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Lafon-Desmurs B, Gachet B, Hennart B, Valentin B, Roosen G, Degrendel M, Loiez C, Beltrand E, D'Elia P, Migaud H, Robineau O, Senneville E. Dalbavancin as suppressive therapy for implant-related infections: a case series with therapeutic drug monitoring and review of the literature. Eur J Clin Microbiol Infect Dis 2024; 43:1475-1480. [PMID: 38753112 DOI: 10.1007/s10096-024-04849-0] [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: 12/21/2023] [Accepted: 05/07/2024] [Indexed: 07/20/2024]
Abstract
Implant-related infections may need suppressive antibiotic therapy (SAT). We describe a SAT strategy using dalbavancin with therapeutic drug monitoring (TDM). This is a retrospective bicentric study of patients with implant-related infection who received dalbavancin SAT between January 2021 and September 2023. Fifteen patients were included. Median number of injections was 4 (IQR: 2-7). Median time between two reinjections was 57 days (IQR 28-82). Dalbavancin plasma concentrations were above 4 mg/L for 97.9% of dosages (93/95) and above 8 mg/L for 85% (81/95). These results support the use of dalbavancin SAT for implant-related infections.
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Affiliation(s)
- Barthelemy Lafon-Desmurs
- Centre Hospitalier Gustave Dron, Department of Infectious Diseases, Service Universitaire Des Maladies Infectieuses, 59210, Tourcoing, France.
| | - Benoit Gachet
- Centre Hospitalier Gustave Dron, Department of Infectious Diseases, Service Universitaire Des Maladies Infectieuses, 59210, Tourcoing, France
- METRICS ULR 2694, Biostatistics, Lille, France
| | - Benjamin Hennart
- Lille University Hospital, Department of Pharmacology and Toxicology, Lille, France
| | - Benjamin Valentin
- Lille University Hospital, Department of Pharmacology, Lille, France
| | - Gabrielle Roosen
- Centre Hospitalier Gustave Dron, Department of Microbiology, Tourcoing, France
| | - Maxime Degrendel
- Centre Hospitalier Gustave Dron, Department of Infectious Diseases, Service Universitaire Des Maladies Infectieuses, 59210, Tourcoing, France
| | - Caroline Loiez
- Lille University Hospital, Department of Microbiology, Lille, France
| | - Eric Beltrand
- Centre Hospitalier Gustave Dron, Department of Orthopedic Surgery, Tourcoing, France
| | - Piervito D'Elia
- Centre Hospitalier Gustave Dron, Départment of Vascular Surgery, Tourcoing, France
| | - Henri Migaud
- Lille University Hospital, Department of Orthopedic Surgery, Lille, France
| | - Olivier Robineau
- Centre Hospitalier Gustave Dron, Department of Infectious Diseases, Service Universitaire Des Maladies Infectieuses, 59210, Tourcoing, France
- METRICS ULR 2694, Biostatistics, Lille, France
- INSERM UMR-S 1136, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, Paris, France
| | - Eric Senneville
- Centre Hospitalier Gustave Dron, Department of Infectious Diseases, Service Universitaire Des Maladies Infectieuses, 59210, Tourcoing, France
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2
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Pardo I, Pierre-Jean M, Bouzillé G, Fauchon H, Corvol A, Prud'homm J, Somme D. Safety of subcutaneous versus intravenous ceftriaxone administration in older patients: A retrospective study. J Am Geriatr Soc 2024; 72:1060-1069. [PMID: 38348519 DOI: 10.1111/jgs.18786] [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: 09/22/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Antibiotics play a central role in infection management. In older patients, antibiotics are frequently administered subcutaneously. Ceftriaxone pharmacokinetics after subcutaneous administration is well documented, but little data are available on its safety. METHODS We compared the occurrence of adverse events associated with ceftriaxone administered subcutaneously versus intravenously in ≥75-year-old patients. We used data from a single-center, retrospective, clinical-administrative database to compare the occurrence of adverse events at day 14 and outcome at day 21 in older patients who received ceftriaxone via the subcutaneous route or the intravenous route at Rennes University Hospital, France, from May 2020 to February 2023. RESULTS The subcutaneous and intravenous groups included 402 and 3387 patients, respectively. Patients in the subcutaneous group were older and more likely to receive palliative care. At least one adverse event was reported for 18% and 40% of patients in the subcutaneous and intravenous group, respectively (RR = 2.21). Mortality at day 21 was higher in the subcutaneous route group, which could be linked to between-group differences in clinical and demographic features. CONCLUSIONS In ≥75-year-old patients, ceftriaxone administered by the subcutaneous route is associated with less-adverse events than by the intravenous route. The subcutaneous route, which is easier to use, has a place in infection management in geriatric settings.
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Affiliation(s)
- Inès Pardo
- Univ Rennes, CHU Rennes, Service de Gériatrie, Rennes, France
| | | | | | - Heloïse Fauchon
- Univ Rennes, CHU Rennes, Service de Gériatrie, Rennes, France
| | - Aline Corvol
- Univ Rennes, CHU Rennes, CNRS, ARENES - UMR 6051, RSMS - U 1309, Rennes, France
| | | | - Dominique Somme
- Univ Rennes, CHU Rennes, CNRS, ARENES - UMR 6051, RSMS - U 1309, Rennes, France
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3
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Leanza GM, Liguoro B, Giuliano S, Moreal C, Montanari L, Angelini J, Cai T, Murri R, Tascini C. The Subcutaneous Administration of Beta-Lactams: A Case Report and Literary Review-To Do Small Things in a Great Way. Infect Dis Rep 2024; 16:93-104. [PMID: 38391585 PMCID: PMC10887887 DOI: 10.3390/idr16010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/24/2024] Open
Abstract
The subcutaneous (s.c.) route is a commonly used method for delivering various drugs, although its application in the administration of antibiotics is relatively uncommon. In this case, we report a successful treatment of nosocomial pneumonia using piperacillin/tazobactam via continuous subcutaneous administration. Furthermore, this article provides an overview of the current literature regarding the s.c. administration of beta-lactam antibiotics. Based on our analysis, we identified only 15 studies that described the s.c. use of beta-lactam antibiotics in human subjects. Among these studies, cephalosporins were the most extensively investigated antibiotic class, with 10 available studies. According to the study findings, all three antibiotic classes (cephalosporins, penicillins, and carbapenems) demonstrated a similar pharmacokinetic profile when administered via the subcutaneous route. The subcutaneous route appears to be associated with a lower peak serum concentration (Cmax) but a comparable minimum blood concentration (Cmin) and an extended half-life (t1/2) when compared to conventional routes of antibiotic administration. Further research is necessary to determine whether subcutaneously administered beta-lactam antibiotics in human subjects achieve pharmacodynamic targets and demonstrate clinical efficacy.
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Affiliation(s)
- Gabriele Maria Leanza
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del S. Cuore, 00168 Rome, Italy
| | - Beatrice Liguoro
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del S. Cuore, 00168 Rome, Italy
| | - Simone Giuliano
- Infectious Diseases Clinic, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Chiara Moreal
- Infectious Diseases Clinic, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Luca Montanari
- Infectious Diseases Clinic, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Jacopo Angelini
- Pharmacology Institute, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, 38123 Trento, Italy
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
| | - Rita Murri
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del S. Cuore, 00168 Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Azienda Sanitaria Universitaria del Friuli Centrale (ASUFC), 33100 Udine, Italy
- Infectious Diseases Clinic, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
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4
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Sánchez-Cárdenas MA, Vargas-Escobar LM, Correa-Morales JE, Michelsen-Andrade M, González-Salazar L, Muñoz-Olivar C, López Alba JA, León-Delgado MX. Effectiveness of Subcutaneous Administration of Antibiotics to Control Infections in Elder Palliative Patients: A Systematic Review. Am J Hosp Palliat Care 2023; 40:1379-1389. [PMID: 36964691 DOI: 10.1177/10499091231156866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Background: Infections are common in patients with advanced illnesses for whom the intravenous or oral route is not possible. The subcutaneous administration of antibiotics is a promising alternative, but there is not enough theoretical support for its use. This study aims to explore the effectiveness and safety of subcutaneous antibiotic therapy in the context of palliative care in elderly patients. Methods: A systematic review was conducted using PubMed and Embase, without time or language limits. Seven articles were selected on the effectiveness of subcutaneous antibiotic therapy in adult patients with chronic progressive diseases. The quality of the articles was assessed with the Newcastle Ottawa Scale and relevant data was extracted using a selection capture file. Results: Seven quasi-experimental studies evaluated 865 elderly patients with advanced diseases, comorbidities, and infections (ie, urinary tract, respiratory system, and bone joint) who received subcutaneous antibiotic therapy (ie, Ceftriaxone, Ertapenem, and Teicoplanin). The pooled success rate of subcutaneous antibiotics for the 7 studies was 71%, the therapy failure rate was 22%, its withdrawal mean was 8%, and the mean mortality rate was 7%. The studies were of low quality and were heterogeneous in the types of infections, types of antibiotics, time of follow-up, and outcomes assessed. Conclusions: Pilot studies have found a limited number of antibiotics that can be safely used to treat specific infections. Nevertheless, the data isn´t robust enough to recommend their use.
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Ruiz-Sancho A, Núñez-Núñez M, Castelo-Corral L, Martínez-Marcos FJ, Lois-Martínez N, Abdul-Aziz MH, Vinuesa-García D. Dalbavancin as suppressive antibiotic therapy in patients with prosthetic infections: efficacy and safety. Front Pharmacol 2023; 14:1185602. [PMID: 37448966 PMCID: PMC10337584 DOI: 10.3389/fphar.2023.1185602] [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: 03/13/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Suppressive antibiotic therapy (SAT) is a strategy to alleviate symptoms and/or to reduce the progression of an infection when other treatment options cannot be used. Dalbavancin, due to its prolonged half-life, enables (bi) weekly dosing. Here, we report our multicenter real-life clinical experience with dalbavancin used as SAT in patients with prosthetic joint or vascular infections. Medical records of all adult patients with documented vascular or orthopedic chronic prosthetic infections, who received dalbavancin as SAT between 2016 and 2018 from four Spanish hospitals were reviewed for inclusion. Descriptive analysis of demographic characteristics, Charlson Comorbidity index, Barthel index, isolated pathogens and indication, concomitant antibiotic use, adverse events, and clinical outcome of SAT were performed. Eight patients were eligible for inclusion, where six patients had prosthetic vascular infections (aortic valve) and two patients had knee prosthetic joint infections. The most common pathogens were methicillin-susceptible Staphylococcus aureus and Enterococcus faecium. All patients had a history of prior antibiotic treatment for the prosthetic infection [median duration of antibiotic days 125 days (IQR, 28-203 days)]. The median number of dalbavancin doses was 29 (IQR, 9-61) and concomitant antibiotic use (n = 5, 62.5%). Clinical success was reported in 75% (n = 6) of patients. Adverse events were reported in two patients (mild renal and hepatic impairment). The median estimated cost savings due to the avoided hospital days was €60185 (IQR, 19,916-94984) per patient. Despite the limitations of our study, this preliminary data provides valuable insight to support further evaluation of dalbavancin for SAT in patients with prosthetic infections in the outpatient setting when alternative treatments are not feasible.
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Affiliation(s)
- Andrés Ruiz-Sancho
- Infectious Diseases Department, University Hospital Clinico San Cecilio, Granada, Spain
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
| | - María Núñez-Núñez
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
- Pharmacy Department, University Hospital Clinico San Cecilio, Granada, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Laura Castelo-Corral
- Infectious Diseases Department, University Hospital Complexo A Coruña, A Coruña, Spain
| | | | | | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - David Vinuesa-García
- Infectious Diseases Department, University Hospital Clinico San Cecilio, Granada, Spain
- Biosanitary Research Institute, Ibs Granada, Granada, Spain
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6
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Jumpertz M, Guilhaumou R, Million M, Parola P, Lagier JC, Brouqui P, Cassir N. Subcutaneously administered antibiotics: a review. J Antimicrob Chemother 2022; 78:1-7. [PMID: 36374566 DOI: 10.1093/jac/dkac383] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Subcutaneous (SC) administration of antibiotics represents an attractive alternative to the intravenous (IV) route. METHODS We performed a systematic electronic search of PubMed and the Cochrane Library for all articles published prior to April 2022, using the key terms and MeSH terms 'subcutaneous', 'antibiotic' and the international non-proprietary name of antibiotics. RESULTS A total of 30 studies were selected including data on the efficacy and tolerability of antibiotics, and seven studies that were conducted in healthy subjects, for relevant information regarding the safety and tolerability of antibiotics. Comparative studies have shown that efficacy is similar for the SC and IV routes for ceftriaxone, teicoplanin and ertapenem. The SC use of other antibiotics such as ampicillin, ceftazidime, cefepime, piperacillin/tazobactam, metronidazole and fosfomycin has also been described. These results have largely been corroborated by pharmacokinetic/pharmacodynamic analyses, especially for time-dependent antibiotics. Complications of SC treatment are rarely severe, with no reports of bacteraemia or other invasive infection related to this route of administration. Therapeutic drug monitoring has been proposed to adapt the dose and avoid toxicity. DISCUSSION The rationale for using SC administration of ceftriaxone, ertapenem and teicoplanin is strong in patients with non-severe infections. It is already commonly practised in some countries, particularly in France. Other antibiotics could be administered subcutaneously, but further studies are needed to validate their use in clinical practice. Further research is needed to safely generalize and optimize this route of administration whenever possible. This would reduce the risk of catheter-related infections and their complications, together with the length of hospital stay.
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Affiliation(s)
- Marie Jumpertz
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, IHU-Méditerranée Infection, Marseille, France
| | - Romain Guilhaumou
- Service de Pharmacologie Clinique et Pharmacovigilance, APHM, INSERM, Institut Neurosciences Système, UMR 1106, Aix Marseille Université, 13005 Marseille, France
| | - Matthieu Million
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, IHU-Méditerranée Infection, Marseille, France
| | - Philippe Parola
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, Aix Marseille University, IRD, AP-HM, SSA, VITROME, Marseille, France
| | - Jean-Christophe Lagier
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, IHU-Méditerranée Infection, Marseille, France
| | - Philippe Brouqui
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, IHU-Méditerranée Infection, Marseille, France
| | - Nadim Cassir
- Infectious Diseases, Aix-Marseille University, IRD, AP-HM, Mephi, Marseille, France.,Infectious Diseases, IHU-Méditerranée Infection, Marseille, France
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7
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Lensen KJ, Escudero-Sanchez R, Cobo J, Trebše R, Gubavu C, Tedeschi S, Lomas J, Arvieux C, Rodriguez-Pardo D, Fantoni M, Pais M, Jover F, Salles M, Sancho I, Sampedro M, Soriano A, Wouthuyzen-Bakker M, ESCMID Study Group of Implant Associated Infections (ESGIAI). The efficacy of suppressive antibiotic treatment in patients managed non-operatively for periprosthetic joint infection and a draining sinus. J Bone Jt Infect 2021; 6:313-319. [PMID: 34422548 PMCID: PMC8375509 DOI: 10.5194/jbji-6-313-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: Patients with prosthetic joint infections (PJIs) not suitable for curative surgery may benefit from suppressive antibiotic therapy (SAT). However, the usefulness of SAT in cases with a draining sinus has never been investigated. Methods: A multicentre, retrospective observational cohort study was performed in which patients with a PJI and a sinus tract were eligible for inclusion if managed conservatively and if sufficient follow-up data were available (i.e. at least 2 years). SAT was defined as a period of > 6 months of oral antibiotic therapy. Results: SAT was initiated in 63 of 72 (87.5 %) included patients. Implant retention during follow-up was the same in patients receiving SAT vs. no SAT (79.4 % vs. 88.9 %; p = 0 .68). In total, 27 % of patients using SAT experienced side effects. In addition, the occurrence of prosthetic loosening in initially fixed implants, the need for surgical debridement, or the occurrence of bacteremia during follow-up could not be fully prevented with the use of SAT, which still occurred in 42 %, 6.3 %, and 3.2 % of cases, respectively. However, the sinus tract tended to close more often (42 % vs. 13 %; p = 0 .14), and a higher resolution of pain was observed (35 % vs. 14 %; p = 0 .22) in patients receiving SAT. Conclusions: SAT is not able to fully prevent complications in patients with a draining sinus. However, it may be beneficial in a subset of patients, particularly in those with pain or the hindrance of a draining sinus. A future prospective study, including a higher number of patients not receiving SAT, is needed.
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Affiliation(s)
- Karel-Jan Dag François Lensen
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
| | | | - Javier Cobo
- Department of Infectious Diseases, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Rihard Trebše
- Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Camelia Gubavu
- Department of Infectious and Tropical Diseases, CHR Orléans,
Orléans, France
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences,
University of Bologna Policlinico di Sant Orsola, Bologna, Italy
| | - Jose M. Lomas
- Department of Infectious Diseases, Virgen del Rocio University Hospital, Seville, Spain
| | - Cedric Arvieux
- Department of Infectious Diseases and Intensive Care, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Dolors Rodriguez-Pardo
- Infectious Diseases Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Massimo Fantoni
- UOC Malattie Infettive, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Jose Garcia Pais
- Infectious Diseases Unit, Hospital Universitario Lucus Augusti, Instituto de
Investigación Sanitaria de Santiago de Compostela (IDIS), Lugo, Spain
| | - Francisco Jover
- Unidad de Enfermedades Infecciosas, Hospital Universitario San Juan de Alicante, Alicante, Spain
| | - Mauro José Costa Salles
- Unit of Infectious Diseases, Department of Internal Medicine, Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Ignacio Sancho
- Department of Infectious Diseases, Hospital Reina Sofía de Tudela, Navarra, Spain
| | - Marta Fernandez Sampedro
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic, IDIBAPS, Catalonia, Barcelona, Spain
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, the
Netherlands
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8
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Suppressive Antibiotic Treatment in Prosthetic Joint Infections: A Perspective. Antibiotics (Basel) 2021; 10:antibiotics10060743. [PMID: 34205424 PMCID: PMC8235685 DOI: 10.3390/antibiotics10060743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
The treatment of prosthetic joint infections (PJIs) is a complex matter in which surgical, microbiological and pharmacological aspects must be integrated and, above all, placed in the context of each patient to make the best decision. Sometimes it is not possible to offer curative treatment of the infection, and in other cases, the probability that the surgery performed will be successful is considered very low. Therefore, indefinite administration of antibiotics with the intention of "suppressing" the course of the infection becomes useful. For decades, we had little information about suppressive antibiotic treatment (SAT). However, due to the longer life expectancy and increase in orthopaedic surgeries, an increasing number of patients with infected joint prostheses experience complex situations in which SAT should be considered as an alternative. In the last 5 years, several studies attempting to answer the many questions that arise on this issue have been published. The aim of this publication is to review the latest published evidence on SAT.
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9
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Wouthuyzen-Bakker M, Shohat N, Parvizi J, Soriano A. Risk Scores and Machine Learning to Identify Patients With Acute Periprosthetic Joints Infections That Will Likely Fail Classical Irrigation and Debridement. Front Med (Lausanne) 2021; 8:550095. [PMID: 34012968 PMCID: PMC8126631 DOI: 10.3389/fmed.2021.550095] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 03/23/2021] [Indexed: 11/24/2022] Open
Abstract
The most preferred treatment for acute periprosthetic joint infection (PJI) is surgical debridement, antibiotics and retention of the implant (DAIR). The reported success of DAIR varies greatly and depends on a complex interplay of several host-related factors, duration of symptoms, the microorganism(s) causing the infection, its susceptibility to antibiotics and many others. Thus, there is a great clinical need to predict failure of the "classical" DAIR procedure so that this surgical option is offered to those most likely to succeed, but also to identify those patients who may benefit from more intensified antibiotic treatment regimens or new and innovative treatment strategies. In this review article, the current recommendations for DAIR will be discussed, a summary of independent risk factors for DAIR failure will be provided and the advantages and limitations of the clinical use of preoperative risk scores in early acute (post-surgical) and late acute (hematogenous) PJIs will be presented. In addition, the potential of implementing machine learning (artificial intelligence) in identifying patients who are at highest risk for failure of DAIR will be addressed. The ultimate goal is to maximally tailor and individualize treatment strategies and to avoid treatment generalization.
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Affiliation(s)
- Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Noam Shohat
- Department of Orthopaedic Surgery, Yitzhak Shamir Medical Center, Zriffin, Israel
- Department of Orthopaedic Surgery, Tel Aviv University, Tel Aviv, Israel
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Alex Soriano
- Service of Infectious Diseases, Hospital Clínic, University of Barcelona, Barcelona, Spain
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10
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Goutelle S, Conrad A, Pouderoux C, Braun E, Laurent F, Gagnieu MC, Cohen S, Guitton J, Valour F, Ferry T. Pharmacokinetic/Pharmacodynamic Dosage Individualization of Suppressive Beta-Lactam Therapy Administered by Subcutaneous Route in Patients With Prosthetic Joint Infection. Front Med (Lausanne) 2021; 8:583086. [PMID: 33869238 PMCID: PMC8044368 DOI: 10.3389/fmed.2021.583086] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Suppressive parenteral antibiotic therapy with beta-lactams may be necessary in patients with Gram-negative bone and joint infection (BJI). Subcutaneous drug administration can facilitate this therapy in outpatient setting, but there is limited information about this practice. We have developed an original approach for drug dosing in this context, based on therapeutic drug monitoring (TDM) and pharmacokinetic/pharmacodynamic (PK/PD) principles. The objective of this study was to describe our approach and its first results in a case series. We analyzed data from patients who received suppressive antibiotic therapy by subcutaneous (SC) route with beta-lactams as salvage therapy for prosthetic joint infection (PJI) and had TDM with PK/PD-based dose adjustment. Ten patients (six women and four men with a mean age of 77 years) were included from January 2017 to May 2020. The drugs administered by SC route were ceftazidime (n = 4), ertapenem (n = 4), and ceftriaxone (n = 2). In each patient, PK/PD-guided dosage individualization was performed based on TDM and minimum inhibitory concentration (MIC) measurements. The dose interval could be prolonged from twice daily to thrice weekly in some patients, while preserving the achievement of PK/PD targets. The infection was totally controlled by the strategy in nine out the 10 patients during a median follow-up of 1,035 days (~3 years). No patient acquired carbapenem-resistant Gram-negative bacteria during the follow-up. One patient presented treatment failure with acquired drug resistance under therapy, which could be explained by late MIC determination and insufficient exposure, retrospectively. To conclude, our innovative approach, based on model-based TDM, MIC determination, and individualized PK/PD goals, facilitates, and optimizes suppressive outpatient beta-lactam therapy administered by SC route for PJI. These encouraging results advocate for larger clinical evaluation.
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Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Anne Conrad
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Cécile Pouderoux
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Evelyne Braun
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France.,Institut des Agents Infectieux, Laboratoire de bactériologie, Centre National de référence des staphylocoques, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Marie-Claude Gagnieu
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Sabine Cohen
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Jérôme Guitton
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Florent Valour
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Tristan Ferry
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
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11
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Ferry T, Lodise TP, Gallagher JC, Forestier E, Goutelle S, Tam VH, Mohr JF, Roubaud-Baudron C. Outpatient Subcutaneous Antimicrobial Therapy (OSCAT) as a Measure to Improve the Quality and Efficiency of Healthcare Delivery for Patients With Serious Bacterial Infections. Front Med (Lausanne) 2020; 7:585658. [PMID: 33425938 PMCID: PMC7785854 DOI: 10.3389/fmed.2020.585658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Since the 1970s, outpatient parenteral antimicrobial therapy (OPAT) has been a viable option for patients who require intravenous antibiotics when hospitalization is not warranted. While the benefits of OPAT as a measure to improve the efficiency of healthcare delivery (i.e., reduced hospital days) and patient satisfaction are well-documented, OPAT is associated with a number of challenges, including line complications and reliance on daily healthcare interactions in some cases at home or in a clinic. To minimize the continued need for intensive healthcare services in the outpatient setting, there is trend toward patients self-administering antibiotics at home without the presence of healthcare workers, after adequate training. In most cases, patients administer the antibiotics through an established intravenous catheter. While this OPAT practice is becoming more accepted as a standard of care, the potential for line complications still exists. Outpatient subcutaneous antimicrobial therapy (OSCAT) has become an increasingly accepted alternative route of administration of antibiotics to IV by French infectious diseases physicians and geriatricians; however, currently, no antibiotics are approved to be administered subcutaneously. Antibiotics with longer half-lives that are completely absorbed and have a favorable local tolerability profile are ideal candidates for OSCAT and have the potential to maximize the quality and efficiency of parenteral antibiotic delivery in the outpatient setting. The increasing development of wearable, on-body subcutaneous delivery systems make OSCAT even more viable as they increase patient independence while avoiding line complications and potentially removing the need for direct healthcare professional observation.
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Affiliation(s)
- Tristan Ferry
- Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, United States
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, PA, United States
| | - Emmanuel Forestier
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier de Métropole Savoie, Chambéry, France
| | - Sylvain Goutelle
- Pharmacie hospitalière, Hospices Civils de Lyon, Groupement Hospitalier Nord, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston, Houston, TX, United States
| | - John F Mohr
- scPharmaceuticals, Burlington, MA, United States
| | - Claire Roubaud-Baudron
- CHU de Bordeaux, Pôle de Gérontologie Clinique, Bordeaux, France.,Univ. Bordeaux, INSERM UMR 1053 BaRITOn, Bordeaux, France
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12
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Ferry T, Batailler C, Brosset S, Kolenda C, Goutelle S, Sappey-Marinier E, Josse J, Laurent F, Lustig S. Medical innovations to maintain the function in patients with chronic PJI for whom explantation is not desirable: a pathophysiology-, multidisciplinary-, and experience-based approach. SICOT J 2020; 6:26. [PMID: 32633714 PMCID: PMC7339926 DOI: 10.1051/sicotj/2020021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION PJI is the most dramatic complication after joint arthroplasty. In patients with chronic infection, prosthesis exchange is in theory the rule. However, this surgical approach is sometimes not desirable especially in elderly patients with multiple comorbidities, as it could be associated with a dramatic loss of function, reduction of the bone stock, fracture, or peroperative death. We propose here to report different approaches that can help to maintain the function in such patients based on a pathophysiology-, multidisciplinary-, and an experience-based approach. METHODS We describe the different points that are needed to treat such patients: (i) the multidisciplinary care management; (ii) understanding the mechanism of bacterial persistence; (iii) optimization of the conservative surgical approach; (iv) use of suppressive antimicrobial therapy (SAT); (v) implementation of innovative agents that could be used locally to target the biofilm. RESULTS In France, a nation-wide network called CRIOAc has been created and funded by the French Health ministry to manage complex bone and joint infection. Based on the understanding of the complex pathophysiology of PJI, it seems to be feasible to propose conservative surgical treatment such as "debridement antibiotics and implant retention" (with or without soft-tissue coverage) followed by SAT to control the disease progression. Finally, there is a rational for the use of particular agents that have the ability to target the bacteria embedded in biofilm such as bacteriophages and phage lysins. DISCUSSION This multistep approach is probably a key determinant to propose innovative management in patients with complex PJI, to improve the outcome. CONCLUSION Conservative treatment has a high potential in patients with chronic PJI for whom explantation is not desirable. The next step will be to evaluate such practices in nation-wide clinical trials.
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Affiliation(s)
- Tristan Ferry
- Service des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France
| | - Cécile Batailler
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sophie Brosset
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Plastique et Reconstructrice, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Camille Kolenda
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sylvain Goutelle
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 Rue du Commandant Charcot, 69005 Lyon, France - UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Elliot Sappey-Marinier
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Jérôme Josse
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Frédéric Laurent
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sébastien Lustig
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
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Local Tissue Response to Subcutaneous Administration of Ceftriaxone in an Animal Model. Antimicrob Agents Chemother 2020; 64:AAC.02090-19. [PMID: 31871078 DOI: 10.1128/aac.02090-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/04/2019] [Indexed: 11/20/2022] Open
Abstract
Subcutaneous administration is a novel way to deliver antibiotics for an infection, but intolerability has been reported. Evaluating the local tolerability of subcutaneously administered antibiotics is not standardized. The goal of this study was to develop an animal model to assess the subcutaneous administration of ceftriaxone. Sprague-Dawley rats were given daily subcutaneous injections for 12 days. The back of each animal was divided into 4 quadrants, with injections rotating each day among the quadrants. Ceftriaxone (1,000 mg/kg of body weight daily) was given in different concentrations and durations. Normal saline and potassium chloride solutions (2 meq/2 ml) were used as negative and positive controls, respectively. After the treatment course, skin samples were biopsied, and the local inflammatory response was assessed histologically using a semiquantitative scoring system. The histopathology scores were compared using a Kruskal-Wallis test. Injections with potassium chloride resulted in full-thickness skin necrosis with subcutaneous atrophy that was not seen in the saline-injected animals; inflammation of the muscular panniculus was observed, with various degrees of myocyte injury. Serosanguinous cavity formation in the subcutaneous compartment was observed when ceftriaxone (125 mg/ml) was given as a bolus injection, but the extent of the local tissue response was remarkably reduced when the same ceftriaxone dose was given at a lower concentration (25 mg/ml) over 120 min (P = 0.63, compared to saline controls). At a low concentration, ceftriaxone infusion was found to be well tolerated in this animal tissue necrosis model. If validated, the model could be an instrumental platform to evaluate different pharmaceutical formulations for subcutaneous delivery.
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Mailhe M, Aubry C, Brouqui P, Michelet P, Raoult D, Parola P, Lagier JC. Complications of peripheral venous catheters: The need to propose an alternative route of administration. Int J Antimicrob Agents 2020; 55:105875. [PMID: 31926285 DOI: 10.1016/j.ijantimicag.2020.105875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/16/2019] [Accepted: 12/28/2019] [Indexed: 12/19/2022]
Abstract
Use of peripheral venous catheters (PVCs) is very common in hospitals. According to the literature, after a visit to the emergency department >75% of hospitalised patients carry a PVC, among which almost 50% are useless. In this study, the presence and complications of PVCs in an infectious diseases (ID) unit of a French tertiary-care university hospital were monitored. A total of 614 patients were prospectively included over a 6-month period. Among the 614 patients, 509 (82.9%) arrived in the ID unit with a PVC, of which 260 (51.1%) were judged unnecessary and were removed as soon as the patients were examined by the ID team. More than one-half of PVCs were removed within 24 h in the unit (308/509; 60.5%). PVCs were complicated for 65 (12.8%) of the 509 patients, with complications including extravasation, cutaneous necrosis, lymphangitis, phlebitis, tearing off the patient, superficial venous thrombosis and arthritis. We must therefore continue to search for unjustified PVC insertion. Alternatives to the intravenous administration route must be proposed, such as subcutaneous infusion or oral antibiotic therapy.
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Affiliation(s)
| | | | - Philippe Brouqui
- IHU-Méditerranée Infection, Marseille, France; Aix-Marseille Université, IRD, AP-HM, MEPHI, Marseille, France
| | - Pierre Michelet
- Service des Urgences Adultes, Hôpital de la Timone, UMR MD2, Aix-Marseille Université, Marseille, France
| | - Didier Raoult
- IHU-Méditerranée Infection, Marseille, France; Aix-Marseille Université, IRD, AP-HM, MEPHI, Marseille, France
| | - Philippe Parola
- IHU-Méditerranée Infection, Marseille, France; Aix-Marseille Université, IRD, AP-HM, SSA, VITROME, Marseille, France
| | - Jean-Christophe Lagier
- IHU-Méditerranée Infection, Marseille, France; Aix-Marseille Université, IRD, AP-HM, MEPHI, Marseille, France.
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