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Qin Y, Jiao Z, Ye YR, Shen Y, Chen Z, Chen YT, Li XY, Lv QZ. External evaluation of the predictive performance of published population pharmacokinetic models of linezolid in adult patients. J Glob Antimicrob Resist 2023; 35:347-353. [PMID: 37573945 DOI: 10.1016/j.jgar.2023.08.003] [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: 04/06/2023] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023] Open
Abstract
OBJECTIVES Several linezolid population pharmacokinetic (popPK) models have been established to facilitate optimal therapy; however, their extrapolated predictive performance to other clinical sites is unknown. This study aimed to externally evaluate the predictive performance of published pharmacokinetic models of linezolid in adult patients. METHODS For the evaluation dataset, 150 samples were collected from 70 adult patients (72.9% of which were critically ill) treated with linezolid at our center. Twenty-five published popPK models were identified from PubMed and Embase. Model predictability was evaluated using prediction-based, simulation-based, and Bayesian forecasting-based approaches to assess model predictability. RESULTS Prediction-based diagnostics found that the prediction error within ±30% (F30) was less than 40% in all models, indicating unsatisfactory predictability. The simulation-based prediction- and variability-corrected visual predictive check and normalized prediction distribution error test indicated large discrepancies between the observations and simulations in most of the models. Bayesian forecasting with one or two prior observations significantly improved the models' predictive performance. CONCLUSION The published linezolid popPK models showed insufficient predictive ability. Therefore, their sole use is not recommended, and incorporating therapeutic drug monitoring of linezolid in clinical applications is necessary.
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Affiliation(s)
- Yan Qin
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yan-Rong Ye
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yun Shen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yue-Ting Chen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao-Yu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qian-Zhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China.
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2
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Xu Y, Qu C, Yan M, Gu Q, Liu N. Indocyanine green clearance test as a predictor of linezolid overexposure in septic patients. Int J Antimicrob Agents 2023; 62:107006. [PMID: 37839718 DOI: 10.1016/j.ijantimicag.2023.107006] [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: 03/28/2023] [Revised: 09/14/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Hepatic impairment increases the risk of drug overexposure in septic patients. However, there is a lack of effective indicators to predict overexposure risk. The indocyanine green (ICG) clearance test is a helpful method for dynamically assessing hepatic function and perfusion. This study aimed to investigate whether the ICG test could serve as a potential predictor of linezolid trough concentration (Cmin) and to compare its efficacy with that of conventional liver function markers. METHODS A total of 35 consecutive septic patients treated with linezolid were grouped into either linezolid Cmin of ≤7 µg/mL or >7 µg/mL. Correlations between linezolid Cmin and ICG-PDR (plasma disappearance rate), ICG-R15 (retention ratio after 15 min) and other traditional indicators were analysed by Spearman's rank test. A multivariable regression model was employed to discern factors contributing independently to overexposure. RESULTS Statistical differences were observed between groups for APACHE II score (P = 0.031), SOFA score (P = 0.018), creatinine clearance (CLCr) (P = 0.003), thrombocytes (P = 0.039), lactate (P = 0.003), ICG-PDR (P < 0.001) and ICG-R15 (P < 0.001). Moreover, linezolid Cmin was correlated with ICG-PDR (ρ = -0.628, P < 0.001), ICG-R15 (ρ = 0.676, P < 0.001) and CLCr (ρ = -0.503, P = 0.002). ICG-PDR was identified as an independent predictor of linezolid overexposure, with an optimal cut-off value of 17.70%/min (93.3% sensitivity, 85.0% specificity; P < 0.001). CONCLUSIONS This pilot clinical trial represents the first investigation of potential of the ICG test to predict linezolid overexposure in septic patients.
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Affiliation(s)
- Ying Xu
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Chen Qu
- Geriatric Medicine Department, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ming Yan
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Qin Gu
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ning Liu
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
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Marriott DJE, Cattaneo D. Why Product Information Should not be Set in Stone: Lessons from a Decade of Linezolid Therapeutic Drug Monitoring: An Opinion Paper. Ther Drug Monit 2023; 45:209-216. [PMID: 36920503 DOI: 10.1097/ftd.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia; and
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
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Cattaneo D, Marriott DJ, Gervasoni C. Hematological toxicities associated with linezolid therapy in adults: key findings and clinical considerations. Expert Rev Clin Pharmacol 2023; 16:219-230. [PMID: 36787631 DOI: 10.1080/17512433.2023.2181160] [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: 02/16/2023]
Abstract
INTRODUCTION Linezolid can cause serious adverse effects including thrombocytopenia and anemia. Here, we focus specifically on linezolid-related hematological toxicity in adult patients requiring prolonged drug treatment. AREAS COVERED We review the available evidence on the likelihood of hematological toxicity in adult patients treated with linezolid, with a focus on the main risk factors and strategies to prevent this adverse event. A MEDLINE PubMed search for articles published from January 2000 to May 2022 was completed matching the terms linezolid, hematology, hematological toxicity, anemia, and thrombocytopenia. Moreover, additional studies were identified from the reference lists of retrieved articles. EXPERT OPINION Thrombocytopenia is the major concern with administration of linezolid for Gram-positive infections, whereas anemia is more common in patients with tuberculosis. The important clinical risk factors for the development of linezolid-related thrombocytopenia are aging, renal dysfunction, low baseline platelet count, duration of treatment, and linezolid plasma trough concentrations >8 mg/L. Patients receiving linezolid for extended periods of time or patient populations with increased risk of altered drug pharmacokinetics would benefit from therapeutic drug monitoring or from the availability of toxico-dynamic predictive models to optimize linezolid dosing.
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Affiliation(s)
- Dario Cattaneo
- Department of Infectious Diseases, Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Department of Laboratory Medicine, Unit of Clinical Pharmacology ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia
| | - Cristina Gervasoni
- Department of Infectious Diseases, Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Department of Infectious Diseases ASST Fatebenefratelli Sacco University Hospital, IIIrd Division of Infectious DiseasesMilan, Italy
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Immunomodulation by Hemoadsorption—Changes in Hepatic Biotransformation Capacity in Sepsis and Septic Shock: A Prospective Study. Biomedicines 2022; 10:biomedicines10102340. [PMID: 36289602 PMCID: PMC9598581 DOI: 10.3390/biomedicines10102340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Sepsis is often associated with liver dysfunction, which is an indicator of poor outcomes. Specific diagnostic tools that detect hepatic dysfunction in its early stages are scarce. So far, the immune modulatory effects of hemoadsorption with CytoSorb® on liver function are unclear. Method: We assessed the hepatic function by using the dynamic LiMAx® test and biochemical parameters in 21 patients with sepsis or septic shock receiving CytoSorb® in a prospective, observational study. Points of measurement: T1: diagnosis of sepsis or septic shock; T2 and T3: 24 h and 48 h after the start of CytoSorb®; T4: 24 h after termination of CytoSorb®. Results: The hepatic biotransformation capacity measured by LiMAx® was severely impaired in up to 95 % of patients. Despite a rapid shock reversal under CytoSorb®, a significant improvement in LiMAx® values appeared from T3 to T4. This decline and recovery of liver function were not reflected by common parameters of hepatic metabolism that remained mostly within the normal range. Conclusions: Hepatic dysfunction can effectively and safely be diagnosed with LiMAx® in ventilated ICU patients under CytoSorb®. Various static liver parameters are of limited use since they do not adequately reflect hepatic dysfunction and impaired hepatic metabolism.
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Lin B, Hu Y, Xu P, Xu T, Chen C, He L, Zhou M, Chen Z, Zhang C, Yu X, Fang L, Zhu J, Ji Y, Lin Q, Cao H, Dai Y, Lu X, Shi C, Li L, Wang C, Li X, Fang Q, Miao J, Zhu Z, Lin G, Zhan H, Lv S, Zhu Y, Cai X, Ying Y, Chen M, Xu Q, Zhang Y, Xu Y, Federico P, Jiang S, Dai H. Expert consensus statement on therapeutic drug monitoring and individualization of linezolid. Front Public Health 2022; 10:967311. [PMID: 36033811 PMCID: PMC9399604 DOI: 10.3389/fpubh.2022.967311] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/19/2022] [Indexed: 01/24/2023] Open
Abstract
Linezolid is an oxazolidinone antibacterial drug, and its therapeutic drug monitoring and individualized treatment have been challenged since its approval. With the in-depth clinical research of linezolid, we have changed our attitude toward its therapeutic drug monitoring and our view of individualized treatment. On the basis of summarizing the existing clinical studies, and based on the practical experience of each expert in their respective professional fields, we have formed this expert consensus. Our team of specialists is a multidisciplinary team that includes pharmacotherapists, clinical pharmacology specialists, critical care medicine specialists, respiratory specialists, infectious disease specialists, emergency medicine specialists and more. We are committed to the safe and effective use of linezolid in patients in need, and the promotion of its therapeutic drug monitoring.
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Affiliation(s)
- Bin Lin
- Department of Pharmacy, Changxing People's Hospital, Changxing Branch, Second Affiliated Hospital of Zhejiang University School of Medicine, Huzhou, China,Key Laboratory of Intelligent Pharmacy and Individualized Therapy of Huzhou, Huzhou, China
| | - Yangmin Hu
- Department of Pharmacy, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ping Xu
- Department of Pharmacy, Ningbo First Hospital, Ningbo, China
| | - Tao Xu
- Department of Pharmacy, Ningbo First Hospital, Ningbo, China
| | - Chunyan Chen
- Department of Pharmacy, Ningbo First Hospital, Ningbo, China
| | - Le He
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mi Zhou
- Department of Pharmacy, Children's Hospital of Soochow University, Suzhou, China
| | - Zhangzhang Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunhong Zhang
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xuben Yu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Luo Fang
- Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Junfeng Zhu
- Department of Pharmacy, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Yanlan Ji
- Department of Pharmacy, Deqing People's Hospital, Huzhou, China
| | - Qun Lin
- Department of Pharmacy, Tiantai People's Hospital, Taizhou, China
| | - Hengbin Cao
- Department of Clinical Pharmacy, Huzhou Central Hospital, Huzhou, China
| | - Youqin Dai
- Department of Pharmacy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Xiaoyan Lu
- Department of Pharmacy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Changcheng Shi
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Li
- Department of Pharmacy, Zhejiang Hospital, Hangzhou, China
| | - Changjiang Wang
- Department of Pharmacy, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xumei Li
- Department of Pharmacy, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Qiongyan Fang
- Department of Pharmacy, Zhoushan Hospital, Zhoushan, China
| | - Jing Miao
- Department of Pharmacy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhengyi Zhu
- Department of Pharmacy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guangyong Lin
- Department of Pharmacy, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haichao Zhan
- Department of Clinical Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Shiwen Lv
- Department of Clinical Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Yalan Zhu
- Department of Clinical Pharmacy, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Xinjun Cai
- Department of Pharmacy, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yin Ying
- Department of Pharmacy, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Meng Chen
- Department of Pharmacy, The First Hospital of Jiaxing, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Qiong Xu
- Department of Pharmacy, Putuo Hospital, Zhoushan, China
| | - Yiwen Zhang
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yubin Xu
- Department of Pharmacy, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Pea Federico
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy,SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Saiping Jiang
- Department of Clinical Pharmacy, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,Saiping Jiang
| | - Haibin Dai
- Key Laboratory of Intelligent Pharmacy and Individualized Therapy of Huzhou, Huzhou, China,Department of Pharmacy, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China,*Correspondence: Haibin Dai
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Ewoldt TMJ, Abdulla A, Hunfeld N, Li L, Smeets TJL, Gommers D, Koch BCP, Endeman H. The impact of sepsis on hepatic drug metabolism in critically ill patients: a narrative review. Expert Opin Drug Metab Toxicol 2022; 18:413-421. [PMID: 35912845 DOI: 10.1080/17425255.2022.2106215] [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: 11/04/2022]
Abstract
INTRODUCTION Hepatic drug metabolism is important in improving drug dosing strategies in sepsis. Pharmacokinetics in the critically ill population are severely altered due to changes in absorption, distribution, excretion and metabolization. Hepatic drug metabolism might be altered due to changes in hepatic blood flow, drug metabolizing protein availability, and protein binding. The purpose of this review is to examine evidence on whether hepatic drug metabolism is significantly affected in septic patients, and to provide insights in the need for future research. AREAS COVERED This review describes the effect of sepsis on hepatic drug metabolism in humans. Clinical trials, pathophysiological background information and example drug groups are further discussed. The literature search has been conducted in Embase, Medline ALL Ovid, and Cochrane CENTRAL register of trials. EXPERT OPINION Limited research has been conducted on drug metabolism in the sepsis population, with some trials having researched healthy individuals using endotoxin injections. Notwithstanding this limitation, hepatic drug metabolism seems to be decreased for certain drugs in sepsis. More research on the pharmacokinetic behavior of hepatic metabolized drugs in sepsis is warranted, using inflammatory biomarkers, hemodynamic changes, mechanical ventilation, organ support, and catecholamine infusion as possible confounders.
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Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Hunfeld
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
In recent years, many studies on population pharmacokinetics of linezolid have been conducted. This comprehensive review aimed to summarize population pharmacokinetic models of linezolid, by focusing on dosage optimization to maximize the probability of attaining a certain pharmacokinetic-pharmacodynamic parameter in special populations. We searched the PubMed and EMBASE databases for population pharmacokinetic analyses of linezolid using a parametric non-linear mixed-effect approach, including both observational and prospective trials. Of the 32 studies, 26 were performed in adults, four in children, and one in both adults and children. High between-subject variability was determined in the majority of the models, which was in line with the variability of linezolid concentrations previously detected in observational studies. Some studies found that patients with renal impairment, hepatic failure, advanced age, or low body weight had higher exposure and adverse reactions rates. In contrast, lower concentrations and therapeutic failure were associated with obese patients, young patients, and patients who had undergone renal replacement techniques. In critically ill patients, the inter-individual and intra-individual variability was even greater, suggesting that this population is at an even higher risk of underexposure and overexposure. Therapeutic drug monitoring may be warranted in a large proportion of patients given that the Monte Carlo simulations demonstrated that the one-size-fits-all labeled dosing of 600 mg every 12 h could lead to toxicity or therapeutic failure for high values of the minimum inhibitory concentration of the target pathogen. Further research on covariates, including renal function, hepatic function, and drug–drug interactions related to P-glycoprotein could help to explain variability and improve linezolid dosing regimens.
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Maray I, Rodríguez-Ferreras A, Álvarez-Asteinza C, Alaguero-Calero M, Valledor P, Fernández J. Linezolid induced thrombocytopenia in critically ill patients: Risk factors and development of a machine learning-based prediction model. J Infect Chemother 2022; 28:1249-1254. [PMID: 35581121 DOI: 10.1016/j.jiac.2022.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Linezolid is an antimicrobial with broad activity against Gram-positive bacteria. Thrombocytopenia is one of its most common side effects often leading to severe complications. The aim of this study is to identify factors related with development of this condition in critically ill patients and to develop and evaluate a predictive machine learning-based model considering easy-to-obtain clinical variables. METHODS Data was obtained from the Medical Information Mart for Intensive Care III. Patients who received linezolid for over three days were considered, excluding those under 18 years and/or lacking laboratory data. Thrombocytopenia was considered as a platelet decrease of at least 50% from baseline. RESULTS Three hundred and twenty patients met inclusion criteria of which 63 developed thrombocytopenia and presented significant greater duration of treatment, aspartate-aminotransferase, bilirubin and international normalized ratio; and lower renal clearance and platelet count at baseline. Thrombocytopenia development was associated with a worse outcome (30 days mortality [OR: 2.77; CI95%: 1.87-5.89; P < .001], 60 days mortality [OR: 3.56; CI95%: 2.18-7.26; P < .001]). Thrombocytopenia was also correlated with higher length of hospital stays (35.56 [20.40-52.99] vs 22.69 [10.05-38.61]; P < .001). Median time until this anomaly was of 23 days (CI95%:19.0-NE). Two multivariate models were performed. Accuracy, sensitivity, specificity and AUROC obtained in the best of them were of 0.75, 0.78, 0.62 and 0.80, respectively. CONCLUSION Linezolid associated thrombocytopenia entails greater mortality rates and hospital stays. Although the proposed predictive model has to be subsequently validated in a real clinical setting, its application could identify patients at risk and establish screening and surveillance strategies.
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Affiliation(s)
- Ivan Maray
- Department of Pharmacy, Hospital Universitario Central de Asturias, Spain.
| | | | | | | | - Pablo Valledor
- Research & Innovation, Artificial Intelligence and Statistical Department, Pragmatech AI Solutions, Spain
| | - Javier Fernández
- Research & Innovation, Artificial Intelligence and Statistical Department, Pragmatech AI Solutions, Spain; Department of Clinical Microbiology, Hospital Universitario Central de Asturias, Spain; Translational Microbiology Group, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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10
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Qin Y, Zhang LL, Ye YR, Chen YT, Jiao Z. Parametric Population Pharmacokinetics of Linezolid: A Systematic Review. Br J Clin Pharmacol 2022; 88:4043-4066. [PMID: 35484096 DOI: 10.1111/bcp.15368] [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: 01/29/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Linezolid is often used for infections caused by drug-resistant Gram-positive bacteria. Recent studies suggest that large between-subject variability (BSV) and within-subject variability could alter drug pharmacokinetics (PK) during linezolid therapy due to pathophysiological changes. OBJECTIVE This review synthesized information on linezolid population PK studies and summarized the significant covariates that influence linezolid PK. METHODS A literature search was performed using PubMed, Web of Science, and Embase from their inception to 30 September 2021. Published studies were included if they contained data analyzing linezolid PK parameters in humans using a population approach with a nonlinear mixed-effects model. RESULTS Twenty-five studies conducted in adults and five in pediatrics were included. One- and two-compartment models were the commonly used structural models for linezolid. Body size (weight, lean body weight, and body surface area), creatinine clearance (CLcr), and age significantly influenced linezolid PK. The median clearance (CL) values (ranges) in infants [0.128 L/h/kg (0.121-0.135)] and children [0.107 L/h/kg (0.088-0.151)] were higher than in adults [0.098 L/h/kg (0.044-0.237)]. For patients with severe renal impairment (CLcr ≤ 30 mL/min), the CL was 37.2% (15.2-55.3%) lower than in patients with normal renal function. CONCLUSION The optimal linezolid dosage should be adjusted based on the patient's body size, renal function, and age. More studies are needed to explore the exact mechanism of linezolid elimination and evaluate the PK characteristics in pediatric patients.
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Affiliation(s)
- Yan Qin
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Li Zhang
- Department of Pharmacy and Purchasing Management, the 900th Hospital of PLA joint logistics support force, Fuzhou, China
| | - Yan-Rong Ye
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yue-Ting Chen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Wu F, Zhang XS, Dai Y, Zhou ZY, Zhang CH, Han L, Xu FM, Wang YX, Shi DW, Lin GY, Yu XB, Chen F. Dosage Strategy of Linezolid According to the Trough Concentration Target and Renal Function in Chinese Critically Ill Patients. Front Pharmacol 2022; 13:844567. [PMID: 35479324 PMCID: PMC9035989 DOI: 10.3389/fphar.2022.844567] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/10/2022] [Indexed: 02/02/2023] Open
Abstract
Background: Linezolid is associated with myelosuppression, which may cause failure in optimally treating bacterial infections. The study aimed to define the pharmacokinetic/toxicodynamic (PK/TD) threshold for critically ill patients and to identify a dosing strategy for critically ill patients with renal insufficiency.Methods: The population pharmacokinetic (PK) model was developed using the NONMEM program. Logistic regression modeling was conducted to determine the toxicodynamic (TD) threshold of linezolid-induced myelosuppression. The dosing regimen was optimized based on the Monte Carlo simulation of the final model.Results: PK analysis included 127 linezolid concentrations from 83 critically ill patients at a range of 0.25–21.61 mg/L. Creatinine clearance (CrCL) was identified as the only covariate of linezolid clearance that significantly explained interindividual variability. Thirty-four (40.97%) of the 83 patients developed linezolid-associated myelosuppression. Logistic regression analysis showed that the trough concentration (Cmin) was a significant predictor of myelosuppression in critically patients, and the threshold for Cmin in predicting myelosuppression with 50% probability was 7.8 mg/L. The Kaplan–Meier plot revealed that the overall median time from the initiation of therapy to the development of myelosuppression was 12 days. Monte Carlo simulation indicated an empirical dose reduction to 600 mg every 24 h was optimal to balance the safety and efficacy in critically ill patients with CrCL of 30–60 ml/min, 450 mg every 24 h was the alternative for patients with CrCL <30 ml/min, and 600 mg every 12 h was recommended for patients with CrCL ≥60 ml/min.Conclusion: Renal function plays a significant role in linezolid PKs for critically ill patients. A dose of 600 mg every 24 h was recommended for patients with CrCL <60 ml/min to minimize linezolid-induced myelosuppression.
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Affiliation(s)
- Fan Wu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ying Dai
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zi-Ye Zhou
- 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
| | - Lu Han
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Fang-Min Xu
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ye-Xuan Wang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Da-Wei Shi
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guan-Yang Lin
- Department of Pharmacy, 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
- *Correspondence: Xu-Ben Yu, ; Fang Chen,
| | - Fang Chen
- Department of Pharmacy, The First Affiliated Hospital of Xiamen University, Xiamen, China
- *Correspondence: Xu-Ben Yu, ; Fang Chen,
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12
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Amann LF, Alraish R, Broeker A, Kaffarnik M, Wicha SG. Tigecycline Dosing Strategies in Critically Ill Liver-Impaired Patients. Antibiotics (Basel) 2022; 11:antibiotics11040479. [PMID: 35453230 PMCID: PMC9028393 DOI: 10.3390/antibiotics11040479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 12/04/2022] Open
Abstract
This study investigated tigecycline exposure in critically ill patients from a population pharmacokinetic perspective to support rational dosing in intensive care unit (ICU) patients with acute and chronic liver impairment. A clinical dataset of 39 patients served as the basis for the development of a population pharmacokinetic model. The typical tigecycline clearance was strongly reduced (8.6 L/h) as compared to other populations. Different models were developed based on liver and kidney function-related covariates. Monte Carlo simulations were used to guide dose adjustments with the most predictive covariates: Child–Pugh score, total bilirubin, and MELD score. The best performing covariate, guiding a dose reduction to 25 mg q12h, was Child–Pugh score C, whereas patients with Child–Pugh score A/B received the standard dose of 50 mg q12h. Of note, the obtained 24 h steady-state area under the concentration vs. time curve (AUCss) range using this dosing strategy was predicted to be equivalent to high-dose tigecycline exposure (100 mg q12h) in non-ICU patients. In addition, 26/39 study participants died, and therapy failure was most correlated with chronic liver disease and renal failure, but no correlation between drug exposure and survival was observed. However, tigecycline in special patient populations needs further investigations to enhance clinical outcome.
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Affiliation(s)
- Lisa F. Amann
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Rawan Alraish
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
| | - Magnus Kaffarnik
- Department of Surgery, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (R.A.); (M.K.)
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany; (L.F.A.); (A.B.)
- Correspondence: ; Tel.: +49-40-42838-3487
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13
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Population pharmacokinetics and toxicodynamics of continuously infused linezolid in critically-ill patients. Int J Antimicrob Agents 2022; 59:106572. [DOI: 10.1016/j.ijantimicag.2022.106572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/07/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
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14
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Tietjen AK, Kroemer N, Cattaneo D, Baldelli S, Wicha SG. Population pharmacokinetics and target attainment analysis of linezolid in multidrug-resistant tuberculosis patients. Br J Clin Pharmacol 2021; 88:1835-1844. [PMID: 34622478 DOI: 10.1111/bcp.15102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 01/02/2023] Open
Abstract
AIM This study investigates the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of linezolid in patients infected with multidrug-resistant (MDR) tuberculosis (TB). METHODS A pharmacometric model was developed including 244 timed linezolid concentration samples from 39 patients employing NONMEM 7.4. The probability of target attainment (PTA, PK/PD target: unbound (f) area-under-the-concentration-time-curve (AUC)/minimal inhibitory concentration (MIC) of 119) as well as a region-specific cumulative fraction of response (CFR) were estimated for different dosing regimens. RESULTS A one-compartment model with linear elimination with a clearance (CL) of 7.69 L/h (interindividual variability 34.1%), a volume of distribution (Vd) of 45.2 L and an absorption constant (KA) of 0.679 h-1 (interoccasion variability 143.7%) allometric scaled by weight best described the PK of linezolid. The PTA at an MIC of 0.5 mg/L was 55% or 97% if patients receiving 300 or 600 mg twice daily, respectively. CFRs varied greatly among populations and geographic regions. A desirable global CFR of ≥90% was achieved if linezolid was administered at a dose of 600 mg twice daily but not at a dose of 300 mg twice daily. CONCLUSION This study showed that a dose of 300 mg twice daily of linezolid might not be sufficient to treat MDR-TB patients from a PK/PD perspective. Thus, it might be recommendable to start with a higher dose of 600 mg twice daily to ensure PK/PD target attainment. Hereby, therapeutic drug monitoring and MIC determination should be performed to control PK/PD target attainment as linezolid shows high variability in its PK in the TB population.
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Affiliation(s)
- Anna K Tietjen
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.,University of Lübeck, Lübeck, Germany
| | - Niklas Kroemer
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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15
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Schwier E, Kirchner C, Eickmeyer C, Winde G, Henzler D, Köhler T. Profound decrease of liver maximum function capacity test of isoflurane sedated patients: A report of three cases. Clin Case Rep 2021; 9:e04862. [PMID: 34594555 PMCID: PMC8462060 DOI: 10.1002/ccr3.4862] [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: 04/01/2021] [Revised: 07/15/2021] [Accepted: 07/17/2021] [Indexed: 12/18/2022] Open
Abstract
LiMAx 13C-methacetin breath test results should be interpreted with caution in patients sedated with isoflurane.
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Affiliation(s)
- Elke Schwier
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Carmen Kirchner
- Department of General and Visceral SurgeryThoracic Surgery and ProctologyRuhr University BochumKlinikum HerfordHerfordGermany
| | - Claas Eickmeyer
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Günther Winde
- Department of General and Visceral SurgeryThoracic Surgery and ProctologyRuhr University BochumKlinikum HerfordHerfordGermany
| | - Dietrich Henzler
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
| | - Thomas Köhler
- Department of AnesthesiologySurgical Intensive Care, Emergency and Pain MedicineRuhr University BochumKlinikum HerfordHerfordGermany
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16
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Qin Y, Liu Y, Chen Z, Cao M, Shen Y, Ye Y. A risk factor-based predictive model for linezolid-induced anaemia: A 7-year retrospective study. J Clin Pharm Ther 2021; 46:1591-1599. [PMID: 34287998 DOI: 10.1111/jcpt.13495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/01/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The primary adverse reaction of linezolid is haematological toxicity, leading to thrombocytopenia and anaemia. This study aimed to investigate the risk factors of linezolid-induced anaemia (LI-AN) and establish a predictive model by multivariate logistic regression model analysis to predict LI-AN risks in Chinese adult patients. METHODS Demographic and clinical data of patients who underwent linezolid therapy for more than three days between January 2014 and December 2020 in Zhongshan Hospital, Fudan University, were retrieved from the hospital's electronic medical record for analysis. Multivariate logistic regression analysis was employed to establish a predictive model, whose predictability was further evaluated by the area under the receiver operating characteristic (ROC) curve. RESULTS AND DISCUSSION The study comprised 298 patients among the 2322 patients who underwent linezolid treatment between 2014 and 2020. Among the 298 patients, 32 (10.7%) developed anaemia with an average of 11.4 (SD 6.2) days after the initiation of linezolid therapy. Multivariate logistic analysis revealed that age ≥60 years (odds ratio [OR] 2.815, 95% confidence interval [CI] 1.242-6.379), higher total bilirubin (TBi) (OR 1.031, 95% CI 1.011-1.051), eGFR < 60 ml/(min·1.73 m2 ) (OR 2.537, 95% CI 1.054-6.106), duration of linezolid therapy (DLT) (OR 1.091, 95% CI 1.023-1.163) and intensive care unit (ICU) admittance (OR 2.664, 95% CI 1.150-6.174) were the independent risk factors for anaemia occurrence among patients receiving linezolid therapy. A logistic regression equation based on the five risk factors was subsequently established and transformed to obtain the calculation formula of the combined predictor: Y(Combined predictor) = XTBi + 34.5 × XAge≥60 + 31.1 × XeGFR<60 + 32.7 × XICU + 2.9 × XDLT , (where Age ≥60 years, yes = 1, no = 0; eGFR < 60 ml/(min·1.73 m2 ), yes = 1, no = 0; ICU admittance, yes = 1, no = 0). The area under the ROC curve of the combined predictors equation was 0.773 with an optimal cut-off point value of 92.4, corresponding to a 75.0% sensitivity and 76.7% specificity. WHAT IS NEW AND CONCLUSION LI-AN is associated with age (≥60 years), higher TBi, eGFR < 60 ml/(min·1.73 m2 ), DLT and ICU admittance. Physicians should thus calculate the combined predictor value at the beginning of linezolid treatment to predict and evaluate the risk of LI-AN. An optimal cut-off value larger than 92.4 indicates that the patient has a higher LI-AN risk. As such, Hb levels should be monitored regularly, and dosage regimens adjusted accordingly to prevent anaemia occurrence. This study provides an evidence-based logistic model that reduces LI-AN incidences and promotes the safe clinical use of linezolid.
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Affiliation(s)
- Yan Qin
- Department of Pharmacy, Zhongshan Hospital, FuDan University, Shanghai, China
| | - Yangxi Liu
- Department of Pharmacy, School of Medicine, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zhe Chen
- Department of Pharmacy, Zhongshan Hospital, FuDan University, Shanghai, China
| | - Mingchen Cao
- School of Pharmacy, Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Yun Shen
- Department of Pharmacy, Zhongshan Hospital, FuDan University, Shanghai, China
| | - Yanrong Ye
- Department of Pharmacy, Zhongshan Hospital, FuDan University, Shanghai, China
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17
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Alraish R, Wicha SG, Frey OR, Roehr AC, Pratschke J, Stockmann M, Wuensch T, Kaffarnik M. Liver function, quantified by the LiMAx test, as a predictor for the clinical outcome of critically ill patients treated with linezolid. Technol Health Care 2021; 30:309-321. [PMID: 34180433 DOI: 10.3233/thc-191847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Critically ill patients commonly suffer from infections that require antimicrobial therapy. In previous studies, liver dysfunction was shown to have an essential impact on the dose selection in these patients. This pilot study aims to assess the influence of liver dysfunction, measured by the novel LiMAx test, on clinical outcomes in critically ill patients treated with linezolid. METHODS Twenty-nine critically ill patients were included and treated with linezolid. Indications for linezolid therapy were secondary or tertiary peritonitis (46.7%), bloodstream infection (6.7%) and 46.7% were other infections with gram-positive bacteria. Linezolid Cmin, maximal liver function capacity (LiMAx test) and plasma samples were collected while linezolid therapy was in a steady-state condition. Furthermore, potential factors for the clinical outcome were investigated using logistic regression analysis. Clinical cure was defined as the resolution or significant improvement of clinical symptoms without using additional antibiotic therapy or intervention. RESULTS Cured patients presented lower median linezolid Cmin yet a significantly higher mean LiMAx-value compared to the clinical failure group (1.9 mg/L vs. 5.1 mg/L) (349 μg/kg/h vs. 131 μg/kg/h). In the logistic regression model, LiMAx < 178 μg/kg/h was the only independent predictor of clinical failure with a sensitivity of 77% and specificity of 93%. CONCLUSIONS The LiMAx test predicts clinical failure more precisely than linezolid trough levels in critically ill surgical patients. Therefore liver failure may have a stronger impact on the outcome of critically ill surgical patients than low linezolid Cmin. While linezolid Cmin failed to predict patient's outcome, LiMAx results were the only independent predictor of clinical failure.
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Affiliation(s)
- Rawan Alraish
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany
| | - Otto R Frey
- Klinikum Heidenheim, Clinical Pharmacy, 89522 Heidenheim, Germany
| | - Anka C Roehr
- Klinikum Heidenheim, Clinical Pharmacy, 89522 Heidenheim, Germany
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Martin Stockmann
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Tilo Wuensch
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Magnus Kaffarnik
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
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18
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Rao GG, Konicki R, Cattaneo D, Alffenaar JW, Marriott DJE, Neely M. Therapeutic Drug Monitoring Can Improve Linezolid Dosing Regimens in Current Clinical Practice: A Review of Linezolid Pharmacokinetics and Pharmacodynamics. Ther Drug Monit 2021; 42:83-92. [PMID: 31652190 DOI: 10.1097/ftd.0000000000000710] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Linezolid is an antibiotic used to treat infections caused by drug-resistant gram-positive organisms, including vancomycin-resistant Enterococcus faecium, multi-drug resistant Streptococcus pneumoniae, and methicillin-resistant Staphylococcus aureus. The adverse effects of linezolid can include thrombocytopenia and neuropathy, which are more prevalent with higher exposures and longer treatment durations. Although linezolid is traditionally administered at a standard 600 mg dose every 12 hours, the resulting exposure can vary greatly between patients and can lead to treatment failure or toxicity. The efficacy and toxicity of linezolid are determined by the exposure achieved in the patient; numerous clinical and population pharmacokinetics (popPK) studies have identified threshold measurements for both parameters. Several special populations with an increased need for linezolid dose adjustments have also been identified. Therapeutic Drug Monitoring (TDM) is a clinical strategy that assesses the response of an individual patient and helps adjust the dosing regimen to maximize efficacy while minimizing toxicity. Adaptive feedback control and model-informed precision dosing are additional strategies that use Bayesian algorithms and PK models to predict patient-specific drug exposure. TDM is a very useful tool for patient populations with sparse clinical data or known alterations in pharmacokinetics, including children, patients with renal insufficiency or those receiving renal replacement therapy, and patients taking co-medications known to interact with linezolid. As part of the clinical workflow, clinicians can use TDM with the thresholds summarized from the current literature to improve linezolid dosing for patients and maximize the probability of treatment success.
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Affiliation(s)
- Gauri G Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Robyn Konicki
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Jan-Willem Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy.,Westmead Hospital, Sydney, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children's Hospital Los Angeles; and.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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19
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Wicha SG, Märtson AG, Nielsen EI, Koch BCP, Friberg LE, Alffenaar JW, Minichmayr IK. From Therapeutic Drug Monitoring to Model-Informed Precision Dosing for Antibiotics. Clin Pharmacol Ther 2021; 109:928-941. [PMID: 33565627 DOI: 10.1002/cpt.2202] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
Therapeutic drug monitoring (TDM) and model-informed precision dosing (MIPD) have evolved as important tools to inform rational dosing of antibiotics in individual patients with infections. In particular, critically ill patients display altered, highly variable pharmacokinetics and often suffer from infections caused by less susceptible bacteria. Consequently, TDM has been used to individualize dosing in this patient group for many years. More recently, there has been increasing research on the use of MIPD software to streamline the TDM process, which can increase the flexibility and precision of dose individualization but also requires adequate model validation and re-evaluation of existing workflows. In parallel, new minimally invasive and noninvasive technologies such as microneedle-based sensors are being developed, which-together with MIPD software-have the potential to revolutionize how patients are dosed with antibiotics. Nonetheless, carefully designed clinical trials to evaluate the benefit of TDM and MIPD approaches are still sparse, but are critically needed to justify the implementation of TDM and MIPD in clinical practice. The present review summarizes the clinical pharmacology of antibiotics, conventional TDM and MIPD approaches, and evidence of the value of TDM/MIPD for aminoglycosides, beta-lactams, glycopeptides, and linezolid, for which precision dosing approaches have been recommended.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, University of Sydney, Camperdown, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia.,Westmead Hospital, Wentworthville, Australia
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20
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Hilgarth H, Baehr M, Kluge S, König C. [Pharmacological/pharmaceutical counseling in intensive care medicine]. Med Klin Intensivmed Notfmed 2021; 116:173-184. [PMID: 33528630 DOI: 10.1007/s00063-020-00767-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 11/25/2022]
Abstract
Adequate pharmacotherapy in critically ill patients is challenging for many clinicians. Disease-related pathophysiological changes often lead to complex therapy strategies including many intensive care treatments (e.g. invasive ventilation, renal replacement therapy). These measures often influence drug prescribing and dosing. Therefore, in organ dysfunction such as renal and liver impairment reduced drug elimination has to be considered by adapting drug dosing towards elimination rates. Moreover, as intensive care medicine often includes the use of multiple drugs the risk for drug-drug interactions increases. The current article gives an overview about the complexity of individual pharmacotherapy in intensive care units whilst providing information for its clinical implementation.
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Affiliation(s)
- H Hilgarth
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland. .,Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - M Baehr
- Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - C König
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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21
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Abstract
BACKGROUND Limited data regarding altered linezolid pharmacokinetics in patients with liver cirrhosis are available. The objective of this study was to evaluate the pharmacokinetics, efficacy and safety of linezolid in cirrhotic patients. METHODS A case-control 1:1 study of patients undergoing linezolid therapeutic drug monitoring was conducted between January 2015 and June 2017. Cases with liver cirrhosis were matched with controls by age, body weight, comorbidities, renal function, and intensive care unit (ICU) admission. RESULTS Fifty-two patients were included, 26 in each group. Patients with Child-Pugh Scores A, B, and C were 1 (3.8%), 13 (50.0%), and 12 (46.2%), respectively. Cases had higher median linezolid trough plasma concentrations than controls [20.6 (17.4) versus 2.7 (11.3); P < 0.001)] and more frequently achieved an optimal pharmacodynamic index [26 (100%) versus 16 (61.5%); P = 0.002]. In addition, potentially toxic concentrations and treatment discontinuation due to overexposure and hematological toxicity were also more frequently seen in cirrhotic patients. Overall clinical cure rate was high (67.4%), and in-hospital mortality was 28.8%. No differences in clinical outcomes were observed between both groups. CONCLUSIONS Linezolid showed a high clinical cure rate. Nevertheless, plasma concentrations and treatment discontinuation due to hematological toxicity were higher in cirrhotic patients. Liver cirrhosis may influence linezolid pharmacokinetics and question the use of standard doses. Therapeutic drug monitoring of linezolid would be valuable in these patients.
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22
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Alraish R, Wicha SG, Frey OR, Roehr AC, Pratschke J, Stockmann M, Wuensch T, Kaffarnik M. Pharmacokinetics of tigecycline in critically ill patients with liver failure defined by maximal liver function capacity test (LiMAx). Ann Intensive Care 2020; 10:106. [PMID: 32754775 PMCID: PMC7403243 DOI: 10.1186/s13613-020-00707-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 06/26/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In critically ill patients, tigecycline (TGC) remains an important therapeutic option due to its efficacy against multiresistant Gram-positive and Gram-negative bacteria. TGC is metabolized and eliminated predominantly by the liver. Critical illness-induced liver failure may have a profound impact on the pharmacokinetic of TGC. In the present study, we aimed to establish a link between the degree of liver dysfunction and TGC plasma concentration using the novel maximum liver function capacity (LiMAx) test, as a dynamic liver function test. MATERIALS/METHODS The prospective study included 33 patients from a surgical ICU with the clinical indication for antibiotic therapy with TGC. The patients received 100 mg loading dose of TGC followed by intermittent standard doses of 50 mg q12. Blood samples for TGC plasma concentration were collected at 0.3, 2, 5, 8 and 11.5 h in a steady-state condition after at least 36 h post-standard dosage. The results were analyzed by means of a high-performance liquid chromatography (HPLC) method. Within the same day, the LiMAx test was carried out and routine blood parameters were measured. RESULTS Peak plasma concentrations of TGC were significantly higher in patients with severe liver failure (LiMAx < 100 µg/kg/h) when compared to patients with normal liver function (LiMAx > 300 µg/kg/h). The pharmacokinetic curves revealed higher values in severe liver failure at any measured point. Moreover, LiMAx and total bilirubin were the only liver-related parameters that correlated with TGC Cmax. CONCLUSIONS The present study demonstrates a high variability of TGC plasma concentrations in critically ill patients. The results show a significant correlation between the degree of liver dysfunction, measured by the LiMAx test, and TGC Cmax. LiMAx test may be a helpful tool beyond others for adjusting the required dosage of hepatic metabolized antibiotics in critically ill patients. Trial registry DRKS-German clinical trials register; Trial registration number: DRKS00008888; Date of registration: 07-17-2015; Date of enrolment of the first participant to the trial: 12-10-2015.
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Affiliation(s)
- Rawan Alraish
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Sebastian G Wicha
- Dept. of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstr. 45, 20146, Hamburg, Germany
| | - Otto R Frey
- Clinical Pharmacy, Klinikum Heidenheim, Schlosshaustraße 100, 89522, Heidenheim, Germany
| | - Anka C Roehr
- Clinical Pharmacy, Klinikum Heidenheim, Schlosshaustraße 100, 89522, Heidenheim, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum Augustenburger Platz 1, 13353, Berlin, Germany
| | - Martin Stockmann
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum Augustenburger Platz 1, 13353, Berlin, Germany
| | - Tilo Wuensch
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum Augustenburger Platz 1, 13353, Berlin, Germany
| | - Magnus Kaffarnik
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte/Campus Virchow-Klinikum Augustenburger Platz 1, 13353, Berlin, Germany
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23
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Population Pharmacokinetics and Dosage Optimization of Linezolid in Patients with Liver Dysfunction. Antimicrob Agents Chemother 2020; 64:AAC.00133-20. [PMID: 32253210 DOI: 10.1128/aac.00133-20] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/27/2020] [Indexed: 12/22/2022] Open
Abstract
Linezolid is the first synthetic oxazolidone agent to treat infections caused by Gram-positive pathogens. Infected patients with liver dysfunction (LD) are more likely to suffer from adverse reactions, such as thrombocytopenia, when standard-dose linezolid is used than patients with LD who did not use linezolid. Currently, pharmacokinetics data of linezolid in patients with LD are limited. This study aimed to characterize pharmacokinetics parameters of linezolid in patients with LD, identify the factors influencing the pharmacokinetics, and propose an optimal dosage regimen. We conducted a prospective study and established a population pharmacokinetics model with the Phoenix NLME software. The final model was evaluated by goodness-of-fit plots, bootstrap analysis, and prediction corrected-visual predictive check. A total of 163 concentration samples from 45 patients with LD were adequately described by a one-compartment model with first-order elimination along with prothrombin activity (PTA) and creatinine clearance as significant covariates. Linezolid clearance (CL) was 2.68 liters/h (95% confidence interval [CI], 2.34 to 3.03 liters/h); the volume of distribution (V) was 58.34 liters (95% CI, 48.00 to 68.68 liters). Model-based simulation indicated that the conventional dose was at risk for overexposure in patients with LD or severe renal dysfunction; reduced dosage (300 mg/12 h) would be appropriate to achieve safe (minimum steady-state concentration [C min,ss] at 2 to 8 μg/ml) and effective targets (the ratio of area under the concentration-time curve from 0 to 24 h [AUC0-24] at steady state to MIC, 80 to 100). In addition, for patients with severe LD (PTA, ≤20%), the dosage (400 mg/24 h) was sufficient at an MIC of ≤2 μg/ml. This study recommended therapeutic drug monitoring for patients with LD. (This study has been registered in the Chinese Clinical Trial Registry under no. ChiCTR1900022118.).
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Nee J, Schroeder T, Vornholt F, Schaeuble J, Leithner C, Stockmann M, Storm C. Dynamic determination of functional liver capacity with the LiMAx test in post-cardiac arrest patients undergoing targeted temperature management-A prospective trial. Acta Anaesthesiol Scand 2020; 64:501-507. [PMID: 31828754 DOI: 10.1111/aas.13523] [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] [Received: 07/31/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Transiently increased transaminases is a common finding after cardiac arrest but little is known about the functional liver capacity (LiMAx) during the post-cardiac arrest syndrome and treatment in the intensive care unit (ICU). The aim of this trial was to evaluate liver function capacity in post-cardiac arrest survivors undergoing targeted temperature management (TTM) in ICU. METHODS Thirty-two post-cardiac arrest survivors were prospectively included with all patients undergoing TTM at 33°C for 24 hours. Blood samples were collected, and LiMAx testing was performed at days 1, 2, 5, and 10 post-cardiac arrest. LiMAx is a non-invasive, in vivo, dynamic breath test determining cytochrome P450 1A2 (CYP1A2) capacity using intravenous (IV) 13 C-methacetin, thus reflecting maximum liver function capacity. Static liver parameters were determined and compared to LiMAx values. RESULTS A typical pattern of transiently, mildly increased transaminases was demonstrated without fulfilling the criteria for hypoxic hepatitis (HH). CYP1A2 activity was reduced with slow normalization over 10 days (lowest median 48 hours after cardiac arrest: 228.5 (25-75 percentile 105.2-301.7 μg/kg/h, P < .05). Parameters reflecting the liver synthetic function were not impaired, as assessed by, in standard laboratory testing. CONCLUSION Liver functional capacity is impaired in patients after cardiac arrest undergoing TTM at 33°C. More data are needed to determine if liver functional capacity may add relevant information, especially in the context of pharmacotherapy, to individualize post-cardiac arrest care.
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Affiliation(s)
- Jens Nee
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Tim Schroeder
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Florian Vornholt
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Julian Schaeuble
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Christoph Leithner
- Department of Neurology Charité Universitätsmedizin Berlin Berlin Germany
| | - Martin Stockmann
- Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhard Stift Lutherstadt Wittenberg Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
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Soraluce A, Barrasa H, Asín-Prieto E, Sánchez-Izquierdo JÁ, Maynar J, Isla A, Rodríguez-Gascón A. Novel Population Pharmacokinetic Model for Linezolid in Critically Ill Patients and Evaluation of the Adequacy of the Current Dosing Recommendation. Pharmaceutics 2020; 12:pharmaceutics12010054. [PMID: 31936614 PMCID: PMC7023070 DOI: 10.3390/pharmaceutics12010054] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/30/2019] [Indexed: 12/30/2022] Open
Abstract
Antimicrobial treatment in critically ill patients remains challenging. The aim of this study was to develop a population pharmacokinetic model for linezolid in critically ill patients and to evaluate the adequacy of current dosing recommendation (600 mg/12 h). Forty inpatients were included, 23 of whom were subjected to continuous renal replacement therapies (CRRT). Blood and effluent samples were drawn after linezolid administration at defined time points, and linezolid levels were measured. A population pharmacokinetic model was developed, using NONMEM 7.3. The percentage of patients that achieved the pharmacokinetic/pharmacodynamic (PK/PD) targets was calculated (AUC24/MIC > 80 and 100% T>MIC). A two-compartment model best described the pharmacokinetics of linezolid. Elimination was conditioned by the creatinine clearance and by the extra-corporeal clearance if the patient was subjected to CRRT. For most patients, the standard dose of linezolid did not cover infections caused by pathogens with MIC ≥ 2 mg/L. Continuous infusion may be an alternative, especially when renal function is preserved.
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Affiliation(s)
- Amaia Soraluce
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Helena Barrasa
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Eduardo Asín-Prieto
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
| | | | - Javier Maynar
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
- Correspondence: ; Tel.: +34-945-01-3094
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26
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Dosing of Antimycotic Treatment in Sepsis-Induced Liver Dysfunction by Functional Liver Testing with LiMAx®. Case Rep Crit Care 2019; 2019:5362514. [PMID: 31949955 PMCID: PMC6948309 DOI: 10.1155/2019/5362514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/04/2019] [Accepted: 10/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background Sepsis-treatment is one of the major challenges in our time. Especially fungal infections play an important role in patient's morbidity and mortality. In patients with septic shock, liver function is often significantly impaired and therefore also hepatic drug metabolism is altered. Case Presentation We report about a 56-year-old man suffering from invasive fungal infection with multiorgan failure, after complicated medical history due to symptomatic infrarenal aortic aneurysm. On the first postoperative day, a CT scan was undertaken due to massive back pain showing renal infarction on both sides. As qualitative and quantitative renal function was impaired, hemodialysis was started immediately. Subsequently, the patient developed a compartment syndrome of the left leg and underwent fasciotomy. On admission day 7, the patient presented with hematochezia leading to colonoscopy. During this procedure, an ischemic colitis was observed. As conservative treatment failed, the patient underwent Hartmann's procedure due to progredient ischemia followed by a worsening of the clinical status due to sepsis. The patient suffered from an invasive fungal infection with Candida spp. and Aspergillus spp. Systemic antifungal treatment was initiated. Although azoles are considered first-line treatment in these cases we chose the echinocandin caspofungin for its presumed lower impact on liver function compared to azoles like voriconazole or Amphothericin B. However, caspofungin is also metabolised in the liver and can cause hepatotoxic effects. Therefore we measured metabolic liver function capacity using LiMAx®and adapted the patient's dose of caspofungin to the evaluated liver function capacity to achieve an effective and liver-protective level of the active drug. After complicated medical history with 15 weeks of hospital stay, the patient was discharged in general good condition. Conclusions To our knowledge, this is the first report that relates antimycotic drug dosing to a functional liver test. We provide a new approach for sepsis treatment considering liver function capacity to optimize dosage of hepatically metabolised drugs with potential hepatotoxic effects.
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Brinkmann A, Röhr AC, Köberer A, Fuchs T, Krüger WA, König C, Richter D, Weigand MA, Frey OR. [Adequate anti-infective treatment : Importance of individual dosing and application]. Anaesthesist 2019; 67:461-476. [PMID: 29766208 DOI: 10.1007/s00101-018-0443-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (Vd) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.
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Affiliation(s)
- A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland.
| | - A C Röhr
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
| | - A Köberer
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - T Fuchs
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Konstanz, Konstanz, Deutschland
| | - C König
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - O R Frey
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
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28
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Buechter M, Kersting S, Gerken G, Kahraman A. Enzymatic liver function measured by LiMAx - a reliable diagnostic and prognostic tool in chronic liver disease. Sci Rep 2019; 9:13577. [PMID: 31537822 PMCID: PMC6753134 DOI: 10.1038/s41598-019-49746-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 08/22/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease (CLD) is a major cause of morbidity and mortality worldwide. Non-invasive assessment of hepatic disease severity represents a relevant issue to further improve clinical management and therapeutic treatment. We retrospectively compared the diagnostic and prognostic performance of different non-invasive tools (LiMAx, transient elastography (TE), and biomarkers) in detecting different severity stages during the course of CLD. Patients were divided into four groups based on clinical parameters: (1) patients without CLD (control group), (2) patients suffering from CLD without having cirrhosis, (3) patients with CLD and compensated cirrhosis, and finally, (4) patients with CLD and decompensated cirrhosis. Patients with acute liver failure were excluded from the analysis. A total of 464 patients who underwent LiMAx measurement at the University Clinic of Essen between 10/2016 and 11/2017 were included in this study. Distribution of the different groups were n = 72 patients for group 1, n = 134 patients for group 2, n = 160 patients for group 3, and n = 98 patients for group 4, respectively. Median LiMAx values significantly declined with respect to increasing degree of CLD: (1) 510 µg/h/kg, (2) 390 µg/h/kg, (3) 264 µg/h/kg, and (4) 151 µg/h/kg (p < 0.001). When comparing the diagnostic accuracy of the LiMAx test in detecting patients with presence of cirrhosis (groups 1 and 2 vs. groups 3 and 4), an AUROC of 0.942 was found (cut-off 322 µg/h/kg, sensitivity 86.1%, specificity 91.3%, p < 0.0001). LiMAx was superior to TE and serum biomarkers in predicting patients’ outcome by 90-day mortality (AUROC 0.811, p < 0.001). Enzymatic liver function measured by LiMAx was closely associated with different severity stages of CLD and was a reliable diagnostic and prognostic tool with an accuracy comparable to current standard methods.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Clinic of Essen, University of Duisburg-Essen, Essen, Germany.
| | - Sarah Kersting
- Department of Gastroenterology and Hepatology, University Clinic of Essen, University of Duisburg-Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Clinic of Essen, University of Duisburg-Essen, Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen, University of Duisburg-Essen, Essen, Germany
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29
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Stockmann M, Vondran FWR, Fahrner R, Tautenhahn HM, Mittler J, Bektas H, Malinowski M, Jara M, Klein I, Lock JF. Randomized clinical trial comparing liver resection with and without perioperative assessment of liver function. BJS Open 2018; 2:301-309. [PMID: 30263981 PMCID: PMC6156169 DOI: 10.1002/bjs5.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/13/2018] [Indexed: 12/11/2022] Open
Abstract
Background Liver function tests may help to predict outcomes after liver surgery. The aim of this study was to evaluate the clinical impact on postoperative outcome and patient management of perioperative liver function testing using the LiMAx® test. Methods A multicentre RCT was conducted in six academic liver centres. Patients with intrahepatic tumours scheduled for open liver resection of at least one segment were eligible. Patients were randomized to undergo additional perioperative liver function tests (LiMAx® group) or standard care (control group). Patients in the intervention arm received two perioperative LiMAx® tests, one before the operation for surgical planning and another after surgery for postoperative management. The primary endpoint was the proportion of patients transferred directly to a general ward. Secondary endpoints were severe complications, length of hospital stay (LOS) and length of intermediate care/ICU (LOI) stay. Results Some 148 patients were randomized. Thirty‐six of 58 patients (62 per cent) in the LiMAx® group were transferred directly to a general ward, compared with one of 60 (2 per cent) in the control group (P < 0·001). The rate of severe complications was significantly lower in the LiMAx® group (14 per cent versus 28 per cent in the control group; P = 0·022). LOS and LOI were significantly shorter in the LiMAx® group (LOS: 10·6 versus 13·3 days respectively, P = 0·012; LOI: 0·8 versus 3·0 days, P < 0·001). Conclusion Perioperative use of the LiMAx® test improves postoperative management and reduces the incidence of severe complications after liver surgery. Registration number: NCT01785082 (
https://clinicaltrials.gov).
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Affiliation(s)
- M Stockmann
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhardt Stift Lutherstadt Wittenberg Germany
| | - F W R Vondran
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany
| | - R Fahrner
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany.,Department of Visceral, Transplant, Thoracic and Vascular Surgery University Hospital Leipzig Leipzig Germany
| | - J Mittler
- Department of Hepatobiliary and Transplantation Surgery Johannes Gutenberg University Mainz Germany
| | - H Bektas
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany.,Department of General, Visceral and Oncological Surgery Bremen Mitte Clinic Bremen Germany
| | - M Malinowski
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral, Vascular and Paediatric Surgery University of Saarland Homburg Germany
| | - M Jara
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany
| | - I Klein
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
| | - J F Lock
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
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