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Wu Y, Lu Z, Liang P, Zhu H, Qi H, Zhang H. Relationship of imipenem therapeutic drug monitoring to clinical outcomes in critically ill patients: a retrospective cohort study. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4791-4798. [PMID: 38153513 DOI: 10.1007/s00210-023-02909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/14/2023] [Indexed: 12/29/2023]
Abstract
The primary objective of this study was to evaluate the predictors associated with target concentration (non-)attainment of imipenem in critically ill patients. The secondary objective was to explore the correlation between achieving imipenem target concentrations and clinical outcomes of therapy. A retrospective cohort study was conducted in critically ill patients treated with imipenem. Clinical data were extracted from the patients' electronic medical records. The pharmacokinetic/pharmacodynamic target was defined as free imipenem concentrations above the minimum inhibitory concentration (MIC) of the pathogen at 100% (100%fT>MIC) of the dosing interval. Factors associated with the non-attainment of target concentrations were evaluated using binomial logistic regression. Kaplan-Meier analysis was used to investigate the correlation between (non-)attainment targets and 30-day mortality. A total of 406 patients were included, and 55.4% achieved the target of 100%fT>MIC. Regression analysis identified an initial daily dose of imipenem ≤ 2 g/day, augmented renal clearance, age ≤ 60 years, recent surgery, and absence of positive microbiology culture as risk factors for target non-attainment. Achieving the 100%fT>MIC target was significantly associated with clinical efficacy but not with 30-day mortality. Selective application of therapeutic drug monitoring in the early stages of imipenem treatment for critically ill patients can improve clinical outcomes. Further research should explore the potential benefits of TDM-guided dosing strategies for imipenem in critical care settings.
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Affiliation(s)
- Yejing Wu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Traditional Chinese and Western Medicine Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhangyang Lu
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Hui Qi
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Haixia Zhang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Traditional Chinese and Western Medicine Clinical College, Nanjing University of Chinese Medicine, Nanjing, China.
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China.
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2
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Gandéga H, Poujol H, Mezzarobba M, Muller L, Boyer JC, Lefrant JY, Leguelinel G, Roger C. Determinants of beta-lactam PK/PD target attainment in critically ill patients: A single center retrospective study. J Crit Care 2024; 83:154828. [PMID: 38759580 DOI: 10.1016/j.jcrc.2024.154828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE We aimed to identify factors associated with achieving target BL plasma concentrations and describe real world data for therapeutic drug monitoring (TDM). METHODS A retrospective single center study was conducted. We collected data from patients admitted to ICU with at least one BL TDM. We assessed the proportion of patients attaining the recommended plasma concentrations (i.e 100%fT > 4 to 8 MIC). Univariate and multivariate analyses was performed to identify the determinants of BL target attainment. RESULTS 156 patients were included. At the first dosing, 34% achieved target BL plasma concentrations, 50% were overdosed, and 16% were underdosed. Median time for 1st TDM were 4 (SD = 2.9) days. Multivariate analysis revealed that CKD-EPI estimated glomerular filtration rate (OR = 1.02; CI [1.01; 1.03]; p < 0.0001) and total body weight (OR = 1.03; CI [1.01; 1.04]; p = 0.0048) were the main determinant of BL target attainment. Conversely, Continuous Renal Replacement Therapy (OR = 0.28; CI [0.09; 0.89]; p = 0.0318) and meropenem use (OR = 0.31; CI [0.14; 0.69]; p = 0.0041) were identified as risk factors for overdosing. No factor was associated with underdosing. CONCLUSION Achieving target BL plasma concentrations remains challenging in ICUs. Identifying predictive factors of BL target attainment would favor implementing rapid dosing optimization strategies in both under and overdosing high risk patients.
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Affiliation(s)
- H Gandéga
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France
| | - H Poujol
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - M Mezzarobba
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University of Montpellier, Nîmes, France
| | - L Muller
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - J C Boyer
- Department of toxicity and biochemistry, Nimes University Hospital, Nimes, France
| | - J Y Lefrant
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - G Leguelinel
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES, EA 2415, University of Montpellier, Montpellier, France
| | - C Roger
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France.
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3
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Rodríguez-Báez AS, Jiménez-Meseguer M, Milán-Segovia RDC, Romano-Moreno S, Barcia E, Ortiz-Álvarez A, García-Díaz B, Medellín-Garibay SE. Comparison of pharmacokinetics software for therapeutic drug monitoring of piperacillin in patients with severe infections. Eur J Hosp Pharm 2024; 31:201-206. [PMID: 36126967 PMCID: PMC11042351 DOI: 10.1136/ejhpharm-2022-003367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the predictive performance of population pharmacokinetic models for piperacillin (PIP) available in the software MwPharm, TDMx and ID-ODs for initial dosing selection and therapeutic drug monitoring (TDM) purposes. METHODS This is a prospective observational study in adult patients with severe infections receiving PIP treatment. Plasma concentrations were quantified by ultra-high performance liquid chromatography coupled to tandem mass spectrometry. The differences between predicted and observed PIP concentrations were evaluated with Bland-Altman plots; additionally, the relative and absolute bias and precision of the models were determined. RESULTS A total of 145 PIP plasma concentrations from 42 patients were analysed. For population prediction, MwPharm showed the best predictive performance with a mean relative difference of 34.68% (95% CI -197% to 266%) and a root mean square error (RMSE) of 60.42 µg/mL; meanwhile TDMx and ID-ODs under-predicted PIP concentrations. For individual prediction, the TDMx model was found to be the most precise with a mean relative difference of 7.61% (95% CI -57.63 to 72.86%), and RMSE of 17.86 µg/mL. CONCLUSION Current software for TDM is a valuable tool, but it may also include different population pharmacokinetic models in patients with severe infections, and should be evaluated before performing a model-based TDM in clinical practice. Considering the heterogeneous characteristics of patients with severe infections, this study demonstrates the need for therapy personalisation for PIP to improve pharmacokinetic/pharmacodynamic target attainment.
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Affiliation(s)
| | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosi, SLP, Mexico
| | - Emilia Barcia
- Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
| | | | - Benito García-Díaz
- Servicio de Farmacia, Hospital Universitario Severo Ochoa, Leganés, Spain
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4
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You X, Dai Q, Hu J, Yu M, Wang X, Weng B, Cheng L, Sun F. Therapeutic drug monitoring of imipenem/cilastatin and meropenem in critically ill adult patients. J Glob Antimicrob Resist 2024; 36:252-259. [PMID: 38272210 DOI: 10.1016/j.jgar.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/30/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVES To investigate the factors influencing imipenem/cilastatin (IMI) and meropenem (MEM) concentrations in critically ill adult patients and the role of these concentrations in the clinical outcome. METHODS Plasma trough concentrations of IMI and MEM were detected by high-performance liquid chromatography. A target value of 100%-time above MIC was used for the drugs. RESULTS A total of 186 patients were included, with 87 receiving IMI and 99 receiving MEM. The percentages of patients reaching the target IMI and MEM concentrations were 44.8% and 38.4%, respectively. The proportions of patients infected with drug-resistant bacteria were 57.5% and 69.7% in the IMI group and MEM group, respectively. In the multivariate analysis, the risk factors for an IMI concentration that did not reach the target were infection with drug-resistant bacteria, and those for MEM were infection with drug-resistant bacteria, estimated glomerular filtration rate, and diabetes mellitus. A total of 47.1% of patients had good outcomes in the IMI cohort, and 38.1% of patients had good outcomes in the MEM cohort. The duration of mechanical ventilation and IMI concentration were associated with ICU stay in patients in the IMI cohort, while MEM concentration and severe pneumonia affected the clinical outcome of patients in the MEM cohort. CONCLUSION Infection with drug-resistant bacteria is an important factor influencing whether IMI and MEM concentrations reach the target. Furthermore, IMI and MEM concentrations are associated with the clinical outcome, and elevated doses of IMI and MEM should be given to patients who are infected with drug-resistant bacteria.
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Affiliation(s)
- Xi You
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Qing Dai
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Jing Hu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Mingjie Yu
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaowen Wang
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Bangbi Weng
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Lin Cheng
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China.
| | - Fengjun Sun
- Department of Pharmacy, The First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
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5
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Yassin A, Huralska M, Pogue JM, Dixit D, Sawyer RG, Kaye KS. State of the Management of Infections Caused by Multidrug-Resistant Gram-Negative Organisms. Clin Infect Dis 2023; 77:e46-e56. [PMID: 37738671 DOI: 10.1093/cid/ciad499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Indexed: 09/24/2023] Open
Abstract
In the past decade, the prevalence of multidrug-resistant gram-negative (MDR-GN) bacterial infections has increased significantly, leading to higher rates of morbidity and mortality. Treating these infections poses numerous challenges, particularly when selecting appropriate empiric therapy for critically ill patients for whom the margin for error is low. Fortunately, the availability of new therapies has improved the treatment landscape, offering safer and more effective options. However, there remains a need to establish and implement optimal clinical and therapeutic approaches for managing these infections. Here, we review strategies for identifying patients at risk for MDR-GN infections, propose a framework for the choice of empiric and definitive treatment, and explore effective multidisciplinary approaches to managing patients in the hospital while ensuring a safe transition to outpatient settings.
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Affiliation(s)
- Arsheena Yassin
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Mariya Huralska
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Jason M Pogue
- Department of Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Deepali Dixit
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
- Ernest Mario School of Pharmacy, Rutgers, State University of New Jersey, Piscataway, New Jersey, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
| | - Keith S Kaye
- Division of Allergy, Immunology and Infectious Diseases, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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6
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Takahashi N, Kondo Y, Kubo K, Egi M, Kano KI, Ohshima Y, Nakada TA. Efficacy of therapeutic drug monitoring-based antibiotic regimen in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. J Intensive Care 2023; 11:48. [PMID: 37936203 PMCID: PMC10631080 DOI: 10.1186/s40560-023-00699-8] [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: 09/08/2023] [Accepted: 11/02/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND The efficacy of therapeutic drug monitoring (TDM)-based antimicrobial dosing optimization strategies on pharmacokinetics/pharmacodynamics and specific drug properties for critically ill patients is unclear. Here, we conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the effectiveness of TDM-based regimen in these patients. METHODS Articles from three databases were systematically retrieved to identify relevant randomized control studies. Version two of the Cochrane tool for assessing risk of bias in randomized trials was used to assess the risk of bias in studies included in the analysis, and quality assessment of evidence was graded using the Grading of Recommendations Assessment, Development, and Evaluation approach. Primary outcome was the 28-day mortality and secondary outcome were in-hospital mortality, clinical cure, length of stay in the intensive care unit (ICU) and target attainment at day 1 and 3. RESULTS In total, 5 studies involving 1011 patients were included for meta-analysis of the primary outcome, of which no significant difference was observed between TDM-based regimen and control groups (risk ratio [RR] 0.94, 95% confidence interval [CI]: 0.77-1.14; I2 = 0%). In-hospital mortality (RR 0.96, 95% CI: 0.76-1.20), clinical cure (RR 1.23, 95% CI: 0.91-1.67), length of stay in the ICU (mean difference 0, 95% CI: - 2.18-2.19), and target attainment at day 1 (RR 1.14, 95% CI: 0.88-1.48) and day 3 (RR 1.35, 95% CI: 0.90-2.03) were not significantly different between the two groups, and all evidence for the secondary outcomes had a low or very low level of certainty because the included studies had serious risk of bias, variation of definition for outcomes, and small sample sizes. CONCLUSION TDM-based regimens had no significant efficacy for clinical or pharmacological outcomes. Further studies with other achievable targets and well-defined outcomes are required. TRIAL REGISTRATION Clinical trial registration; PROSPERO ( https://www.crd.york.ac.uk/prospero/ ), registry number: CRD 42022371959. Registered 24 November 2022.
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Affiliation(s)
- Nozomi Takahashi
- Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moritoki Egi
- Department of Anesthesia and Intensive Care, Kyoto University Hospital, Kyoto, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Fukui, Japan
| | | | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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7
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Zerbib Y, Gaulin C, Bodeau S, Batteux B, Lemaire-Hurtel AS, Maizel J, Kontar L, Bennis Y. Neurological burden and outcomes of excessive β-lactam serum concentrations of critically ill septic patients: a prospective cohort study. J Antimicrob Chemother 2023; 78:2691-2695. [PMID: 37694500 DOI: 10.1093/jac/dkad284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) contributes to optimizing exposure to β-lactam antibiotics. However, how excessive exposure to β-lactams can increase the burden of care of critically ill patients is unclear. PATIENTS AND METHODS In a prospective cohort study, we examined whether excessive β-lactam serum concentrations contribute to neurological deterioration and the associated complications of adult septic patients without recent history of neurological disease treated with β-lactams in a medical ICU. Excessive β-lactam concentrations were defined as serum concentrations that exceeded the upper limit of the therapeutic range recommended by the French Societies of Pharmacology and Therapeutics (SFPT) and Anesthesia and Intensive Care Medicine (SFAR). Neurological deterioration was defined as an increase in the neurological Sequential Organ Failure Assessment score (nSOFA) of ≥1 between the day of starting treatment at admission and the day of TDM performed 2 days after treatment initiation. RESULTS We included 119 patients [median age: 65 years; males: 78 (65.5%)] admitted for acute respiratory distress [59 (49.6%)] or septic shock [25 (21%)]. In adjusted logistic regression analysis, an excessive β-lactam serum concentration was associated with neurological deterioration [OR (95% CI): 10.38 (3.23-33.35), P < 0.0001]. Furthermore, in adjusted linear regression analysis, an excessive β-lactam serum concentration was associated with longer time to discharge alive (β=0.346, P = 0.0007) and, among mechanically ventilated patients discharged alive, with longer time to extubation following the withdrawal of sedation (β=0.248, P = 0.0030). CONCLUSIONS These results suggest that excessive exposure to β-lactams could complicate the management of septic patients in the ICU and confirm the clinical relevance of the upper concentration limits recommended for dose reduction.
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Affiliation(s)
- Yoann Zerbib
- Department of Intensive Care Medicine, CHU Amiens-Picardie, Amiens, France
| | - Clement Gaulin
- Department of Intensive Care Medicine, CHU Amiens-Picardie, Amiens, France
| | - Sandra Bodeau
- Department of Clinical Pharmacology, CHU Amiens-Picardie, Amiens, France
- MP3CV Laboratory, UR 7517, UPJV, Amiens, France
| | - Benjamin Batteux
- Department of Clinical Pharmacology, CHU Amiens-Picardie, Amiens, France
- MP3CV Laboratory, UR 7517, UPJV, Amiens, France
| | | | - Julien Maizel
- Department of Intensive Care Medicine, CHU Amiens-Picardie, Amiens, France
- MP3CV Laboratory, UR 7517, UPJV, Amiens, France
| | - Loay Kontar
- Department of Intensive Care Medicine, CHU Amiens-Picardie, Amiens, France
| | - Youssef Bennis
- Department of Clinical Pharmacology, CHU Amiens-Picardie, Amiens, France
- MP3CV Laboratory, UR 7517, UPJV, Amiens, France
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8
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Williams P, Cotta MO, Abdul‐Aziz MH, Wilks K, Farkas A, Roberts JA. In silico evaluation of a beta-lactam dosing guideline among adults with serious infections. Pharmacotherapy 2023; 43:1121-1130. [PMID: 36567467 PMCID: PMC10946580 DOI: 10.1002/phar.2753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to compare the achievement of therapeutic pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for beta-lactam antibiotics using product information dosing or guideline-based dosing for the treatment of serious infections. DESIGN In silico study. DATA SOURCE ID-ODSTM (Individually Designed Optimum Dosing Strategies). PATIENTS AND INTERVENTION None. MEASUREMENTS AND MAIN RESULTS In silico product information and guideline-based dosing simulations for cefepime, ceftazidime, flucloxacillin, meropenem, and piperacillin/tazobactam were performed using pharmacokinetic models from seriously ill patient populations. The median simulated concentration at 48 and 96 h was used to measure the probability of target attainment (PTA) to achieve predefined therapeutic and toxicity PK-PD targets. A multiple linear regression model was constructed to identify the effect of guideline-based dosing covariates on achieving pre-defined therapeutic targets. In total, 480 dosing simulations were performed. The PTA percentage with guideline-based dosing at 48 and 96 h was 80% and 68%, respectively, yielding significantly higher results when compared to product information dosing (48.45% and 49%, respectively), p < 0.001 at both time points. At 48 h, predefined toxicity thresholds were exceeded in 4.7% and 0% of simulations for guideline-based and product information-based dosing, respectively (p = 0.002). eGFR was significantly associated with the % PTA by guideline-based dosing, with eGFR values of 20 and 50 ml/min both statistically significant in leading to an increase in PTA. CONCLUSIONS Our study demonstrated that achievement of PK-PD exposures associated with an increased likelihood of effectiveness was more likely to occur with guideline-based dosing; especially at 48 h.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Pharmacy DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Mohd H. Abdul‐Aziz
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Kathryn Wilks
- Infectious Diseases DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
- School of Public HealthThe University of QueenslandBrisbaneQueenslandAustralia
| | - Andras Farkas
- Department of PharmacyMount Sinai WestNew YorkNew YorkUSA
- Optimum Dosing StrategiesBloomingdaleNew JerseyUSA
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Pharmacy DepartmentRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Division of Anaesthesiology Critical Care Emergency and Pain MedicineNîmes University Hospital, University of MontpellierNîmesFrance
- Herston Infectious Diseases Institute (HeIDI)BrisbaneQueenslandAustralia
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9
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Barreto EF, Chang J, Bjergum MW, Gajic O, Jannetto PJ, Mara KC, Meade LA, Rule AD, Vollmer KJ, Scheetz MH. Adequacy of cefepime concentrations in the early phase of critical illness: A case for precision pharmacotherapy. Pharmacotherapy 2023; 43:1112-1120. [PMID: 36648390 PMCID: PMC10350476 DOI: 10.1002/phar.2766] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE In critically ill patients, adequacy of early antibiotic exposure has been incompletely evaluated. This study characterized factors associated with inadequate cefepime exposure in the first 24 h of critical illness. DESIGN Prospective cohort study. SETTING Academic Medical Center. PATIENTS Critically ill adults treated with cefepime. Patients with acute kidney injury or treated with kidney replacement therapy or extracorporeal membrane oxygenation were excluded. INTERVENTION None. MEASUREMENTS A nonlinear mixed-effects pharmacokinetic (PK) model was developed to estimate cefepime concentrations for each patient over time. The percentage of time the free drug concentration exceeded 8 mg/L during the first 24 h of therapy was calculated (%ƒT>8; appropriate for the susceptible breakpoint for Pseudomonas aeruginosa). Factors predictive of low %ƒT>8 were explored with multivariable regression. MAIN RESULTS In the 100 included patients, a one-compartment PK model was developed with first-order elimination with covariates for weight and estimated glomerular filtration rate based on creatinine and cystatin C (eGFRSCr-CysC). The median (interquartile range) %ƒT>8 for cefepime in the first 24 h of therapy based on this model was 85% (66%, 100%). Less than 100% ƒT>8 during first 24 h of therapy occurred in 70 (70%) individuals. Lower Sequential Organ Failure Assessment score (p = 0.032) and higher eGFRSCr-CysC (p < 0.001) predicted a lower %ƒT>8. Central nervous system infection source was protective (i.e., associated with a higher %ƒT>8; p = 0.008). CONCLUSIONS During early critical illness, cefepime concentrations were inadequate in a significant proportion of patients. Antimicrobial optimization is needed to improve the precision of pharmacotherapy in the critically ill patients.
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Affiliation(s)
- Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Northwestern Medicine, Department of Pharmacy, Chicago, Illinois, USA
| | - Matthew W. Bjergum
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ognjen Gajic
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C. Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Minnesota, USA
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn J. Vollmer
- Rutgers Institute for Pharmaceutical Industry Fellowships, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Northwestern Medicine, Department of Pharmacy, Chicago, Illinois, USA
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10
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Yasmin M, Nutman A, Wang L, Marshall S, Chen K, Wang J, Yahav D, Lupinsky L, Hujer AM, Bhimraj A, van Duin D, Li J, Bonomo RA. Utilizing Ceftazidime/Avibactam Therapeutic Drug Monitoring in the Treatment of Neurosurgical Meningitis Caused by Difficult-to-Treat Resistant Pseudomonas aeruginosa and KPC-Producing Enterobacterales. Open Forum Infect Dis 2023; 10:ofad507. [PMID: 38023540 PMCID: PMC10661062 DOI: 10.1093/ofid/ofad507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Central nervous system (CNS) infections caused by Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales and difficult-to-treat resistant (DTR) Pseudomonas aeruginosa represent a formidable clinical challenge. Antimicrobial regimens that efficiently penetrate the cerebrospinal fluid (CSF) and achieve sufficient concentrations associated with microbiologic and clinical cure are limited. We evaluated therapy with ceftazidime-avibactam (CAZ-AVI) in order to guide precise dosing in the treatment of CNS infections. Methods Therapeutic drug monitoring (TDM) was performed in 3 patients with health care-associated ventriculitis and meningitis (HAVM) using CAZ-AVI 2.5 g infused intravenously every 8 hours as standard and extended infusion. Simultaneous CSF and plasma samples were obtained throughout the dosing interval in each patient. Concentrations of CAZ and AVI were determined by liquid chromatography/mass spectrometry. Results Bacterial identification revealed KPC-producing Klebsiella pneumoniae (KPC-Kp), DTR Pseudomonas aeruginosa, and KPC-producing Enterobacter cloacae (KPC-Ent.c). All isolates were resistant to carbapenems. The minimum inhibitory concentrations (MICs) of CAZ-AVI were 0.25/4, 4/4, and 0.25/4 μg/mL, respectively. CAZ and AVI concentrations were determined in CSF samples ranging from 29.0 to 15.0 µg/mL (CAZ component) and 4.20 to 0.92 µg/mL (AVI component), respectively. AVI achieved concentrations ≥1 µg/mL in 11 out of 12 CSF samples collected throughout the dosing interval. Clinical and microbiologic cure were attained in all patients. Conclusions Postinfusion concentrations of CAZ-AVI were measured in plasma and CSF samples obtained from 3 patients with complicated CNS infections caused by antimicrobial-resistant isolates. The measured concentrations revealed that standard CAZ and AVI exposures sufficiently attained values correlating to 50% fT > MIC, which are associated with efficient bacterial killing.
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Affiliation(s)
- Mohamad Yasmin
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Amir Nutman
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lu Wang
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Steven Marshall
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Ke Chen
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Jiping Wang
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liad Lupinsky
- Neurosurgical Department, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
| | - Andrea M Hujer
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Adarsh Bhimraj
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas, USA
| | - David van Duin
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Robert A Bonomo
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, Ohio, USA
- Departments of Proteomics and Bioinformatics, Pharmacology, and Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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11
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Pai Mangalore R, Peel TN, Udy AA, Peleg AY. The clinical application of beta-lactam antibiotic therapeutic drug monitoring in the critical care setting. J Antimicrob Chemother 2023; 78:2395-2405. [PMID: 37466209 PMCID: PMC10566322 DOI: 10.1093/jac/dkad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Critically ill patients have increased variability in beta-lactam antibiotic (beta-lactam) exposure due to alterations in their volume of distribution and elimination. Therapeutic drug monitoring (TDM) of beta-lactams, as a dose optimization and individualization tool, has been recommended to overcome this variability in exposure. Despite its potential benefit, only a few centres worldwide perform beta-lactam TDM. An important reason for the low uptake is that the evidence for clinical benefits of beta-lactam TDM is not well established. TDM also requires the availability of specific infrastructure, knowledge and expertise. Observational studies and systematic reviews have demonstrated that TDM leads to an improvement in achieving target concentrations, a reduction in potentially toxic concentrations and improvement of clinical and microbiological outcomes. However, a small number of randomized controlled trials have not shown a mortality benefit. Opportunities for improved study design are apparent, as existing studies are limited by their inclusion of heterogeneous patient populations, including patients that may not even have infection, small sample size, variability in the types of beta-lactams included, infections caused by highly susceptible bacteria, and varied sampling, analytical and dosing algorithm methods. Here we review the fundamentals of beta-lactam TDM in critically ill patients, the existing clinical evidence and the practical aspects involved in beta-lactam TDM implementation.
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Affiliation(s)
- Rekha Pai Mangalore
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Andrew A Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
- Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
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12
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Ausman SE, Moreland-Head LN, Abu Saleh OM, Jannetto PJ, Rivera CG, Stevens RW, Wessel RJ, Wieruszewski PM, Barreto EF. 'How to' Guide for Pharmacist-led Implementation of Beta-Lactam Therapeutic Drug Monitoring in the Critically Ill. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2023; 6:964-975. [PMID: 37731602 PMCID: PMC10511216 DOI: 10.1002/jac5.1819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/12/2023] [Indexed: 09/22/2023]
Abstract
Beta-lactam therapeutic drug monitoring (TDM) can improve precision dosing and clinical outcomes in critically ill patients, but has not been implemented widely in the United States. Mayo Clinic recently implemented a beta-lactam TDM program. This single-center experience forms the basis of the manuscript which outlines practical considerations involved with implementation, including the pharmacist's role as a leader. Our implementation effort focused on three primary domains. First, we aimed to ensure a supportive organizational infrastructure. Early leadership engagement by the pharmacist-led core team facilitated advocacy for the clinical need, allocation of resources, and assay development. Second, core clinical workflows were developed that addressed the preferred patient population for use, desirable pharmacokinetic and pharmacodynamic targets, and the preferred sampling strategy. Clinical tools to guide pharmacists in interpreting the results (e.g., pharmacokinetics calculator) and documenting decisions were developed. Third, stakeholders were offered repeated exposure to evidence and expertise to facilitate understanding and application of the new practice. This act of 'individual internalization' seems to be uniquely important to beta-lactam TDM implementation compared with implementation of other antimicrobial TDM programs. Educational strategies and supportive materials that were developed were focused on providing substantive and varied information tailored to the stakeholders' role in the process. For pharmacists, this included both clinical and operational considerations. A continuous improvement plan to support management of the process was instituted to address necessary updates and changes that inevitably emerged. In summary, the described approach to implementation of a pharmacist led beta-lactam TDM program could be used as a roadmap to aid other institutions that aim to develop such a program.
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Affiliation(s)
- Sara E. Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| | | | - Omar M. Abu Saleh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ryan W. Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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Joynt GM, Ling L, Wong WT, Lipman J. Therapeutic drug monitoring of carbapenem antibiotics in critically ill patients: an overview of principles, recommended dosing regimens, and clinical outcomes. Expert Rev Clin Pharmacol 2023; 16:703-714. [PMID: 36942827 DOI: 10.1080/17512433.2023.2194629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION The importance of antibiotic treatment for sepsis in critically ill septic patients is well established. Consistently achieving the dose of antibiotics required to optimally kill bacteria, minimize the development of resistance, and avoid toxicity is challenging. The increasing understanding of the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of antibiotics, and the effects of critical illness on key PK/PD parameters, is gradually re-shaping how antibiotics are dosed in critically ill patients. AREAS COVERED The PK/PD characteristics of commonly used carbapenem antibiotics, the principles of the application of therapeutic drug monitoring (TDM), and current as well as future methods of utilizing TDM to optimally devise dosing regimens will be reviewed. The limitations and evidence-base supporting the use of carbapenem TDM to improve outcomes in critically ill patients will be examined. EXPERT OPINION It is important to understand the principles of TDM in order to correctly inform dosing regimens. Although the concept of TDM is attractive, and the ability to utilize PK software to optimize dosing in the near future is expected to rapidly increase clinicians' ability to meet pre-defined PK/PD targets more accurately, current evidence provides only limited support for the use of TDM to guide carbapenem dosing in critically ill patients.
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Affiliation(s)
- Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Jeffrey Lipman
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesia Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Australia
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14
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Legg A, Carmichael S, Chai MG, Roberts JA, Cotta MO. Beta-Lactam Dose Optimisation in the Intensive Care Unit: Targets, Therapeutic Drug Monitoring and Toxicity. Antibiotics (Basel) 2023; 12:antibiotics12050870. [PMID: 37237773 DOI: 10.3390/antibiotics12050870] [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: 03/02/2023] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023] Open
Abstract
Beta-lactams are an important family of antibiotics used to treat infections and are commonly used in critically ill patients. Optimal use of these drugs in the intensive care unit (ICU) is important because of the serious complications from sepsis. Target beta-lactam antibiotic exposures may be chosen using fundamental principles of beta-lactam activity derived from pre-clinical and clinical studies, although the debate regarding optimal beta-lactam exposure targets is ongoing. Attainment of target exposures in the ICU requires overcoming significant pharmacokinetic (PK) and pharmacodynamic (PD) challenges. For beta-lactam drugs, the use of therapeutic drug monitoring (TDM) to confirm if the desired exposure targets are achieved has shown promise, but further data are required to determine if improvement in infection-related outcomes can be achieved. Additionally, beta-lactam TDM may be useful where a relationship exists between supratherapeutic antibiotic exposure and drug adverse effects. An ideal beta-lactam TDM service should endeavor to efficiently sample and report results in identified at-risk patients in a timely manner. Consensus beta-lactam PK/PD targets associated with optimal patient outcomes are lacking and should be a focus for future research.
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Affiliation(s)
- Amy Legg
- Menzies School of Health Research, Tiwi, Darwin, NT 0810, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, QLD 4029, Australia
| | - Sinead Carmichael
- Royal Brisbane and Women's Hospital, Departments of Intensive Care Medicine and Pharmacy, Brisbane, QLD 4029, Australia
| | - Ming G Chai
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
| | - Jason A Roberts
- Herston Infectious Diseases Institute, Herston, Brisbane, QLD 4029, Australia
- Royal Brisbane and Women's Hospital, Departments of Intensive Care Medicine and Pharmacy, Brisbane, QLD 4029, Australia
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Menino O Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
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15
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Salehi M, Rezazade-Moayed F, Khalili H, Hemati H, Aghdami N, Dashtkoohi M, Dashtkoohi M, Beig-Mohammadi MT, Ramezani M, Hajiabdolbaghi M, Fattah-Ghazi S. Safety of megadose meropenem in the empirical treatment of nosocomial sepsis: a pilot randomized clinical trial. Future Microbiol 2023; 18:335-342. [PMID: 37140270 DOI: 10.2217/fmb-2022-0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
Objective: To evaluate the safety of megadose meropenem as empirical treatment of nosocomial sepsis. Materials & methods: Critically ill patients diagnosed with sepsis received either high-dose (2 g every 8 h) or megadose (4 g every 8 h) meropenem as an intravenous infusion over 3 h. Results: A total of 23 patients with nosocomial sepsis were eligible and included in the megadose (n = 11) or high-dose (n = 12) group. No treatment-related adverse events were observed during a 14-day follow-up. Clinical response was also comparable between the groups. Conclusion: Megadose meropenem may be considered for empirical treatment of nosocomial sepsis without serious concern regarding its safety.
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Affiliation(s)
- Mohammadreza Salehi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Farah Rezazade-Moayed
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Hemati
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Aghdami
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology & Technology, Academic Center for Education, Culture & Research, Tehran, Iran
| | - Mohadese Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoud Ramezani
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Hajiabdolbaghi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Samrand Fattah-Ghazi
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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16
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Katz JB, Shah P, Trillo CA, Alshaer MH, Peloquin C, Lascano J. Therapeutic drug monitoring in cystic fibrosis and associations with pulmonary exacerbations and lung function. Respir Med 2023; 212:107237. [PMID: 37030586 DOI: 10.1016/j.rmed.2023.107237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy have resulted in longer life expectancies, yet pulmonary exacerbations remain a leading cause of morbidity. Intravenous antibiotics is the mainstay treatment, however achieving adequate concentrations remains challenging. The effect of therapeutic drug monitoring (TDM) of beta-lactams on exacerbations and lung function has not been studied. METHODS Patient demographics, antibiotic regimens, forced expiratory volume 1 second (FEV1), and exacerbation history was obtained from 32 patients with cystic fibrosis admitted for exacerbations. All patients were colonized with Pseudomonas aeruginosa, received CFTR therapy for at least one year, and had 3-month interval follow ups. Plasma concentrations, FEV1, and exacerbation history was obtained before and after therapeutic drug monitoring. This included peak and trough plasma concentrations of piperacillin-tazobactam and cefepime using liquid chromatography with mass spectrometry. T-test and Mann-Whitney U test were used to compare medians/means of FEV1 and pulmonary exacerbations pre and post-TDM as well as free trough-to-minimum inhibitory concentration ratio (fCmin/MIC) ≥1 and ≥ 4. RESULTS TDM was associated with decreased exacerbations/year from 1.91 to 1.31 (p = 0.04) and among the cohort with >/ = 2 exacerbations per year, there was a longer exacerbation free interval after TDM (196.2 vs 103.7 days, p = 0.02). The decline in FEV1% predicted after therapeutic drug monitoring to the first exacerbation was -4.9 compared to -9.7 prior (p = 0.03). CONCLUSIONS TDM for cystic fibrosis pulmonary exacerbations results in decreased pulmonary exacerbations, longer intervals to pulmonary exacerbation, and lower decline in FEV1% predicted.
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Affiliation(s)
- Jason Brandon Katz
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Purav Shah
- Department of Internal Medicine, Pulmonary and Critical Care Division, Emory, Atlanta, GA, 30322, USA.
| | - Cesar A Trillo
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Charles Peloquin
- Department of Pharmacotherapy and Translational Research, University of Florida Infectious Disease Pharmacokinetics Laboratory, UF College of Pharmacy, Gainesville, FL, 32610, USA.
| | - Jorge Lascano
- Department of Internal Medicine, Pulmonary and Critical Care Division, UF Health-Shands Hospital, University of Florida, Gainesville, FL, 32611, USA.
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Yin T, Liang H, Huang Q, Zhou B, Tang M, Lou J, Xiang D. A Survey of Therapeutic Drug Monitoring Status in China. Ther Drug Monit 2023; 45:151-158. [PMID: 36920501 PMCID: PMC10013164 DOI: 10.1097/ftd.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/21/2021] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To understand the status of therapeutic drug monitoring (TDM) in China Mainland, and thus lay down the foundation for further improvement in TDM. METHODS In the present study, a nationwide questionnaire survey was conducted, which was distributed and collected using a mobile-based application. Clinicians, pharmacists, and clinical laboratory physicians belonging to different levels of public hospitals were involved as subjects/objects. The contents of the survey included TDM implementation in their hospital and information regarding their opinions and suggestions on TDM work. Mann-Whitney test was used to compare the difference between top tertiary hospitals and non-top tertiary hospitals. RESULTS A total of 475 questionnaires were collected, 383 from top tertiary hospitals (3A hospitals) and 92 from non-top tertiary hospitals (other than 3A hospitals). A total of 240 clinicians, TDM pharmacists, and clinical laboratory physicians were involved, with an effective rate of 50.5%. Top tertiary hospitals were associated with certain advantages, such as the number of TDM testing facilities, annual sample size, number of monitoring varieties, and interpretation rate of monitoring reports, compared with non-top tertiary hospitals. In particular, β-lactamase inhibitor, olanzapine, carbamazepine, and glucocorticoids seemed to be the main projects that clinicians wanted to assess. The drugs for which TDM was commonly performed included vancomycin, valproic acid, carbamazepine, phenytoin sodium, and methotrexate. The most commonly used detection methods include high-performance liquid chromatography, immunization, 2D-LC, and LC-MS. The monitoring concentration range was found to be inconsistent for most of the drugs. Currently, no unified regulation exists for TDM charges in China, which is no more than ¥200 in general. Clinicians rely on pharmacists for professional guidance. Importantly, improvement in the interpretation of monitoring reports, proficiency testing, and cooperation with clinical departments may aid in improving the level of TDM service. CONCLUSIONS This survey objectively reflected the current status of TDM work in hospitals in China, and provided a strong reference base for devising strategies for improvement and effective execution of TDM work.
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Affiliation(s)
- Tao Yin
- Department of Pharmacy,Xiangya Hospital,Central South University,Changsha,China
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18
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Telles JP, Morales R, Yamada CH, Marins TA, D'Amaro Juodinis V, Sztajnbok J, Silva M, Bassetti BR, Albiero J, Tuon FF. Optimization of Antimicrobial Stewardship Programs Using Therapeutic Drug Monitoring and Pharmacokinetics-Pharmacodynamics Protocols: A Cost-Benefit Review. Ther Drug Monit 2023; 45:200-208. [PMID: 36622029 DOI: 10.1097/ftd.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Antimicrobial stewardship programs are important for reducing antimicrobial resistance because they can readjust antibiotic prescriptions to local guidelines, switch intravenous to oral administration, and reduce hospitalization times. Pharmacokinetics-pharmacodynamics (PK-PD) empirically based prescriptions and therapeutic drug monitoring (TDM) programs are essential for antimicrobial stewardship, but there is a need to fit protocols according to cost benefits. The cost benefits can be demonstrated by reducing toxicity and hospital stay, decreasing the amount of drug used per day, and preventing relapses in infection. Our aim was to review the data available on whether PK-PD empirically based prescriptions and TDM could improve the cost benefits of an antimicrobial stewardship program to decrease global hospital expenditures. METHODS A narrative review based on PubMed search with the relevant studies of vancomycin, aminoglycosides, beta-lactams, and voriconazole. RESULTS TDM protocols demonstrated important cost benefit for patients treated with vancomycin, aminoglycosides, and voriconazole mainly due to reduce toxicities and decreasing the hospital length of stay. In addition, PK-PD strategies that used infusion modifications to meropenem, piperacillin-tazobactam, ceftazidime, and cefepime, such as extended or continuous infusion, demonstrated important cost benefits, mainly due to reducing daily drug needs and lengths of hospital stays. CONCLUSIONS TDM protocols and PK-PD empirically based prescriptions improve the cost-benefits and decrease the global hospital expenditures.
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Affiliation(s)
- João Paulo Telles
- - AC Camargo Cancer Center, Infectious Diseases Department, São Paulo
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
| | - Ronaldo Morales
- - Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo
- - Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês. São Paulo
| | - Carolina Hikari Yamada
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
- - Hospital Universitário Evangélico Mackenzie, Department of Infectious Diseases, Curitiba
| | - Tatiana A Marins
- - Hospital Israelita Albert Einstein, Department of Clinical Pharmacy, São Paulo
| | | | - Jaques Sztajnbok
- - Instituto de Infectologia Emílio Ribas, São Paulo
- - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr/HC-FMUSP)
| | - Moacyr Silva
- - Hospital Israelita Albert Einstein, Department of Infection Prevention and Control, São Paulo
| | - Bil Randerson Bassetti
- - Hospital Santa Rita de Cássia, Department of Infectious Disease and Infection Control, Vitória ; and
| | - James Albiero
- - Universidade Estadual de Maringá, Pharmacy Department, Programa de Pós-Graduação em Assistência Farmacêutica, Maringá, Brazil
| | - Felipe Francisco Tuon
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
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Chaïbi K, Jaureguy F, Do Rego H, Ruiz P, Mory C, El Helali N, Mrabet S, Mizrahi A, Zahar JR, Pilmis B. What to Do with the New Antibiotics? Antibiotics (Basel) 2023; 12:antibiotics12040654. [PMID: 37107016 PMCID: PMC10135159 DOI: 10.3390/antibiotics12040654] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Multidrug-resistant Gram-negative bacteria-related infections have become a real public health problem and have exposed the risk of a therapeutic impasse. In recent years, many new antibiotics have been introduced to enrich the therapeutic armamentarium. Among these new molecules, some are mainly of interest for the treatment of the multidrug-resistant infections associated with Pseudomonas aeruginosa (ceftolozane/tazobactam and imipenem/relebactam); others are for carbapenem-resistant infections associated with Enterobacterales (ceftazidime/avibactam, meropenem/vaborbactam); and finally, there are others that are effective on the majority of multidrug-resistant Gram-negative bacilli (cefiderocol). Most international guidelines recommend these new antibiotics in the treatment of microbiologically documented infections. However, given the significant morbidity and mortality of these infections, particularly in the case of inadequate therapy, it is important to consider the place of these antibiotics in probabilistic treatment. Knowledge of the risk factors for multidrug-resistant Gram-negative bacilli (local ecology, prior colonization, failure of prior antibiotic therapy, and source of infection) seems necessary in order to optimize antibiotic prescriptions. In this review, we will assess these different antibiotics according to the epidemiological data.
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Mieresova M, Balazova K, Kubele J, Cerny D, Halacova M. Piperacillin/Tazobactam in critically ill morbidly obese patients: A case series: The first One-Centre experience with TDM. Clin Case Rep 2023; 11:e7032. [PMID: 36919150 PMCID: PMC10008261 DOI: 10.1002/ccr3.7032] [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: 11/05/2022] [Revised: 01/20/2023] [Accepted: 02/13/2023] [Indexed: 03/14/2023] Open
Abstract
The aim of this article is to demonstrate extreme interindividual variability of piperacilin/tazobactam (PIP/TAZO) pharmacokinetics in critically ill morbidly obese patients and to emphasize the need for the practice of routine PIP/TAZO plasma concentrations measurement in order to ensure optimal efficacy and safety of antibiotic therapy.
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Affiliation(s)
- M Mieresova
- Department of Clinical Pharmacy Na Homolce Hospital Prague Czech Republic.,Department of Pharmacology Motol University Hospital and 2nd Faculty of Medicine, Charles University Prague Czech Republic
| | - K Balazova
- Department of Clinical Pharmacy Na Homolce Hospital Prague Czech Republic
| | - J Kubele
- Department of Clinical Microbiology and Antibiotic Surveillance Na Homolce Hospital Prague Czech Republic
| | - D Cerny
- Department of Clinical Pharmacy Na Homolce Hospital Prague Czech Republic.,Institute of Pharmacology, General University Hospital and 1st Faculty of Medicine, Charles University Prague Czech Republic
| | - M Halacova
- Department of Clinical Pharmacy Na Homolce Hospital Prague Czech Republic.,Department of Pharmacology Motol University Hospital and 2nd Faculty of Medicine, Charles University Prague Czech Republic
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21
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Riezk A, Wilson RC, Rawson TM, Vasikasin V, Arkel P, Ferris TJ, Haigh LD, Cass AEG, Holmes AH. A rapid, simple, high-performance liquid chromatography method for the clinical measurement of beta-lactam antibiotics in serum and interstitial fluid. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2023; 15:829-836. [PMID: 36727437 DOI: 10.1039/d2ay01276f] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Background: enhanced methods of therapeutic drug monitoring are required to support the individualisation of antibiotic dosing based on pharmacokinetics (PK) parameters. PK studies can be hampered by limited total serum volume, especially in neonates, or by sensitivity in the case of critically ill patients. We aimed to develop a liquid chromatography-mass spectrometry (LC/MS) analysis of benzylpenicillin, phenoxymethylpenicillin and amoxicillin in single low volumes of human serum and interstitial fluid (ISF) samples, with an improved limit of detection (LOD) and limit of quantification (LOQ), compared with previously published assays. Methods: sample clean-up was performed by protein precipitation using acetonitrile. Reverse phase chromatography was performed using triple quadrupole LC/MS. The mobile phase consisted of 55% methanol in water + 0.1% formic acid, with a flow rate of 0.4 mL min-1. Antibiotics stability was assessed at different temperatures. Results: chromatographic separation was achieved within 3 minutes for all analytes. Three common penicillins can now be measured in a single low-volume blood and ISF sample (15 μL) for the first time. Validation has demonstrated the method to be linear over the range 0.0015-10 mg L-1, with an accuracy of 93-104% and high sensitivity, with LOD ≈ 0.003 mg L-1 and LOQ ≈ 0.01 mg L-1 for all three analytes, which is critical for use in dose optimisation/individualisation. All evaluated penicillins indicated good stability at room temperature over 4 h, at (4 °C) over 24 h and at -80 °C for 6 months. Conclusion: the developed method is simple, rapid, accurate and clinically applicable for the quantification of three penicillin classes.
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Affiliation(s)
- Alaa Riezk
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Richard C Wilson
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Timothy M Rawson
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Vasin Vasikasin
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Paul Arkel
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Trevor J Ferris
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Lisa D Haigh
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Anthony E G Cass
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
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22
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Haddad N, Carr M, Balian S, Lannin J, Kim Y, Toth C, Jarvis J. The Blood-Brain Barrier and Pharmacokinetic/Pharmacodynamic Optimization of Antibiotics for the Treatment of Central Nervous System Infections in Adults. Antibiotics (Basel) 2022; 11:antibiotics11121843. [PMID: 36551500 PMCID: PMC9774927 DOI: 10.3390/antibiotics11121843] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Bacterial central nervous system (CNS) infections are serious and carry significant morbidity and mortality. They encompass many syndromes, the most common being meningitis, which may occur spontaneously or as a consequence of neurosurgical procedures. Many classes of antimicrobials are in clinical use for therapy of CNS infections, some with established roles and indications, others with experimental reporting based on case studies or small series. This review delves into the specifics of the commonly utilized antibacterial agents, updating their therapeutic use in CNS infections from the pharmacokinetic and pharmacodynamic perspectives, with a focus on the optimization of dosing and route of administration that have been described to achieve good clinical outcomes. We also provide a concise synopsis regarding the most focused, clinically relevant information as pertains to each class and subclass of antimicrobial therapeutics. CNS infection morbidity and mortality remain high, and aggressive management is critical in ensuring favorable patient outcomes while averting toxicity and upholding patient safety.
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Affiliation(s)
- Nicholas Haddad
- College of Medicine, Central Michigan University (CMU), Mt Pleasant, MI 48859, USA
- Correspondence: ; Tel.: +1-(989)-746-7860
| | | | - Steve Balian
- CMU Medical Education Partners, Saginaw, MI 48602, USA
| | | | - Yuri Kim
- CMU Medical Education Partners, Saginaw, MI 48602, USA
| | - Courtney Toth
- Ascension St. Mary’s Hospital, Saginaw, MI 48601, USA
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23
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Tang Girdwood S, Pavia K, Paice K, Hambrick HR, Kaplan J, Vinks AA. β-lactam precision dosing in critically ill children: Current state and knowledge gaps. Front Pharmacol 2022; 13:1044683. [PMID: 36532752 PMCID: PMC9752101 DOI: 10.3389/fphar.2022.1044683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Sonya Tang Girdwood,
| | - Kathryn Pavia
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kelli Paice
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - H. Rhodes Hambrick
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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24
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An Ultra-High-Performance Liquid Chromatography-Tandem Mass Spectrometry Method for Simultaneous Determination of 4 β-Lactam Antibiotics, Tazobactam, and Linezolid in Human Plasma Samples. Ther Drug Monit 2022; 44:784-790. [PMID: 35971670 DOI: 10.1097/ftd.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/25/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Optimization of antimicrobial therapy is a challenge in critically ill patients who develop extreme interindividual and intraindividual pharmacokinetic variability. Therapeutic drug monitoring is a valuable tool for maximizing the effect of a drug and minimizing its adverse and unwanted effects. The aim of the current work was to develop and validate an ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to determine multiple antibiotics in clinical plasma samples from critically ill patients; low sample volume and rapid processing of samples were considered the main criteria. METHODS A separation method based on an online combination of UHPLC-MS/MS was developed for the simultaneous determination of 4 β-lactam antibiotics (cefepime, meropenem, cefotaxime, and piperacillin), tazobactam, and linezolid in human plasma samples. The volume of plasma sample used for analysis was 20 µL. The developed method was validated according to Food and Drug Administration guidelines. RESULTS The chromatographic run time was 8 minutes. Calibration curves were linear for concentration ranges of 0.1-100 mcg/mL (r 2 > 0.99) for tazobactam, meropenem, cefotaxime, linezolid, and piperacillin and 1-100 mcg/mL (r 2 > 0.99) for cefepime. The intraday and interday accuracy of the method ranged from 92.4% to 110.7% and 93.6% to 113.3%, respectively. The intraday and interday precision values were ≤17.3% and ≤17.4%, respectively. No interfering and carryover analytes were observed. CONCLUSIONS The developed UHPLC-MS/MS method is an appropriate and practical tool for therapeutic drug monitoring of the selected antibiotics. Owing to its rapidity, requirement of low sample volume, and high selectivity, sensitivity, and reliability, it can be effectively implemented in routine clinical laboratory tests for critically ill patients.
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25
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Pai Mangalore R, Ashok A, Lee SJ, Romero L, Peel TN, Udy AA, Peleg AY. Beta-Lactam Antibiotic Therapeutic Drug Monitoring in Critically Ill Patients: A Systematic Review and Meta-Analysis. Clin Infect Dis 2022; 75:1848-1860. [PMID: 35731853 PMCID: PMC9662173 DOI: 10.1093/cid/ciac506] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Indexed: 11/12/2022] Open
Abstract
Therapeutic drug monitoring (TDM) of beta-lactam antibiotics is recommended to address the variability in exposure observed in critical illness. However, the impact of TDM-guided dosing on clinical outcomes remains unknown. We conducted a systematic review and meta-analysis on TDM-guided dosing and clinical outcomes (all-cause mortality, clinical cure, microbiological cure, treatment failure, hospital and intensive care unit length of stay, target attainment, antibiotic-related adverse events, and emergence of resistance) in critically ill patients with suspected or proven sepsis. Eleven studies (n = 1463 participants) were included. TDM-guided dosing was associated with improved clinical cure (relative risk, 1.17; 95% confidence interval [CI], 1.04 to 1.31), microbiological cure (RR, 1.14; 95% CI, 1.03 to 1.27), treatment failure (RR, 0.79; 95% CI, .66 to .94), and target attainment (RR, 1.85; 95% CI, 1.08 to 3.16). No associations with mortality and length of stay were found. TDM-guided dosing improved clinical and microbiological cure and treatment response. Larger, prospective, randomized trials are required to better assess the utility of beta-lactam TDM in critically ill patients.
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Affiliation(s)
- Rekha Pai Mangalore
- Department of Infectious Diseases, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Aadith Ashok
- Department of Infectious Diseases, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
| | - Sue J Lee
- Department of Infectious Diseases, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Lorena Romero
- Ian Potter Library, Alfred Hospital, Melbourne, Victoria, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine Australia, Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Melbourne, Victoria, Australia
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26
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Kang S, Yang S, Hahn J, Jang JY, Min KL, Wi J, Chang MJ. Dose Optimization of Meropenem in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Cardiac Patients: Pharmacokinetic/Pharmacodynamic Modeling. J Clin Med 2022; 11:jcm11226621. [PMID: 36431106 PMCID: PMC9693387 DOI: 10.3390/jcm11226621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/23/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Our objective was to determine an optimal dosage regimen of meropenem in patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) by developing a pharmacokinetic/pharmacodynamic (PK/PD) model. Methods: This was a prospective cohort study. Blood samples were collected during ECMO (ECMO-ON) and after ECMO (ECMO-OFF). The population pharmacokinetic model was developed using nonlinear mixed-effects modeling. A Monte Carlo simulation was used (n = 10,000) to assess the probability of target attainment. Results: Thirteen adult patients on ECMO receiving meropenem were included. Meropenem pharmacokinetics was best fitted by a two-compartment model. The final pharmacokinetic model was: CL (L/h) = 3.79 × 0.44CRRT, central volume of distribution (L) = 2.4, peripheral volume of distribution (L) = 8.56, and intercompartmental clearance (L/h) = 21.3. According to the simulation results, if more aggressive treatment is needed (100% fT > MIC target), dose increment or extended infusion is recommended. Conclusions: We established a population pharmacokinetic model for meropenem in patients receiving V-A ECMO and revealed that it is not necessary to adjust the dosage depending on V-A ECMO. Instead, more aggressive treatment is needed than that of standard treatment, and higher dosage is required without continuous renal replacement therapy (CRRT). Also, extended infusion could lead to better target attainment, and we could provide updated nomograms of the meropenem dosage regimen.
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Affiliation(s)
- Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- School of Pharmacy, Jeonbuk National University, Jeonju 54896, Korea
| | - June Young Jang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
| | - Min Jung Chang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
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27
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Effectiveness and Safety of Beta-Lactam Antibiotics with and without Therapeutic Drug Monitoring in Patients with Pseudomonas aeruginosa Pneumonia or Bloodstream Infection. Antimicrob Agents Chemother 2022; 66:e0064622. [PMID: 36073943 PMCID: PMC9578394 DOI: 10.1128/aac.00646-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This objective of this study was to compare clinical outcomes in hospitalized patients with Pseudomonas aeruginosa pneumonia (PNA) or bloodstream infection (BSI) receiving beta-lactam antibiotic (BLA) infusions with and without the guidance of therapeutic drug monitoring (TDM). A retrospective, parallel cohort study was conducted at two academic medical centers between December 2015 and January 2020, UF Shands Gainesville, which uses BLA TDM for select patients (BLA TDM), and UF Health Jacksonville, which does not use BLA TDM (No-BLA TDM). All hospitalized adult patients with respiratory or blood culture positive for P. aeruginosa who met diagnosis criteria for lower respiratory tract infection with a positive P. aeruginosa respiratory culture and who received ≥48 h of intravenous BLA with in vitro susceptibility within 72 h of positive culture collection were included. The primary outcome was a composite of presumed treatment failure defined as the presence of any of the following from index-positive P. aeruginosa culture collection to the end of BLA therapy: all-cause mortality, escalation of and/or additional antimicrobial therapy for P. aeruginosa infection after 48 h of treatment with susceptible BLA due to worsening clinical status, or transfer to a higher level of care (i.e., the intensive care unit [ICU]). Analyses were adjusted for possible confounding with inverse probability of treatment weighting (IPTW). Two-hundred patients were included (BLA TDM, n = 95; No-BLA TDM, n = 105). In IPTW-adjusted analysis of the primary composite endpoint, BLA TDM demonstrated a significant decrease in presumed treatment failure compared to No-BLA TDM (adjusted odds ratio [aOR] 0.037, 95% confidence interval [CI] [0.013 to 0.107]; P < 0.001). BLA TDM had more 30-, 60- and 90-day infection-related readmissions ([aOR], 11.301, 95% CI (3.595 to 35.516); aOR 10.389, 95% CI [2.496 to 43.239], and aOR 24.970, 95% CI [6.703 to 93.028]) in IPTW analyses. For both unadjusted and IPTW-adjusted cohorts, there was no significant difference in hospital and ICU length of stay, adverse effects while on BLA, or microbiological eradication between BLA TDM and No-BLA TDM. In hospitalized adult patients with P. aeruginosa PNA or BSI, the use of TDM-guided BLA infusions decreased the odds of presumed treatment failure compared to patients receiving BLA infusions without TDM guidance. Future studies should evaluate BLA TDM impact on readmission.
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28
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Luxton TN, King N, Wälti C, Jeuken LJC, Sandoe JAT. A Systematic Review of the Effect of Therapeutic Drug Monitoring on Patient Health Outcomes during Treatment with Carbapenems. Antibiotics (Basel) 2022; 11:antibiotics11101311. [PMID: 36289971 PMCID: PMC9598625 DOI: 10.3390/antibiotics11101311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Adjusting dosing regimens based on measurements of carbapenem levels may improve carbapenem exposure in patients. This systematic review aims to describe the effect carbapenem therapeutic drug monitoring (TDM) has on health outcomes, including the emergence of antimicrobial resistance (AMR). Four databases were searched for studies that reported health outcomes following adjustment to dosing regimens, according to measurements of carbapenem concentration. Bias in the studies was assessed with risk of bias analysis tools. Study characteristics and outcomes were tabulated and a narrative synthesis was performed. In total, 2 randomised controlled trials (RCTs), 17 non-randomised studies, and 19 clinical case studies were included. Significant variation in TDM practice was seen; consequently, a meta-analysis was unsuitable. Few studies assessed impacts on AMR. No significant improvement on health outcomes and no detrimental effects of carbapenem TDM were observed. Five cohort studies showed significant associations between achieving target concentrations and clinical success, including suppression of resistance. Studies in this review showed no obvious improvement in clinical outcomes when TDM is implemented. Optimisation and standardisation of carbapenem TDM practice are needed to improve intervention success and enable study synthesis. Further suitably powered studies of standardised TDM are required to assess the impact of TMD on clinical outcomes and AMR.
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Affiliation(s)
- Timothy N. Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
- Correspondence:
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars J. C. Jeuken
- Leiden Institute of Chemistry, Leiden University, P.O. Box 9502, 2300 RA Leiden, The Netherlands
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29
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Alshaer M, Mazirka P, Burch G, Peloquin C, Drabick Z, Carson J. Experience with Implementing a Beta-lactam Therapeutic Drug Monitoring Service in a Burn Intensive Care Unit: A Retrospective Chart Review. J Burn Care Res 2022; 44:121-128. [PMID: 35896122 PMCID: PMC9825314 DOI: 10.1093/jbcr/irac099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Indexed: 01/13/2023]
Abstract
Thermal injuries alter pharmacokinetics, complicating the prediction of standard antibiotic dose effectiveness. Therapeutic drug monitoring (TDM) has been proposed to prevent subtherapeutic dosing of antibiotic therapy, but remains scarcely studied in the burn patient population. A retrospective chart review of burn patients receiving beta-lactam TDM from 2016 to 2019 was conducted. Adult patients with thermal injury receiving cefepime, piperacillin/tazobactam, or meropenem for ≥48 hours were included. Between February 2016 and July 2017, we utilized selective TDM based on clinical judgement to guide treatment. From October 2018 until July 2019, TDM was expanded to all burn patients on beta-lactams. The primary endpoint was achievement of therapeutic concentration, and the secondary endpoints were clinical cure, culture clearance, new resistance, length of stay, and mortality. The selective (control) group included 19 patients and the universal (study) group reviewed 23 patients. In both groups, skin and lungs were the most common primary infection sources, with Pseudomonas aeruginosa as the most common species. In the universal cohort, patients were older with higher risk factors, but more frequently achieved the target drug concentration, required less days to start TDM (p < .0001), and had more frequent measurements and beta-lactam dose adjustments. Positive clinical outcome was reported in 77%, and microbial eradication in 82% of all patients. All clinical outcomes were similar between the groups. The implementation of beta-lactam TDM protocol shortened the time, increased the probability of appropriate target attainment, and individualized beta-lactam therapy in burn patients.
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Affiliation(s)
- Mohammad Alshaer
- Infectious Disease Pharmacokinetics Laboratory College of Pharmacy, and Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Pavel Mazirka
- Address Correspondence to: Pavel Mazirka, MD, Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Rd., PO Box 100287, Gainesville, FL 32608, USA.
| | - Gena Burch
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Charles Peloquin
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Zachary Drabick
- College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, USA
| | - Joshua Carson
- The Loyola Burn Center, Loyola University Medical Center, Maywood, Illinois, USA
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30
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Dreesen E, Gijsen M, Elkayal O, Annaert P, Debaveye Y, Wauters J, Karlsson MO, Spriet I. Ceftriaxone dosing based on the predicted probability of augmented renal clearance in critically ill patients with pneumonia. J Antimicrob Chemother 2022; 77:2479-2488. [PMID: 35815604 DOI: 10.1093/jac/dkac209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES PTA of protein-unbound ceftriaxone may be compromised in critically ill patients with community-acquired pneumonia (CAP) with augmented renal clearance (ARC). We aimed to determine an optimized ceftriaxone dosage regimen based on the probability of developing ARC on the next day (PARC,d+1; www.arcpredictor.com). PATIENTS AND METHODS Thirty-three patients enrolled in a prospective cohort study were admitted to the ICU with severe CAP and treated with ceftriaxone 2 g once daily. Patients contributed 259 total ceftriaxone concentrations, collected during 1 or 2 days (±7 samples/day). Unbound fractions of ceftriaxone were determined in all peak and trough samples (n = 76). Population pharmacokinetic modelling and simulation were performed using NONMEM7.4. Target attainment was defined as an unbound ceftriaxone concentration >4 mg/L throughout the dosing interval. RESULTS A two-compartment population pharmacokinetic model described the data well. The maximal protein-bound ceftriaxone concentration decreased with lower serum albumin. Ceftriaxone clearance increased with body weight and PARC,d+1 determined on the previous day. A high PARC,d+1 was identified as a clinically relevant predictor for underexposure on the next day (area under the receiver operating characteristics curve 0.77). Body weight had a weak predictive value and was therefore considered clinically irrelevant. Serum albumin had no predictive value. An optimal PARC,d+1 threshold of 5.7% was identified (sensitivity 73%, specificity 69%). Stratified once- or twice-daily 2 g dosing when below or above the 5.7% PARC,d+1 cut-off, respectively, was predicted to result in 81% PTA compared with 47% PTA under population-level once-daily 2 g dosing. CONCLUSIONS Critically ill patients with CAP with a high PARC,d+1 may benefit from twice-daily 2 g ceftriaxone dosing for achieving adequate exposure on the next day.
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Affiliation(s)
- Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Uppsala Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Omar Elkayal
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,BioNotus, Niel, Belgium
| | - Yves Debaveye
- Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Mats O Karlsson
- Uppsala Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value. Crit Care Explor 2022; 4:e0726. [PMID: 35815181 PMCID: PMC9259115 DOI: 10.1097/cce.0000000000000726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE: DATA SOURCES: STUDY SELECTION: DATA EXTRACTION: DATA SYNTHESIS: CONCLUSIONS:
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Seraissol P, Lanot T, Baklouti S, Mané C, Ruiz S, Lavit M, De Riols P, Garrigues JC, Gandia P. Evaluation of 4 quantification methods for monitoring 16 antibiotics and 1 beta-lactamase inhibitor in human serum by high-performance liquid chromatography with tandem mass spectrometry detection. J Pharm Biomed Anal 2022; 219:114900. [PMID: 35752026 DOI: 10.1016/j.jpba.2022.114900] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Antibiotic (ATB) prescription in an intensive care unit (ICU) requires continuous monitoring of serum dosages due to the patient's pathophysiological condition. Dosing adjustment is necessary to achieve effective targeted concentrations. Since ICUs routinely use a large number of ATBs, global monitoring needs to be developed. In the present study, we developed a global analytical method for extracting, separating and quantifying the most widely used ATBs in ICUs: amoxicillin, piperacillin, cefazolin, cefepime, cefotaxime, ceftazidime, ceftolozane, ceftriaxone, ertapenem, meropenem, ciprofloxacin, moxifloxacin, levofloxacin, daptomycin, dalbavancin, linezolid and a beta-lactamase inhibitor: tazobactam. To guarantee the robustness of the quantification, we differentiated the 16 ATBs and the beta lactamase inhibitor into 4 pools (ATB1 to ATB4), taking into account prescription frequency in the ICU, the physicochemical properties and the calibration ranges of the ATBs selected. The whole ATB was then separated with two LC columns in reversed phase: Kinetex Polar-C18 100 Å and Polar-RP-80 synergy, in less than 6.5 min. Detection was carried out by electrospray in positive ion mode, by tandem mass spectrometry (LC-MS/MS. The four quantification methods were validated according to the European guidelines on bioanalytical method validation (EMEA guide), after determining the extraction yields, matrix effects, recovery, precision, accuracy, within-run precision and between-run precision. For all analyses, bias is < 15% and is comparable to the literature and LOQs vary from 0.05 mg.L-1 for ciprofloxacin to 1.00 mg.L-1 for ceftriaxone and dalbavancin. The stability time of cefepime and piperacillin is 3 hrs and for the other ATBs 6 hrs in serum at room temperature. For long-term stability, freezing at - 80 °C guarantees 3 months of stability for ceftriaxone and dalbavancin and more than 6 months for the other ATBs.
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Affiliation(s)
- Patrick Seraissol
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France; Laboratoire Départemental 31, Eau - Vétérinaire - Air, 76 chemin de Boudou, CS 50013, 31140 Launaguet, France
| | - Thomas Lanot
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Sarah Baklouti
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Camille Mané
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Stéphanie Ruiz
- Service de Réanimation Polyvalente Adulte, Hôpital Rangueil, 1 avenue du Professeur Jean Poulhès, 31059 Toulouse Cedex 9, France
| | - Michel Lavit
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Pascale De Riols
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France
| | - Jean-Christophe Garrigues
- Laboratoire des IMRCP, Université de Toulouse, UMR 5623, 118 Route de Narbonne, 31062 Toulouse Cedex 9, France.
| | - Peggy Gandia
- Laboratoire de Pharmacocinétique et Toxicologie, IFB, Hôpital Purpan, 330 Avenue de Grande-Bretagne, 31059 Toulouse Cedex 9, France; INTHERES, Université de Toulouse, INRA, ENVT, 23 Chemin des Capelles, BP 87614, 31 076 Toulouse Cedex 3, France
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Yang N, Wang J, Xie Y, Ding J, Wu C, Liu J, Pei Q. External Evaluation of Population Pharmacokinetic Models to Inform Precision Dosing of Meropenem in Critically Ill Patients. Front Pharmacol 2022; 13:838205. [PMID: 35662716 PMCID: PMC9157771 DOI: 10.3389/fphar.2022.838205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/10/2022] [Indexed: 11/21/2022] Open
Abstract
Routine clinical meropenem therapeutic drug monitoring data can be applied to model-informed precision dosing. The current study aimed to evaluate the adequacy and predictive capabilities of the published models with routine meropenem data and identify the dosing adaptations using a priori and Bayesian estimation. For this, 14 meropenem models for the external evaluation carried out on an independent cohort of 134 patients with 205 meropenem concentrations were encoded in NONMEM 7.3. The performance was determined using: 1) prediction-based and simulation-based diagnostics; and 2) predicted meropenem concentrations by a priori prediction using patient covariates only; and Bayesian forecasting using previous observations. The clinical implications were assessed according to the required dose adaptations using the meropenem concentrations. All assessments were stratified based on the patients with or without continuous renal replacement therapy. Although none of the models passed all tests, the model by Muro et al. showed the least bias. Bayesian forecasting could improve the predictability over an a priori approach, with a relative bias of −11.63–68.89% and −302.96%–130.37%, and a relative root mean squared error of 34.99–110.11% and 14.78–241.81%, respectively. A dosing change was required in 40.00–68.97% of the meropenem observation results after Bayesian forecasting. In summary, the published models couldn’t adequately describe the meropenem pharmacokinetics of our center. Although the selection of an initial meropenem dose with a priori prediction is challenging, the further model-based analysis combining therapeutic drug monitoring could be utilized in the clinical practice of meropenem therapy.
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Affiliation(s)
- Nan Yang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jing Wang
- Department of Pharmacy, Xiamen Children's Hospital (Children's Hospital of Fudan University Xiamen Branch), Xiamen, China
| | - Yueliang Xie
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Junjie Ding
- Center for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jingjing Liu
- Department of Intensive Medicine, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qi Pei
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China
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C/MIC > 4: A Potential Instrument to Predict the Efficacy of Meropenem. Antibiotics (Basel) 2022; 11:antibiotics11050670. [PMID: 35625314 PMCID: PMC9137711 DOI: 10.3390/antibiotics11050670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
This prospective study aimed to explore the determinants of meropenem trough concentration (Ctrough) in patients with bacterial pneumonia and to investigate the association between its concentration and efficacy. From January 2019 to December 2019, patients with pulmonary infections were prospectively enrolled from the intensive care unit. Factors affecting the meropenem trough concentration were analyzed, and a multiple linear regression model was constructed. Logistic regression analyses were used to investigate the relationship between Ctrough and clinical efficacy. A total of 64 patients were enrolled, in whom 210 meropenem concentrations were measured. Of the total, 60.9% (39/64) were considered clinically successful after treatment. Ctrough may increase with increased blood urea nitrogen, albumin, and concomitant antifungal use. By contrast, concentration may decrease with increased endogenous creatinine clearance rate. Six variables, including Ctrough/minimum inhibitory concentration (MIC) > 4, were associated with the efficacy of meropenem. There was an independent correlation between Ctrough/MIC > 4 and efficacy after fully adjusting for confounding factors. Based upon renal function indexes, it is possible to predict changes in meropenem concentration and adjust the dosage precisely and individually. Ctrough/MIC > 4 is a potential instrument to predict successful treatment with meropenem.
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Huriez P, Ourghanlian C, Razazi K, Vindrios W, Hulin A, Lepeule R, Habibi A, Gallien S. Probenecid, an old β-lactams pharmacokinetic enhancer for a renewed use: a retrospective study. Infect Dis Now 2022; 52:273-279. [DOI: 10.1016/j.idnow.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/13/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
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Maimongkol P, Yonwises W, Anugulruengkitt S, Sophonphan J, Treyaprasert W, Wacharachaisurapol N. Therapeutic drug monitoring of meropenem and pharmacokinetic-pharmacodynamic target assessment in critically ill pediatric patients from a prospective observational study. Int J Infect Dis 2022; 120:96-102. [PMID: 35489632 DOI: 10.1016/j.ijid.2022.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To compare the unbound plasma meropenem concentrations at mid-dosing intervals (Cmid, 50%fT), end-dosing intervals (Ctrough, 100%fT), and proportions of patients achieving 50%fT and 100%fT above MIC (50%fT>MIC and 100%fT>MIC) between extended infusion (EI) and intermittent bolus (IB) administration in a therapeutic drug monitoring (TDM) program in children. METHODS A prospective observational study was conducted in children aged 1 month to 18 years receiving meropenem every 8 h by either EI or IB. Meropenem Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC were compared. RESULTS TDM data from 72 patients with a median age (IQR) of 12 months (3-37) were used. Meropenem dose was 120 and 60 mg/kg/day in EI and IB groups, respectively. Geometric mean (95% CI) Cmid of EI versus IB was 17.3 mg/L (13.7-21.8) versus 3.4 mg/L (1.7-6.7) (P<0.001). Geometric mean (95% CI) Ctrough of EI versus IB was 2.3 mg/L (1.6-3.4) versus 0.8 mg/L (0.4-1.5) (P=0.005). Greater proportions of patients achieving 50%fT>MIC and 100%fT>MIC were observed in the EI group. CONCLUSIONS A meropenem dose of 20 mg/kg/dose given by IB should not be used in critically ill children, even if they are not suspected of having a CNS infection. A dose of 40 mg/kg/dose given by EI resulted in higher Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC.
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Affiliation(s)
- Passara Maimongkol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wanlika Yonwises
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jiratchaya Sophonphan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Wanchai Treyaprasert
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
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Methods for Determination of Meropenem Concentration in Biological Samples. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2022-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Measuring the concentration of antibiotics in biological samples allow implementation of therapeutic monitoring of these drugs and contribute to the adjustment of the dosing regimen in patients. This increases the effectiveness of antimicrobial therapy, reduces the toxicity of these drugs and prevents the development of bacterial resistance. This review article summarizes current knowledge on methods for determining concentration of meropenem, an antibiotic drug from the group of carbapenems, in different biological samples. It provides a brief discussion of the chemical structure, physicochemical and pharmacokinetic properties of meropenem, different sample preparation techniques, use of apparatus and equipment, knowledge of the advantages and limitations of available methods, as well as directions in which new methods should be developed. This review should facilitate clinical laboratories to select and apply one of the established methods for measuring of meropenem, as well as to provide them with the necessary knowledge to develop new methods for quantification of meropenem in biological samples according to their needs.
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de Cacqueray N, Boujaafar S, Bille E, Moulin F, Gana I, Benaboud S, Hirt D, Béranger A, Toubiana J, Renolleau S, Tréluyer JM, Oualha M. Therapeutic Drug Monitoring of Antibiotics in Critically Ill Children: An Observational Study in a Pediatric Intensive Care Unit. Ther Drug Monit 2022; 44:319-327. [PMID: 35292609 DOI: 10.1097/ftd.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Septic critically ill children are at a high risk of inadequate antibiotic exposure, requiring them to undergo therapeutic drug monitoring (TDM). The aim of this study was to describe the use of TDM for antibiotics in critically ill children. METHODS The authors conducted a single-center observational study between June and December 2019, with all children treated with antibiotics in a pediatric intensive care unit located in a French university hospital. Standard clinical and laboratory data were recorded. Blood samples were collected for routine laboratory tests, and plasma antibiotic levels were assayed using validated analytical methods. RESULTS A total of 209 children received antibiotics. TDM was performed in 58 patients (27.8%) who had a greater mean organ dysfunction (according to the International Pediatric Sepsis Consensus Conference) (3 versus 1 in the non-TDM group; P < 0.05) and were treated with antibiotics for longer. A total of 208 samples were analyzed. The median [interquartile range] assay turnaround time was 3 (1-5) days, and 48 (46.2%) of the 104 initial antibiotic concentration values were below the pharmacokinetic/pharmacodynamic targets. A total of 34 (46%) of the 74 off-target TDM measurements available before the end of the antibiotic treatment prompted dose adjustment. This dose adjustment increased the proportion of on-target TDM measurements (70% versus 20% without adjustment). Subsequent measurements of the minimum inhibitory concentration showed that the use of the European Committee on Antimicrobial Susceptibility Testing's epidemiological cutoff values led to underestimation of pharmacokinetic/pharmacodynamic target attainment in 10 cases (20%). CONCLUSIONS TDM seems to be an effective means of optimizing antibiotic exposure in critically ill children. This requires timely plasma antibiotic assays and minimum inhibitory concentration measurements. It is important to define which patients should undergo TDM and how this monitoring should be managed.
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Affiliation(s)
- Noémie de Cacqueray
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
| | - Sana Boujaafar
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Emmanuelle Bille
- Microbiological Laboratory, Necker Enfants Malades Hospital, Université de Paris; and
| | - Florence Moulin
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
| | - Inès Gana
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Sihem Benaboud
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Déborah Hirt
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Agathe Béranger
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Julie Toubiana
- Department of General Pediatrics and Pediatric Infectious Diseases, Necker Enfants Malades Hospital, Université de Paris, Paris, France
| | - Sylvain Renolleau
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
| | - Jean M Tréluyer
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
| | - Mehdi Oualha
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris
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Effect of therapeutic drug monitoring-based dose optimization of piperacillin/tazobactam on sepsis-related organ dysfunction in patients with sepsis: a randomized controlled trial. Intensive Care Med 2022; 48:311-321. [PMID: 35106617 PMCID: PMC8866359 DOI: 10.1007/s00134-021-06609-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Insufficient antimicrobial exposure is associated with worse outcomes in sepsis. We evaluated whether therapeutic drug monitoring (TDM)-guided antibiotic therapy improves outcomes. METHODS Randomized, multicenter, controlled trial from January 2017 to December 2019. Adult patients (n = 254) with sepsis or septic shock were randomly assigned 1:1 to receive continuous infusion of piperacillin/tazobactam with dosing guided by daily TDM of piperacillin or continuous infusion with a fixed dose (13.5 g/24 h if eGFR ≥ 20 mL/min). Target plasma concentration was four times the minimal inhibitory concentration (range ± 20%) of the underlying pathogen, respectively, of Pseudomonas aeruginosa in empiric situation. Primary outcome was the mean of daily total Sequential Organ Failure Assessment (SOFA) score up to day 10. RESULTS Among 249 evaluable patients (66.3 ± 13.7 years; female, 30.9%), there was no significant difference in mean SOFA score between patients with TDM (7.9 points; 95% CI 7.1-8.7) and without TDM (8.2 points; 95% CI 7.5-9.0) (p = 0.39). Patients with TDM-guided therapy showed a lower 28-day mortality (21.6% vs. 25.8%, RR 0.8, 95% CI 0.5-1.3, p = 0.44) and a higher rate of clinical (OR 1.9; 95% CI 0.5-6.2, p = 0.30) and microbiological cure (OR 2.4; 95% CI 0.7-7.4, p = 0.12), but these differences did not reach statistical significance. Attainment of target concentration was more common in patients with TDM (37.3% vs. 14.6%, OR 4.5, CI 95%, 2.9-6.9, p < 0.001). CONCLUSION TDM-guided therapy showed no beneficial effect in patients with sepsis and continuous infusion of piperacillin/tazobactam with regard to the mean SOFA score. Larger studies with strategies to ensure optimization of antimicrobial exposure are needed to definitively answer the question.
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Matusik E, Boidin C, Friggeri A, Richard JC, Bitker L, Roberts JA, Goutelle S. Therapeutic Drug Monitoring of Antibiotic Drugs in Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis: A Critical Review. Ther Drug Monit 2022; 44:86-102. [PMID: 34772891 DOI: 10.1097/ftd.0000000000000941] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM. METHODS Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines. RESULTS In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes. CONCLUSIONS Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.
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Affiliation(s)
- Elodie Matusik
- Pôle Pharmacie & Pôle Urgences-Réanimation-Anesthésie, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Pharmacie, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon 1, EA 3738 CICLY - Centre pour l'Innovation en Cancérologie de Lyon, Oullins
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service d'Anesthésie, Médecine Intensive et Réanimation, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon, Faculté de Médecine Lyon Sud-Charles Mérieux, Oullins
- UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, Laboratoire des Pathogènes Émergents
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Jason A Roberts
- Faculty of Medicine the University of Queensland, University of Queensland Centre for Clinical Research
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon ; and
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive Villeurbanne, France
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Matusik E, Lemtiri J, Wabont G, Lambiotte F. Beta-lactam dosing during continuous renal replacement therapy: a survey of practices in french intensive care units. BMC Nephrol 2022; 23:48. [PMID: 35093011 PMCID: PMC8800323 DOI: 10.1186/s12882-022-02678-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/15/2022] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Little information is available on current practice in beta-lactam dosing during continuous renal replacement therapy (CRRT). Optimized dosing is essential for improving outcomes, and there is no consensus on the appropriate dose regimens. The objective of the present study was to describe current practice for beta-lactam dosing during CRRT in intensive care units (ICUs).
Methods
We conducted a nationwide survey by e-mailing an online questionnaire to physicians working in ICUs in France. The questionnaire included three sections: demographic characteristics, CRRT practices, and beta-lactam dosing regimens during CRRT.
Results
157 intensivists completed the questionnaire. Continuous venovenous hemofiltration was the most frequently used CRRT technique, and citrate was the most regularly used anticoagulant. The median prescribed dose at baseline was 30 mL/kg/h. The majority of prescribers (57%) did not reduce beta-lactam dosing during CRRT. The tools were used to adapt dosing regimens during CRRT included guidelines, therapeutic drug monitoring (TDM), and data from the literature. When TDM was used, 100% T > 4 time the MIC was the most common mentioned pharmacokinetic/pharmacodynamic target (53%). Pharmacokinetic software tools were rarely used. Prolonged or continuous infusions were widely used during CRRT (88%). Institutional guidelines on beta-lactam dosing during CRRT were rare. 41% of physicians sometimes consulted another specialist before adapting the dose of antibiotic during CRRT.
Conclusions
Our present results highlight the wide range of beta-lactam dosing practices adopted during CRRT. Personalized TDM and the implementation of Bayesian software appear to be essential for optimizing beta-lactam dosing regimens and improving patient outcomes.
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Quantitative Determination of Unbound Piperacillin and Imipenem in Biological Material from Critically Ill Using Thin-Film Microextraction-Liquid Chromatography-Mass Spectrometry. Molecules 2022; 27:molecules27030926. [PMID: 35164191 PMCID: PMC8839241 DOI: 10.3390/molecules27030926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
β-Lactam antibiotics are most commonly used in the critically ill, but their effective dosing is challenging and may result in sub-therapeutic concentrations that can lead to therapy failure and even promote antimicrobial resistance. In this study, we present the analytical tool enabling specific and sensitive determination of the sole biologically active fraction of piperacillin and imipenem in biological material from the critically ill. Thin-film microextraction sampling technique, followed by rapid liquid chromatography–tandem mass spectrometry (LC-MS/MS) analysis, was optimized and validated for the quantitative determination of antibiotics in blood and bronchoalveolar lavage (BAL) specimens collected from intensive care unit (ICU) patients suffering from ventilation-associated pneumonia (n = 18 and n = 9, respectively). The method was optimized and proved to meet the criteria of US Food and Drug Administration (FDA) guidelines for bioanalytical method validation. Highly selective, sensitive, accurate and precise analysis by means of thin-film microextraction–LC-MS/MS, which is not affected by matrix-related factors, was successfully applied in clinical settings, revealing poor penetration of piperacillin and imipenem from blood into BAL fluid (reflecting the site of bacterial infection), nonlinearity in antibiotic binding to plasma-proteins and drug-specific dependence on creatinine clearance. This work demonstrates that only a small fraction of biologically active antibiotics reach the site of infection, providing clinicians with a high-throughput analytical tool for future studies on personalized therapeutic drug monitoring when tailoring the dosing strategy to an individual patient.
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Tait JR, Bilal H, Rogers KE, Lang Y, Kim TH, Zhou J, Wallis SC, Bulitta JB, Kirkpatrick CMJ, Paterson DL, Lipman J, Bergen PJ, Roberts JA, Nation RL, Landersdorfer CB. Effect of Different Piperacillin-Tazobactam Dosage Regimens on Synergy of the Combination with Tobramycin against Pseudomonas aeruginosa for the Pharmacokinetics of Critically Ill Patients in a Dynamic Infection Model. Antibiotics (Basel) 2022; 11:antibiotics11010101. [PMID: 35052977 PMCID: PMC8772788 DOI: 10.3390/antibiotics11010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 12/10/2022] Open
Abstract
We evaluated piperacillin-tazobactam and tobramycin regimens against Pseudomonas aeruginosa isolates from critically ill patients. Static-concentration time-kill studies (SCTK) assessed piperacillin-tazobactam and tobramycin monotherapies and combinations against four isolates over 72 h. A 120 h-dynamic in vitro infection model (IVM) investigated isolates Pa1281 (MICpiperacillin 4 mg/L, MICtobramycin 0.5 mg/L) and CR380 (MICpiperacillin 32 mg/L, MICtobramycin 1 mg/L), simulating the pharmacokinetics of: (A) tobramycin 7 mg/kg q24 h (0.5 h-infusions, t1/2 = 3.1 h); (B) piperacillin 4 g q4 h (0.5 h-infusions, t1/2 = 1.5 h); (C) piperacillin 24 g/day, continuous infusion; A + B; A + C. Total and less-susceptible bacteria were determined. SCTK demonstrated synergy of the combination for all isolates. In the IVM, regimens A and B provided initial killing, followed by extensive regrowth by 72 h for both isolates. C provided >4 log10 CFU/mL killing, followed by regrowth close to initial inoculum by 96 h for Pa1281, and suppressed growth to <4 log10 CFU/mL for CR380. A and A + B initially suppressed counts of both isolates to <1 log10 CFU/mL, before regrowth to control or starting inoculum and resistance emergence by 72 h. Overall, the combination including intermittent piperacillin-tazobactam did not provide a benefit over tobramycin monotherapy. A + C, the combination regimen with continuous infusion of piperacillin-tazobactam, provided synergistic killing (counts <1 log10 CFU/mL) of Pa1281 and CR380, and suppressed regrowth to <2 and <4 log10 CFU/mL, respectively, and resistance emergence over 120 h. The shape of the concentration–time curve was important for synergy of the combination.
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Affiliation(s)
- Jessica R. Tait
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Hajira Bilal
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Kate E. Rogers
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Tae-Hwan Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan 38430, Korea;
| | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Steven C. Wallis
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Carl M. J. Kirkpatrick
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - David L. Paterson
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jeffrey Lipman
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Phillip J. Bergen
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Jason A. Roberts
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
- Correspondence: ; Tel.: +61-3-990-39011
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Therapeutic drug monitoring of meropenem and piperacillin-tazobactam in the Singapore critically ill population - A prospective, multi-center, observational study (BLAST 1). J Crit Care 2022; 68:107-113. [PMID: 34999376 DOI: 10.1016/j.jcrc.2021.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To determine percentage of patients with sub-therapeutic beta-lactam exposure in our intensive care units (ICU) and to correlate target attainment with clinical outcomes. MATERIALS AND METHODS Multi-centre, prospective, observational study was conducted in ICUs from three hospitals in Singapore from July 2016 to May 2018. Adult patients (≥21 years) receiving meropenem or piperacillin-tazobactam were included. Four blood samples were obtained during a dosing interval to measure and determine attainment of therapeutic targets: unbound beta-lactam concentration above (i) minimum inhibitory concentration (MIC) at 40% (meropenem) or 50% (piperacillin) of dosing interval (40-50%fT > MIC) and (ii) 5 × MIC at 100% of dosing interval (100%fT > 5 × MIC). Correlation to clinical outcomes was evaluated using Cox regression. RESULTS Beta-lactam levels were highly variable among 61 patients, with trough meropenem and piperacillin levels at 21.5 ± 16.8 mg/L and 101.6 ± 81.1 mg/L respectively. Among 85 sets of blood samples, current dosing practices were able to achieve 94% success for 40-50%fT > MIC and 44% for 100%fT > 5 × MIC. Failure to achieve 40-50%fT > MIC within 48 h was significantly associated with all-cause mortality (HR: 9.0, 95% CI: 1.8-45.0), after adjustment for APACHE II score. Achievement of 100%fT > 5 × MIC within 48 h was significantly associated with shorter length of hospital stay. CONCLUSION Current dosing practices may be suboptimal for ICU patients. Beta-lactam TDM may be useful.
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Luxton T, King N, Wälti C, Jeuken L, Sandoe J. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1532-1541. [PMID: 35355067 PMCID: PMC9155611 DOI: 10.1093/jac/dkac101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Dosing regimens guided by therapeutic drug monitoring (TDM) may be able to improve penicillin exposure in patients, which could result in improved patient health outcomes. Objectives This systematic review aims to describe the impact penicillin TDM has on health outcomes, including antimicrobial resistance (AMR). Methods Studies measuring penicillins in patient samples that adjusted regimens according to the result, and reported health outcomes were selected. Study bias was assessed according to study type. Included study characteristics were tabulated and described by narrative synthesis. Results Three randomized controlled trials (RCTs), 16 cohort studies, and 9 case studies were included. No RCTs showed statistically significant improvements in health outcomes. Five cohort studies showed improvement in at least one health outcome associated with target attainment. However, there was a high risk of bias in all studies for health outcomes. One study assessed the impact of penicillin TDM on AMR and found that improved target attainment was associated with suppression of resistance. No studies found a detrimental effect of penicillin TDM. Conclusions There is little evidence to suggest that TDM improves health outcomes, however neither health outcomes nor impact on AMR were adequately addressed. Variations in TDM implementation meant that a meta-analysis was not suitable. Penicillin TDM needs standardization, however there is currently no clear evidence of optimal conditions. Suitably powered studies are required to resolve the ambiguity surrounding the impact of TDM on clinical outcomes, including AMR. Further, standardized protocols and concentration targets need to be identified for TDM to be implemented successfully.
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Affiliation(s)
- Timothy Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
- Corresponding author. E-mail:
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars Jeuken
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
- Leiden Institute of Chemistry, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
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Ates HC, Mohsenin H, Wenzel C, Glatz RT, Wagner HJ, Bruch R, Hoefflin N, Spassov S, Streicher L, Lozano-Zahonero S, Flamm B, Trittler R, Hug MJ, Köhn M, Schmidt J, Schumann S, Urban GA, Weber W, Dincer C. Biosensor-Enabled Multiplexed On-Site Therapeutic Drug Monitoring of Antibiotics. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2104555. [PMID: 34545651 DOI: 10.1002/adma.202104555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/31/2021] [Indexed: 05/20/2023]
Abstract
Personalized antibiotherapy ensures that the antibiotic concentration remains in the optimal therapeutic window to maximize efficacy, minimize side effects, and avoid the emergence of drug resistance due to insufficient dosing. However, such individualized schemes need frequent sampling to tailor the blood antibiotic concentrations. To optimally integrate therapeutic drug monitoring (TDM) into the clinical workflow, antibiotic levels can either be measured in blood using point-of-care testing (POCT), or can rely on noninvasive sampling. Here, a versatile biosensor with an antibody-free assay for on-site TDM is presented. The platform is evaluated with an animal study, where antibiotic concentrations are quantified in different matrices including whole blood, plasma, urine, saliva, and exhaled breath condensate (EBC). The clearance and the temporal evaluation of antibiotic levels in EBC and plasma are demonstrated. Influence of matrix effects on measured drug concentrations is determined by comparing the plasma levels with those in noninvasive samples. The system's potential for blood-based POCT is further illustrated by tracking ß-lactam concentrations in untreated blood samples. Finally, multiplexing capabilities are explored successfully for multianalyte/sample analysis. By enabling a rapid, low-cost, sample-independent, and multiplexed on-site TDM, this system can shift the paradigm of "one-size-fits-all" strategy.
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Affiliation(s)
- H Ceren Ates
- FIT Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Georges-Koehler-Allee 105, 79110, Freiburg, Germany
- Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Hasti Mohsenin
- Faculty of Biology and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Schaenzlestrasse 18, 79104, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Regina T Glatz
- FIT Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Georges-Koehler-Allee 105, 79110, Freiburg, Germany
- Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Hanna J Wagner
- Faculty of Biology and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Schaenzlestrasse 18, 79104, Freiburg, Germany
- Department of Biosystems Science and Engineering, ETH Zurich, Mattenstrasse 26, Basel, 4058, Switzerland
| | - Richard Bruch
- FIT Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Georges-Koehler-Allee 105, 79110, Freiburg, Germany
- Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
| | - Nico Hoefflin
- Faculty of Biology and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Schaenzlestrasse 18, 79104, Freiburg, Germany
| | - Sashko Spassov
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Lea Streicher
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Sara Lozano-Zahonero
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Bernd Flamm
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Rainer Trittler
- Department of Pharmacy, Medical Center - University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Martin J Hug
- Department of Pharmacy, Medical Center - University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Maja Köhn
- Faculty of Biology and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Schaenzlestrasse 18, 79104, Freiburg, Germany
| | - Johannes Schmidt
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Gerald A Urban
- Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
- Freiburg Materials Research Center (FMF), University of Freiburg, Stefan-Meier-Straße 21, 79104, Freiburg, Germany
| | - Wilfried Weber
- Faculty of Biology and Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Schaenzlestrasse 18, 79104, Freiburg, Germany
| | - Can Dincer
- FIT Freiburg Center for Interactive Materials and Bioinspired Technologies, University of Freiburg, Georges-Koehler-Allee 105, 79110, Freiburg, Germany
- Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, University of Freiburg, Georges-Koehler-Allee 103, 79110, Freiburg, Germany
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Schouwenburg S, Wildschut ED, de Hoog M, Koch BCP, Abdulla A. The Pharmacokinetics of Beta-Lactam Antibiotics Using Scavenged Samples in Pediatric Intensive Care Patients: The EXPAT Kids Study Protocol. Front Pharmacol 2021; 12:750080. [PMID: 34955824 PMCID: PMC8703159 DOI: 10.3389/fphar.2021.750080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Emerging evidence supports the importance of optimized antibiotic exposure in pediatric intensive care unit (PICU) patients. Traditional antibiotic dosing is not designed for PICU patients, as the extreme pharmacokinetic (PK) behavior of drugs threatens the achievement of optimal antibiotic treatment outcomes. Scavenged sampling is a sampling strategy which may have positive implications for routine TDM and PK research, as well as monitoring other biomarkers. EXPAT Kids study was designed to analyze whether current empiric dosing regimens of frequently used beta-lactam antibiotics achieve defined therapeutic target concentrations in PICU patients. Methods: A mono-centre, exploratory pharmacokinetic and pharmacodynamic study was designed to assess target attainment of beta-lactam antibiotics. One hundred forty patients will be included within 24 months after start of inclusion. At various time points serum concentration of the study antibiotic (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, flucloxacillin, and meropenem) are determined. In parallel with these sampling moments, residual material is collected to validate the use of blood of scavenged heparinized astrup syringes for the quantification of antibiotic exposure. The primary outcome is the time that the free (unbound) concentration of the study antibiotic remains above one to four the minimal inhibitory concentration during a dosing interval (100%ƒT > MIC and 100%ƒT>4xMIC). Other included outcomes are disease severity, safety, length of stay, and inflammatory biomarkers. Discussion: Potentially, scavenged sampling may enrich the EXPAT Kids dataset, and reduce additional blood sampling and workload for clinical personnel. The findings from the EXPAT Kids study will lead to new insights in the PK parameters of beta-lactams and consecutive effects on target attainment and clinical outcomes. Is there a need for more precision in dosing? Netherlands Trial Register Number: Trial NL9326.
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Affiliation(s)
- Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M de Hoog
- Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Schmitt L, Huisinga W, Michelet R, Hennig S, Kloft C. Development of a Model-Informed Dosing Tool to Optimise Initial Antibiotic Dosing-A Translational Example for Intensive Care Units. Pharmaceutics 2021; 13:pharmaceutics13122128. [PMID: 34959409 PMCID: PMC8708464 DOI: 10.3390/pharmaceutics13122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
The prevalence and mortality rates of severe infections are high in intensive care units (ICUs). At the same time, the high pharmacokinetic variability observed in ICU patients increases the risk of inadequate antibiotic drug exposure. Therefore, dosing tailored to specific patient characteristics has a high potential to improve outcomes in this vulnerable patient population. This study aimed to develop a tabular dosing decision tool for initial therapy of meropenem integrating hospital-specific, thus far unexploited pathogen susceptibility information. An appropriate meropenem pharmacokinetic model was selected from the literature and evaluated using clinical data. Probability of target attainment (PTA) analysis was conducted for clinically interesting dosing regimens. To inform dosing prior to pathogen identification, the local pathogen-independent mean fraction of response (LPIFR) was calculated based on the observed minimum inhibitory concentrations distribution in the hospital. A simple, tabular, model-informed dosing decision tool was developed for initial meropenem therapy. Dosing recommendations achieving PTA > 90% or LPIFR > 90% for patients with different creatinine clearances were integrated. Based on the experiences during the development process, a generalised workflow for the development of tabular dosing decision tools was derived. The proposed workflow can support the development of model-informed dosing tools for initial therapy of various drugs and hospital-specific conditions.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50656
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Vegas Cómitre MD, Cortellini S, Cherlet M, Devreese M, Roques BB, Bousquet-Melou A, Toutain PL, Pelligand L. Population Pharmacokinetics of Intravenous Amoxicillin Combined With Clavulanic Acid in Healthy and Critically Ill Dogs. Front Vet Sci 2021; 8:770202. [PMID: 34869739 PMCID: PMC8636140 DOI: 10.3389/fvets.2021.770202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/18/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Data regarding antimicrobial pharmacokinetics (PK) in critically ill dogs are lacking and likely differ from those of healthy dogs. The aim of this work is to describe a population PK model for intravenous (IV) amoxicillin–clavulanic acid (AMC) in both healthy and sick dogs and to simulate a range of clinical dosing scenarios to compute PK/PD cutoffs for both populations. Methods: This study used a prospective clinical trial in normal and critically ill dogs. Twelve client-owned dogs hospitalized in the intensive care unit (ICU) received IV AMC 20 mg/kg every 8 h (0.5-h infusion) during at least 48 h. Eight blood samples were collected at predetermined times, including four trough samples before the next administration. Clinical covariates and outcome were recorded, including survival to discharge and bacteriologic clinical failure. Satellite PK data were obtained de novo from a group of 12 healthy research dogs that were dosed with a single AMC 20 mg/kg IV. Non-linear mixed-effects model was used to estimate the PK parameters (and the effect of health upon them) together with variability within and between subjects. Monte Carlo simulations were performed with seven dosage regimens (standard and increased doses). The correlation between model-derived drug exposure and clinical covariates was tested with Spearman's non-parametric correlation analysis. Outcome was recorded including survival to discharge and bacteriologic clinical failure. Results: A total of 218 amoxicillin concentrations in plasma were available for healthy and sick dogs. A tricompartmental model best described the data. Amoxicillin clearance was reduced by 56% in sick dogs (0.147 L/kg/h) compared with healthy dogs (0.336 L/kg/h); intercompartmental clearance was also decreased (p <0.01). None of the clinical data covariates were significantly correlated with individual exposure. Monte Carlo simulations showed that higher PK/PD cutoff values of 8 mg/L could be reached in sick dogs by extending the infusion to 3 h or doubling the dose. Conclusions: The PK of AMC is profoundly different in critically ill dogs compared with normal dogs, with much higher interindividual variability and a lower systemic clearance. Our study allows to generate hypotheses with regard to higher AMC exposure in clinical dogs and provides supporting data to revise current AMC clinical breakpoint for IV administration.
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Affiliation(s)
- Maria D Vegas Cómitre
- Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, United Kingdom
| | - Stefano Cortellini
- Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, United Kingdom
| | - Marc Cherlet
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Mathias Devreese
- Department of Pharmacology, Toxicology and Biochemistry, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | | | | | - Pierre-Louis Toutain
- INTHERES, Université de Toulouse, INRAE, ENVT, Toulouse, France.,Department of Comparative Biomedical Science, The Royal Veterinary College, Hatfield, United Kingdom
| | - Ludovic Pelligand
- Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, United Kingdom.,Department of Comparative Biomedical Science, The Royal Veterinary College, Hatfield, United Kingdom
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