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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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2
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Paul SK, Roberts JA, Lipman J, Deans R, Samanta M. A Robust Statistical Approach to Analyse Population Pharmacokinetic Data in Critically Ill Patients Receiving Renal Replacement Therapy. Clin Pharmacokinet 2020; 58:263-270. [PMID: 30094712 DOI: 10.1007/s40262-018-0690-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND AIM Current approaches to antibiotic dose determination in critically ill patients requiring renal replacement therapy are primarily based on the assessment of highly heterogeneous data from small number of patients. The standard modelling approaches limit the scope of constructing robust confidence boundaries of the distribution of pharmacokinetics (PK) parameters, especially when the evaluation of possible association of demographic and clinical factors at different levels of the distribution of drug clearance is of interest. Commonly used compartmental models generally construct the inferences through a linear or non-linear mean regression, which is inadequate when the distribution is skewed, multi-modal or effected by atypical observation. In this study, we discuss the statistical challenges in robust estimation of the confidence boundaries of the PK parameters in the presence of highly heterogenous patient characteristics. METHODS A novel stepwise approach to evaluate the confidence boundaries of PK parameters is proposed by combining PK modelling with mixed-effects quantile regression (MEQR) methods. RESULTS This method allows the assessment demographic and clinical factors' effects at any arbitrary quantiles of the outcome of interest, without restricting assumptions on the distributions. The MEQR approach allows us to investigate if the levels of association of the covariates are different at low, medium or high concentration. CONCLUSIONS This methodological assessment is deemed as a background initial approach to support the development of a class of statistical algorithm in constructing robust confidence intervals of PK parameters which can be used for developing an optimised antibiotic dosing guideline for critically ill patients requiring renal replacement therapy.
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Affiliation(s)
- Sanjoy Ketan Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, VIC, Australia. .,The Royal Melbourne Hospital, City Campus, 7 East, Main Building, Grattan Street, Parkville, VIC, 3050, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Centre for Translational Anti-Infective Pharmacodynamics, The University of Queensland, Brisbane, QLD, Australia.,Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Centre for Translational Anti-Infective Pharmacodynamics, The University of Queensland, Brisbane, QLD, Australia
| | - Renae Deans
- Burns Trauma and Critical Care Research Centre, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Mayukh Samanta
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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3
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Kielstein JT, Kruse AK, Anderson N, Vaitiekunas H, Scherneck S. [Hot rods in the ICU : What is the antibiotic mileage of your renal replacement therapy?]. Med Klin Intensivmed Notfmed 2017; 114:139-145. [PMID: 28484827 DOI: 10.1007/s00063-017-0303-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/04/2017] [Accepted: 03/25/2017] [Indexed: 01/21/2023]
Abstract
We would neither be disappointed nor upset if the gas mileage on the sticker of a car didn't match our personal, real-life fuel consumption. Depending on our daily route to work, our style of accelerating and the number of passengers in our carpool, the gas mileage will vary. As soon as the falcon wing door of our car is closed and entrance to the ICU is granted, we tend to forget all of this, even though another hot rod is waiting there for us. Renal replacement therapy is like a car; it fulfills goals, such as the removal of uremic toxins and accumulated fluids, but it also "consumes" (removes) antibiotics. Unlike catecholamines, where we have the mean arterial pressure on our ICU dashboard, we do not have a gauge to measure antibiotic "consumption", i.e. elimination by renal replacement therapy. This manuscript describes the principles and basic knowledge to improve dosing of antibiotics in critically ill patients undergoing renal replacement therapy. As in modern cars, we briefly touch on hybrid therapies combining renal replacement therapy with extracorporeal lung support or adsorbent technologies that remove cytokines or bacteria. Further, the importance of considering body size and body composition is addressed, especially for choosing the right initial dose of antibiotics. Lastly we point out the dire need to increase the availability of timely and affordable therapeutic drug monitoring on the most commonly used antiinfectives, ideally using point-of-care devices at the bedside.
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Affiliation(s)
- J T Kielstein
- Medizinische Klinik V, Städtisches Klinikum Braunschweig, Salzdahlumer Straße 90, 38126, Braunschweig, Deutschland.
| | - A K Kruse
- Krankenhausapotheke, Städtisches Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Deutschland
| | - N Anderson
- Medizinische Klinik V, Städtisches Klinikum Braunschweig, Salzdahlumer Straße 90, 38126, Braunschweig, Deutschland
| | - H Vaitiekunas
- Krankenhausapotheke, Städtisches Klinikum Braunschweig, Celler Straße 38, 38114, Braunschweig, Deutschland
| | - S Scherneck
- Institut für Pharmakologie, Toxikologie und Klinische Pharmazie, Technische Universität Braunschweig, Mendelssohnstr. 1, 38106, Braunschweig, Deutschland
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4
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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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5
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Roberts DM, Liu X, Roberts JA, Nair P, Cole L, Roberts MS, Lipman J, Bellomo R. A multicenter study on the effect of continuous hemodiafiltration intensity on antibiotic pharmacokinetics. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:84. [PMID: 25881576 PMCID: PMC4404619 DOI: 10.1186/s13054-015-0818-8] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 02/17/2015] [Indexed: 12/02/2022]
Abstract
Introduction Continuous renal replacement therapy (CRRT) may alter antibiotic pharmacokinetics and increase the risk of incorrect dosing. In a nested cohort within a large randomized controlled trial, we assessed the effect of higher (40 mL/kg per hour) and lower (25 mL/kg per hour) intensity CRRT on antibiotic pharmacokinetics. Methods We collected serial blood samples to measure ciprofloxacin, meropenem, piperacillin-tazobactam, and vancomycin levels. We calculated extracorporeal clearance (CL), systemic CL, and volume of distribution (Vd) by non-linear mixed-effects modelling. We assessed the influence of CRRT intensity and other patient factors on antibiotic pharmacokinetics. Results We studied 24 patients who provided 179 pairs of samples. Extracorporeal CL increased with higher-intensity CRRT but the increase was significant for vancomycin only (mean 28 versus 22 mL/minute; P = 0.0003). At any given prescribed CRRT effluent rate, extracorporeal CL of individual antibiotics varied widely, and the effluent-to-plasma concentration ratio decreased with increasing effluent flow. Overall, systemic CL varied to a greater extent than Vd, particularly for meropenem, piperacillin, and tazobactam, and large intra-individual differences were also observed. CRRT dose did not influence overall (systemic) CL, Vd, or half-life. The proportion of systemic CL due to CRRT varied widely and was high in some cases. Conclusions In patients receiving CRRT, there is great variability in antibiotic pharmacokinetics, which complicates an empiric approach to dosing and suggests the need for therapeutic drug monitoring. More research is required to investigate the apparent relative decrease in clearance at higher CRRT effluent rates. Trial registration ClinicalTrials.gov NCT00221013. Registered 14 September 2005. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0818-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Darren M Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Xin Liu
- Therapeutics Research Centre, School of Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland, 4102, Australia. .,University of South Australia, City East Campus, GPO Box 2471, Adelaide, South Australia, 5000, Australia. .,The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia. .,Department of Intensive Care Medicine, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital, Victoria Street, Darlinghurst, NSW, 2010, Australia.
| | - Louise Cole
- Intensive Care Unit, Nepean Hospital, Derby Street, Kingswood, NSW, 2747, Australia.
| | - Michael S Roberts
- Therapeutics Research Centre, School of Medicine, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Brisbane, Queensland, 4102, Australia. .,University of South Australia, City East Campus, GPO Box 2471, Adelaide, South Australia, 5000, Australia. .,The Queen Elizabeth Hospital, 28 Woodville Road, Woodville South, Adelaide, South Australia, 5011, Australia.
| | - Jeffrey Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia. .,Department of Intensive Care Medicine, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Brisbane, Queensland, 4029, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
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How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy? Diagn Microbiol Infect Dis 2015; 82:92-103. [PMID: 25698632 DOI: 10.1016/j.diagmicrobio.2015.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 12/28/2014] [Accepted: 01/25/2015] [Indexed: 12/30/2022]
Abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
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7
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The Impact of Variation in Renal Replacement Therapy Settings on Piperacillin, Meropenem, and Vancomycin Drug Clearance in the Critically Ill. Crit Care Med 2014; 42:1640-50. [DOI: 10.1097/ccm.0000000000000317] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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8
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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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Udy AA, Roberts JA, Lipman J. Clinical implications of antibiotic pharmacokinetic principles in the critically ill. Intensive Care Med 2013; 39:2070-82. [DOI: 10.1007/s00134-013-3088-4] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/23/2013] [Indexed: 12/21/2022]
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10
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Arzuaga A, Maynar J, Gascón AR, Isla A, Corral E, Fonseca F, Sánchez-Izquierdo JA, Rello J, Canut A, Pedraz JL. Influence of Renal Function on the Pharmacokinetics of Piperacillin/Tazobactam in Intensive Care Unit Patients During Continuous Venovenous Hemofiltration. J Clin Pharmacol 2013; 45:168-76. [PMID: 15647409 DOI: 10.1177/0091270004269796] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The pharmacokinetics of piperacillin/tazobactam (4 g/0.5 g every 6 or 8 hours, by 20-minute intravenous infusion) were studied in 14 patients with acute renal failure who underwent continuous venovenous hemofiltration with AN69 membranes. Patients were grouped according to severity (CL(CR) < or =10 mL/min, 10 < CL(CR) < or =50 mL/min, and CL(CR) > 50 mL/min). A noncompartmental analysis was performed. The sieving coefficient (0.78 +/- 0.28) was similar to the unbound fraction (0.65 +/- 0.24) for tazobactam, but it was significantly different (0.34 +/- 0.25) from the unbound fraction (0.78 +/- 0.14) for piperacillin. Extracorporeal clearance was 37.0% +/- 28.8%, 12.7% +/- 12.6%, and 2.8% +/- 3.2% for piperacillin in each group and 62.5% +/- 44.9%, 35.4% +/- 17.0%, and 13.1% +/- 8.0% for tazobactam. No patients presented tazobactam accumulation. In patients with CL(CR) < 50 mL/min, t(%)ss >MIC90 values were 100% for a panel of 19 pathogens, but in those with CL(CR) > 50 mL/min, t(%)ss >MIC90 indexes were 55.5% and 16.6% for pathogens with MIC90 values of 32 and 64. The extracorporeal clearance of piperacillin/tazobactam is clinically significant in patients with CL(CR) > 50 mL/min, in which the risk of underdosing and clinical failure is important and extra doses are required.
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Affiliation(s)
- Alazne Arzuaga
- Laboratorio de Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Paseo de la Universidad no. 7, 01006 Vitoria-Gasteiz, Spain
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Fissell WH. Antimicrobial dosing in acute renal replacement. Adv Chronic Kidney Dis 2013; 20:85-93. [PMID: 23265600 DOI: 10.1053/j.ackd.2012.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/11/2012] [Accepted: 10/11/2012] [Indexed: 12/28/2022]
Abstract
Acute kidney injury (AKI) is a common problem in hospitalized patients and is associated with significant morbidity and mortality. Two large trials showed no benefit from increased doses of renal replacement therapy (RRT) despite previous clinical data suggesting that increased clearance from RRT has beneficial effects. Since infection is the leading cause of death in AKI, my group and others hypothesized that increased RRT antibiotic clearance might create a competing morbidity. The data from my group, as well as those of other groups, show that many patients are underdosed when routine "1 size fits all" antibiotic dosing is used in patients with AKI receiving continuous RRT (CRRT). Here, concepts of drug distribution and clearance in AKI are briefly discussed and then 1 antibiotic (piperacillin) is discussed in depth to illustrate the challenges in applying the medical literature to clinical practice. The fact that published data on drug dosing in AKI and dialysis reflect the evolution of practice patterns and often do not apply to present prescribing habits is also discussed. A more general approach to drug dosing facilitates situation-specific prescribing by the nephrologist and critical care specialist.
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12
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Carcelero San Martín E, Soy Muner D. [Dosage of antipseudomonal antibiotics in patients with acute kidney injury subjected to continuous renal replacement therapies]. Med Intensiva 2012; 37:185-200. [PMID: 22475763 DOI: 10.1016/j.medin.2012.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 02/07/2012] [Accepted: 02/18/2012] [Indexed: 12/31/2022]
Abstract
Critically ill patients are often affected by infections produced by Pseudomonas, which can be a cause of sepsis and renal failure. Early and adequate antibiotic treatment at correct dosage levels is crucial. Acute kidney injury is also frequent in critically ill patients. In those patients who require renal replacement therapy, continuous techniques are gaining relevance as filtering alternatives to intermittent hemodialysis. It must be taken into account that many antibiotics are largely cleared by continuous renal replacement therapies (CRRT). The aim of this review is to assess the clinical evidence on the pharmacokinetics and dosage recommendations of the main antibiotic groups used to treat Pseudomonas spp. infections in critically ill patients subjected to CRRT.
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Cortés JA, Soto R, Álvarez CA, Buitrago G, Camargo RD, Cataño JC, Gómez CH, Otero E, Reyes P, Roncancio G, Vargas JG. Consenso de uso de antimicrobianos en pacientes críticamente enfermos con falla renal o en riesgo de padecerla. INFECTIO 2011. [DOI: 10.1016/s0123-9392(11)70076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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14
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Eyler RF, Mueller BA. Antibiotic dosing in critically ill patients with acute kidney injury. Nat Rev Nephrol 2011; 7:226-35. [PMID: 21343897 DOI: 10.1038/nrneph.2011.12] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A common cause of acute kidney injury (AKI) is sepsis, which makes appropriate dosing of antibiotics in these patients essential. Drug dosing in critically ill patients with AKI, however, can be complicated. Critical illness and AKI can both substantially alter pharmacokinetic parameters as compared with healthy individuals or patients with end-stage renal disease. Furthermore, drug pharmacokinetic parameters are highly variable within the critically ill population. The volume of distribution of hydrophilic agents can increase as a result of fluid overload and decreased binding of the drug to serum proteins, and antibiotic loading doses must be adjusted upwards to account for these changes. Although renal elimination of drugs is decreased in patients with AKI, residual renal function in conjunction with renal replacement therapies (RRTs) result in enhanced drug clearance, and maintenance doses must reflect this situation. Antibiotic dosing decisions should be individualized to take into account patient-related, RRT-related, and drug-related factors. Efforts must also be made to optimize the attainment of antibiotic pharmacodynamic goals in this population.
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Affiliation(s)
- Rachel F Eyler
- Department of Clinical, Social, and Administrative Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065, USA
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15
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Hayashi Y, Roberts JA, Paterson DL, Lipman J. Pharmacokinetic evaluation of piperacillin-tazobactam. Expert Opin Drug Metab Toxicol 2010; 6:1017-31. [DOI: 10.1517/17425255.2010.506187] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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16
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A systematic review of antibiotic dosing regimens for septic patients receiving continuous renal replacement therapy: do current studies supply sufficient data? J Antimicrob Chemother 2009; 64:929-37. [DOI: 10.1093/jac/dkp302] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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18
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Moriyama B, Henning SA, Neuhauser MM, Danner RL, Walsh TJ. Continuous-infusion beta-lactam antibiotics during continuous venovenous hemofiltration for the treatment of resistant gram-negative bacteria. Ann Pharmacother 2009; 43:1324-37. [PMID: 19584386 PMCID: PMC10807507 DOI: 10.1345/aph.1l638] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the rationale, principles, and dosage calculations for continuous-infusion beta-lactam antibiotics to treat multidrug-resistant bacteria in patients undergoing continuous venovenous hemofiltration (CVVH). DATA SOURCES A MEDLINE search (1968-November 2008) of the English-language literature was performed using the terms continuous infusion and Pseudomonas or Acinetobacter; hemofiltration or CVVH or hemodiafiltration or CVVHDF or continuous renal replacement therapy or pharmacokinetics; and terms describing different beta-lactam antibiotics. STUDY SELECTION AND DATA EXTRACTION In vitro, in vivo, and human studies were evaluated that used continuous-infusion beta-lactam antibiotics to treat Pseudomonas aeruginosa and Acinetobacter baumannii infections. Studies were reviewed that described the pharmacokinetics of beta-lactam antibiotics during CVVH as well as other modalities of continuous renal replacement therapy. DATA SYNTHESIS Continuous infusion of beta-lactam antibiotics, maintaining drug concentrations 4-5 times higher than the minimum inhibitory concentration, is a promising approach for managing infections caused by P. aeruginosa and A. baumannii. Safe yet effective continuous infusion therapy is made difficult by the occurrence of acute renal failure and the need for renal replacement therapy. Case series and pharmacokinetic properties indicate that several beta-lactam antimicrobials that have been studied for continuous infusion, such as cefepime, ceftazidime, piperacillin, ticarcillin, clavulanic acid, and tazobactam, are significantly cleared by hemofiltration. Methodology and formulas are provided that allow practitioners to calculate dosage regimens and reach target drug concentrations for continuous beta-lactam antibiotic infusions during CVVH based on a literature review, pharmacokinetic principles, and our experience at the National Institutes of Health Clinical Center. CONCLUSIONS Continuous infusion of beta-lactam antibiotics may be a useful treatment strategy for multidrug-resistant gram-negative infections in the intensive care unit. Well-established pharmacokinetic and pharmacodynamic principles can be used to safely reach and maintain steady-state target concentrations of beta-lactam antibiotics in critical illness complicated by acute renal failure requiring CVVH.
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Affiliation(s)
- Brad Moriyama
- Pharmacy Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
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19
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Glossop AJ, Seidel J. Dosing Regimes for Antimicrobials during Continuous Veno-Venous Haemofiltration (CVVH). J Intensive Care Soc 2008. [DOI: 10.1177/175114370800900214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The pharmacokinetic profile of antibiotics used in critically ill patients during continuous haemofiltration is different both from healthy people and from stable patients on long-term dialysis. This article reviews the patient-related, drug-related and haemofiltration-related variables influencing drug elimination in this group of patients, and provides specific recommendations for antibiotic dosing for different classes of antibiotics. Loading doses do not need to be altered. Subsequent dose adjustment should be based on the estimated ultrafiltration capacity of the renal replacement technique and the degree of extracorporeal clearance. A table of recommended doses is provided.
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Affiliation(s)
- Alastair J Glossop
- Specialist Registrar in Anaesthetics and Intensive Care Medicine, Sheffield Teaching Hospitals NHS Trust
| | - Jochen Seidel
- Consultant in Anaesthesia and Intensive Care Medicine, Doncaster and Bassetlaw Hospitals NHS Foundation Trust
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20
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Pea F, Viale P, Pavan F, Furlanut M. Pharmacokinetic Considerations for Antimicrobial Therapy in Patients Receiving Renal Replacement Therapy. Clin Pharmacokinet 2007; 46:997-1038. [DOI: 10.2165/00003088-200746120-00003] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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21
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Arzuaga A, Isla A, Gascón AR, Maynar J, Corral E, Pedraz JL. Elimination of piperacillin and tazobactam by renal replacement therapies with AN69 and polysulfone hemofilters: evaluation of the sieving coefficient. Blood Purif 2006; 24:347-54. [PMID: 16645266 DOI: 10.1159/000092921] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Piperacillin-tazobactam is commonly used to treat infections in ICU patients. Controversial data have been published about the sieving/saturation coefficient (Sc/Sa) of piperacillin during continuous renal replacement therapies (CRRT). The objective was to evaluate the Sc/Sa of piperacillin-tazobactam during continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodialysis (CVVHD) using AN69 and polysulfone. METHODS Ringer lactate, BSA-containing Ringer lactate and plasma were circulated at 150 ml/min. The ultrafiltrate/dialysis flow was kept at 1,500 ml/min. A bolus was injected and samples were taken. Drugs were measured using HPLC. Sc/Sa was calculated according to standard formula. RESULTS Free passage of drugs through the membranes was reported with protein free solutions. In the presence of proteins the Sc/Sa lowered and correlated to protein free fraction. Polysulfone had a significantly higher permeability than AN69 during CVVH. CONCLUSION Drug binding to albumin contributes to the decrease of the Sc/Sa of piperacillin but it does not completely justify the in vivo value obtained by some authors.
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Affiliation(s)
- A Arzuaga
- Laboratory of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
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22
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Trotman RL, Williamson JC, Shoemaker DM, Salzer WL. Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy. Clin Infect Dis 2005; 41:1159-66. [PMID: 16163635 DOI: 10.1086/444500] [Citation(s) in RCA: 232] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2005] [Accepted: 06/19/2005] [Indexed: 11/03/2022] Open
Abstract
Continuous renal replacement therapy (CRRT) is now commonly used as a means of support for critically ill patients with renal failure. No recent comprehensive guidelines exist that provide antibiotic dosing recommendations for adult patients receiving CRRT. Doses used in intermittent hemodialysis cannot be directly applied to these patients, and antibiotic pharmacokinetics are different than those in patients with normal renal function. We reviewed the literature for studies involving the following antibiotics frequently used to treat critically ill adult patients receiving CRRT: vancomycin, linezolid, daptomycin, meropenem, imipenem-cilastatin, nafcillin, ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavulanic acid, cefazolin, cefotaxime, ceftriaxone, ceftazidime, cefepime, aztreonam, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, colistin, amikacin, gentamicin, tobramycin, fluconazole, itraconazole, voriconazole, amphotericin B (deoxycholate and lipid formulations), and acyclovir. We used these data, as well as clinical experience, to make recommendations for antibiotic dosing in critically ill patients receiving CRRT.
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Affiliation(s)
- Robin L Trotman
- Department of Internal Medicine, Section of Infectious Diseases, Wake Forest University Health Sciences, Winston-Salem, North Carolina 27157, USA.
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Veltri MA, Neu AM, Fivush BA, Parekh RS, Furth SL. Drug dosing during intermittent hemodialysis and continuous renal replacement therapy : special considerations in pediatric patients. Paediatr Drugs 2004; 6:45-65. [PMID: 14969569 DOI: 10.2165/00148581-200406010-00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Chronic renal failure is, fortunately, an unusual occurrence in children; however, many children with various underlying illnesses develop acute renal failure, and transiently require renal replacement therapy - peritoneal dialysis, intermittent hemodialysis (IHD), or continuous renal replacement therapy (CRRT). As children with acute and chronic renal failure often have multiple comorbid conditions requiring drug therapy, generalists, intensivists, nephrologists, and pharmacists need to be aware of the issues surrounding the management of drug therapy in pediatric patients undergoing renal replacement therapy. This article summarizes the pharmacokinetics and dosing of many drugs commonly prescribed for pediatric patients, and focuses on the management of drug therapy in pediatric patients undergoing IHD and CRRT in the intensive care unit setting. Peritoneal dialysis is not considered in this review. Finally, a summary table with recommended initial dosages for drugs commonly encountered in pediatric patients requiring IHD or CRRT is presented.
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Affiliation(s)
- Michael A Veltri
- Pediatric Division, Department of Pharmacy, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-6180, USA.
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