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Hypoalbuminemia and Pharmacokinetics: When the Misunderstanding of a Fundamental Concept Leads to Repeated Errors over Decades. Antibiotics (Basel) 2023; 12:antibiotics12030515. [PMID: 36978382 PMCID: PMC10044130 DOI: 10.3390/antibiotics12030515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Surprisingly, misinterpretation of the influence of hypoalbuminemia on pharmacokinetics and the clinical effects of drugs seems to be a current problem, even though hypoalbuminemia has no impact on the pharmacologically active exposure. Exceptions to this fact are highly protein-bound anaesthetics with high elimination capacity (i.e., <5 drugs on the market). To assess the frequency of misinterpretation of the influence of hypoalbuminemia on pharmacokinetics and the clinical effects of drugs between 1975 and 2021, a PubMed literature review was conducted. Each paragraph on albumin binding was classified as correct, ambiguous or incorrect, creating two acceptable categories: (1) content without any errors, and (2) content containing some incorrect and/or ambiguous statements. The analyses of these articles showed that fewer than 11% of articles contained no interpretation errors. In order to contain this misinterpretation, several measures are proposed: (1) Make the message accessible to a wide audience by offering a simplified and didactic video representation of the lack of impact of albumin binding to drugs. (2) Precise terminology (unbound/free form/concentration) should be used for highly bound drugs. (3) Unbound/free forms should be systematically quantified for highly plasma protein bound drugs for clinical trials as well as for therapeutic drug monitoring.
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McAleenan A, Ambrose PG, Bhavnani SM, Drusano GL, Hope WW, Mouton JW, Higgins JPT, MacGowan AP. Methodological features of clinical pharmacokinetic-pharmacodynamic studies of antibacterials and antifungals: a systematic review. J Antimicrob Chemother 2021; 75:1374-1389. [PMID: 32083674 DOI: 10.1093/jac/dkaa005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK)-pharmacodynamic (PD) indices relate measures of drug exposure to antibacterial effect. Clinical PK-PD studies aim to correlate PK-PD indices with outcomes in patients. Optimization of dosing based on pre-clinical studies means that PK-PD relationships are difficult to establish; therefore studies need to be designed and reported carefully to validate pre-clinical findings. OBJECTIVES To describe the methodological features of clinical antibacterial and antifungal PK-PD studies that reported the relationship between PK-PD indices and clinical or microbiological responses. METHODS Studies published between 1980 and 2015 were identified through systematic searches. Methodological features of eligible studies were extracted. RESULTS We identified 85 publications containing 97 PK-PD analyses. Most studies were small, with fewer than 100 patients. Around a quarter were performed on patients with infections due to a single specific pathogen. In approximately one-third of studies, patients received concurrent antibiotics/antifungals and in some other studies patients received other treatments that may confound the PK-PD-outcome relationship. Most studies measured antimicrobial concentrations in blood/serum and only four measured free concentrations. Most performed some form of regression, time-to-event analysis or used the Hill/Emax equation to examine the association between PK-PD index and outcome. Target values of PK-PD indices that predict outcomes were investigated in 52% of studies. Target identification was most commonly done using recursive partitioning or logistic regression. CONCLUSIONS Given the variability in conduct and reporting, we suggest that an agreed set of standards for the conduct and reporting of studies should be developed.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Paul G Ambrose
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - Sujata M Bhavnani
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - George L Drusano
- Institute for Therapeutic Innovation, Department of Medicine, University of Florida, UF Research and Academic Center at Lake Nowa, 6550 Sanger Road, Orlando, Florida 32827, USA
| | - William W Hope
- Centre for Antimicrobial Pharmacodynamics, Institute of Translational Medicine, University of Liverpool, Liverpool L69 4BX, UK
| | - Johan W Mouton
- Department of Medical Microbiology & Infectious Diseases, Erasmus Medical Centre, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation, Infection Sciences, Pathology Science Quarter, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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Fujii M, Karumai T, Yamamoto R, Kobayashi E, Ogawa K, Tounai M, Lipman J, Hayashi Y. Pharmacokinetic and pharmacodynamic considerations in antimicrobial therapy for sepsis. Expert Opin Drug Metab Toxicol 2020; 16:415-430. [DOI: 10.1080/17425255.2020.1750597] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Motoki Fujii
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Infectious Disease, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Toshiyuki Karumai
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Ryohei Yamamoto
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Eri Kobayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Kenta Ogawa
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Mayuko Tounai
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
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Don't Get Wound Up: Revised Fluoroquinolone Breakpoints for Enterobacteriaceae and Pseudomonas aeruginosa. J Clin Microbiol 2019; 57:JCM.02072-18. [PMID: 31043468 DOI: 10.1128/jcm.02072-18] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Fluoroquinolones remain some of the more commonly prescribed antimicrobial agents in the United States, despite the wide array of reported side effects that are associated with their use. In 2019, the Clinical and Laboratory Standards Institute revised the fluoroquinolone antimicrobial susceptibility testing breakpoints for both Enterobacteriaceae and Pseudomonas aeruginosa This breakpoint revision was deemed necessary on the basis of pharmacokinetic and pharmacodynamic analyses suggesting that the previous breakpoints were too high, in addition to the inability of the previous breakpoints to detect low-level resistance to this antibiotic class. In this minireview, we review the published data in support of this revision, as well as the potential challenges that these breakpoint revisions are likely to pose for clinical laboratories.
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El-Najjar N, Hösl J, Holzmann T, Jantsch J, Gessner A. UPLC-MS/MS method for therapeutic drug monitoring of 10 antibiotics used in intensive care units. Drug Test Anal 2017; 10:584-591. [PMID: 28753737 DOI: 10.1002/dta.2253] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/20/2017] [Accepted: 07/24/2017] [Indexed: 12/27/2022]
Abstract
A large variation in the levels of different ß-lactams and other antibiotics used in critically ill patients has been documented. The aim of this study is to establish and validate a fast, ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for the simultaneous analysis of ten antibiotics (Meropenem, Cefepime, Ceftazidime, Piperacillin, Benzylpenicillin, Ampicillin, Flucloxacillin, Linezolid, and Sulfamethoxazole/Trimethoprim) in human plasma according to European Medicines Agency (EMA) guidelines. Protein precipitation with ice-cold methanol containing 9 isotopically labeled internal standards was used for sample clean up. Antibiotics were detected, following a 4-minute gradient separation, in multiple reactions monitoring (MRM) using API 4000 instrument equipped with electrospray source operating in positive ion mode. The lower limit of quantification was 0.1 mg/L for Meropenem, Ceftazidime, Piperacillin, Ampicillin, Flucloxacillin, and Sulfamethoxazole; 0.05 mg/L for Cefepime, Benzylpenicillin, and Trimethoprim; and 0.02 mg/L for Linezolid. The method proved to be precise and accurate and applicable for therapeutic drug monitoring and other pharmacokinetic studies.
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Affiliation(s)
- Nahed El-Najjar
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Germany
| | - Julian Hösl
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - Thomas Holzmann
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - Jonathan Jantsch
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Germany
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El-Najjar N, Jantsch J, Gessner A. The use of liquid chromatography-tandem mass spectrometry for therapeutic drug monitoring of antibiotics in cancer patients. ACTA ACUST UNITED AC 2017; 55:1246-1261. [DOI: 10.1515/cclm-2016-0700] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/28/2016] [Indexed: 12/24/2022]
Abstract
AbstractCancer remains a leading cause of mortality and morbidity worldwide. In addition to organ failure, the most frequent reasons for admission of cancer patients to intensive care units (ICU) are: infections and sepsis. As critically ill, the complexity of the health situation of cancer patients renders the standard antimicrobial regimen more complex and even inadequate which results in increased mortality rates. This is due to pathophysiological changes in the volume of distribution, increased clearance, as well as to organ dysfunction. While in the former cases a decrease in drug efficacy is observed, the hallmark of the latter one is overdosing leading to increased toxicity at the expense of efficacy. Furthermore, an additional risk factor is the potential drug-drug interaction between antibiotics and antineoplastic agents. Therefore, therapeutic drug monitoring (TDM) is a necessity to improve the clinical outcome of antimicrobial therapy in cancer patients. To be applied in routine analysis the method used for TDM should be cheap, fast and highly accurate/sensitive. Furthermore, as ICU patients are treated with a cocktail of antibiotics the method has to cover the simultaneous analysis of antibiotics used as a first/second line of treatment. The aim of the current review is to briefly survey the pitfalls in the current antimicrobial therapy and the central role of TDM in dose adjustment and drug-drug interaction’s evaluation. A major section is dedicated to summarize the currently published analytical methods and to shed light on the difficulties and potential problems that can be encountered during method development.
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Mitsuboshi S, Yamada H, Nagai K, Ueno K. No effect of protein binding ratio of levofloxacin in hemodialysis patients. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0042-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Hites M, Taccone FS. Optimization of antibiotic therapy in the obese, critically ill patient. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1060-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Safarika A, Galani I, Pistiki A, Giamarellos-Bourboulis EJ. Time–kill effect of levofloxacin on multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii: synergism with imipenem and colistin. Eur J Clin Microbiol Infect Dis 2014; 34:317-23. [DOI: 10.1007/s10096-014-2231-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
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Chant C, Leung A, Friedrich JO. Optimal dosing of antibiotics in critically ill patients by using continuous/extended infusions: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R279. [PMID: 24289230 PMCID: PMC4056781 DOI: 10.1186/cc13134] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
Introduction The aim of this study was to determine whether using pharmacodynamic-based dosing of antimicrobials, such as extended/continuous infusions, in critically ill patients is associated with improved outcomes as compared with traditional dosing methods. Methods We searched Medline, HealthStar, EMBASE, Cochrane Clinical Trial Registry, and CINAHL from inception to September 2013 without language restrictions for studies comparing the use of extended/continuous infusions with traditional dosing. Two authors independently selected studies, extracted data on methodology and outcomes, and performed quality assessment. Meta-analyses were performed by using random-effects models. Results Of 1,319 citations, 13 randomized controlled trials (RCTs) (n = 782 patients) and 13 cohort studies (n = 2,117 patients) met the inclusion criteria. Compared with traditional non-pharmacodynamic-based dosing, RCTs of continuous/extended infusions significantly reduced clinical failure rates (relative risk (RR) 0.68; 95% confidence interval (CI) 0.49 to 0.94, P = 0.02) and intensive care unit length of stay (mean difference, −1.5; 95% CI, −2.8 to −0.2 days, P = 0.02), but not mortality (RR, 0.87; 95% CI, 0.64 to 1.19; P = 0.38). No significant between-trial heterogeneity was found for these analyses (I2 = 0). Reduced mortality rates almost achieved statistical significance when the results of all included studies (RCTs and cohort studies) were pooled (RR, 0.83; 95% CI, 0.69 to 1.00; P = 0.054). Conclusions Pooled results from small RCTs suggest reduced clinical failure rates and intensive care unit length-of-stay when using continuous/extended infusions of antibiotics in critically ill patients. Reduced mortality rates almost achieved statistical significance when the results of RCTs were combined with cohort studies. These results support the conduct of adequately powered RCTs to define better the utility of continuous/extended infusions in the era of antibiotic resistance.
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Kontou P, Manika K, Chatzika K, Papaioannou M, Sionidou M, Pitsiou G, Kioumis I. Pharmacokinetics of moxifloxacin and high-dose levofloxacin in severe lower respiratory tract infections. Int J Antimicrob Agents 2013; 42:262-7. [PMID: 23830621 DOI: 10.1016/j.ijantimicag.2013.04.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/25/2013] [Accepted: 04/26/2013] [Indexed: 01/30/2023]
Abstract
This study evaluated the pharmacokinetics of intravenous moxifloxacin 400 mg once and levofloxacin 500 mg twice daily in patients with lower respiratory tract infections (LRTIs) and assessed their pharmacodynamic adequacy against common respiratory pathogens. Eighteen patients with LRTIs hospitalised in general wards were included. Serial blood samples were obtained at steady state and concentrations were determined using HPLC. Pharmacokinetic variables were estimated by a two-compartment model. The characteristic pharmacodynamic parameter for fluoroquinolones (AUC(0-24)/MIC) was calculated. Peak and trough concentrations were, respectively, 4.81 ± 1.03 and 0.59 ± 1.13 mg/L for moxifloxacin and 6.42 ± 1.08 and 0.79 ± 0.39 mg/L for levofloxacin. Pharmacokinetic data for moxifloxacin and levofloxacin, respectively, were: CL, 10.27 ± 1.24 and 22.66 ± 6.62 L/h; t1/2, 13.43 ± 5.12 and 6.75 ± 1.34 h; Vss, 163.03 ± 53.88 and 170.73 ± 39.59 L; and AUC(0-24), 39.38 ±5.28 and 47.06 ± 14.09 mg·h/L. The pharmacodynamic target was attained in all patients by both antibiotics against the majority of respiratory pathogens. Moxifloxacin proved to be pharmacodynamically efficacious against Gram-positive bacteria with MICs ≤ 0.79 mg/L and Gram-negative bacteria with MICs ≤ 0.32 mg/L. These MIC thresholds for levofloxacin were 1.1 mg/L and 0.38 mg/L, respectively. Moxifloxacin and high-dose levofloxacin show a favourable pharmacokinetic profile in plasma of patients with severe LRTIs, without significant interpatient variability. They ensure optimal pharmacodynamic exposure against the majority of microbes involved in these infections. However, the predicted efficacy against Gram-negative bacteria with MICs ≥ 0.5 mg/L appears to be low.
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Affiliation(s)
- Paschalina Kontou
- A' Intensive Care Unit, G. Papanikolaou Hospital, Thessaloniki, Greece
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Zhang J, Xie X, Zhou X, Chen YQ, Yu JC, Cao GY, Wu XJ, Shi YG, Zhang YY. Permeability and Concentration of Levofloxacin in Epithelial Lining Fluid in Patients With Lower Respiratory Tract Infections. J Clin Pharmacol 2013; 50:922-8. [DOI: 10.1177/0091270009355160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Asín E, Isla A, Canut A, Rodríguez Gascón A. Comparison of antimicrobial pharmacokinetic/pharmacodynamic breakpoints with EUCAST and CLSI clinical breakpoints for Gram-positive bacteria. Int J Antimicrob Agents 2012; 40:313-22. [PMID: 22921422 DOI: 10.1016/j.ijantimicag.2012.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/20/2012] [Accepted: 06/08/2012] [Indexed: 11/28/2022]
Abstract
This study compared the susceptibility breakpoints based on pharmacokinetic/pharmacodynamic (PK/PD) models and Monte Carlo simulation with those defined by the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST) for antibiotics used for the treatment of infections caused by Gram-positive bacteria. A secondary objective was to evaluate the probability of achieving the PK/PD target associated with the success of antimicrobial therapy. A 10,000-subject Monte Carlo simulation was executed to evaluate 13 antimicrobials (47 intravenous dosing regimens). Susceptibility data were extracted from the British Society for Antimicrobial Chemotherapy database for bacteraemia isolates. The probability of target attainment and the cumulative fraction of response (CFR) were calculated. No antibiotic was predicted to be effective (CFR≥90%) against all microorganisms. The PK/PD susceptibility breakpoints were also estimated and were compared with CLSI and EUCAST breakpoints. The percentages of strains affected by breakpoint discrepancies were calculated. In the case of β-lactams, breakpoint discrepancies affected <15% of strains. However, higher differences were detected for low doses of vancomycin, daptomycin and linezolid, with PK/PD breakpoints being lower than those defined by the CLSI and EUCAST. If this occurs, an isolate will be considered susceptible based on CLSI and EUCAST breakpoints although the PK/PD analysis predicts failure, which may explain treatment failures reported in the literature. This study reinforces the idea of considering not only the antimicrobial activity but also the dosing regimen to increase the probability of clinical success of an antimicrobial treatment.
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Affiliation(s)
- Eduardo Asín
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, University of the Basque Country, 01006 Vitoria-Gasteiz, Spain
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Theuretzbacher U. Pharmacokinetic and Pharmacodynamic Issues for Antimicrobial Therapy in Patients With Cancer. Clin Infect Dis 2012; 54:1785-92. [DOI: 10.1093/cid/cis210] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Housman ST, Kuti JL, Nicolau DP. Optimizing Antibiotic Pharmacodynamics in Hospital-acquired and Ventilator-acquired Bacterial Pneumonia. Clin Chest Med 2011; 32:439-50. [DOI: 10.1016/j.ccm.2011.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pellegatti M, Pagliarusco S, Solazzo L, Colato D. Plasma protein binding and blood-free concentrations: which studies are needed to develop a drug? Expert Opin Drug Metab Toxicol 2011; 7:1009-20. [DOI: 10.1517/17425255.2011.586336] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Zelenitsky SA, Ariano RE. Support for higher ciprofloxacin AUC24/MIC targets in treating Enterobacteriaceae bloodstream infection. J Antimicrob Chemother 2010; 65:1725-32. [DOI: 10.1093/jac/dkq211] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Diaz E, Ulldemolins M, Lisboa T, Rello J. Management of ventilator-associated pneumonia. Infect Dis Clin North Am 2009; 23:521-33. [PMID: 19665081 DOI: 10.1016/j.idc.2009.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Ventilator-associated pneumonia (VAP) management depends on the interaction between the infective agent, the host response, and the antimicrobial drug used. After the pathogen reaches the lungs, two outcomes are possible: either the microorganisms are eliminated by the host immune system, or they overcome the immune system and cause pulmonary infection. When a patient is thought to have VAP, two steps are strongly recommended: etiologic diagnostic testing and the immediate initiation of antibiotics. The daily management of VAP remains a challenge for physicians in the ICU. In recent years, a more dynamic approach has evolved, updating local epidemiology, evaluating VAP and diagnostic tools every day, and assessing host response using clinical and biochemical parameters.
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Affiliation(s)
- Emili Diaz
- Critical Care Department, Joan XXIII University Hospital, University Rovira i Virgili, IISPV, CIBER Enfermedades Respiratorias, Carrer Mallafre Guasch 4,Tarragona 43007 , Spain.
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Liu X, Kruger P, Roberts MS. Optimizing Drug Dosing in the ICU. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dufour G, Montravers P. Pharmacokinetics of antibiotics or antifungal drugs in intensive care units. Curr Infect Dis Rep 2008; 11:14-20. [DOI: 10.1007/s11908-009-0003-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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