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Zhang X, Wang Y, Li S, Xie F, Yi H. Simulated drug disposition in critically ill patients to evaluate effective PK/PD targets for combating Pseudomonas aeruginosa resistance to meropenem. Antimicrob Agents Chemother 2024; 68:e0154123. [PMID: 38319075 PMCID: PMC10916391 DOI: 10.1128/aac.01541-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/13/2024] [Indexed: 02/07/2024] Open
Abstract
Bacterial infections, including those caused by Pseudomonas aeruginosa, often lead to sepsis, necessitating effective antibiotic treatment like carbapenems. The key pharmacokinetic/pharmacodynamic (PK/PD) index correlated to carbapenem efficacy is the fraction time of unbound plasma concentration above the minimum inhibitory concentration (MIC) of the pathogen (%fT > MIC). While multiple targets exist, determining the most effective one for critically ill patients remains a matter of debate. This study evaluated meropenem's bactericidal potency and its ability to combat drug resistance in Pseudomonas aeruginosa under three representative PK/PD targets: 40% fT > MIC, 100% fT > MIC, and 100% fT > 4× MIC. The hollow fiber infection model (HFIM) was constructed, validated, and subsequently inoculated with a substantial Pseudomonas aeruginosa load (1 × 108 CFU/mL). Different meropenem regimens were administered to achieve the specified PK/PD targets. At specified intervals, samples were collected from the HFIM system and subjected to centrifugation. The resulting supernatant was utilized to determine drug concentrations, while the precipitates were used to track changes in both total and drug-resistant bacterial populations over time by the spread plate method. The HFIM accurately reproduced meropenem's pharmacokinetics in critically ill patients. All three PK/PD target groups exhibited a rapid bactericidal response within 6 h of the initial treatment. However, the 40% fT > MIC and 100% fT > MIC groups subsequently showed bacterial resurgence and resistance, whereas the 100% fT > 4× MIC group displayed sustained bactericidal activity with no evidence of drug resistance. The HFIM system revealed that maintaining 100% fT > 4× MIC offers a desirable microbiological response for critically ill patients, demonstrating strong bactericidal capacity and effective prevention of drug resistance.
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Affiliation(s)
- Xiaonan Zhang
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Yan Wang
- Yueyang Inspection and Testing Center, Yueyang, China
| | - Sanwang Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, China
| | - Hanxi Yi
- Department of Pathology, School of Basic Medical Science, Central South University, Changsha, China
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2
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Shi AX, Qu Q, Zhuang HH, Teng XQ, Xu WX, Liu YP, Xiao YW, Qu J. Individualized antibiotic dosage regimens for patients with augmented renal clearance. Front Pharmacol 2023; 14:1137975. [PMID: 37564179 PMCID: PMC10410082 DOI: 10.3389/fphar.2023.1137975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023] Open
Abstract
Objectives: Augmented renal clearance (ARC) is a state of enhanced renal function commonly observed in 30%-65% of critically ill patients despite normal serum creatinine levels. Using unadjusted standard dosing regimens of renally eliminated drugs in ARC patients often leads to subtherapeutic concentrations, poor clinical outcomes, and the emergence of multidrug-resistant bacteria. We summarized pharmaceutical, pharmacokinetic, and pharmacodynamic research on the definition, underlying mechanisms, and risk factors of ARC to guide individualized dosing of antibiotics and various strategies for optimizing outcomes. Methods: We searched for articles between 2010 and 2022 in the MEDLINE database about ARC patients and antibiotics and further provided individualized antibiotic dosage regimens for patients with ARC. Results: 25 antibiotic dosage regimens for patients with ARC and various strategies for optimization of outcomes, such as extended infusion time, continuous infusion, increased dosage, and combination regimens, were summarized according to previous research. Conclusion: ARC patients, especially critically ill patients, need to make individualized adjustments to antibiotics, including dose, frequency, and method of administration. Further comprehensive research is required to determine ARC staging, expand the range of recommended antibiotics, and establish individualized dosing guidelines for ARC patients.
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Affiliation(s)
- A-Xi Shi
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
- Department of Pharmacy, The First Hospital of Lanzhou University, Lanzhou, China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China
| | - Hai-Hui Zhuang
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Xin-Qi Teng
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Wei-Xin Xu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Ping Liu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yi-Wen Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Institute of Clinical Pharmacy, Central South University, Changsha, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China
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3
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Joynt GM, Ling L, Wong WT, Lipman J. Therapeutic drug monitoring of carbapenem antibiotics in critically ill patients: an overview of principles, recommended dosing regimens, and clinical outcomes. Expert Rev Clin Pharmacol 2023; 16:703-714. [PMID: 36942827 DOI: 10.1080/17512433.2023.2194629] [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: 11/28/2022] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION The importance of antibiotic treatment for sepsis in critically ill septic patients is well established. Consistently achieving the dose of antibiotics required to optimally kill bacteria, minimize the development of resistance, and avoid toxicity is challenging. The increasing understanding of the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of antibiotics, and the effects of critical illness on key PK/PD parameters, is gradually re-shaping how antibiotics are dosed in critically ill patients. AREAS COVERED The PK/PD characteristics of commonly used carbapenem antibiotics, the principles of the application of therapeutic drug monitoring (TDM), and current as well as future methods of utilizing TDM to optimally devise dosing regimens will be reviewed. The limitations and evidence-base supporting the use of carbapenem TDM to improve outcomes in critically ill patients will be examined. EXPERT OPINION It is important to understand the principles of TDM in order to correctly inform dosing regimens. Although the concept of TDM is attractive, and the ability to utilize PK software to optimize dosing in the near future is expected to rapidly increase clinicians' ability to meet pre-defined PK/PD targets more accurately, current evidence provides only limited support for the use of TDM to guide carbapenem dosing in critically ill patients.
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Affiliation(s)
- Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Jeffrey Lipman
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesia Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Venuti F, Trunfio M, Martson AG, Lipani F, Audagnotto S, Di Perri G, Calcagno A. Extended and Continuous Infusion of Novel Protected β-Lactam Antibiotics: A Narrative Review. Drugs 2023:10.1007/s40265-023-01893-6. [PMID: 37314633 DOI: 10.1007/s40265-023-01893-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
Consolidated data from pharmacokinetic and pharmacodynamic studies support the administration of β-lactam antibiotics in prolonged infusion (i.e., extended or continuous) to optimize therapeutic efficacy by increasing the probability of attaining maximal bactericidal activity. This is the longest possible time during which the free drug concentrations are approximately four-fold the minimum inhibitory concentration between dosing intervals. In the context of antimicrobial stewardship strategies, achieving aggressive pharmacokinetic and pharmacodynamic targets is an important tool in the management of multi-drug resistant (MDR) bacterial infections and in the attainment of mutant preventing concentrations. However, prolonged infusion remains an unexploited resource. Novel β-lactam/β-lactamase inhibitor (βL/βLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-cilastatin-relebactam) have been released in recent years to face the emerging challenge of MDR Gram-negative bacteria. Pre-clinical and real-life evidence has confirmed the promising role of prolonged infusion of these molecules in specific settings and clinical populations. In this narrative review we have summarized available pharmacological and clinical data, future perspectives, and current limitations of prolonged infusion of the novel protected β-lactams, their application in hospital settings and in the context of outpatient parenteral antimicrobial therapy.
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Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy.
| | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Anne-Grete Martson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Filippo Lipani
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
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Li L, Sassen SDT, Ewoldt TMJ, Abdulla A, Hunfeld NGM, Muller AE, de Winter BCM, Endeman H, Koch BCP. Meropenem Model-Informed Precision Dosing in the Treatment of Critically Ill Patients: Can We Use It? Antibiotics (Basel) 2023; 12:antibiotics12020383. [PMID: 36830294 PMCID: PMC9951903 DOI: 10.3390/antibiotics12020383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
The number of pharmacokinetic (PK) models of meropenem is increasing. However, the daily role of these PK models in the clinic remains unclear, especially for critically ill patients. Therefore, we evaluated the published meropenem models on real-world ICU data to assess their suitability for use in clinical practice. All models were built in NONMEM and evaluated using prediction and simulation-based diagnostics for the ability to predict the subsequent meropenem concentrations without plasma concentrations (a priori), and with plasma concentrations (a posteriori), for use in therapeutic drug monitoring (TDM). Eighteen PopPK models were included for evaluation. The a priori fit of the models, without the use of plasma concentrations, was poor, with a prediction error (PE)% of the interquartile range (IQR) exceeding the ±30% threshold. The fit improved when one to three concentrations were used to improve model predictions for TDM purposes. Two models were in the acceptable range with an IQR PE% within ±30%, when two or three concentrations were used. The role of PK models to determine the starting dose of meropenem in this population seems limited. However, certain models might be suitable for TDM-based dose adjustment using two to three plasma concentrations.
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Affiliation(s)
- Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Sebastiaan D. T. Sassen
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Correspondence:
| | - Tim M. J. Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Nicole G. M. Hunfeld
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Anouk E. Muller
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Medical Microbiology, Haaglanden Medical Centre, 2597 AX The Hague, The Netherlands
| | - Brenda C. M. de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Birgit C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Center for Antimicrobial Treatment Optimization Rotterdam (CATOR), 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
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6
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Herald F, Burgos RM. Clinical Evaluation of Meropenem-Vaborbactam Combination for the Treatment of Urinary Tract Infection: Evidence to Date. Infect Drug Resist 2023; 16:555-568. [PMID: 36726388 PMCID: PMC9885963 DOI: 10.2147/idr.s187360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/16/2021] [Indexed: 01/27/2023] Open
Abstract
As antimicrobial resistance continues to grow, one of the biggest threats includes the members of the Enterobacterales order presenting with carbapenem resistance (CRE). Meropenem-vaborbactam, along with other beta-lactam/beta-lactamase agents, has been developed to help combat this growing concern and is currently approved to treat complicated urinary tract infections (cUTI), as well as acute pyelonephritis (AP), in the USA. Vaborbactam is a novel beta-lactamase inhibitor designed specifically to optimize and restore the activity of meropenem against resistant Enterobacterales. Vaborbactam inhibits a number of beta-lactamases, including in vitro activity against extended-spectrum beta-lactamases (ESBL) and the Klebsiella pneumoniae carbapenemase (KPC) group. KPC represents one of the most clinically relevant carbapenemase in the USA, accounting for the majority of carbapenemase-producing CRE. Meropenem-vaborbactam has been studied in the two Phase 3, noninferiority trials, TANGO I and TANGO II. TANGO I compared meropenem-vaborbactam against piperacillin-tazobactam in patients with cUTIs and was found to be noninferior for overall success and microbial eradication. TANGO II expanded to other disease states (bacteremia, hospital-acquired/ventilator-associated bacterial pneumonia [HAP/VAP], complicated intra-abdominal infection [cIAI], cUTI/AP) and was found to be noninferior against best available therapy (BAT) with respect to clinical cure at the end of treatment and the test of cure. Meropenem-vaborbactam maintained the established safety profile of meropenem alone, with headache as the most common adverse event in both phase 3 studies. Overall, clinical efficacy has been demonstrated and suggests the use of meropenem-vaborbactam for the treatment of cUTI is an option.
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Affiliation(s)
- Fischer Herald
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA,Correspondence: Fischer Herald 833 South Wood Street, Room 164, M/C 886, Chicago, IL, 60612, USATel +1 312 996 1654Fax +1 312 413 1797 Email
| | - Rodrigo M Burgos
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA,Department of Medicine, College of Medicine, University of Illinois Chicago, Chicago, IL, USA
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Haddad N, Carr M, Balian S, Lannin J, Kim Y, Toth C, Jarvis J. The Blood-Brain Barrier and Pharmacokinetic/Pharmacodynamic Optimization of Antibiotics for the Treatment of Central Nervous System Infections in Adults. Antibiotics (Basel) 2022; 11:antibiotics11121843. [PMID: 36551500 PMCID: PMC9774927 DOI: 10.3390/antibiotics11121843] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Bacterial central nervous system (CNS) infections are serious and carry significant morbidity and mortality. They encompass many syndromes, the most common being meningitis, which may occur spontaneously or as a consequence of neurosurgical procedures. Many classes of antimicrobials are in clinical use for therapy of CNS infections, some with established roles and indications, others with experimental reporting based on case studies or small series. This review delves into the specifics of the commonly utilized antibacterial agents, updating their therapeutic use in CNS infections from the pharmacokinetic and pharmacodynamic perspectives, with a focus on the optimization of dosing and route of administration that have been described to achieve good clinical outcomes. We also provide a concise synopsis regarding the most focused, clinically relevant information as pertains to each class and subclass of antimicrobial therapeutics. CNS infection morbidity and mortality remain high, and aggressive management is critical in ensuring favorable patient outcomes while averting toxicity and upholding patient safety.
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Affiliation(s)
- Nicholas Haddad
- College of Medicine, Central Michigan University (CMU), Mt Pleasant, MI 48859, USA
- Correspondence: ; Tel.: +1-(989)-746-7860
| | | | - Steve Balian
- CMU Medical Education Partners, Saginaw, MI 48602, USA
| | | | - Yuri Kim
- CMU Medical Education Partners, Saginaw, MI 48602, USA
| | - Courtney Toth
- Ascension St. Mary’s Hospital, Saginaw, MI 48601, USA
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8
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Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
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Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
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9
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Schneider F, Gessner A, El-Najjar N. Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update. Antibiotics (Basel) 2022; 11:antibiotics11020173. [PMID: 35203776 PMCID: PMC8868565 DOI: 10.3390/antibiotics11020173] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.
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10
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Gijsen M, Elkayal O, Annaert P, Van Daele R, Meersseman P, Debaveye Y, Wauters J, Dreesen E, Spriet I. Meropenem Target Attainment and Population Pharmacokinetics in Critically Ill Septic Patients with Preserved or Increased Renal Function. Infect Drug Resist 2022; 15:53-62. [PMID: 35035223 PMCID: PMC8754504 DOI: 10.2147/idr.s343264] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/14/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Critically ill patients with preserved or increased renal function have been shown to be at risk of underexposure to meropenem. Although many meropenem population pharmacokinetic (PK) models have been published, there is no large prospective population PK study with rich sampling focusing on patients most at risk of suboptimal pharmacokinetic/pharmacodynamic (PK/PD) target attainment. Therefore, the aim of the present study was to evaluate PK/PD target attainment and to perform a thorough covariate screening using population PK modelling of meropenem in septic patients with preserved or increased renal function. Patients and Methods A single-centre prospective observational PK study was performed in the intensive care unit (ICU) of the University Hospitals Leuven. Patients with severe sepsis or septic shock and treated with meropenem in the ICU were screened for inclusion. Patients were excluded if they received renal replacement therapy or had an estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology collaboration equation <70 mL/min/1.73m2 on the day of PK sampling. Successful PK/PD target attainment was defined as an unbound meropenem trough concentration above 2 mg/L or 8 mg/L. Population PK modelling was performed with NONMEM7.4. Results In total, 58 patients were included, contributing 345 plasma samples over 70 dosing intervals. The 2 mg/L and 8 mg/L targets were successfully attained in 46% and 11% of all dosing intervals, respectively. A two-compartment population PK model with linear elimination and interindividual variability on clearance best described meropenem PK. The estimated creatinine clearance according to the Cockcroft-Gault equation was the only covariate retained during population PK analysis. Conclusion This study provided detailed insight into meropenem PK in critically ill patients with preserved or increased renal function. We observed poor PK/PD target attainment, for which renal function was the only significant covariate. Trial Registration This study is registered at ClinicalTrials.gov (NCT03560557).
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Affiliation(s)
- Matthias Gijsen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,BioNotus, Niel, Belgium
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | | | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Joost Wauters
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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11
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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12
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Wang Y, Chen W, Huang Y, Wang G, Li Z, Yan G, Chen C, Lu G. Optimized Dosing Regimens of Meropenem in Septic Children Receiving Extracorporeal Life Support. Front Pharmacol 2021; 12:699191. [PMID: 34504424 PMCID: PMC8421735 DOI: 10.3389/fphar.2021.699191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
Objectives: To develop a population pharmacokinetic model of meropenem in children with sepsis receiving extracorporeal life support (ECLS) and optimize the dosage regimen based on investigating the probability of target attainment (PTA). Methods: The children with sepsis were prospectively enrolled in a pediatric intensive care unit from January 2018 to December 2019. The concentration-time data were fitted using nonlinear mixed effect model approach by NONMEM program. The stochastic simulation considering various scenarios based on proposed population pharmacokinetics model were conducted, and the PTAs were calculated to optimize the dosage regimens. Results: A total of 25 children with sepsis were enrolled, of whom13 received ECMO, 9 received CRRT, and 4 received ECMO combined with CRRT. 12 children received a two-step 3-h infusion and 13 children received 1-h infusion. Bodyweight and creatinine clearance had significant impacts on the PK parameters. ECMO intervention was not related to the PK properties. If 100%T > MIC was chosen as target, children receiving 40 mg/kg q8h over a 3 h-infusion only reached the PTA up to 77.4%. If bacteria with MIC 2 mg/L were to be treated with meropenem and the PTA target was 50%T > MIC, a dose of 40 mg/kg q8h for 1 h infusion would be necessary. Conclusions: The PK properties of meropenem in septic children receiving extracorporeal life support were best described. We recommended the opitimized dosing regimens for septic children receiving ECLS depending on the PTA of PK target 50%T > MIC and 100%T > MIC, for children with sepsis during ECLS with different body weight, estimated creatinine clearance (eCRCL) and MIC of bacteria.
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Affiliation(s)
- Yixue Wang
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Weiming Chen
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Guangfei Wang
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Gangfeng Yan
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Guoping Lu
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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13
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Pařízková RČ, Martínková J, Havel E, Šafránek P, Kaška M, Astapenko D, Bezouška J, Chládek J, Černý V. Impact of cumulative fluid balance on the pharmacokinetics of extended infusion meropenem in critically ill patients with sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:251. [PMID: 34274013 PMCID: PMC8285835 DOI: 10.1186/s13054-021-03680-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/06/2021] [Indexed: 12/29/2022]
Abstract
Background Meropenem dosing for septic critically patients is difficult due to pathophysiological changes associated with sepsis as well as supportive symptomatic therapies. A prospective single-center study assessed whether fluid retention alters meropenem pharmacokinetics and the achievement of the pharmacokinetic/pharmacodynamic (PK/PD) targets for efficacy. Methods Twenty-five septic ICU patients (19 m, 6f) aged 32–86 years with the mean APACHE II score of 20.2 (range 11–33), suffering mainly from perioperative intra-abdominal or respiratory infections and septic shock (n = 18), were investigated over three days after the start of extended 3-h i.v. infusions of meropenem q8h. Urinary creatinine clearance (CLcr) and cumulative fluid balance (CFB) were measured daily. Plasma meropenem was measured, and Bayesian estimates of PK parameters were calculated. Results Eleven patients (9 with peritonitis) were classified as fluid overload (FO) based on a positive day 1 CFB of more than 10% body weight. Compared to NoFO patients (n = 14, 11 with pneumonia), the FO patients had a lower meropenem clearance (CLme 8.5 ± 3.2 vs 11.5 ± 3.5 L/h), higher volume of distribution (V1 14.9 ± 3.5 vs 13.5 ± 4.1 L) and longer half-life (t1/2 1.4 ± 0.63 vs 0.92 ± 0.54 h) (p < 0.05). Over three days, the CFB of the FO patients decreased (11.7 ± 3.3 vs 6.7 ± 4.3 L, p < 0.05) and the PK parameters reached the values comparable with NoFO patients (CLme 12.4 ± 3.8 vs 11.5 ± 2.0 L/h, V1 13.7 ± 2.0 vs 14.0 ± 5.1 L, t1/2 0.81 ± 0.23 vs 0.87 ± 0.40 h). The CLcr and Cockroft–Gault CLcr were stable in time and comparable. The correlation with CLme was weak to moderate (CLcr, day 3 CGCLcr) or absent (day 1 and 2 CGCLcr). Dosing with 2 g meropenem q8h ensured adequate concentrations to treat infections with sensitive pathogens (MIC 2 mg/L). The proportion of pre-dose concentrations exceeding the MIC 8 mg/L and the fraction time with a target-exceeding concentration were higher in the FO group (day 1–3 f Cmin > MIC: 67 vs 27%, p < 0.001; day 1%f T > MIC: 79 ± 17 vs 58 ± 17, p < 0.05). Conclusions These findings emphasize the importance of TDM and a cautious approach to augmented maintenance dosing of meropenem to patients with FO infected with less susceptible pathogens, if guided by population covariate relationships between CLme and creatinine clearance. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03680-9.
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Affiliation(s)
- Renata Černá Pařízková
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jiřina Martínková
- Department of Surgery, University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Eduard Havel
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Petr Šafránek
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Milan Kaška
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - David Astapenko
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jan Bezouška
- Department of Surgery, University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jaroslav Chládek
- Department of Pharmacology, Charles University, Faculty of Medicine in Hradec Králové, Šimkova 870, 50003, Hradec Králové, Czech Republic.
| | - Vladimír Černý
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
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14
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Gijsen M, Dreesen E, Annaert P, Nicolai J, Debaveye Y, Wauters J, Spriet I. Meropenem Pharmacokinetics and Target Attainment in Critically Ill Patients Are Not Affected by Extracorporeal Membrane Oxygenation: A Matched Cohort Analysis. Microorganisms 2021; 9:microorganisms9061310. [PMID: 34208553 PMCID: PMC8234236 DOI: 10.3390/microorganisms9061310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022] Open
Abstract
Existing evidence is inconclusive whether meropenem dosing should be adjusted in patients receiving extracorporeal membrane oxygenation (ECMO). Therefore, the aim of this observational matched cohort study was to evaluate the effect of ECMO on pharmacokinetic (PK) variability and target attainment (TA) of meropenem. Patients admitted to the intensive care unit (ICU) simultaneously treated with meropenem and ECMO were eligible. Patients were matched 1:1, based on renal function and body weight, with non-ECMO ICU patients. Meropenem blood sampling was performed over one or two dosing intervals. Population PK modelling was performed using NONMEM7.5. TA was defined as free meropenem concentrations >2 or 8 mg/L (i.e., 1 or 4× minimal inhibitory concentration, respectively) throughout the whole dosing interval. In total, 25 patients were included, contributing 27 dosing intervals. The overall TA was 56% and 26% for the 2 mg/L and 8 mg/L target, respectively. Population PK modelling identified estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology equation and body weight, but not ECMO, as significant predictors. In conclusion, TA of meropenem was confirmed to be poor under standard dosing in critically ill patients but was not found to be influenced by ECMO. Future studies should focus on applying dose optimisation strategies for meropenem based on renal function, regardless of ECMO.
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Affiliation(s)
- Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (P.A.); (J.N.)
- BioNotus, 2845 Niel, Belgium
| | - Johan Nicolai
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (P.A.); (J.N.)
- Development Science, UCB Biopharma SRL, 1420 Braine-l’Alleud, Belgium
| | - Yves Debaveye
- Laboratory for Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium;
| | - Joost Wauters
- Medical Intensive Care Unit, UZ Leuven, 3000 Leuven, Belgium;
- Laboratory for Clinical Infectious and Inflammatory Diseases, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
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15
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Aldaz A, Idoate Grijalba AI, Ortega A, Aquerreta I, Monedero P. Effectiveness of Pharmacokinetic/Pharmacodynamic-Guided Meropenem Treatment in Critically Ill Patients: A Comparative Cohort Study. Ther Drug Monit 2021; 43:256-263. [PMID: 33149053 DOI: 10.1097/ftd.0000000000000826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The proper dosage of antibiotics is a key element in the effective treatment of infection, especially in critically ill patients. This study aimed to evaluate the efficacy of optimized meropenem regimens based on pharmacokinetic/pharmacodynamic criteria in patients admitted to the intensive care unit. METHODS This observational, naturalistic, retrospective, unicentric cohort study was performed between May 2011 and December 2017. The clinical and bacteriologic responses of 77 control intensive care unit patients receiving meropenem were compared with those of 77 propensity score-balanced patients who received meropenem dose adjusted by therapeutic drug monitoring. The primary end point of clinical response was a reduction at the end of treatment of at least 80% of the maximum procalcitonin (PCT) value recorded during the meropenem treatment. RESULTS The primary end point was met by 55 patients (71.4%) in the adjusted group compared with 41 (53.3%) patients in the control group (mean difference 18.1%, P = 0.02). Fifty-one patients (66.2%) in the adjusted group required a meropenem dose adjustment, being necessary in 46 of them (90.2%) to decrease the dose. The reduction of PCT was the greatest in the adjusted group compared with the unadjusted group (93% versus 85%, P = 0.004); a greater percentage of patients reached a PCT level < 0.5 ng/mL (63.6% versus 41.6%, P = 0.006), and there was a trend toward an improved bacteriologic response (relative risk = 1.27; 95% confidence interval: 0.92-1.56). There were no differences in early mortality or safety between groups. CONCLUSIONS Adjustment of meropenem therapy by monitoring is a useful strategy for improving meropenem effectiveness in the treatment of infection in critically ill patients, with no impact on safety.
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Affiliation(s)
- Azucena Aldaz
- Clínica Universidad de Navarra, Pharmacy Services; and
| | | | - Ana Ortega
- Clínica Universidad de Navarra, Pharmacy Services; and
| | | | - Pablo Monedero
- Clínica Universidad de Navarra, Anaesthesia and Intensive Care Department, Pamplona, Spain
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16
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Contejean A, Jaffrelot L, Benaboud S, Tréluyer JM, Grignano E, Willems L, Gauzit R, Bouscary D, Gana I, Boujaafar S, Kernéis S, Hirt D. A meropenem pharmacokinetics model in patients with haematological malignancies. J Antimicrob Chemother 2020; 75:2960-2968. [DOI: 10.1093/jac/dkaa275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Optimal dosing of antibiotics is critical in immunocompromised patients suspected to have an infection. Data on pharmacokinetics (PK) of meropenem in patients with haematological malignancies are scarce.
Objectives
To optimize dosing regimens, we aimed to develop a PK population model for meropenem in this population.
Methods
Patients aged ≥18 years, hospitalized in the haematology department of our 1500 bed university hospital for a malignant haematological disease and who had received at least one dose of meropenem were eligible. Meropenem was quantified by HPLC. PK were described using a non-linear mixed-effect model and external validation performed on a distinct database. Monte Carlo simulations estimated the PTA, depending on renal function, duration of infusion and MIC. Target for free trough concentration was set at >4× MIC.
Results
Overall, 88 patients (181 samples) were included, 66 patients (75%) were in aplasia and median Modification of Diet in Renal Disease (MDRD) CLCR was 117 mL/min/1.73 m2 (range: 35–359). Initial meropenem dosing regimen ranged from 1 g q8h to 2 g q8h over 30 to 60 min. A one-compartment model with first-order elimination adequately described the data. Only MDRD CLCR was found to be significantly associated with CL. Only continuous infusion achieved a PTA of 100% whatever the MIC and MDRD CLCR. Short duration of infusion (<60 min) failed to reach an acceptable PTA, except for bacteria with MIC < 0.25 mg/L in patients with MDRD CLCR below 90 mL/min/1.73 m2.
Conclusions
In patients with malignant haematological diseases, meropenem should be administered at high dose (6 g/day) and on continuous infusion to reach acceptable trough concentrations.
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Affiliation(s)
- A Contejean
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - L Jaffrelot
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Benaboud
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - J -M Tréluyer
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - E Grignano
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - L Willems
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
| | - R Gauzit
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Bouscary
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - I Gana
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Boujaafar
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Kernéis
- Université de Paris, Faculté de Médecine, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Hirt
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- INSERM, U1018, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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17
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Costenaro P, Minotti C, Cuppini E, Barbieri E, Giaquinto C, Donà D. Optimizing Antibiotic Treatment Strategies for Neonates and Children: Does Implementing Extended or Prolonged Infusion Provide any Advantage? Antibiotics (Basel) 2020; 9:antibiotics9060329. [PMID: 32560411 PMCID: PMC7344997 DOI: 10.3390/antibiotics9060329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Optimizing the use of antibiotics has become mandatory, particularly for the pediatric population where limited options are currently available. Selecting the dosing strategy may improve overall outcomes and limit the further development of antimicrobial resistance. Time-dependent antibiotics optimize their free concentration above the minimal inhibitory concentration (MIC) when administered by continuous infusion, however evidences from literature are still insufficient to recommend its widespread adoption. The aim of this review is to assess the state-of-the-art of intermittent versus prolonged intravenous administration of antibiotics in children and neonates with bacterial infections. We identified and reviewed relevant literature by searching PubMed, from 1 January 1 2000 to 15 April 2020. We included studies comparing intermittent versus prolonged/continuous antibiotic infusion, among the pediatric population. Nine relevant articles were selected, including RCTs, prospective and retrospective studies focusing on different infusion strategies of vancomycin, piperacillin/tazobactam, ceftazidime, cefepime and meropenem in the pediatric population. Prolonged and continuous infusions of antibiotics showed a greater probability of target attainment as compared to intermittent infusion regimens, with generally good clinical outcomes and safety profiles, however its impact in terms on efficacy, feasibility and toxicity is still open, with few studies led on children and adult data not being fully extendable.
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Affiliation(s)
- Paola Costenaro
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Chiara Minotti
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elena Cuppini
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Paediatric Network for Treatment of AIDS (Penta) Foundation, 35128 Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
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Menegucci TC, Fedrigo NH, Lodi FG, Albiero J, Nishiyama SAB, Mazucheli J, Carrara-Marroni FE, Voelkner NMF, Gong H, Sy SK, Tognim MCB. Pharmacodynamic Effects of Sulbactam/Meropenem/Polymyxin-B Combination Against Extremely Drug Resistant Acinetobacter baumannii Using Checkerboard Information. Microb Drug Resist 2019; 25:1266-1274. [DOI: 10.1089/mdr.2018.0283] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thatiany Cevallos Menegucci
- Laboratório de Microbiologia Médica, Departamento de Ciências Básicas da Saúde, Universidade Estadual de Maringá, Maringá, Brazil
| | - Nayara Helisandra Fedrigo
- Laboratório de Microbiologia Médica, Departamento de Ciências Básicas da Saúde, Universidade Estadual de Maringá, Maringá, Brazil
| | - Fernanda Gomes Lodi
- Laboratório de Microbiologia Médica, Departamento de Ciências Básicas da Saúde, Universidade Estadual de Maringá, Maringá, Brazil
| | - James Albiero
- Laboratório de Microbiologia Médica, Departamento de Ciências Básicas da Saúde, Universidade Estadual de Maringá, Maringá, Brazil
| | | | - Josmar Mazucheli
- Programa de Pós-Graduação em Bioestatística, Departamento de Estatística, Universidade Estadual de Maringá, Maringá, Brazil
| | | | | | - Hui Gong
- Department of Mathematics and Statistics, Valparaiso University, Valparaiso, Indiana
| | - Sherwin K.B. Sy
- Programa de Pós-Graduação em Bioestatística, Departamento de Estatística, Universidade Estadual de Maringá, Maringá, Brazil
| | - Maria Cristina Bronharo Tognim
- Laboratório de Microbiologia Médica, Departamento de Ciências Básicas da Saúde, Universidade Estadual de Maringá, Maringá, Brazil
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19
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Population pharmacokinetics of meropenem in critically ill children with different renal functions. Eur J Clin Pharmacol 2019; 76:61-71. [DOI: 10.1007/s00228-019-02761-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
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20
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Germovsek E, Lutsar I, Kipper K, Karlsson MO, Planche T, Chazallon C, Meyer L, Trafojer UMT, Metsvaht T, Fournier I, Sharland M, Heath P, Standing JF. Plasma and CSF pharmacokinetics of meropenem in neonates and young infants: results from the NeoMero studies. J Antimicrob Chemother 2019; 73:1908-1916. [PMID: 29684147 PMCID: PMC6005047 DOI: 10.1093/jac/dky128] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/12/2018] [Indexed: 01/18/2023] Open
Abstract
Background Sepsis and bacterial meningitis are major causes of mortality and morbidity in neonates and infants. Meropenem, a broad-spectrum antibiotic, is not licensed for use in neonates and infants below 3 months of age and sufficient information on its plasma and CSF disposition and dosing in neonates and infants is lacking. Objectives To determine plasma and CSF pharmacokinetics of meropenem in neonates and young infants and the link between pharmacokinetics and clinical outcomes in babies with late-onset sepsis (LOS). Methods Data were collected in two recently conducted studies, i.e. NeoMero-1 (neonatal LOS) and NeoMero-2 (neonatal meningitis). Optimally timed plasma samples (n = 401) from 167 patients and opportunistic CSF samples (n = 78) from 56 patients were analysed. Results A one-compartment model with allometric scaling and fixed maturation gave adequate fit to both plasma and CSF data; the CL and volume (standardized to 70 kg) were 16.7 (95% CI 14.7, 18.9) L/h and 38.6 (95% CI 34.9, 43.4) L, respectively. CSF penetration was low (8%), but rose with increasing CSF protein, with 40% penetration predicted at a protein concentration of 6 g/L. Increased infusion time improved plasma target attainment, but lowered CSF concentrations. For 24 patients with culture-proven Gram-negative LOS, pharmacodynamic target attainment was similar regardless of the test-of-cure visit outcome. Conclusions Simulations showed that longer infusions increase plasma PTA but decrease CSF PTA. CSF penetration is worsened with long infusions so increasing dose frequency to achieve therapeutic targets should be considered.
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Affiliation(s)
- Eva Germovsek
- Department of Infection, Inflammation and Rheumatology, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Karin Kipper
- Department of Microbiology, University of Tartu, Tartu, Estonia.,Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Tim Planche
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | | | | | - Ursula M T Trafojer
- Neonatal Intensive Care Unit, Department for Women and Child Health, University of Padua, Padua, Italy
| | | | | | - Mike Sharland
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | - Paul Heath
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | - Joseph F Standing
- Department of Infection, Inflammation and Rheumatology, Great Ormond Street Institute of Child Health, University College London, London, UK.,Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
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21
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Ohata Y, Tomita Y, Sunakawa K, Drusano GL, Tanigawara Y. Cerebrospinal pharmacokinetic and pharmacodynamic analysis of efficacy of meropenem in paediatric patients with bacterial meningitis. Int J Antimicrob Agents 2019; 54:292-300. [PMID: 31279154 DOI: 10.1016/j.ijantimicag.2019.06.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/23/2019] [Accepted: 06/28/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Meropenem is widely used for the treatment of paediatric patients with bacterial meningitis, but the pharmacodynamic (PD) basis for this has not been fully elucidated. OBJECTIVES A cerebrospinal pharmacokinetic (PK) and PD analysis was performed to identify the optimal dosage regimen for paediatric patients with inflamed central nervous system disease (bacterial men-ingitis). PATIENTS AND METHODS Paediatric data from three clinical studies were used to build a novel population PK model with a cerebrospinal fluid (CSF) compartment, assuming CSF clearance of 0.021 L/h from a physical-anatomical perspective. The bactericidal target attainment rates in CSF [50%T>MIC(CSF)], after various dosage regimens, were simulated on the basis of reported or observed minimum inhibitory concentration (MIC) distributions and a newly developed population PK model including CSF concentrations. The effects of increased dose and/or prolonged infusion on target attainment were investigated. RESULTS Clinical data from 154 patients {mean age 30.6 [standard deviation (SD) 34.4] months, mean body weight 12.4 (SD 7.6) kg} were used for the population PK analysis. The flat profile of the CSF concentration-time curve and attainment of 50%T>MIC(CSF) did not change markedly when the duration of infusion was increased, whereas attainment of 50%T>MIC(CSF) was improved by increasing the dose from 20 to 40 mg/kg q8h for penicillin-resistant Streptococcus pneumoniae and Pseudomonas aeruginosa. Thirty-six patients who achieved satisfactory clinical cure showed at least 75.3%T>MIC(CSF). CONCLUSIONS A high dose of meropenem (40 mg/kg q8h) is necessary to achieve clinical efficacy in paediatric patients with bacterial meningitis.
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Affiliation(s)
- Yuka Ohata
- Drug Development Division, Sumitomo Dainippon Pharma Co., Ltd, Osaka, Japan
| | - Yoshiko Tomita
- Drug Development Division, Sumitomo Dainippon Pharma Co., Ltd, Osaka, Japan
| | - Keisuke Sunakawa
- Kitasato University Research Organization for Infection Control Science, Tokyo, Japan
| | - George L Drusano
- Institute for Therapeutic Innovation, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yusuke Tanigawara
- Department of Clinical Pharmacokinetics and Pharmacodynamics, Keio University School of Medicine, Tokyo, Japan.
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22
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Pharmacodynamic Attainment of the Synergism of Meropenem and Fosfomycin Combination against Pseudomonas aeruginosa Producing Metallo-β-Lactamase. Antimicrob Agents Chemother 2019; 63:AAC.00126-19. [PMID: 30910903 DOI: 10.1128/aac.00126-19] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/11/2019] [Indexed: 01/21/2023] Open
Abstract
Fosfomycin combined with other antimicrobials has shown good efficacy against multidrug-resistant (MDR) bacteria in both in vitro and clinical studies; however, the activity of fosfomycin combined with other antimicrobials against metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa strains has not been tested. The objective of this study was to determine the synergism and optimal intravenous dosing regimens of fosfomycin with meropenem against MDR and MBL-producing P. aeruginosa strains. The MICs of both antimicrobials were determined by the checkerboard method and analyzed by two synergism tests with 19 clones of P. aeruginosa isolates, 10 of which were MBL producers. A pharmacodynamic (PD) analysis was performed for meropenem (administered at 1 g every 8 h [q8h], 1.5 g every 6 h [q6h], and 2 g q8h) and fosfomycin (administered at 4 g q8h, 4 g q6h, 6 g q8h, and 8 g q8h) regimens with a dose reduction for renal impairment by determining the probability of target attainment (PTA) for target PD indices of meropenem (the percentage of the time in a 24-h duration at which the free drug concentration remains above the MIC [fT >MIC], ≥40%) and fosfomycin (the ratio of the area under the free drug concentration-versus-time curve over 24 h and the MIC [fAUC/MIC], ≥40.8). The combination reduced the MIC50 and MIC90 by 8-fold. Seven (44%) isolates with MICs in the intermediate or resistant ranges became sensitive to meropenem. For the MBL-producing isolates, the combination resulted in 40% of isolates becoming sensitive to meropenem. The meropenem regimens reached a PTA of ≥90% (MIC = 4 μg/ml) in 6 (32%) isolates when they were used as monotherapy and 13 (68%) isolates when they were combined with fosfomycin. None of the fosfomycin monotherapy regimens reached the PTA of ≥90% (MIC = 16 μg/ml). When combined with meropenem, the fosfomycin regimens reached the PTA of ≥90% in 14 (74%) isolates. The increase in pharmacodynamic activities resulting from the synergistic action of meropenem with fosfomycin demonstrates the potential relevance of this combination to fight infections caused by MDR and MBL-producing P. aeruginosa strains.
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23
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Huang Q, Zhou Q, Ju T, Xu H, Wang W. Meropenem and Amikacin for Management of Post-Neurosurgical Infections from Acinetobacter baumannii. Surg Infect (Larchmt) 2019; 20:292-297. [PMID: 30785859 DOI: 10.1089/sur.2018.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Intra-cranial infection with Acinetobacter baumannii is a tough problem because of the presence of multi-resistance and poor drug penetration through the blood-brain barrier. Such intra-cranial infections can lead to serious complications and death. We retrospectively analyzed the culture results and clinical characteristics of patients with intra-cranial infections in our hospital and suggested intravenous (IV) meropenem and intra-thecal (IT) amikacin therapy may be effective in the management of A. baumannii infection. Case presentation: We reported four cases of post-neuro-surgical A. baumannii intra-cranial infection whose clinical futures were high fever and consciousness disturbance. Our patients were treated successfully with IV meropenem and IT amikacin. Conclusion: We presented our cases of pandrug-resistant A. baumannii intra-cranial infection that was managed successfully with a systemic provision of IV meropenem and IT amikacin. Therefore, these cases exemplify that systemic administration of IV meropenem and IT amikacin can be a good therapeutic option against A. baumannii intra-cranial infection when colistin is not available.
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Affiliation(s)
- Qiang Huang
- Department of Critical Care Medicine, Suizhou Hospital Affiliated to Hubei Medical College, Hubei, China
| | - Quan Zhou
- Department of Critical Care Medicine, Suizhou Hospital Affiliated to Hubei Medical College, Hubei, China
| | - Tao Ju
- Department of Critical Care Medicine, Suizhou Hospital Affiliated to Hubei Medical College, Hubei, China
| | - Huaqiang Xu
- Department of Critical Care Medicine, Suizhou Hospital Affiliated to Hubei Medical College, Hubei, China
| | - Wenguo Wang
- Department of Critical Care Medicine, Suizhou Hospital Affiliated to Hubei Medical College, Hubei, China
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24
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Burgos RM, Biagi MJ, Rodvold KA, Danziger LH. Pharmacokinetic evaluation of meropenem and vaborbactam for the treatment of urinary tract infection. Expert Opin Drug Metab Toxicol 2018; 14:1007-1021. [PMID: 30106599 DOI: 10.1080/17425255.2018.1511702] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Meropenem/vaborbactam (M/V) represents the first carbapenem and β-lactamase inhibitor combination approved for treatment of complicated urinary tract infections (cUTIs), including pyelonephritis. Vaborbactam is a novel boronic acid, β-lactamase inhibitor with a high affinity for serine β-lactamases, including Klebsiella pneumoniae carbapenemase (KPC). This combination, Vabomere™, was approved in August 2017 by the United States Food and Drug Administration for the treatment of cUTIs in patients 18 years or older, including pyelonephritis, caused by the following susceptible microorganisms: Escherichia coli, K. pneumoniae, and Enterobacter cloacae species complex. Areas covered: Relevant literature regarding microbiology, pharmacokinetics, pharmacodynamics, and clinical trials evaluating efficacy, safety, and tolerability will be discussed. Expert opinion: Current treatment options for KPC-producing infections such as aminoglycosides, polymyxins, fosfomycin, and tigecycline are associated with concerns regarding efficacy, toxicities, optimal dosing, and/or development of resistance. Additionally, resistance to the new combination product of ceftazidime/avibactam has also emerged. Current clinical evidence supporting the use of M/V for KPC-producing infections is limited to an open-label, randomized, phase III study in a small number of patients with serious infections due to carbapenem-resistant Enterobacteriaceae. Although M/V is not approved for KPC-producing infections, we believe that M/V will become a preferred agent for KPC-producing Enterobacteriaceae infections.
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Affiliation(s)
- Rodrigo M Burgos
- a College of Pharmacy , University of Illinois at Chicago , Chicago , IL , USA
| | - Mark J Biagi
- a College of Pharmacy , University of Illinois at Chicago , Chicago , IL , USA
| | - Keith A Rodvold
- a College of Pharmacy , University of Illinois at Chicago , Chicago , IL , USA.,b College of Medicine , University of Illinois at Chicago , Chicago , IL , USA
| | - Larry H Danziger
- a College of Pharmacy , University of Illinois at Chicago , Chicago , IL , USA.,b College of Medicine , University of Illinois at Chicago , Chicago , IL , USA
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25
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Bonomo RA, Burd EM, Conly J, Limbago BM, Poirel L, Segre JA, Westblade LF. Carbapenemase-Producing Organisms: A Global Scourge. Clin Infect Dis 2018; 66:1290-1297. [PMID: 29165604 PMCID: PMC5884739 DOI: 10.1093/cid/cix893] [Citation(s) in RCA: 361] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/13/2017] [Indexed: 12/21/2022] Open
Abstract
The dramatic increase in the prevalence and clinical impact of infections caused by bacteria producing carbapenemases is a global health concern. Carbapenemase production is especially problematic when encountered in members of the family Enterobacteriaceae. Due to their ability to readily spread and colonize patients in healthcare environments, preventing the transmission of these organisms is a major public health initiative and coordinated international effort are needed. Central to the treatment and control of carbapenemase-producing organisms (CPOs) are phenotypic (growth-/biochemical-dependent) and nucleic acid-based carbapenemase detection tests that identify carbapenemase activity directly or their associated molecular determinants. Importantly, bacterial isolates harboring carbapenemases are often resistant to multiple antibiotic classes, resulting in limited therapy options. Emerging agents, novel antibiotic combinations and treatment regimens offer promise for management of these infections. This review highlights our current understanding of CPOs with emphasis on their epidemiology, detection, treatment, and control.
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Affiliation(s)
- Robert A Bonomo
- Medical Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
- Departments of Medicine, Pharmacology, Molecular Biology, and Microbiology, Case Western Reserve University and Research Service, CWRU-VA Center for Antimicrobial Resistance and Epidemiology (CARES), Cleveland, Ohio
| | - Eileen M Burd
- Department of Pathology and Laboratory Medicine, Atlanta, Georgia
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - John Conly
- Departments of Medicine, Pathology and Laboratory Medicine, Microbiology, Calgary, Alberta, Canada
- Immunology and Infectious Diseases, Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
| | - Brandi M Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laurent Poirel
- Medical and Molecular Microbiology Unit, Department of Medicine, Faculty of Science, University of Fribourg, Switzerland
| | - Julie A Segre
- Microbial Genomics Section, Translational and Functional Genomics Branch, National Human Genome Research Institute, Bethesda, Maryland
| | - Lars F Westblade
- Department of Pathology and Laboratory Medicine, New York, New York
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
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26
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Kuti JL, Pettit RS, Neu N, Cies JJ, Lapin C, Muhlebach MS, Novak KJ, Nguyen ST, Saiman L, Nicolau DP. Meropenem time above the MIC exposure is predictive of response in cystic fibrosis children with acute pulmonary exacerbations. Diagn Microbiol Infect Dis 2018; 91:294-297. [PMID: 29661528 DOI: 10.1016/j.diagmicrobio.2018.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 01/04/2018] [Accepted: 01/24/2018] [Indexed: 11/28/2022]
Abstract
Meropenem exposures from 15 children (8-17 years old) with cystic fibrosis (CF) acute pulmonary exacerbation were analyzed to define the pharmacodynamic threshold required for a positive response. The primary endpoint was the relative increase in forced expiratory volume in 1 s (↑FEV1) between pre- and posttreatment. Meropenem pharmacodynamic indices (fT > MIC, fAUC/MIC, fCmin/MIC) over the first 24 h were estimated for each participant based on their individual parameter estimates and the isolated pathogen with the highest meropenem MIC. Pseudomonas aeruginosa was the most common pathogen (n = 11/15). The mean ± SD ↑FEV1 was 18.8% ± 11.3% posttreatment. The mean (range) fT > MIC exposure was 63% (0-100%). An Emax model determined a significant relationship between fT > MIC and ↑FEV1 (r2 = 0.8, P < 0.0004). 65% fT > MIC was a significant predictor of response; the median (25th, 75th %) ↑FEV1 was 28.5% (22.2%, 31.7%) in those patients who achieved above 65% fT > MIC and 7.8% (1.1%, 12.6%) in those at or below 65% fT > MIC (P = 0.001). This is the first study in CF children to link meropenem exposure with a positive response as measured by ↑FEV1. Larger studies are required to confirm this exposure threshold.
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Affiliation(s)
- Joseph L Kuti
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA.
| | - Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children, Indianapolis, IN, USA
| | - Natalie Neu
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Jeffrey J Cies
- Department of Pharmacy, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Craig Lapin
- Pediatric Pulmonology, Connecticut Children's Medical Center, Hartford, CT, USA
| | | | - Kimberly J Novak
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sean T Nguyen
- Department of Pharmacy, Children's Medical Center, Dallas, TX, USA
| | - Lisa Saiman
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - David P Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA
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27
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Clinical and Pathophysiological Overview of Acinetobacter Infections: a Century of Challenges. Clin Microbiol Rev 2017; 30:409-447. [PMID: 27974412 DOI: 10.1128/cmr.00058-16] [Citation(s) in RCA: 634] [Impact Index Per Article: 90.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Acinetobacter is a complex genus, and historically, there has been confusion about the existence of multiple species. The species commonly cause nosocomial infections, predominantly aspiration pneumonia and catheter-associated bacteremia, but can also cause soft tissue and urinary tract infections. Community-acquired infections by Acinetobacter spp. are increasingly reported. Transmission of Acinetobacter and subsequent disease is facilitated by the organism's environmental tenacity, resistance to desiccation, and evasion of host immunity. The virulence properties demonstrated by Acinetobacter spp. primarily stem from evasion of rapid clearance by the innate immune system, effectively enabling high bacterial density that triggers lipopolysaccharide (LPS)-Toll-like receptor 4 (TLR4)-mediated sepsis. Capsular polysaccharide is a critical virulence factor that enables immune evasion, while LPS triggers septic shock. However, the primary driver of clinical outcome is antibiotic resistance. Administration of initially effective therapy is key to improving survival, reducing 30-day mortality threefold. Regrettably, due to the high frequency of this organism having an extreme drug resistance (XDR) phenotype, early initiation of effective therapy is a major clinical challenge. Given its high rate of antibiotic resistance and abysmal outcomes (up to 70% mortality rate from infections caused by XDR strains in some case series), new preventative and therapeutic options for Acinetobacter spp. are desperately needed.
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28
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Wilby KJ, Nasr ZG, Elazzazy S, Lau TTY, Hamad A. A Review of Clinical Outcomes Associated with Two Meropenem Dosing Strategies. Drugs R D 2017; 17:73-78. [PMID: 28101836 PMCID: PMC5318341 DOI: 10.1007/s40268-017-0173-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Meropenem is a carbapenem antibiotic that exhibits time-dependent bactericidal activity, traditionally dosed intravenously at 1 g every 8 h. In order to maximize its pharmacodynamic activity and reduce costs, an alternative regimen employed by many institutions is 500 mg every 6 h. The objective of this review was to summarize and evaluate published literature comparing clinical outcomes associated with these two meropenem dosing regimens. The literature was searched up to October 2016 using the MEDLINE, EMBASE, and Google Scholar databases. Three retrospective cohort studies were identified that compared clinical outcomes in general infectious disease patients (two studies) and patients with febrile neutropenia (one study). All studies reported no difference in clinical outcomes (clinical success, time to defervescence, sign or symptom resolution, length of stay, mortality, need for other antibiotics, and seizure rates). One study reported reduced economic costs with the alternative dosing. Interpretation of findings was primarily limited by small sample sizes and generalizability. Based on the data reviewed, the alternative dosing regimen of meropenem 500 mg intravenously every 6 h could be considered a therapeutic option. Future studies are needed to confirm the findings of this review, especially in high-risk populations such as immunocompromised patients or those with severe infections.
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Affiliation(s)
- Kyle John Wilby
- College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar.
| | | | - Shereen Elazzazy
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Tim T Y Lau
- Pharmaceutical Sciences, Vancouver General Hospital, 899 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
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29
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Menegucci TC, Albiero J, Migliorini LB, Alves JLB, Viana GF, Mazucheli J, Carrara-Marroni FE, Cardoso CL, Tognim MCB. Strategies for the treatment of polymyxin B-resistant Acinetobacter baumannii infections. Int J Antimicrob Agents 2017; 47:380-5. [PMID: 27068675 DOI: 10.1016/j.ijantimicag.2016.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/12/2016] [Accepted: 02/20/2016] [Indexed: 01/21/2023]
Abstract
In this study, the activity of meropenem (MEM), fosfomycin (FOF) and polymyxin B (PMB), alone and in combination, was analysed. In addition, optimisation of the pharmacodynamic index of MEM and FOF against six isolates of OXA-23-producing Acinetobacter baumannii (including three resistant to PMB) that were not clonally related was assessed. Antimicrobial combinations were evaluated by chequerboard analysis and were considered synergistic when the fractional inhibitory concentration index (FICI) was ≤0.5. Pharmacodynamic analyses of the MEM and FOF dosing schemes were performed by Monte Carlo simulation. The target pharmacodynamic index (%ƒT>MIC) for MEM and FOF was ≥40% and ≥70%, respectively, and a probability of target attainment (PTA) ≥0.9 was considered adequate. Among the PMB-resistant isolates, combinations of PMB+MEM and PMB+FOF+MEM showed the highest synergistic activity (FICI ≤0.125); isolates that were previously PMB-resistant were included in the susceptible category using CLSI interpretive criteria. Pharmacodynamic evaluation found that for a FOF minimum inhibitory concentration (MIC) of ≤16μg/mL, treatment both by bolus dosing and prolonged infusion achieved adequate PTA, whilst for MIC=32μg/mL only infusion achieved adequate PTA. For a MEM MIC of 4μg/mL, only the bolus treatment scheme with 1.5g q6h and the infusion schemes with 1.0g q8h, 1.5g q6h and 2.0g q8h achieved PTA ≥0.9. Results of antimicrobial and pharmacodynamic analyses can assist in treating infections caused by multidrug-resistant A. baumannii. However, in vivo clinical studies are essential to evaluate the true role of these compounds, including intravenous antimicrobial FOF therapy.
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Affiliation(s)
| | - James Albiero
- Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil
| | | | - Janio Leal Borges Alves
- Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil
| | - Giselle Fukita Viana
- Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil
| | - Josmar Mazucheli
- Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil
| | | | - Celso Luiz Cardoso
- Universidade Estadual de Maringá, Avenida Colombo 5790, CEP 87020-900 Maringá, Paraná, Brazil
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30
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Lorente L, Lorenzo L, Martín MM, Jiménez A, Mora ML. Meropenem by Continuous Versus Intermittent Infusion in Ventilator-Associated Pneumonia due to Gram-Negative Bacilli. Ann Pharmacother 2016; 40:219-23. [PMID: 16449546 DOI: 10.1345/aph.1g467] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: It is known that β-lactam antibiotics exhibit time-dependent bactericidal activity. Several studies have found continuous infusion of meropenem more effective than intermittent infusion in maintaining constant serum concentrations in excess of the minimum inhibitory concentration. However, limited data exist on the clinical efficacy of meropenem administered by continuous infusion. Objective: To evaluate the clinical efficacy of continuous versus intermittent infusion of meropenem for the treatment of ventilator-associated pneumonia (VAP) due to gram-negative bacilli. Methods: A retrospective cohort study was conducted of patients with VAP caused by gram-negative bacilli who received initial empiric antibiotic therapy with meropenem. We analyzed 2 contemporary cohorts: one group received meropenem by continuous infusion (1 g over 360 min every 6 h), the other by intermittent infusion (1 g over 30 min every 6 h). The administration method was prescribed according to the physician's discretion. Patients received meropenem plus tobramycin for 14 days. Results: There were no significant differences between patient groups with regard to gender, age, APACHE-II at intensive care unit admission, diagnosis, microorganism responsible for VAP, or organ dysfunction severity at the time VAP was suspected. The group receiving medication by continuous infusion showed a greater clinical cure rate than the group treated with intermittent infusion (38 of 42, 90.47%, vs 28 of 47, 59.57%, respectively, with OR 6.44 [95% Cl 1.97 to 21.05; p < 0.001]). Conclusions: Meropenem administered by continuous infusion may have more clinical efficacy than intermittent infusion.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Tenerife, Spain.
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Population Pharmacokinetics and Dosing Regimen Optimization of Meropenem in Cerebrospinal Fluid and Plasma in Patients with Meningitis after Neurosurgery. Antimicrob Agents Chemother 2016; 60:6619-6625. [PMID: 27572392 PMCID: PMC5075067 DOI: 10.1128/aac.00997-16] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/13/2016] [Indexed: 11/22/2022] Open
Abstract
Meropenem is used to manage postneurosurgical meningitis, but its population pharmacokinetics (PPK) in plasma and cerebrospinal fluid (CSF) in this patient group are not well-known. Our aims were to (i) characterize meropenem PPK in plasma and CSF and (ii) recommend favorable dosing regimens in postneurosurgical meningitis patients. Eighty-two patients were enrolled to receive meropenem infusions of 2 g every 8 h (q8h), 1 g q8h, or 1 g q6h for at least 3 days. Serial blood and CSF samples were collected, and concentrations were determined and analyzed via population modeling. Probabilities of target attainment (PTA) were predicted via Monte Carlo simulations, using the target of unbound meropenem concentrations above the MICs for at least 40% of dosing intervals in plasma and at least of 50% or 100% of dosing intervals in CSF. A two-compartment model plus another CSF compartment best described the data. The central, intercentral/peripheral, and intercentral/CSF compartment clearances were 22.2 liters/h, 1.79 liters/h, and 0.01 liter/h, respectively. Distribution volumes of the central and peripheral compartments were 17.9 liters and 3.84 liters, respectively. The CSF compartment volume was fixed at 0.13 liter, with its clearance calculated by the observed drainage amount. The multiplier for the transfer from the central to the CSF compartment was 0.172. Simulation results show that the PTAs increase as infusion is prolonged and as the daily CSF drainage volume decreases. A 4-hour infusion of 2 g q8h with CSF drainage of less than 150 ml/day, which provides a PTA of >90% for MICs of ≤8 mg/liter in blood and of ≤0.5 mg/liter or 0.25 mg/liter in CSF, is recommended. (This study has been registered at ClinicalTrials.gov under identifier NCT02506686.)
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Pharmacodynamic Evaluation of the Potential Clinical Utility of Fosfomycin and Meropenem in Combination Therapy against KPC-2-Producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2016; 60:4128-39. [PMID: 27139468 DOI: 10.1128/aac.03099-15] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 04/22/2016] [Indexed: 11/20/2022] Open
Abstract
KPC-producing Klebsiella pneumoniae causes serious infections associated with high death rates worldwide. Combination therapy consisting of fosfomycin and a carbapenem is better than monotherapy to combat multidrug-resistant microorganisms, but no dosages for the combination have been defined. The MICs of meropenem and fosfomycin were evaluated against 18 clinical isolates of KPC-2-producing K. pneumoniae The activities of combination antimicrobials were also determined by the checkerboard method. The MIC50 and MIC90 of each agent alone and in combination were challenged against short (1.5-h) or prolonged (3-h) infusion regimens of meropenem (1 g every 8 h [q8h], 1.5 g q6h, 2 g q8h) and fosfomycin (4 g q8h, 6 g q6h, 8 g q8h) by Monte Carlo simulation to evaluate the time above the MIC of the free drug concentration as a percentage of the dosing interval (fT>MIC). The monotherapy MIC50s and MIC90s were 32 and 256 mg/liter for meropenem and 64 and 512 mg/liter for fosfomycin, respectively. Antimicrobial combination increased bacterial susceptibility to 1/4 the MIC50s and to 1/8 to 1/16 the MIC90s of monotherapy. The antimicrobial combination demonstrated a synergistic effect for at least two-thirds of the isolates. In combination therapy, fosfomycin regimens of 6 g q6h and 8 g q8h as a 3-h infusion against the MIC50 and MIC90 had better chances of achieving ≥90% probability of target attainment (PTA) of 70% fT>MIC. Meropenem regimens of 1.5 g q6h and 2 g q8h in prolonged infusion can achieve close to 90% PTA of 40% fT>MIC for MIC50 but not MIC90 The significant reduction in the MIC values and the achievement of appropriate PTA demonstrated that regimens containing fosfomycin with meropenem can be effective against KPC-2-producing K. pneumoniae.
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Tsala M, Vourli S, Kotsakis S, Daikos GL, Tzouvelekis L, Zerva L, Miriagou V, Meletiadis J. Pharmacokinetic-pharmacodynamic modelling of meropenem against VIM-producing Klebsiella pneumoniae isolates: clinical implications. J Med Microbiol 2015; 65:211-218. [PMID: 26697851 DOI: 10.1099/jmm.0.000214] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
VIM-producing Klebsiella pneumoniae isolates are usually associated with high MICs to carbapenems. Preclinical studies investigating the pharmacokinetic-pharmacodynamic (PK-PD) characteristics of carbapenems against these isolates are lacking. The in vitro antibacterial activity of meropenem against one WT and three VIM-producing K. pneumoniae clinical isolates (median MICs 0.031, 8, 16 and 128 mg l- 1) was studied in a dialysis-diffusion PK-PD model and verified in a thigh infection neutropenic animal model by testing selected strains and exposures. The in vitro PK-PD target associated with bactericidal activity was estimated and the target attainment for different dosing regimens was calculated with Monte Carlo analysis. The in vitro model was correlated with the in vivo data, with log10CFU/ml reduction of < 1 for the VIM-producing (MIC 16 mg l- 1) and >2 for the WT (MIC 0.031 mg l- 1) isolates, with %f T >MIC 25 and 100%, respectively. The in vitro bactericidal activity for all isolates was associated with 40 % f T>MIC and attained in >90% of cases with the standard 1 g q8 0.5 h infusion dosing regimen only for isolates with MICs up to 1 mg l- 1. For isolates with MICs of 2-8 mg l- 1, prolonged infusion regimens (4 h infusion q8 or 2 h infusion q4) of standard (1 g) and higher (2 g) doses or continuous infusion regimens (3-6 g) are required. For isolates with a MIC of 16 mg l- 1 the unconventional dosing regimen of 2 g as 2 h infusion q4 or 12 g continuous infusion will be required. Prolonged and continuous infusion regimens of meropenem may increase efficacy against VIM-producing K. pneumoniae isolates.
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Affiliation(s)
- Marilena Tsala
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Vourli
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Stathis Kotsakis
- Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece
| | - George L Daikos
- First Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Tzouvelekis
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Loukia Zerva
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vivi Miriagou
- Laboratory of Bacteriology, Hellenic Pasteur Institute, Athens, Greece
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.,Department of Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
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Pettit RS, Neu N, Cies JJ, Lapin C, Muhlebach MS, Novak KJ, Nguyen ST, Saiman L, Nicolau DP, Kuti JL. Population pharmacokinetics of meropenem administered as a prolonged infusion in children with cystic fibrosis. J Antimicrob Chemother 2015; 71:189-95. [PMID: 26416780 DOI: 10.1093/jac/dkv289] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/17/2015] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Meropenem is frequently used to treat pulmonary exacerbations in children with cystic fibrosis (CF) in the USA. Prolonged-infusion meropenem improves the time that free drug concentrations remain above the MIC (fT> MIC) in adults, but data in CF children are sparse. We describe the population pharmacokinetics, tolerability and treatment burden of prolonged-infusion meropenem in CF children. METHODS Thirty children aged 6-17 years with a pulmonary exacerbation received 40 mg/kg meropenem every 8 h; each dose was administered as a 3 h infusion. Pharmacokinetics were determined using population methods in Pmetrics. Monte Carlo simulation was employed to compare 0.5 with 3 h infusions to estimate the probability of pharmacodynamic target attainment (PTA) at 40% fT> MIC. NCT#01429259. RESULTS A two-compartment model fitted the data best with clearance and volume predicted by body weight. Clearance and volume of the central compartment were 0.41 ± 0.23 L/h/kg and 0.30 ± 0.17 L/kg, respectively. Half-life was 1.11 ± 0.38 h. At MICs of 1, 2 and 4 mg/L, PTAs for the 0.5 h infusion were 87.6%, 70.1% and 35.4%, respectively. The prolonged infusion increased PTAs to >99% for these MICs and achieved 82.8% at 8 mg/L. Of the 30 children, 18 (60%) completed treatment with prolonged infusion; 5 did so at home without any reported burden. Nine patients were changed to a 0.5 h infusion when discharged home. CONCLUSIONS In these CF children, meropenem clearance was greater compared with published values from non-CF children. Prolonged infusion provided an exposure benefit against pathogens with MICs ≥1 mg/L, was well tolerated and was feasible to administer in the hospital and home settings, the latter depending on perception and family schedule.
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Affiliation(s)
- Rebecca S Pettit
- Department of Pharmacy, Riley Hospital for Children, Indianapolis, IN, USA
| | - Natalie Neu
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Jeffrey J Cies
- Department of Pharmacy, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Craig Lapin
- Pediatric Pulmonology, Connecticut Children's Medical Center, Hartford, CT, USA
| | | | - Kimberly J Novak
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Sean T Nguyen
- Department of Pharmacy, Children's Medical Center, Dallas, TX, USA
| | - Lisa Saiman
- Department of Pediatrics, Division of Infectious Diseases, Columbia University Medical Center and New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - David P Nicolau
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research & Development, Hartford Hospital, Hartford, CT, USA
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Nichols KR, Knoderer CA, Jackson NG, Manaloor JJ, Christenson JC. Success With Extended-Infusion Meropenem After Recurrence of Baclofen Pump-Related Achromobacter Xylosoxidans Meningitis in an Adolescent. J Pharm Pract 2015; 28:430-3. [PMID: 26033796 DOI: 10.1177/0897190015585757] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 13-year-old female experienced a recurrence of baclofen pump-related central nervous system (CNS) infection caused by Achromobacter, despite absence of retained foreign material. Due to the failure of meropenem (120 mg/kg/d in divided doses every 8 hours and infused over 30 minutes) in the initial infection, the dose was infused over 4 hours during the recurrence. Meropenem is an antibiotic for which efficacy is time dependent, and 4-hour versus 30-minute infusions have been shown to prolong the time the concentration of the antibiotic exceeds the minimum inhibitory concentration (MIC) of the organism at the site of infection (T>MIC). Meropenem serum concentrations were obtained and indicated that T>MIC was at least 75% of the dosing interval. Our patient improved with no noted recurrences or adverse effects on the extended-infusion meropenem regimen. Utilization of extended-infusion beta-lactam dosing whenever possible in the treatment of serious infections caused by gram-negative organisms should be considered, as this dosing appears to be safe and improves the probability of achieving pharmacokinetic/pharmacodynamic goals.
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Affiliation(s)
- Kristen R Nichols
- Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA Department of Pharmacy, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chad A Knoderer
- Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA
| | - Nicholas G Jackson
- Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA Nicholas G. Jackson was a PharmD Candidate at Butler University at the time of writing this manuscript, he has since graduated
| | - John J Manaloor
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John C Christenson
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease, Indiana University School of Medicine, Indianapolis, IN, USA
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Yuan LG, Tang YZ, Zhang YX, Sun J, Luo XY, Zhu LX, Zhang Z, Wang R, Liu YH. Dosage assessment of valnemulin in pigs based on population pharmacokinetic and Monte Carlo simulation. J Vet Pharmacol Ther 2015; 38:400-9. [PMID: 25604162 DOI: 10.1111/jvp.12199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/21/2014] [Indexed: 11/27/2022]
Abstract
To estimate the valnemulin pharmacokinetic profile in a swine population and to assess a dosage regimen for increasing the likelihood of optimization. This study was, respectively, performed in 22 sows culled by p.o. administration and in 80 growing-finishing pigs by i.v. administration at a single dose of 10 mg/kg to develop a population pharmacokinetic model and Monte Carlo simulation. The relationships among the plasma concentration, dose, and time of valnemulin in pigs were illustrated as C(i,v) = X(0 )(8.4191 × 10(-4) × e(-0.2371t) + 1.2788 × 10(-5) × e(-0.0069t)) after i.v. and C(p.o) = X(0) (-8.4964 × 10(-4) × e(-0.5840t) + 8.4195 × e(-0.2371t) + 7.6869 × 10(-6) × e(-0.0069t)) after p.o. Monte Carlo simulation showed that T(>MIC) was more than 24 h when a single daily dosage at 13.5 mg/kg BW in pigs was administrated by p.o., and MIC was 0.031 mg/L. It was concluded that the current dosage regimen at 10-12 mg/kg BW led to valnemulin underexposure if the MIC was more than 0.031 mg/L and could increase the risk of treatment failure and/or drug resistance.
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Affiliation(s)
- L G Yuan
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Prevention and Control for Severe Clinical Animal Diseases, Guangzhou, Guangdong Province, China
| | - Y Z Tang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Prevention and Control for Severe Clinical Animal Diseases, Guangzhou, Guangdong Province, China
| | - Y X Zhang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China.,Guangdong Provincial Key Laboratory of Prevention and Control for Severe Clinical Animal Diseases, Guangzhou, Guangdong Province, China
| | - J Sun
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
| | - X Y Luo
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
| | - L X Zhu
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
| | - Z Zhang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
| | - R Wang
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
| | - Y H Liu
- College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong Province, China
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Comparison of the accuracy and precision of pharmacokinetic equations to predict free meropenem concentrations in critically ill patients. Antimicrob Agents Chemother 2014; 59:1411-7. [PMID: 25512414 DOI: 10.1128/aac.04001-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Population pharmacokinetic analyses can be applied to predict optimized dosages for individual patients. The aim of this study was to compare the prediction performance of the published population pharmacokinetic models for meropenem in critically ill patients. We coded the published population pharmacokinetic models with covariate relationships into dosing software to predict unbound meropenem concentrations measured in a separate cohort of critically ill patients. The agreements between the observed and predicted concentrations were evaluated with Bland-Altman plots. The absolute and relative bias and precision of the models were determined. The clinical implications of the results were evaluated according to whether dose adjustments were required from the predictions to achieve a meropenem concentration of >2 mg/liter throughout the dosing interval. A total of 157 free meropenem concentrations from 56 patients were analyzed. Eight published population pharmacokinetic models were compared. The models showed an absolute bias in predicting the unbound meropenem concentrations from a mean percent difference (95% confidence interval [CI]) of -108.5% (-119.9% to -97.3%) to 19.9% (7.3% to 32.7%), while absolute precision ranged from -249.1% (-263.4% to -234.8%) to 31.9% (17.6% to 46.2%) and -178.9% (-196.9% to -160.9%) to 175.0% (157.0% to 193.0%). A dose change was required in 44% to 64% of the concentration results. Seven of the eight equations evaluated underpredicted free meropenem concentrations. In conclusion, the overall accuracy of these models supports their inclusion in dosing software and application for individualizing meropenem doses in critically ill patients to increase the likelihood of achievement of optimal antibiotic exposures.
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Leite GMDL, Baeza LC, Ramos RT, Yamada SS, Magon TFDS, Kimura E, Svidzinski TIE. Lack of effect of cell-wall targeted antibacterials on biofilm formation and antifungal susceptibility of Candidaspecies. BRAZ J PHARM SCI 2014. [DOI: 10.1590/s1984-82502014000300004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The use of central venous catheters (CVC) and broad-spectrum antibacterials are among the main risk factors for the development of candidemia in patients admitted to intensive care units (ICU). It is known that some antibacterials increase the resistance of these yeasts to azole antifungals. Thus, the aim of this research was to determine whether yeast present in CVC colonizations previously exposed to cell-wall targeted antibacterials benefit from a reduction in susceptibility to fluconazole and voriconazole, facilitating their ability to form biofilms. Candida albicans, C. tropicalis, C. glabrata, C. parapsilosis and C. guilhermondii were seeded into antibacterial (cefepime, meropenem, vancomycin, and piperacillin-tazobactam) gradient plates produced in Mueller-Hinton Agar. The susceptibility to fluconazole and voriconazole and the biofilm formation of the yeasts were tested before and after exposure to the antibacterials. None of the antibacterials exerted a significant effect on the in vitro susceptibility of the yeasts to the antifungal agents or on their ability to form biofilms. These results suggest that increased candidemia in ICU patients is not attributable to possible alterations in the yeasts, but is more likely caused by a weakening of the patient's general condition after long exposure to infection.
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Fehér C, Rovira M, Soriano A, Esteve J, Martínez JA, Marco F, Carreras E, Martínez C, Fernández-Avilés F, Suárez-Lledó M, Mensa J. Effect of meropenem administration in extended infusion on the clinical outcome of febrile neutropenia: a retrospective observational study. J Antimicrob Chemother 2014; 69:2556-62. [PMID: 24855125 DOI: 10.1093/jac/dku150] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES Information on the efficacy of extended meropenem administration in neutropenic patients is scarce. Our objective was to determine whether the administration of meropenem in a 4 h extended infusion (EI) leads to a better clinical outcome in patients with febrile neutropenia than the conventional short infusion (SI). METHODS This was a retrospective observational study. The subjects were neutropenic patients who presented with fever after receiving haematopoietic stem-cell transplantation or induction chemotherapy for acute myeloid leukaemia. The primary endpoint was the success of treatment after 5 days of meropenem therapy, defined as follows: the disappearance of fever leading to a maintained (≥ 24 h) feverless state; the resolution or improvement of the clinical signs and symptoms of infection; the absence of persistent or breakthrough bacteraemia; and no additional antibiotics prescribed because of an unsatisfactory clinical evolution. RESULTS Eighty-eight patients received meropenem (1 g/8 h) in SI and 76 received the same dose in EI. Treatment success on day 5 was superior in the EI group [52/76 (68.4%) versus 36/88 (40.9%); P<0.001]. Meropenem administered in EI was independently associated with success (OR 3.13, 95% CI 1.61-6.10). Fewer additional antibiotics were prescribed in the EI group during the first 5 days of treatment [20/76 (26.3%) versus 44/88 (50.0%); P=0.002]. Using Kaplan-Meier survival analysis a more prompt defervescence and a faster decrease in C-reactive protein concentration were observed in the EI group (P=0.021 and P=0.037, respectively). There were no significant differences in the length of hospital stay and in the mortality rate. CONCLUSIONS Meropenem administration in EI results in a better clinical outcome for febrile neutropenia episodes, with fewer additional antibiotics needed.
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Affiliation(s)
- Csaba Fehér
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain
| | - Montserrat Rovira
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain University of Barcelona, Barcelona, Spain
| | - Jordi Esteve
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José Antonio Martínez
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesc Marco
- Microbiology Service, Hospital Clínic, Barcelona, Spain Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-University of Barcelona, Barcelona, Spain
| | - Enric Carreras
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Carmen Martínez
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Francesc Fernández-Avilés
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - María Suárez-Lledó
- Department of Haematology and Bone Marrow Transplant Unit, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Josep Mensa
- Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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Abstract
The threat of antibacterial resistance continues to increase globally, and therapeutic options for the treatment of some serious infectious diseases are diminishing. The carbapenems are a potent class of broad-spectrum drugs, and their stability against hydrolysis by many important beta-lactamases make them an important weapon in the treatment of beta-lactamase-producing bacterial pathogens. This review focuses on four carbapenems of clinical importance in the USA: imipenem, meropenem, ertapenem and doripenem. After a historical review of carbapenem development, these four carbapenems are evaluated based on their mechanism of action, spectrum of activity, potency, pharmacodynamics, clinical pharmacokinetics, clinical profiles and toxicity issues.
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Affiliation(s)
- Philip D Lister
- Creighton University School of Medicine, Department of Medical Microbiology and Immunology, 2500 California Plaza, Omaha, NE 68178, USA.
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Scaglione F, Paraboni L. Influence of pharmacokinetics/pharmacodynamics of antibacterials in their dosing regimen selection. Expert Rev Anti Infect Ther 2014; 4:479-90. [PMID: 16771624 DOI: 10.1586/14787210.4.3.479] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The choice of antimicrobial dosing in clinical practice in the past was based upon a 'penicillin mentality', that is, on the assumption that the in vivo antimicrobial efficacy is dependent on the duration of drug levels above the minimum inhibitory concentration of target microorganisms. Really, a rational antimicrobial therapy is strongly related to a basic understanding of the influence the patient has on the antibiotic (pharmacokinetics [PKs]) and the patient's response to the specific drug effects (pharmacodynamics [PDs]). PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. This review will analyze the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach with the most commonly utilized antimicrobial agent classes.
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Affiliation(s)
- Francesco Scaglione
- University of Milan, Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, Via Vanvitelli 32, 20129, Milan, Italy.
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Adaptation-based resistance to siderophore-conjugated antibacterial agents by Pseudomonas aeruginosa. Antimicrob Agents Chemother 2013; 57:4197-207. [PMID: 23774440 DOI: 10.1128/aac.00629-13] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Multidrug resistance in Gram-negative bacteria has become so threatening to human health that new antibacterial platforms are desperately needed to combat these deadly infections. The concept of siderophore conjugation, which facilitates compound uptake across the outer membrane by hijacking bacterial iron acquisition systems, has received significant attention in recent years. While standard in vitro MIC and resistance frequency methods demonstrate that these compounds are potent, broad-spectrum antibacterial agents whose activity should not be threatened by unacceptably high spontaneous resistance rates, recapitulation of these results in animal models can prove unreliable, partially because of the differences in iron availability in these different methods. Here, we describe the characterization of MB-1, a novel siderophore-conjugated monobactam that demonstrates excellent in vitro activity against Pseudomonas aeruginosa when tested using standard assay conditions. Unfortunately, the in vitro findings did not correlate with the in vivo results we obtained, as multiple strains were not effectively treated by MB-1 despite having low MICs. To address this, we also describe the development of new in vitro assays that were predictive of efficacy in mouse models, and we provide evidence that competition with native siderophores could contribute to the recalcitrance of some P. aeruginosa isolates in vivo.
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Retrospective Study of Prolonged Versus Intermittent Infusion Piperacillin-Tazobactam and Meropenem in Intensive Care Unit Patients at an Academic Medical Center. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e31822e9bf5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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44
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Housman ST, Kuti JL, Nicolau DP. Optimizing Antibiotic Pharmacodynamics in Hospital-acquired and Ventilator-acquired Bacterial Pneumonia. Clin Chest Med 2011; 32:439-50. [DOI: 10.1016/j.ccm.2011.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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45
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Ohata Y, Tomita Y, Nakayama M, Kozuki T, Sunakawa K, Tanigawara Y. Optimal Dosage Regimen of Meropenem for Pediatric Patients Based on Pharmacokinetic/Pharmacodynamic Considerations. Drug Metab Pharmacokinet 2011; 26:523-31. [DOI: 10.2133/dmpk.dmpk-11-rg-027] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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46
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Optimal treatment schedule of meropenem for adult patients with febrile neutropenia based on pharmacokinetic–pharmacodynamic analysis. J Infect Chemother 2011; 17:831-41. [DOI: 10.1007/s10156-011-0271-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 06/07/2011] [Indexed: 11/25/2022]
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47
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Mazzei T. The pharmacokinetics and pharmacodynamics of the carbapanemes: focus on doripenem. J Chemother 2010; 22:219-25. [PMID: 20685624 DOI: 10.1179/joc.2010.22.4.219] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Carbapenems are the most potent group of beta-lactam agents, having a broad spectrum of bactericidal activity against both Gram-negative and Gram-positive bacteria including anaerobes. Doripenem is a new carbapenem endowed with excellent bactericidal activity, a wide spectrum of antibacterial activity against difficult nosocomial pathogens, including extended-spectrum beta-lactamase producers. Its high stability in solution render it extremely flexible for dosing and infusion time. It is the only carbapenem which has been registered officially for administration as an extended infusion of more than 4 hours, which can thus enhance its potential clinical efficacy against difficult bacterial pathogens with MICs of 4-8 mg/L.
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Affiliation(s)
- T Mazzei
- Department of Pharmacology, University of Florence, Florence, Italy.
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48
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In vivo efficacy of simulated human dosing regimens of prolonged-infusion doripenem against carbapenemase- producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2010; 54:4112-5. [PMID: 20660688 DOI: 10.1128/aac.00026-10] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Carbapenemase-producing Klebsiella pneumoniae (KPC) bacteria are rapidly becoming one of the most detrimental drug-resistant Gram-negative pathogens. Doripenem is the newest FDA-approved carbapenem that has the greatest in vitro potency against a wide range of Gram-negative organisms, including multidrug-resistant organisms. Previous work in an animal model has shown efficacy against Pseudomonas aeruginosa with MICs above the current breakpoints of susceptibility. The purpose of this study is to evaluate the efficacy of 1-g and 2-g dose prolonged infusions of doripenem against KPC isolates in both an immunocompetent and neutropenic murine thigh model. Seven clinical KPC isolates (broth microdilution [BMD] MIC range, 4 to 32 μg/ml; Etest MIC range, 3 to >32 μg/ml) were used. After infection, groups of mice were administered doripenem doses previously shown to simulate the exposures observed in humans after the administration of 1 or 2 g every 8 h as a 4-h infusion. In immunocompromised mice, 1- and 2-g doses of doripenem achieved bacteriostasis against isolates with MICs up to and including 8 μg/ml and 16 μg/ml, respectively. In immunocompetent animals, statistically significant reductions in the number of CFU were observed with overall decreases of approximately 1 log (P < 0.05). While carbapenemase-producing Klebsiella pneumoniae continues to decrease our meager supply of active agents, the ability of doripenem to produce CFU reductions in the presence of white blood cells (WBCs) using humanized exposures suggests the potential utility of this agent in combination against this increasingly problematic pathogen.
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49
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Chu YZ, Tian SF, Chen BY, Nian H, Shang H, Sun GQ. Pharmacokinetic-pharmacodynamic profiling of four antimicrobials against gram-negative bacteria collected from Shenyang, China. BMC Infect Dis 2010; 10:171. [PMID: 20546625 PMCID: PMC2895603 DOI: 10.1186/1471-2334-10-171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 06/15/2010] [Indexed: 12/20/2022] Open
Abstract
Background To examine common antimicrobial regimens used in eradicating certain nosocomial Gram-negative pathogens and determine which ones are likely to be the most suitable as empirical choices in Shenyang, China. Methods A 5000-subject Monte Carlo simulation was conducted to determine the cumulative fraction of response (CFR) for meropenem, imipenem, cefepime, piperacillin/tazobactam and levofloxacin against Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Acinetobacter baumannii and Pseudomonas aeruginosa collected in 2006 and 2007 from Shenyang. Results Meropenem and imipenem had the highest CFRs against the Enterobacteriaceae (97%-100%), followed by cefepime. No antibiotic simulated regimen achieved optimal CFR against P. aeruginosa and A. baumannii. Piperacillin/tazobactam dosed at 4.5 g q8h achieved the lowest CFR against all bacteria. Conclusions This study suggests that the carbapenems provide the greatest likelihood of clinical success for the Enterobacteriaceae, and combination therapy might be needed when choosing empirical therapy, especially when A. baumannii or P. aeruginosa are suspected.
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Affiliation(s)
- Yun Zhuo Chu
- Department of Laboratory Medicine, The First Hospital of China Medical University, Shenyang, 110001, China
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50
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Antibiotic dose impact on resistance selection in the community: a mathematical model of beta-lactams and Streptococcus pneumoniae dynamics. Antimicrob Agents Chemother 2010; 54:2330-7. [PMID: 20231396 DOI: 10.1128/aac.00331-09] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Streptococcus pneumoniae is a major pathogen in the community and presents high rates of resistance to the available antibiotics. To prevent antibiotic treatment failure caused by highly resistant bacteria, increasing the prescribed antibiotic dose has recently been suggested. The aim of the present study was to assess the influence of beta-lactam prescribed doses on the emergence of resistance and selection in the community. A mathematical model was constructed by combining S. pneumoniae pharmacodynamic and population-dynamic approaches. The received-dose heterogeneity in the population was specifically modeled. Simulations over a 50-year period were run to test the effects of dose distribution and antibiotic exposure frequency changes on community resistance patterns, as well as the accuracy of the defined daily dose as a predictor of resistance. When the frequency of antibiotic exposure per year was kept constant, dose levels had a strong impact on the levels of resistance after a 50-year simulation. The lowest doses resulted in a high prevalence of nonsusceptible strains (> or =70%) with MICs that were still low (1 mg/liter), whereas high doses resulted in a lower prevalence of nonsusceptible strains (<40%) and higher MICs (2 mg/liter). Furthermore, by keeping the volume of antibiotics constant in the population, different patterns of use (low antibiotic dose and high antibiotic exposure frequency versus high dose and low frequency) could lead to markedly different rates of resistance distribution and prevalence (from 10 to 100%). Our results suggest that pneumococcal resistance patterns in the community are strongly related to the individual beta-lactam doses received: limiting beta-lactam use while increasing the doses could help reduce the prevalence of resistance, although it should select for higher levels of resistance. Surveillance networks are therefore encouraged to collect both daily antibiotic exposure frequencies and individual prescribed doses.
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