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Hong LT, Downes KJ, FakhriRavari A, Abdul-Mutakabbir JC, Kuti JL, Jorgensen S, Young DC, Alshaer MH, Bassetti M, Bonomo RA, Gilchrist M, Jang SM, Lodise T, Roberts JA, Tängdén T, Zuppa A, Scheetz MH. International consensus recommendations for the use of prolonged-infusion beta-lactam antibiotics: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2023; 43:740-777. [PMID: 37615245 DOI: 10.1002/phar.2842] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 08/25/2023]
Abstract
Intravenous β-lactam antibiotics remain a cornerstone in the management of bacterial infections due to their broad spectrum of activity and excellent tolerability. β-lactams are well established to display time-dependent bactericidal activity, where reductions in bacterial burden are directly associated with the time that free drug concentrations remain above the minimum inhibitory concentration (MIC) of the pathogen during the dosing interval. In an effort to take advantage of these bactericidal characteristics, prolonged (extended and continuous) infusions (PIs) can be applied during the administration of intravenous β-lactams to increase time above the MIC. PI dosing regimens have been implemented worldwide, but implementation is inconsistent. We report consensus therapeutic recommendations for the use of PI β-lactams developed by an expert international panel with representation from clinical pharmacy and medicine. This consensus guideline provides recommendations regarding pharmacokinetic and pharmacodynamic targets, therapeutic drug-monitoring considerations, and the use of PI β-lactam therapy in the following patient populations: severely ill and nonseverely ill adult patients, pediatric patients, and obese patients. These recommendations provide the first consensus guidance for the use of β-lactam therapy administered as PIs and have been reviewed and endorsed by the American College of Clinical Pharmacy (ACCP), the British Society for Antimicrobial Chemotherapy (BSAC), the Cystic Fibrosis Foundation (CFF), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the Infectious Diseases Society of America (IDSA), the Society of Critical Care Medicine (SCCM), and the Society of Infectious Diseases Pharmacists (SIDP).
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Affiliation(s)
- Lisa T Hong
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Kevin J Downes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Jacinda C Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
- Divisions of Clinical Pharmacy and Black Diaspora and African American Studies, University of California San Diego, La Jolla, California, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | | | - David C Young
- University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | | | | | - Robert A Bonomo
- Cleveland Veteran Affairs Medical Center, Cleveland, Ohio, USA
- Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark Gilchrist
- Imperial College Healthcare National Health Services Trust, London, UK
| | - Soo Min Jang
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Center for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marc H Scheetz
- College of Pharmacy, Pharmacometric Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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Plasma and Interstitial Fluid Pharmacokinetics of Prophylactic Cefazolin in Elective Bariatric Surgery Patients. Antimicrob Agents Chemother 2022; 66:e0041922. [PMID: 35762797 PMCID: PMC9295570 DOI: 10.1128/aac.00419-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Guidelines for surgical prophylactic dosing of cefazolin in bariatric surgery vary in terms of recommended dose. This study aimed to describe the plasma and interstitial fluid (ISF) cefazolin pharmacokinetics in patients undergoing bariatric surgery and to determine an optimum dosing regimen. Abdominal subcutaneous ISF concentrations (measured using microdialysis) and plasma samples were collected at regular time points after administration of cefazolin 2 g intravenously. Total and unbound cefazolin concentrations were assayed and then modeled using Pmetrics. Monte Carlo dosing simulations (n = 5,000) were used to define cefazolin dosing regimens able to achieve a fractional target attainment (FTA) of >95% in the ISF suitable for the MIC for Staphylococcus aureus in isolates of ≤2 mg · L-1 and for a surgical duration of 4 h. Fourteen patients were included, with a mean (standard deviation [SD]) bodyweight of 148 (35) kg and body mass index (BMI) of 48 kg · m-2. Cefazolin protein binding ranged from 14 to 36% with variable penetration into ISF of 58% ± 56%. Cefazolin was best described as a four-compartment model including nonlinear protein binding. The mean central volume of distribution in the final model was 18.2 (SD 3.31) L, and the mean clearance was 32.4 (SD 20.2) L · h-1. A standard 2-g dose achieved an FTA of >95% for all patients with BMIs ranging from 36 to 69 kg · m-2. A 2-g prophylactic cefazolin dose achieves appropriate unbound plasma and ISF concentrations in obese and morbidly obese bariatric surgery patients.
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Coates M, Shield A, Peterson GM, Hussain Z. Prophylactic Cefazolin Dosing in Obesity-a Systematic Review. Obes Surg 2022; 32:3138-3149. [PMID: 35809198 PMCID: PMC9392691 DOI: 10.1007/s11695-022-06196-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 11/02/2022]
Abstract
Currently, there is no consensus on whether a standard 2-g prophylactic cefazolin dose provides sufficient antimicrobial coverage in obese surgical patients. This systematic review analysed both outcome and pharmacokinetic studies, aiming to determine the appropriate cefazolin dose. A systematic search was conducted using 4 databases. In total, 3 outcome and 15 pharmacokinetic studies met the inclusion criteria. All 3 outcome studies concluded that there is no need for increased dose. Also, 9 pharmacokinetic studies reached this conclusion; however, 6 pharmacokinetic studies recommended that 2-g dose is insufficient to achieve adequate plasma or tissue concentrations. The stronger body of evidence supports that 2-g dose of cefazolin is sufficient for surgery lasting up to 4 h; however, large-scale outcome studies are needed to confirm this evidence.
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Affiliation(s)
- Matthew Coates
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Alison Shield
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Gregory M Peterson
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.,School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Australia
| | - Zahid Hussain
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.
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4
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Population pharmacokinetic model of cefazolin in total hip arthroplasty. Sci Rep 2021; 11:19763. [PMID: 34611213 PMCID: PMC8492877 DOI: 10.1038/s41598-021-99162-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/13/2021] [Indexed: 02/02/2023] Open
Abstract
Cefazolin is an antibiotic recommended for infection prevention in total hip arthroplasty (THA). However, the dosing regimen necessary to achieve therapeutic concentrations in obese patients remains unclear. The aim of this study was to conduct a population analysis of cefazolin pharmacokinetics (PK) and assess whether cefazolin administration should be weight adapted in THA. Adult patients undergoing THA surgery received an injection of 2000 mg of cefazolin, doubled in the case of BMI > 35 kg/m2 and total body weight > 100 kg. A population PK study was conducted to quantify cefazolin exposure over time compared to the therapeutic concentration threshold. A total of 484 cefazolin measurements were acquired in 100 patients, of whom 29% were obese. A 2-compartment model best fitted the data, and creatinine clearance determined interpatient variability in elimination clearance. Our PK simulations using a 2000 mg cefazolin bolus showed that cefazolin concentrations remained above the threshold throughout surgery, regardless of weight or renal function. A 2000 mg cefazolin single injection without adaptation to weight or renal function and without intraoperative reinjection was efficient in maintaining therapeutic concentrations throughout surgery. The optimal target concentration and necessary duration of its maintenance remain unclear.
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Rambaud A, Gaborit BJ, Deschanvres C, Le Turnier P, Lecomte R, Asseray-Madani N, Leroy AG, Deslandes G, Dailly É, Jolliet P, Boutoille D, Bellouard R, Gregoire M. Development and validation of a dosing nomogram for amoxicillin in infective endocarditis. J Antimicrob Chemother 2021; 75:2941-2950. [PMID: 32601687 DOI: 10.1093/jac/dkaa232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Amoxicillin is the first-line treatment for streptococcal or enterococcal infective endocarditis (IE) with a dose regimen adapted to weight. OBJECTIVES Covariates influencing pharmacokinetics (PK) of amoxicillin were identified in order to develop a dosing nomogram based on identified covariates for individual adaptation. PATIENTS AND METHODS Patients treated with amoxicillin administered by continuous infusion for IE were included retrospectively. The population PK analysis was performed using the Pmetrics package for R (NPAG algorithm). Influence of weight, ideal weight, height, BMI, body surface area, glomerular filtration rate adapted to the body surface area and calculated by the CKD-EPI method (mL/min), additional ceftriaxone treatment and serum protein level on amoxicillin PK was tested. A nomogram was then developed to determine the daily dose needed to achieve a steady-state free plasma concentration above 4× MIC, 100% of the time, without exceeding a total plasma concentration of 80 mg/L. RESULTS A total of 160 patients were included. Population PK analysis was performed on 540 amoxicillin plasma concentrations. A two-compartment model best described amoxicillin PK and the glomerular filtration rate covariate significantly improved the model when included in the calculation of the elimination constant Ke. CONCLUSIONS This work allowed the development of a dosing nomogram that can help to increase achievement of the PK/pharmacodynamic targets in IE treated with amoxicillin.
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Affiliation(s)
- Antoine Rambaud
- Clinical Pharmacology Department, CHU Nantes, Nantes, France
| | - Benjamin Jean Gaborit
- Department of Infectious Diseases, CHU Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, University of Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, CHU Nantes and CIC 1413, INSERM, Nantes, France
| | - Paul Le Turnier
- Department of Infectious Diseases, CHU Nantes and CIC 1413, INSERM, Nantes, France
| | - Raphaël Lecomte
- Department of Infectious Diseases, CHU Nantes and CIC 1413, INSERM, Nantes, France
| | | | - Anne-Gaëlle Leroy
- EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, University of Nantes, France.,Department of Bacteriology, CHU Nantes, Nantes, France
| | | | - Éric Dailly
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,EE 1701, MiHAR, University of Nantes, Nantes, France
| | - Pascale Jolliet
- Clinical Pharmacology Department, CHU Nantes, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, CHU Nantes and CIC 1413, INSERM, Nantes, France.,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, University of Nantes, France
| | - Ronan Bellouard
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,EE 1701, MiHAR, University of Nantes, Nantes, France
| | - Matthieu Gregoire
- Clinical Pharmacology Department, CHU Nantes, Nantes, France.,UMR INSERM 1235, The Enteric Nervous System in Gut and Brain Disorders, University of Nantes, Nantes, France
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Zimmerman DE, Shank BR. Weighing in on antibiotic dosing for surgical site prophylaxis. Am J Health Syst Pharm 2020; 77:408-409. [DOI: 10.1093/ajhp/zxz347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- David E Zimmerman
- Duquesne University Pittsburgh, PA
- UPMC-Mercy Hospital Pittsburgh, PA
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Ferraz ÁAB, Santa-Cruz F, Edmiston CE. Antibiotic Prophylaxis in Bariatric Surgical Procedures: Is There an Ideal Antimicrobial Agent? Surg Infect (Larchmt) 2020; 21:654-658. [PMID: 32109196 DOI: 10.1089/sur.2019.275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
When patients with significant comorbid risk factors undergo surgical procedures, they are at high risk for development of post-operative infectious complications, including surgical site infection (SSI). Obese patients characteristically fit within this risk category, and thus it is of paramount importance to establish evidence-based strategies to mitigate these infectious complications. The use of an antimicrobial prophylactic regimen is a well-established practice and is based on the principle of the "right drug, at the right time, in the right place." The subject of this article is to review the current evidence-based data on antimicrobial prophylaxis in obese patients undergoing bariatric surgical procedures.
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Affiliation(s)
- Álvaro A B Ferraz
- Department of Surgery, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Fernando Santa-Cruz
- Medical School, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Charles E Edmiston
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Population Pharmacokinetic Study of Cefazolin Dosage Adaptation in Bacteremia and Infective Endocarditis Based on a Nomogram. Antimicrob Agents Chemother 2019; 63:AAC.00806-19. [PMID: 31307987 DOI: 10.1128/aac.00806-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/09/2019] [Indexed: 01/06/2023] Open
Abstract
Optimal dosing of continuous-infusion cefazolin can be challenging in patients being treated for bacteremia or infective endocarditis. The aim of this work is to describe and analyze the pharmacokinetics of cefazolin in those patients using a population pharmacokinetics modeling approach and to establish a nomogram to determine the optimal daily dose. Population pharmacokinetics were modeled using the Pmetrics package for R. Plasma concentrations were collected retrospectively from patients treated with continuous-infusion cefazolin for bacteremia or infective endocarditis. The influence of multiple parameters, including renal function, total body weight, body mass index, body surface area (BSA), ideal weight, lean body weight, height, and age, was tested. The probabilities of target attainment for selected target concentrations (40, 60, and 80 mg/liter) were calculated. A dosing nomogram was then developed, using the absolute value of the glomerular filtration rate (aGFR), to determine the optimal daily dose required to achieve the target concentrations in at least 90% of patients. In total, 346 cefazolin plasma concentrations from 162 patients were collected. A one-compartment model best described the data set. The only covariate was aGFR, calculated according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula and the patient's body surface area, for the rate of elimination. Using the nomogram, achieving a cefazolin concentration target of 40 mg/liter with a success rate of at least 90% and with an aGFR of 30, 60, 90, and 120 ml/min requires a daily dose of 2.6, 4.3, 6.1, and 8.0 g/day, respectively. These results confirm the interest of posology adaptation of cefazolin according to aGFR.
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