1
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Lewis SJ, Mueller BA. Antibiotic dosing recommendations in critically ill patients receiving new innovative kidney replacement therapy. BMC Nephrol 2024; 25:73. [PMID: 38413858 PMCID: PMC10900833 DOI: 10.1186/s12882-024-03469-2] [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: 11/03/2023] [Accepted: 01/16/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The Tablo Hemodialysis System is a new innovative kidney replacement therapy (KRT) providing a range of options for critically ill patients with acute kidney injury. The use of various effluent rate and treatment durations/frequencies may clear antibiotics differently than traditional KRT. This Monte Carlo Simulation (MCS) study was to develop antibiotic doses likely to attain therapeutic targets for various KRT combinations. METHODS Published body weights and pharmacokinetic parameter estimates were used to predict drug exposure for cefepime, ceftazidime, imipenem, meropenem and piperacillin/tazobactam in virtual critically ill patients receiving five KRT regimens. Standard free β-lactam plasma concentration time above minimum inhibitory concentration targets (40-60%fT> MIC and 40-60%fT> MICx4) were used as efficacy targets. MCS assessed the probability of target attainment (PTA) and likelihood of toxicity for various antibiotic dosing strategies. The smallest doses attaining PTA ≥ 90% during 1-week of therapy were considered optimal. RESULTS MCS determined β-lactam doses achieving ∼90% PTA in all KRT options. KRT characteristics influenced antibiotic dosing. Cefepime and piperacillin/tazobactam regimens designed for rigorous efficacy targets were likely to exceed toxicity thresholds. CONCLUSION The flexibility offered by new KRT systems can influence β-lactam antibiotic dosing, but doses can be devised to meet therapeutic targets. Further clinical validations are warranted.
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Affiliation(s)
- Susan J Lewis
- Department of Pharmacy Practice, College of Pharmacy, University of Findlay, 1000 N. Main Street, 45840, Findlay, OH, USA.
- Department of Pharmacy, Mercy Health - St. Anne Hospital, 43623, Toledo, OH, USA.
| | - Bruce A Mueller
- Clinical Pharmacy Department, College of Pharmacy, University of Michigan, MI, 48109, Ann Arbor, USA
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Liu HX, Tang BH, van den Anker J, Hao GX, Zhao W, Zheng Y. Population pharmacokinetics of antibacterial agents in the older population: a literature review. Expert Rev Clin Pharmacol 2024; 17:19-31. [PMID: 38131668 DOI: 10.1080/17512433.2023.2295009] [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: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Older individuals face an elevated risk of developing bacterial infections. The optimal use of antibacterial agents in this population is challenging because of age-related physiological alterations, changes in pharmacokinetics (PK) and pharmacodynamics (PD), and the presence of multiple underlying diseases. Therefore, population pharmacokinetics (PPK) studies are of great importance for optimizing individual treatments and prompt identification of potential risk factors. AREA COVERED Our search involved keywords such as 'elderly,' 'old people,' and 'geriatric,' combined with 'population pharmacokinetics' and 'antibacterial agents.' This comprehensive search yielded 11 categories encompassing 28 antibacterial drugs, including vancomycin, ceftriaxone, meropenem, and linezolid. Out of 127 studies identified, 26 (20.5%) were associated with vancomycin, 14 (11%) with meropenem, and 14 (11%) with piperacillin. Other antibacterial agents were administered less frequently. EXPERT OPINION PPK studies are invaluable for elucidating the characteristics and relevant factors affecting the PK of antibacterial agents in the older population. Further research is warranted to develop and validate PPK models for antibacterial agents in this vulnerable population.
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Affiliation(s)
- Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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3
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El-Haffaf I, Guilhaumou R, Velly L, Marsot A. Impact of piperacillin unbound fraction variability on dosing recommendations in critically ill patients. Br J Clin Pharmacol 2023; 89:1502-1508. [PMID: 36445340 DOI: 10.1111/bcp.15619] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/02/2022] Open
Abstract
A common approach to assess the efficacy of piperacillin is to first measure the total concentration and afterwards apply a theoretical unbound fraction of 70% to obtain the unbound concentration. However, hypoalbuminemia is a common phenomenon in critically ill patients, resulting in variations in unbound fraction, therefore we aimed to simulate the impact of piperacillin unbound fraction fluctuations on the predictive performance of a population pharmacokinetic model and on the dosing recommendations of piperacillin. Unbound factors of 70%, 75%, 80% and 85% were applied to total concentrations of piperacillin administered by continuous infusion from an external dataset. A validated model was used for assessment of predictive performance and to estimate patient clearance. Dosing simulations were performed to evaluate target attainment. Variation in unbound fractions caused minimal impact on piperacillin clearance and target attainment but seemed to influence model validity.
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Affiliation(s)
- Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, Montreal, Québec, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, Québec, Canada
| | - Romain Guilhaumou
- Service de Pharmacologie Clinique et Pharmacovigilance, Assistance Publique des Hôpitaux de Marseille, Marseille, France.,Institut de neurosciences des systèmes, Inserm UMR 1106, Aix Marseille Université, Marseille, France
| | - Lionel Velly
- Service d'anesthésie-réanimation, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille et Institut de neurosciences de la Timone, CNRS, Aix Marseille Université, Marseille, France
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, Montreal, Québec, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, Québec, Canada.,Centre de recherche, CHU Sainte-Justine, Montréal, Québec, Canada
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4
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Martínez-Casanova J, Esteve-Pitarch E, Colom-Codina H, Gumucio-Sanguino VD, Cobo-Sacristán S, Shaw E, Maisterra-Santos K, Sabater-Riera J, Pérez-Fernandez XL, Rigo-Bonnin R, Tubau-Quintano F, Carratalà J, Padullés-Zamora A. Predictive Factors of Piperacillin Exposure and the Impact on Target Attainment after Continuous Infusion Administration to Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12030531. [PMID: 36978398 PMCID: PMC10044067 DOI: 10.3390/antibiotics12030531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/30/2023] Open
Abstract
Critically ill patients undergo significant pathophysiological changes that affect antibiotic pharmacokinetics. Piperacillin/tazobactam administered by continuous infusion (CI) improves pharmacokinetic/pharmacodynamic (PK/PD) target attainment. This study aimed to characterize piperacillin PK after CI administration of piperacillin/tazobactam in critically ill adult patients with preserved renal function and to determine the empirical optimal dosing regimen. A total of 218 piperacillin concentrations from 106 patients were simultaneously analyzed through the population PK approach. A two-compartment linear model best described the data. Creatinine clearance (CLCR) estimated by CKD-EPI was the covariate, the most predictive factor of piperacillin clearance (CL) interindividual variability. The mean (relative standard error) parameter estimates for the final model were: CL: 12.0 L/h (6.03%); central and peripheral compartment distribution volumes: 20.7 L (8.94%) and 62.4 L (50.80%), respectively; intercompartmental clearance: 4.8 L/h (26.4%). For the PK/PD target of 100% fT>1×MIC, 12 g of piperacillin provide a probability of target attainment > 90% for MIC < 16 mg/L, regardless of CLCR, but higher doses are needed for MIC = 16 mg/L when CLCR > 100 mL/min. For 100% fT>4×MIC, the highest dose (24 g/24 h) was not sufficient to ensure adequate exposure, except for MICs of 1 and 4 mg/L. Our model can be used as a support tool for initial dose guidance and during therapeutic drug monitoring.
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Affiliation(s)
- Javier Martínez-Casanova
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
| | - Erika Esteve-Pitarch
- Pharmacy Department, Hospital Universitari de Tarragona Joan XXIII, 43005 Tarragona, Spain
| | - Helena Colom-Codina
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Pharmacy and Pharmaceutical Technology and Physical Chemistry Department, Universitat de Barcelona, 08028 Barcelona, Spain
| | | | - Sara Cobo-Sacristán
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
| | - Evelyn Shaw
- Infectious Diseases Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Epidemiologia de les Infeccions Bacterianes, Patologia Infecciosa i Transplantament, Institut d'Investigacio Biomedica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Kristel Maisterra-Santos
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Joan Sabater-Riera
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Xosé L Pérez-Fernandez
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Raül Rigo-Bonnin
- Clinical Laboratory Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Fe Tubau-Quintano
- Department of Microbiology, Hospital Universitari de Bellvitge-IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Campus Ciencias de la Salud de Bellvitge, University of Barcelona, 08907 Hospitalet de Llobregat, Spain
| | - Ariadna Padullés-Zamora
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
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5
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Shi Q, Huang C, Chen W, Wu S, Ji J, Ying C, Wu H, Xiao Y. Cefepime, not Piperacillin/Tazobactam use, for empirical treatment of bloodstream infections caused by Enterobacter spp.: Results from a population pharmacokinetic/pharmacodynamic analysis. Eur J Pharm Sci 2023; 180:106334. [PMID: 36402309 DOI: 10.1016/j.ejps.2022.106334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/28/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE There is a paucity of published data to evaluate the efficacy and safety of imipenem, cefepime and piperacillin/tazobactam dosing regimens against bloodstream infections caused by Klebsiella aerogenes (BSIs-Kae) and Enterobacter cloacae complex (BSIs-Ecc) in patients with various degrees of renal function. METHODS Pathogens were isolated from China's blood bacterial resistant investigation network. The dosing regimens of imipenem, cefepime and piperacillin were simulated with intermittent infusion and extended infusion. Monte Carlo simulation was performed to calculate the probability of target attainment and a cumulative fraction of response (CFR) against BSIs-Kae/Ecc. RESULTS In total, 203 BSIs-Kae, and 785 BSIs-Ecc were isolated from the surveillance network. Imipenem showed the highest in vitro activity against BSIs-Kae/Ecc, followed by cefepime (85%) and piperacillin/tazobactam (70-80%). The MIC90 values of imipenem, cefepime and piperacillin/tazobactam aginst BSIs-Kae and BSIs-Ecc were 1/1 mg/L, 16/16 mg/L, and 64/128 mg/L, respectively. The simulation results showed imipenem achieved the highest CFRs in patients with normal or decreased renal function, with values of 91-99%, followed by FEP (88-96%), without risk of excessive dosing. However, the intermittent and extended dosing regimens of piperacillin/tazobactam were unlikely to provide adequate exposure for empirical management of BSIs-Kae/Ecc (CFRs, 50-80%), regardless of renal function. Besides, the traditional intermittent piperacillin/tazobactam dosing regimens were highly likely to contribute to suboptimal therapeutic exposure when MIC was close to clinical breakpoints. CONCLUSIONS Cefepime, not piperacillin/tazobactam, can be a reasonable carbapenem-sparing option in empirically treating BSIs-Kae/Ecc.
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Affiliation(s)
- Qingyi Shi
- Department of Immunology and Rheumatology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Chen Huang
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Weizhuang Chen
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Shibo Wu
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Jinru Ji
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chaoqun Ying
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongcheng Wu
- Department of Respiratory Medicine, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China..
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6
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Piperacillin Population Pharmacokinetics and Dosing Regimen Optimization in Critically Ill Children Receiving Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2022; 66:e0113522. [PMID: 36342152 PMCID: PMC9764994 DOI: 10.1128/aac.01135-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We aimed to develop a piperacillin population pharmacokinetic (PK) model in critically ill children receiving continuous renal replacement therapy (CRRT) and to optimize dosing regimens. The piperacillin plasma concentration was quantified by high-performance liquid chromatography. Piperacillin PK was investigated using a nonlinear mixed-effect modeling approach. Monte Carlo simulations were performed to compute the optimal scheme of administration according to the target of 100% interdose interval time in which concentration is one to four times above the MIC (100% fT > 1 to 4× MIC). A total of 32 children with a median (interquartile range [IQR]) postnatal age of 2 years (0 to 11), body weight (BW) of 15 kg (6 to 38), and receiving CRRT were included. Concentration-time courses were best described by a one-compartment model with first-order elimination. BW and residual diuresis (Qu) explained some between-subject variabilities on volume of distribution (V), where [Formula: see text], and clearance (CL), where [Formula: see text], where CLpop and Vpop are 6.78 L/h and 55.0 L, respectively, normalized to a 70-kg subject and median residual diuresis of 0.06 mL/kg/h. Simulations with intermittent and continuous administrations for 4 typical patients with different rates of residual diuresis (0, 0.1, 0.25, and 0.5 mL/kg/h) showed that continuous infusions were appropriate to attain the PK target for patients with residual diuresis higher than 0.1 mL/kg/h according to BW and MIC, while for anuric patients, less frequent intermittent doses were mandatory to avoid accumulation. Optimal exposure to piperacillin in critically ill children on CRRT should be achieved by using continuous infusions with escalating doses for high-MIC bacteria, except for anuric patients who require less frequent intermittent doses.
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7
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Wallenburg E, Ter Heine R, Schouten JA, Raaijmakers J, Ten Oever J, Kolwijck E, Burger DM, Pickkers P, Frenzel T, Brüggemann RJM. An Integral Pharmacokinetic Analysis of Piperacillin and Tazobactam in Plasma and Urine in Critically Ill Patients. Clin Pharmacokinet 2022; 61:907-918. [PMID: 35377133 PMCID: PMC9249689 DOI: 10.1007/s40262-022-01113-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Although dose optimization studies have been performed for piperacillin and tazobactam separately, a combined integral analysis is not yet reported. As piperacillin and tazobactam pharmacokinetics are likely to show correlation, a combined pharmacokinetic model should be preferred to account for this correlation when predicting the exposure. Therefore, the aim of this study was to describe the pharmacokinetics and evaluate different dosing regimens of piperacillin and tazobactam in critically ill patients using an integral population pharmacokinetic model in plasma and urine. METHODS In this observational study, a total of 39 adult intensive care unit patients receiving piperacillin-tazobactam as part of routine clinical care were included. Piperacillin and tazobactam concentrations in plasma and urine were measured and analyzed using non-linear mixed-effects modeling. Monte Carlo simulations were performed to predict the concentrations for different dosing strategies and different categories of renal function. RESULTS A combined two-compartment linear pharmacokinetic model for both piperacillin and tazobactam was developed, with an output compartment for the renally excreted fraction. The addition of 24-h urine creatinine clearance significantly improved the model fit. A dose of 12/1.5 g/24 h as a continuous infusion is sufficient to reach a tazobactam concentration above the target (2.89 mg/L) and a piperacillin concentration above the target of 100% f T>1×MIC (minimum inhibitory concentration [MIC] ≤ 16 mg/L). To reach a target of 100% f T>5×MIC with an MIC of 16 mg/L, piperacillin doses of up to 20 g/24 h are inadequate. Potential toxic piperacillin levels were reached in 19.6% and 47.8% of the population with a dose of 12 g/24 h and 20 g/24 h, respectively. CONCLUSIONS A regular dose of 12/1.5 g/24 h is sufficient in > 90% of the critically ill population to treat infections caused by Escherichia coli and Klebsiella pneumoniae with MICs ≤ 8 mg/L. In case of infections caused by Pseudomonas aeruginosa with an MIC of 16 mg/L, there is a fine line between therapeutic and toxic exposure. Dosing guided by renal function and therapeutic drug monitoring could enhance target attainment in such cases. CLINICALTRIALS GOV IDENTIFIER NCT03738683.
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Affiliation(s)
- Eveline Wallenburg
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, 864, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, 864, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelmer Raaijmakers
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Kolwijck
- Department of Medical Microbiology, Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, 864, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tim Frenzel
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, 864, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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8
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Butragueño-Laiseca L, Marco-Ariño N, Troconiz IF, Grau S, Campillo N, García X, Padilla B, Fernández SN, Slöcker M, Santiago MJ. Population pharmacokinetics of piperacillin in critically ill children including those undergoing continuous kidney replacement therapy. Clin Microbiol Infect 2022; 28:1287.e9-1287.e15. [PMID: 35390523 DOI: 10.1016/j.cmi.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Despite that piperacillin-tazobactam combination is commonly used in critically ill children, increasing evidence suggests that the current dosing schedules are not optimal for these patients. The aim of this work is to develop a population pharmacokinetic (PK) model for piperacillin to evaluate the efficacy of standard dosing in children with and without kidney replacement therapy (CKRT), and to propose alternative dosing schemes maximizing target attainment. METHODS 429 piperacillin concentrations measured in different matrices, obtained from 32 critically ill children (19 without CKRT, 13 with CKRT) receiving 100 mg/kg of piperacillin/tazobactam every 8 hours (increased to 12h after the 4th dose) were modelled simultaneously using the population approach with NONMEM 7.4. The percentage of patients with 90% fT>MIC and target attainment (percentage of dosing interval above MIC) were estimated for different intermittent and continuous infusions in the studied population. RESULTS Piperacillin PK was best described with a two-compartment model. Renal (CLR), nonrenal (CLM), and hemofilter (CLCKRT) clearances were found to be influenced by the glomerular filtration rate, height (CLR), weight (CLM) and filter surface (CLCKRT). Only 7 (37%) children without CKRT and 7 (54%) with CKRT achieved 90% fT >MIC with the current dosing schedule. Of the alternative regimens evaluated, a 24h continuous infusion of 200 mg/kg (CKRT) and 300 mg/kg (no CKRT) provided 100% fT >MIC(≤16mg/L) and target attainments ≥90% across all evaluated MICs. CONCLUSIONS In children with and without CKRT, standard dosing failed to provide an adequate systemic exposure, while prolonged and continuous infusions showed an improved efficacy.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Nicolás Marco-Ariño
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Iñaki F Troconiz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Nuria Campillo
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Xandra García
- Pharmacy Department, Hospital General Universitario Gregorio Marañón
| | - Belén Padilla
- Clinical Microbiology Department, Hospital General Universitario Gregorio Marañón
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.
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9
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Selig DJ, DeLuca JP, Chung KK, Pruskowski KA, Livezey JR, Nadeau RJ, Por ED, Akers KS. Pharmacokinetics of piperacillin and tazobactam in critically Ill patients treated with continuous kidney replacement therapy: A mini-review and population pharmacokinetic analysis. J Clin Pharm Ther 2022; 47:1091-1102. [PMID: 35352374 PMCID: PMC9544041 DOI: 10.1111/jcpt.13657] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/16/2022] [Accepted: 03/04/2022] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Timely and appropriate dosing of antibiotics is essential for the treatment of bacterial sepsis. Critically ill patients treated with continuous kidney replacement therapy (CKRT) often have physiologic derangements that affect pharmacokinetics (PK) of antibiotics and dosing may be challenging. We sought to aggregate previously published piperacillin and tazobactam (pip-tazo) pharmacokinetic data in critically ill patients undergoing CKRT to better understand pharmacokinetics of pip-tazo in this population and better inform dosing. METHODS The National Library of Medicine Database was searched for original research containing piperacillin or tazobactam clearance (CL) or volume of distribution (V) estimates in patients treated with CKRT. The search yielded 77 articles, of which 26 reported suitable estimates of CL or V. Of the 26 articles, 10 for piperacillin and 8 for tazobactam had complete information suitable for population pharmacokinetic modelling. Also included in the analysis was piperacillin and tazobactam PK data from 4 critically ill patients treated with CKRT in the Military Health System, 2 with burn and 2 without burn. RESULTS AND DISCUSSION Median and range of literature reported PK parameters for piperacillin (CL 2.76 L/hr, 1.4-7.92 L/hr, V 31.2 L, 16.77-42.27 L) and tazobactam (CL 2.34 L/hr, 0.72-5.2 L/hr, V 36.6 L, 26.2-58.87 L) were highly consistent with population estimates (piperacillin CL 2.7 L/hr, 95%CI 1.99-3.41 L/hr, V 25.83 22.07-29.59 L, tazobactam CL 2.49 L/hr, 95%CI 1.55-3.44, V 30.62 95%CI 23.7-37.54). The proportion of patients meeting pre-defined pharmacodynamic (PD) targets (median 88.7, range 71%-100%) was high despite significant mortality (median 44%, range 35%-60%). High mortality was predicted by baseline severity of illness (median APACHE II score 23, range 21-33.25). Choice of lenient or strict PD targets (ie 100%fT >MIC or 100%fT >4XMIC) had the largest impact on probability of target attainment (PTA), whereas presence or intensity of CKRT had minimal impact on PTA. WHAT IS NEW AND CONCLUSION Pip-tazo overexposure may be associated with increased mortality, although this is confounded by baseline severity of illness. Achieving adequate pip-tazo exposure is essential; however, risk of harm from overexposure should be considered when choosing a PD target and dose. If lenient PD targets are desired, doses of 2250-3375 mg every 6 h are reasonable for most patients receiving CKRT. However, if a strict PD target is desired, continuous infusion (at least 9000-13500 mg per day) may be required. However, some critically ill CKRT populations may need higher or lower doses and dosing strategies should be tailored to individuals based on all available clinical data including the specific critical care setting.
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Affiliation(s)
- Daniel J Selig
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Jesse P DeLuca
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kaitlin A Pruskowski
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,United States Army Institute of Surgical Research, US Army Burn Center, San Antonio, Texas, USA
| | - Jeffrey R Livezey
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Robert J Nadeau
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Elaine D Por
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Kevin S Akers
- United States Army Institute of Surgical Research, US Army Burn Center, San Antonio, Texas, USA
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10
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Kim YK, Kim HS, Park S, Kim HI, Lee SH, Lee DH. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1353-1364. [PMID: 35224630 PMCID: PMC9047688 DOI: 10.1093/jac/dkac059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/05/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hwan-il Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Dong-Hwan Lee
- Department of Clinical Pharmacology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
- Corresponding author. E-mail:
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11
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Population Pharmacokinetics and Dosing Optimization of Piperacillin-Tazobactam in Critically Ill Patients on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy. Microbiol Spectr 2021; 9:e0063321. [PMID: 34937189 PMCID: PMC8694146 DOI: 10.1128/spectrum.00633-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Critical illness and extracorporeal circulation, such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), may alter the pharmacokinetics of piperacillin-tazobactam. We aimed to develop a population pharmacokinetic model of piperacillin-tazobactam in critically ill patients during ECMO or CRRT and investigate the optimal dosage regimen needed to achieve ≥90% of patients attaining the piperacillin pharmacodynamic target of 100% of dosage time above MIC of 16 mg/L. This prospective observational study included 26 ECMO patients, of which 13 patients received continuous venovenous hemodiafiltration (CVVHDF). A population pharmacokinetic model was developed using nonlinear mixed-effects models, and Monte Carlo simulations were performed to evaluate creatinine clearance (CrCL) and infusion method in relation to the probability of target attainment (PTA) in four patient groups according to combination of ECMO and CVVHDF. A total of 244 plasma samples were collected. In a two-compartment model, clearance decreased during ECMO and CVVHDF contributed to an increase in the volume of distribution. The range of PTA reduction as CrCL increased was greater in the order of intermittent bolus, extended infusion, and continuous infusion method. Continuous infusion should be considered in critically ill patients with CrCL of ≥60 mL/min, and at least 12, 16, and 20 g/day was required for CrCL of <40, 40 to 60, and 60 to 90 mL/min, respectively, regardless of ECMO or CVVHDF. In patients with CrCL of ≥90 mL/min, even a continuous infusion of 24 g/day was insufficient to achieve adequate PTA. Therefore, further research on permissible high continuous infusion dose focused on the risk of toxicity is required. (This trial has been registered at ClinicalTrials.gov under registration no. NCT02581280, December 1, 2014.) IMPORTANCE To the best of our knowledge, this is the first large prospective pharmacokinetic/pharmacodynamic (PK/PD) study of piperacillin-tazobactam in ECMO patients. We used piperacillin-tazobactam plasma concentration data from four different cases (concomitant use of ECMO and CVVHDF, receiving ECMO only, weaned from ECMO and receiving CVVHDF, and weaned from ECMO and not receiving CVVHDF) to provide preliminary insights into the incremental effects of critical illness, ECMO, and CVVHDF on PK. Our analysis revealed that volume of distribution increased in patients on CVVHDF and clearance decreased during ECMO and as creatinine clearance was reduced. When targeting 100% fT>MIC (16 mg/L, clinical breakpoint for Pseudomonas aeruginosa), continuous infusions would have achieved the highest percentage of target attainment compared to intermittent bolus or extended infusion if the total daily dose was the same. Continuous infusion should be considered in critically ill patients with creatinine clearance of ≥60 mL/min, regardless of ECMO or CVVHDF.
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12
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Farrar JE, Mueller SW, Stevens V, Kiser TH, Taleb S, Reynolds PM. Correlation of antimicrobial fraction unbound and sieving coefficient in critically ill patients on continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2021; 77:310-319. [DOI: 10.1093/jac/dkab396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Fraction unbound has been used as a surrogate for antimicrobial sieving coefficient (SC) to predict extracorporeal clearance in critically ill patients on continuous renal replacement therapy (CRRT), but this is based largely on expert opinion.
Objectives
To examine relationships between package insert-derived fraction unbound (Fu-P), study-specific fraction unbound (Fu-S), and SC in critically ill patients receiving CRRT.
Methods
English-language studies containing patient-specific in vivo pharmacokinetic parameters for antimicrobials in critically ill patients requiring CRRT were included. The primary outcome included correlations between Fu-S, Fu-P, and SC. Secondary outcomes included correlations across protein binding quartiles, serum albumin, and predicted in-hospital mortality, and identification of predictors for SC through multivariable analysis.
Results
Eighty-nine studies including 32 antimicrobials were included for analysis. SC was moderately correlated to Fu-S (R2 = 0.55, P < 0.001) and Fu-P (R2 = 0.41, P < 0.001). SC was best correlated to Fu-S in first (<69%) and fourth (>92%) quartiles of fraction unbound and above median albumin concentrations of 24.5 g/L (R2 = 0.71, P = 0.07). Conversely, correlation was weaker in patients with mortality estimates greater than the median of 55% (R2 = 0.06, P = 0.84). SC and Fu-P were also best correlated in the first quartile of antimicrobial fraction unbound (R2 = 0.66, P < 0.001). Increasing Fu-P, flow rate, membrane surface area, and serum albumin, and decreasing physiologic charge significantly predicted increasing SC.
Conclusions
Fu-S and Fu-P were both reasonably correlated to SC. Caution should be taken when using Fu-S to calculate extracorporeal clearance in antimicrobials with 69%–92% fraction unbound or with >55% estimated in-hospital patient mortality. Fu-P may serve as a rudimentary surrogate for SC when Fu-S is unavailable.
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Affiliation(s)
- Julie E. Farrar
- Auburn University Harrison School of Pharmacy, 650 Clinic Dr, Mobile, AL 36688, USA
| | - Scott W. Mueller
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Victoria Stevens
- University of Colorado Hospital, 12505 E 16th Ave, Aurora, CO 80045, USA
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Sim Taleb
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
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13
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Caro Y, Van Strate P, Sartorio M, Cámara M, De Zan M. Application of the lifecycle approach to the development and validation of a chromatographic method for therapeutic drug monitoring of ceftazidime, meropenem, and piperacillin. Microchem J 2021. [DOI: 10.1016/j.microc.2021.106692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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El-Haffaf I, Caissy JA, Marsot A. Piperacillin-Tazobactam in Intensive Care Units: A Review of Population Pharmacokinetic Analyses. Clin Pharmacokinet 2021; 60:855-875. [PMID: 33876381 DOI: 10.1007/s40262-021-01013-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 12/15/2022]
Abstract
Piperacillin-tazobactam is a potent β-lactam/β-lactamase inhibitor antibiotic commonly prescribed in the intensive care unit setting. Admitted patients often show large variability in treatment response due to multiple pathophysiological changes present in this population that alter the drug's pharmacokinetics. This review summarizes the population pharmacokinetic models developed for piperacillin-tazobactam and provides comprehensive data on current dosing strategies while identifying significant covariates in critically ill patients. A literature search on the PubMed database was conducted, from its inception to July 2020. Relevant articles were retained if they met the defined inclusion/exclusion criteria. A total of ten studies, published between 2009 and 2020, were eligible. One- and two-compartment models were used in two and eight studies, respectively. The lowest estimated piperacillin clearance value was 3.12 L/h, and the highest value was 19.9 L/h. The estimations for volume of distribution varied between 11.2 and 41.2 L. Tazobactam clearance values ranged between 5.1 and 6.78 L/h, and tazobactam volume of distribution values ranged between 17.5 and 76.1 L. The most frequent covariates were creatinine clearance and body weight, each present in four studies. Almost all studies used an exponential approach for the interindividual variability. The highest variability was observed in piperacillin central volume of distribution, at a value of 75.0%. Simulations showed that continuous or extended infusion methods performed better than intermittent administration to achieve appropriate pharmacodynamic targets. This review synthesizes important pharmacokinetic elements for piperacillin-tazobactam in an intensive care unit setting. This will help clinicians better understand changes in the drug's pharmacokinetic parameters in this specific population.
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Affiliation(s)
- Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
| | - Jean-Alexandre Caissy
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.,Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
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15
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Poor Correlation between Meropenem and Piperacillin Plasma Concentrations and Delivered Dose of Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2021; 65:AAC.02029-20. [PMID: 33495227 DOI: 10.1128/aac.02029-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/17/2021] [Indexed: 12/12/2022] Open
Abstract
There is insufficient data on the relationship between antibiotic dosing and plasma concentrations in patients treated with continuous renal replacement therapy (CRRT). In this prospective observational study, we explored the variability in plasma concentrations of meropenem and piperacillin in critically ill patients treated with CRRT and the correlation between concentrations and CRRT intensity. Antibiotic concentrations were measured at the middle and end of the dosing interval and repeated after 2 to 3 days when feasible. Measured concentrations were compared to the clinical susceptible breakpoints for Pseudomonas aeruginosa, 16 and 2 mg/liter for piperacillin and meropenem, respectively. CRRT intensity was estimated by delivered, time-averaged, total effluent flow (Q eff), corrected for predilution. Concentrations were also compared between patients with different residual diuresis. We included 140 meropenem concentrations from 98 patients and 47 piperacillin concentrations from 37 patients. Concentrations at the middle of the dosing interval were above target at all occasions for both antibiotics. For meropenem, 6.5% of trough concentrations were below target, and for piperacillin, 22%. Correlations between Q eff and antibiotic concentrations or the concentration half-life (t 1/2) were either statistically not significant or weak. Meropenem concentrations and t 1/2 values differed between patients with different residual diuresis. Thus, when treating intensive care patients with CRRT and recommended doses of meropenem or piperacillin, both low, suboptimal plasma concentrations and unnecessarily high, potentially toxic, plasma concentrations are common. Plasma concentrations cannot be predicted from CRRT intensity. Residual diuresis is associated with lower meropenem concentrations, but the correlation is weak. Concentration measurement is probably the most useful approach to avoid suboptimal treatment.
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16
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Landersdorfer CB, Nation RL. Key Challenges in Providing Effective Antibiotic Therapy for Critically Ill Patients with Bacterial Sepsis and Septic Shock. Clin Pharmacol Ther 2021; 109:892-904. [PMID: 33570163 DOI: 10.1002/cpt.2203] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
Early initiation of effective antibiotic therapy is vitally important for saving the lives of critically ill patients with sepsis or septic shock. The susceptibility of the infecting pathogen and the ability of the selected dosage regimen to safely achieve the required antibiotic exposure need to be carefully considered to achieve a high probability of a successful outcome. Critically ill patients commonly experience substantial pathophysiological changes that impact the functions of various organs, including the kidneys. Many antibiotics are predominantly renally eliminated and thus renal function is a major determinant of the regimen needed to achieve the required antibiotic exposure. However, currently, there is a paucity of guidelines to inform antibiotic dosing in critically ill patients, including those with sepsis or septic shock. This paper briefly reviews methods that are commonly used in critically ill patients to provide a measure of renal function, and approaches that describe the relationship between the exposure to an antibiotic and its antibacterial effects. Two common conditions that very substantially complicate the use of antibiotics in critically ill patients with sepsis, unstable renal function, and augmented renal clearance, are considered in detail and their potential therapeutic implications are explored. Suggestions are provided on how treatment of bacterial infections in critically ill patients with sepsis might be improved. Of high potential are model-informed approaches that aim to individualize initial treatment regimens based on patient and bacterial characteristics, with refinement of regimens during treatment in response to monitoring antibiotic concentrations, responsive measures of renal function, and other important clinical data.
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Affiliation(s)
- Cornelia B Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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17
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Lonsdale DO, Shah RV, Lipman J. Infection, Sepsis and the Inflammatory Response: Mechanisms and Therapy. Front Med (Lausanne) 2020; 7:588863. [PMID: 33344475 PMCID: PMC7738462 DOI: 10.3389/fmed.2020.588863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis secondary to bacterial infection remains a significant cause of morbidity and mortality globally. Recent decades have seen the evolution of international collaborations to improve care for these patients and identify areas for research. In this article we discuss the pathophysiology underlying the condition, review the current recommended management strategies, discuss areas of controversy, and highlight the need for ongoing research, particularly in diagnostics.
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Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Reya V Shah
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, NÎmes University Hospital, University of Montpellier, NÎmes, France
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18
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Jin Y, Mao H, Liu B, Zhou F, Yang J, Xu L, Tong J, Huang C, Ding Y. <p>Optimal Empiric Treatment for <em>Klebsiella pneumoniae</em> Infections in Short-Stay ICU Patients During Continuous Renal Replacement Therapy: Results from a Population Pharmacokinetic/Pharmacodynamic Analysis</p>. Infect Drug Resist 2020; 13:4155-4166. [PMID: 33244245 PMCID: PMC7683353 DOI: 10.2147/idr.s284754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/30/2020] [Indexed: 12/29/2022] Open
Abstract
Objective There is a paucity of published data to evaluate the efficacy and safety of imipenem (IPM) and piperacillin-tazobactam (PT) dosing regimens in the treatment of septic patients acquiring continuous renal replacement therapy (CRRT). Methods and Materials Critically-ill patients were grouped into short-stay and long-stay intensive care unit (ICU) patients. Pathogens were isolated from bloodstream infections in these patients. Minimum inhibitory concentration (MIC) value was determined by agar dilution method. Population PK models were introduced in this study, and differences in the likelihood of achieving efficacious and toxic exposures of IPM and PT for critically-ill patients were assessed. Results A total of 86 K. pneumoniae bloodstream infection associated isolates were collected, and the MIC50 and MIC90 for short-stay ICU patients were 0.5/4 mg/L and 32/128 mg/L, respectively. IMP 0.5g q8h reached 90% probability of target attainment (PTA) against isolates with MICs ≤2 mg/L and was recommended to empirically treat short-stay ICU patients during CRRT based on the target of 40% ƒT>MIC. However, based on a more aggressive target of 100% ƒT>MIC, all the simulated IMP regimens except for IMP 1g q6h failed to achieve >80% cumulative fraction of response (CFR) in such patients. Unfortunately, the risk of drug-related toxicity for IMP 1g q6h was relatively high (50–85%). For PT, even the regimen of 4/0.5g q6h failed to provide sufficient antimicrobial exposure in short-stay ICU patients acquiring CRRT. Conclusion No dose adjustment was required for the conventional IMP and PT regimens in the critically-ill population acquiring CRRT. Empirical treatment of IMP 0.5g q8h/q6h, not for PT, may provide sufficient antimicrobial exposure for short-stay ICU patients during CRRT. PT should be used in the knowledge of MIC results.
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Affiliation(s)
- Yuhong Jin
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Haiyan Mao
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Bingyang Liu
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Fen Zhou
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Junjie Yang
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Lei Xu
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Jingtao Tong
- Department of Radiotherapy, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
| | - Chen Huang
- Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
- Correspondence: Chen Huang Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo315000, People’s Republic of ChinaTel +86-574-87018701Fax +86- 574-87392232 Email
| | - Yi Ding
- Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo, People’s Republic of China
- Yi Ding Department of Intensive Care, Lihuili Hospital, Ningbo Medical Center, Ningbo315000, People’s Republic of ChinaTel +86-574-87018661 Email
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19
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Milla P, Ferrari F, Muntoni E, Sartori M, Ronco C, Arpicco S. Validation of a simple and economic HPLC-UV method for the simultaneous determination of vancomycin, meropenem, piperacillin and tazobactam in plasma samples. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1148:122151. [PMID: 32417718 DOI: 10.1016/j.jchromb.2020.122151] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022]
Abstract
Critically ill patients are often affected by several pathophysiological conditions requiring antibiotic administration and, frequently, extracorporeal therapy that significantly alter the normal pharmacokinetics of drugs. Therapeutic drug monitoring (TDM) may assist to establish the correct antibiotic dosage, but a TDM service is usually available only for some aminoglycosides and glycopeptides. The aim of this study is the validation of an HPLC-UV method for the simultaneous quantification of meropenem, vancomycin, piperacillin and tazobactam in human plasma samples. The analytes were extracted from 250 μL of human plasma by the addition of acetonitrile for protein precipitation. After evaporation to dryness of the solvent, samples were reconstituted with 250 μL of mobile phase, and 100 μL were injected in HPLC. Chromatographic analysis was performed using a Kinetex C18 column and an UV/Vis detector set at 220 and 298 nm. The mobile phase was a mixture of phosphate buffer 0.1 M pH 3.15 and methanol in gradient, delivered at 1 mL/min. The method was validated over clinical concentration ranges. For all the analytes, the lower limit of quantification was 1 μg/mL, and the calibration curves were linear between 1 and 100 μg/mL, with coefficients of determination ≥ 0.999. Intra-day precision was < 4%, while inter-day precision was < 7% for each analyte. The applicability of the method has been evaluated by analysing plasma samples collected from 4 critically ill patients undergoing continuous renal replacement therapy. Moreover, the analysis of vancomycin with VANC Flex® confirmed a good correlation between the results of HPLC-UV and commercially available kits usually used by TDM service. The method we developed only requires a small volume of plasma and uses the same sample preparation protocol, stationary phase and elution conditions for all analytes. This method offers the additional advantages of simple and rather inexpensive sample preparation and instrumentation, features that make this method an easy implementation for a general TDM laboratory.
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Affiliation(s)
- Paola Milla
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, I-10125 Turin, Italy.
| | - Fiorenza Ferrari
- Intensive Care Unit, I.R.C.C.S. Fondazione Policlinico San Matteo di Pavia, Viale C. Golgi 19, I-27100 Pavia, Italy.
| | - Elisabetta Muntoni
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, I-10125 Turin, Italy.
| | - Marco Sartori
- International Renal Research Institute of Vicenza and Department of Nephrology, Dialysis and Transplant of San Bortolo Hospital, Viale F. Rodolfi 37, I-36100 Vicenza, Italy.
| | - Claudio Ronco
- International Renal Research Institute of Vicenza and Department of Nephrology, Dialysis and Transplant of San Bortolo Hospital, Viale F. Rodolfi 37, I-36100 Vicenza, Italy; Department of Medicine, University of Padova, Via N. Giustiniani 2, I-35128 Padova, Italy.
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, I-10125 Turin, Italy.
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Caro Y, Cámara M, De Zan M. A review of bioanalytical methods for the therapeutic drug monitoring of β-lactam antibiotics in critically ill patients: Evaluation of the approaches used to develop and validate quality attributes. Talanta 2020; 210:120619. [DOI: 10.1016/j.talanta.2019.120619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022]
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Population Pharmacokinetic Modeling and Pharmacodynamic Target Attainment Simulation of Piperacillin/Tazobactam for Dosing Optimization in Late Elderly Patients with Pneumonia. Antibiotics (Basel) 2020; 9:antibiotics9030113. [PMID: 32155905 PMCID: PMC7148462 DOI: 10.3390/antibiotics9030113] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 12/03/2022] Open
Abstract
The aim of this study was to develop a population pharmacokinetic model for piperacillin (PIPC)/tazobactam (TAZ) in late elderly patients with pneumonia and to optimize the administration planning by applying pharmacokinetic/pharmacodynamic (PK/PD) criteria. PIPC/TAZ (total dose of 2.25 or 4.5 g) was infused intravenously three times daily to Japanese patients over 75 years old. The plasma concentrations of PIPC and TAZ were determined using high-performance liquid chromatography and modeled using the NONMEM program. PK/PD analysis with a random simulation was conducted using the final population PK model to estimate the probability of target attainment (PTA) profiles for various PIPC/TAZ-regimen–minimum-inhibitory-concentration (MIC) combinations. The PTAs for PIPC and TAZ were determined as the fraction that achieved at least 50% free time > MIC and area under the free-plasma-concentration–time curve over 24 h ≥ 96 μg h/mL, respectively. A total of 18 cases, the mean age of which was 86.5 ± 6.0 (75–101) years, were investigated. The plasma-concentration–time profiles of PIPC and TAZ were characterized by a two-compartment model. The parameter estimates for the final model, namely the total clearance, central distribution volume, peripheral distribution volume, and intercompartmental clearance, were 4.58 + 0.061 × (CLcr − 37.4) L/h, 5.39 L, 6.96 L, and 20.7 L/h for PIPC, and 5.00 + 0.059 × (CLcr − 37.4) L/h, 6.29 L, 7.73 L, and 24.0 L/h for TAZ, respectively, where CLcr is the creatinine clearance. PK/PD analysis using the final model showed that in drug-resistant strains with a MIC > 8 μg/mL, 4.5 g of PIPC/TAZ every 6 h was required, even for the patients with a CLcr of 50–60 mL/min. The population PK model developed in this study, together with MIC value, can be useful for optimizing the PIPC/TAZ dosage in the over-75-year-old patients, when they are administered PIPC/TAZ. Therefore, the findings of present study may contribute to improving the efficacy and safety of the administration of PIPC/TAZ therapy in late elderly patients with pneumonia.
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23
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Population pharmacokinetics of piperacillin in plasma and subcutaneous tissue in patients on continuous renal replacement therapy. Int J Infect Dis 2020; 92:133-140. [PMID: 31978581 DOI: 10.1016/j.ijid.2020.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Piperacillin is a β-lactam antimicrobial frequently used in critically ill patients with acute kidney injury treated with continuous renal replacement therapy (CRRT). However, data regarding piperacillin tissue concentrations in this patient population are limited. A prospective observational study was conducted of free piperacillin concentrations during a single 8-h dosing interval in plasma (8 samples) and subcutaneous tissue (SCT) (13 samples), in 10 patients treated with CRRT following piperacillin 4 g given every 8 h as intermittent administration over 3 min. METHODS A population pharmacokinetic model was developed using NONMEM 7.4.3, to simulate alternative administration modes and dosing regimens. SCT concentrations were obtained using microdialysis. Piperacillin concentrations were compared to the clinical breakpoint minimum inhibitory concentration (MIC) for Pseudomonas aeruginosa (16 mg/l), with evaluation of the following pharmacokinetic/pharmacodynamics targets: 50% fT > 1 × MIC, 100% fT > 1 × MIC, and 100% fT > 4 × MIC. RESULTS SCT concentrations were generally lower than plasma concentrations. For the target of 50% free time (fT) > 1 × MIC and 100% fT > 1 × MIC, piperacillin 4 g every 8 h resulted in probability of target attainment (PTA) >90% in both plasma and SCT. PTA > 90% for the target of 100% fT > 4 × MIC was only achieved for continuous infusion. CONCLUSIONS Piperacillin 4 g every 8 h is likely to provide sufficient exposure in both plasma and SCT to treat P.aeruginosa infections in critically ill patients on CRRT, given that targets of 50% fT > 1 × MIC or 100% fT > 1 × MIC are adequate. However, if a more aggressive target of 100% fT > 4 × MIC is adopted, continuous infusion is needed.
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Soraluce A, Barrasa H, Asín-Prieto E, Sánchez-Izquierdo JÁ, Maynar J, Isla A, Rodríguez-Gascón A. Novel Population Pharmacokinetic Model for Linezolid in Critically Ill Patients and Evaluation of the Adequacy of the Current Dosing Recommendation. Pharmaceutics 2020; 12:pharmaceutics12010054. [PMID: 31936614 PMCID: PMC7023070 DOI: 10.3390/pharmaceutics12010054] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/30/2019] [Indexed: 12/30/2022] Open
Abstract
Antimicrobial treatment in critically ill patients remains challenging. The aim of this study was to develop a population pharmacokinetic model for linezolid in critically ill patients and to evaluate the adequacy of current dosing recommendation (600 mg/12 h). Forty inpatients were included, 23 of whom were subjected to continuous renal replacement therapies (CRRT). Blood and effluent samples were drawn after linezolid administration at defined time points, and linezolid levels were measured. A population pharmacokinetic model was developed, using NONMEM 7.3. The percentage of patients that achieved the pharmacokinetic/pharmacodynamic (PK/PD) targets was calculated (AUC24/MIC > 80 and 100% T>MIC). A two-compartment model best described the pharmacokinetics of linezolid. Elimination was conditioned by the creatinine clearance and by the extra-corporeal clearance if the patient was subjected to CRRT. For most patients, the standard dose of linezolid did not cover infections caused by pathogens with MIC ≥ 2 mg/L. Continuous infusion may be an alternative, especially when renal function is preserved.
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Affiliation(s)
- Amaia Soraluce
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Helena Barrasa
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Eduardo Asín-Prieto
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy and Nutrition, University of Navarra, 31008 Pamplona, Spain;
| | | | - Javier Maynar
- Intensive Care Unit, Araba University Hospital, 01004 Vitoria-Gasteiz, Spain; (H.B.); (J.M.)
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain; (A.S.); (A.I.)
- Correspondence: ; Tel.: +34-945-01-3094
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Pharmacokinetics and Pharmacodynamics of Anti-infective Agents during Continuous Veno-venous Hemofiltration in Critically Ill Patients: Lessons Learned from an Ancillary Study of the IVOIRE Trial. J Transl Int Med 2019; 7:155-169. [PMID: 32010602 PMCID: PMC6985915 DOI: 10.2478/jtim-2019-0031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Hemofiltration rate, changes in blood and ultrafiltration flow, and discrepancies between the prescribed and administered doses strongly influence pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobial agents during continuous veno-venous hemofiltration (CVVH) in critically ill patients. Methods Ancillary data were from the prospective multicenter IVOIRE (hIgh VOlume in Intensive caRE) study. High volume (HV, 70 mL/kg/h) was at random compared with standard volume (SV, 35 mL/kg/h) CVVH in septic shock patients with acute kidney injury (AKI). PK/PD parameters for all antimicrobial agents used in each patient were studied during five days. Results Antimicrobial treatment met efficacy targets for both percentage of time above the minimal inhibitory concentration and inhibitory quotient. A significant correlation was observed between the ultrafiltration flow and total systemic clearance (Spearman test: P < 0.005) and between CVVH clearance and drug elimination half-life (Spearman test: P < 0.005). All agents were easily filtered. Mean sieving coefficient ranged from 38.7% to 96.7%. Mean elimination half-life of all agents was significantly shorter during HV-CVVH (from 1.29 to 28.54 h) than during SV-CVVH (from 1.51 to 33.85 h) (P < 0.05). Conclusions This study confirms that CVVH influences the PK/PD behavior of most antimicrobial agents. Antimicrobial elimination was directly correlated with convection rate. Current antimicrobial dose recommendations will expose patients to underdosing and increase the risk for treatment failure and development of resistance. Dose recommendations are proposed for some major antibiotic and antifungal treatments in patients receiving at least 25 mL/kg/h CVVH.
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26
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Boidin C, Moshiri P, Dahyot-Fizelier C, Goutelle S, Lefeuvre S. Pharmacokinetic variability of beta-lactams in critically ill patients: A narrative review. Anaesth Crit Care Pain Med 2019; 39:87-109. [PMID: 31513935 DOI: 10.1016/j.accpm.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/05/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022]
Abstract
The use of antibacterial drugs is very common in critically ill patients and beta-lactam agents are widely used in this context. Critically ill patients show several characteristics (e.g., sepsis, renal impairment or conversely augmented renal clearance, renal replacement therapy) that may alter beta-lactam pharmacokinetics (PK) in comparison with non-critically ill patients. This narrative literature review aims to identify recent studies quantifying the variability of beta-lactams volume of distribution and clearance and to determine its main determinants. Seventy studies published between 2000 and 2018 were retained. Data on volume of distribution and clearance variability were reported for 5 penicillins, 3 beta-lactamase inhibitors, 6 cephalosporins and 4 carbapenems. Data confirm specific changes in PK parameters and important variability of beta-lactam PK in critically ill patients. Renal function, body weight and use of renal replacement therapy are the principal factors influencing PK parameters described in this population. Few studies have directly compared beta-lactam PK in critically ill versus non-critically ill patients. Conclusions are also limited by small study size and sparse PK data in several studies. These results suggest approaches to assess this PK variability in clinical practice. Beta-lactam therapeutic drug monitoring seems to be the best way to deal with this issue.
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Affiliation(s)
- Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France.
| | - Parastou Moshiri
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Service d'Anesthésie-Réanimation, 2, rue de la Milétrie, 86021 Poitiers, France; Université de Poitiers, UMR 1070, 6, rue de la Milétrie, 86073 Poitiers, France.
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France; Univ Lyon, Université Claude Bernard Lyon 1, ISPB - Faculté de Pharmacie de Lyon, 8, avenue Rockefeller, 69008 Lyon, France.
| | - Sandrine Lefeuvre
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
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Basic Principles of Antibiotics Dosing in Patients with Sepsis and Acute Kidney Damage Treated with Continuous Venovenous Hemodiafiltration. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2018-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Sepsis is the leading cause of acute kidney damage in patients in intensive care units. Pathophysiological mechanisms of the development of acute kidney damage in patients with sepsis may be hemodynamic and non-hemodynamic. Patients with severe sepsis, septic shock and acute kidney damage are treated with continuous venovenous hemodiafiltration. Sepsis, acute kidney damage, and continuous venovenous hemodiafiltration have a significant effect on the pharmacokinetics and pharmacodynamics of antibiotics. The impact dose of antibiotics is increased due to the increased volume of distribution (increased administration of crystalloids, hypoalbuminemia, increased capillary permeability syndrome toproteins). The dose of antibiotic maintenance depends on renal, non-renal and extracorporeal clearance. In the early stage of sepsis, there is an increased renal clearance of antibiotics, caused by glomerular hyperfiltration, while in the late stage of sepsis, as the consequence of the development of acute renal damage, renal clearance of antibiotics is reduced. The extracorporeal clearance of antibiotics depends on the hydrosolubility and pharmacokinetic characteristics of the antibiotic, but also on the type of continuous dialysis modality, dialysis dose, membrane type, blood flow rate, dialysis flow rate, net filtration rate, and effluent flow rate. Early detection of sepsis and acute kidney damage, early target therapy, early administration of antibiotics at an appropriate dose, and early extracorporeal therapy for kidney replacement and removal of the inflammatory mediators can improve the outcome of patients with sepsis in intensive care units.
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Hoff BM, Maker JH, Dager WE, Heintz BH. Antibiotic Dosing for Critically Ill Adult Patients Receiving Intermittent Hemodialysis, Prolonged Intermittent Renal Replacement Therapy, and Continuous Renal Replacement Therapy: An Update. Ann Pharmacother 2019; 54:43-55. [PMID: 31342772 DOI: 10.1177/1060028019865873] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: To summarize current antibiotic dosing recommendations in critically ill patients receiving intermittent hemodialysis (IHD), prolonged intermittent renal replacement therapy (PIRRT), and continuous renal replacement therapy (CRRT), including considerations for individualizing therapy. Data Sources: A literature search of PubMed from January 2008 to May 2019 was performed to identify English-language literature in which dosing recommendations were proposed for antibiotics commonly used in critically ill patients receiving IHD, PIRRT, or CRRT. Study Selection and Data Extraction: All pertinent reviews, selected studies, and references were evaluated to ensure appropriateness for inclusion. Data Synthesis: Updated empirical dosing considerations are proposed for antibiotics in critically ill patients receiving IHD, PIRRT, and CRRT with recommendations for individualizing therapy. Relevance to Patient Care and Clinical Practice: This review defines principles for assessing renal function, identifies RRT system properties affecting drug clearance and drug properties affecting clearance during RRT, outlines pharmacokinetic and pharmacodynamic dosing considerations, reviews pertinent updates in the literature, develops updated empirical dosing recommendations, and highlights important factors for individualizing therapy in critically ill patients. Conclusions: Appropriate antimicrobial selection and dosing are vital to improve clinical outcomes. Dosing recommendations should be applied cautiously with efforts to consider local epidemiology and resistance patterns, antibiotic dosing and infusion strategies, renal replacement modalities, patient-specific considerations, severity of illness, residual renal function, comorbidities, and patient response to therapy. Recommendations provided herein are intended to serve as a guide in developing and revising therapy plans individualized to meet a patient's needs.
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Affiliation(s)
- Brian M Hoff
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jenana H Maker
- University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, Stockton, CA, USA.,University of California Davis Medical Center, Sacramento, CA, USA
| | - William E Dager
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Brett H Heintz
- University of Iowa College of Pharmacy, Iowa City, IA, USA.,Iowa City Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
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Guilhaumou R, Benaboud S, Bennis Y, Dahyot-Fizelier C, Dailly E, Gandia P, Goutelle S, Lefeuvre S, Mongardon N, Roger C, Scala-Bertola J, Lemaitre F, Garnier M. Optimization of the treatment with beta-lactam antibiotics in critically ill patients-guidelines from the French Society of Pharmacology and Therapeutics (Société Française de Pharmacologie et Thérapeutique-SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation-SFAR). Crit Care 2019; 23:104. [PMID: 30925922 PMCID: PMC6441232 DOI: 10.1186/s13054-019-2378-9] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/26/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Beta-lactam antibiotics (βLA) are the most commonly used antibiotics in the intensive care unit (ICU). ICU patients present many pathophysiological features that cause pharmacokinetic (PK) and pharmacodynamic (PD) specificities, leading to the risk of underdosage. The French Society of Pharmacology and Therapeutics (SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (SFAR) have joined forces to provide guidelines on the optimization of beta-lactam treatment in ICU patients. METHODS A consensus committee of 18 experts from the two societies had the mission of producing these guidelines. The entire process was conducted independently of any industry funding. A list of questions formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes) was drawn-up by the experts. Then, two bibliographic experts analysed the literature published since January 2000 using predefined keywords according to PRISMA recommendations. The quality of the data identified from the literature was assessed using the GRADE® methodology. Due to the lack of powerful studies having used mortality as main judgement criteria, it was decided, before drafting the recommendations, to formulate only "optional" recommendations. RESULTS After two rounds of rating and one amendment, a strong agreement was reached by the SFPT-SFAR guideline panel for 21 optional recommendations and a recapitulative algorithm for care covering four areas: (i) pharmacokinetic variability, (ii) PK-PD relationship, (iii) administration modalities, and (iv) therapeutic drug monitoring (TDM). The most important recommendations regarding βLA administration in ICU patients concerned (i) the consideration of the many sources of PK variability in this population; (ii) the definition of free plasma concentration between four and eight times the Minimal Inhibitory Concentration (MIC) of the causative bacteria for 100% of the dosing interval as PK-PD target to maximize bacteriological and clinical responses; (iii) the use of continuous or prolonged administration of βLA in the most severe patients, in case of high MIC bacteria and in case of lower respiratory tract infection to improve clinical cure; and (iv) the use of TDM to improve PK-PD target achievement. CONCLUSIONS The experts strongly suggest the use of personalized dosing, continuous or prolonged infusion and therapeutic drug monitoring when administering βLA in critically ill patients.
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Affiliation(s)
- Romain Guilhaumou
- AP-HM Hôpital de la Timone, Service de Pharmacologie Clinique et Pharmacovigilance, 264 rue Saint Pierre, 13005 Marseille, France
| | - Sihem Benaboud
- AP-HP Hôpital Cochin, Service de Pharmacologie, 27 rue du Faubourg St-Jacques, 75679 Paris Cedex 14, France
| | - Youssef Bennis
- CHU d’Amiens Picardie, Service de Pharmacologie Clinique, UPJV EA7517, Avenue Laennec, 80054 Amiens Cedex 1, France
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Département d’Anesthésie Réanimation, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Eric Dailly
- CHU de Nantes, Département de Pharmacologie Clinique, 5 allée de l’île gloriette, 44093 Nantes Cedex 01, France
| | - Peggy Gandia
- CHU de Toulouse, Laboratoire de Pharmacocinétique et Toxicologie Clinique, Institut Fédératif de Biologie, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France
| | - Sylvain Goutelle
- CHU de Lyon, Service de Pharmacie, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69322 Lyon cedex 05, France
| | - Sandrine Lefeuvre
- CHR d’Orléans, Laboratoire de Biochimie, 14 Avenue de l’Hôpital, 45067 Orléans, France
| | - Nicolas Mongardon
- AP-HP Hôpital Henri Mondor, Département d’Anesthésie-Réanimation, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Claire Roger
- CHU de Nîmes, Département d’anesthésie, réanimation, douleur et médicine d’urgence, Place du Pr Robert Debré, 30029 Nîmes cedex 9, France
| | - Julien Scala-Bertola
- CHRU de Nancy, Département de pharmacologie clinique et de toxicologie, 29 rue Lionnois, 54000 Nancy, France
| | - Florian Lemaitre
- CHU Pontchaillou, Service de Pharmacologie Clinique et épidémiologique, 2 Rue Henri le Guilloux, 35000 Rennes, France
| | - Marc Garnier
- AP-HP Hôpital Tenon, Département d’Anesthésie et Réanimation, 4 rue de la Chine, 75020 Paris, France
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Lonsdale DO, Baker EH, Kipper K, Barker C, Philips B, Rhodes A, Sharland M, Standing JF. Scaling beta-lactam antimicrobial pharmacokinetics from early life to old age. Br J Clin Pharmacol 2018; 85:316-346. [PMID: 30176176 DOI: 10.1111/bcp.13756] [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: 04/02/2018] [Revised: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Beta-lactam dose optimization in critical care is a current priority. We aimed to review the pharmacokinetics (PK) of three commonly used beta-lactams (amoxicillin ± clavulanate, piperacillin-tazobactam and meropenem) to compare PK parameters reported in critically and noncritically ill neonates, children and adults, and to investigate whether allometric and maturation scaling principles could be applied to describe changes in PK parameters through life. METHODS A systematic review of PK studies of the three drugs was undertaken using MEDLINE and EMBASE. PK parameters and summary statistics were extracted and scaled using allometric principles to 70 kg individual for comparison. Pooled data were used to model clearance maturation and decline using a sigmoidal (Hill) function. RESULTS A total of 130 papers were identified. Age ranged from 29 weeks to 82 years and weight from 0.9-200 kg. PK parameters from critically ill populations were reported with wider confidence intervals than those in healthy volunteers, indicating greater PK variability in critical illness. The standard allometric size and sigmoidal maturation model adequately described increasing clearance in neonates, and a sigmoidal model was also used to describe decline in older age. Adult weight-adjusted clearance was achieved at approximately 2 years postmenstrual age. Changes in volume of distribution were well described by the standard allometric model, although amoxicillin data suggested a relatively higher volume of distribution in neonates. CONCLUSIONS Critical illness is associated with greater PK variability than in healthy volunteers. The maturation models presented will be useful for optimizing beta-lactam dosing, although a prospective, age-inclusive study is warranted for external validation.
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Affiliation(s)
- Dagan O Lonsdale
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George's, University of London, London, UK.,Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International Ltd
| | - Charlotte Barker
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Barbara Philips
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Veiga RP, Paiva JA. Pharmacokinetics-pharmacodynamics issues relevant for the clinical use of beta-lactam antibiotics in critically ill patients. Crit Care 2018; 22:233. [PMID: 30244674 PMCID: PMC6151903 DOI: 10.1186/s13054-018-2155-1] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/08/2018] [Indexed: 12/15/2022] Open
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients and beta-lactams are the most common antibiotic class used. Critically ill patient's pathophysiological factors lead to altered pharmacokinetics and pharmacodynamics of beta-lactams.A comprehensive bibliographic search in PubMed database of all English language articles published from January 2000 to December 2017 was performed, allowing the selection of articles addressing the pharmacokinetics or pharmacodynamics of beta-lactam antibiotics in critically ill patients.In critically ill patients, several factors may increase volume of distribution and enhance renal clearance, inducing high intra- and inter-patient variability in beta-lactam concentration and promoting the risk of antibiotic underdosing. The duration of infusion of beta-lactams has been shown to influence the fT > minimal inhibitory concentration and an improved beta-lactam pharmacodynamics profile may be obtained by longer exposure with more frequent dosing, extended infusions, or continuous infusions.The use of extracorporeal support techniques in the critically ill may further contribute to this problem and we recommend not reducing standard antibiotic dosage since no drug accumulation was found in the available literature and to maintain continuous or prolonged infusion, especially for the treatment of infections caused by multidrug-resistant bacteria.Prediction of outcome based on concentrations in plasma results in overestimation of antimicrobial activity at the site of infection, namely in cerebrospinal fluid and the lung. Therefore, although no studies have assessed clinical outcome, we recommend using higher than standard dosing, preferably with continuous or prolonged infusions, especially when treating less susceptible bacterial strains at these sites, as the pharmacodynamics profile may improve with no apparent increase in toxicity.A therapeutic drug monitoring-guided approach could be particularly useful in critically ill patients in whom achieving target concentrations is more difficult, such as obese patients, immunocompromised patients, those infected by highly resistant bacterial strains, patients with augmented renal clearance, and those undergoing extracorporeal support techniques.
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Affiliation(s)
- Rui Pedro Veiga
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
| | - José-Artur Paiva
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
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Morse J, Blackburn L, Hannam JA, Voss L, Anderson BJ. Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures. Paediatr Anaesth 2018; 28:686-693. [PMID: 29961951 DOI: 10.1111/pan.13428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 12/17/2022]
Abstract
Postoperative wound infections represent an important source of morbidity and mortality in children. Perioperative antibiotic prophylaxis has been shown to decrease the risk of developing infections and hospital guidelines surrounding antibiotic use exist to standardize patient care. Despite supporting evidence, rates of compliance with guidelines vary. Quality improvement initiatives have been introduced to improve compliance with intraoperative antibiotic guidelines. Thorough infection surveillance, including antibiotic provision in presurgical checklists, computerized voice antibiotic administration prompts, and national feedback systems are now increasingly common. Few studies have been conducted investigating the effectiveness of prophylactic antibiotics in children. Outcome measures such as morbidity and mortality and return to the operating room can be used to examine the relationship between antibiotic use and patient outcome but these measures are limited in that they occur infrequently or are subjective and difficult to measure. Metrics such as days alive out of hospital and length of hospital stay may be useful alternatives for ongoing monitoring of infections and identifying improvements in patient outcomes. Guidelines on antibiotic prophylaxis have facilitated an increase in the correct provision of perioperative antibiotics and a reduction in the incidence of postoperative infection. Measures of patient outcome such as days alive out of hospital and length of hospital stay are easy to collect and calculate but further work is needed to confirm the utility of these measures for monitoring infection rates.
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Affiliation(s)
- James Morse
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Lee Blackburn
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Lesley Voss
- Department of Paediatrics, Starship Children's Hospital, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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Jang SM, Gharibian KN, Lewis SJ, Fissell WH, Tolwani AJ, Mueller BA. A Monte Carlo Simulation Approach for Beta-Lactam Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy. J Clin Pharmacol 2018; 58:1254-1265. [PMID: 29746711 DOI: 10.1002/jcph.1137] [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] [Received: 01/29/2018] [Accepted: 03/23/2018] [Indexed: 11/05/2022]
Abstract
Cefepime, ceftazidime, and piperacillin/tazobactam are commonly used beta-lactam antibiotics in the critical care setting. For critically ill patients receiving prolonged intermittent renal replacement therapy (PIRRT), limited pharmacokinetic data are available to inform clinicians on the dosing of these agents. Monte Carlo simulations (MCS) can be used to guide drug dosing when pharmacokinetic trials are not feasible. For each antibiotic, MCS using previously published pharmacokinetic data derived from critically ill patients was used to evaluate multiple dosing regimens in 4 different prolonged intermittent renal replacement therapy effluent rates and prolonged intermittent renal replacement therapy duration combinations (4 L/h × 10 hours or 5 L/h × 8 hours in hemodialysis and hemofiltration modes). Antibiotic regimens were also modeled depending on whether drugs were administered during or well before prolonged intermittent renal replacement therapy therapy commenced. The probability of target attainment (PTA) was calculated using each antibiotic's pharmacodynamic target during the first 48 hours of therapy. Optimal doses were defined as the smallest daily dose achieving ≥90% probability of target attainment in all prolonged intermittent renal replacement therapy effluent and duration combinations. Cefepime 1 g every 6 hours following a 2 g loading dose, ceftazidime 2 g every 12 hours, and piperacillin/tazobactam 4.5 g every 6 hours attained the desired pharmacodynamic target in ≥90% of modeled prolonged intermittent renal replacement therapy patients. Alternatively, if an every 6-hours cefepime regimen is not desired, the cefepime 2 g pre-prolonged intermittent renal replacement therapy and 3 g post-prolonged intermittent renal replacement therapy regimen also met targets. For ceftazidime, 1 g every 6 hours or 3 g continuous infusion following a 2 g loading dose also met targets. These recommended doses provide simple regimens that are likely to achieve the pharmacodynamics target while yielding the least overall drug exposure, which should result in lower toxicity rates. These findings should be validated in the clinical setting.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda School of Pharmacy, Loma Linda, CA, USA
| | - Katherine N Gharibian
- Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA
| | - Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA
| | - William H Fissell
- Nephrology and Hypertension Division, Vanderbilt University, School of Medicine and School of Engineering, Nashville, TN, USA
| | - Ashita J Tolwani
- Division of Nephrology, University of Alabama-Birmingham, School of Medicine, Birmingham, AL, USA
| | - Bruce A Mueller
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Pharmacokinetic/Pharmacodynamic Considerations of Beta-Lactam Antibiotics in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:9. [PMID: 29619607 DOI: 10.1007/s11908-018-0613-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Beta-lactam antibiotics are commonly prescribed in critically ill patients for a variety of infectious conditions. Our understanding of how critical illness alters beta-lactam pharmacokinetics/pharmacodynamics (PK/PD) is rapidly evolving. RECENT FINDINGS There is a growing body of literature in adult patients demonstrating that physiological alterations occurring in critically ill patients may limit our ability to optimally dose beta-lactam antibiotics to reach these PK/PD targets. These alterations include changes in volume of distribution and renal clearance with multiple, often overlapping causative pathways, including hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Strategies to overcome these PK alterations include extended infusions and therapeutic drug monitoring. Combined data has demonstrated a possible survival benefit associated with extending beta-lactam infusions in critically ill adult patients. This review highlights research on physiological derangements affecting beta-lactam concentrations and strategies to optimize beta-lactam PK/PD in critically ill adults.
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Udy AA, Roberts JA, Lipman J, Blot S. The effects of major burn related pathophysiological changes on the pharmacokinetics and pharmacodynamics of drug use: An appraisal utilizing antibiotics. Adv Drug Deliv Rev 2018; 123:65-74. [PMID: 28964882 DOI: 10.1016/j.addr.2017.09.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/31/2017] [Accepted: 09/22/2017] [Indexed: 12/13/2022]
Abstract
Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.
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Association between augmented renal clearance and clinical failure of antibiotic treatment in brain-injured patients with ventilator-acquired pneumonia: A preliminary study. Anaesth Crit Care Pain Med 2017; 37:35-41. [PMID: 28756331 DOI: 10.1016/j.accpm.2017.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This preliminary study aimed to determine whether augmented renal clearance (ARC) impacts negatively on the clinical outcome in traumatic brain-injured patients (TBI) treated for a first episode of ventilator-acquired pneumonia (VAP). METHODS During a 5-year period, all TBI patients who had developed VAP were retrospectively reviewed to assess variables associated with clinical failure in multivariate analysis. Clinical failure was defined as an impaired clinical response with a need for escalating antibiotics during treatment and/or within 15 days after the end-of-treatment. Recurrence was considered if at least one of the initial causative bacterial strains was growing at a significant concentration from a second sample. Augmented renal clearance (ARC) was defined by an enhanced creatinine clearance exceeding 130mL/min/1.73m2 calculated from a urinary sample during the first three days of antimicrobial therapy. MAIN RESULTS During the study period, 223 TBI patients with VAP were included and 59 (26%) presented a clinical failure. Factors statistically associated with clinical failure were GSC≤7 (OR=2.2 [1.1-4.4], P=0.03), early VAP (OR=3.9 [1.9-7.8], P=0.0001), bacteraemia (OR=11 [2.2-54], P=0.003) and antimicrobial therapy≤7 days (OR=3.7 [1.8-7.4], P=0.0003). ARC was statistically associated with recurrent infections with an OR of 4.4 [1.2-16], P=0.03. CONCLUSION ARC was associated with recurrent infection after a first episode of VAP in TBI patients. The optimal administration and dosing of the antimicrobial agents in this context remain to be determined.
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Roger C, Cotta MO, Muller L, Wallis SC, Lipman J, Lefrant JY, Roberts JA. Impact of renal replacement modalities on the clearance of piperacillin-tazobactam administered via continuous infusion in critically ill patients. Int J Antimicrob Agents 2017; 50:227-231. [PMID: 28689876 DOI: 10.1016/j.ijantimicag.2017.03.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/27/2017] [Accepted: 03/11/2017] [Indexed: 01/31/2023]
Abstract
This prospective pharmacokinetic study aimed to compare the clearance of piperacillin-tazobactam administered as a 24-h continuous infusion between continuous venovenous haemodiafiltration (CVVHDF) and continuous venovenous haemofiltration (CVVH) applied at equal dose in critically ill patients. A loading dose of 4.5 g of piperacillin-tazobactam followed by a continuous infusion (500 mg/h) was administered to patients randomized to receive CVVHDF or CVVH. Serial pre- and postfilter blood samples were drawn during an 8-h sampling interval. Piperacillin plasma concentrations were measured using a validated chromatography method. Piperacillin pharmacokinetics were calculated using a non-compartmental approach. In total, 212 piperacillin plasma concentrations were determined. Median [interquartile range (IQR)] total piperacillin clearance was 7.5 (5.9-11.2) L/h in the CVVHDF group and 4.7 (4.5-9.6) L/h in the CVVH group (P = 0.21). Median (IQR) piperacillin clearance related to continuous renal replacement therapy (CRRT) was 3.0 (2.7-3.2) L/h in the CVVHDF group and 2.6 (1.9-3.0) L/h in the CVVH group (P = 0.29). Mean (standard deviation) steady state concentrations were 68.4 (25.8) mg/L in the CVVHDF group and 89.1 (35.6) mg/L in the CVVH group (P = 0.16). The estimated unbound concentrations resulting from piperacillin continuous infusion were above the target susceptibility breakpoint (16 mg/L) for the entire dosing interval (100% fT>MIC) in all study patients. In the present study, higher (but not significantly) piperacillin clearance and lower piperacillin exposure were observed in patients receiving CVVHDF compared with CVVH. In patients receiving CRRT, the use of piperacillin continuous infusion should be considered to ensure optimal exposure for less susceptible pathogens.
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Affiliation(s)
- Claire Roger
- Service des réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, France; Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
| | - Menino O Cotta
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Royal Brisbane and Womens' Hospital, Brisbane, Queensland, Australia
| | - Laurent Muller
- Service des réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, France
| | - Steven C Wallis
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, Royal Brisbane and Womens' Hospital, Brisbane, Queensland, Australia
| | - Jean-Yves Lefrant
- Service des réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, France
| | - Jason A Roberts
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, Royal Brisbane and Womens' Hospital, Brisbane, Queensland, Australia; Pharmacy Department, Royal Brisbane and Womens' Hospital, Brisbane, Queensland, Australia
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Delattre IK, Taccone FS, Jacobs F, Hites M, Dugernier T, Spapen H, Laterre PF, Wallemacq PE, Van Bambeke F, Tulkens PM. Optimizing β-lactams treatment in critically-ill patients using pharmacokinetics/pharmacodynamics targets: are first conventional doses effective? Expert Rev Anti Infect Ther 2017; 15:677-688. [PMID: 28571493 DOI: 10.1080/14787210.2017.1338139] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The pharmacokinetic/pharmacodynamic index determining β-lactam activity is the percentage of the dosing interval (%T) during which their free serum concentration remains above a critical threshold over the minimum inhibitory concentration (MIC). Regrettably, neither the value of %T nor that of the threshold are clearly defined for critically-ill patients. Areas covered: We review and assess the targets proposed for β-lactams in critical illness by screening the literature since 1997. Depending on the study intention (clinical cure vs. suppression of resistance), targets proposed range from 20%T > 1xMIC to 100%T > 5xMIC. Assessment and comparative analysis of their respective clinical efficacy suggest that a value of 100%T > 4xMIC may be needed. Simulation studies, however, show that this target will not be reached at first dose for the majority of critically-ill patients if using the most commonly recommended doses. Expert commentary: Considering that critically-ill patients are highly vulnerable and likely to experience antibiotic underexposure, and because effective initial treatment is a key determinant of clinical outcome, we support the use of a target of 100%T > 4xMIC, which could not only maximize efficacy but also minimize emergence of resistance. Clinical and microbiological studies are needed to test for the feasibility and effectiveness of reaching such a demanding target.
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Affiliation(s)
- Isabelle K Delattre
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium.,b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Fabio S Taccone
- c Department of Intensive Care , Hôpital Erasme , Brussels , Belgium
| | - Frédérique Jacobs
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Maya Hites
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Thierry Dugernier
- e Department of Intensive Care , Clinique St-Pierre , Ottignies , Belgium
| | - Herbert Spapen
- f Department of Intensive Care , Universitair Ziekenhuis Brussel , Brussels , Belgium
| | | | - Pierre E Wallemacq
- b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Françoise Van Bambeke
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
| | - Paul M Tulkens
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
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Chen R, Qian Q, Sun MR, Qian CY, Zou SL, Wang ML, Wang LY. Population Pharmacokinetics and Pharmacodynamics of Piperacillin/Tazobactam in Patients with Nosocomial Infections. Eur J Drug Metab Pharmacokinet 2017; 41:363-72. [PMID: 25894901 DOI: 10.1007/s13318-015-0276-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The study was to establish a population pharmacokinetic (PPK) model of piperacillin (PIP) and tazobactam (TAZ) that explain pharmacokinetic variability and to propose optimized dosage regimens in patients with nosocomial infections. METHODS In total, 310 PIP and 280 TAZ concentration-time points were collected at steady state over multiple dosing intervals from 50 patients who received PIP/TAZ infused within 30 min or over 3 h. Drug analysis was performed by high-performance liquid chromatography (HPLC). Nonlinear mixed effects modeling was employed to develop PPK model and 1000 Monte Carlo simulation was used to predict the probability of target attainment (PTA) with a target time of non-protein-bound concentration above MIC > 50 % of the dosing interval. RESULTS A model with one-compartment model had the best predictive performance for the PPK model. The population estimates of PIP were 13.8 L/h (31.1 %) for clearance (CL) and 21.7 L (38 %) for volume of distribution (V). The population estimates of TAZ were 9.3 L/h (29.1 %) for CL and 16 L (35.3 %) for V. Influence of creatinine clearance (CLcr) and body weight were identified as important covariates for PIP/TAZ CL and V, respectively. A 30-min infusion of 4 g every 6 h achieved robust (≥90 %) PTAs for MIC ≤ 16 mg/L. As an alternative mode of administration, a 3-h infusion of 4 g every 6 h achieved robust PTAs for Pseudomonas aeruginosa and Klebsiella pneumoniae. CONCLUSIONS Prolonged infusions achieved better PTAs compared with shorter infusions at similar daily doses. This benefit was most pronounced for MICs between 16 and 40 mg/L.
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Affiliation(s)
- Rong Chen
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
| | - Qing Qian
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
| | - Meng-Ru Sun
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
| | - Chun-Yan Qian
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
| | - Su-Lan Zou
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
| | - Ming-Li Wang
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China.
| | - Li-Ying Wang
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, Changzhou, Jiang Su, China
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40
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Zander J, Döbbeler G, Nagel D, Scharf C, Huseyn-Zada M, Jung J, Frey L, Vogeser M, Zoller M. Variability of piperacillin concentrations in relation to tazobactam concentrations in critically ill patients. Int J Antimicrob Agents 2016; 48:435-9. [PMID: 27476810 DOI: 10.1016/j.ijantimicag.2016.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 06/16/2016] [Accepted: 06/18/2016] [Indexed: 11/18/2022]
Abstract
Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is described as a useful tool. However, the minimum inhibitory concentration of piperacillin depends on a sufficiently high concentration of tazobactam in case of β-lactamase-producing strains. Therefore, the relationship between piperacillin and tazobactam concentrations was assessed in a heterogeneous group of critically ill patients. Sixty patients with severe infections receiving 4.5 g of piperacillin/tazobactam 2-3 times daily by intermittent infusion were included in this prospective observational study (NCT01793012). Over 4 days, multiple serum samples were obtained to determine the total piperacillin and tazobactam concentrations. The target ranges were defined as trough levels >16 mg/L (>22.5 mg/L) and >4 mg/L (>5.7 mg/L) for the calculated unbound concentrations (measured total concentrations) of piperacillin and tazobactam, respectively. Despite a high correlation coefficient (r = 0.93) comparing piperacillin and tazobactam trough levels, the piperacillin/tazobactam quotients varied between ca. 1 and 10. From linear regression analysis of piperacillin versus tazobactam values, it follows that a piperacillin trough level of 22.5 mg/L might be associated with tazobactam trough levels ranging from 1.5 mg/L to 10.1 mg/L. A 70 mg/L threshold for total piperacillin trough levels would be necessary to ensure that tazobactam concentrations are >5.7 mg/L. Because of the observed variability of piperacillin/tazobactam quotients, defining the total piperacillin target range ≥70 mg/L might be useful to ensure that tazobactam concentrations do not fall below 5.7 mg/L. Further studies are necessary to confirm that the used therapeutic ranges are associated with optimal outcomes in critically ill patients.
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Affiliation(s)
- Johannes Zander
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Gundula Döbbeler
- Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Dorothea Nagel
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Mikayil Huseyn-Zada
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Jette Jung
- Max von Pettenkofer-Institute, Ludwig-Maximilians-University of Munich, Marchioninistrasse 17, 81377 Munich, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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41
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Zander J, Döbbeler G, Nagel D, Maier B, Scharf C, Huseyn-Zada M, Jung J, Frey L, Vogeser M, Zoller M. Piperacillin concentration in relation to therapeutic range in critically ill patients--a prospective observational study. Crit Care 2016; 20:79. [PMID: 27039986 PMCID: PMC4819271 DOI: 10.1186/s13054-016-1255-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/24/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Piperacillin levels after standard dosing have been shown frequently to be subtherapeutic, especially when renal clearance was augmented. Here, we aimed to determine if piperacillin was in its therapeutic range in a typically heterogeneous intensive care unit patient group, and also to describe target attainment dependent on daily dosage, creatinine clearance, and renal replacement therapy (RRT). METHODS Sixty patients with severe infections were included in this monocentric prospective observational study. Patients received 4.5 g of piperacillin-tazobactam two to three times daily by intermittent infusion depending on renal function according to clinical guidelines. Over 4 days, multiple serum samples (median per patient, 29; in total, 1627) were obtained to determine total piperacillin concentrations using ultra-high-performance liquid chromatography/tandem mass spectrometry. RESULTS A high heterogeneity of patient characteristics was observed (e.g., on day 1: creatinine clearance 2-233 mL/min and ten patients on RRT). Piperacillin trough levels showed inter-individual variation from 123 to >1785-fold on different study days. Each day, approximately 50% and 60% of the patients had piperacillin levels below the target ranges 1 and 2, respectively [defined for the calculated unbound piperacillin fraction according to the literature as 100% time above MIC (100%fT > MIC) (target range 1) and ≥ 50%fT > 4 × MIC (target range 2); MIC = 16 mg/L]. Whereas only the minority of patients who received piperacillin-tazobactam three times daily (TID) reached target 1 (38% on day 1), most patients who received piperacillin-tazobactam only twice daily (BID) because of severely impaired renal function reached this target (100% on day 1). Patients with RRT had significant higher percentages of fT > MIC. Zero percent, 55% and 100% of patients without RRT who received antibiotics TID reached target 1 when creatinine clearance was > 65 mL/min, 30-65 mL/min and < 30 mL/min, respectively. In patients with causative strains only sensitive to piperacillin-tazobactam of all antibiotics given to the patient, piperacillin levels negatively correlated with CRP concentrations of day 4 (p < 0.05). CONCLUSIONS A dosage of 4.5 g piperacillin-tazobactam TID seems to be frequently insufficient in critically ill patients, and also in patients where renal function is mildly to moderately impaired. For these patients, prescription of 4.5 g piperacillin-tazobactam four times daily could be considered. TRIAL REGISTRATION Clinicaltrials.gov NCT01793012. Registered 24 January 2013.
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Affiliation(s)
- Johannes Zander
- />Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Gundula Döbbeler
- />Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Dorothea Nagel
- />Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Barbara Maier
- />Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Christina Scharf
- />Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Mikayil Huseyn-Zada
- />Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Jette Jung
- />Max von Pettenkofer-Institute, Ludwig-Maximilians-University of Munich, Marchioninistrasse 17, 81377 Munich, Germany
| | - Lorenz Frey
- />Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Vogeser
- />Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Zoller
- />Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-University of Munich, Marchioninistrasse 15, 81377 Munich, Germany
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Ulldemolins M, Martín-Loeches I, Llauradó-Serra M, Fernández J, Vaquer S, Rodríguez A, Pontes C, Calvo G, Torres A, Soy D. Piperacillin population pharmacokinetics in critically ill patients with multiple organ dysfunction syndrome receiving continuous venovenous haemodiafiltration: effect of type of dialysis membrane on dosing requirements. J Antimicrob Chemother 2016; 71:1651-9. [PMID: 26869692 DOI: 10.1093/jac/dkv503] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/29/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES This multicentre study aimed to describe the pharmacokinetics (PK) of piperacillin in critically ill patients with multiple organ dysfunction syndrome (MODS) receiving continuous venovenous haemodiafiltration (CVVHDF), to identify the sources of PK variability and evaluate different dosing regimens to develop recommendations based on clinical parameters. PATIENTS AND METHODS Nineteen patients with MODS and CVVHDF receiving piperacillin/tazobactam were enrolled from three tertiary hospitals (95 plasma samples). Population PK modelling and Monte Carlo simulations were performed using NONMEM v7.3(®). RESULTS Patients' median age was 70 years (range 39-82), median weight was 80 kg (45-129), median APACHE II score at admission was 21 (13-33) and median SOFA score on the day of study was 11 (8-21). The final population PK model was characterized by CL (L/h) = 6.11 * [weight (kg)/80](1.39) * CLMEMB. If membrane = 1.5 m(2) AN69ST, CLMEMB = 1; if membrane = 0.9 m(2) AN69, CLMEMB = 0.51. Monte Carlo simulations showed that: (i) to maintain unbound piperacillin concentrations above the MIC for the bacteria for 100% of dosing interval T (100%fuT>MIC), patients receiving CVVHDF with 1.5 m(2) AN69ST membranes required doses of 4000 mg q8h for the treatment of bacteria with a susceptibility to piperacillin close to the clinical breakpoint (MIC = 8-16 mg/L) (2000 mg q8h was sufficient for patients with CVVHDF using 0.9 m(2) AN69 membranes); and (ii) for the treatment of bacteria with high susceptibility to piperacillin (MIC <4 mg/L) or for the attainment of a more traditional pharmacodynamic target (50%fuT>MIC), 2000 mg q8h sufficed regardless of type of membrane and body weight. CONCLUSIONS Our results suggest that type of membrane and body weight should be considered for piperacillin dose titration in critically ill patients with MODS and CVVHDF requirement.
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Affiliation(s)
- Marta Ulldemolins
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Critical Care Department, Sabadell Hospital, University Institute Parc Taulí - Universitat Autònoma de Barcelona (UAB), Sabadell, Spain Universitat de Barcelona (UB), Barcelona, Spain
| | - Ignacio Martín-Loeches
- Critical Care Department, Sabadell Hospital, University Institute Parc Taulí - Universitat Autònoma de Barcelona (UAB), Sabadell, Spain Multidisciplinary Intensive Care Research Organization (MICRO), Critical Care Department, St James University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Mireia Llauradó-Serra
- Nursing Department, Universitat Rovira i Virgili (URV), Tarragona, Spain Critical Care Department, Joan XXIII University Hospital, Institut d'Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, Tarragona, Spain
| | - Javier Fernández
- Universitat de Barcelona (UB), Barcelona, Spain Liver Department, Hospital Clínic de Barcelona, Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Madrid, Spain
| | - Sergi Vaquer
- Critical Care Department, Sabadell Hospital, University Institute Parc Taulí - Universitat Autònoma de Barcelona (UAB), Sabadell, Spain
| | - Alejandro Rodríguez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Critical Care Department, Joan XXIII University Hospital, Institut d'Investigació Sanitària Pere Virgili (IISPV), Universitat Rovira i Virgili, Tarragona, Spain
| | - Caridad Pontes
- Clinical Pharmacology Unit, Hospital de Sabadell, Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona, Sabadell, Spain Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Gonzalo Calvo
- Universitat de Barcelona (UB), Barcelona, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Department of Clinical Pharmacology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antoni Torres
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Universitat de Barcelona (UB), Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Respiratory Critical Care Unit, Pneumology Department, Institut Clínic del Tòrax, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Dolors Soy
- Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain Universitat de Barcelona (UB), Barcelona, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain Pharmacy Department, Hospital Clínic de Barcelona, Barcelona, Spain
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Tamme K, Oselin K, Kipper K, Tasa T, Metsvaht T, Karjagin J, Herodes K, Kern H, Starkopf J. Pharmacokinetics and pharmacodynamics of piperacillin/tazobactam during high volume haemodiafiltration in patients with septic shock. Acta Anaesthesiol Scand 2016; 60:230-40. [PMID: 26830215 DOI: 10.1111/aas.12629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/26/2015] [Accepted: 06/29/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of the study was to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of piperacillin and tazobactam during high-volume haemodiafiltration (HVHDF). METHODS A single dose of piperacillin/tazobactam (4/0.5 g) was administered as 30 minute infusion during HVHDF to 10 patients with acute kidney injury due to septic shock. Arterial blood samples were collected before and at 30 or 60 min intervals over 8 h (12 samples) after study drug administration. Concentrations of piperacillin and tazobactam were determined by HPLC-MS/MS. R software was used for population PK analysis and Monte Carlo Simulation of probability of PK/PD target attainment (PTA) in 1000 subjects. RESULTS A total of 101 samples were collected during HVHDF. The median (IQR) estimated glomerular filtration rate of the patients was 16 (11.25-27.5) ml/min/1.73 m(2) and HVHDF effluent rate was 208 (146.3-298.3) ml/kg/h. A final two-compartment population PK model predicted mean (%SE) total piperacillin clearance on HVHDF was 6.9 (6.4) l/h, volume of distribution of central compartment 9.0 (10.1) l and of peripheral compartment 11.2 (12.2) l. The PTA of 50% fT>MIC for piperacillin 4 g/tazobactam 0.5 g dosed every 8 h as 0.5-h and 4-h infusion was 84.3% and 100% for MIC of 16 mg/l respectively. Aiming 100% fT>MIC of 16 mg/l, the PTA values were 88.6% and 61.0%, for piperacillin 4 g/tazobactam 0.5 g 4-h infusion every 6 and 8 h respectively. CONCLUSIONS For bactericidal PK/PD target attainment piperacillin/tazobactam doses of 4/0.5 g every 8 h appear appropriate in septic shock patients with minimal residual renal function during HVHDF.
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Affiliation(s)
- K. Tamme
- Clinic of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
| | - K. Oselin
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
| | - K. Kipper
- Testing Centre; Institute of Chemistry; University of Tartu; Tartu Estonia
| | - T. Tasa
- Faculty of Mathematics and Computer Science; University of Tartu; Tartu Estonia
| | - T. Metsvaht
- Clinic of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
| | - J. Karjagin
- Clinic of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
| | - K. Herodes
- Testing Centre; Institute of Chemistry; University of Tartu; Tartu Estonia
| | - H. Kern
- Clinic of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
- Department of Anaesthesiology and Intensive Care; DRK Kliniken; Berlin Köpenick Germany
| | - J. Starkopf
- Clinic of Anaesthesiology and Intensive Care; Tartu University Hospital; Tartu Estonia
- Department of Anaesthesiology and Intensive Care; University of Tartu; Tartu Estonia
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Awissi DK, Beauchamp A, Hébert E, Lavigne V, Munoz DL, Lebrun G, Savoie M, Fagnan M, Amyot J, Tétreault N, Robitaille R, Varin F, Lavallée C, Pichette V, Leblanc M. Pharmacokinetics of an extended 4-hour infusion of piperacillin-tazobactam in critically ill patients undergoing continuous renal replacement therapy. Pharmacotherapy 2016; 35:600-7. [PMID: 26095008 DOI: 10.1002/phar.1604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the pharmacokinetic and pharmacodynamic profiles of piperacillin-tazobactam administered as a 4-hour infusion in critically ill patients undergoing continuous renal replacement therapy (CRRT). DESIGN Prospective, observational, pharmacokinetic study. SETTING Intensive care unit of a tertiary care hospital in Montréal, Canada. PATIENTS Twenty critically ill adults who were undergoing continuous venovenous hemodiafiltration and receiving a 4-hour infusion of piperacillin 4 g-tazobactam 0.5 g every 8 hours for a documented or suspected infection. INTERVENTION Blood samples were collected every hour over an 8-hour dosing interval. Prefilter and postfilter blood samples, and effluent and urine samples were also collected. MEASUREMENTS AND MAIN RESULTS The primary outcome was the proportion of patients who achieved an unbound piperacillin plasma concentration above a target minimum inhibitory concentration (MIC) of 64 mg/L (MIC that inhibits 90% of isolates for Pseudomonas aeruginosa) for at least 50% of the dosing interval; 18 (90%) of the 20 patients achieved this outcome. In all patients, the free piperacillin concentrations were above the Pseudomonas aeruginosa breakpoint of 16 mg/L for the entire time interval. Regarding piperacillin pharmacokinetic parameters, the median (interquartile range) minimum unbound plasma concentration was 65.15 mg/L (51.30-89.30), maximum unbound plasma concentration was 141.3 mg/L (116.75-173.90), sieving coefficient was 0.809 (0.738-0.938), total clearance was 65.82 ml/minute (53.79-102.87), and renal clearance was 0.16 ml/minute (0.05-3.04). The median CRRT dose was 32.0 ml/kg/h (25.0-39.8). CONCLUSIONS Administration of a 4-hour infusion of piperacillin-tazobactam was associated with a favorable pharmacodynamic profile in patients undergoing CRRT. Concentrations associated with maximal activity were attained in our patients.
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Affiliation(s)
- Don-Kelena Awissi
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Annie Beauchamp
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Elisabeth Hébert
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Viviane Lavigne
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Danya Lucia Munoz
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Geneviève Lebrun
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Michel Savoie
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Mylène Fagnan
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Julie Amyot
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Nicolas Tétreault
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Robert Robitaille
- Biochemistry Department, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - France Varin
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Christian Lavallée
- Department of Infectious Diseases and Medical Microbioloy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Vincent Pichette
- Department of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Martine Leblanc
- Department of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.,Intensive Care Unit, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
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Sy SKB, Zhuang L, Derendorf H. Pharmacokinetics and pharmacodynamics in antibiotic dose optimization. Expert Opin Drug Metab Toxicol 2015; 12:93-114. [DOI: 10.1517/17425255.2016.1123250] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fishovitz J, Taghizadeh N, Fisher JF, Chang M, Mobashery S. The Tipper-Strominger Hypothesis and Triggering of Allostery in Penicillin-Binding Protein 2a of Methicillin-Resistant Staphylococcus aureus (MRSA). J Am Chem Soc 2015; 137:6500-5. [PMID: 25964995 DOI: 10.1021/jacs.5b01374] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The transpeptidases involved in the synthesis of the bacterial cell wall (also known as penicillin-binding proteins, PBPs) have evolved to bind the acyl-D-Ala-D-Ala segment of the stem peptide of the nascent peptidoglycan for the physiologically important cross-linking of the cell wall. The Tipper-Strominger hypothesis stipulates that β-lactam antibiotics mimic the acyl-D-Ala-D-Ala moiety of the stem and, thus, are recognized by the PBPs with bactericidal consequences. We document that this mimicry exists also at the allosteric site of PBP2a of methicillin-resistant Staphylococcus aureus (MRSA). Interactions of different classes of β-lactam antibiotics, as mimics of the acyl-D-Ala-D-Ala moiety at the allosteric site, lead to a conformational change, across a distance of 60 Å to the active site. We directly visualize this change using an environmentally sensitive fluorescent probe affixed to the protein loops that frame the active site. This conformational mobility, documented in real time, allows antibiotic access to the active site of PBP2a. Furthermore, we document that this allosteric trigger enables synergy between two different β-lactam antibiotics, wherein occupancy at the allosteric site by one facilitates occupancy by a second at the transpeptidase catalytic site, thus lowering the minimal-inhibitory concentration. This synergy has important implications for the mitigation of facile emergence of resistance to these antibiotics by MRSA.
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Affiliation(s)
- Jennifer Fishovitz
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana 46556, United States
| | - Negin Taghizadeh
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana 46556, United States
| | - Jed F Fisher
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana 46556, United States
| | - Mayland Chang
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana 46556, United States
| | - Shahriar Mobashery
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, Indiana 46556, United States
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47
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Canut A, Isla A, Rodríguez-Gascón A. Pharmacokinetic/pharmacodynamic analysis to evaluate ceftaroline fosamil dosing regimens for the treatment of community-acquired bacterial pneumonia and complicated skin and skin-structure infections in patients with normal and impaired renal function. Int J Antimicrob Agents 2015; 45:399-405. [PMID: 25700566 DOI: 10.1016/j.ijantimicag.2014.12.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 12/12/2014] [Accepted: 12/16/2014] [Indexed: 11/27/2022]
Abstract
In this study, the probability of pharmacokinetic/pharmacodynamic target attainment (PTA) of ceftaroline against clinical isolates causing community-acquired bacterial pneumonia (CABP) and complicated skin and skin-structure infection (cSSSI) in Europe was evaluated. Three dosing regimens were assessed: 600 mg every 12 h (q12 h) as a 1-h infusion (standard dose) or 600 mg every 8 h (q8 h) as a 2-h infusion in virtual patients with normal renal function; and 400 mg q12 h as a 1-h infusion in patients with moderate renal impairment. Pharmacokinetic and microbiological data were obtained from the literature. The PTA and the cumulative fraction of response (CFR) were calculated by Monte Carlo simulation. In patients with normal renal function, the ceftaroline standard dose (600 mg q12 h as a 1-h infusion) can be sufficient to treat CABP due to ceftazidime-susceptible (CAZ-S) Escherichia coli, CAZ-S Klebsiella pneumoniae, meticillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis (CFR>90%). However, against meticillin-resistant S. aureus (MRSA), the CFR was 72%. In cSSSI, the CFR was also <80% for MRSA. Administration of ceftaroline 600 mg q8 h as a 2-h infusion or 400 mg q12 h as a 1-h infusion in patients with moderate renal insufficiency provided a high probability of treatment success (CFR ca. 100%) for most micro-organisms causing CABP and cSSSI, including MRSA and penicillin-non-susceptible S. pneumoniae. These results suggest that in patients with normal renal function, ceftaroline 600 mg q8 h as a 2-h infusion may be a better option than the standard dose, especially if the MRSA rate is high.
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Affiliation(s)
- A Canut
- Microbiology Service, Hospital Universitario de Álava, Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, Spain; Instituto de Investigación Sanitaria de Álava (BIOARABA), Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, Spain
| | - A Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - A Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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Jamal JA, Roberts DM, Udy AA, Mat-Nor MB, Mohamad-Nor FS, Wallis SC, Lipman J, Roberts JA. Pharmacokinetics of piperacillin in critically ill patients receiving continuous venovenous haemofiltration: A randomised controlled trial of continuous infusion versus intermittent bolus administration. Int J Antimicrob Agents 2015; 46:39-44. [PMID: 25881872 DOI: 10.1016/j.ijantimicag.2015.02.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/26/2022]
Abstract
Here we describe the pharmacokinetics of piperacillin administered by continuous infusion (CI) versus intermittent bolus (IB) dosing in critically ill patients receiving continuous venovenous haemofiltration (CVVH) and compare the frequency of pharmacodynamic/pharmacokinetic (PK/PD) target attainment with each dosing strategy. This was a prospective pharmacokinetic trial in 16 critically ill patients with severe sepsis or septic shock undergoing CVVH and randomised to receive either CI or IB administration of a standard daily dose of piperacillin/tazobactam (11.25g/day on Day 1 followed by 9g/day). Serial blood samples were measured on two occasions. Piperacillin pharmacokinetics were calculated using a non-compartmental approach. Blood concentrations were compared with established PK/PD targets. On occasion 1 (Days 1-3 of therapy), IB administration resulted in significantly higher piperacillin peak concentrations (169 vs. 89mg/L; P=0.002), whereas significantly higher steady-state concentrations were observed in CI patients (83 vs. 57mg/L; P=0.04). Total clearance and clearance not mediated by CVVH were significantly higher with CI administration [median (interquartile range), 1.0 (0.7-1.1) and 0.8 (0.6-1.0)mL/kg/min; P=0.001 and 0.001, respectively]. The estimated unbound piperacillin concentrations were four times above the target susceptibility breakpoint (16mg/L) for the entire dosing interval (100%fT>4xMIC) in 87.5% of patients receiving CI administration (sampling occasion 1), compared with 62.5% of IB patients achieving the desired target (50%fT>4xMIC). Compared with IB dosing, and despite similar CVVH settings, CI administration of piperacillin results in a pharmacokinetic profile that may optimise outcomes for less susceptible pathogens.
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Affiliation(s)
- Janattul-Ain Jamal
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Darren M Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew A Udy
- Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
| | - Mohd-Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, Kulliyyah of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | | | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Pharmacy, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Asín-Prieto E, Rodríguez-Gascón A, Isla A. Applications of the pharmacokinetic/pharmacodynamic (PK/PD) analysis of antimicrobial agents. J Infect Chemother 2015; 21:319-29. [PMID: 25737147 DOI: 10.1016/j.jiac.2015.02.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/20/2015] [Accepted: 02/02/2015] [Indexed: 12/15/2022]
Abstract
The alarming increase of resistance against multiple currently available antibiotics is leading to a rapid lose of treatment options against infectious diseases. Since the antibiotic resistance is partially due to a misuse or abuse of the antibiotics, this situation can be reverted when improving their use. One strategy is the optimization of the antimicrobial dosing regimens. In fact, inappropriate drug choice and suboptimal dosing are two major factors that should be considered because they lead to the emergence of drug resistance and consequently, poorer clinical outcomes. Pharmacokinetic/pharmacodynamic (PK/PD) analysis in combination with Monte Carlo simulation allows to optimize dosing regimens of the antibiotic agents in order to conserve their therapeutic value. Therefore, the aim of this review is to explain the basis of the PK/PD analysis and associated techniques, and provide a brief revision of the applications of PK/PD analysis from a therapeutic point-of-view. The establishment and reevaluation of clinical breakpoints is the sticking point in antibiotic therapy as the clinical use of the antibiotics depends on them. Two methodologies are described to establish the PK/PD breakpoints, which are a big part of the clinical breakpoint setting machine. Furthermore, the main subpopulations of patients with altered characteristics that can condition the PK/PD behavior (such as critically ill, elderly, pediatric or obese patients) and therefore, the outcome of the antibiotic therapy, are reviewed. Finally, some recommendations are provided from a PK/PD point of view to enhance the efficacy of prophylaxis protocols used in surgery.
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Affiliation(s)
- Eduardo Asín-Prieto
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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50
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Ulldemolins M, Vaquer S, Llauradó-Serra M, Pontes C, Calvo G, Soy D, Martín-Loeches I. Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:227. [PMID: 25042938 PMCID: PMC4075152 DOI: 10.1186/cc13938] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required to compensate the increased volume of distribution, regardless of impaired organ function. An additional loading dose may be required when CRRT is initiated due to steady-state equilibrium breakage driven by clearance variation. From day 2, dosing must be adjusted to CRRT settings and residual renal function. Therapeutic drug monitoring of beta-lactams may be regarded as a useful tool to daily individualize dosing and to ensure optimal antibiotic exposure.
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