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Why We May Need Higher Doses of Beta-Lactam Antibiotics: Introducing the 'Maximum Tolerable Dose'. Antibiotics (Basel) 2022; 11:antibiotics11070889. [PMID: 35884143 PMCID: PMC9312263 DOI: 10.3390/antibiotics11070889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/29/2022] [Accepted: 07/03/2022] [Indexed: 01/25/2023] Open
Abstract
The surge in antimicrobial resistance and the limited availability of new antimicrobial drugs has fueled the interest in optimizing antibiotic dosing. An ideal dosing regimen leads to maximal bacterial cell kill, whilst minimizing the risk of toxicity or antimicrobial resistance. For beta-lactam antibiotics specifically, PK/PD-based considerations have led to the widespread adoption of prolonged infusion. The rationale behind prolonged infusion is increasing the percentage of time the beta-lactam antibiotic concentration remains above the minimal inhibitory concentration (%fT>MIC). The ultimate goal of prolonged infusion of beta-lactam antibiotics is to improve the outcome of infectious diseases. However, merely increasing target attainment (or the %fT>MIC) is unlikely to lead to improved clinical outcome for several reasons. First, the PK/PD index and target are dynamic entities. Changing the PK (as is the case if prolonged instead of intermittent infusion is used) will result in different PK/PD targets and even PK/PD indices necessary to obtain the same level of bacterial cell kill. Second, the minimal inhibitory concentration is not a good denominator to describe either the emergence of resistance or toxicity. Therefore, we believe a different approach to antibiotic dosing is necessary. In this perspective, we introduce the concept of the maximum tolerable dose (MTD). This MTD is the highest dose of an antimicrobial drug deemed safe for the patient. The goal of the MTD is to maximize bacterial cell kill and minimize the risk of antimicrobial resistance and toxicity. Unfortunately, data about what beta-lactam antibiotic levels are associated with toxicity and how beta-lactam antibiotic toxicity should be measured are limited. This perspective is, therefore, a plea to invest in research aimed at deciphering the dose−response relationship between beta-lactam antibiotic drug concentrations and toxicity. In this regard, we provide a theoretical approach of how increasing uremic toxin concentrations could be used as a quantifiable marker of beta-lactam antibiotic toxicity.
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Ruch Y, Ursenbach A, Danion F, Reisz F, Nai T, Hoellinger B, Hansmann Y, Lefebvre N, Martzloff J. High Incidence of Acute Kidney Injury in Patients Treated with High-Dose Amoxicillin and Cloxacillin Combination Therapy. Antibiotics (Basel) 2022; 11:antibiotics11060770. [PMID: 35740176 PMCID: PMC9220067 DOI: 10.3390/antibiotics11060770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 11/17/2022] Open
Abstract
High-dose amoxicillin and cloxacillin combination therapy is recommended for the empiric treatment of selected patients with infective endocarditis despite a low level of evidence. The main objective of this study was to evaluate the renal tolerance of high-dose intravenous amoxicillin and cloxacillin combination. We studied 27 patients treated with amoxicillin and cloxacillin (≥100 mg/kg daily) for at least 48 h. The primary endpoint was the occurrence of acute kidney injury (AKI). The median patient age was 68 ± 8 years, and 16 (59%) were male. The indication for this combination therapy was suspected or confirmed endocarditis with no bacterial identification in 22 (81%) patients. The primary endpoint occurred in 16 (59%) patients after initiating this combination therapy within an average of 4.4 ± 3.6 days. Among them, seven (26%) patients developed severe AKI, including four (15%) patients who required hemodialysis. Other risk factors for AKI were identified in all patients, including injection of iodinated contrast media in 21 (78%), acute heart failure in 18 (67%), cardiac surgery in 11 (41%), and aminoglycoside use in 9 (33%) patients. This study reports an incidence of 59% of AKI after initiating amoxicillin and cloxacillin combination therapy in a population at high renal risk.
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Affiliation(s)
- Yvon Ruch
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
- Correspondence:
| | - Axel Ursenbach
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
| | - François Danion
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
| | - Fanny Reisz
- Department of Pharmacy, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (F.R.); (T.N.)
| | - Thierry Nai
- Department of Pharmacy, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (F.R.); (T.N.)
| | - Baptiste Hoellinger
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
| | - Yves Hansmann
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
| | - Nicolas Lefebvre
- Department of Infectious and Tropical Diseases, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France; (A.U.); (F.D.); (B.H.); (Y.H.); (N.L.)
| | - Jonas Martzloff
- Department of Nephrology, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France;
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Demotier S, Limelette A, Charmillon A, Baux E, Parent X, Mestrallet S, Pavel S, Servettaz A, Dramé M, Muggeo A, Wynckel A, Gozalo C, Taam MA, Fillion A, Jaussaud R, Trenque T, Piroth L, Bani-Sadr F, Hentzien M. Incidence, associated factors, and effect on renal function of amoxicillin crystalluria in patients receiving high doses of intravenous amoxicillin (The CRISTAMOX Study): A cohort study. EClinicalMedicine 2022; 45:101340. [PMID: 35295665 PMCID: PMC8919213 DOI: 10.1016/j.eclinm.2022.101340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Amoxicillin crystalluria (AC), potentially responsible for acute kidney injury (AKI), is reported more and more frequently in patients treated with high doses of intravenous amoxicillin (HDIVA). The main objective of this study was to evaluate AC incidence in these patients. The secondary objectives were to identify factors associated with AC and to evaluate its impact on the risk of AKI. METHODS This multicentre, observational, cohort study was conducted between Mar 18, 2014 and Aug 16, 2019 in Dijon, Nancy, and Reims University Hospitals as well as Châlon-sur-Saône, Charleville-Mézières, and Troyes general hospitals in France. Adult patients (≥18 years) treated with HDIVA and having been tested for AC at least once during treatment were included. Clinical, biological, and therapeutic characteristics of the patients were collected. A univariable mixed logistic regression model assessed the factors associated with AC. A multivariable Cox model with AC as a time-dependent variable assessed the prognostic factors for AKI. ClinicalTrials.gov number: NCT02853292. FINDINGS Of the 112 included patients, 27 (24.1%, 95% CI [16.2-32.0]) developed at least one episode of AC within a mean of 5.1 days. The factors associated with its occurrence were the concomitant use of angiotensin converting enzyme (ACE) inhibitors (OR=4.6, 95% CI [2.2-9.3], p<0.0001) and the decrease of urinary pH (OR=2.1 for one pH point decrease, 95% CI [1.2-3.7], p=0.009). 20 patients (17.9%) presented with AKI, within a mean time of 10.9 days. The main factor associated with the occurrence of AKI was the occurrence of AC (aHR=7.4, 95% CI [2.5-22.2], p=0.0003). INTERPRETATION AC occurred in a quarter of patients treated with HDIVA and was highly prognostic of AKI. FUNDING None.
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Affiliation(s)
- Sophie Demotier
- Service de Médecine Interne— Maladies infectieuses, Immunologie Clinique. Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Anne Limelette
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Alexandre Charmillon
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Elisabeth Baux
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Xavier Parent
- Laboratoire de Biochimie, Hôpitaux Civils de Colmar, Colmar, France
| | - Stéphanie Mestrallet
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier Intercommunal Nord-Ardennes, Charleville-Mézières, France
| | - Simona Pavel
- Service de Médecine Interne et Maladies Infectieuses, Centre Hospitalier, Troyes, France
| | - Amélie Servettaz
- Service de Médecine Interne— Maladies infectieuses, Immunologie Clinique. Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Moustapha Dramé
- Département de Recherche Clinique et Innovation, Centre Hospitalier Universitaire Pierre Zobda-Quitman, Fort-de-France, France
| | - Anaelle Muggeo
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Alain Wynckel
- Service de Néphrologie, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Claire Gozalo
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Malak Abou Taam
- Pôle antalgie, anesthésie, rhumatologie, médicaments des addictions, Direction Médicale Médicament 2, ANSM, Saint-Denis, France
| | - Aurélie Fillion
- Service de Maladies Infectieuses, Centre Hospitalier William Morey, Chalon-sur-Saône, France
| | - Roland Jaussaud
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Thierry Trenque
- Centre Régional de Pharmacovigilance et de Pharmacoépidémiologie, Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Lionel Piroth
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire François Mitterand, Dijon, France
| | - Firouze Bani-Sadr
- Service de Médecine Interne— Maladies infectieuses, Immunologie Clinique. Centre Hospitalier Universitaire Robert Debré, Reims, France
| | - Maxime Hentzien
- Service de Médecine Interne— Maladies infectieuses, Immunologie Clinique. Centre Hospitalier Universitaire Robert Debré, Reims, France
- Corresponding author: Dr Maxime Hentzien, Service de Médecine Interne—Maladies infectieuses, Immunologie Clinique, Centre Hospitalier Universitaire Robert Debré, Avenue du général Koenig, 51092 Reims Cedex, France, Phone number: 0033 3 26 78 71 89 or 0033 6 07 85 01 77, Fax number: 0033 3 26 78 40 90
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Roger C, Louart B. Beta-Lactams Toxicity in the Intensive Care Unit: An Underestimated Collateral Damage? Microorganisms 2021; 9:microorganisms9071505. [PMID: 34361942 PMCID: PMC8306322 DOI: 10.3390/microorganisms9071505] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022] Open
Abstract
Beta-lactams are the most commonly prescribed antimicrobials in intensive care unit (ICU) settings and remain one of the safest antimicrobials prescribed. However, the misdiagnosis of beta-lactam-related adverse events may alter ICU patient management and impact clinical outcomes. To describe the clinical manifestations, risk factors and beta-lactam-induced neurological and renal adverse effects in the ICU setting, we performed a comprehensive literature review via an electronic search on PubMed up to April 2021 to provide updated clinical data. Beta-lactam neurotoxicity occurs in 10-15% of ICU patients and may be responsible for a large panel of clinical manifestations, ranging from confusion, encephalopathy and hallucinations to myoclonus, convulsions and non-convulsive status epilepticus. Renal impairment, underlying brain abnormalities and advanced age have been recognized as the main risk factors for neurotoxicity. In ICU patients, trough concentrations above 22 mg/L for cefepime, 64 mg/L for meropenem, 125 mg/L for flucloxacillin and 360 mg/L for piperacillin (used without tazobactam) are associated with neurotoxicity in 50% of patients. Even though renal complications (especially severe complications, such as acute interstitial nephritis, renal damage associated with drug induced hemolytic anemia and renal obstruction by crystallization) remain rare, there is compelling evidence of increased nephrotoxicity using well-known nephrotoxic drugs such as vancomycin combined with beta-lactams. Treatment mainly relies on the discontinuation of the offending drug but in the near future, antimicrobial optimal dosing regimens should be defined, not only based on pharmacokinetics/pharmacodynamic (PK/PD) targets associated with clinical and microbiological efficacy, but also on PK/toxicodynamic targets. The use of dosing software may help to achieve these goals.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
- Correspondence:
| | - Benjamin Louart
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
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