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Kim M, Mahmood M, Estes LL, Wilson JW, Martin NJ, Marcus JE, Mittal A, O'Connell CR, Shah A. A narrative review on antimicrobial dosing in adult critically ill patients on extracorporeal membrane oxygenation. Crit Care 2024; 28:326. [PMID: 39367501 DOI: 10.1186/s13054-024-05101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 09/14/2024] [Indexed: 10/06/2024] Open
Abstract
The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.
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Affiliation(s)
- Myeongji Kim
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lynn L Estes
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - John W Wilson
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph E Marcus
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, TX, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ankit Mittal
- Department of Infectious Diseases, AIG Hospitals, Hyderabad, India
| | | | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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2
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Ferre A, Giglio A, Zylbersztajn B, Valenzuela R, Van Sint Jan N, Fajardo C, Reccius A, Dreyse J, Hasbun P. Analysis of Vancomycin Dosage and Plasma Levels in Critically Ill Adult Patients Requiring Extracorporeal Membrane Oxygenation (ECMO). J Intensive Care Med 2024; 39:909-915. [PMID: 38557265 DOI: 10.1177/08850666241243306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction: Critically ill patients undergoing extracorporeal membrane oxygenation (ECMO) exhibit unique pharmacokinetics. This study aimed to assess the achievement of vancomycin therapeutic targets in these patients. Methods: This retrospective cohort study included patients on ECMO treated with vancomycin between January 2010 and December 2018. Ninety patients were analyzed based on ECMO connection modality, baseline creatinine levels, estimated glomerular filtration rate (eGFR), renal replacement therapy (RRT) requirements, and vancomycin loading dose administration. Results: Twenty-three percent of the patients achieved the therapeutic range defined by baseline levels. No significant differences in meeting the therapeutic goal were found in multivariate analysis considering ECMO cannulation modality, initial creatinine level, initial eGFR, RRT requirement, or loading dose use. All trough levels between 15 and 20 mcg/mL achieved an estimated area under the curve/minimum inhibitory concentration (AUC/MIC) between 400 and 600, almost all trough levels over 10 mcg/mL predicted an AUC/MIC >400. Discussion: Achieving therapeutic plasma levels in these patients remains challenging, potentially due to factors such as individual pharmacokinetics and pathophysiology. A trough plasma level between 12 and 20 estimated the therapeutic AUC/MIC for all models, proposing a possible lower target, maintaining exposure, and potentially avoiding adverse effects. Despite being one of the largest cohorts of vancomycin use in ECMO patients studied, its retrospective nature and single-center focus limits its broad applicability.
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Affiliation(s)
- Andrés Ferre
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | - Andrés Giglio
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | | | | | - Nicolette Van Sint Jan
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | | | - Andres Reccius
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
- Neurology Department, Clinica Las Condes, Santiago, Chile
| | - Jorge Dreyse
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
| | - Pablo Hasbun
- Critical Care Medicine Program, Universidad Finis Terrae, Santiago, Chile
- Adult Critical Care Unit, Clinica Las Condes, Santiago, Chile
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3
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Dilawri A, Muir J, Brodie D, Abrams D, Agerstrand C, Madahar P, Dzierba AL. Practices surrounding antimicrobial use in patients managed with extracorporeal membrane oxygenation: An international survey. J Crit Care 2024; 81:154534. [PMID: 38367526 DOI: 10.1016/j.jcrc.2024.154534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/23/2024] [Accepted: 02/04/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE This study aimed to survey critical care clinicians and characterize their perception of antimicrobial dosing strategies in patients receiving extracorporeal membrane oxygenation (ECMO). METHODS International, cross-sectional survey distributed to members of the Society of Critical Care Medicine in October 2022. RESULTS Respondents were primarily physicians (45%), with 92% practicing in North America. Ninety-seven percent of respondents reported antimicrobial dosing in critically ill patients to be challenging, due to physiological derangements seen in the patient population. Eighty-seven percent reported consideration of physicochemical drug properties when dosing antimicrobials in ECMO-supported patients, with lipophilicity (83%) and degree of protein binding (74%) being the two most common. Respondents' approach to antimicrobial dosing strategies did not significantly differ in critically ill ECMO-supported patients, compared to patients with equal severity of illness not receiving ECMO support. CONCLUSION Approaches to antimicrobial dosing strategies do not significantly differ among respondents between critically ill patients on ECMO support, compared to patients with equal severity of illness not receiving ECMO support. These findings were unexpected considering the added physiologic complexity of the ECMO circuit to critically ill adult patients and the need for well designed and adequately powered studies to inform empiric dosing guidance for ECMO-supported patients.
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Affiliation(s)
- Atul Dilawri
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Justin Muir
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Brodie
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Darryl Abrams
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Cara Agerstrand
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Purnema Madahar
- Division of Pulmonary and Critical Care Medicine, Columbia College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Amy L Dzierba
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, United States of America; Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons and NewYork-Presbyterian Hospital, New York, NY, United States of America.
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4
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Shekar K, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Cho YJ, Corley A, Diehl A, Gilder E, Jakob SM, Kim HS, Levkovich BJ, Lim SY, McGuinness S, Parke R, Pellegrino V, Que YA, Reynolds C, Rudham S, Wallis SC, Welch SA, Zacharias D, Fraser JF, Roberts JA. Antimicrobial Exposures in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2023; 207:704-720. [PMID: 36215036 DOI: 10.1164/rccm.202207-1393oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Data suggest that altered antimicrobial concentrations are likely during extracorporeal membrane oxygenation (ECMO). Objectives: The primary aim of this analysis was to describe the pharmacokinetics (PKs) of antimicrobials in critically ill adult patients receiving ECMO. Our secondary aim was to determine whether current antimicrobial dosing regimens achieve effective and safe exposure. Methods: This study was a prospective, open-labeled, PK study in six ICUs in Australia, New Zealand, South Korea, and Switzerland. Serial blood samples were collected over a single dosing interval during ECMO for 11 antimicrobials. PK parameters were estimated using noncompartmental methods. Adequacy of antimicrobial dosing regimens were evaluated using predefined concentration exposures associated with maximal clinical outcomes and minimal toxicity risks. Measurements and Main Results: We included 993 blood samples from 85 patients. The mean age was 44.7 ± 14.4 years, and 61.2% were male. Thirty-eight patients (44.7%) were receiving renal replacement therapy during the first PK sampling. Large variations (coefficient of variation of ⩾30%) in antimicrobial concentrations were seen leading to more than fivefold variations in all PK parameters across all study antimicrobials. Overall, 70 (56.5%) concentration profiles achieved the predefined target concentration and exposure range. Target attainment rates were not significantly different between modes of ECMO and renal replacement therapy. Poor target attainment was observed across the most frequently used antimicrobials for ECMO recipients, including for oseltamivir (33.3%), piperacillin (44.4%), and vancomycin (27.3%). Conclusions: Antimicrobial PKs were highly variable in critically ill patients receiving ECMO, leading to poor target attainment rates. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000559819).
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Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
- St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Amanda Corley
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Eileen Gilder
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Stephan M Jakob
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Hyung-Sook Kim
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bianca J Levkovich
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Shay McGuinness
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Rachael Parke
- Department of Intensive Care Medicine and Pharmacy, 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
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Yok-Ai Que
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Claire Reynolds
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - David Zacharias
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - John F Fraser
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, 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
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5
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Patel JS, Kooda K, Igneri LA. A Narrative Review of the Impact of Extracorporeal Membrane Oxygenation on the Pharmacokinetics and Pharmacodynamics of Critical Care Therapies. Ann Pharmacother 2022; 57:706-726. [PMID: 36250355 DOI: 10.1177/10600280221126438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Extracorporeal membrane oxygenation (ECMO) utilization is increasing on a global scale, and despite technological advances, minimal standardized approaches to pharmacotherapeutic management exist. This objective was to create a comprehensive review for medication dosing in ECMO based on the most current evidence. Data Sources: A literature search of PubMed was performed for all pertinent articles prior to 2022. The following search terms were utilized: ECMO, pharmacokinetics, pharmacodynamics, sedation, analgesia, antiepileptic, anticoagulation, antimicrobial, antifungal, nutrition. Retrospective cohort studies, case-control studies, case series, case reports, and ex vivo investigations were reviewed. Study Selection and Data Extraction: PubMed (1975 through July 2022) was the database used in the literature search. Non-English studies were excluded. Search terms included both drug class categories, specific drug names, ECMO, and pharmacokinetics. Data Synthesis: Medications with high protein binding (>70%) and high lipophilicity (logP > 2) are associated with circuit sequestration and the potential need for dose adjustment. Volume of distribution changes with ECMO may also impact dosing requirements of common critical care medications. Lighter sedation targets and analgosedation may help reduce sedative and analgesia requirements, whereas higher antiepileptic dosing is recommended. Vancomycin is minimally affected by the ECMO circuit and recommendations for dosing in critically ill adults are reasonable. Anticoagulation remains challenging as optimal aPTT goals have not been established. Relevance to Patient Care and Clinical Practice: This review describes the anticipated impacts of ECMO circuitry on sedatives, analgesics, anticoagulation, antiepileptics, antimicrobials, antifungals, and nutrition support and provides recommendations for drug therapy management. Conclusions: Medication pharmacokinetic/pharmacodynamic parameters should be considered when determining the potential impact of the ECMO circuit on attainment of therapeutic effect and target serum drug concentrations, and should guide therapy choices and/or dose adjustments when data are not available.
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Affiliation(s)
| | - Kirstin Kooda
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
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6
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Gomez F, Veita J, Laudanski K. Antibiotics and ECMO in the Adult Population-Persistent Challenges and Practical Guides. Antibiotics (Basel) 2022; 11:338. [PMID: 35326801 PMCID: PMC8944696 DOI: 10.3390/antibiotics11030338] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an emerging treatment modality associated with a high frequency of antibiotic use. However, several covariables emerge during ECMO implementation, potentially jeopardizing the success of antimicrobial therapy. These variables include but are not limited to: the increased volume of distribution, altered clearance, and adsorption into circuit components, in addition to complex interactions of antibiotics in critical care illness. Furthermore, ECMO complicates the assessment of antibiotic effectiveness as fever, or other signs may not be easily detected, the immunogenicity of the circuit affects procalcitonin levels and other inflammatory markers while disrupting the immune system. We provided a review of pharmacokinetics and pharmacodynamics during ECMO, emphasizing practical application and review of patient-, illness-, and ECMO hardware-related factors.
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Affiliation(s)
- Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO 65021, USA;
| | - Jesyree Veita
- Society for Healthcare Innovation, Philadelphia, PA 19146, USA;
| | - Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19146, USA
- Leonard Davis Institute for HealthCare Economics, University of Pennsylvania, Philadelphia, PA 19146, USA
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19146, USA
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7
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478-1493. [PMID: 34559091 DOI: 10.1213/ane.0000000000005733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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8
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists- Part II, Intraoperative Management and Troubleshooting. J Cardiothorac Vasc Anesth 2021; 35:3513-3527. [PMID: 34774253 DOI: 10.1053/j.jvca.2021.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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9
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A personalised approach to antibiotic pharmacokinetics and pharmacodynamics in critically ill patients. Anaesth Crit Care Pain Med 2021; 40:100970. [PMID: 34728411 DOI: 10.1016/j.accpm.2021.100970] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 01/01/2023]
Abstract
Critically ill patients admitted to intensive care unit (ICU) with severe infections, or those who develop nosocomial infections, have poor outcomes with substantial morbidity and mortality. Such patients commonly have suboptimal antibiotic exposures at routinely used antibiotic doses related to an increased volume of distribution and altered clearance due to their underlying altered physiology. Furthermore, the use of extracorporeal devices such as renal replacement therapy and extracorporeal membrane oxygenation in these group of patients also has the potential to alter in vivo drug concentrations. Moreover, ICU patients are likely to be infected with less-susceptible pathogens. Therefore, one potential contributing cause to the poor outcomes observed in critically ill patients may be related to subtherapeutic antibiotic exposures. Newer concepts include the clinician considering optimised dosing based on a blood antibiotic exposure defined by pharmacokinetic modelling and therapeutic drug monitoring, combined with a knowledge of the antibiotic penetration into the site of infection, thereby achieving optimal bacterial killing. Such optimised dosing is likely to improve patient outcomes. The aim of this review is to highlight key aspects of antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in critically ill patients and provide a PK/PD approach to tailor antibiotic dosing to the individual patient.
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10
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Population pharmacokinetics of vancomycin in critically ill adult patients receiving extracorporeal membrane oxygenation (an ASAP ECMO study). Antimicrob Agents Chemother 2021; 66:e0137721. [PMID: 34633852 DOI: 10.1128/aac.01377-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Our study aimed to describe the population pharmacokinetics (PK) of vancomycin in critically ill patients receiving extracorporeal membrane oxygenation (ECMO), including those receiving concomitant renal replacement therapy (RRT). Dosing simulations were used to recommend maximally effective and safe dosing regimens. Serial vancomycin plasma concentrations were measured and analysed using a population PK approach on Pmetrics®. The final model was used to identify dosing regimens that achieved target exposures of area under the curve (AUC0-24) of 400 - 700 mg·h/L at steady state. Twenty-two patients were enrolled, of which 11 patients received concomitant RRT. In the non-RRT patients, the median creatinine clearance (CrCL) was 75 mL/min and the mean daily dose of vancomycin was 25.5 mg/kg. Vancomycin was well described in a two-compartment model with CrCL, the presence of RRT and total body weight found as significant predictors of clearance and central volume of distribution (Vc). The mean vancomycin renal clearance and Vc were 3.20 L/h and 29.7 L respectively, while the clearance for patients on RRT was 0.15 L/h. ECMO variables did not improve the final covariate model. We found that recommended dosing regimens for critically ill adult patients not on ECMO can be safely and effectively used in those on ECMO. Loading doses of at least 25 mg/kg followed by maintenance doses of 12.5 - 20 mg/kg 12-hourly are associated with a 97 - 98% probability of efficacy and 11 - 12% probability of toxicity, in patients with normal renal function. Therapeutic drug monitoring along with reductions in dosing are warranted for patients with renal impairment and those with concomitant RRT.
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11
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Duceppe MA, Kanji S, Do AT, Ruo N, Cavayas YA, Albert M, Robert-Halabi M, Zavalkoff S, Dupont P, Samoukovic G, Williamson DR. Pharmacokinetics of Commonly Used Antimicrobials in Critically Ill Adults During Extracorporeal Membrane Oxygenation: A Systematic Review. Drugs 2021; 81:1307-1329. [PMID: 34224115 DOI: 10.1007/s40265-021-01557-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Adequate dosing of antimicrobials is critical to properly treat infections and limit development of resistance and adverse effects. Limited guidance exists for antimicrobial dosing adjustments in patients requiring extracorporporeal membrane oxygenation (ECMO) therapy. A systematic review was conducted to delineate the pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in critically ill adult patients requiring ECMO. METHODS Medline, EMBASE, Global Health, and All EBM Reviews databases were searched. Grey literature was examined. All studies reporting PK/PD parameters of antimicrobials in critically ill adults treated with ECMO were included, except for case reports and congress abstracts. Ex vivo studies were included. Two independent reviewers applied the inclusion and exclusion criteria. Reviewers were then paired to independently abstract data and evaluate methodological quality of studies using the ROBINS-I tool and the compliance with ClinPK guidelines. Patients' and studies' characteristics, key PK/PD findings, details of ECMO circuits and co-treatments were summarized qualitatively. Dosing recommendations were formulated based on data from controlled studies. RESULTS Thirty-two clinical studies were included; most were observational and uncontrolled. Fourteen ex vivo studies were analysed. Information on patient characteristics and co-treatments was often missing. The effect of ECMO on PK/PD parameters of antimicrobials varied depending on the studied drugs. Few dosing recommendations could be formulated given the lack of good quality data. CONCLUSION Limited data exist on the PK/PD of antimicrobials during ECMO therapy. Rigorously designed and well powered populational PK studies are required to establish empiric dosing guidelines for antimicrobials in patients requiring ECMO support. PROSPERO REGISTRATION NUMBER CRD42018099992 (Registered: July 24th 2018).
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Affiliation(s)
- Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada.
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
| | - Anh Thu Do
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada
| | - Ni Ruo
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada
| | - Yiorgos Alexandros Cavayas
- Department of Medicine, Division of Critical Care, Hôpital du Sacré-Coeur de Montréal Research Centre, Montreal, Canada.,Department of Surgery, Division of Critical Care, Montreal Heart Institute, Montreal, Canada.,Département de Médecine, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Martin Albert
- Department of Medicine, Division of Critical Care, Hôpital du Sacré-Coeur de Montréal Research Centre, Montreal, Canada.,Department of Surgery, Division of Critical Care, Montreal Heart Institute, Montreal, Canada.,Département de Médecine, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Maxime Robert-Halabi
- Department of Medicine, Division of Cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Samara Zavalkoff
- Department of Pediatrics, Division of Pediatric Critical Care, McGill University Health Centre, Montreal, Canada.,Faculty of Medicine, McGill University, Montreal, Canada
| | - Patrice Dupont
- Bibliothèque de la santé, Université de Montréal, Montreal, Canada
| | - Gordan Samoukovic
- Faculty of Medicine, McGill University, Montreal, Canada.,Department of Surgery, Division of Critical Care, McGill University Health Centre, Montreal, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
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12
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Zhang Y, Zeng Z, Zhang Q, Ou Q, Chen Z. [Effect of extracorporeal membrane oxygenation on pharmacokinetics of antimicrobial drugs: recent progress and recommendations]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:793-800. [PMID: 34134970 DOI: 10.12122/j.issn.1673-4254.2021.05.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an effective means to provide life support for patients with severe respiratory or heart failure. Existing studies have shown that ECMO may affect the metabolic process of some drugs by drug adsorption, increasing the apparent distribution volume and changing the clearance rate of the drugs. This review summarizes the recent progress in the studies of the effect of ECMO on the pharmacokinetics of antibacterial and antifungal drugs. For the antibacterial drugs, it is recommended that the dose of teicoplanin, imipenem, and linezolid should be increased during ECMO support, while the dose of azithromycin, ciprofloxacin, and tigecycline should not be modified for the time being. Currently studies on pharmacokinetic changes of antifungal drugs during ECMO support remain limited. Voriconazole can be absorbed substantially by ECMO due to its high lipophilicity, and higher doses are therefore recommended. The dose of micafungin also needs to be increased in children undergoing ECMO. However, current evidence concerning the dose of caspofungin and fluconazole are limited, and it is not clear whether the routine dose should be adjusted during ECMO support.
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Affiliation(s)
- Y Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Z Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Q Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Q Ou
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Z Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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13
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Prospective Cohort Study of Population Pharmacokinetics and Pharmacodynamic Target Attainment of Vancomycin in Adults on Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother 2021; 65:AAC.02408-20. [PMID: 33257444 DOI: 10.1128/aac.02408-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 01/01/2023] Open
Abstract
The aim of this study was to develop a population pharmacokinetics (PK) model for vancomycin and to evaluate its pharmacodynamic target attainment in adults on extracorporeal membrane oxygenation (ECMO). After a single 1,000-mg dose of vancomycin, samples were collected 9 times per patient prospectively. A population PK model was developed using a nonlinear mixed-effect model. The probability of target attainment (PTA) of vancomycin was evaluated for various dosing strategies using Monte Carlo simulation. The ratio of the area under the vancomycin concentration-time curve at steady state over 24 h to the MIC (AUC/MIC ratio) was investigated by applying the vancomycin breakpoint distribution of MICs for methicillin-resistant Staphylococcus aureus A total of 22 adult patients with 194 concentration measurements were included. The population PK was best described by a three-compartment model with a proportional residual error model. Vancomycin clearance and steady-state volume of distribution were 4.01 liters/h (0.0542 liters/h/kg) and 29.6 liters (0.400 liters/kg), respectively. If the treatment target AUC/MIC value was only ≥400, a total daily dose of 3 to 4 g would be optimal (PTA of ≥90%) for patients with normal renal function (estimated glomerular filtration rate [eGFR] = 60 to 120 ml/min/1.73 m2) when the MIC was presumed to be 1 mg/liter. However, AUC/MIC values of 400 to 600 were difficult to attain with any dosing strategy regardless of MIC and eGFR. Thus, it is hard to achieve efficacy and safety targets in patients on ECMO using the population dosing approach with Monte Carlo simulations, and therapeutic drug monitoring should be implemented in these patients.
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14
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Comparison of the Predictive Performance Between Cystatin C and Serum Creatinine by Vancomycin via a Population Pharmacokinetic Models: A Prospective Study in a Chinese Population. Eur J Drug Metab Pharmacokinet 2020; 45:135-149. [PMID: 31541402 DOI: 10.1007/s13318-019-00578-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Most of the current published population pharmacokinetic (PopPK) models are based on serum creatinine, but we often encounter an underestimation of its concentration in our clinical work. Therefore, we established a cystatin C-based model of vancomycin. OBJECTIVES The purpose of this study was to externally verify the PopPK model of vancomycin based on the glomerular filtration rate (GFR) estimated by serum cystatin C in our previous study and to compare the prediction performance of cystatin C (Cys C) and serum creatinine (SCR)-based models. METHODS The external data set consists of adults receiving vancomycin treatment at The First Affiliated Hospital of Guangxi Medical University. We summarized and restored published models based on serum creatinine values from the literature and used our external data set for initial screening. Visual and external verifications were used to further select candidate models for comparison. The mean prediction error (ME), mean absolute error (MAE) and root mean squared error (RMSE) were the primary outcomes for the overall comparison. Group comparisons of patients with different glomerular filtration rates (GFRs), ages and body mass index (BMI) levels were obtained by the Bayesian method. RESULTS A total of 156 patients with 233 samples were collected as an external data set. Sixteen published models were summarized and restored. After screening, four candidate models suitable for the external data set were finally obtained for comparison. The cystatin C-based model has a smaller ME value in the overall comparison. In the group comparison, serum creatinine-based models were underestimated in the prediction for patient groups with age ≥ 60 years, abnormal BMI values and GFR < 90 ml/min/1.73 m2, for which the cystatin C-based model could solve this problem. CONCLUSION After comparison, we suggest that cystatin C is a superior renal function marker to serum creatinine for vancomycin PopPK models.
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15
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Kim SW, Kim DJ, Zang DY, Lee DH. Impact of Sampling Period on Population Pharmacokinetic Analysis of Antibiotics: Why do You Take Blood Samples Following the Fourth Dose? Pharmaceuticals (Basel) 2020; 13:ph13090249. [PMID: 32947890 PMCID: PMC7558941 DOI: 10.3390/ph13090249] [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: 08/17/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
To date, many population pharmacokinetic models of antibiotics have been developed using blood sampling data after the fourth or fifth dose, which represents steady-state levels. However, if a model developed using blood sampled after the first dose is equivalent to that using blood sampled after the fourth dose, it would be advantageous to utilize the former. The aim of this study was to investigate the effect of blood sampling after the first and/or fourth drug administration on the accuracy and precision of parameter estimates. A previously reported robust, two-compartment model of vancomycin was used for simulation to evaluate the performances of the parameter estimates. The parameter estimation performances were assessed using relative bias and relative root mean square error. Performance was investigated in 72 scenarios consisting of a combination of two blood sampling periods (the first and fourth dose), two total clearances, three infusion times, and four sample sizes. The population pharmacokinetic models from data collected at the first dose and those collected at the fourth dose produced parameter estimates that were similar in accuracy and precision. This study will contribute to increasing the efficiency and simplicity of antibiotic pharmacokinetic studies.
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Affiliation(s)
- So Won Kim
- Department of Pharmacology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Dong Jin Kim
- Drug Evaluation Department, National Institute of Food and Drug Safety Evaluation, Ministry of Food and Drug Safety, Osong, Cheongju 28159, Korea;
| | - Dae Young Zang
- Division of Hematology-Oncology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang 14066, Korea;
| | - Dong-Hwan Lee
- Department of Clinical Pharmacology, Hallym University Sacred Heart Hospital, Anyang 14066, Korea
- Correspondence: ; Tel.: +82-31-380-4778
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16
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Zhou S, Zhang R, Lv C, Lu J, Wei Y, Li C, Chen M, Li Q, Liu T. Initial Dosage Optimization of Tacrolimus in Pediatric Patients With Thalassemia Major Undergoing Hematopoietic Stem Cell Transplantation Based on Population Pharmacokinetics. Ann Pharmacother 2020; 55:440-451. [PMID: 32924532 DOI: 10.1177/1060028020959039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) is an effective treatment for hematological disorders. Tacrolimus is widely used after HSCT, but it has highly interindividual variable pharmacokinetics. Population pharmacokinetics (PPK) researches of tacrolimus in children with β-thalassemia major (β-TM) undergoing HSCT are insufficient. OBJECTIVE To establish a PPK model of tacrolimus in children with β-TM and optimize initial dosing regimen for achieving target concentration of 5 to 15 ng/mL. METHODS Data on patients aged <18 years were retrospectively collected from January 2017 to December 2018. PPK analysis and Monte Carlo simulations were performed using nonlinear mixed-effects modeling. RESULTS A data set of 55 patients with 332 concentrations was included. A 2-compartment model could best describe the pharmacokinetics of tacrolimus. The body surface area and gender were significant covariates in the final model. The typical value of clearance, the distribution volume of the central room, the distribution volume of the peripheral room, and the intercompartmental clearance were 5.05L/h, 4.33L, 155L, and 6.22L/h, respectively. The optimal initial dosing regimen of 0.03, 0.04, 0.05, 0.06, and 0.10 mg/kg were appropriate for female children with a weight (WT) of 50 to 10 kg. The regimen of 0.04, 0.05, 0.06, 0.07, and 0.12 mg/kg is suitable for male children with a WT of 50 to 10 kg. The probability of target attainment (PTA) of each regimen reached 91%. CONCLUSION AND RELEVANCE A stable PPK model of tacrolimus was established. The proposed dosage regimen reached a good PTA, which could provide a reference for tacrolimus therapy.
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Affiliation(s)
- Siru Zhou
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ren Zhang
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chunle Lv
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jiejiu Lu
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yinyi Wei
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chengxin Li
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ming Chen
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qiaochuan Li
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Taotao Liu
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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17
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Effectiveness of Vancomycin Dosing Guided by Therapeutic Drug Monitoring in Adult Patients Receiving Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother 2020; 64:AAC.01179-20. [PMID: 32571814 DOI: 10.1128/aac.01179-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 01/02/2023] Open
Abstract
The clinical situation for patients receiving extracorporeal membrane oxygenation (ECMO) is complex, and drug dosing is complicated by significant pharmacokinetic alterations. We sought to describe the frequency of achievement of therapeutic vancomycin concentrations in critically ill patients receiving ECMO with therapeutic drug monitoring (TDM). In this retrospective observational study, we included all critically ill patients receiving TDM for vancomycin while on ECMO. The primary outcome was the proportion of plasma vancomycin concentrations in the therapeutic range (15 to 20 mg/liter). Factors associated with not achieving therapeutic concentrations were investigated, including ECMO duration and use of renal replacement therapies. Vancomycin TDM was performed for 77 of 116 (66%) patients on ECMO. Median (interquartile range) duration of ECMO support was 7 days (4 to 16 days). The proportion of measurements in the therapeutic range (15 to 20 mg/liter) was 24%, while 46% were subtherapeutic (<15 mg/liter) and 30% were supratherapeutic (>20 mg/liter). The proportion of measures in the therapeutic range was significantly higher on ECMO days for 6 to 13 (incidence rate ratio [IRR], 2.4; 95% confidence interval [CI], 1.2 to 4.6; P = 0.01). Supratherapeutic concentrations were more frequently observed in patients on renal replacement therapy (RRT) (IRR, 2.0; 95% CI, 1.3 to 3.1; P = 0.002). The vancomycin concentrations in patients did not vary with age, gender, or type of ECMO support. Patients receiving vancomycin had suboptimal concentrations early in the course of ECMO. Patients not receiving RRT and those with mild to moderate acute kidney injury (AKI) were at a risk of underdosing, while those with established AKI on RRT were likelier to experience supratherapeutic concentrations.
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18
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Wu C, Lin F, Lin S, Ho Y, Huang C, Shen L, Wu FL. Clinical pharmacy service and international collaboration: Model and experience from a medical center in Taiwan. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Chien‐Chih Wu
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Fang‐Ju Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Shu‐Wen Lin
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Yunn‐Fang Ho
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Chih‐Fen Huang
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Li‐Jiuan Shen
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
| | - Fe‐Lin Lin Wu
- Graduate Institute of Clinical Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- School of Pharmacy College of Medicine, National Taiwan University Taipei Taiwan
- Department of Pharmacy Cancer Center, College of Medicine, National Taiwan University Taipei Taiwan
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19
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Liu D, Chen W, Wang Q, Li M, Zhang Z, Cui G, Li P, Zhang X, Ma Y, Zhan Q, Wang C. Influence of venovenous extracorporeal membrane oxygenation on pharmacokinetics of vancomycin in lung transplant recipients. J Clin Pharm Ther 2020; 45:1066-1075. [PMID: 32542736 DOI: 10.1111/jcpt.13163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/05/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The influence of venovenous extracorporeal membrane oxygenation (VV-ECMO) on the population pharmacokinetics (PPK) of vancomycin in recipients after lung transplantation (LTx) is unknown. We investigated whether VV-ECMO influences vancomycin PPK and determined optimal recommended dosage for patients after LTx. METHODS We tested vancomycin serum concentration and calculated PPK parameters using NONMEM. To check for any potential influence of ECMO on vancomycin PK, we compared ECMO patients with a non-ECMO patient control group, and patients before and after ECMO weaning as self-control to analysed changes in vancomycin PK. Monte Carlo dosing simulation was conducted to explore vancomycin dosing regimens. RESULTS Nineteen ECMO and 6 non-ECMO lung transplant recipients were enrolled. Vancomycin serum concentrations did not significantly differ between patients with and without ECMO support. Comparison of separate vancomycin population pharmacokinetic models showed that ECMO patients had smaller peripheral compartment volume of distribution (V2 ) [Estimate (relative standard error, RSE, %) 19.7 (12) vs. 22 (17) L, P = .003] than non-ECMO patients. For treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections with MIC ≤ 0.5 µg/mL, venous infusion of 400 mg vancomycin every 8 hours was recommended. For MRSA infection with MIC ≤ 1 µg/mL, the proposed dosage was 600 mg every 8 hours. WHAT IS NEW AND CONCLUSION Venovenous extracorporeal membrane oxygenation slightly alters vancomycin PK but does not significantly impact vancomycin serum concentration in patients after LTx. Dose adjustment is not necessary for VV-ECMO support. Specific vancomycin dosing regimens with lower nephrotoxicity may benefit LTx recipients with VV-ECMO.
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Affiliation(s)
- Donglin Liu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Qianlin Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Gang Cui
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xianglin Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Yi Ma
- School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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20
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Mahmoud AA, Avedissian SN, Al-Qamari A, Bohling T, Pham M, Scheetz MH. Pharmacokinetic Assessment of Pre- and Post-Oxygenator Vancomycin Concentrations in Extracorporeal Membrane Oxygenation: A Prospective Observational Study. Clin Pharmacokinet 2020; 59:1575-1587. [PMID: 32468446 DOI: 10.1007/s40262-020-00902-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary life support frequently utilized in catastrophic lung and or cardiac failure. Patients on ECMO often receive vancomycin therapy for treatment or prophylaxis against Gram-positive organisms. It is unclear if ECMO affects vancomycin pharmacokinetics, thus we modeled the pharmacokinetic behavior of vancomycin according to ECMO-specific variables. METHODS Adult patients receiving vancomycin and Veno-Arterial-ECMO between 12/1/2016 and 10/1/2017 were prospectively enrolled. Extracorporeal membrane oxygenation settings and four sets of pre- and post-oxygenator vancomycin concentrations were collected for each patient. Compartmental models were built and assessed ECMO flow rates on vancomycin clearance and potential circuit sequestration. Bayesian posterior concentrations of the pre- and post-oxygenator concentrations were obtained for each patient, and summary pharmacokinetic parameters were calculated. Simulations were performed from the final model for efficacy and toxicity predictions. RESULTS Eight patients contributed 64 serum concentrations. Patients were a median (interquartile range) age of 58.5 years (50.8-62.3) with a calculated creatinine clearance of 39 mL/min (29.5-62.5) and ECMO flow rates of 3980 mL/min (interquartile range = 3493.75-4132.5). A three-compartment model best fit the data (Bayesian: plasma pre-oxygenation R2 = 0.99, post-oxygenation R2 = 0.99). Vancomycin clearance was not impacted by ECMO flow rate (p = 0.7). Simulations demonstrated that vancomycin 1 g twice daily was rarely sufficient for minimum inhibitory concentrations > 0.5 mg/L. Doses ≥ 1.5 g twice daily often exceeded toxicity thresholds for exposure. CONCLUSIONS Extracorporeal membrane oxygenation flow rates did not influence vancomycin clearance between flow rates of 3500 and 5000 mL/min and vancomycin was not sequestered in ECMO. Common vancomycin regimens resulted in suboptimal efficacy and/or excessive toxicity. Individual therapeutic drug monitoring is recommended for patients on ECMO.
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Affiliation(s)
- Ahmed A Mahmoud
- Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron Street, Feinberg Pavilion, LC 700, Chicago, IL, 60611, USA
| | - Sean N Avedissian
- Antiviral Pharmacology Laboratory, Medical Center (UNMC) for Drug Discovery, University of Nebraska, Omaha, NE, USA.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Abbas Al-Qamari
- Department of Anesthesiology, Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, IL, USA
| | - Tiffany Bohling
- Department of Anesthesia-Critical Care Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Michelle Pham
- Antiviral Pharmacology Laboratory, Medical Center (UNMC) for Drug Discovery, University of Nebraska, Omaha, NE, USA.,College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marc H Scheetz
- Department of Pharmacy, Northwestern Memorial Hospital, 251 E. Huron Street, Feinberg Pavilion, LC 700, Chicago, IL, 60611, USA. .,Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA. .,Pharmacometric Center of Excellence, Chicago College of Pharmacy, Midwestern University, 555, 31st St., Downers Grove, IL, 60515, USA.
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21
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Antibiotic dosing during extracorporeal membrane oxygenation: does the system matter? Curr Opin Anaesthesiol 2020; 33:71-82. [PMID: 31764007 DOI: 10.1097/aco.0000000000000810] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The aims of this review are to discuss the impact of extracorporeal membrane oxygenation (ECMO) on antibiotic pharmacokinetics and how this phenomenon may influence antibiotic dosing requirements in critically ill adult ECMO patients. RECENT FINDINGS The body of literature describing antibiotic pharmacokinetic and dosing requirements during ECMO support in critically adult patients is currently scarce. However, significant development has recently been made in this research area and more clinical pharmacokinetic data have emerged to inform antibiotic dosing in these patients. Essentially, these clinical data highlight several important points that clinicians need to consider when dosing antibiotics in critically ill adult patients receiving ECMO: physicochemical properties of antibiotics can influence the degree of drug loss/sequestration in the ECMO circuit; earlier pharmacokinetic data, which were largely derived from the neonatal and paediatric population, are certainly useful but cannot be extrapolated to the critically ill adult population; modern ECMO circuitry has minimal adsorption and impact on the pharmacokinetics of most antibiotics; and pharmacokinetic changes in ECMO patients are more reflective of critical illness rather than the ECMO therapy itself. SUMMARY An advanced understanding of the pharmacokinetic alterations in critically ill patients receiving ECMO is essential to provide optimal antibiotic dosing in these complex patients pending robust dosing guidelines. Antibiotic dosing in this patient population should generally align with the recommended dosing strategies for critically ill patients not on ECMO support. Performing therapeutic drug monitoring (TDM) to guide antibiotic dosing in this patient population appears useful.
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22
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Aljutayli A, Marsot A, Nekka F. An Update on Population Pharmacokinetic Analyses of Vancomycin, Part I: In Adults. Clin Pharmacokinet 2020; 59:671-698. [DOI: 10.1007/s40262-020-00866-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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23
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Raffaeli G, Cavallaro G, Allegaert K, Koch BCP, Mosca F, Tibboel D, Wildschut ED. Sequestration of Voriconazole and Vancomycin Into Contemporary Extracorporeal Membrane Oxygenation Circuits: An in vitro Study. Front Pediatr 2020; 8:468. [PMID: 32974242 PMCID: PMC7481439 DOI: 10.3389/fped.2020.00468] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Bacterial and fungal infections are common and often contribute to death in patients undergoing extracorporeal membrane oxygenation (ECMO). Drug disposition is altered during ECMO, and adsorption in the circuit is an established causative factor. Vancomycin and voriconazole are widely used, despite the lack of evidence-based prescription guidelines. Objective: The objective of this study was to determine the extraction of voriconazole and vancomycin by the Xenios/Novalung ECMO circuits. Methods: We have set up nine closed-loop ECMO circuits, consisting of four different iLAActivve ® kits for neonatal, pediatric, and adult support: three iLA-ActivveMiniLung ® petite kits, two iLA-ActivveMiniLung ® kits, two iLA-ActivveiLA ® kits, and two iLA-Activve X-lung ® kits. The circuits were primed with whole blood and maintained at physiologic conditions for 24 h. Voriconazole and vancomycin were injected as a single-bolus age-related dose into the circuits. Pre-membrane (P2) blood samples were obtained at baseline and after drug injection at 2, 10, 30, 180, 360 min, and 24 h. A control sample at 2 min was collected for spontaneous drug degradation testing at 24 h. Results: Seventy-two samples were analyzed in triplicate. The mean percentage of drug recovery at 24 h was 20% for voriconazole and 62% for vancomycin. Conclusions: The extraction of voriconazole and vancomycin by contemporary ECMO circuits is clinically relevant across all age-related circuit sizes and may result in reduced drug exposure in vivo.
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Affiliation(s)
- Genny Raffaeli
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Karel Allegaert
- Department of Development and Regeneration and Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | | | - Fabio Mosca
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enno D Wildschut
- Intensive Care and Department of Pediatric Surgery Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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Thibault C, Collier H, Naim MY, Heichel J, Schwartz E, Zuppa AF. Patterns of Medication Exposure in Children on Extracorporeal Membrane Oxygenation: A Step in Prioritizing Future Pharmacologic Studies. Crit Care Explor 2019; 1:e0045. [PMID: 32166287 PMCID: PMC7063935 DOI: 10.1097/cce.0000000000000045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To identify medications administered to pediatric patients on extracorporeal membrane oxygenation and to review the available pharmacokinetics and pharmacodynamics literature for the most commonly administered medications. DESIGN Retrospective single-center study. SETTING ICUs at Children's Hospital of Philadelphia. PATIENTS Pediatric patients supported by extracorporeal membrane oxygenation between October 1, 2014, and September 30, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Drug exposure was described according to age group (< 1 mo, 1 mo to < 2 yr, 2 to < 12 yr, and > 12 yr) and ICU (cardiac, neonatal, pediatric). The association of drug exposure with patient's characteristics was examined using one-way analysis of variance for categorical variables and linear regression for continuous variables. All pharmacokinetics and pharmacodynamics literature for the 50 most commonly administered medications on extracorporeal membrane oxygenation was reviewed, with inclusion of studies that reported dosing regimens in conjunction with pharmacokinetics or pharmacodynamics data. A total of 179 different medications were administered to 254 children. Cumulative drug exposure increased with the duration of extracorporeal membrane oxygenation from a median (interquartile) of 10 drugs (6-14) at 1 week to 31 drugs (21-45) at 5 weeks following cannulation. There were significant differences in total drug exposure between age groups and ICUs. With exclusion of in vitro studies, published literature was available to support the use of 40% (20/50) of the most commonly administered medications. Dosing guidance was available for 20% (10/50) of medications and was primarily based on simulations and retrospective studies focusing on neonates and infants. CONCLUSIONS This study highlights specific needs for future pharmacokinetics and pharmacodynamics studies. Dosing guidelines are essential to optimize the care of critically ill children supported by extracorporeal membrane oxygenation.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hailey Collier
- Department of Pharmacy Services, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jenna Heichel
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Emily Schwartz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
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Abdul-Aziz MH, Shekar K, Roberts JA. Antimicrobial therapy during ECMO - customised dosing with therapeutic drug monitoring: The way to go? Anaesth Crit Care Pain Med 2019; 38:451-453. [PMID: 31323318 DOI: 10.1016/j.accpm.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Australia; Critical Care Research Group, Centre of Research Excellence for Advanced Cardiorespiratory Therapies Improving Organ Support (ACTIONS), The University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, University of Queensland Centre for Clinical Research (UQCCR), QLD, Australia.
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26
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Liu TT, Pang HM, Jing L, Wei WX, Qin XL, Guo Q, Lu H, Cheng DH, Jiang WZ. A population pharmacokinetic model of vancomycin for dose individualization based on serum cystatin C as a marker of renal function. ACTA ACUST UNITED AC 2019; 71:945-955. [PMID: 30873627 DOI: 10.1111/jphp.13071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/19/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study aimed to establish a vancomycin population pharmacokinetics (PPK) model based on serum cystatin C and to optimize dosing for achieving targeted steady-state trough concentrations (Css ) of 10-15 and 15-20 mg/l. METHODS Patients aged ≥18 years were prospectively enrolled. A vancomycin PPK model was built with glomerular filtration rate (GFR) as a renal covariate estimated by cystatin C. A new group of patients were used for external evaluation. PPK analysis and Monte Carlo simulations were performed using nonlinear mixed effect modelling programme. KEY FINDINGS Two hundreds of patients with 514 samples were included. The final model was CL (L/h) = (5.07 × (GFR/105.5)0.524 × (AGE/48.5)-0.309 × (WT/60)0.491 ); V (l) = 46.3. Internal and external evaluations demonstrated good stability and predictability. The average probability of target attainment (PTA) of optimal dosing regimens for targeted Css achieving 10-15 and 15-20 mg/l were 51.2% and 40.6%, respectively. An average PTA ≥71% for targeted concentration of 10-20 mg/l was obtained. CONCLUSIONS A vancomycin PPK model with cystatin C as the renal marker has good stability and predictability. The new proposed dosing regimens were predicted to achieve a good PTA.
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Affiliation(s)
- Tao-Tao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hui-Mei Pang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Li Jing
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wen-Xing Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao-Ling Qin
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qing Guo
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hua Lu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dao-Hai Cheng
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wei-Zhe Jiang
- Department of Pharmacology, Guangxi Medical University, Nanning, Guangxi, China
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27
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Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Overcoming barriers to optimal drug dosing during ECMO in critically ill adult patients. Expert Opin Drug Metab Toxicol 2019; 15:103-112. [PMID: 30582435 DOI: 10.1080/17425255.2019.1563596] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION One major challenge to achieving optimal patient outcome in extracorporeal membrane oxygenation (ECMO) is the development of effective dosing strategies in this critically ill patient population. Suboptimal drug dosing impacts on patient outcome as patients on ECMO often require reversal of the underlying pathology with effective pharmacotherapy in order to be liberated of the life-support device. Areas covered: This article provides a concise review of the effective use of antibiotics, analgesics, and sedative by characterizing the specific changes in PK secondary to the introduction of the ECMO support. We also discuss the barriers to achieving optimal pharmacotherapy in patients on ECMO and also the current and potential research that can be undertaken to address these clinical challenges. Expert opinion: Decreased bioavailability due to sequestration of drugs in the ECMO circuit and ECMO induced PK alterations are both significant barriers to optimal drug dosing. Evidence-based drug choices may minimize sequestration in the circuit and would enable safety and efficacy to be maintained. More work to characterize ECMO related pharmacodynamic alterations such as effects of ECMO on hepatic cytochrome system are still needed. Novel techniques to increase target site concentrations should also be explored.
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Affiliation(s)
- Vesa Cheng
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia
| | - Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,b School of Pharmacy , International Islamic University Malaysia , Kuantan , Malaysia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,d Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Australia.,e Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Kiran Shekar
- f Adult Intensive Care Services , The Prince Charles Hospital , Chermside , Australia.,g Critical Care Research Group , Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS) and the University of Queensland , Brisbane , Australia.,h Faculty of Health Sciences and Medicine , Bond University , Gold Coast , Australia
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28
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Abstract
OBJECTIVES Describe the pharmacokinetics of vancomycin in pediatric patients undergoing extracorporeal membrane oxygenation and provide dosing recommendations to attain an area under the curve for 24 hours greater than 400 in this population. DESIGN Retrospective, population pharmacokinetic analysis. SETTING PICU of a large tertiary care children's hospital. INTERVENTIONS Population pharmacokinetic analysis and simulation were performed with NONMEM v7.3 (Icon, PLC, Dublin, Ireland). PATIENTS Patients less than 19 years old who received IV vancomycin and had serum vancomycin concentration monitoring while undergoing extracorporeal membrane oxygenation from January 1, 2011, to June 30, 2017. MEASUREMENTS AND MAIN RESULTS A total of 93 patients met study criteria (male 51%, median age 0.64 yr [interquartile range 0.07-6.7 yr]). Mean estimated creatinine clearance was 65 ± 47 mL/min/1.73 m. Patients received 1,116 vancomycin doses (14.6 ± 1.9 mg/kg/dose) and had 433 vancomycin serum concentrations (13.6 ± 6.9 mg/L) at 13.2 ± 10.7 hours after a dose. A two-compartment pharmacokinetic model with allometrically scaled weight on clearance (0.75) and volumes of distribution (1) was developed. Serum creatinine, postmenstrual age were significant covariates for clearance, patient age for central volume of distribution, and albumin for peripheral volume of distribution. Simulation identified a doses of 25-30 mg/kg/dose every 12-24 hours as having the highest percentage of patients with an area under the curve for 24 hours greater than 400 with the highest percentage trough concentrations in the less than 15 mg/L range. CONCLUSIONS A vancomycin dose of 25-30 mg/kg/dose every 12-24 hours with serum concentration monitoring is a reasonable empiric dosing strategy to obtain an area under the curve for 24 hours greater than 400 in pediatric extracorporeal membrane oxygenation patients.
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29
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Tukacs M. Pharmacokinetics and Extracorporeal Membrane Oxygenation in Adults: A Literature Review. AACN Adv Crit Care 2018; 29:246-258. [DOI: 10.4037/aacnacc2018439] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation is a rapidly emerging treatment for respiratory or cardiac failure and is used as a bridge to recovery, transplant, or destination therapy. Adult patients receiving extracorporeal membrane oxygenation also receive significant amounts of pharmacotherapy. Although the body of literature on extra-corporeal membrane oxygenation in general is extensive, only a few publications focus on pharmacokinetic changes related to extracorporeal membrane oxygenation in adults. Understanding pharmacokinetics in adult patients receiving extracorporeal membrane oxygenation is important to correctly select and dose medications in this patient population. This article reviews published studies of the effects of extracorporeal membrane oxygenation on pharmacokinetics in adults.
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Affiliation(s)
- Monika Tukacs
- Monika Tukacs is Clinical Nurse III, Cardiothoracic Intensive Care Unit, Columbia University Irving Medical Center and New York-Presbyterian Hospital; and Academic Research Fellow at the Columbia University School of Nursing, 177 Fort Washington Ave, New York, NY 10032
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30
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Monteiro JF, Hahn SR, Gonçalves J, Fresco P. Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations. Pharmacol Res Perspect 2018; 6:e00420. [PMID: 30156005 PMCID: PMC6113434 DOI: 10.1002/prp2.420] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Vancomycin is a fundamental antibiotic in the management of severe Gram-positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.
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Affiliation(s)
- Joaquim F. Monteiro
- Faculdade de Medicina da Universidade do Porto (FMUP)PortoPortugal
- Instituto de Investigação e Formação Avançadas em Ciências e Tecnologias da Saúde (IINFACTS)Instituto Universitário de Ciências da Saúde (IUCS)GandraPortugal
| | - Siomara R. Hahn
- Instituto de Ciências BiológicasCurso de FarmáciaUniversidade de Passo Fundo (UPF)Passo FundoBrasil
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
| | - Jorge Gonçalves
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
| | - Paula Fresco
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
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31
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Prospective evaluation of vancomycin pharmacokinetics in a heterogeneous critically ill population. Diagn Microbiol Infect Dis 2018; 92:346-351. [PMID: 30025969 DOI: 10.1016/j.diagmicrobio.2018.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 05/21/2018] [Accepted: 06/21/2018] [Indexed: 11/21/2022]
Abstract
Rich pharmacokinetic data on vancomycin in critically ill patients are lacking. The purpose of this study was to evaluate the pharmacokinetics of vancomycin in this population using rich pharmacokinetic sampling. Nineteen critically ill patients received individualized vancomycin doses by intermittent infusion to achieve target trough concentrations (15-20 mg/L). Blood samples were collected following the third or later dose of vancomycin. Serial blood samples were collected at 30 min following initiation of the vancomycin infusion; at the end of the infusion; serially at 60, 120, 300, and 480 min after the infusion finished; and immediately prior to the next dose. Vancomycin concentration-time profiles at steady state were fit to a noncompartmental model to determine the pharmacokinetic parameters. Vancomycin trough concentration was correlated to AUC0-24 (r = 0.83, P < 0.001). Total body weight was a predictor of volume of distribution (r = 0.43, P = 0.03). Age, serum creatinine, and creatinine clearance (CrCl) were found to be predictors for vancomycin clearance (r = -0.67, -0.52, and, 0.72, respectively). CrCl was the best predictor of vancomycin systemic clearance, and addition of other variables to a multivariate model failed to improve model fit. Vancomycin trough concentration may not be an adequate surrogate of AUC0-24. Additional research is needed to determine dosing strategies to optimize AUC0-24 while limiting toxicity.
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32
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Therapeutic drug monitoring of vancomycin in a patient on extracorporeal membrane oxygenation therapy in intensive care unit. Eur J Clin Pharmacol 2018; 74:1093-1094. [DOI: 10.1007/s00228-018-2473-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/01/2018] [Indexed: 10/17/2022]
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33
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Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Optimising drug dosing in patients receiving extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:S629-S641. [PMID: 29732181 DOI: 10.21037/jtd.2017.09.154] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Optimal pharmacological management during extracorporeal membrane oxygenation (ECMO) involves more than administering drugs to reverse underlying disease. ECMO is a complex therapy that should be administered in a goal-directed manner to achieve therapeutic endpoints that allow reversal of disease and ECMO wean, minimisation of complications (treatment of complications when they do occur), early interruption of sedation and rehabilitation, maximising patient comfort and minimising risks of delirium. ECMO can alter both the pharmacokinetics (PK) and pharmacodynamics (PD) of administered drugs and our understanding of these alterations is still evolving. Based on available data it appears that modern ECMO circuitry probably has a less significant impact on PK when compared with critical illness itself. However, these findings need further confirmation in clinical population PK studies and such studies are underway. The altered PD associated with ECMO is less understood and more research is indicated. Until robust dosing guidelines become available, clinicians will have to rely on the principles of drug dosing in critically ill and known PK alterations induced by ECMO itself. This article summarises the PK alterations and makes preliminary recommendations on possible dosing approaches.
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Affiliation(s)
- Vesa Cheng
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,School of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Jason A Roberts
- Faculty of Medicine, The University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Chermside, Australia.,Critical Care Research Group, Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS) and the University of Queensland, Brisbane, Australia
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34
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Abstract
The need for extracorporeal membrane oxygenation (ECMO) therapy is a marker of disease severity for which multiple medications are required. The therapy causes physiologic changes that impact drug pharmacokinetics. These changes can lead to exposure-driven decreases in efficacy or increased incidence of side effects. The pharmacokinetic changes are drug specific and largely undefined for most drugs. We review available drug dosing data and provide guidance for use in the ECMO patient population.
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35
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Hahn J, Choi JH, Chang MJ. Pharmacokinetic changes of antibiotic, antiviral, antituberculosis and antifungal agents during extracorporeal membrane oxygenation in critically ill adult patients. J Clin Pharm Ther 2017; 42:661-671. [PMID: 28948652 DOI: 10.1111/jcpt.12636] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 09/07/2017] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is a life-saving system used for critically ill patients with cardiac and/or respiratory failure. The pharmacokinetics (PK) of drugs can change in patients undergoing ECMO, which can result in therapeutic failure or drug toxicity requiring further management of drug complications. In this review, we discussed changes in the PK of antibiotic, antiviral, antituberculosis and antifungal agents administered to adult patients on ECMO. These drugs are crucial for managing infections, which commonly occur during ECMO. METHODS A literature search was conducted using the PubMed and EMBASE databases with the following keywords: "extracorporeal membrane oxygenation OR extracorporeal membrane oxygenations OR ECMO" and "PK OR pharmacokinetics OR pharmacokinetic*" and "anti infective* OR antibiotic* OR antiviral* OR antituberculosis OR antifungal*." RESULTS AND DISCUSSION Generally, the volume of distribution (Vd) increases and drug clearance (CL) and elimination decrease during ECMO. Highly significant changes in drug PK can occur by interactions with the ECMO device itself, drug characteristics, pathological changes and patient characteristics. This may affect the blood concentrations of drugs, which influence the success of therapy. The PK of vancomycin, piperacillin-tazobactam, meropenem, azithromycin, amikacin and caspofungin did not change significantly in adult patients receiving ECMO. However, there were significant changes in the PK of imipenem, oseltamivir, rifampicin and voriconazole. The trough concentrations of imipenem were highly variable; oseltamivir had a decreased CL and increased Vd, and rifampicin concentrations were below therapeutic levels, even when a higher-than-standard dose was used in patients treated with ECMO. Additionally, voriconazole exhibited high mean peak concentrations during ECMO. WHAT IS NEW AND CONCLUSION The impact of ECMO on PK varies among drugs in adult patients, and there is no consistent correlation between the effects observed in adult and infant studies. This review suggested that doses of imipenem, oseltamivir, rifampicin and voriconazole should be adjusted and therapeutic drug monitoring is needed when ECMO is used in adult patients. In the future, large PK trials in adults on ECMO are needed to provide optimal dosing guidelines. A PK/PD modelling approach will be useful for determining the precise impact of ECMO and other factors that contribute to PK changes for each drug. Finally, it is important to develop dosing guidelines based on PK/PD modelling studies that can be used in clinical practice.
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Affiliation(s)
- J Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea
| | - J H Choi
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea
| | - M J Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Korea.,Department of Pharmaceutical Medicine and Regulatory Science, College of Medicine and Pharmacy, Yonsei University, Incheon, Korea
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36
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Biffi S, Di Bella S, Scaravilli V, Peri AM, Grasselli G, Alagna L, Pesenti A, Gori A. Infections during extracorporeal membrane oxygenation: epidemiology, risk factors, pathogenesis and prevention. Int J Antimicrob Agents 2017; 50:9-16. [DOI: 10.1016/j.ijantimicag.2017.02.025] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 11/27/2022]
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37
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Wijesekara PNK, Kumbukgolla WW, Jayaweera JAAS, Rawat D. Review on Usage of Vancomycin in Livestock and Humans: Maintaining Its Efficacy, Prevention of Resistance and Alternative Therapy. Vet Sci 2017; 4:vetsci4010006. [PMID: 29056665 PMCID: PMC5606620 DOI: 10.3390/vetsci4010006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/05/2017] [Accepted: 01/22/2017] [Indexed: 12/27/2022] Open
Abstract
Vancomycin is one of the “last-line” classes of antibiotics used in the treatment of life-threatening infections caused by Gram-positive bacteria. Even though vancomycin was discovered in the 1950s, it was widely used after the 1980s for the treatment of infections caused by methicillin-resistant Staphylococci, as the prevalence of these strains were increased. However, it is currently evident that vancomycin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci have developed for various reasons, including the use of avaparcin—an analog of vancomycin—as a feed additive in livestock. Therefore, prophylactic and empiric use of antibiotics and their analogues need to be minimized. Herein we discuss the rational use of vancomycin in treating humans, horses, farm animals, and pet animals such as dogs, cats, and rabbits. In present day context, more attention should be paid to the prevention of the emergence of resistance to antibiotics in order to maintain their efficacy. In order to prevent emergence of resistance, proper guidance for the responsible use of antimicrobials is indispensable. Therefore, almost all stakeholders who use antibiotics should have an in-depth understanding of the antibiotic that they use. As such, it is imperative to be aware of the important aspects of vancomycin. In the present review, efforts have been made to discuss the pharmacokinetics and pharmacodynamics, indications, emergence of resistance, control of resistance, adverse effects, and alternative therapy for vancomycin.
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Affiliation(s)
| | - Wikum Widuranga Kumbukgolla
- Department of Biochemistry, Faculty of Medicine and Allied Sciences, Rajarata University Mihintale, Mihintale 50008, Sri Lanka.
| | | | - Diwan Rawat
- Department of Chemistry, University of Delhi, Delhi 110007, India.
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38
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Moore JN, Healy JR, Thoma BN, Peahota MM, Ahamadi M, Schmidt L, Cavarocchi NC, Kraft WK. A Population Pharmacokinetic Model for Vancomycin in Adult Patients Receiving Extracorporeal Membrane Oxygenation Therapy. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2016; 5:495-502. [PMID: 27639260 PMCID: PMC5036424 DOI: 10.1002/psp4.12112] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/20/2022]
Abstract
The literature on the pharmacokinetics of vancomycin in patients undergoing extracorporeal membrane oxygenation (ECMO) therapy is sparse. A population pharmacokinetic (PK) model for vancomycin in ECMO patients was developed using a nonlinear mixed effects modeling on the concentration–time profiles of 14 ECMO patients who received intravenous vancomycin. Model selection was based on log‐likelihood criterion, goodness of fit plots, and scientific plausibility. Identification of covariates was done using a full covariate model approach. The pharmacokinetics of vancomycin was adequately described with a two‐compartment model. Parameters included clearance of 2.83 L/hr, limited central volume of distribution 24.2 L, and low residual variability 0.67%. Findings from the analysis suggest that standard dosing recommendations for vancomycin in non‐ECMO patients are adequate to achieve therapeutic trough concentrations in ECMO patients. This further shows that ECMO minimally affects the PK of vancomycin in adults including in higher‐weight patients.
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Affiliation(s)
- J N Moore
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - J R Healy
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - B N Thoma
- Department of Pharmacy, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M M Peahota
- Department of Pharmacy, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - M Ahamadi
- Quantitative Pharmacology and Pharmacometrics, Pharmacokinetics, Pharmacodynamics & Drug Metabolism, Merck Research Laboratories, Merck & Co., Inc., Upper Gwynedd, Pennsylvania, USA
| | - L Schmidt
- Department of Pharmacy, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - N C Cavarocchi
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - W K Kraft
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pharmacokinetics and Dosing of Anti-infective Drugs in Patients on Extracorporeal Membrane Oxygenation: A Review of the Current Literature. Clin Ther 2016; 38:1976-94. [PMID: 27553752 DOI: 10.1016/j.clinthera.2016.07.169] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/23/2016] [Accepted: 07/27/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary bypass device that is used to temporarily support the most critically ill of patients with respiratory and/or cardiac failure. Infection and its sequelae may be an indication for ECMO or infections may be acquired while on ECMO and are associated with a mortality >50%. Effective therapy requires optimal dosing. However, optimal dosing can be different in patients on ECMO because the ECMO circuit can alter drug pharmacokinetics. This review assessed the current literature for pharmacokinetic data and subsequent dosing recommendations for anti-infective drugs in patients on ECMO. METHODS We searched the PubMed and Embase databases (1965 to February 2016) and included case reports, case series, or studies that provided pharmacokinetic data for anti-infective drugs including antibiotics, antifungals, and antivirals being used to treat patients of all age groups on ECMO. Pharmacokinetic parameters and dosing recommendations based on these data are presented. FINDINGS The majority of data on this topic comes from neonatal studies of antibiotics from the 1980s and 1990s. These studies generally demonstrate a larger volume of distribution due to ECMO and therefore higher doses are needed initially. More adult data are now emerging, but with a predominance of case reports and case series without comparison with critically ill controls. The available pharmacokinetic analyses do suggest that volume of distribution and clearance are unchanged in the adult population, and therefore dosing recommendations largely remain unchanged. There is a lack of data on children older than 1 year of age. The data support the importance of therapeutic drug monitoring when available in this population of patients. IMPLICATIONS This review found reasonably robust dosing recommendations for some drugs and scant or no data for other important anti-infectives. In order to better determine optimal dosing for patients on ECMO, a systematic approach is needed. Approaches that combine ex vivo ECMO experiments, animal studies, specialized pharmacokinetic modeling, and human clinical trials are being developed.
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