1
|
Azamgarhi T, Gerrand C, Skinner JA, Sell A, McCulloch RA, Warren S. Antimicrobial prophylaxis with teicoplanin plus gentamicin in primary total joint arthroplasty. J Bone Jt Infect 2023; 8:219-227. [PMID: 38039328 PMCID: PMC10654607 DOI: 10.5194/jbji-8-219-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/28/2023] [Indexed: 12/03/2023] Open
Abstract
Objectives: To compare prosthetic joint infection (PJI) and acute kidney injury (AKI) rates among cohorts before and after changing our hospital's antimicrobial prophylactic regimen from cefuroxime to teicoplanin plus gentamicin. Methods: We retrospectively studied all patients undergoing primary total joint arthroplasty at our hospital 18 months pre- and post-implementation of the change in practice. All deep infections identified during follow-up were assessed against the European Bone and Joint Infection Society (EBJIS) definitions for PJI. Survival analysis using Cox regression was employed to adjust for differences in baseline characteristics and compare the risk of PJI between the groups. AKIs were identified using pathology records and categorized according to the KDIGO (Kidney Disease - Improving Global Outcomes) criteria. AKI rates were calculated for the pre- and post-intervention periods. Results: Of 1994 evaluable patients, 1114 (55.9 %) received cefuroxime only (pre-intervention group) and 880 (44.1 %) patients received teicoplanin plus gentamicin (post-intervention group). The overall rate of PJI in our study was 1.50 % (30 of 1994), with a lower PJI rate in the post-intervention group (0.57 %; 5 of 880) compared with the pre-intervention group (2.24 %; 25 of 1114). A corresponding risk reduction for PJI of 75.2 % (95 % CI of 35.2-90.5; p = 0 .004) was seen in the post-intervention group, which was most pronounced for early-onset and delayed infections due to coagulase-negative staphylococci (CoNS) and cefuroxime-resistant Enterobacteriaceae. Significantly higher AKI rates were seen in the post-intervention group; however, 84 % of cases (32 of 38) were stage 1, and there were no differences in the rate of stage-2 or -3 AKI. Conclusions: Teicoplanin plus gentamicin was associated with a significant reduction in PJI rates compared with cefuroxime. Increases in stage-1 AKI were seen with teicoplanin plus gentamicin.
Collapse
Affiliation(s)
- Tari Azamgarhi
- Pharmacy Department, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
| | - Craig Gerrand
- Division of Orthopaedic Oncology, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
| | - John A Skinner
- Research and Innovation Centre, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
- Division of Surgery and Interventional Science, University College London, London, WC1E 6BT, UK
| | - Alexander Sell
- Department of Anaesthesia, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
| | - Robert A McCulloch
- Joint Reconstruction Unit, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
| | - Simon Warren
- Bone Infection Unit, Royal National Orthopaedic Hospital NHS Trust, Stanmore, HA7 4LP, UK
- The Royal Free Hospital NHS Foundation Trust, Hampstead, London, NW3 2QG, UK
| |
Collapse
|
2
|
Azamgarhi T, Warren S, Fouch S, Standing JF, Gerrand C. Prophylactic antibiotics for massive endoprostheses in orthopaedic oncology. Bone Joint J 2023; 105-B:850-856. [PMID: 37524359 DOI: 10.1302/0301-620x.105b8.bjj-2022-1418.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
The recently published Prophylactic Antibiotic Regimens In Tumor Surgery (PARITY) trial found no benefit in extending antibiotic prophylaxis from 24 hours to five days after endoprosthetic reconstruction for lower limb bone tumours. PARITY is the first randomized controlled trial in orthopaedic oncology and is a huge step forward in understanding antibiotic prophylaxis. However, significant gaps remain, including questions around antibiotic choice, particularly in the UK, where cephalosporins are avoided due to concerns of Clostridioides difficile infection. We present a review of the evidence for antibiotic choice, dosing, and timing, and a brief description of PARITY, its implication for practice, and the remaining gaps in our understanding.
Collapse
Affiliation(s)
- Tariq Azamgarhi
- Pharmacy Department, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Simon Warren
- Bone Infection Unit, Royal National Orthopaedic Hospital NHS Trust, London, UK
| | - Sarah Fouch
- School of Pharmacy and Biomedical Sciences, Portsmouth, UK
| | - Joseph F Standing
- Infection, Inflammation and Rheumatology, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Craig Gerrand
- Division of Orthopaedic Oncology, Royal National Orthopaedic Hospital NHS Trust Sarcoma Unit, London, UK
| |
Collapse
|
3
|
Cao Y, Li Y, Guo B, Zhang J, Wu X, Yu J, Cao G, Fan Y, Wu H. Population pharmacokinetics of levornidazole in healthy subjects and patients, and sequential dosing regimen proposal using pharmacokinetic/pharmacodynamic analysis. Int J Antimicrob Agents 2023; 61:106754. [PMID: 36773938 DOI: 10.1016/j.ijantimicag.2023.106754] [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: 06/24/2022] [Revised: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
Although sequential treatment with levornidazole has been used for anaerobic infection in clinical practice, there is no evidence-based dosing regimen. This study aimed to evaluate the pharmacokinetics (PK) of levornidazole in healthy subjects and patients, and to propose an evidence-based sequential dosing regimen by pharmacokinetic/pharmacodynamic (PK/PD) analysis. A population PK model was built using the data of 116 Chinese subjects, including 88 healthy young subjects, 12 healthy elderly subjects, and 16 patients with intra-abdominal anaerobic infection. PK/PD analysis was performed combining the minimum inhibitory concentration (MIC) values of levornidazole against 375 anaerobic strains. Four sequential dosing regimens (500 mg q12h, 1000 mg loading dose followed by 500 mg q12h, 750 mg q24h, and 1000 mg q24h) were evaluated in terms of cumulative fraction of response (CFR) and probability of target attainment (PTA) by Monte Carlo simulation. The concentration data of levornidazole and its active metabolites were described adequately by two- and one-compartment models, respectively. Body weight was identified as a significant covariate of levornidazole clearance. Simulations showed that satisfactory PTA (>90%) was achieved for the four dosing regimens when MIC ≤1 mg/L. Considering the simulation results, patients' safety and compliance, levornidazole 750 mg intravenous infusion q24h for 2 days followed by 750 mg oral dose q24h for 5 days was optimal for Bacteroides spp. with an identified MIC ≤1 mg/L.
Collapse
Affiliation(s)
- Yuran Cao
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
| | - Beining Guo
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China.
| | - Jing Zhang
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai, China; Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
| | - Xiaojie Wu
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Jicheng Yu
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Guoying Cao
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
| | - Hailan Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, National Health Commission, Shanghai, China
| |
Collapse
|
4
|
The Impact of a Pharmacist-Led Intravenous to Oral Switch of Metronidazole: A Before-and-After Study. Antibiotics (Basel) 2022; 11:antibiotics11101303. [PMID: 36289961 PMCID: PMC9598063 DOI: 10.3390/antibiotics11101303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background. Intravenous (IV) to oral switch (IVOS) of antibiotics can reduce the length of hospitalisation, risk of IV catheter complications, and hospital costs. Pharmacists can play an instrumental role in implementing an IVOS initiative. The aim of this study is to evaluate the impact of pharmacist-led IVOS of metronidazole. (2) Method. This was an observational study conducted in a New Zealand hospital. During a 3-month intervention period, pharmacists identified patients receiving IV metronidazole; then initiated an IVOS for patients who met the criteria. The comparator groups were patients who were not switched by pharmacists in the post-intervention (post-IVOS) group, or patients treated with either IV or oral metronidazole prior to the intervention (pre-IVOS). Primary outcome measures were switch rate and duration of IV metronidazole treatment. Secondary outcome measures were readmission and/or repeat surgery within 90 days of discharge and the length of hospital stay. (3) Results. In total, 203 patients were included: 100 in the pre-IVOS and 103 in the post-IVOS groups. Pharmacists switched 63/93 (67.7%) of eligible patients to oral metronidazole in the post-IVOS period. Only 9/89 (10.1%) of IVOS eligible patients were switched in the pre-IVOS group. In the post-IVOS group, the mean duration of IV metronidazole treatment in patients switched by pharmacists was shorter than in those who were not switched by pharmacists (2.5 ± 2.8 days vs. 4.8 ± 5.9 days, p = 0.012). No significant difference was found in readmission or repeat surgery within 90 days of discharge for patients switched by pharmacists versus patients who were not switched by pharmacists. (4) Conclusion. Our data have demonstrated successful implementation of the hospital-approved pharmacist-led IVOS service.
Collapse
|
5
|
da Silva Neto MJJ, MacKay G, Agaram R, MacLeod M, Watson DG, Thomson AH. Evaluation of amoxicillin, metronidazole and gentamicin dosage regimens for use in antibiotic prophylaxis in colorectal surgery. J Antimicrob Chemother 2021; 76:3212-3219. [PMID: 34542630 DOI: 10.1093/jac/dkab337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 08/23/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To evaluate amoxicillin, metronidazole and gentamicin dosage regimens for antibiotic prophylaxis in colorectal surgery. METHODS The study was conducted in 20 patients undergoing colorectal surgery. Patients received one or two doses of amoxicillin 1000 mg, metronidazole 500 mg and gentamicin 3 mg/kg ideal body weight, banded by height. Antibiotic concentrations were measured up to 7 h post dose. Population pharmacokinetic (PopPK) analysis with NONMEM followed by Monte Carlo simulation of different dosage regimens was used to estimate the PTA for potential organisms associated with surgical site infections (SSIs). RESULTS A median of 5 (range 3-6) concentrations were available per patient. CL and V of all antibiotics were related to weight; gentamicin CL was also related to CLCR. The administered doses maintained the desired PTA up to 8 h for the Streptococcus anginosus group but not for enterococci, Bacteroides fragilis group, MSSA, and Escherichia coli. An additional 500 mg amoxicillin every 4 h was sufficient to achieve the PTA for most relevant organisms but 2 hourly dosing was required for patients at risk of infective endocarditis. A metronidazole dose of 1000 mg was required for patients >85 kg. In patients with CLCR >50 mL/min, 5 mg/kg gentamicin (with an additional 2.5 mg/kg in prolonged surgery at 6 h) maintained PTA targets for >10 h. CONCLUSIONS PopPK analysis with Monte Carlo simulation identified prophylactic antibiotic regimens that would maintain the PTA for organisms associated with SSIs during short- and long-duration colorectal surgery.
Collapse
Affiliation(s)
- M J J da Silva Neto
- Pharmacy Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - G MacKay
- Lister Department of Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
| | - R Agaram
- Anaesthetic Department, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK
| | - M MacLeod
- Clinical Microbiology Department, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow G31 2ER, UK
| | - D G Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| | - A H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow G4 0RE, UK
| |
Collapse
|
6
|
Kalin R, Köksal Z, Bayrak S, Gerni S, Ozyürek IN, Usanmaz H, Karaman M, Atasever A, Özdemir H, Gülçin İ. Molecular docking and inhibition profiles of some antibiotics on lactoperoxidase enzyme purified from bovine milk. J Biomol Struct Dyn 2020; 40:401-410. [PMID: 32856529 DOI: 10.1080/07391102.2020.1814416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Antibiotics are generally used for human and veterinary applications to preserve and to control microbial diseases. Milk has a biologically significant enzyme known as lactoperoxidase (LPO) that is a member of peroxidase family. In metabolism, LPO has ability to catalyze the transformation of thiocyanate (SCN-) to hypothiocyanite (OSCN-) that is an antibacterial agent and the reaction occurs with hydrogen peroxide. In this work, LPO inhibition effects of some antibiotics including cefazolin, oxytetracycline, flunixin meglumine, cefuroxime, tylosin, vancomycin, chloramphenicol and lincomycin were tested. Among the antibiotics cefazolin was indicated the strongest inhibitory efficacy. The half maximal inhibitory concentration (IC50) and the inhibition constant (Ki) values of cefazolin were found as 8.19 and 34.66 µM, respectively. It was shown competitive inhibition. 5-Methyl-1,3,4-thiadiazol-2-yl moiety activity plays a key role in the inhibition mechanism of cefazolin.Communicated by Ramaswamy H. Sarma.
Collapse
Affiliation(s)
- Ramazan Kalin
- Department of Basic Science, Faculty of Science, Erzurum Technical University, Erzurum, Turkey
| | - Zeynep Köksal
- Department of Chemistry, Faculty of Engineering and Natural Sciences, İstanbul Medeniyet University, İstanbul, Turkey
| | - Songül Bayrak
- Department of Chemistry, Faculty of Science, Atatürk University, Erzurum, Turkey
| | - Serpil Gerni
- Department of Chemistry, Faculty of Science, Atatürk University, Erzurum, Turkey
| | - Işıl Nihan Ozyürek
- Department of Chemistry, Faculty of Science, Atatürk University, Erzurum, Turkey
| | - Hande Usanmaz
- Department of Bioengineering, Faculty of Engineering and Architecture, Sinop University, Sinop, Turkey
| | - Muhammet Karaman
- Department of Molecular Biology and Genetics, Faculty of Arts and Science, Kilis 7 Aralik University, Kilis, Turkey
| | - Ali Atasever
- Ispir Hamza Polat Vocational Training School, Ataturk University, Erzurum, Turkey
| | - Hasan Özdemir
- Department of Chemistry, Faculty of Science, Atatürk University, Erzurum, Turkey
| | - İlhami Gülçin
- Department of Chemistry, Faculty of Science, Atatürk University, Erzurum, Turkey
| |
Collapse
|
7
|
Extension of Pharmacokinetic/Pharmacodynamic Time-Kill Studies To Include Lipopolysaccharide/Endotoxin Release from Escherichia coli Exposed to Cefuroxime. Antimicrob Agents Chemother 2020; 64:AAC.02070-19. [PMID: 31988100 PMCID: PMC7179275 DOI: 10.1128/aac.02070-19] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
The release of inflammatory bacterial products, such as lipopolysaccharide (LPS)/endotoxin, may be increased upon the administration of antibiotics. An improved quantitative understanding of endotoxin release and its relation to antibiotic exposure and bacterial growth/killing may be gained by an integrated analysis of these processes. The aim of this work was to establish a mathematical model that relates Escherichia coli growth/killing dynamics at various cefuroxime concentrations to endotoxin release in vitro. The release of inflammatory bacterial products, such as lipopolysaccharide (LPS)/endotoxin, may be increased upon the administration of antibiotics. An improved quantitative understanding of endotoxin release and its relation to antibiotic exposure and bacterial growth/killing may be gained by an integrated analysis of these processes. The aim of this work was to establish a mathematical model that relates Escherichia coli growth/killing dynamics at various cefuroxime concentrations to endotoxin release in vitro. Fifty-two time-kill experiments informed bacterial and endotoxin time courses and included both static (0×, 0.5×, 1×, 2×, 10×, and 50× MIC) and dynamic (0×, 15×, and 30× MIC) cefuroxime concentrations. A model for the antibiotic-bacterium interaction was established, and antibiotic-induced bacterial killing followed a sigmoidal Emax relation to the cefuroxime concentration (MIC-specific 50% effective concentration [EC50], maximum antibiotic-induced killing rate [Emax] = 3.26 h−1 and γ = 3.37). Endotoxin release was assessed in relation to the bacterial processes of growth, antibiotic-induced bacterial killing, and natural bacterial death and found to be quantitatively related to bacterial growth (0.000292 endotoxin units [EU]/CFU) and antibiotic-induced bacterial killing (0.00636 EU/CFU). Increased release following the administration of a second cefuroxime dose was described by the formation and subsequent antibiotic-induced killing of filaments (0.295 EU/CFU). Release due to growth was instantaneous, while release due to antibiotic-induced killing was delayed (mean transit time of 7.63 h). To conclude, the in vitro release of endotoxin is related to bacterial growth and antibiotic-induced killing, with higher rates of release upon the killing of formed filaments. Endotoxin release over 24 h is lowest when antibiotic exposure rapidly eradicates bacteria, while increased release is predicted to occur when growth and antibiotic-induced killing occur simultaneously.
Collapse
|
8
|
Thønnings S, Jensen KS, Nielsen NB, Skjønnemand M, Hansen DS, Lange KHW, Frimodt-Møller N. Cefuroxime pharmacokinetics and pharmacodynamics for intravenous dosage regimens with 750 mg or 1500 mg doses in healthy young volunteers. J Med Microbiol 2020; 69:387-395. [DOI: 10.1099/jmm.0.001138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Cefuroxime is an important antibiotic to treat several serious infections. Rapid elimination through the kidneys and the variation in MICs of various susceptible pathogens such as Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus and
Streptococcus pneumoniae
give rise to dosing issues, especially in otherwise healthy patients.
Aim. To investigate the probability of target attainment (PTA) for obtaining the optimal dosage regimens for cefuroxime in healthy young people.
Methodology. Two weeks apart 750 and 1500 mg cefuroxime were administered as an intravenous bolus to 20 healthy volunteers (mean age: 27 years). Population modelling and simulation studies were done based on the obtained data for cefuroxime plasma concentration.
Results. With a target value of time above MIC (T
>MIC) greater than 50 % the simulations revealed that a PTA of >99 % is obtained for
S. pneumoniae
with a dosage regimen of 750 mg q12h. For
E. coli
and
K. pneumoniae
the PTA was <90 % even with the highest, simulated dosage of 1500 mg q6h. For
S. aureus
a dosage of 1500 mg q8h gave a PTA above 97 %.
Conclusions.
S. pneumoniae
is most likely treatable with a two-daily dose of 750 mg cefuroxime. Not treatable are
K. pneumoniae
and
E. coli
. For
S. aureus
1500 mg q8h constitutes an optimal dosing schedule.
Collapse
Affiliation(s)
- Sara Thønnings
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Ninna B. Nielsen
- Department of Anesthesiology and Intensive Care, Nordsjællands hospital, Hillerød, Denmark
| | - Martin Skjønnemand
- Department of Anesthesiology and Intensive Care, Nordsjællands hospital, Hillerød, Denmark
| | | | - Kai H. W. Lange
- Department of Anesthesiology and Intensive Care, Nordsjællands hospital, Hillerød, Denmark
| | - Niels Frimodt-Møller
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
9
|
Colo-Pro: a pilot randomised controlled trial to compare standard bolus-dosed cefuroxime prophylaxis to bolus-continuous infusion-dosed cefuroxime prophylaxis for the prevention of infections after colorectal surgery. Eur J Clin Microbiol Infect Dis 2018; 38:357-363. [PMID: 30519893 PMCID: PMC6514115 DOI: 10.1007/s10096-018-3435-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/13/2018] [Indexed: 11/03/2022]
Abstract
Standard bolus-dosed antibiotic prophylaxis may not inhibit growth of antibiotic resistant colonic bacteria, a cause of SSIs after colorectal surgery. An alternative strategy is continuous administration of antibiotic throughout surgery, maintaining concentrations of antibiotics that inhibit growth of resistant bacteria. This study is a pilot comparing bolus-continuous infusion with bolus-dosed cefuroxime prophylaxis in colorectal surgery. This is a pilot randomised controlled trial in which participants received cefuroxime bolus-infusion (intervention arm) targeting free serum cefuroxime concentrations of 64 mg/L, or 1.5 g cefuroxime as a bolus dose four-hourly (standard arm). Patients in both arms received metronidazole (500 mg intravenously). Eligible participants were adults undergoing colorectal surgery expected to last for over 2 h. Results were analysed on an intention-to-treat basis. The study was successfully piloted, with 46% (90/196) of eligible patients recruited and 89% (80/90) of participants completing all components of the protocol. A trialled bolus-continuous dosing regimen was successful in maintaining free serum cefuroxime concentrations of 64 mg/L. No serious adverse reactions were identified. Rates of SSIs (superficial and deep SSIs) were lower in the intervention arm than the standard treatment arm (24% (10/42) vs. 30% (13/43)), as were infection within 30 days of operation (41% (17/43) vs 51% (22/43)) and urinary tract infections (2% (1/42) vs. 9% (4/43)). These infection rates can be used to power future clinical trials. This study demonstrates the feasibility of cefuroxime bolus-continuous infusion of antibiotic prophylaxis trials, and provides safety data for infusions targeting free serum cefuroxime concentrations of 64 mg/L. Trial registration: NCT02445859 .
Collapse
|
10
|
Stancil SL, van Haandel L, Abdel-Rahman S, Pearce RE. Development of a UPLC-MS/MS method for quantitation of metronidazole and 2-hydroxy metronidazole in human plasma and its application to a pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2018; 1092:272-278. [DOI: 10.1016/j.jchromb.2018.06.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/11/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
|
11
|
Population Pharmacokinetic Model-Based Evaluation of Standard Dosing Regimens for Cefuroxime Used in Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass. Antimicrob Agents Chemother 2018; 62:AAC.02241-17. [PMID: 29358296 DOI: 10.1128/aac.02241-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to investigate the population pharmacokinetics (PK) of cefuroxime in patients undergoing coronary artery bypass graft (CABG) surgery. In this observational pharmacokinetic study, multiple blood samples were collected over a 48-h interval of intravenous cefuroxime administration. The samples were analyzed by using a validated high-performance liquid chromatography (HPLC) method. Population pharmacokinetic models were developed using Monolix (version 4.4) software. Pharmacokinetic-pharmacodynamic (PD) simulations were performed to explore the ability of different dosage regimens to achieve the pharmacodynamic targets. A total of 468 blood samples from 78 patients were analyzed. The PK for cefuroxime were best described by a two-compartment model with between-subject variability on clearance, the volume of distribution of the central compartment, and the volume of distribution of the peripheral compartment. The clearance of cefuroxime was related to creatinine clearance (CLCR). Dosing simulations showed that standard dosing regimens of 1.5 g could achieve the PK-PD target of the percentage of the time that the free concentration is maintained above the MIC during a dosing interval (fTMIC) of 65% for an MIC of 8 mg/liter in patients with a CLCR of 30, 60, or 90 ml/min, whereas this dosing regimen failed to achieve the PK-PD target in patients with a CLCR of ≥125 ml/min. In conclusion, administration of standard doses of 1.5 g three times daily provided adequate antibiotic prophylaxis in patients undergoing CABG surgery. Lower doses failed to achieve the PK-PD target. Patients with high CLCR values required either higher doses or shorter intervals of cefuroxime dosing. On the other hand, lower doses (1 g three times daily) produced adequate target attainment for patients with low CLCR values (≤30 ml/min).
Collapse
|
12
|
Zelenitsky SA, Lawson C, Calic D, Ariano RE, Roberts JA, Lipman J, Zhanel GG. Integrated pharmacokinetic-pharmacodynamic modelling to evaluate antimicrobial prophylaxis in abdominal surgery. J Antimicrob Chemother 2016; 71:2902-8. [PMID: 27402005 DOI: 10.1093/jac/dkw247] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/20/2016] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To use Monte Carlo simulation with an integrated pharmacokinetic-pharmacodynamic (PK-PD) model to evaluate guideline-recommended antimicrobial prophylaxis (AP) regimens with anaerobic coverage in abdominal surgery. METHODS AP regimens were tested in simulated subjects undergoing elective abdominal surgery using relevant PK models and pathogen distributions in surgical site infections (SSIs). Predicted cumulative target attainment was the percentage of simulated subjects with free (unbound) antimicrobial plasma concentrations above the MICs for potential SSI pathogens. RESULTS Cefazolin plus metronidazole covered SSI aerobes in 70% and the Bacteroides fragilis group in 99% of subjects, whereas cefoxitin only covered aerobes and anaerobes in 63% and 27% of cases, respectively. The broad-spectrum ceftriaxone plus metronidazole covered aerobes in 82% and anaerobes in 99% of simulations, while ertapenem covered aerobes in 88% and anaerobes in 90% of cases. Clindamycin covered the B. fragilis group in only 11% of cases. For cefazolin, 2 g doses maintained target attainment in simulated subjects from 80 to 120 kg, whereas 1 g doses were associated with lower target attainment against potential Gram-negative pathogens even in those <80 kg. For gentamicin, 3 mg/kg doses were comparable to the suggested 5 mg/kg, but superior to the traditional 1.5 mg/kg. CONCLUSIONS This study demonstrates the use of PK-PD to inform decisions regarding AP in abdominal surgery. In this case, the findings support avoiding cefoxitin, avoiding clindamycin for anaerobic coverage, selecting 2 g doses of cefazolin even in patients <80 kg and using 3 mg/kg doses of gentamicin.
Collapse
Affiliation(s)
- S A Zelenitsky
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Department of Pharmacy, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - C Lawson
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - D Calic
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - R E Ariano
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Department of Pharmacy, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - J Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia The University of Witwatersrand, Johannesburg, South Africa
| | - G G Zhanel
- Department of Medical Microbiology and Infectious Diseases, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
13
|
Asín-Prieto E, Rodríguez-Gascón A, Isla A. Applications of the pharmacokinetic/pharmacodynamic (PK/PD) analysis of antimicrobial agents. J Infect Chemother 2015; 21:319-29. [PMID: 25737147 DOI: 10.1016/j.jiac.2015.02.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/20/2015] [Accepted: 02/02/2015] [Indexed: 12/15/2022]
Abstract
The alarming increase of resistance against multiple currently available antibiotics is leading to a rapid lose of treatment options against infectious diseases. Since the antibiotic resistance is partially due to a misuse or abuse of the antibiotics, this situation can be reverted when improving their use. One strategy is the optimization of the antimicrobial dosing regimens. In fact, inappropriate drug choice and suboptimal dosing are two major factors that should be considered because they lead to the emergence of drug resistance and consequently, poorer clinical outcomes. Pharmacokinetic/pharmacodynamic (PK/PD) analysis in combination with Monte Carlo simulation allows to optimize dosing regimens of the antibiotic agents in order to conserve their therapeutic value. Therefore, the aim of this review is to explain the basis of the PK/PD analysis and associated techniques, and provide a brief revision of the applications of PK/PD analysis from a therapeutic point-of-view. The establishment and reevaluation of clinical breakpoints is the sticking point in antibiotic therapy as the clinical use of the antibiotics depends on them. Two methodologies are described to establish the PK/PD breakpoints, which are a big part of the clinical breakpoint setting machine. Furthermore, the main subpopulations of patients with altered characteristics that can condition the PK/PD behavior (such as critically ill, elderly, pediatric or obese patients) and therefore, the outcome of the antibiotic therapy, are reviewed. Finally, some recommendations are provided from a PK/PD point of view to enhance the efficacy of prophylaxis protocols used in surgery.
Collapse
Affiliation(s)
- Eduardo Asín-Prieto
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
| |
Collapse
|