1
|
Ibe Y, Kakizaki R, Inamura H, Ishigo T, Fujiya Y, Inoue H, Uemura S, Fujii S, Takahashi S, Narimatsu E, Fukudo M. Tazobactam/ceftolozane and tobramycin combination therapy in extensively drug-resistant Pseudomonas aeruginosa infections in severe burn injury: a case report. J Pharm Health Care Sci 2023; 9:25. [PMID: 37550794 PMCID: PMC10408163 DOI: 10.1186/s40780-023-00294-x] [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: 03/28/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Combination therapy with tazobactam/ceftolozane (TAZ/CTLZ) and high-dose aminoglycosides has been reported to be efficacious in extensively drug-resistant (XDR)-Pseudomonas aeruginosa infection. However, there are no reports of efficacy in XDR-P. aeruginosa infection for combination therapy with low-dose aminoglycosides and TAZ/CTLZ. Herein, we describe a rare case of severe burn injury patients with persistent bacteremia due to XDR-P. aeruginosa, which was successfully treated with TAZ/CTLZ and low-dose tobramycin (TOB). CASE PRESENTATION A 31-year-old man was admitted to the intensive care unit with severe burn injury involving 52% of the total body surface area and a prognostic burn index of 79.5. The patient had recurrent bacterial infections since admission, and blood cultures collected on the 37th day of admission revealed the presence of P. aeruginosa strains that were resistant to all β-lactams and amikacin (AMK). The results of the antimicrobial synergistic study showed no synergistic effect of low-dose meropenem (MEPM) and AMK combination therapy. The patient had acute renal failure, and it was difficult to increase the dose of MEPM and AMK, respectively. Thus, we initiated TAZ/CTLZ 1.5 g/8 h instead of the AMK and MEPM combination therapy on the 43rd day of hospitalization. Low-dose TAZ/CTLZ was continued because of prolonged renal dysfunction and resulted in a transient clinical improvement. However, the dosage of TAZ/CTLZ could be increased as the renal function improved, but despite an increased TAZ/CTLZ dose, bacteremia persisted, and the blood cultures remained positive. Thus, TOB was added to TAZ/CTLZ at low doses for synergistic effect against Gram-negative bacteria. Blood cultures collected after initiation of combination therapy with TAZ/CTLZ and low-dose TOB were negative on two consecutive follow-up evaluations. Thereafter, although the patient had several episodes of fever and increased inflammatory response, blood cultures consistently tested negative, and all of the wounds healed. On the 93rd day, due to the good healing progress, the patient was transferred to another hospital. CONCLUSIONS TAZ/CTLZ and low-dose TOB combination therapy showed the potential for synergistic effects. Our present report suggests a novel synergistic treatment strategy for rare cases that are refractory to the treatment of infections, such as XDR-P. aeruginosa infection.
Collapse
Affiliation(s)
- Yuta Ibe
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Ryuichiro Kakizaki
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hirotoshi Inamura
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Tomoyuki Ishigo
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Yoshihiro Fujiya
- Department of Infection Control and Laboratory Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroyuki Inoue
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Satoshi Fujii
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan
| | - Satoshi Takahashi
- Department of Infection Control and Laboratory Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masahide Fukudo
- Department of Hospital Pharmacy, Sapporo Medical University Hospital, South-1, West-16, Chuo-Ku, Sapporo, 060-8543, Japan.
| |
Collapse
|
2
|
Sharma D, Jain S, Mishra AK, Sharma R, Tanwar A. Medicinal Herbs from Phyto-informatics: An aid for Skin Burn Management. Curr Pharm Biotechnol 2022; 23:1436-1448. [PMID: 35272596 DOI: 10.2174/1389201023666220310141308] [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: 08/25/2021] [Revised: 12/13/2021] [Accepted: 01/03/2022] [Indexed: 01/08/2023]
Abstract
Skin burn injury is the most common cause of trauma that is still considered a dreadful condition in healthcare emergencies around the globe. Due to the availability of a variety of regimes, their management remains a dynamical challenge for the entire medical and paramedical community. Indeed, skin burn injuries are accompanied by a series of several devastating events that lead to sepsis and multiple organ dysfunction syndromes. Hence the challenge lies in to develop better understanding as well as clear diagnostic criteria and predictive biomarkers which are important in their management. Though there are several regimes available in the market, there are still numerous limitations and challenges in the management. In this review article, we have discussed the various biomarkers that could be targeted for managing skin burn injuries. Instead of focusing on allopathic medication which has its adverse events per se, we have discussed the history, ethnopharmacology properties, and prospects of identified phytomedicines from a well-established herbal informatics model. This review article not only discusses the benefits of scrutinized phytocompounds but also leads to develop novel druggable Phyto-compounds to target skin burn injury at lower cost with no adverse effects.
Collapse
Affiliation(s)
- Deepti Sharma
- Division of CBRN Defence, Institute of Nuclear Medicine and Allied Sciences, Delhi 110054, India
| | - Sapna Jain
- Vaccine and Infectious Disease Research Center, Translational Health Science and Technology Institute, Haryana,121001, India
| | - Amit Kumar Mishra
- Faculty of Life Science and Biotechnology, South Asian University, New Delhi 110021, India
| | - Ruby Sharma
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, New York, NY, 10461, USA
| | - Ankit Tanwar
- Department of Cell Biology, Albert Einstein College of Medicine, New York, NY, 10461, USA
| |
Collapse
|
3
|
Sabur NF, Brar MS, Wu L, Brode SK. Low-dose amikacin in the treatment of Multidrug-resistant Tuberculosis (MDR-TB). BMC Infect Dis 2021; 21:254. [PMID: 33691624 PMCID: PMC7945371 DOI: 10.1186/s12879-021-05947-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization recommends intravenous amikacin for the treatment of MDR-TB at a dose of 15 mg/kg. However, higher doses are associated with significant toxicity. METHODS Patients with MDR-TB treated at our institution receive amikacin at 8-10 mg/kg, with dose adjustment based on therapeutic drug monitoring. We conducted a retrospective cohort study of patients with MDR-TB who received amikacin between 2010 and 2016. RESULTS Forty-nine patients were included in the study. The median starting dose of amikacin was 8.9 mg/kg (IQR 8, 10), and target therapeutic drug levels were achieved at a median of 12 days (IQR 5, 26). The median duration of amikacin treatment was 7.2 months (IQR 5.7, 8), and median time to sputum culture conversion was 1 month (IQR 1,2). Six patients (12.2%) experienced hearing loss based on formal audiometry testing (95% CI 4.6-24.8%); 22.2% had subjective hearing loss (95% CI 11.2-37.1%) and 31.9% subjective tinnitus (95% CI 19.1-47.1%). Ten patients (23%) had a significant rise in serum creatinine (95% CI 11.8-38.6%), but only 5 patients had a GFR < 60 at treatment completion. 84% of patients had a successful treatment outcome (95% CI 84-99%). CONCLUSIONS Low dose amikacin is associated with relatively low rates of aminoglycoside-related adverse events. We hypothesize that low-dose amikacin can be used as a safe and effective treatment for MDR-TB in situations where an adequate regimen cannot be constructed with Group A and B drugs, and where careful monitoring for adverse events is feasible.
Collapse
Affiliation(s)
- Natasha F Sabur
- Department of Respirology, St. Michael's Hospital and West Park Healthcare Centre, Rm 6-049, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - Mantaj S Brar
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Lisa Wu
- West Park Healthcare Centre, Toronto, Canada
| | - Sarah K Brode
- Department of Respirology, Toronto Western Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Canada
| |
Collapse
|
4
|
Corcione S, De Nicolò A, Lupia T, Segala FV, Pensa A, Corgiat Loia R, Romeo MR, Di Perri G, Stella M, D'Avolio A, De Rosa FG. Observed concentrations of amikacin and gentamycin in the setting of burn patients with gram-negative bacterial infections: Preliminary data from a prospective study. Therapie 2020; 76:409-414. [PMID: 33257012 DOI: 10.1016/j.therap.2020.10.003] [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: 05/19/2020] [Revised: 09/19/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
AIM OF THE STUDY Critically ill populations often have shown subtherapeutic aminoglycosides' concentrations mostly because of unavoidable changes in drug volume distribution and clearance. We present a real life prospective study evaluating plasma concentrations for once-daily dosing for amikacin and gentamycin among a population of severe burn adults. METHODS We conducted a real life prospective study on the plasma observed concentrations of amikacin and gentamycin among severe burn patients, using aminoglycoside as combination therapy. Antibiotics were prescribed at the standard doses of 15-20mg/kg/day for amikacin and 3-5mg/kg/day for gentamycin. RESULTS Eight patients (4 in amikacin and 4 in gentamycin groups, respectively) were enrolled in the study. All subjects were admitted for severe burns. The most common site of infection was bloodstream (5; 62.5%) and pneumonia (4; 50%). Pseudomonas aeruginosa, followed by Klebsiella pneumoniae and multi-drug resistant Acinetobacter baumannii were the most prevalent agents isolated. Amikacin and gentamycin never achieved the target peak concentration of 60mg/L and 30mg/L: in our study Cmax, for amikacin, was 33.1±15.6mg/L (SD), while for gentamycin was 14.3mg/L±9. Cmax and total body surface area have shown a strong negative correlation with borderline statistical significance (amikacin: ρ=0.922, P=0.078; gentamycin: ρ=0.937, P=0.063). At the standard dosage, the pharmacokinetic/pharmacodynamic (PK/PD) target of Cmax>8×highest MIC was reached for 8 (53.3%) out of 15 isolated pathogens. CONCLUSIONS The present study found that, in a population of septic burn patients, standard doses of gentamycin and amikacin most often lead to plasma concentrations under the PK/PD target.
Collapse
Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy; Tufts University School of Medicine, 02111 Boston, MA, USA
| | - Amedeo De Nicolò
- Department of Medical Sciences, University of Turin-ASL Città di Torino Laboratory of Clinical Pharmacology and Pharmacogenetics, Amedeo di Savoia Hospital, 10149 Turin, Italy
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy.
| | - Francesco Vladimiro Segala
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy
| | - Anna Pensa
- Burn Centre, C.T.O Hospital, A.O.U.Città della Salute e della Scienza, 10126 Turin, Italy
| | - Riccardo Corgiat Loia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy
| | - Maria Rosa Romeo
- Burn Centre, C.T.O Hospital, A.O.U.Città della Salute e della Scienza, 10126 Turin, Italy
| | - Giovanni Di Perri
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy
| | - Maurizio Stella
- Burn Centre, C.T.O Hospital, A.O.U.Città della Salute e della Scienza, 10126 Turin, Italy
| | - Antonio D'Avolio
- Department of Medical Sciences, University of Turin-ASL Città di Torino Laboratory of Clinical Pharmacology and Pharmacogenetics, Amedeo di Savoia Hospital, 10149 Turin, Italy
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Via Verdi 8, 10124 Turin, Italy
| |
Collapse
|
5
|
Hubab M, Maab H, Hayat A, Ur Rehman M. Burn Wound Microbiology and the Antibiotic Susceptibility Patterns of Bacterial Isolates in Three Burn Units of Abbottabad, Pakistan. J Burn Care Res 2020; 41:1207-1211. [PMID: 32403126 DOI: 10.1093/jbcr/iraa073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Infection is the leading cause of morbidity and mortality among burn patients and is accentuated multifold by the emergence of antimicrobial resistance among the nosocomial isolates. It is vital to know the common organisms involved in infected burn wound etiology and their respective antibiotic susceptibility patterns. These crucial findings can help in formulating a better and more efficient antimicrobial therapy plan for controlling burn wound infections. The current study was conducted to identify the common bacteria involved in causing infections in wounds of burn patients and their respective antibiotic susceptibility patterns in three hospitals of Abbottabad, Pakistan. A total of 100 patients were included from the burn units of three hospitals in Abbottabad. Wound swabs were taken from the deepest portions of infected burns, and the organisms involved were isolated via standard microbiological techniques. The Kirby-Bauer disc diffusion technique was used to monitor antibiotic susceptibility. Gram-positive organisms were found readily in infected burn wounds. Staphylococcus aureus (46%) was the most common isolate followed by Staphylococcus epidermidis (17%), Escherichia coli (16%), Proteus spp. (12%), Klebsiella pneumoniae (10%), and Pseudomonas aeruginosa, which was only 7%. Gram-positive bacteria were sensitive to amikacin, gentamicin, cefotaxime, and norfloxacin. In contrast, the gram-negative isolates were sensitive to amikacin, chloramphenicol, and nalidixic acid. Pseudomonas was resistant to most of the antibiotics tested in the present study.
Collapse
Affiliation(s)
- Muhammad Hubab
- Department of Microbiology, Abbottabad University of Science and Technology, Havelian, Pakistan
| | - Hira Maab
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Azam Hayat
- Department of Microbiology, Abbottabad University of Science and Technology, Havelian, Pakistan
| | - Mujaddad Ur Rehman
- Department of Microbiology, Abbottabad University of Science and Technology, Havelian, Pakistan
| |
Collapse
|
6
|
Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
Collapse
Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
| |
Collapse
|
7
|
Hill DM, Velamuri SR, Lanfranco J, Romero Legro I, Sinclair SE, Hickerson WL. Optimization of an empiric vancomycin dosing algorithm for improved target concentration attainment in patients with thermal injury. Burns 2018; 45:423-432. [PMID: 30340863 DOI: 10.1016/j.burns.2018.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 08/17/2018] [Accepted: 09/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Vancomycin empirical dosing studies in thermally injured patients have netted low successful target attainment and most excluded renal dysfunction, limiting applicability. In a previous study, the authors performed a retrospective analysis of 124 patients' measured pharmacokinetic parameters to calculate optimal dose and interval for intermittent infusion regimens and find predictors of clearance and total daily dose. The objective of this study was to improve the accuracy of attaining goal therapeutic targets with initial vancomycin regimens in patients with thermal injury through retrospective modeling. METHODS In this phase 2 study, variables collected and calculated regimens in phase 1 were utilized to try and create an improved empiric vancomycin dosing algorithm in patients with thermal injury. Logistic regression was utilized to determine best predictors of dosing vancomycin every 6 and 8h. The strongest models were built as individual algorithms and tested for accuracy of target attainment. Each algorithm produced a regimen for each patient that was then tested utilizing each patient's actual measured pharmacokinetic parameters. RESULTS Univariable logistic regression of 41 variables identified 27 and 23 to be predictive of dosing every 8 or 6h, respectively. The most predictive multivariable model for dosing every 8h consisted of creatinine clearance (CrCl)≥80ml/min, Acute Kidney Injury Network classification <1, and total body surface area burned≥10 percent. For dosing every 6h, CrCl≥80ml/min, age≤40years old, days since injury≤6, and serum creatinine (SCr)≤0.8 were most predictive. Based on the top 5 multivariable models for each dosing interval, 7 algorithms were built to produce recommended regimens. The highest performing algorithm resulted in trough concentrations of <10mg/L (23%), 10-20mg/L (65%), 15-20mg/L (26%), and >20mg/L (11%); area under the concentration curve (AUC)>400mghr/L (83%); and AUC >400mghr/L without having a trough >20mg/L (72%). CONCLUSIONS The algorithm that resulted in the highest target attainment without overdosing recommended 15mg/kg dosed every 24h for CrCl≥30, every 12h for CrCl 31-79, every 8h for patients with CrCl≥80ml/min, and every 6h only if the patient with a CrCl≥80ml/min is also≤40 years old and has a SCr≤0.8. Caution is warranted for groups underrepresented in this study, such as those with very low CrCl, a low BMI, or receiving renal replacement therapy. This algorithm should be validated in other centers for patients with thermal injuries.
Collapse
Affiliation(s)
- David M Hill
- Firefighters Burn Center, Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Ave, Memphis, TN 38163, USA.
| | - Sai R Velamuri
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38103, USA.
| | - Julio Lanfranco
- Department of Medicine, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Ivan Romero Legro
- Department of Medicine, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Scott E Sinclair
- Department of Medicine, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - William L Hickerson
- Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38103, USA.
| |
Collapse
|
8
|
Validation of a Nomogram for Achieving Target Trough Concentration of Vancomycin: Accuracy in Patients With Augmented Renal Function. Ther Drug Monit 2018; 40:693-698. [PMID: 30157096 DOI: 10.1097/ftd.0000000000000562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adjustment of initial vancomycin (VCM) dosage has been recommended on the basis of the renal function nomogram in therapeutic drug monitoring guidelines in Japan. However, this nomogram has not been clinically validated, and few studies have focused on its usefulness in patients with risk of augmented renal function. Therefore, this study aimed to evaluate the validity of the VCM nomogram and the association between patient conditions related to augmented renal function and its accuracy. METHODS In this retrospective study, we screened data of 398 patients who received VCM and had estimated glomerular filtration rates ≥30 mL·min·1.73 m. Patients who met nomogram dosing criteria were categorized into a nomogram group, and the associations of age, renal function, and individual conditions such as febrile neutropenia, solid tumor, blood cancer, and brain injury with subtherapeutic concentrations (<10.0 mcg/mL) of VCM were evaluated. RESULTS In total, 177 patients were categorized into the nomogram group, and 83 (47%), 81 (46%), and 13 patients (7%) had VCM trough concentrations of 10-20, <10, and >20 mcg/mL, respectively. Age <50 years was only significantly associated with subtherapeutic trough concentrations. Specific conditions of patients such as febrile neutropenia, solid tumor, and blood cancer were associated with elevated VCM clearance; however, there was no decline in trough VCM concentrations regardless of the presence of the specific conditions. CONCLUSIONS The Japanese VCM dosing nomogram was effective in minimizing the number of instances of supratherapeutic VCM serum concentrations; however, it lacked accuracy in achieving target trough concentrations. The accuracy of the nomogram could be enhanced by categorizing patients according to age. Nevertheless, this study provides novel evidence of the usefulness of this nomogram in avoiding subtherapeutic concentrations of VCM in patients with risk factors for augmented renal clearance.
Collapse
|
9
|
Augmented Renal Clearance in Critically Ill Patients: A Systematic Review. Clin Pharmacokinet 2018; 57:1107-1121. [DOI: 10.1007/s40262-018-0636-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
10
|
Udy AA, Roberts JA, Lipman J, Blot S. The effects of major burn related pathophysiological changes on the pharmacokinetics and pharmacodynamics of drug use: An appraisal utilizing antibiotics. Adv Drug Deliv Rev 2018; 123:65-74. [PMID: 28964882 DOI: 10.1016/j.addr.2017.09.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/31/2017] [Accepted: 09/22/2017] [Indexed: 12/13/2022]
Abstract
Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.
Collapse
|
11
|
Affiliation(s)
- Jing Lu
- West China Hospital, Sichuan University; Department of Pharmacy; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Ming Yang
- West China Hospital, Sichuan University; The Center of Gerontology and Geriatrics; No. 37, Guo Xue Lane Chengdu Sichuan China 610041
| | - Mei Zhan
- West China Hospital, Sichuan University; Department of Pharmacy; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Xuewen Xu
- West China Hospital, Sichuan University; Department of Burns and Plastic Surgery; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Jirong Yue
- West China Hospital, Sichuan University; The Center of Gerontology and Geriatrics; No. 37, Guo Xue Lane Chengdu Sichuan China 610041
| | - Ting Xu
- West China Hospital, Sichuan University; Department of Pharmacy; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| |
Collapse
|
12
|
Lee C, Walker SAN, Walker SE, Seto W, Simor A, Jeschke M. A prospective study evaluating tobramycin pharmacokinetics and optimal once daily dosing in burn patients. Burns 2017. [PMID: 28647460 DOI: 10.1016/j.burns.2017.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Once-daily aminoglycoside dosing (ODA) is used in most patient populations to optimize antibacterial activity and reduce toxicity. Unfortunately, burn patients are excluded from ODA due to concerns over altered pharmacokinetics resulting in a shortened half-life and low peak aminoglycoside concentrations. Retrospective studies suggest that ODA may be appropriate if higher milligram/kilogram doses are used. However, no prospective clinical trials in burn patients exist to confirm these findings. OBJECTIVE To determine the adequacy of once daily tobramycin dosed at 10mg/kg in adult burn patients. METHODS This prospective single dose pharmacokinetic clinical trial was conducted at the Ross Tilley Burn Centre. Patients with a total burn surface area (TBSA) of <20% and creatinine clearance ≥50mL/min were eligible. A first-order one compartment model was used to determine the pharmacokinetic profile from 3 or 5 tobramycin levels over a 24h period per patient. Monte Carlo simulation (MCS) was performed to determine the probability of target level attainment. RESULTS The mean percent TBSA, partial, and full thickness burn were 10%, 6%, and 4%, respectively. Nine of the ten patients recruited achieved peak concentrations of ≥20mg/L (mean of 29.4±5.7mg/L) and all patients had a trough level ≤0.5mg/L. The mean half-life, volume of distribution, and clearance were 2.58h, 0.33L/kg, and 7.40L/h, respectively. The MCS determined probability of attaining target peak concentrations with the 10mg/kg dose was 97%, which almost doubled that predicted with the usual 7mg/kg dose. CONCLUSION Burn patients with adequate renal function and <20% TBSA are candidates for ODA. Tobramycin half-life was similar to healthy, non-burn patients. The larger than normal volume of distribution supports the use of the higher empiric dose of 10mg/kg total body or adjusted weight in non-obese and obese patients, respectively, with further dose adjustment based on therapeutic drug monitoring.
Collapse
Affiliation(s)
- Colin Lee
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Sandra A N Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada.
| | - Scott E Walker
- Sunnybrook Health Sciences Centre (SHSC), Department of Pharmacy, Canada; University of Toronto, Leslie Dan Faculty of Pharmacy, Canada
| | - Winnie Seto
- University of Toronto, Leslie Dan Faculty of Pharmacy, Canada; Hospital for Sick Children (HSC), Department of Pharmacy, Canada
| | - Andrew Simor
- SHSC, Division of Infectious Diseases, Canada; SHSC, Sunnybrook Research Institute, Canada; University of Toronto, Faculty of Medicine, Canada
| | - Marc Jeschke
- University of Toronto, Faculty of Medicine, Canada; SHSC, Ross Tilley Burn Centre, Canada
| |
Collapse
|
13
|
Cota JM, FakhriRavari A, Rowan MP, Chung KK, Murray CK, Akers KS. Intravenous Antibiotic and Antifungal Agent Pharmacokinetic-Pharmacodynamic Dosing in Adults with Severe Burn Injury. Clin Ther 2016; 38:2016-31. [PMID: 27586127 DOI: 10.1016/j.clinthera.2016.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/30/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Despite advances in the care of patients with severe burn injury, infection-related morbidity and mortality remain high and can potentially be reduced with antimicrobial dosing optimized for the infecting pathogen. However, anti-infective dose selection is difficult because of the highly abnormal physiologic features of burn patients, which can greatly affect the pharmacokinetic (PK) disposition of these agents. We review published PK data from burn patients and offer evidence-based dosing recommendations for antimicrobial agents in burn-injured patients. METHODS Because most infections occur at least 48 hours after initial burn injury and anti-infective therapy often lasts ≥10 days, we reviewed published data informing PK-pharmacodynamic (PD) dosing of anti-infectives administered during the second, hypermetabolic stage of burn injury, in those with >20% total body surface area burns, and in those with normal or augmented renal clearance (estimated creatinine clearance ≥130 mL/min). Analyses were performed using 10,000-patient Monte Carlo simulations, which uses PK variability observed in burn patients and MIC data to determine the probability of reaching predefined PK-PD targets. The probability of target attainment, defined as the likelihood that an anti-infective dosing regimen would achieve a specific PK-PD target at the single highest susceptible MIC, and the cumulative fraction of response, defined as the population probability of target attainment given a specific dose and a distribution of MICs, were calculated for each recommended anti-infective dosing regimen. FINDINGS Evidence-based doses were derived for burn-injured patients for 15 antibiotics and 2 antifungal agents. Published data were unavailable or insufficient for several agents important to the care of burn patients, including newer antifungal and antipseudomonal agents. Furthermore, available data suggest that antimicrobial PK properties in burned patients is highly variable. We recommend that, where possible, therapeutic drug monitoring be performed to optimize PK-PD parameter achievement in individual patients. IMPLICATIONS Given the high variability in PK disposition observed in burn patients, doses recommended in the package insert may not achieve PK-PD parameters associated with optimal infectious outcomes. Our study is limited by the necessity for fixed assumptions in depicting this highly variable patient population. New rapid-turnaround analytical technology is needed to expand the menu of antimicrobial agents for which therapeutic drug monitoring is available to guide dose modification within a clinically actionable time frame.
Collapse
Affiliation(s)
- Jason M Cota
- University of the Incarnate Word, Feik School of Pharmacy, San Antonio, Texas
| | | | - Matthew P Rowan
- US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Kevin K Chung
- US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | | | - Kevin S Akers
- US Army Institute of Surgical Research, Fort Sam Houston, Texas.
| |
Collapse
|
14
|
Denny KJ, Cotta MO, Parker SL, Roberts JA, Lipman J. The use and risks of antibiotics in critically ill patients. Expert Opin Drug Saf 2016; 15:667-78. [PMID: 26961691 DOI: 10.1517/14740338.2016.1164690] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The altered pathophysiology in critically ill patients presents a unique challenge in both the diagnosis of infection and the appropriate prescription of antibiotics. In this context, the importance of effective and timely treatment needs to be weighed against the individual and community harms associated with antibiotic collateral damage and antibiotic resistance. AREAS COVERED We evaluate the principles of antibiotic use in critically ill patients, including dose optimisation, use of combination antibiotic therapy, therapeutic drug monitoring, appropriate antibiotic therapy duration, de-escalation, and utilisation of sepsis biomarkers. We also describe the potential risks associated with antibiotic therapy including antibiotic resistance, delayed treatment, treatment failure, and collateral damage. EXPERT OPINION Prescribing teams must be aware of the impact of critical illness on their patients and tailor antibiotic therapy appropriately to prevent the significant harms associated with suboptimal antibiotic administration.
Collapse
Affiliation(s)
- Kerina J Denny
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia
| | - Menino O Cotta
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,c School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Suzanne L Parker
- b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia
| | - Jason A Roberts
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia.,c School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Jeffrey Lipman
- a Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,b Burns, Trauma and Critical Care Research Centre, School of Medicine , The University of Queensland , Brisbane , Australia.,d School of Nursing , Queensland University of Technology , Brisbane , Australia
| |
Collapse
|
15
|
Lu J, Yang M, Zhan M, Xu X, Yue J, Xu T. Antibiotics for treating infected burn wounds. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
16
|
Faris J, Mynatt RP, Hall Snyder AD, Rybak MJ. Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA) Pneumonia with Ceftaroline Fosamil in a Patient with Inhalational Thermal Injury. Infect Dis Ther 2015; 4:519-28. [PMID: 26541469 PMCID: PMC4675765 DOI: 10.1007/s40121-015-0096-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Indexed: 11/30/2022] Open
Abstract
A 48-year-old female, who was found unresponsive and suffered inhalation injury secondary to a house fire, was transferred to our burn center for definitive treatment. Post tracheostomy, the patient became febrile and tachycardic. On hospital day (HD) 5, the patient expressed thick yellow secretions during suctioning and diffuse rhonchi was noted on physical exam. Blood cultures and a culture from the broncheo-alvelolar lavage grew Gram-positive cocci in clusters and the patient was started on empiric vancomycin. Despite aggressive vancomycin dosing (1750 mg intravenously every 6 h), the patient's status continued to deteriorate. The organism was identified as methicillin-resistant Staphylococcus aureus (MRSA) with a vancomycin minimum inhibitory concentration (MIC) of 2 mg/L. Based on the potential for drug-drug interactions with linezolid, the patient was started on ceftaroline fosamil (MIC = 0.5 mg/L) 600 mg intravenously every 8 h with a prolonged 2-h infusion to anticipate suboptimal concentrations secondary to thermal burn injury. Post change in antibiotic therapy, a rapid clinical improvement was observed with the patient becoming afebrile at 48 h after initiation of ceftaroline. The patient completed a total of 14 days of ceftaroline therapy and was subsequently weaned from the ventilator on HD 22 and decannulated 2 days later. To our knowledge, this is the first report of the use of ceftaroline for the treatment of MRSA pneumonia in a patient with thermal injury.
Collapse
Affiliation(s)
- Janie Faris
- Trauma Surgery Critical Care, Department of Pharmacy, Carilion Roanoke Memorial Hospital, 1906 Belleview Avenue, Roanoke, VA, 24014, USA
| | - Ryan P Mynatt
- Detroit Receiving Hospital, Wayne State University, Detroit, MI, USA
| | - Ashley D Hall Snyder
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.
- School of Medicine, Wayne State University, Detroit, MI, USA.
| |
Collapse
|
17
|
Blackburn LM, Tverdek FP, Hernandez M, Bruno JJ. First-dose pharmacokinetics of aminoglycosides in critically ill haematological malignancy patients. Int J Antimicrob Agents 2015; 45:46-53. [DOI: 10.1016/j.ijantimicag.2014.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 08/28/2014] [Accepted: 09/02/2014] [Indexed: 11/27/2022]
|
18
|
Determination of Optimal Amikacin Dosing Regimens for Pediatric Patients With Burn Wound Sepsis. J Burn Care Res 2015; 36:e244-52. [DOI: 10.1097/bcr.0000000000000159] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
19
|
Pharmacokinetics and Pharmacodynamics of Antibacterial and Antifungal Agents in Adult Patients With Thermal Injury. J Burn Care Res 2015; 36:e72-84. [DOI: 10.1097/bcr.0000000000000147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
Wong G, Sime FB, Lipman J, Roberts JA. How do we use therapeutic drug monitoring to improve outcomes from severe infections in critically ill patients? BMC Infect Dis 2014; 14:288. [PMID: 25430961 PMCID: PMC4289211 DOI: 10.1186/1471-2334-14-288] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/23/2014] [Indexed: 11/16/2022] Open
Abstract
High mortality and morbidity rates associated with severe infections in the critically ill continue to be a significant issue for the healthcare system. In view of the diverse and unique pharmacokinetic profile of drugs in this patient population, there is increasing use of therapeutic drug monitoring (TDM) in attempt to optimize the exposure of antibiotics, improve clinical outcome and minimize the emergence of antibiotic resistance. Despite this, a beneficial clinical outcome for TDM of antibiotics has only been demonstrated for aminoglycosides in a general hospital patient population. Clinical outcome studies for other antibiotics remain elusive. Further, there is significant variability among institutions with respect to the practice of TDM including the selection of patients, sampling time for concentration monitoring, methodologies of antibiotic assay, selection of PK/PD targets as well as dose optimisation strategies. The aim of this paper is to review the available evidence relating to practices of antibiotic TDM, and describe how TDM can be applied to potentially improve outcomes from severe infections in the critically ill.
Collapse
Affiliation(s)
| | | | | | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
| |
Collapse
|
21
|
Ma JL, Gao L, Li X, Chu WL, Feng YQ, Wang XQ, Zhang QZ. Comparison of the pharmacokinetics of linezolid in burn and non-burn rabbits. Eur J Drug Metab Pharmacokinet 2014; 40:355-61. [PMID: 24924311 DOI: 10.1007/s13318-014-0209-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 05/31/2014] [Indexed: 11/30/2022]
Abstract
Linezolid is effective on many resistant organisms for the treatment of severe infections in burns. However, its pharmacokinetics was difficult to predict after major burns. The study aimed to describe the pharmacokinetic properties of linezolid administered intravenously at a dose of 10 mg/kg in severely burned rabbits in comparison to that in non-burns. Linezolid concentrations were quantitatively analyzed by high-performance liquid chromatography. The direct consequence of the physiological changes after burn injury was lower plasma linezolid concentrations. In addition, burn injury induced significantly altered pharmacokinetic parameters with higher inter-individual variability. The distribution volume and clearance rate were increased (2.88 vs. 1.92 L/kg, P > 0.05; 0.28 vs. 0.20 L/h/kg, P < 0.05), and the AUC0-∞ was significantly lower (37.99 vs. 51.47 mg/L h, P < 0.05). However, there were almost no changes in half-life and mean residence time. These results suggested that therapeutic drug monitoring and dosage individualization of linezolid in patients with severe burns were necessary.
Collapse
Affiliation(s)
- Jian-Li Ma
- Department of Pharmacy, The First Affiliated Hospital of General Hospital of PLA, 51 Fucheng Road, Beijing, 100048, China,
| | | | | | | | | | | | | |
Collapse
|
22
|
Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, Hope WW, Farkas A, Neely MN, Schentag JJ, Drusano G, Frey OR, Theuretzbacher U, Kuti JL. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. THE LANCET. INFECTIOUS DISEASES 2014; 14:498-509. [PMID: 24768475 DOI: 10.1016/s1473-3099(14)70036-2] [Citation(s) in RCA: 680] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness.
Collapse
Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Johan W Mouton
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Alexander A Vinks
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andras Farkas
- Department of Pharmacy, Nyack Hospital, Nyack, NY, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, CA, USA
| | | | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Otto R Frey
- Department of Pharmacy, Heidenheim Hospital, Heidenheim, Germany
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | | |
Collapse
|
23
|
Determination of Tobramycin Pharmacokinetics in Burn Patients to Evaluate the Potential Utility of Once-Daily Dosing in this Population. J Burn Care Res 2014; 35:e240-9. [DOI: 10.1097/bcr.0b013e3182a226fb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
24
|
Udy AA, Roberts JA, Lipman J. Clinical implications of antibiotic pharmacokinetic principles in the critically ill. Intensive Care Med 2013; 39:2070-82. [DOI: 10.1007/s00134-013-3088-4] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/23/2013] [Indexed: 12/21/2022]
|
25
|
Casu GS, Hites M, Jacobs F, Cotton F, Wolff F, Beumier M, De Backer D, Vincent JL, Taccone FS. Can changes in renal function predict variations in β-lactam concentrations in septic patients? Int J Antimicrob Agents 2013; 42:422-8. [PMID: 23993066 DOI: 10.1016/j.ijantimicag.2013.06.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/23/2013] [Accepted: 06/27/2013] [Indexed: 12/31/2022]
Abstract
This study investigated whether variations in creatinine clearance (CLCr) are correlated with changes in β-lactam concentrations or pharmacokinetics in septic patients. Data for 56 adult patients admitted to the ICU in whom routine therapeutic drug monitoring (TDM) of broad-spectrum β-lactams (ceftazidime, cefepime, piperacillin or meropenem) was performed were reviewed. Patients were included if they had at least two TDM during their ICU stay for the same antibiotic and were not concomitantly treated with any extracorporeal replacement therapy. Serum drug concentrations were measured by HPLC-UV. Antibiotic pharmacokinetics were calculated using a one-compartment model and the percentage of time spent above four times the MIC (%T>4×MIC) for Pseudomonas aeruginosa and the antibiotic clearance (ATB-CL) were obtained. CLCr was measured on the same day as the TDM using 24-h urine collection. The %T>4×MIC and ATB-CL were significantly correlated with CLCr at the first (r=-0.41, P=0.002; r=0.56, P<0.001, respectively) and second (r=-0.61, P<0.001; r=0.63, P<0.001, respectively) TDM. However, changes in ATB-CL were only weakly correlated with changes in CLCr (r=0.34, P=0.01). The proportion of patients with insufficient β-lactam concentrations at the first and second TDM were 39% and 30%, respectively, and increased proportionally to CLCr. Although CLCr was significantly correlated with concentrations and clearance of broad-spectrum β-lactams, changes in CLCr did not reliably predict variations in drug pharmacokinetics/pharmacodynamics. Routine TDM should be considered to adapt β-lactam doses in this setting.
Collapse
Affiliation(s)
- Giuseppe Stefano Casu
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, route de Lennik 808, 1070 Brussels, Belgium
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Sherwin CMT, Wead S, Stockmann C, Healy D, Spigarelli MG, Neely A, Kagan R. Amikacin population pharmacokinetics among paediatric burn patients. Burns 2013; 40:311-8. [PMID: 23876785 DOI: 10.1016/j.burns.2013.06.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 06/13/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The objectives of this study were to (1) determine the pharmacokinetics of amikacin among children with severe burn and (2) identify influential covariates. METHODS Population-based pharmacokinetic modelling was performed in NONMEM 7.2 for hospitalized children who received amikacin at 10-20mg/kg divided two, three, or four times per day as part of early empiric treatment of presumed burn-related sepsis. RESULTS The analysis included data from 70 patients (6 months to 17 years) with 282 amikacin serum concentrations. Amikacin's mean Cmax was 33.2±9.4μg/mL and the mean Cmin was 3.8±4.6μg/mL. The final covariate model estimated clearance as 5.98L/h/70kg (4.97-6.99, 95% CI), the volume of distribution in the central compartment as 16.7L/70kg (14.0-19.4, 95% CI), the volume of distribution in the peripheral compartment as 40.1L/70kg (15.0-80.4, 95% CI), and the inter-compartmental clearance as 3.38L/h/70kg (2.44-4.32, 95% CI). In multivariate analyses, current weight (P<0.001) was a significant covariate, while age, sex, height, serum creatinine, C-reactive protein, platelet count, the extent and type of burn, and concomitant vancomycin administration did not influence amikacin pharmacokinetics. DISCUSSION Children with burn featured elevated amikacin clearance when compared to healthy adult volunteers. However, peak amikacin concentrations are comparable to those attained in other critically-ill children, suggesting that elevated amikacin clearance may not result in sub-therapeutic antibacterial effects. In this study, we found that amikacin displays two-compartment pharmacokinetics, with weight exerting a strong effect upon amikacin clearance. Further pharmacodynamic studies are needed to establish the optimal dosing regimen for amikacin in paediatric burn patients.
Collapse
Affiliation(s)
- Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, Utah, United States.
| | - Stephanie Wead
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio, United States
| | - Chris Stockmann
- Division of Clinical Pharmacology, Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Daniel Healy
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio, United States; The Shriners Hospitals for Children(®), Cincinnati, Ohio, United States
| | - Michael G Spigarelli
- Division of Clinical Pharmacology, Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Alice Neely
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, United States; The Shriners Hospitals for Children(®), Cincinnati, Ohio, United States
| | - Richard Kagan
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, United States; The Shriners Hospitals for Children(®), Cincinnati, Ohio, United States
| |
Collapse
|
27
|
Roberts DJ, Hall RI. Drug absorption, distribution, metabolism and excretion considerations in critically ill adults. Expert Opin Drug Metab Toxicol 2013; 9:1067-84. [PMID: 23682923 DOI: 10.1517/17425255.2013.799137] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION All critically ill patients require medication to treat organ dysfunction. However, the pharmacokinetics of drugs used to treat these patients is complex due to frequent alterations in drug absorption, distribution, metabolism, and excretion (ADME). AREAS COVERED This review examines pharmacokinetic aspects of drug administration for adult intensive care unit (ICU) patients. Specifically, the authors examine the ADME changes that occur and which should be considered by clinicians when delivering drug therapy to critically ill patients. EXPERT OPINION Dosage pharmacokinetics determined from single-dose or limited-duration administration studies in healthy volunteers may not apply to critically ill patients. Organ dysfunction among these patients may be due to pre-existing disease or the effects of a systemic or locoregional inflammatory response precipitated by their illness. Alterations in pharmacokinetics observed among the critically ill include altered bioavailability after enteral administration, increased volume of distribution and blood-brain barrier permeability and changes in P-glycoprotein and cytochrome P450 enzyme function. However, the effect of these changes on clinically important outcomes remains uncertain and poorly studied. Future investigations should examine not only pharmacokinetic changes among the critically ill, but also whether recognition of these changes and alterations in drug therapy directed as a consequence of their observation alters patient outcomes.
Collapse
Affiliation(s)
- Derek J Roberts
- University of Calgary, Departments of Surgery and Community Health Sciences, Calgary, Alberta T2N 5A1, Canada
| | | |
Collapse
|
28
|
Once-daily amikacin dosing in burn patients treated with continuous venovenous hemofiltration. Antimicrob Agents Chemother 2011; 55:4639-42. [PMID: 21825289 DOI: 10.1128/aac.00374-11] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Amikacin clearance can be increased in burn injury, which is often complicated by renal insufficiency. Little is known about the impact of renal replacement therapies, such as continuous venovenous hemofiltration (CVVH), on amikacin pharmacokinetics. We retrospectively examined the clinical pharmacokinetics, bacteriology, and clinical outcomes of 60 burn patients given 15 mg/kg of body weight of amikacin in single daily doses. Twelve were treated with concurrent CVVH therapy, and 48 were not. The pharmacodynamic target of ≥10 for the maximum concentration of drug in serum divided by the MIC (C(max)/MIC) was achieved in only 8.5% of patients, with a small reduction of C(max) in patients receiving CVVH and no difference in amikacin clearance. Mortality and burn size were greater in patients who received CVVH. Overall, 172 Gram-negative isolates were recovered from the blood cultures of 39 patients, with amikacin MIC data available for 82 isolates from 24 patients. A 10,000-patient Monte Carlo simulation was conducted incorporating pharmacokinetic and MIC data from these patients. The cumulative fraction of response (CFR) was similar in CVVH and non-CVVH patients. The CFR rates were not significantly improved by a theoretical 20 mg/kg amikacin dose. Overall, CVVH did not appear to have a major impact on amikacin serum concentrations. The low pharmacodynamic target attainment appears to be primarily due to higher amikacin MICs rather than more rapid clearance of amikacin related to CVVH therapy.
Collapse
|
29
|
Venisse N, Boulamery A. [Level of evidence for therapeutic drug monitoring of aminoglycosides]. Therapie 2011; 66:39-44. [PMID: 21466776 DOI: 10.2515/therapie/2011001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 04/27/2010] [Indexed: 12/20/2022]
Abstract
Aminoglycosides are major antibiotics indicated for the treatment of infection with gram-negative bacilli. They are characterized by high clinical effectiveness but their main drawback is the occurrence of toxicity in a significant number of patients. Pharmacokinetic parameters of aminoglycosides exhibit wide inter-individual variability and the relationships between concentration and effect have been clearly demonstrated. Consistent studies have demonstrated that therapeutic drug monitoring (TDM) of aminoglycosides administered in multiple daily doses was cost-effective in maximising antibiotic efficacy and/or reducing incidence of toxicity. Therefore TDM of aminoglycosides should be considered "essential". Level of evidence for TDM of aminoglycosides administered once daily is not so clearly demonstrated however it should be highly recommended.
Collapse
Affiliation(s)
- Nicolas Venisse
- Service de Toxicologie et Pharmacocinétique, CHU, Poitiers, France. n.venisse@chu--poitiers.fr
| | | | | |
Collapse
|
30
|
Conil JM, Georges B, Ruiz S, Rival T, Seguin T, Cougot P, Fourcade O, Pharmd GH, Saivin S. Tobramycin disposition in ICU patients receiving a once daily regimen: population approach and dosage simulations. Br J Clin Pharmacol 2011; 71:61-71. [PMID: 21143502 DOI: 10.1111/j.1365-2125.2010.03793.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT? It is well known that tobramycin given as an once daily dose according to the usual recommendations needs therapeutic drug monitoring by measurement of peak and trough concentrations. In the literature, there are only few published studies on the population pharmacokinetics of once daily tobramycin in critically ill patients. Glomerular filtration rate and bodyweight were identified as covariates contributing to the inter-individual variability in the disposition of aminoglycosides. The study, by Peris-Marti et al. [24], only evaluated the pharmacodynamic effectiveness of a 4 mg kg(-1) dose of tobramycin given once daily in critically ill patients. The authors concluded with a simulation showing that for a theoretical MIC of 1 or 2 mg l(-1) , a 7 mg kg(-1) dose was required. WHAT THIS STUDY ADDS Our results confirm the high variability of tobramycin disposition in intensive care patients and consequently the possible lack of effectiveness. By using a population pharmacokinetic approach, two explicative covariates (height and Cockcroft creatinine clearance) added to a two-compartment model with proportional error, explained much of the inter-individual variability of tobramycin disposition in the critically ill patient population. In a median ICU patient, simulations were performed at various dosage regimens and peak and AUC pharmacodynamic targets could not be reached simultaneously in more than 45% of the ICU patient population. Drug monitoring is required to manage efficacy and toxicity. AIM The aim of this study was to evaluate the disposition of tobramycin (TOB) in critically ill patients (ICU) by a population pharmacokinetic approach, to determine the covariates involved, and to simulate tobramycin dosage regimens. METHODS Forty-nine adult ICU patients received TOB (5 mg kg(-1) ) once daily. NonMem modelling was performed on 32 patients. The 17 other patients were used for the qualification process by normalized prediction distribution error. Then Monte Carlo simulations (MCS) were performed. RESULTS A two-compartment model with a proportional error best fitted the data. TOB total clearance (CL(TOB) ) was significantly correlated with Cockcroft creatinine clearance (COCK) and height. TOB clearance was 4.8 ± 1.9 l h(-1) (range 1.22-8.95), the volume of distribution of the central compartment was 24.7 ± 3.7 l (range 17.34-32.83) and that of the peripheral compartment and the inter-compartmental clearance were 30.6 l and 4.74 l h(-1) , respectively. Only 29% of the patients presented a target AUC between 80 and 125 mg l(-1) h and 61% were lower than 80 mg l(-1) h. After considering COCK and height, MCS showed that only 50% of the population could achieve the target AUC for the 375 and 400 mg dosages. CONCLUSION Even after taking into account COCK and height, for strains with an MIC ≤ 1 mg l(-1) , MCS doses evidenced that peak and AUC pharmacodynamic targets could not be reached simultaneously in more than 45% of the ICU patient population. Combination therapy in addition to drug monitoring are required to manage efficacy and toxicity.
Collapse
Affiliation(s)
- Jean-Marie Conil
- Pôle d'Anesthésie-Réanimation, Hôpital de Rangueil, Toulouse Cedex 9 , France
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Minville V, Asehnoune K, Ruiz S, Breden A, Georges B, Seguin T, Tack I, Jaafar A, Saivin S, Fourcade O, Samii K, Conil JM. Increased creatinine clearance in polytrauma patients with normal serum creatinine: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R49. [PMID: 21291554 PMCID: PMC3221979 DOI: 10.1186/cc10013] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 09/06/2010] [Accepted: 02/03/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The aim of this study, performed in an intensive care unit (ICU) population with a normal serum creatinine, was to estimate urinary creatinine clearance (CLCR) in a population of polytrauma patients (PT) through a comparison with a population of non trauma patients (NPT). METHODS This was a retrospective, observational study in a medical and surgical ICU in a university hospital. A total of 284 patients were consecutively included. Two different groups were studied: PT (n = 144) and NPT (n = 140). Within the second week after admission to the ICU, renal function was assessed using serum creatinine, 24 h urinary CLCR . RESULTS Among the 106 patients with a CLCR above 120 mL minute(-1) 1.73 m(-2), 79 were PT and 27 NPT (P < 0.0001). Only 63 patients had a CLCR below 60 mL minute(-1) 1.73 m(-2) with 15 PT and 48 NPT (P < 0.0001). Patients with CLCR greater than 120 mL minute(-1). 1.73 m(-2) were younger, had a lower SAPS II score and a higher male ratio as compared to those having CLCR lower than 120 mL minute(-1). 1.73 m(-2). Through a logistic regression analysis, age and trauma were the only factors independently correlated to CLCR. CONCLUSIONS In ICU patients with normal serum creatinine, CLCR, is higher in PT than in NPT. The measure of CLCR should be proposed as routine for PT patients in order to adjust dose regimen, especially for drugs with renal elimination.
Collapse
Affiliation(s)
- Vincent Minville
- Department of Anesthesiology and Intensive Care, GRCB 48, IFR 150, Toulouse University Hospital, Toulouse, France.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Ravat F, Le-Floch R, Vinsonneau C, Ainaud P, Bertin-Maghit M, Carsin H, Perro G. Antibiotics and the burn patient. Burns 2011; 37:16-26. [DOI: 10.1016/j.burns.2009.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 09/15/2009] [Accepted: 10/13/2009] [Indexed: 12/22/2022]
|
33
|
Radigan EA, Gilchrist NA, Miller MA. Management of aminoglycosides in the intensive care unit. J Intensive Care Med 2010; 25:327-42. [PMID: 20837630 DOI: 10.1177/0885066610377968] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antibacterial resistance is increasing throughout the world, while the development of new agents is slowly progressing. In addition, the increasing prevalence of fluoroquinolone resistance may force many practitioners to choose an aminoglycoside agent in gram-negative regimens. Aminoglycosides are bactericidal agents with potent activity against gram-negative infections and activity against gram-positive infections when added to a cell wall active antimicrobial-based regimen. These agents may be dosed multiple times a day or consolidated as high-dose, extended-interval dosing to maximize pharmacokinetic and pharmacodynamic properties to achieve possible improved efficacy with reduced toxicity. Clinical application includes the treatment of bacteremia, endocarditis, health-care and nosocomial pneumonias, intra-abdominal infections, and others. Nephrotoxicity and ototoxicity are potential risks of aminoglycoside therapy that may be minimized with serum monitoring and short courses of therapy.
Collapse
Affiliation(s)
- Elizabeth A Radigan
- Department of Pharmacy, Infectious Diseases, UMass Memorial Medical Center, Worcester, MA 01655, USA.
| | | | | |
Collapse
|
34
|
Udy AA, Putt MT, Shanmugathasan S, Roberts JA, Lipman J. Augmented renal clearance in the Intensive Care Unit: an illustrative case series. Int J Antimicrob Agents 2010; 35:606-8. [DOI: 10.1016/j.ijantimicag.2010.02.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 02/11/2010] [Accepted: 02/13/2010] [Indexed: 11/26/2022]
|
35
|
de Gatta MDMF, Moreno SR, Calvo MV, Ardanuy R, Domínguez-Gil A, Lanao JM. Evaluation of population pharmacokinetic models for amikacin dosage individualization in critically ill patients. J Pharm Pharmacol 2010. [DOI: 10.1211/jpp.61.06.0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Objectives
The aim of this study was to evaluate the reliability for dosage individualization and Bayesian adaptive control of several literature-retrieved amikacin population pharmacokinetic models in patients who were critically ill.
Methods
Four population pharmacokinetic models, three of them customized for critically-ill patients, were applied using pharmacokinetic software to fifty-one adult patients on conventional amikacin therapy admitted to the intensive care unit. An estimation of patient-specific pharmacokinetic parameters for each model was obtained by retrospective analysis of the amikacin serum concentrations measured (n = 162) and different clinical covariates. The model performance for a priori estimation of the area under the serum concentration-time curve (AUC) and maximum serum drug concentration (Cmax) targets was obtained.
Key findings
Our results provided valuable confirmation of the clinical importance of the choice of population pharmacokinetic models when selecting amikacin dosages for patients who are critically ill. Significant differences in model performance were especially evident when only information concerning clinical covariates was used for dosage individualization and over the two most critical determinants of clinical efficacy of amikacin i.e. the AUC and Cmax values.
Conclusions
Only a single amikacin serum level seemed necessary to diminish the influence of population model on dosage individualization.
Collapse
Affiliation(s)
| | | | | | - Ramón Ardanuy
- Department of Statistics Faculty of Sciences, University of Salamanca, Spain
| | - Alfonso Domínguez-Gil
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Spain
- Pharmacy Service, University Hospital of Salamanca, Spain
| | - José M Lanao
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Salamanca, Spain
| |
Collapse
|
36
|
|
37
|
|
38
|
|
39
|
Le Floch R, Arnould JF, Pilorget A, Dally E, Naux E. [Antimicrobial blood concentrations in burns. A five years' retrospective survey]. ACTA ACUST UNITED AC 2009; 58:137-43. [PMID: 19854584 DOI: 10.1016/j.patbio.2009.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Accepted: 07/19/2009] [Indexed: 11/26/2022]
Abstract
The monitoring of antimicrobial agents is a routine in our unit. We reviewed the results either of peak-and-through concentrations (peak and through is one sample) or concentrations at steady state (Css) of all antimicrobials given over five years (2001 to 2005) and studied the antimicrobials with at least 20 samples. We found 706 samples in 122 patients, the antimicrobials being amikacin, amoxicillin, ceftazidime, ciprofloxacin, cloxacillin, gentamicin, imipenem, ofloxacin, tobramycin and vancomycin. When comparing samples in witch the concentrations were above a value thought to be predictive of efficacy to those were not, we could notice: that no parameter about patients or burn surface was predictable for achieving targeted blood concentration; that usual regimen could not achieve targeted concentrations, excepted with ceftazidime, provided it was used in continuous infusion; that, with the other beta-lactams, continuous infusion was more likely to achieve targeted blood concentrations; that, with fluoroquinolones, both higher and more frequent injections were needed; that, with aminoglycosides used once a day, the dosage had to be higher than usually recommended. We conclude that antimicrobial regimen should be altered in burns and that a monitoring of blood concentrations should be performed in these patients.
Collapse
Affiliation(s)
- R Le Floch
- Service d'anesthésie et des brûlés, CHU de Nantes, 44093 Nantes cedex 01, France.
| | | | | | | | | |
Collapse
|
40
|
Pea F, Viale P. Bench-to-bedside review: Appropriate antibiotic therapy in severe sepsis and septic shock--does the dose matter? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:214. [PMID: 19519961 PMCID: PMC2717408 DOI: 10.1186/cc7774] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Appropriate antibiotic therapy in patients with severe sepsis and septic shock should mean prompt achievement and maintenance of optimal exposure at the infection site with broad-spectrum antimicrobial agents administered in a timely manner. Once the causative pathogens have been identified and tested for in vitro susceptibility, subsequent de-escalation of antimicrobial therapy should be applied whenever feasible. The goal of appropriate antibiotic therapy must be pursued resolutely and with continuity, in view of the ongoing explosion of antibiotic-resistant infections that plague the intensive care unit setting and of the continued decrease in new antibiotics emerging. This article provides some principles for the correct handling of antimicrobial dosing regimens in patients with severe sepsis and septic shock, in whom various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs.
Collapse
Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology, Institute of Clinical Pharmacology & Toxicology, Medical School, University of Udine, 33100 Udine, Italy.
| | | |
Collapse
|
41
|
[Guidelines for use of antibiotics in burn patient at the acute phase--long text. Société française d'étude et de traitement des brûlures]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:265-274. [PMID: 19324514 DOI: 10.1016/j.annfar.2008.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2008] [Accepted: 12/22/2008] [Indexed: 05/27/2023]
|
42
|
Bracco D, Landry C, Dubois MJ, Eggimann P. Pharmacokinetic variability of extended interval tobramycin in burn patients. Burns 2008; 34:791-6. [PMID: 18395988 DOI: 10.1016/j.burns.2007.11.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2007] [Accepted: 11/06/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aminoglycosides are mandatory in the treatment of severe infections in burns. However, their pharmacokinetics are difficult to predict in critically ill patients. Our objective was to describe the pharmacokinetic parameters of high doses of tobramycin administered at extended intervals in severely burned patients. METHODS We prospectively enrolled 23 burned patients receiving tobramycin in combination therapy for Pseudomonas species infections in a burn ICU over 2 years in a therapeutic drug monitoring program. Trough and post peak tobramycin levels were measured to adjust drug dosage. Pharmacokinetic parameters were derived from two points first order kinetics. RESULTS Tobramycin peak concentration was 7.4 (3.1-19.6)microg/ml and Cmax/MIC ratio 14.8 (2.8-39.2). Half-life was 6.9 (range 1.8-24.6)h with a distribution volume of 0.4 (0.2-1.0)l/kg. Clearance was 35 (14-121)ml/min and was weakly but significantly correlated with creatinine clearance. CONCLUSION Tobramycin had a normal clearance, but an increased volume of distribution and a prolonged half-life in burned patients. However, the pharmacokinetic parameters of tobramycin are highly variable in burned patients. These data support extended interval administration and strongly suggest that aminoglycosides should only be used within a structured pharmacokinetic monitoring program.
Collapse
Affiliation(s)
- David Bracco
- Montreal Burn Centre, Montreal University Hospital, Campus Hotel Dieu, Montreal, Canada.
| | | | | | | |
Collapse
|
43
|
Abstract
PURPOSE OF REVIEW This article reviews and critiques new developments in the critical care of burn patients. RECENT FINDINGS The practice of restrictive transfusion is slowly gaining traction. Abdominal compartment syndrome is associated with resuscitation volumes of 300 ml/kg per 24 h, and percutaneous decompression may be a treatment option. Adrenal insufficiency is common, but whom and when to treat are unclear. Imaging or noninvasive monitoring may confirm renal perfusion before urine output, and the concept of permissive hypovolemia should be explored. There is progress in the laboratory in smoke inhalation and myocardial depression, but no human translation. Antibiotic pharmacokinetics in large burns are unpredictable, and so aminoglycosides (measurable concentrations) are not obsolete. Selective digestive decontamination remains controversial. Nutritional predictions by formula are inaccurate. Oxandrolone is safe and effective in promoting anabolism in large burns. Deep venous thrombosis prophylaxis remains guided only by expert opinion. Females fare worse than male patients after burns. SUMMARY The application of the scientific method to burn care is improving slowly. Randomized controlled trials are becoming more common. There is a need for translation of excellent animal work to the human arena.
Collapse
Affiliation(s)
- Nicholas Namias
- Department of Surgery, University of Miami/Miller School of Medicine, Miami, Florida 33101, USA.
| |
Collapse
|