (76%). Only 51% of hospitals had access to dose prediction software, with access generally better amongst principal referral (69%) (P = 0.01) and children's hospitals (100%) (P = 0.04). Whenever a laboratory-derived minimum inhibitory concentration (MIC) was not available to guide dosing decisions, a surrogate target MIC was assumed in 77% of hospitals. This was based on a 'worst-case' scenario infection in 11% of hospitals. The rates of clinical practice consistent with current guideline recommendations across all aspects of TDM were demonstrated to be 0% for vancomycin, 4% for gentamicin and 35% for voriconazole. At present, there is significant institutional variability in the clinical practice of TDM for anti-infective agents in Australia for established TDM drugs.
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27
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Abdulla A, Dijkstra A, Hunfeld NGM, Endeman H, Bahmany S, Ewoldt TMJ, Muller AE, van Gelder T, Gommers D, Koch BCP. Failure of target attainment of beta-lactam antibiotics in critically ill patients and associated risk factors: a two-center prospective study (EXPAT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:558. [PMID: 32933574 PMCID: PMC7493358 DOI: 10.1186/s13054-020-03272-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022]
Abstract
Background Early and appropriate antibiotic dosing is associated with improved clinical outcomes in critically ill patients, yet target attainment remains a challenge. Traditional antibiotic dosing is not suitable in critically ill patients, since these patients undergo physiological alterations that strongly affect antibiotic exposure. For beta-lactam antibiotics, the unbound plasma concentrations above at least one to four times the minimal inhibitory concentration (MIC) for 100% of the dosing interval (100%ƒT > 1–4×MIC) have been proposed as pharmacodynamic targets (PDTs) to maximize bacteriological and clinical responses. The objectives of this study are to describe the PDT attainment in critically ill patients and to identify risk factors for target non-attainment. Methods This prospective observational study was performed in two ICUs in the Netherlands. We enrolled adult patients treated with the following beta-lactam antibiotics: amoxicillin (with or without clavulanic acid), cefotaxime, ceftazidime, ceftriaxone, cefuroxime, and meropenem. Based on five samples within a dosing interval at day 2 of therapy, the time unbound concentrations above the epidemiological cut-off (ƒT > MICECOFF and ƒT > 4×MICECOFF) were determined. Secondary endpoints were estimated multivariate binomial and binary logistic regression models, for examining the association of PDT attainment with patient characteristics and clinical outcomes. Results A total of 147 patients were included, of whom 63.3% achieved PDT of 100%ƒT > MICECOFF and 36.7% achieved 100%ƒT > 4×MICECOFF. Regression analysis identified male gender, estimated glomerular filtration rate (eGFR) ≥ 90 mL/min/1.73 m2, and high body mass index (BMI) as risk factors for target non-attainment. Use of continuous renal replacement therapy (CRRT) and high serum urea significantly increased the probability of target attainment. In addition, we found a significant association between the 100%ƒT > MICECOFF target attainment and ICU length of stay (LOS), but no significant correlation was found for the 30-day survival. Conclusions Traditional beta-lactam dosing results in low target attainment in the majority of critically ill patients. Male gender, high BMI, and high eGFR were significant risk factors for target non-attainment. These predictors, together with therapeutic drug monitoring, may help ICU clinicians in optimizing beta-lactam dosing in critically ill patients. Trial registration Netherlands Trial Registry (EXPAT trial), NTR 5632. Registered on 7 December 2015.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
| | - Annemieke Dijkstra
- Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Soma Bahmany
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
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The ONTAI study - a survey on antimicrobial dosing and the practice of therapeutic drug monitoring in German intensive care units. J Crit Care 2020; 60:260-266. [PMID: 32932111 DOI: 10.1016/j.jcrc.2020.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Optimization of antibiotic therapy is still urgently needed in critically ill patients. The aim of the ONTAI survey (online survey on the use of Therapeutic Drug Monitoring of antibiotics in intensive care units) was to evaluate which strategies intensive care physicians in Germany use to improve the quality of antibiotic therapy and what role a Therapeutic Drug Monitoring (TDM) plays. METHODS Among the members of the German Society for Anaesthesiology and the German Society for Medical Intensive Care Medicine and Emergency Medicine, a national cross-sectional survey was conducted using an online questionnaire. RESULTS The questionnaire was completely answered by 398 respondents. Without TDM, prolonged infusion was judged to be the most appropriate dosing regimen for beta lactams. A TDM for piperacillin, meropenem and vancomycin was performed in 17, 22 and 75% of respondents, respectively. For all beta lactams, a TDM was requested more often than it was available. There was great uncertainty as to the optimal pharmacokinetic/pharmacodynamic index for beta-lactams. 86% of the respondents who received minimal inhibitory concentrations adapted the therapy accordingly. CONCLUSION German intensive care physicians are convinced of TDM for dose optimization. However, practical implementation, the determination of MICs and defined target values are still lacking.
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Rafailidis PI, Falagas ME. Benefits of prolonged infusion of beta-lactam antibiotics in patients with sepsis: personal perspectives. Expert Rev Anti Infect Ther 2020; 18:957-966. [PMID: 32564641 DOI: 10.1080/14787210.2020.1776113] [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: 10/24/2022]
Abstract
INTRODUCTION In the current era of relatively scarce antibiotic production and significant levels of antimicrobial resistance, optimization of pharmacokinetics and pharmacodynamics of antibiotic therapy is mandatory. Prolonged infusion of beta-lactam antibiotics in comparison to the intermittent infusion has the theoretical advantage of better patient outcomes. Apparently, conflicting data in the literature possibly underestimate the benefits of prolonged infusion of antibiotic treatment. AREAS COVERED We provide our perspective on the subject based on our experience and by critically evaluating literature data. EXPERT OPINION COMMENTARY In our opinion, the available data are suggestive of the beneficial role of prolonged infusion of beta-lactams in regard to piperacillin/tazobactam and carbapenems after administering a loading dose. While more data from randomized controlled trials are necessary to solidify or negate the evident benefits of prolonged infusion of the aforementioned antibiotics, clinicians should strongly consider this mode of administration of relevant antibiotics, especially in patients with severe infections.
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Affiliation(s)
- Petros I Rafailidis
- School of Medicine, Democritus University of Thrace , Alexandroupolis, Greece.,Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece.,Department of Internal Medicine - Infectious Diseases, Henry Dunant Hospital Center , Athens, Greece.,Department of Medicine, Tufts University School of Medicine , Boston, MA, USA
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Dhaese SAM, Farkas A, Colin P, Lipman J, Stove V, Verstraete AG, Roberts JA, De Waele JJ. Population pharmacokinetics and evaluation of the predictive performance of pharmacokinetic models in critically ill patients receiving continuous infusion meropenem: a comparison of eight pharmacokinetic models. J Antimicrob Chemother 2020; 74:432-441. [PMID: 30376103 DOI: 10.1093/jac/dky434] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 09/26/2018] [Indexed: 01/02/2023] Open
Abstract
Background Several population pharmacokinetic (PopPK) models for meropenem dosing in ICU patients are available. It is not known to what extent these models can predict meropenem concentrations in an independent validation dataset when meropenem is infused continuously. Patients and methods A PopPK model was developed with concentration-time data collected from routine care of 21 ICU patients (38 samples) receiving continuous infusion meropenem. The predictability of this model and seven other published PopPK models was studied using an independent dataset that consisted of 47 ICU patients (161 samples) receiving continuous infusion meropenem. A statistical comparison of imprecision (mean square prediction error) and bias (mean prediction error) was conducted. Results A one-compartment model with linear elimination and creatinine clearance as a covariate of clearance best described our data. The mean ± SD parameter estimate for CL was 9.89 ± 3.71 L/h. The estimated volume of distribution was 48.1 L. The different PopPK models showed a bias in predicting serum concentrations from the validation dataset that ranged from -8.76 to 7.06 mg/L. Imprecision ranged from 9.90 to 42.1 mg/L. Conclusions Published PopPK models for meropenem vary considerably in their predictive performance when validated in an external dataset of ICU patients receiving continuous infusion meropenem. It is necessary to validate PopPK models in a target population before implementing them in a therapeutic drug monitoring program aimed at optimizing meropenem dosing.
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Affiliation(s)
- Sofie A M Dhaese
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West Hospital, New York, NY, USA
| | - Pieter Colin
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands.,Laboratory of Medical Biochemistry and Clinical Analysis, Ghent University, Ghent, Belgium
| | - Jeffrey Lipman
- Centre for Clinical Research, University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Veronique Stove
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium.,Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium
| | - Alain G Verstraete
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium.,Department of Clinical Chemistry, Microbiology and Immunology, Ghent University, Ghent, Belgium
| | - Jason A Roberts
- Centre for Clinical Research, University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Masse M, Genay S, Martin Mena A, Carta N, Lannoy D, Barthélémy C, Décaudin B, Odou P. Evaluation of the stability of vancomycin solutions at concentrations used in clinical services. Eur J Hosp Pharm 2020; 27:e87-e92. [PMID: 32296513 DOI: 10.1136/ejhpharm-2019-002076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/25/2019] [Accepted: 12/31/2019] [Indexed: 01/27/2023] Open
Affiliation(s)
- Morgane Masse
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Stéphanie Genay
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Anthony Martin Mena
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Natacha Carta
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Damien Lannoy
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Christine Barthélémy
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Bertrand Décaudin
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France
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da Silva SD, Alves GCDS, Chequer FMD, Farkas A, Daróczi G, Roberts JA, Sanches C. Linguistic and cultural adaptation to the Portuguese language of antimicrobial dose adjustment software. EINSTEIN-SAO PAULO 2020; 18:eAO5023. [PMID: 31994606 PMCID: PMC6986457 DOI: 10.31744/einstein_journal/2020ao5023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 09/11/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To adapt an antibiotic dose adjustment software initially developed in English, to Portuguese and to the Brazilian context. METHODS This was an observational, descriptive study in which the Delphi method was used to establish consensus among specialists from different health areas, with questions addressing the visual and operational aspects of the software. In a second stage, a pilot experimental study was performed with the random comparison of patients for evaluation and adaptation of the software in the real environment of an intensive care unit, where it was compared between patients who used the standardized dose of piperacillin/tazobactam, and those who used an individualized dose adjusted through the software Individually Designed and Optimized Dosing Strategies. RESULTS Twelve professionals participated in the first round, whose suggestions were forwarded to the software developer for adjustments, and subsequently submitted to the second round. Eight specialists participated in the second round. Indexes of 80% and 90% of concordance were obtained between the judges, characterizing uniformity in the suggestions. Thus, there was modification in the layout of the software for linguistic and cultural adequacy, minimizing errors of understanding and contradictions. In the second stage, 21 patients were included, and there were no differences between doses of piperacillin in the standard dose and adjusted dose Groups. CONCLUSION The adapted version of the software is safe and reliable for its use in Brazil.
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Affiliation(s)
- Samuel Dutra da Silva
- Universidade Federal de São João del-ReiDivinópolisMGBrazilUniversidade Federal de São João del-Rei, Divinópolis, MG, Brazil.
- Universidade de ItaúnaItaúnaMGBrazilUniversidade de Itaúna, Itaúna, MG, Brazil.
| | - Geisa Cristina da Silva Alves
- Universidade Federal de São João del-ReiDivinópolisMGBrazilUniversidade Federal de São João del-Rei, Divinópolis, MG, Brazil.
- Universidade de ItaúnaItaúnaMGBrazilUniversidade de Itaúna, Itaúna, MG, Brazil.
| | - Farah Maria Drumond Chequer
- Universidade Federal de São João del-ReiDivinópolisMGBrazilUniversidade Federal de São João del-Rei, Divinópolis, MG, Brazil.
| | - Andras Farkas
- Optimum Dosing StrategiesBloomingdaleNJUnited StatesOptimum Dosing Strategies, Bloomingdale, NJ, United States.
| | - Gergely Daróczi
- Optimum Dosing StrategiesBloomingdaleNJUnited StatesOptimum Dosing Strategies, Bloomingdale, NJ, United States.
| | - Jason A. Roberts
- University of QueenslandQueenslandQLDAustraliaUniversity of Queensland, Queensland, QLD, Australia.
| | - Cristina Sanches
- Universidade Federal de São João del-ReiDivinópolisMGBrazilUniversidade Federal de São João del-Rei, Divinópolis, MG, Brazil.
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Williams P, Beall G, Cotta MO, Roberts JA. Antimicrobial dosing in critical care: A pragmatic adult dosing nomogram. Int J Antimicrob Agents 2019; 55:105837. [PMID: 31722224 DOI: 10.1016/j.ijantimicag.2019.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 11/27/2022]
Abstract
Standard dosing of antimicrobials derived from product information is considered to have limited application in critically ill patients given the pharmacokinetic and pharmacodynamic changes often seen in these patients relative to other groups in the hospital. Dosing nomograms that account for the altered needs of critically ill patients are needed to minimise the likelihood of antimicrobial underdosing (risk of treatment failure) and overdosing (risk of toxicity) in these patients. The aim of this paper is to present a pragmatic, evidence-based, adult dosing nomogram for a selection of antimicrobials frequently prescribed to treat infections in critically ill patients.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.
| | - Gareth Beall
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Nationwide survey of hospital antibiotic stewardship programs in France. Med Mal Infect 2019; 50:414-422. [PMID: 31575446 DOI: 10.1016/j.medmal.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/06/2018] [Accepted: 09/03/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We aimed to evaluate the current state of antibiotic stewardship (ABS) in French public and private acute care hospitals. METHODS We conducted a cross-sectional online questionnaire survey. The selection of participating hospitals was performed through a stratified random sampling procedure among all French public and private hospitals with acute care beds. RESULTS 97/215 (45%) hospitals participated. A formal ABS program was implemented in 84% (80/95) of hospitals. A person officially in charge of this program (i.e., ABS program leader) was present in almost all participating hospitals (99%, 95/96) and s/he coordinated a multidisciplinary ABS team in 42% (40/96) of cases. The median time spent on ABS activities was 1.7, 1.6, and 0.8hours/week/100 acute care beds for infectious disease (ID) specialists, pharmacists, and microbiologists respectively; 27% (7/26) of ID specialists/other clinicians, 58% (15/26) of pharmacists, and 80% (16/20) of microbiologists received no salary support for the stewardship activities conducted as part of the team. Local guidelines (94%, 88/94), electronic medical records (85%, 80/94), and an antibiotic restriction policy (92%, 82/89) were implemented in almost all hospitals. Reports on antibiotic consumption and local resistance rates were available in 100% (91/91) and 84% (76/91) of hospitals, respectively. CONCLUSION Despite the existence of national requirements, hospital ABS programs are not fully implemented in France, mainly because of inadequate institutional support and funding.
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Boidin C, Moshiri P, Dahyot-Fizelier C, Goutelle S, Lefeuvre S. Pharmacokinetic variability of beta-lactams in critically ill patients: A narrative review. Anaesth Crit Care Pain Med 2019; 39:87-109. [PMID: 31513935 DOI: 10.1016/j.accpm.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/05/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022]
Abstract
The use of antibacterial drugs is very common in critically ill patients and beta-lactam agents are widely used in this context. Critically ill patients show several characteristics (e.g., sepsis, renal impairment or conversely augmented renal clearance, renal replacement therapy) that may alter beta-lactam pharmacokinetics (PK) in comparison with non-critically ill patients. This narrative literature review aims to identify recent studies quantifying the variability of beta-lactams volume of distribution and clearance and to determine its main determinants. Seventy studies published between 2000 and 2018 were retained. Data on volume of distribution and clearance variability were reported for 5 penicillins, 3 beta-lactamase inhibitors, 6 cephalosporins and 4 carbapenems. Data confirm specific changes in PK parameters and important variability of beta-lactam PK in critically ill patients. Renal function, body weight and use of renal replacement therapy are the principal factors influencing PK parameters described in this population. Few studies have directly compared beta-lactam PK in critically ill versus non-critically ill patients. Conclusions are also limited by small study size and sparse PK data in several studies. These results suggest approaches to assess this PK variability in clinical practice. Beta-lactam therapeutic drug monitoring seems to be the best way to deal with this issue.
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Affiliation(s)
- Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France.
| | - Parastou Moshiri
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Service d'Anesthésie-Réanimation, 2, rue de la Milétrie, 86021 Poitiers, France; Université de Poitiers, UMR 1070, 6, rue de la Milétrie, 86073 Poitiers, France.
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France; Univ Lyon, Université Claude Bernard Lyon 1, ISPB - Faculté de Pharmacie de Lyon, 8, avenue Rockefeller, 69008 Lyon, France.
| | - Sandrine Lefeuvre
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
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Dhaese SAM, Colin P, Willems H, Heffernan A, Gadeyne B, Van Vooren S, Depuydt P, Hoste E, Stove V, Verstraete AG, Lipman J, Roberts JA, De Waele JJ. Saturable elimination of piperacillin in critically ill patients: implications for continuous infusion. Int J Antimicrob Agents 2019; 54:741-749. [PMID: 31479741 DOI: 10.1016/j.ijantimicag.2019.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/29/2019] [Accepted: 08/24/2019] [Indexed: 12/24/2022]
Abstract
The study aimed to evaluate saturation of piperacillin elimination in critically ill adult patients. Seventeen critically ill adult patients received continuous and intermittent infusion of piperacillin/tazobactam. Piperacillin plasma concentrations (n = 217) were analysed using population pharmacokinetic (PopPK) modelling. Post-hoc simulations were performed to evaluate the type I error rate associated with the study. Unseen data were used to validate the final model. The mean error (ME) and root mean square error (RMSE) were calculated as a measure of bias and imprecision, respectively. A PopPK model with parallel linear and non-linear elimination best fitted the data. The median and 95% confidence interval (CI) for the model parameters drug clearance (CL), volume of central compartment (V), volume of peripheral compartment (Vp) and intercompartmental clearance (Q) were 9 (7.69-11) L/h, 6.18 (4.93-11.2) L, 11.17 (7.26-12) L and 15.61 (12.66-23.8) L/h, respectively. The Michaelis-Menten constant (Km) and the maximum elimination rate for Michaelis-Menten elimination (Vmax) were estimated without population variability in the model to avoid overfitting and inflation of the type I error rate. The population estimates for Km and Vmax were 37.09 mg/L and 353.57 mg/h, respectively. The bias (ME) was -20.8 (95% CI -26.2 to -15.4) mg/L, whilst imprecision (RMSE) was 49.2 (95% CI 41.2-56) mg/L. In conclusion, piperacillin elimination is (partially) saturable. Moreover, the population estimate for Km lies within the therapeutic window and therefore saturation of elimination should be accounted for when defining optimum dosing regimens for piperacillin in critically ill patients.
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Affiliation(s)
- S A M Dhaese
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium.
| | - P Colin
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Groningen, The Netherlands; Ghent University, Laboratory of Medical Biochemistry and Clinical Analysis, Ghent, Belgium
| | - H Willems
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - A Heffernan
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; School of Medicine, Griffith University, Southport, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - B Gadeyne
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - S Van Vooren
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium
| | - P Depuydt
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - E Hoste
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - V Stove
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium; Ghent University Hospital, Department of Laboratory Medicine, Ghent, Belgium
| | - A G Verstraete
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium; Ghent University Hospital, Department of Laboratory Medicine, Ghent, Belgium
| | - J Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Intensive Care Medicine, Brisbane, QLD, Australia; CHU Nîmes, Department of Anesthesiology and Critical Care, Nîmes, France
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Intensive Care Medicine, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Pharmacy, Brisbane, QLD, Australia
| | - J J De Waele
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
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Overcoming stability challenges during continuous intravenous administration of high-dose amoxicillin using portable elastomeric pumps. PLoS One 2019; 14:e0221391. [PMID: 31419268 PMCID: PMC6697341 DOI: 10.1371/journal.pone.0221391] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 12/13/2022] Open
Abstract
While treatment of serious infectious diseases may require high-dose amoxicillin, continuous infusion may be limited by lack of knowledge regarding the chemical stability of the drug. Therefore, we have performed a comprehensive study so as to determine the chemical stability of high-dose amoxicillin solutions conducive to safe and effective continuous intravenous administration using portable elastomeric pumps. First, amoxicillin solubility in water was assessed within the range of 25 to 300 mg/mL. Then, amoxicillin solutions were prepared at different concentrations (25, 50, 125, 250 mg/mL) and stored in different conditions (5±2°C, 25±1°C, 30±1°C and 37±1°C) to investigate the influence of concentration and temperature on the chemical stability of amoxicillin. Finally, its stability was assessed under optimized conditions using a fully validated HPLC-UV stability-indicating method. Degradation products of amoxicillin were investigated by accurate mass determination using high-resolution mass spectrometry. Amoxicillin displayed limited water solubility requiring reconstitution at concentrations below or equal to 150 mg/mL. Amoxicillin degradation were time, temperature as well as concentration-dependent, resulting in short-term stability, in particular at high concentrations. Four degradation products of amoxicillin have been identified. Among them, amoxicilloic acid and diketopiperazine amoxicillin are at risk of allergic reaction and may accumulate in the patient. Optimized conditions allowing for continuous infusion of high-dose amoxicillin has been determined: amoxicillin should be reconstituted at 25 mg/mL and stored up to 12 hours at room temperature (22 ± 4°C) or up to 24 hours between 4 and 8°C.
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Choi R, Woo HI, Park HD, Lee SY. A nationwide utilization survey of therapeutic drug monitoring for five antibiotics in South Korea. Infect Drug Resist 2019; 12:2163-2173. [PMID: 31410036 PMCID: PMC6646174 DOI: 10.2147/idr.s208783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/31/2019] [Indexed: 12/15/2022] Open
Abstract
Purpose The current status of therapeutic drug monitoring (TDM) assay utilization by clinical laboratories in South Korea remains little known. We investigated the TDM status of five antibiotics known for nephrotoxicity (vancomycin, amikacin, gentamicin, tobramycin, and teicoplanin) for the improvement of TDM in South Korea among patients with infectious diseases using a cross-sectional nationwide survey. Patients and methods We developed an online questionnaire and collected responses using a user-friendly web-based platform. The survey included questions about laboratory characteristics, implementation and operation of drug assays, implementation and operation of TDM consulting services, patient needs, and barriers to providing better TDM service including expectations and concerns about other platform-based drug assays. Results Among a total of 235 clinical laboratories, 112 (47.7%) responded, and 62 of the responding laboratories (55.4%) possessed drug assay facilities. Only 41.2% to 58.1% of respondents were providing TDM consulting services for each antibiotic. Respondents indicated that there are unmet needs regarding drug assays and TDM consultation as well as barriers to TDM utilization including high operating costs, lack of knowledge about TDM, lack of user-friendly software, lack of medical and laboratory information systems that can access patient information critical for TDM dose calculation, and reimbursement issues. Conclusion This study, the first nationwide survey addressing these questions, showed that there are barriers against the utilization of TDM in South Korea. These barriers may be addressed by improving drug assays and TDM consulting services with the goals of new analytical method development, better interpretation of results, consultation services, and quality control.
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Affiliation(s)
- Rihwa Choi
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Laboratory Medicine, Green Cross Laboratories, Yongin, Gyeonggi, Republic of Korea
| | - Hye In Woo
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Clinical Pharmacology and Therapeutics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Weier N, Tebano G, Thilly N, Demoré B, Pulcini C, Zaidi STR. Pharmacist participation in antimicrobial stewardship in Australian and French hospitals: a cross-sectional nationwide survey. J Antimicrob Chemother 2019; 73:804-813. [PMID: 29237051 DOI: 10.1093/jac/dkx435] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background Hospital pharmacists are an integral part of antimicrobial stewardship (AMS) programmes globally. Currently, little is known as to how hospital pharmacists see their role and involvement within the AMS framework. Objectives To assess the current level of involvement of Australian and French hospital pharmacists in AMS programmes and identify barriers limiting their involvement in AMS. Methods Hospital pharmacists throughout Australia and France were invited to participate in a nationwide online survey throughout March-May 2016. The survey was promoted through the national hospital pharmacists' association in Australia, while a stratified sampling method was used in France to invite pharmacists working in a variety of hospital settings. Results Invitations to participate in this survey were sent to 334 Australian pharmacists and 482 French pharmacists. Responses from 133 Australian and 126 French pharmacists were included for analysis. A total of 78.4% (203/259) of pharmacists reported the presence of an AMS programme. Pharmacists were most likely to be involved in AMS through assessing total antibiotic consumption and participating in AMS committee meetings. Barriers to participating in AMS included a lack of time and substantial non-clinical activities limiting involvement in AMS. Differences in responses were found between the two countries. Conclusions While the majority of pharmacists reported the presence of an AMS programme, multiple barriers to participation were identified by pharmacists in both countries. Further research should consider how to overcome the identified barriers to optimize the involvement of pharmacists in AMS.
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Affiliation(s)
- Naomi Weier
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Nathalie Thilly
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Centre Hospitalier Régional Universitaire de Nancy, Plateforme d'Aide à la Recherche Clinique, Nancy, France
| | - Béatrice Demoré
- Centre Hospitalier Régional Universitaire de Nancy, Pharmacie Brabois, Nancy, France.,UMR 7565, SRSMC, CNRS-Lorraine University, Faculté de Pharmacie, Rue Albert Lebrun, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Centre Hospitalier Régional Universitaire de Nancy, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - Syed Tabish R Zaidi
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Mouton JW, Muller AE, Canton R, Giske CG, Kahlmeter G, Turnidge J. MIC-based dose adjustment: facts and fables. J Antimicrob Chemother 2019; 73:564-568. [PMID: 29216348 DOI: 10.1093/jac/dkx427] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Over recent decades, several publications have described optimization procedures for antibiotic therapy in the individual patient based on antimicrobial MIC values. Most methods include therapeutic drug monitoring and use a single MIC determination plus the relevant pharmacokinetics/pharmacodynamics to adjust the dose to optimize antimicrobial drug exposure and antibacterial effects. However, the use of an MIC obtained by a single MIC determination is inappropriate. First, routine clinical laboratories cannot determine MICs with sufficient accuracy to guide dosage owing to the inherent assay variation in the MIC test. Second, the variation in any MIC determination, whatever method is used, must be accounted for. If dose adjustments are made based on therapeutic drug monitoring and include MIC determinations, MIC variation must be considered to prevent potential underdosing of patients. We present the problems and some approaches that could be used in clinical practice.
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Affiliation(s)
- Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Rafael Canton
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYIS), Madrid, Spain
| | - Christian G Giske
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Central Hospital, 351 85, Växjö, Sweden
| | - John Turnidge
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
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Muller AE, Huttner B, Huttner A. Therapeutic Drug Monitoring of Beta-Lactams and Other Antibiotics in the Intensive Care Unit: Which Agents, Which Patients and Which Infections? Drugs 2019; 78:439-451. [PMID: 29476349 DOI: 10.1007/s40265-018-0880-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotics are among the medications most frequently administered to the critically ill, a population with high levels of intra- and inter-individual pharmacokinetic variability. Our knowledge of the relationships among antibiotic dosing, exposure and clinical effect in this population has increased in recent decades. Therapeutic drug monitoring (TDM) of serum antibiotic concentrations is the most practical means of assessing adequate antibiotic exposure, though until recently, it has been underutilised for this end. Now TDM is becoming more widespread, particularly for the beta-lactam antibiotics, a class historically thought to have a wide therapeutic range. We review the basic requirements, indications, and targets for effective TDM of the glycopeptides, aminoglycosides, quinolones and beta-lactam antibiotics in the adult intensive-care setting, with a special focus on TDM of the beta-lactam antibiotics, the most widely used antibiotic class.
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Affiliation(s)
- Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Benedikt Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland
| | - Angela Huttner
- Division of Infectious Diseases, University Hospitals of Geneva, Rue Gabrielle-Gentil-Perret 4, 1205, Geneva, Switzerland.
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Outpatient parenteral antimicrobial therapy and antibiotic stewardship: opponents or teammates? Infection 2018; 47:169-181. [PMID: 30443780 DOI: 10.1007/s15010-018-1250-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/09/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE This narrative review aims to describe barriers of outpatient parenteral antimicrobial therapy at home (OPAT), potentially compromising general standards of antibiotic stewardship (ABS) and facilitators of OPAT for ABS. METHODS After a literature review, five authors determined the barriers and facilitators to discuss in this review. RESULTS Sixty-six publications were included in the narrative review and seven barriers and five facilitators are discussed in this article. The impracticability of multiple daily dosing during OPAT, the impact of real-life temperature variations, deviations of the infusion rates of elastomeric devices, access to prolonged intravenous antibiotic therapy, not administering loading doses before the initiation of extended or continuous infusions and the transmural nature of care associated with OPAT, can lead to deviations of recommended treatment regimens and sub-optimal clinical and laboratory follow-up, with a risk of inferior clinical outcomes, adverse events, drug-resistance and higher costs. On the other hand, OPAT provides access to treatments with intravenous antibiotics and simultaneously avoids prolonged hospitalization. CONCLUSION Implementing ABS guidelines in OPAT programs, e.g., by using a multidisciplinary team approach and facility-specific protocols for OPAT with patient selection criteria and instructions for selection, storage, preparation and administration of antibiotics, can improve appropriate antibiotic use. Additionally, further research should examine the effectiveness of these interventions on outcomes of OPAT.
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Camargo MS, Mistro S, Oliveira MG, Passos LCS. Association between increased mortality rate and antibiotic dose adjustment in intensive care unit patients with renal impairment. Eur J Clin Pharmacol 2018; 75:119-126. [PMID: 30276417 DOI: 10.1007/s00228-018-2565-7] [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] [Received: 07/30/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Adjusting the antibiotic dose based on an estimation of the glomerular filtration rate (eGFR) may result in subdosing, which may actually be significantly more problematic for intensive care unit (ICU) patients than not adjusting the dose. The aim of this study was to assess the outcomes of antibiotic dose adjustment in ICU patients with renal impairment. METHODS A retrospective cohort study was conducted in adult patients admitted to an ICU of a Brazilian hospital from January 2014 to December 2015. The eGFR was determined using Cockcroft-Gault and Modified Diet in Renal Disease equations for each day of hospitalization. Treatment failure was defined based on the clinical, laboratory, and radiological criteria. RESULTS A total of 126 patients were assessed to meet the inclusion criteria and subsequently enrolled in the study (19.9% of patients admitted to the ICU during the study period). Of the 168 opportunities for dose adjustment, 99 (58.9%) adjustments were made. The mean eGFR in the group with dose adjustment was lower than that in the group without dose adjustment (38.5 vs. 40.7 mL/min/1.73 m2, respectively). The treatment failure rate among patients with dose adjustment and those treated with the usual dose was 59.3 and 38.9%, respectively (p = 0.023), and the mortality rates in the respective groups were 74.1 and 55.5% (p = 0.033). An association between dose adjustment and treatment failure/mortality rates was also observed in the multivariate analysis including the prognostic score. CONCLUSIONS In ICU patients with renal impairment, adjustments in antibiotic dose based on eGFR, significantly increased the risk of treatment failure and death.
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Affiliation(s)
- Marianne Silveira Camargo
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Rua Padre Feijó, S/N, Canela, Salvador, Bahia, Brazil. .,, Rua Rio de Contas, n. 350, Candeias, Vitória da Conquista, 45029-094, Bahia, Brazil.
| | - Sóstenes Mistro
- Post-Graduate Program in Public Health, Multidisciplinary Institute of Health, Federal University of Bahia, Rua Rio de Contas, 58, Vitória da Conquista, Bahia, Brazil
| | - Márcio Galvão Oliveira
- Post-Graduate Program in Public Health, Multidisciplinary Institute of Health, Federal University of Bahia, Rua Rio de Contas, 58, Vitória da Conquista, Bahia, Brazil
| | - Luiz Carlos Santana Passos
- Post-Graduate Program in Medicine and Health, Federal University of Bahia, Rua Padre Feijó, S/N, Canela, Salvador, Bahia, Brazil
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Emergence of antimicrobial resistance to piperacillin/tazobactam or meropenem in the ICU: Intermittent versus continuous infusion. A retrospective cohort study. J Crit Care 2018; 47:164-168. [PMID: 30005302 DOI: 10.1016/j.jcrc.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 07/01/2018] [Accepted: 07/02/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Prolonged infusion of beta-lactam antibiotics is broadly recognized as a strategy to optimize antibiotic therapy by achieving a higher percentage of time that concentrations remain above the minimal inhibitory concentration (% fT>MIC), i.e. the pharmacokinetic/pharmacodynamic (PK/PD) index. However, %fT>MIC may not be the PK/PD index of choice for inhibition of resistance emergence and it is therefore unsure what impact prolonged infusion of beta-lactam antibiotics may have on the emergence of resistance. METHODS A retrospective cohort study including 205 patients receiving either intermittent (101 patients) or continuous (104 patients) infusion of piperacillin/tazobactam or meropenem was conducted in the ICU of the Ghent University Hospital. Logistic regression analysis was used to develop a prediction model and to determine whether the mode of infusion was a predictor of emergence of antimicrobial resistance. RESULTS Resistant strains emerged in 24 out of the 205 patients (11.7%). The mode of infusion was no predictor of emergence of antimicrobial resistance. Infection with Pseudomonas aeruginosa was associated with a significantly higher risk for emergence of resistance. CONCLUSIONS In this retrospective cohort study, the emergence of antimicrobial resistance to piperacillin/tazobactam or meropenem was not related to the mode of infusion.
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Monteiro JF, Hahn SR, Gonçalves J, Fresco P. Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations. Pharmacol Res Perspect 2018; 6:e00420. [PMID: 30156005 PMCID: PMC6113434 DOI: 10.1002/prp2.420] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Vancomycin is a fundamental antibiotic in the management of severe Gram-positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.
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Affiliation(s)
- Joaquim F. Monteiro
- Faculdade de Medicina da Universidade do Porto (FMUP)PortoPortugal
- Instituto de Investigação e Formação Avançadas em Ciências e Tecnologias da Saúde (IINFACTS)Instituto Universitário de Ciências da Saúde (IUCS)GandraPortugal
| | - Siomara R. Hahn
- Instituto de Ciências BiológicasCurso de FarmáciaUniversidade de Passo Fundo (UPF)Passo FundoBrasil
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
| | - Jorge Gonçalves
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
| | - Paula Fresco
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
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Lavergne A, Vigneau C, Polard E, Triquet L, Rioux-Leclercq N, Tattevin P, Golbin L. Acute kidney injury during treatment with high-dose cloxacillin: a report of 23 cases and literature review. Int J Antimicrob Agents 2018; 52:344-349. [PMID: 29665445 DOI: 10.1016/j.ijantimicag.2018.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 04/01/2018] [Accepted: 04/07/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND International guidelines recommend high-dose cloxacillin for endocarditis or osteoarticular infections due to methicillin-susceptible staphylococci. However, data on the tolerability of these regimens are scarce. METHODS We used the computerized registry of suspected drug-related adverse events in our institution. Cases of acute kidney injury (AKI), as defined by KDIGO, in patients receiving high-dose cloxacillin were retrospectively reviewed. Data were collected from medical charts on a standardized questionnaire. RESULTS From 2009 to 2015, 23 consecutive patients (16 men, 7 women) with a median age of 75 years (interquartile range [IQR], 66-80) fulfilled inclusion criteria. By the time of AKI diagnosis, patients were treated with a median cloxacillin dose of 12 g/day (IQR, 10-12) after a median duration of 7 days (IQR, 4-10). Most patients (n=20) fulfilled RIFLE criteria for failure, with a median peak serum creatinine concentration of 339 µmol/L (IQR, 249-503). Urinalysis was indicative of tubular disease in 7 patients, 3 had hypereosinophilia and 8 had abnormal liver function tests. All patients presented at least one risk factor for AKI, including concomitant nephrotoxic drugs: gentamicin (n=19), diuretics (n=15), angiotensin-converting enzyme inhibitors (n=8) and angiotensin II receptor-blockers (n=6). Thirteen patients (57%) had cloxacillin plasma concentrations >50 µg/mL. Thirteen patients (57%) had complete recovery of renal function. CONCLUSIONS AKI during high-dose cloxacillin treatment mostly occurs in elderly patients taking concomitant nephrotoxic drugs. The outcome is usually favourable after cloxacillin discontinuation. Therapeutic drug monitoring may decrease the risk of AKI in patients treated with high-dose cloxacillin.
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Affiliation(s)
- Aurélie Lavergne
- CHU Rennes, Service de Néphrologie, F-35033 Rennes, France; Université Rennes1, F-35043 Rennes, France
| | - Cécile Vigneau
- CHU Rennes, Service de Néphrologie, F-35033 Rennes, France; Université Rennes1, F-35043 Rennes, France; INSERM, U1085 IRSET-9, F-35033 Rennes, France
| | - Elisabeth Polard
- CHU Rennes, Service de Pharmacovigilance, F-35033 Rennes, France
| | - Louise Triquet
- CHU Rennes, Service de Pharmacovigilance, F-35033 Rennes, France
| | - Nathalie Rioux-Leclercq
- Université Rennes1, F-35043 Rennes, France; INSERM, U1085 IRSET-9, F-35033 Rennes, France; CHU Rennes, Service d'Anatomie et cytologie pathologiques, F-35033 Rennes, France
| | - Pierre Tattevin
- Université Rennes1, F-35043 Rennes, France; INSERM, U1085 IRSET-9, F-35033 Rennes, France; CHU Rennes, Service des Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France.
| | - Léonard Golbin
- CHU Rennes, Service de Néphrologie, F-35033 Rennes, France; Université Rennes1, F-35043 Rennes, France
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Pharmacokinetic/Pharmacodynamic Considerations of Beta-Lactam Antibiotics in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:9. [PMID: 29619607 DOI: 10.1007/s11908-018-0613-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Beta-lactam antibiotics are commonly prescribed in critically ill patients for a variety of infectious conditions. Our understanding of how critical illness alters beta-lactam pharmacokinetics/pharmacodynamics (PK/PD) is rapidly evolving. RECENT FINDINGS There is a growing body of literature in adult patients demonstrating that physiological alterations occurring in critically ill patients may limit our ability to optimally dose beta-lactam antibiotics to reach these PK/PD targets. These alterations include changes in volume of distribution and renal clearance with multiple, often overlapping causative pathways, including hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Strategies to overcome these PK alterations include extended infusions and therapeutic drug monitoring. Combined data has demonstrated a possible survival benefit associated with extending beta-lactam infusions in critically ill adult patients. This review highlights research on physiological derangements affecting beta-lactam concentrations and strategies to optimize beta-lactam PK/PD in critically ill adults.
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Rawson TM, O’Hare D, Herrero P, Sharma S, Moore LSP, de Barra E, Roberts JA, Gordon AC, Hope W, Georgiou P, Cass AEG, Holmes AH. Delivering precision antimicrobial therapy through closed-loop control systems. J Antimicrob Chemother 2018; 73:835-843. [PMID: 29211877 PMCID: PMC5890674 DOI: 10.1093/jac/dkx458] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
| | - D O’Hare
- Department of Bioengineering, Imperial College London, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - S Sharma
- College of Engineering, Swansea University, Swansea, UK
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
| | - E de Barra
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Centre for Translational Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - A C Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - A E G Cass
- Department of Chemistry & Institute of Biomedical Engineering, Imperial College London, Kensington Campus, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
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Paul M, Theuretzbacher U. β-lactam prolonged infusion: it's time to implement! THE LANCET. INFECTIOUS DISEASES 2017; 18:13-14. [PMID: 29102323 DOI: 10.1016/s1473-3099(17)30614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus and Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
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Lefeuvre S, Bois-Maublanc J, Hocqueloux L, Bret L, Francia T, Eleout-Da Violante C, Billaud EM, Barbier F, Got L. A simple ultra-high-performance liquid chromatography-high resolution mass spectrometry assay for the simultaneous quantification of 15 antibiotics in plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1065-1066:50-58. [PMID: 28946125 DOI: 10.1016/j.jchromb.2017.09.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 09/05/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
Abstract
Antibiotic (ATB) treatment of critically ill patients with pathophysiological injuries remains a challenge due to the constant increase in antimicrobial resistance. Therapeutic drug monitoring (TDM) is advised for ATB dose adjustments to avoid suboptimal concentrations and dose-related adverse effects. Therefore, a single and reliable analytical method for a broad selection of ATBs was developed using a high-resolution mass spectrometry (HRMS) platform for frequent use in intensive care units. An UHPLC assay coupled to high resolution accurate mass acquisition has been developed for the quantification of penicillins (amoxicillin, oxacillin, piperacillin, and ticarcillin), cephalosporines (cefepime, cefotaxime, ceftazidime, and ceftriaxone), carbapenems (ertapenem, imipenem, and meropenem), lincosamide (clindamycin), quinolones (ofloxacin and ciprofloxacin) and tazobactam. Plasma samples (100μL) were spiked with an internal standard solution followed by protein precipitation. Separation was achieved on an Accucore C18 column, which enabled sample analysis every 9min. All compounds were detected in electrospray positive ion mode and quantified with a linear regression between 0.5 and 32mg/L (r2>0.998). Overall precision and accuracy did not exceed 15%. No significant matrix effect was observed for the studied ATBs. Stored stock solutions at -20°C were stable for 6 months, except for amoxicillin and imipenem. Analytes in plasma were stable for 24h under ambient conditions as well as in post-preparation in an autosampler, except for amoxicillin and imipenem. This HRMS assay provides the simultaneous quantification of 15 ATB; it fulfills the usual quality criteria and was successfully applied for routine TDM of ATBs. The method is based on a full scan acquisition, and it would be easy to add other compounds to the present panel in the future, as this assay has already been proven to be efficient for different classes of compounds.
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Affiliation(s)
- S Lefeuvre
- Laboratory of Biochemistry, CHR Orléans, France.
| | | | - L Hocqueloux
- Tropical and Infectious Deseases Department, CHR Orléans, France
| | - L Bret
- Laboratory de Microbiology-Virology, CHR Orléans, France
| | - T Francia
- Laboratory of Biochemistry, CHR Orléans, France
| | | | - E M Billaud
- Pharmacology Department, AP-HP, Hôpital Européen Georges Pompidou, Paris Descartes University, Paris, France
| | - F Barbier
- Intensive care Department, CHR Orléans, France
| | - L Got
- Laboratory of Biochemistry, CHR Orléans, France
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