1
|
Williams P, Cotta MO, Abdul‐Aziz MH, Wilks K, Farkas A, Roberts JA. In silico evaluation of a beta-lactam dosing guideline among adults with serious infections. Pharmacotherapy 2023; 43:1121-1130. [PMID: 36567467 PMCID: PMC10946580 DOI: 10.1002/phar.2753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to compare the achievement of therapeutic pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for beta-lactam antibiotics using product information dosing or guideline-based dosing for the treatment of serious infections. DESIGN In silico study. DATA SOURCE ID-ODSTM (Individually Designed Optimum Dosing Strategies). PATIENTS AND INTERVENTION None. MEASUREMENTS AND MAIN RESULTS In silico product information and guideline-based dosing simulations for cefepime, ceftazidime, flucloxacillin, meropenem, and piperacillin/tazobactam were performed using pharmacokinetic models from seriously ill patient populations. The median simulated concentration at 48 and 96 h was used to measure the probability of target attainment (PTA) to achieve predefined therapeutic and toxicity PK-PD targets. A multiple linear regression model was constructed to identify the effect of guideline-based dosing covariates on achieving pre-defined therapeutic targets. In total, 480 dosing simulations were performed. The PTA percentage with guideline-based dosing at 48 and 96 h was 80% and 68%, respectively, yielding significantly higher results when compared to product information dosing (48.45% and 49%, respectively), p < 0.001 at both time points. At 48 h, predefined toxicity thresholds were exceeded in 4.7% and 0% of simulations for guideline-based and product information-based dosing, respectively (p = 0.002). eGFR was significantly associated with the % PTA by guideline-based dosing, with eGFR values of 20 and 50 ml/min both statistically significant in leading to an increase in PTA. CONCLUSIONS Our study demonstrated that achievement of PK-PD exposures associated with an increased likelihood of effectiveness was more likely to occur with guideline-based dosing; especially at 48 h.
Collapse
Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Pharmacy DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Mohd H. Abdul‐Aziz
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Kathryn Wilks
- Infectious Diseases DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
- School of Public HealthThe University of QueenslandBrisbaneQueenslandAustralia
| | - Andras Farkas
- Department of PharmacyMount Sinai WestNew YorkNew YorkUSA
- Optimum Dosing StrategiesBloomingdaleNew JerseyUSA
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Pharmacy DepartmentRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Division of Anaesthesiology Critical Care Emergency and Pain MedicineNîmes University Hospital, University of MontpellierNîmesFrance
- Herston Infectious Diseases Institute (HeIDI)BrisbaneQueenslandAustralia
| |
Collapse
|
2
|
Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
Collapse
Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| |
Collapse
|
3
|
Bellouard R, Rambaud A, Delaunay C, Dailly É, Lecomte R, Deschanvres C, Leroy AG, Boutoille D, Le Turnier P, Grégoire M. Development and validation of a dosing nomogram for continuous infusion cloxacillin in infective endocarditis. J Antimicrob Chemother 2023; 78:965-974. [PMID: 36760090 DOI: 10.1093/jac/dkad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Cloxacillin is the first-line treatment for methicillin-susceptible staphylococcal infective endocarditis (IE). The recommended dose is 12 g per day regardless of the patient characteristics, despite the importance of renal function on its pharmacokinetics. OBJECTIVES We sought to build a population pharmacokinetics model of continuous infusion cloxacillin in IE patients to evaluate the influence of multiple covariates and then develop a nomogram based on significant covariates for individual adaptation. PATIENTS AND METHODS We included patients of a local IE cohort who were treated with cloxacillin administered by continuous infusion, excluding those who received intermittent or continuous dialysis, extracorporeal membrane oxygenation or extracorporeal circulation. The population pharmacokinetic analysis was performed using Pmetrics. The influence of weight, ideal weight, height, body mass index, body surface area, glomerular filtration rate (GFR) calculated with the Chronic Kidney Disease Epidemiology Collaboration formula (both expressed in mL/min/1.73 m² and in mL/min) and serum protein level on cloxacillin pharmacokinetics was assessed. Accounting for relevant covariates, a dosing nomogram was developed to determine the optimal daily dose required to achieve a steady-state plasma concentration range of 20-50 mg/L with a probability ≥0.9. RESULTS A total of 114 patients (331 plasma concentrations) were included. A one-compartment model including GFR expressed in mL/min as a covariate was chosen. Using the nomogram, achieving the cloxacillin concentration target requires a daily dose ranging from 3.5 to 13.1 g for a GFR ranging from 20 to 125 mL/min. CONCLUSIONS This work provided a practical tool for cloxacillin dose adjustment in IE according to renal function.
Collapse
Affiliation(s)
- Ronan Bellouard
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR 1155, Service de Pharmacologie Clinique, F-44000 Nantes, France
| | - Antoine Rambaud
- Nantes Université, CHU Nantes, Service de Pharmacologie Clinique, F-44000 Nantes, France
| | - Clarisse Delaunay
- Nantes Université, CHU Nantes, Service de Maladies Infectieuses et Tropicales, F-44000 Nantes, France
| | - Éric Dailly
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR 1155, Service de Pharmacologie Clinique, F-44000 Nantes, France
| | - Raphaël Lecomte
- Nantes Université, CHU Nantes, Service de Maladies Infectieuses et Tropicales, F-44000 Nantes, France
| | - Colin Deschanvres
- Nantes Université, CHU Nantes, Service de Maladies Infectieuses et Tropicales, F-44000 Nantes, France
| | - Anne-Gaëlle Leroy
- Nantes Université, CHU Nantes, Service de Bactériologie et Contrôles Microbiologiques des Produits de Santé, F-44000 Nantes, France
| | - David Boutoille
- Nantes Université, CHU Nantes, INSERM, Service de Maladies infectieuses et Tropicales, CIC 1413, F-44000 Nantes, France
| | - Paul Le Turnier
- Nantes Université, CHU Nantes, INSERM, Service de Maladies infectieuses et Tropicales, CIC 1413, F-44000 Nantes, France
| | - Matthieu Grégoire
- Nantes Université, CHU Nantes, Cibles et médicaments des infections et de l'immunité, IICiMed, UR 1155, Service de Pharmacologie Clinique, F-44000 Nantes, France
| | | |
Collapse
|
4
|
Tritscher P, Delannoy M, Agrinier N, Charmillon A, Degand N, Dellamonica J, Roger C, Leone M, Scala-Bertola J, Novy E. Assessment of current practice for β-lactam therapeutic drug monitoring in French ICUs in 2021: a nationwide cross-sectional survey. J Antimicrob Chemother 2022; 77:2650-2657. [PMID: 36059108 DOI: 10.1093/jac/dkac291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Current guidelines and literature support the use of therapeutic drug monitoring (TDM) to optimize β-lactam treatment in adult ICU patients. OBJECTIVES To describe the current practice of β-lactam monitoring in French ICUs. METHODS A nationwide cross-sectional survey was conducted from February 2021 to July 2021 utilizing an online questionnaire that was sent as an email link to ICU specialists (one questionnaire per ICU). RESULTS Overall, 119 of 221 (53.8%) French ICUs participated. Eighty-seven (75%) respondents reported having access to β-lactam TDM, including 52 (59.8%) with on-site access. β-Lactam concentrations were available in 24-48 h and after 48 h for 36 (41.4%) and 26 (29.9%) respondents, respectively. Most respondents (n = 61; 70.1%) reported not knowing whether the β-lactam concentrations in the TDM results were expressed as unbound fractions or total concentrations. The 100% unbound fraction of the β-lactam above the MIC was the most frequent pharmacokinetic and pharmacodynamic target used (n = 62; 73.0%). CONCLUSIONS Despite the publication of international guidelines, β-lactam TDM is not optimally used in French ICUs. The two major barriers are β-lactam TDM interpretation and the required time for results.
Collapse
Affiliation(s)
- Perrine Tritscher
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France
| | - Matthieu Delannoy
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France
| | - Nelly Agrinier
- Université de Lorraine, APEMAC, F-54000 Nancy, France.,CHRU-Nancy, INSERM, Université de Lorraine, CIC, Épidémiologie Clinique, F-54000 Nancy, France
| | - Alexandre Charmillon
- Université de Lorraine, CHRU-Nancy, Service de maladies infectieuses, coordonnateur équipe transversale en infectiologie, F-54000 Nancy, France
| | - Nicolas Degand
- Centre Hospitalier d'Antibes Juan les Pins, Service de Biologie, F-06600 Antibes, France
| | - Jean Dellamonica
- Université de Nice Cote d'Azur, CHU de Nice, Service de médecine intensive et réanimation, F-06202 Nice, France.,UR2CA Unité de Recherche Clinique Côte d'Azur, Université Cote d'Azur, F-06202 Nice, France
| | - Claire Roger
- CHU Nîmes, Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, F-30000 Nîmes, France.,UR UM 103 IMAGINE, Université de Montpellier, F-34090 Montpellier, France
| | - Marc Leone
- Aix Marseille Université, APHM, Hôpital Nord, Service d'anesthésie et de Réanimation, F-13015 Marseille, France
| | - Julien Scala-Bertola
- Université de Lorraine, CHRU-Nancy, Service de pharmacologie Clinique et toxicologie, F-54000 Nancy, France.,Université de Lorraine, CNRS, IMoPA, F-54000 Nancy, France
| | - Emmanuel Novy
- Université de Lorraine, CHRU-Nancy, Service d'anesthésie-réanimation et médecine péri-opératoire Brabois Adulte, F-54000 Nancy, France.,Université de Lorraine, SIMPA, F-54000 Nancy, France
| |
Collapse
|
5
|
Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part I: focused on acute kidney injury. Expert Rev Clin Pharmacol 2022; 15:551-561. [PMID: 35734940 DOI: 10.1080/17512433.2022.2093713] [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 Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article, we searched PubMed, Scopus, and Google Scholar for estimating renal function in acute kidney injury, nephrotoxicity of commonly used antibiotics, and nephrotoxin stewardship in intensive care units. EXPERT OPINION Early estimation of kidney function with an accurate method may be helpful to optimize antimicrobial treatment in critically ill patients. Different antibiotic dosing regimens may be required for patients with acute kidney injury. In many low-resource settings, therapeutic drug monitoring is not available for antibiotics. Acute kidney injury may influence treatment effectiveness and patient outcome.
Collapse
Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
6
|
Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
Collapse
Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
7
|
Kadivarian S, Heydarpour F, Karimpour H, Shahbazi F. Measured versus estimated creatinine clearance in critically ill patients with acute kidney injury: an observational study. Acute Crit Care 2022; 37:185-192. [PMID: 35545239 PMCID: PMC9184982 DOI: 10.4266/acc.2021.01256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background Acute kidney injury (AKI) commonly occurs in critically ill patients. Estimation of renal function and antibiotics dose adjustment in patients with AKI is a challenging issue. Methods Urinary creatinine clearance was measured in a 6-hour urine collection from patients with acute kidney injuries. The correlations between different formulas including the modified Cockcroft-Gault, modification of diet in renal disease, chronic kidney disease-epidemiology collaboration, Jelliffe, kinetic-glomerular filtration rate (GFR), Brater, and Chiou formulas were considered. The pattern of the prescribed antimicrobial agents was also compared with the patterns in the available resources. Results Ninety-five patients with acute kidney injuries were included in the research. The mean age of the participants was 63.11±17.58 years old. The most patients (77.89%) were in stage 1 of AKI according to the Acute Kidney Injury Network criteria, followed by stage 2 (14.73%) and stage 3 (7.36), respectively. None of the formulations had a high or very high correlation with the measured creatinine clearance. In stage 1, Chiou (r=0.26), and in stage 2 and 3, kinetic-GFR (r=0.76 and r=0.37) had the highest correlation coefficient. Antibiotic over- and under-dosing were frequently observed in the study. Conclusions The results showed that none of the static methods can predict the measured creatinine clearance in the critically ill patients. The dynamic methods such as kinetic-GFR can be helpful for patients who do not receive diuretics and vasopressors. Further studies are needed to confirm our results.
Collapse
|
8
|
Optimizing antimicrobial use: challenges, advances and opportunities. Nat Rev Microbiol 2021; 19:747-758. [PMID: 34158654 DOI: 10.1038/s41579-021-00578-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
An optimal antimicrobial dose provides enough drug to achieve a clinical response while minimizing toxicity and development of drug resistance. There can be considerable variability in pharmacokinetics, for example, owing to comorbidities or other medications, which affects antimicrobial pharmacodynamics and, thus, treatment success. Although current approaches to antimicrobial dose optimization address fixed variability, better methods to monitor and rapidly adjust antimicrobial dosing are required to understand and react to residual variability that occurs within and between individuals. We review current challenges to the wider implementation of antimicrobial dose optimization and highlight novel solutions, including biosensor-based, real-time therapeutic drug monitoring and computer-controlled, closed-loop control systems. Precision antimicrobial dosing promises to improve patient outcome and is important for antimicrobial stewardship and the prevention of antimicrobial resistance.
Collapse
|
9
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 899] [Impact Index Per Article: 299.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
10
|
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1463] [Impact Index Per Article: 487.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
11
|
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.
Collapse
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
| | | |
Collapse
|
12
|
Chiriac U, Frey OR, Roehr AC, Koeberer A, Gronau P, Fuchs T, Roberts JA, Brinkmann A. Personalized ß-lactam dosing in patients with coronavirus disease 2019 (COVID-19) and pneumonia: A retrospective analysis on pharmacokinetics and pharmacokinetic target attainment. Medicine (Baltimore) 2021; 100:e26253. [PMID: 34087915 PMCID: PMC8183774 DOI: 10.1097/md.0000000000026253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/05/2021] [Accepted: 05/18/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Pathophysiological changes are important risk factors for critically ill patients with pneumonia manifesting sub-therapeutic antibiotic exposures during empirical treatment. The effect of coronavirus disease 2019 (COVID-19) on antibiotic dosing requirements is uncertain. We aimed to determine the effect of COVID-19 on ß-lactam pharmacokinetics (PK) and PK target attainment in critically ill patients with a personalized dosing strategy.Retrospective, single-center analysis of COVID-19 ± critically ill patients with pneumonia (community-acquired pneumonia or hospital-acquired pneumonia) who received continuous infusion of a ß-lactam antibiotic with dosing personalized through dosing software and therapeutic drug monitoring. A therapeutic exposure was defined as serum concentration between (css) 4 to 8 times the EUCAST non-species related breakpoint).Data from 58 patients with pneumonia was analyzed. Nineteen patients were tested COVID-19-positive before the start of the antibiotic therapy for community-acquired pneumonia or hospital-acquired pneumonia. Therapeutic exposure was achieved in 71% of COVID-19 patients (68% considering all patients). All patients demonstrated css above the non-species-related breakpoint. Twenty percent exceeded css above the target range (24% of all patients). The median ß-lactam clearance was 49% compared to ß-lactam clearance in a standard patient without a significant difference regarding antibiotic, time of sampling or present COVID-19 infection. Median daily doses were 50% lower compared to standard bolus dosing.COVID-19 did not significantly affect ß-lactam pharmacokinetics in critically ill patients. Personalized ß-lactam dosing strategies were safe in critically ill patients and lead to high PK target attainment with less resources.
Collapse
Affiliation(s)
- Ute Chiriac
- Department of Pharmacy, University Hospital of Heidelberg
| | - Otto R. Frey
- Department of Pharmacy, Heidenheim General Hospital
| | | | - Andreas Koeberer
- Department of Anesthesiology and Intensive Care Medicine, Heidenheim General Hospital
| | - Patrick Gronau
- Department of Anesthesiology and Intensive Care Medicine, Heidenheim General Hospital
| | - Thomas Fuchs
- Department of Anesthesiology and Intensive Care Medicine, Heidenheim General, Heidenheim, Germany
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
| | - Alexander Brinkmann
- Department of Anesthesiology and Intensive Care Medicine, Heidenheim General Hospital
| |
Collapse
|
13
|
Personalized Piperacillin Dosing for the Critically Ill: A Retrospective Analysis of Clinical Experience with Dosing Software and Therapeutic Drug Monitoring to Optimize Antimicrobial Dosing. Antibiotics (Basel) 2021; 10:antibiotics10060667. [PMID: 34205135 PMCID: PMC8227218 DOI: 10.3390/antibiotics10060667] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022] Open
Abstract
Optimization of antibiotic dosing is a treatment intervention that is likely to improve outcomes in severe infections. The aim of this retrospective study was to describe the therapeutic exposure of steady state piperacillin concentrations (cPIP) and clinical outcome in critically ill patients with sepsis or septic shock who received continuous infusion of piperacillin with dosing personalized through software-guided empiric dosing and therapeutic drug monitoring (TDM). Therapeutic drug exposure was defined as cPIP of 32–64 mg/L (2–4× the ‘MIC breakpoint’ of Pseudomonas aeruginosa). Of the 1544 patients screened, we included 179 patients (335 serum concentrations), of whom 89% achieved the minimum therapeutic exposure of >32 mg/L and 12% achieved potentially harmful cPIP > 96 mg/L within the first 48 h. Therapeutic exposure was achieved in 40% of the patients. Subsequent TDM-guided dose adjustments significantly enhanced therapeutic exposure to 65%, and significantly reduced cPIP > 96 mg/L to 5%. Mortality in patients with cPIP > 96 mg/L (13/21; 62%) (OR 5.257, 95% CI 1.867–14.802, p = 0.001) or 64–96 mg/L (30/76; 45%) (OR 2.696, 95% CI 1.301–5.586, p = 0.007) was significantly higher compared to patients with therapeutic exposure (17/72; 24%). Given the observed variability in critically ill patients, combining the application of dosing software and consecutive TDM increases therapeutic drug exposure of piperacillin in patients with sepsis and septic shock.
Collapse
|
14
|
Barreto EF, Webb AJ, Pais GM, Rule AD, Jannetto PJ, Scheetz MH. Setting the Beta-Lactam Therapeutic Range for Critically Ill Patients: Is There a Floor or Even a Ceiling? Crit Care Explor 2021; 3:e0446. [PMID: 34136822 PMCID: PMC8202642 DOI: 10.1097/cce.0000000000000446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Beta-lactam antibiotics exhibit high interindividual variability in drug concentrations in patients with critical illness which led to an interest in the use of therapeutic drug monitoring to improve effectiveness and safety. To implement therapeutic drug monitoring, it is necessary to define the beta-lactam therapeutic range-in essence, what drug concentration would prompt a clinician to make dose adjustments up or down. This objective of this narrative review was to summarize evidence for the "floor" (for effectiveness) and "ceiling" (for toxicity) for the beta-lactam therapeutic range to be used with individualized therapeutic drug monitoring. DATA SOURCES Research articles were sourced from PubMed using search term combinations of "pharmacokinetics," "pharmacodynamics," "toxicity," "neurotoxicity," "therapeutic drug monitoring," "beta-lactam," "cefepime," "meropenem," "piperacillin/tazobactam," "ICU," and "critical illness." STUDY SELECTION Articles were selected if they included preclinical, translational, or clinical data on pharmacokinetic and pharmacodynamic thresholds for effectiveness and safety for beta-lactams in critical illness. DATA SYNTHESIS Experimental data indicate a beta-lactam concentration above the minimum inhibitory concentration of the organism for greater than or equal to 40-60% of the dosing interval is needed, but clinical data indicate that higher concentrations may be preferrable. In the first 48 hours of critical illness, a free beta-lactam concentration at or above the susceptibility breakpoint of the most likely pathogen for 100% of the dosing interval would be reasonable (typically based on Pseudomonas aeruginosa). After 48 hours, the lowest acceptable concentration could be tailored to 1-2× the observed minimum inhibitory concentration of the organism for 100% of the dosing interval (often a more susceptible organism). Neurotoxicity is the primary dose-dependent adverse effect of beta-lactams, but the evidence remains insufficient to link a specific drug concentration to greater risk. CONCLUSIONS As studies advance the understanding of beta-lactam exposure and response in critically ill patients, it is essential to clearly define the acceptable therapeutic range to guide regimen selection and adjustment.
Collapse
Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| |
Collapse
|
15
|
Phe K, Heil EL, Tam VH. Optimizing Pharmacokinetics-Pharmacodynamics of Antimicrobial Management in Patients with Sepsis: A Review. J Infect Dis 2021; 222:S132-S141. [PMID: 32691832 DOI: 10.1093/infdis/jiaa118] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Critically ill patients with sepsis or septic shock are at an increased risk of death. Early and aggressive interventions are essential for improving clinical outcomes. There are a number of therapeutic and practical challenges in the management of antimicrobials in patients with sepsis. These include the timely selection and administration of appropriate antimicrobials, significant physiological alterations that can influence antimicrobial pharmacokinetics, and significant interpatient variability of antimicrobial concentrations using standard dosing approaches. Understanding the impact of these factors on the probability of attaining pharmacokinetic-pharmacodynamic target goals is essential to guide optimal therapy. Using rapid diagnostic technology could facilitate timely selection of antimicrobials, and therapeutic drug monitoring would provide a more individualized dosing approach. Using an interdisciplinary sepsis team would also be beneficial in coordinating efforts to overcome the challenges encountered during this critical period to ensure optimal care.
Collapse
Affiliation(s)
- Kady Phe
- Baylor St Luke's Medical Center, Houston, Texas
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Vincent H Tam
- University of Houston College of Pharmacy, Houston, Texas
| |
Collapse
|
16
|
Hughes S, Gilchrist M, Heard K, Hamilton R, Sneddon J. Treating infections caused by carbapenemase-producing Enterobacterales (CPE): a pragmatic approach to antimicrobial stewardship on behalf of the UKCPA Pharmacy Infection Network (PIN). JAC Antimicrob Resist 2020; 2:dlaa075. [PMID: 34223030 PMCID: PMC8210165 DOI: 10.1093/jacamr/dlaa075] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The emergence of carbapenemase-producing Enterobacterales (CPE) as a major cause of invasive infection both within the UK and internationally poses a very real concern for all providers of healthcare. The burden of morbidity and mortality associated with CPE infections is well described. The need for early, targeted, effective and safe antimicrobial therapy remains key for the management of these infected patients yet reliable antimicrobial treatment options remain scarce. In the absence of a universal treatment for these CPE invasive infections, individual treatment options tailored to susceptibilities and severity of infection are required. This working group from within the UK Clinical Pharmacy Association (UKCPA) Pharmacy Infection Network has developed evidence-based treatment recommendations to support infection specialists in managing these complex infections. A systematic review of peer-reviewed research was performed and analysed. We report consensus recommendations for the management of CPE-associated infections. The national expert panel makes therapeutic recommendations regarding the pharmacokinetic and pharmacodynamic properties of the drugs and pharmacokinetic targets, dosing, dosage adjustment and monitoring of parameters for novel and established antimicrobial therapies with CPE activity. This manuscript provides the infection specialist with pragmatic and evidence-based options for the management of CPE infections.
Collapse
Affiliation(s)
- Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Katie Heard
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Ryan Hamilton
- School of Pharmacy, De Montfort University, Leicester LE2 7DP, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, 50 West Nile Street, Glasgow G1 2NP, UK
| |
Collapse
|
17
|
Management of infections caused by WHO critical priority Gram-negative pathogens in Arab countries of the Middle East: a consensus paper. Int J Antimicrob Agents 2020; 56:106104. [PMID: 32721603 DOI: 10.1016/j.ijantimicag.2020.106104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/17/2020] [Accepted: 07/20/2020] [Indexed: 12/22/2022]
Abstract
Antimicrobial resistance is an important global issue that impacts the efficacy of established antimicrobial therapy. This is true globally and within the Arab countries of the Middle East, where a range of key Gram-negative pathogens pose challenges to effective therapy. There is a need to establish effective treatment recommendations for this region given specific challenges to antimicrobial therapy, including variations in the availability of antimicrobials, infrastructure and specialist expertise. This consensus provides regional recommendations for the first-line treatment of hospitalized patients with serious infections caused by World Health Organization critical priority Gram-negative pathogens Acinetobacter baumannii and Pseudomonas aeruginosa resistant to carbapenems, and Enterobacteriaceae resistant to carbapenems and third-generation cephalosporins. A working group comprising experts in infectious disease across the region was assembled to review contemporary literature and provide additional consensus on the treatment of key pathogens. Detailed therapeutic recommendations are formulated for these pathogens with a focus on bacteraemia, nosocomial pneumonia, urinary tract infections, skin and soft tissue infections, and intra-abdominal infections. First-line treatment options are provided, along with alternative agents that may be used where variations in antimicrobial availability exist or where local preferences and resistance patterns should be considered. These recommendations take into consideration the diverse social and healthcare structures of the Arab countries of the Middle East, meeting a need that is not filled by international guidelines. There is a need for these recommendations to be updated continually to reflect changes in antimicrobial resistance in the region, as well as drug availability and emerging data from clinical trials.
Collapse
|