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Wicha SG, Kinast C, Münchow M, Wittova S, Greppmair S, Kunzelmann AK, Zoller M, Paal M, Vogeser M, Habler K, Weig T, Terpolilli N, Heck S, Dimitriadis K, Scharf C, Liebchen U. Meropenem pharmacokinetics in cerebrospinal fluid: comparing intermittent and continuous infusion strategies in critically ill patients-a prospective cohort study. Antimicrob Agents Chemother 2024; 68:e0045124. [PMID: 39082803 PMCID: PMC11373225 DOI: 10.1128/aac.00451-24] [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: 03/25/2024] [Accepted: 07/08/2024] [Indexed: 09/05/2024] Open
Abstract
Meropenem penetration into the cerebrospinal fluid (CSF) is subject to high interindividual variability resulting in uncertain target attainment in CSF. Recently, several authors recommended administering meropenem as a continuous infusion (CI) to optimize CSF exposure. This study aimed to compare the concentrations and pharmacokinetics of meropenem in CSF after intermittent infusion (II) and CI. This prospective, observational study (NCT04426383) included critically ill patients with external ventricular drains who received either II or CI of meropenem. Meropenem pharmacokinetics in plasma and CSF were characterized using population pharmacokinetic modeling (NONMEM 7.5). The developed model was used to compare the concentration-time profile and probability of target attainment (PTA) between II and CI. A total of 16 patients (8 CI, 8 II; samples: nplasma = 243, nCSF = 263) were recruited, with nine patients (5 CI, 4 II) suffering from cerebral and seven patients from extracerebral infections. A one-compartment model described the plasma concentrations adequately. Meropenem penetration into the CSF (partition coefficient (KP), cCSF/cplasma) was generally low (6.0%), exhibiting substantial between-subject variability (coefficient of variation: 84.0%). There was no correlation between the infusion mode and KP, but interleukin (IL)-6 measured in CSF showed a strong positive correlation with KP (P < 0.001). Dosing simulations revealed no relevant differences in CSF concentrations and PTA in CSF between CI and II. Our study did not demonstrate increased penetration rates or higher concentrations of meropenem in the CSF with CI compared with II. CLINICAL TRIALS This study is registered with ClinicalTrials.gov as NCT04426383.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Christina Kinast
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Max Münchow
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sandra Wittova
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sebastian Greppmair
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Michael Zoller
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Katharina Habler
- Institute of Laboratory Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Weig
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nicole Terpolilli
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Suzette Heck
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Christina Scharf
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
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Peng Y, Minichmayr IK, Liu H, Xie F, Friberg LE. Multistate modeling for survival analysis in critically ill patients treated with meropenem. CPT Pharmacometrics Syst Pharmacol 2024; 13:222-233. [PMID: 37881115 PMCID: PMC10864930 DOI: 10.1002/psp4.13072] [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: 07/17/2023] [Revised: 09/19/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
Appropriate antibiotic dosing to ensure early and sufficient target attainment is crucial for improving clinical outcome in critically ill patients. Parametric survival analysis is a preferred modeling method to quantify time-varying antibiotic exposure - response effects, whereas bias may be introduced in hazard functions and survival functions when competing events occur. This study investigated predictors of in-hospital mortality in critically ill patients treated with meropenem by pharmacometric multistate modeling. A multistate model comprising five states (ongoing meropenem treatment, other antibiotic treatment, antibiotic treatment termination, discharge, and death) was developed to capture the transitions in a cohort of 577 critically ill patients treated with meropenem. Various factors were investigated as potential predictors of the transitions, including patient demographics, creatinine clearance calculated by Cockcroft-Gault equation (CLCRCG ), time that unbound concentrations exceed the minimum inhibitory concentration (fT>MIC ), and microbiology-related measures. The probabilities to transit to other states from ongoing meropenem treatment increased over time. A 10 mL/min decrease in CLCRCG was found to elevate the hazard of transitioning from states of ongoing meropenem treatment and antibiotic treatment termination to the death state by 18%. The attainment of 100% fT>MIC significantly increased the transition rate from ongoing meropenem treatment to antibiotic treatment termination (by 9.7%), and was associated with improved survival outcome. The multistate model prospectively assessed predictors of death and can serve as a useful tool for survival analysis in different infection scenarios, particularly when competing risks are present.
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Affiliation(s)
- Yaru Peng
- Department of PharmacyUppsala UniversityUppsalaSweden
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical SciencesCentral South UniversityChangshaChina
| | - Iris K. Minichmayr
- Department of PharmacyUppsala UniversityUppsalaSweden
- Department of Clinical PharmacologyMedical University ViennaViennaAustria
| | - Han Liu
- Department of PharmacyUppsala UniversityUppsalaSweden
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical SciencesCentral South UniversityChangshaChina
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Jia X, Yin Z, Zhang W, Du S. The Efficacy and Influencing Factors of Polymyxin B in High-Level Carbapenem-Resistant Klebsiella pneumoniae Infections. Infect Drug Resist 2023; 16:4177-4187. [PMID: 37396067 PMCID: PMC10314750 DOI: 10.2147/idr.s409090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background Polymyxin B (PMB) is a remedial treatment for carbapenem-resistant Klebsiella pneumoniae (CRKP) infection; however, there is a paucity of reports on the treatment of high-level CRKP infections with polymyxin B. Studies are needed to explore its treatment efficacy and associated influencing factors. Methods Patients with high-level CRKP infections treated with PMB during hospitalization from June 2019 to June 2021 in a hospital were retrospectively studied, and risk factors affecting the efficacy were explored by subgroup analysis. Results A total of 92 patients were enrolled, and the results showed that the PMB-based regimen had a bacterial clearance rate of 45.7%, an all-cause discharge mortality rate of 22.8%, and an incidence of acute kidney injury (AKI) of 27.2% for high-level CRKP treatment. The combination of β-lactams other than carbapenems facilitated bacterial clearance, and the combination of electrolyte disturbances and higher APACHE II scores was detrimental to microbial clearance. Risk factors for all-cause discharge mortality were advanced age, concomitant antifungal drugs, concomitant tigecycline and incidence of AKI. Conclusion PMB-based regimens are an effective option for the treatment of high-level CRKP infections. However, the optimal dose of treatment and the choice of combination regimens need to be explored in further studies.
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Affiliation(s)
- Xuedong Jia
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Zhao Yin
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Wan Zhang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
| | - Shuzhang Du
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
- The Precision Clinical Pharmacy Key Laboratory of Henan Province, Zhengzhou, People’s Republic of China
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Salehi M, Rezazade-Moayed F, Khalili H, Hemati H, Aghdami N, Dashtkoohi M, Dashtkoohi M, Beig-Mohammadi MT, Ramezani M, Hajiabdolbaghi M, Fattah-Ghazi S. Safety of megadose meropenem in the empirical treatment of nosocomial sepsis: a pilot randomized clinical trial. Future Microbiol 2023; 18:335-342. [PMID: 37140270 DOI: 10.2217/fmb-2022-0170] [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: 05/05/2023] Open
Abstract
Objective: To evaluate the safety of megadose meropenem as empirical treatment of nosocomial sepsis. Materials & methods: Critically ill patients diagnosed with sepsis received either high-dose (2 g every 8 h) or megadose (4 g every 8 h) meropenem as an intravenous infusion over 3 h. Results: A total of 23 patients with nosocomial sepsis were eligible and included in the megadose (n = 11) or high-dose (n = 12) group. No treatment-related adverse events were observed during a 14-day follow-up. Clinical response was also comparable between the groups. Conclusion: Megadose meropenem may be considered for empirical treatment of nosocomial sepsis without serious concern regarding its safety.
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Affiliation(s)
- Mohammadreza Salehi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Farah Rezazade-Moayed
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Hemati
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Aghdami
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology & Technology, Academic Center for Education, Culture & Research, Tehran, Iran
| | - Mohadese Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Dashtkoohi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoud Ramezani
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Hajiabdolbaghi
- Research Center for Antibiotic Stewardship and Antimicrobial Resistance, Imam Khomeini Hospital Complex, Department of Infectious Diseases, Tehran University of Medical Sciences, Tehran, Iran
| | - Samrand Fattah-Ghazi
- Critical Care Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Population Pharmacokinetics of Meropenem in Critically Ill Korean Patients and Effects of Extracorporeal Membrane Oxygenation. Pharmaceutics 2021; 13:pharmaceutics13111861. [PMID: 34834278 PMCID: PMC8625191 DOI: 10.3390/pharmaceutics13111861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Limited studies have investigated population pharmacokinetic (PK) models and optimal dosage regimens of meropenem for critically ill adult patients using the probability of target attainment, including patients receiving extracorporeal membrane oxygenation (ECMO). A population PK analysis was conducted using non-linear mixed-effect modeling. Monte Carlo simulation was used to determine for how long the free drug concentration was above the minimum inhibitory concentration (MIC) at steady state conditions in patients with various degrees of renal function. Meropenem PK in critically ill patients was described using a two-compartment model, in which glomerular filtration rate was identified as a covariate for clearance. ECMO did not affect meropenem PK. The simulation results showed that the current meropenem dosing regimen would be sufficient for attaining 40%fT>MIC for Pseudomonas aeruginosa at MIC ≤ 4 mg/L. Prolonged infusion over 3 h or a high-dosage regimen of 2 g/8 h was needed for MIC > 2 mg/L or in patients with augmented renal clearance, for a target of 100%fT>MIC or 100%fT>4XMIC. Our study suggests that clinicians should consider prolonged infusion or a high-dosage regimen of meropenem, particularly when treating critically ill patients with augmented renal clearance or those infected with pathogens with decreased in vitro susceptibility, regardless of ECMO support.
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Garduno A, Martín-Loeches I. Efficacy and appropriateness of novel antibiotics in response to antimicrobial-resistant Gram-negative bacteria in patients with sepsis in the ICU. Expert Rev Anti Infect Ther 2021; 20:513-531. [PMID: 34727820 DOI: 10.1080/14787210.2022.1999804] [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] [Indexed: 12/20/2022]
Abstract
INTRODUCTION There is an ever-increasing range of antibiotic-resistant pathogens that have led to higher community-acquired infections, and substantial mortality rates in critically ill patients. AREAS COVERED We have critically appraised available evidence through a structured literature review, investigating effective empiric antibiotic administration and appropriateness on outcomes of critically ill patients with an increased risk of developing resistant pathogens. The use of new antibiotics should be determined based on relevant knowledge of their spectrum and properties to provide effective mode of action for critically ill patients. EXPERT OPINION Restricting severely ill patients access to new broad-spectrum empirical drugs is not the answer. Rather there should be a focus on identifying host response to infection to differentiate between colonization or contamination and true infection, and the sensitivity to antibiotics used in the intensive care unit (ICU). Management relies on adequate antibiotic administration, the ability to monitor response, and facilitate the cessation of antibiotic treatment. The major determinant of patient success in a patient with a severe infection is the 'right' antibiotic or complementary course of treatment. As an overarching criterion, the following 3 appropriate "Ds" should be considered: Dosing, Duration and De-escalation to empirically assess the right antibiotic optimal antimicrobial selection.
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Affiliation(s)
- Alexis Garduno
- Department of Clinical Medicine, Intensive Care Translational Research, Trinity College Dublin
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, (Ireland)
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Luque S, Benítez-Cano A, Larrañaga L, Sorlí L, Navarrete ME, Campillo N, Carazo J, Ramos I, Adalia R, Grau S. Pharmacokinetics and Pharmacodynamics of Meropenem by Extended or Continuous Infusion in Low Body Weight Critically Ill Patients. Antibiotics (Basel) 2021; 10:antibiotics10060666. [PMID: 34204943 PMCID: PMC8228202 DOI: 10.3390/antibiotics10060666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Pathophysiological changes such as extreme body weights in critically ill patients with severe infections may alter the pharmacokinetics (PK) of antimicrobials, leading to treatment failure or toxicity. There are almost no PK data on meropenem in critically ill patients with low body weight (LwBW) and therefore information is lacking on the most appropriate dosing regimens, especially when administered by extended infusion. Objectives: To assess if the current administered doses of meropenem could lead to supratherapeutic concentrations in LwBW patients and to identify the factors independently associated with overexposure. Methods: A matched case-control 1:1 study of surgical critically ill patients treated with meropenem administered by extended or continuous infusion and undergoing therapeutic drug monitoring was conducted. Cases (patients with LwBW (body mass index (BMI) < 18.5 kg/m2)) were matched with normal body weight controls (NBW) (patients with BMI ≥ 18.5 kg/m2 and ≤30 kg/m2)) by age, gender, baseline renal function and severity status (APACHE II score). A 100% fT > MIC was considered an optimal pharmacokinetic/pharmacodynamic (PK/PD) target and 100% fT > 10 × MIC as supratherapeutic exposure. Results: Thirty-six patients (18 cases and 18 controls) were included (median (range) age, 57.5 (26–75) years; 20 (55.6% male)). Meropenem was administered by 6 h (extended) or 8 h (continuous) infusion at a median (range) daily dose of 5 (1–6) g/day. Similar median meropenem trough plasma concentrations (Cmin,ss), measured pre-dose on day three to four of treatment) were observed in the two groups (19.9 (22.2) mg/L vs 22.4 (25.8) mg/L, p > 0.999). No differences in the proportion of patients with an optimal or a supratherapeutic PKPD target between cases and controls were observed. A baseline estimated glomerular filtration rate (eGFR) < 90 mL/min was the only factor independently associated with a supratherapeutic PK/PD target. Conclusions: LwBW seems not to be a risk factor for achieving a supratherapeutic PK/PD target in critically ill patients receiving meropenem at standard doses by extended or continuous infusion.
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Affiliation(s)
- Sonia Luque
- Department of Pharmacy, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Universitat Autonoma de Barcelona, 08003 Barcelona, Spain; (M.E.N.); (N.C.); (S.G.)
- Correspondence: (S.L.); (A.B.-C.); Tel.: +34-932-483-824 (S.L.); +34-932-483-350 (A.B.-C.)
| | - Adela Benítez-Cano
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, IMIM (Hospital del Mar Research Institute), 08003 Barcelona, Spain; (L.L.); (J.C.); (I.R.); (R.A.)
- Correspondence: (S.L.); (A.B.-C.); Tel.: +34-932-483-824 (S.L.); +34-932-483-350 (A.B.-C.)
| | - Leire Larrañaga
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, IMIM (Hospital del Mar Research Institute), 08003 Barcelona, Spain; (L.L.); (J.C.); (I.R.); (R.A.)
| | - Luisa Sorlí
- Department of Infectious Diseases, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Universitat Autonoma de Barcelona, 08003 Barcelona, Spain;
| | - María Eugenia Navarrete
- Department of Pharmacy, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Universitat Autonoma de Barcelona, 08003 Barcelona, Spain; (M.E.N.); (N.C.); (S.G.)
| | - Nuria Campillo
- Department of Pharmacy, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Universitat Autonoma de Barcelona, 08003 Barcelona, Spain; (M.E.N.); (N.C.); (S.G.)
| | - Jesús Carazo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, IMIM (Hospital del Mar Research Institute), 08003 Barcelona, Spain; (L.L.); (J.C.); (I.R.); (R.A.)
| | - Isabel Ramos
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, IMIM (Hospital del Mar Research Institute), 08003 Barcelona, Spain; (L.L.); (J.C.); (I.R.); (R.A.)
| | - Ramón Adalia
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, IMIM (Hospital del Mar Research Institute), 08003 Barcelona, Spain; (L.L.); (J.C.); (I.R.); (R.A.)
| | - Santiago Grau
- Department of Pharmacy, Hospital del Mar, IMIM (Hospital del Mar Research Institute), Universitat Autonoma de Barcelona, 08003 Barcelona, Spain; (M.E.N.); (N.C.); (S.G.)
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