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Gebreyesus MS, Dresner A, Wiesner L, Coetzee E, Verschuuren T, Wasmann R, Denti P. Dose optimization of cefazolin in South African children undergoing cardiac surgery with cardiopulmonary bypass. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38962872 DOI: 10.1002/psp4.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/27/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
Cefazolin is an antibiotic used to prevent surgical site infections. During cardiac surgery with cardiopulmonary bypass (CPB), its efficacy target could be underachieved. We aimed to develop a population pharmacokinetic model for cefazolin in children and optimize the prophylactic dosing regimen. Children under 25 kg undergoing cardiac surgery with CPB and receiving cefazolin at standard doses (50 mg/kg IV every 4-6 h) were included in this analysis. A population pharmacokinetic model and Monte Carlo simulations were used to evaluate the probability of target attainment (PTA) for efficacy and toxicity with the standard regimen and an alternative regimen of continuous infusion, where loading and maintenance doses were calculated from model-derived individual parameters. Twenty-two patients were included, with median (range) age, body weight, and eGFR of 19.5 (1-94) months, 8.7 (2-21) kg, and 116 (48-159) mL/min, respectively. Six patients received an additional dose in the CPB circuit. A two-compartment disposition model with an additional compartment for the CPB was developed, including weight-based allometric scaling and eGFR. For a 10 kg patient with eGFR of 120 mL/min/1.73 m2, clearance was estimated as 0.856 L/h. Simulations indicated that the standard dosing regimen fell short of achieving the efficacy target >40% of the time within a dosing duration and in patients with good renal function, PTA ranged from <20% to 70% for the smallest to the largest patients, respectively, at high MICs. In contrast, the alternative regimen consistently maintained target concentrations throughout the procedure for all patients while using a lower overall dose.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexandra Dresner
- Department of Anesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ettienne Coetzee
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Tess Verschuuren
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 186] [Impact Index Per Article: 186.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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3
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Wang L, Yu XB, Zhou ZY, Wang J, Zheng LP, Dai Y, Wang YZ, Zhang XS, Chen C, Shi DW, Zhang CH. Modification of Vancomycin Dosing in Cardiac Surgery With Cardiopulmonary Bypass. J Clin Pharmacol 2023; 63:490-497. [PMID: 36458612 DOI: 10.1002/jcph.2190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
This study aims to assess the risk factors for insufficient vancomycin concentrations for its prophylactic use in adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to modify the dosing regimen to achieve appropriate plasma concentrations. A total of 27 patients with vancomycin dosing of 1 to 1.5 g based on a weight cutoff of 67 kg were included, of which only 13 (48.15%) had vancomycin plasma concentration >15 mg/L at surgical closure. Risk factors of vancomycin concentration <15 mg/L at surgical-site closure were confirmed by multivariate logistic regression analysis, which showed that CPB duration was an independent predictor. Patients with CPB duration >4 hours had significantly lower vancomycin concentrations and lower proportion in achieving target vancomycin concentration at the end of CPB and surgical closure. For patients with CPB >4 hours, the modified dosing regimen that a second dose of 0.5 to 0.75 g added at 4 hours since the onset of CPB improved the target achievement of vancomycin concentration at surgical closure. Taken together, CPB duration >4 hours was the risk factor for insufficient vancomycin concentration at surgical closure, while our modified dosing could improve the vancomycin concentrations for its prophylactic use in patients undergoing cardiac surgery with CPB.
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Affiliation(s)
- Lei Wang
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu-Ben Yu
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, China.,Department of Pharmacology, Chonnam National University, Gwangju, South Korea
| | - Zi-Ye Zhou
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jue Wang
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liu-Pu Zheng
- Division of Cardiac Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Dai
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu-Zhen Wang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Chuang Chen
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Da-Wei Shi
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chun-Hong Zhang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Zukowska A, Zukowski M. Surgical Site Infection in Cardiac Surgery. J Clin Med 2022; 11:jcm11236991. [PMID: 36498567 PMCID: PMC9738257 DOI: 10.3390/jcm11236991] [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: 10/28/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.
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Affiliation(s)
- Agnieszka Zukowska
- Department of Infection Control, Regional Hospital Stargard, 73-110 Stargard, Poland
| | - Maciej Zukowski
- Department of Anesthesiology, Intensive Care and Acute Intoxication, Pomeranian Medical University, 70-204 Szczecin, Poland
- Correspondence: ; Tel.: +48-504-451-924
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5
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Šantavý P, Šíma M, Zuščich O, Kubíčková V, Michaličková D, Slanař O, Urbánek K. Population Pharmacokinetics of Prophylactic Cefazolin in Cardiac Surgery with Standard and Minimally Invasive Extracorporeal Circulation. Antibiotics (Basel) 2022; 11:1582. [PMID: 36358235 PMCID: PMC9686470 DOI: 10.3390/antibiotics11111582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 05/05/2024] Open
Abstract
The objectives of this study were to develop a population pharmacokinetic model of prophylactically administered cefazolin in patients undergoing cardiac surgery with and without the use of the cardiopulmonary bypass of both existing types-standard (ECC) and minimallyu invasive extracorporeal circulation (MiECC)-and to propose cefazoline dosing optimization based on this model. A total of 65 adult patients undergoing cardiac surgery were recruited to this clinical trial. A prophylactic cefazolin dose of 2 g was intravenously administered before surgery. Blood samples were collected using a rich sampling design and cefazolin serum concentrations were measured using the HPLC/UV method. The pharmacokinetic population model was calculated using a nonlinear mixed-effects modeling approach, and the Monte Carlo simulation was used to evaluate the PK/PD target attainment. The population cefazolin central volume of distribution (Vd) of 4.91 L increased by 0.51 L with each 1 m2 of BSA, peripheral Vd of 22.07 L was reduced by 0.77 L or 0.79 L when using ECC or MiECC support, respectively, while clearance started at 0.045 L/h and increased by 0.49 L/h with each 1 mL/min/1.73 m2 of eGFR. ECC/MiECC was shown to be covariate of cefazolin Vd, but without relevance to clinical practice, while eGFR was most influential for the PK/PD target attainment. The standard dose of 2 g was sufficient for PK/PD target attainment throughout surgery in patients with normal renal status or with renal impairment. In patients with augmented renal clearance, an additive cefazolin dose should be administered 215, 245, 288 and 318 min after the first dose at MIC of 4, 3, 2 and 1.5 mg/L, respectively.
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Affiliation(s)
- Petr Šantavý
- Department of Cardiac Surgery, Faculty of Medicine and Dentistry, Palacký University and University Hospital, 779 00 Olomouc, Czech Republic
| | - Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
| | - Ondřej Zuščich
- Department of Cardiac Surgery, Faculty of Medicine and Dentistry, Palacký University and University Hospital, 779 00 Olomouc, Czech Republic
| | - Vendula Kubíčková
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacký University and University Hospital, Hněvotínská 3, 775 15 Olomouc, Czech Republic
| | - Danica Michaličková
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
| | - Karel Urbánek
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacký University and University Hospital, Hněvotínská 3, 775 15 Olomouc, Czech Republic
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Staib-Lasarzik I, Lehr S, Rosner AK, Timaru-Kast R, Hoeter K, Bruns K, Wollschläger D, Heinrich S, Thal SC, Engelhard K. Influence of intraoperative fluid replacement on ampicillin serum levels and surgical site infections. Surgery 2022; 172:648-654. [DOI: 10.1016/j.surg.2022.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 03/11/2022] [Accepted: 03/27/2022] [Indexed: 11/29/2022]
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Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study. Antibiotics (Basel) 2022; 11:antibiotics11050554. [PMID: 35625198 PMCID: PMC9137830 DOI: 10.3390/antibiotics11050554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.
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Suna J, Moloney G, Marathe SP, Bierbach B, Roberts JA, Parker S, Ungerer JPJ, Mcwhinney B, Dorofaeff T, Venugopal P, Alphonso N. Perioperative cefazolin prophylaxis in paediatric cardiac surgery: a prospective, cohort study. Ann Thorac Surg 2022; 114:1434-1440. [PMID: 35292260 DOI: 10.1016/j.athoracsur.2022.02.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND This study's objective was to determine the effect of age, prolonged bypass, and hypothermia on serum cefazolin concentrations in children undergoing cardiac surgery. METHODS A prospective, single-centre, observational study was conducted. Children undergoing cardiac surgery were examined. Participants received cefazolin intravenously approximately 1 hour before skin incision, 3 hourly intraoperatively and 8 hourly postoperatively. Blood samples were collected at 6-8 timepoints intraoperatively and 6-time points in the first 24 hours postoperatively. Target unbound serum cefazolin concentrations were of 2 mg/L. RESULTS Sixty-eight patients were enrolled in the study, and 64 included in the analysis. All maintained concentrations ≥ 2 mg/L throughout the operation. Nineteen patients (30%) did not maintain concentrations ≥ 2 mg/L in the first 24 hours following surgery. Older, larger children (p < 0.0001) were significantly less likely to achieve target unbound serum cefazolin concentrations. CONCLUSIONS Intraoperative cefazolin concentrations reached the target concentration in all paediatric cardiac surgical cases. Postoperative cefazolin dosing appears insufficient to achieve minimum inhibitory concentrations in many patients.
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Affiliation(s)
- Jessica Suna
- Industry Fellow, University of Queensland, Brisbane, Australia; Deputy Director, Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.
| | - Gregory Moloney
- Senior Medical Officer, Department of Anaesthetics, Queensland Children's Hospital, Brisbane, Australia
| | - Supreet P Marathe
- Lecturer, University of Queensland Clinical School, Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Cardiac Surgery Fellow, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Benjamin Bierbach
- Department of Paediatric Cardiac Surgery, University Hospital Bonn, Germany
| | - Jason A Roberts
- NHMRC Practitioner Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Consultant Pharmacist, Pharmacy Department and Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Scientific Consultant, Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Suzanne Parker
- NHMRC Early Career Research Fellow, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jacobus P J Ungerer
- Director Chemical Pathology, Pathology Queensland, Queensland Health, Brisbane Australia; School of Biomedical Sciences, University of Queensland, Brisbane Australia
| | - Brett Mcwhinney
- Supervising Scientist, Pathology Queensland, Queensland Health, Brisbane Australia
| | - Tavey Dorofaeff
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Senior Medical Officer, Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia
| | - Prem Venugopal
- Senior Lecturer, University of Queensland Clinical School Queensland Children's Hospital, University of Queensland, Brisbane, Australia; Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Associate Professor, Child Health Research Centre, University of Queensland, Brisbane, Australia; Deputy Director of Cardiac Surgery, Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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Abstract
The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.
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Jannati M. The value of prophylactic antibiotics in coronary artery bypass graft surgery: A review of literature. JOURNAL OF VASCULAR NURSING 2021; 39:100-103. [PMID: 34865718 DOI: 10.1016/j.jvn.2021.07.005] [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: 04/07/2020] [Revised: 05/15/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022]
Abstract
Infections have a significant impact on increasing both the morbidity and mortality rate of patients who have undergone coronary artery bypass graft (CABG) surgery. Infection after CABG imposes a clinical and economic burden on patients and health care organizations; therefore, prevention should be on the agenda. This review will focus on the value of using prophylactic antibiotics in coronary artery bypass graft surgery (CABG). Prophylactic antibiotics like cephalosporin and vancomycin are more commonly used antibiotics and are strongly associated with reduced infection risk in patients. The results showed that using antibiotics during the perioperative period and after CABG is an effective strategy for reducing post-infection problems without compromising the patients' clinical outcomes. Diabetic patients are prone to postoperative infection after CABG, however, prophylactic antibiotics should not be the only strategy used to reduce the risk of postoperative infection in diabetic patients. Perioperative glycaemic control is essential for diabetic patients undergoing CABG. Appropriate antibiotic prophylaxis has a great impact on preventing infection after CABG but duration and selecting appropriate antibiotic is important. Standardizing the use of antibiotic prophylaxis reduces the rate of infection and unwanted bacterial resistance, which could subsequently reduce economic costs to patients and public health.
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Affiliation(s)
- Mansour Jannati
- Department of Cardiovascular Surgery, Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
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Edlinger-Stanger M, al Jalali V, Andreas M, Jäger W, Böhmdorfer M, Zeitlinger M, Hutschala D. Plasma and Lung Tissue Pharmacokinetics of Ceftaroline Fosamil in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: an In Vivo Microdialysis Study. Antimicrob Agents Chemother 2021; 65:e0067921. [PMID: 34280013 PMCID: PMC8448148 DOI: 10.1128/aac.00679-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022] Open
Abstract
Ceftaroline fosamil, a fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), is currently approved for the treatment of pneumonia and complicated skin and soft tissue infections. However, pharmacokinetics data on free lung tissue concentrations in critical patient populations are lacking. The aim of this study was to evaluate the pharmacokinetics of the high-dose regimen of ceftaroline in plasma and lung tissue in cardiac surgery patients during intermittent and continuous administration. Nine patients undergoing elective cardiac surgery on cardiopulmonary bypass were included in this study and randomly assigned to intermittent or continuous administration. Eighteen hundred milligrams of ceftaroline fosamil was administered intravenously as either 600 mg over 2 h every 8 h (q8h) (intermittent group) or 600 mg over 2 h (loading dose) plus 1,200 mg over 22 h (continuous group). Interstitial lung tissue concentrations were measured by in vivo microdialysis. Relevant pharmacokinetics parameters were calculated for each group. Plasma exposure levels during intermittent and continuous administration were comparable to those of previously published studies and did not differ significantly between the two groups. In vivo microdialysis demonstrated reliable and adequate penetration of ceftaroline into lung tissue during intermittent and continuous administration. The steady-state area under the concentration-time curve from 0 to 8 h (AUCss 0-8) and the ratio of AUCSS 0-8 in lung tissue and AUC in plasma (AUClung/plasma) were descriptively higher in the continuous group. Continuous administration of ceftaroline fosamil achieved a significantly higher proportion of time for which the free drug concentration remained above 4 times the minimal inhibitory concentration (MIC) during the dosing interval (% fT>4xMIC) than intermittent administration for pathogens with a MIC of 1 mg/liter. Ceftaroline showed adequate penetration into interstitial lung tissue of critically ill patients undergoing major cardiothoracic surgery, supporting its use for pneumonia caused by susceptible pathogens.
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Affiliation(s)
- M. Edlinger-Stanger
- Medical University of Vienna, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Vienna, Austria
| | - V. al Jalali
- Medical University of Vienna, Department of Clinical Pharmacology, Vienna, Austria
| | - M. Andreas
- Medical University of Vienna, Department of Surgery, Division of Cardiac Surgery, Vienna, Austria
| | - W. Jäger
- University of Vienna, Department of Pharmaceutical Chemistry, Vienna, Austria
| | - M. Böhmdorfer
- University of Vienna, Department of Pharmaceutical Chemistry, Vienna, Austria
| | - M. Zeitlinger
- Medical University of Vienna, Department of Clinical Pharmacology, Vienna, Austria
| | - D. Hutschala
- Medical University of Vienna, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Vienna, Austria
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12
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Suna J, Alphonso N. Cefazolin prophylaxis in children undergoing cardiac surgery-is it too little too late? Eur J Cardiothorac Surg 2021; 61:34-35. [PMID: 34269388 DOI: 10.1093/ejcts/ezab327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jessica Suna
- Children's Centre for Health Research, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.,Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
| | - Nelson Alphonso
- Children's Centre for Health Research, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia.,School of Clinical Medicine, Children's Health Queensland Clinical Unit, University of Queensland, Brisbane, Australia.,Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, Australia
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13
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Jaworski R, Dzierzanowska-Fangrat K, Czajkowska A, Maruszewski B, Kansy A. Cefazolin prophylaxis in children undergoing cardiac surgery with the use of cardiopulmonary bypass-is the dosing correct? Eur J Cardiothorac Surg 2021; 61:27-33. [PMID: 34269390 DOI: 10.1093/ejcts/ezab251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To determine the recommended concentrations of cefazolin to be used for antibiotic prophylaxis during paediatric cardiac surgery with extracorporeal circulation (ECC). METHODS Twenty paediatric patients undergoing cardiac surgery with ECC and cefazolin antibiotic prophylaxis were included in the study. Blood samples for measurement of total cefazolin plasma concentration were collected at the following measurement time points: directly after skin incision, 15 min after ECC start, 5 min after ECC cessation and at skin closure. The target concentration was set for ≥40 mg/l, which corresponded to ≥8 mg/l of unbound cefazolin concentration. RESULTS The median total cefazolin plasma concentrations at the measurement time points were 62.8, 67.7, 45.8 and 34.2 mg/l, respectively, and target concentrations were achieved in 90%, 85%, 65% and 40% of children, respectively. Among patients who received ≥30 mg of cefazolin per 100 ml of ECC priming, target concentrations after ECC cessation were reached in 80% of patients, while in those with <30 mg cefazolin per 100 ml in 20% of patients (P = 0.031). CONCLUSIONS Direct extrapolation of antibiotic prophylaxis recommendations from adults to children may result in suboptimal antibiotic concentrations. An additional cefazolin dose to ECC priming appears necessary and the dosing should be based on ECC priming volume rather than on the weight of the patient.
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Affiliation(s)
- Radoslaw Jaworski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Agnieszka Czajkowska
- Department of Biochemistry, Radioimmunology and Experimental Medicine, Pharmacokinetics Laboratory, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Kansy
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
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Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [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: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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Caruso TJ, Lin C, O'Connell C, Weiss D, MD GB, Wu M, Kwiatkowski D, Maeda K, Tsui BC. Systemic Absorption of Lidocaine from Continuous Erector Spinae Plane Catheters After Congenital Cardiac Surgery: A Retrospective Study. J Cardiothorac Vasc Anesth 2020; 34:2986-2993. [DOI: 10.1053/j.jvca.2020.05.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 12/14/2022]
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17
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Cefoxitin Prophylaxis During Pediatric Cardiac Surgery: Retrospective Exploration of Postoperative Trough Levels. Pediatr Infect Dis J 2019; 38:484-489. [PMID: 30169486 DOI: 10.1097/inf.0000000000002179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to explore inter-individual variability of cefoxitin trough levels, predictors of serum cefoxitin concentration and the probability of target attainment of drug levels above 4 mg/L after pediatric cardiac surgery. METHODS Retrospective study on children scheduled for elective cardiac surgery and having cefoxitin trough levels available up to 24 hours postsurgery. RESULTS Overall, 68 children (9 neonates, 34 infants, 15 children below or equal to 10 years old and 10 patients above this age) were included. Of these, 16 surgeries were performed off cardiopulmonary bypass and 52 were performed on cardiopulmonary bypass. The free cefoxitin concentrations showed a median (interquartile range) concentration of 1.7 (0.6-4.2) mg/L. The range of cefoxitin concentrations showed a 150-fold and 340-fold variability at cardiac intensive care unit admission and after 24 hours, respectively. The pharmacodynamics (PD) targets of free cefoxitin at 100% of the dosing interval, considering Eucast breakpoints for Methicillin Sensitive Staphylococcus Aureus (4 mg/L) and E.Coli (8 mg/L), were obtained in 28% and 16% of patients, respectively. Patient weight (odds ratio, 0.7; 95% confidence interval, 0.62-0.92; P = 0.006) and serum creatinine concentrations (odds ratio, 25; 95% confidence interval, 18-36; P = 0.004) showed a significant relationship with the PD targets. CONCLUSIONS Cefoxitin trough concentrations vary significantly in the first 24 hours after pediatric cardiac surgery. Both serum creatinine and body weight showed independent associations with cefoxitin concentration. The PD target was not obtained in the vast majority of the explored population, regardless of the target bacteria.
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Asada M, Nagata M, Mizuno T, Uchida T, Kurashima N, Takahashi H, Makita K, Arai H, Echizen H, Yasuhara M. Effects of cardiopulmonary bypass on the disposition of cefazolin in patients undergoing cardiothoracic surgery. Pharmacol Res Perspect 2018; 6:e00440. [PMID: 30410768 PMCID: PMC6218359 DOI: 10.1002/prp2.440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 11/21/2022] Open
Abstract
The aim of the study was to evaluate the disposition of plasma unbound cefazolin in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). Adult patients undergoing cardiothoracic surgery with CPB were enrolled in the study. Cefazolin sodium was given intravenously before skin incision (1 g) and at the beginning of CPB (2 g). Thereafter, an additional dose (1 g) was given every 4 hours. Seven to ten blood samples were collected before and during surgery. Plasma total and unbound (ultrafiltrated) cefazolin concentrations were analyzed using an HPLC-UV method. Plasma protein binding was analyzed with the Langmuir model. Twenty-seven patients (aged 70 ± 12 years, body weight 62 ± 12 kg, mean ± SD) with GFR >30 mL min-1 completed the study. There was a significant (P < 0.001) increase in median plasma unbound fraction of cefazolin from 21% before skin incision to 45% during CPB (P < 0.001), which was accompanied by a significant (P < 0.001) reduction in median plasma albumin concentration from 36 to 27 g L-1. Plasma concentrations of unbound cefazolin exceeded the assumed target thresholds of 2 μg mL-1 in all samples and of 8 μg mL-1 in all but one of 199 samples. The increased plasma unbound fraction of cefazolin would be attributable to dilutional reduction of serum albumin at the beginning of CPB and to saturable plasma protein binding of cefazolin. These data reveal CPB may alter the plasma protein binding and possibly distribution of cefazolin. Further studies are warranted to reappraise the protocol of antimicrobial prophylaxis with cefazolin in patients undergoing surgery with CPB.
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Affiliation(s)
- Mizuho Asada
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Masashi Nagata
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
- Department of Pharmacokinetics and PharmacodynamicsGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Tomohiro Mizuno
- Department of Cardiovascular SurgeryGraduate School of Medical and Dental ScienceTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Tokujiro Uchida
- Department of AnesthesiologyGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Naoki Kurashima
- Medical Engineering CenterMedical Hospital of Tokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hiromitsu Takahashi
- Department of PharmacyMedical HospitalTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Koshi Makita
- Department of AnesthesiologyGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hirokuni Arai
- Department of Cardiovascular SurgeryGraduate School of Medical and Dental ScienceTokyo Medical and Dental University (TMDU)TokyoJapan
| | - Hirotoshi Echizen
- Department of PharmacotherapyMeiji Pharmaceutical UniversityTokyoJapan
| | - Masato Yasuhara
- Department of Pharmacokinetics and PharmacodynamicsGraduate School of Medical and Dental SciencesTokyo Medical and Dental University (TMDU)TokyoJapan
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Antimicrobial Prophylaxis for Patients Undergoing Cardiac Surgery: Intraoperative Cefazolin Concentrations and Sternal Wound Infections. Antimicrob Agents Chemother 2018; 62:AAC.01360-18. [PMID: 30150469 DOI: 10.1128/aac.01360-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022] Open
Abstract
This study characterizes the pharmacodynamics of antimicrobial prophylaxis and sternal wound infections following cardiac surgery. Duration of surgery and cefazolin plasma concentration during wound closure were independently associated with surgical site infection at 30 days. Furthermore, a duration of surgery of >346 min and a total cefazolin closure concentration of <104 mg/liter were significant thresholds for an increased risk of infection. This study provides new data that informs dosing strategies for effective antimicrobial prophylaxis (AP) in patients undergoing cardiac surgery with cardiopulmonary bypass.
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Adiraju SKS, Shekar K, Fraser JF, Smith MT, Ghassabian S. Effect of cardiopulmonary bypass on cytochrome P450 enzyme activity: implications for pharmacotherapy. Drug Metab Rev 2017; 50:109-124. [PMID: 29254370 DOI: 10.1080/03602532.2017.1417423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
For patients undergoing cardiopulmonary bypass (CPB) during cardiac surgery, there are well-documented changes in the pharmacokinetics (PK) of commonly administered drugs. Although multiple factors potentially underpin these changes, there has been scant research attention on the impact of CPB to alter the activities of cytochrome P450 (CYP) isoenzymes. PK changes during cardiac surgery with CPB have the potential to adversely affect the safety and efficacy of pharmacotherapy and increase the risk of drug-drug interactions. Clinically significant changes in drug PK during CPB are likely to be prominent for drugs where CYP metabolism is a major clearance (CL) mechanism. However, clinical data from patients undergoing CPB surgery in support of this hypothesis are lacking, leaving a significant knowledge gap. In this review, we address the effects of CPB on the release of pro-inflammatory cytokines, in surgeries with and without CPB, both pre and post initiation of surgery. We reviewed literature to explore the relationship between the release of pro-inflammatory cytokines, and the expression and activities of CYP enzymes. Through this approach, we provide new insight on the effects of CPB on the PK of drugs administered to patients in the clinical setting. Future research to address this knowledge gap will have considerable impact to assist clinicians with optimizing pharmacotherapy in this patient population.
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Affiliation(s)
- Santosh Kumar Sreevatsav Adiraju
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
| | - Kiran Shekar
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - John F Fraser
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - Maree T Smith
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia.,c School of Pharmacy, Faculty of Health and Behavioral Sciences , The University of Queensland , Brisbane , QLD , Australia
| | - Sussan Ghassabian
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
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