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De Sutter PJ, Hermans E, De Cock P, Van Bocxlaer J, Gasthuys E, Vermeulen A. Penetration of Antibiotics into Subcutaneous and Intramuscular Interstitial Fluid: A Meta-Analysis of Microdialysis Studies in Adults. Clin Pharmacokinet 2024; 63:965-980. [PMID: 38955946 DOI: 10.1007/s40262-024-01394-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND OBJECTIVE The interstitial fluid of tissues is the effect site for antibiotics targeting extracellular pathogens. Microdialysis studies investigating these concentrations in muscle and subcutaneous tissue have reported notable variability in tissue penetration. This study aimed to comprehensively summarise the existing data on interstitial fluid penetration in these tissues and to identify potential factors influencing antibiotic distribution. METHODS A literature review was conducted, focusing on subcutaneous and intramuscular microdialysis studies of antibiotics in both adult healthy volunteers and patients. Random-effect meta-analyses were used to aggregate effect size estimates of tissue penetration. The primary parameter of interest was the unbound penetration ratio, which represents the ratio of the area under the concentration-time curve in interstitial fluid relative to the area under the concentration-time curve in plasma, using unbound concentrations. RESULTS In total, 52 reports were incorporated into this analysis. The unbound antibiotic exposure in the interstitial fluid of healthy volunteers was, on average, 22% lower than in plasma. The unbound penetration ratio values were higher after multiple dosing but did not significantly differ between muscle and subcutaneous tissue. Unbound penetration ratio values were lower for acids and bases compared with neutral antibiotics. Neither the molecular weight nor the logP of the antibiotics accounted for the variations in the unbound penetration ratio. Obesity was associated with lower interstitial fluid penetration. Conditions such as sepsis, tissue inflammation and tissue ischaemia were not significantly associated with altered interstitial fluid penetration. CONCLUSIONS This study highlights the variability and generally lower exposure of unbound antibiotics in the subcutaneous and intramuscular interstitial fluid compared with exposure in plasma. Future research should focus on understanding the therapeutic relevance of these differences and identify key covariates that may influence them.
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Affiliation(s)
- Pieter-Jan De Sutter
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
| | - Eline Hermans
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Pieter De Cock
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Jan Van Bocxlaer
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Elke Gasthuys
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - An Vermeulen
- Department of Bioanalysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
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Pei S, Babity S, Sara Cordeiro A, Brambilla D. Integrating microneedles and sensing strategies for diagnostic and monitoring applications: The state of the art. Adv Drug Deliv Rev 2024; 210:115341. [PMID: 38797317 DOI: 10.1016/j.addr.2024.115341] [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: 02/17/2024] [Revised: 04/23/2024] [Accepted: 05/18/2024] [Indexed: 05/29/2024]
Abstract
Microneedles (MNs) offer minimally-invasive access to interstitial fluid (ISF) - a potent alternative to blood in terms of monitoring physiological analytes. This property is particularly advantageous for the painless detection and monitoring of drugs and biomolecules. However, the complexity of the skin environment, coupled with the inherent nature of the analytes being detected and the inherent physical properties of MNs, pose challenges when conducting physiological monitoring using this fluid. In this review, we discuss different sensing mechanisms and highlight advancements in monitoring different targets, with a particular focus on drug monitoring. We further list the current challenges facing the field and conclude by discussing aspects of MN design which serve to enhance their performance when monitoring different classes of analytes.
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Affiliation(s)
- Shihao Pei
- Faculté de pharmacie, Université de Montréal, 2940 Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
| | - Samuel Babity
- Faculté de pharmacie, Université de Montréal, 2940 Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
| | - Ana Sara Cordeiro
- Leicester Institute for Pharmaceutical Innovation, Leicester School of Pharmacy, De Montfort University, Leicester LE1 9BH, United Kingdom.
| | - Davide Brambilla
- Faculté de pharmacie, Université de Montréal, 2940 Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada.
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Hermans E, Meersschaut J, Van Herteryck I, Devreese M, Walle JV, De Paepe P, De Cock PA. Have We Neglected to Study Target-Site Drug Exposure in Children? A Systematic Review of the Literature. Clin Pharmacokinet 2024; 63:439-468. [PMID: 38551787 DOI: 10.1007/s40262-024-01364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND AND OBJECTIVE Drug dosing should ideally be based on the drug concentrations at the target site, which, for most drugs, corresponds to the tissue. The exact influence of growth and development on drug tissue distribution is unclear. This systematic review compiles the current knowledge on the tissue distribution of systemically applied drugs in children, with the aim to identify priorities in tissue pharmacokinetic (PK) research in this population. METHODS A systematic literature search was performed in the MEDLINE and Embase databases. RESULTS Forty-two relevant articles were identified, of which 71% investigated antibiotics, while drug classes from the other studies were anticancer drugs, antifungals, anthelmintics, sedatives, thyreostatics, immunomodulators, antiarrhythmics, and exon skipping therapy. The majority of studies (83%) applied tissue biopsy as the sampling technique. Tonsil and/or adenoid tissue was most frequently examined (70% of all included patients). The majority of studies had a small sample size (median 9, range 1-93), did not include the youngest age categories (neonates and infants), and were of low reporting quality. Due to the heterogeneous data from different study compounds, dosing schedules, populations, and target tissues, the possibility for comparison of PK data between studies was limited. CONCLUSION The influence of growth and development on drug tissue distribution continues to be a knowledge gap, due to the paucity of tissue PK data in children, especially in the younger age categories. Future research in this field should be encouraged as techniques to safely investigate drug tissue disposition in children are available.
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Affiliation(s)
- Eline Hermans
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium.
- Department of Pediatrics, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Jozefien Meersschaut
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Isis Van Herteryck
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Mathias Devreese
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Pediatric Nephrology, SafePeDrug, Erknet Center, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Emergency Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Pieter A De Cock
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Pharmacy, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
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Hermans E, Devreese M, Zeitlinger M, Dhont E, Verougstraete N, Colman R, Vande Walle J, De Paepe P, De Cock PA. Microdialysis as a safe and feasible method to study target-site piperacillin-tazobactam disposition in septic piglets and children. Int J Antimicrob Agents 2023; 62:106970. [PMID: 37716576 DOI: 10.1016/j.ijantimicag.2023.106970] [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: 02/22/2023] [Revised: 08/17/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVES Knowledge on the tissue penetration of piperacillin-tazobactam in children with sepsis is lacking. In this study, the feasibility and performance of microdialysis experiments were explored in septic piglets and children as part of a translational research project. METHODS Multiple-day microdialysis investigations were performed in muscle tissue of 22 piglets (of which 11 were septic) and 6 children with sepsis. An in vitro experiment preceded the (pre)clinical trials to derive optimal experimental settings and calibration technique. Linear mixed-effects models quantified the impact of sepsis on relative recovery (RR) and intercatheter, interindividual, interoccasion, and residual variability. RESULTS In vivo microdialysis was well tolerated in piglets and children, with no significant adverse events reported. Using identical experimental settings, lower RR values were recorded in healthy and septic piglets (range: piperacillin, 17.2-29.1% and tazobactam, 23.5-29.1%) compared with the in vitro experiment (piperacillin, 43.3% and tazobactam, 55.3%), and there were unacceptably low values in children with sepsis (<10%). As a result, methodological changes were made in the pediatric trial. Realistic tissue concentration-time curves were derived in piglets and children. In piglets, sepsis reduced the RR. The greatest contributors to RR variability were residual (>40%) and interoccasion (>30%) variability. The internal standard method was the preferred calibration technique in both piglets and children. CONCLUSIONS Microdialysis is a safe and applicable method for the measurement of tissue drug concentrations in piglets and children. This study demonstrated the impact of experimental settings, sepsis, and target population on individual RR.
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Affiliation(s)
- Eline Hermans
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium; Department of Pediatrics, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Mathias Devreese
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Evelyn Dhont
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Nick Verougstraete
- Department of Laboratory Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Nephrology, SafePeDrug, Erknet center, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Emergency Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Pieter A De Cock
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pediatric Intensive Care, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium; Department of Pharmacy, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
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Brasier N, Ates HC, Sempionatto JR, Cotta MO, Widmer AF, Eckstein J, Goldhahn J, Roberts JA, Gao W, Dincer C. A three-level model for therapeutic drug monitoring of antimicrobials at the site of infection. THE LANCET. INFECTIOUS DISEASES 2023; 23:e445-e453. [PMID: 37348517 DOI: 10.1016/s1473-3099(23)00215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 06/24/2023]
Abstract
The silent pandemic of bacterial antimicrobial resistance is a leading cause of death worldwide, prolonging hospital stays and raising health-care costs. Poor incentives to develop novel pharmacological compounds and the misuse of antibiotics contribute to the bacterial antimicrobial resistance crisis. Therapeutic drug monitoring (TDM) based on blood analysis can help alleviate the emergence of bacterial antimicrobial resistance and effectively decreases the risk of toxic drug concentrations in patients' blood. Antibiotic tissue penetration can vary in patients who are critically or chronically ill and can potentially lead to treatment failure. Antibiotics such as β-lactams and glycopeptides are detectable in non-invasively collectable biofluids, such as sweat and exhaled breath. The emergence of wearable sensors enables easy access to these non-invasive biofluids, and thus a laboratory-independent analysis of various disease-associated biomarkers and drugs. In this Personal View, we introduce a three-level model for TDM of antibiotics to describe concentrations at the site of infection (SOI) by use of wearable sensors. Our model links blood-based drug measurement with the analysis of drug concentrations in non-invasively collectable biofluids stemming from the SOI to characterise drug concentrations at the SOI. Finally, we outline the necessary clinical and technical steps for the development of wearable sensing platforms for SOI applications.
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Affiliation(s)
- Noé Brasier
- Institute for Translational Medicine, ETH Zurich, Zurich, Switzerland; Department of Digitalization & ICT, University Hospital Basel, Basel, Switzerland.
| | - H Ceren Ates
- FIT Freiburg Centre for Interactive Materials and Bioinspired Technology, University of Freiburg, Freiburg, Germany; Department of Microsystems Engineering, IMTEK, University of Freiburg, Freiburg, Germany
| | - Juliane R Sempionatto
- Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Menino O Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Andreas F Widmer
- Department of Infectious Disease and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Jens Eckstein
- Department of Digitalization & ICT, University Hospital Basel, Basel, Switzerland; Division for Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Jörg Goldhahn
- Institute for Translational Medicine, ETH Zurich, Zurich, Switzerland
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, QLD, Australia; Department of Pharmacy and Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Division of Anaesthesiology, Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Wei Gao
- Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Can Dincer
- FIT Freiburg Centre for Interactive Materials and Bioinspired Technology, University of Freiburg, Freiburg, Germany; Department of Microsystems Engineering, IMTEK, University of Freiburg, Freiburg, Germany.
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De Sutter PJ, De Cock P, Johnson TN, Musther H, Gasthuys E, Vermeulen A. Predictive Performance of Physiologically Based Pharmacokinetic Modelling of Beta-Lactam Antibiotic Concentrations in Adipose, Bone, and Muscle Tissues. Drug Metab Dispos 2023; 51:499-508. [PMID: 36639242 DOI: 10.1124/dmd.122.001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Physiologically based pharmacokinetic (PBPK) models consist of compartments representing different tissues. As most models are only verified based on plasma concentrations, it is unclear how reliable associated tissue profiles are. This study aimed to assess the accuracy of PBPK-predicted beta-lactam antibiotic concentrations in different tissues and assess the impact of using effect site concentrations for evaluation of target attainment. Adipose, bone, and muscle concentrations of five beta-lactams (piperacillin, cefazolin, cefuroxime, ceftazidime, and meropenem) in healthy adults were collected from literature and compared with PBPK predictions. Model performance was evaluated with average fold errors (AFEs) and absolute AFEs (AAFEs) between predicted and observed concentrations. In total, 26 studies were included, 14 of which reported total tissue concentrations and 12 unbound interstitial fluid (uISF) concentrations. Concurrent plasma concentrations, used as baseline verification of the models, were fairly accurate (AFE: 1.14, AAFE: 1.50). Predicted total tissue concentrations were less accurate (AFE: 0.68, AAFE: 1.89). A slight trend for underprediction was observed but none of the studies had AFE or AAFE values outside threefold. Similarly, predictions of microdialysis-derived uISF concentrations were less accurate than plasma concentration predictions (AFE: 1.52, AAFE: 2.32). uISF concentrations tended to be overpredicted and two studies had AFEs and AAFEs outside threefold. Pharmacodynamic simulations in our case showed only a limited impact of using uISF concentrations instead of unbound plasma concentrations on target attainment rates. The results of this study illustrate the limitations of current PBPK models to predict tissue concentrations and the associated need for more accurate models. SIGNIFICANCE STATEMENT: Clinical inaccessibility of local effect site concentrations precipitates a need for predictive methods for the estimation of tissue concentrations. This is the first study in which the accuracy of PBPK-predicted tissue concentrations of beta-lactam antibiotics in humans were assessed. Predicted tissue concentrations were found to be less accurate than concurrent predicted plasma concentrations. When using PBPK models to predict tissue concentrations, this potential relative loss of accuracy should be acknowledged when clinical tissue concentrations are unavailable to verify predictions.
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Affiliation(s)
- Pieter-Jan De Sutter
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
| | - Pieter De Cock
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
| | - Trevor N Johnson
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
| | - Helen Musther
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
| | - Elke Gasthuys
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
| | - An Vermeulen
- Laboratory of Medical Biochemistry and Clinical Analysis, Department of Bioanalysis, Faculty of Pharmaceutical Sciences (P-J.DS., E.G., A.V.), Department of Basic and Applied Medical Science, Faculty of Medicine and Health Sciences (P.D-C), Ghent University, Ghent, Belgium; Department of Pharmacy and Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium (P.D-C.); and Certara UK Limited, Sheffield, United Kingdom (T.N.J., H.M.)
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Finazzi S, Luci G, Olivieri C, Langer M, Mandelli G, Corona A, Viaggi B, Di Paolo A. Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review—Part I. Antibiotics (Basel) 2022; 11:antibiotics11091164. [PMID: 36139944 PMCID: PMC9495190 DOI: 10.3390/antibiotics11091164] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/14/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022] Open
Abstract
The challenging severity of some infections, especially in critically ill patients, makes the diffusion of antimicrobial drugs within tissues one of the cornerstones of chemotherapy. The knowledge of how antibacterial agents penetrate tissues may come from different sources: preclinical studies in animal models, phase I–III clinical trials and post-registration studies. However, the particular physiopathology of critically ill patients may significantly alter drug pharmacokinetics. Indeed, changes in interstitial volumes (the third space) and/or in glomerular filtration ratio may influence the achievement of bactericidal concentrations in peripheral compartments, while inflammation can alter the systemic distribution of some drugs. On the contrary, other antibacterial agents may reach high and effective concentrations thanks to the increased tissue accumulation of macrophages and neutrophils. Therefore, the present review explores the tissue distribution of beta-lactams and other antimicrobials acting on the cell wall and cytoplasmic membrane of bacteria in critically ill patients. A systematic search of articles was performed according to PRISMA guidelines, and tissue/plasma penetration ratios were collected. Results showed a highly variable passage of drugs within tissues, while large interindividual variability may represent a hurdle which must be overcome to achieve therapeutic concentrations in some compartments. To solve that issue, off-label dosing regimens could represent an effective solution in particular conditions.
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Affiliation(s)
- Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Giacomo Luci
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Carlo Olivieri
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Anesthesia and Intensive Care, Sant’Andrea Hospital, ASL VC, 13100 Vercelli, Italy
| | - Martin Langer
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Giulia Mandelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bruno Viaggi
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Department of Anesthesiology, Neuro-Intensive Care Unit, Florence Careggi University Hospital, 50139 Florence, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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van Os W, Zeitlinger M. Predicting Antimicrobial Activity at the Target Site: Pharmacokinetic/Pharmacodynamic Indices versus Time-Kill Approaches. Antibiotics (Basel) 2021; 10:antibiotics10121485. [PMID: 34943697 PMCID: PMC8698708 DOI: 10.3390/antibiotics10121485] [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: 10/29/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/21/2022] Open
Abstract
Antibiotic dosing strategies are generally based on systemic drug concentrations. However, drug concentrations at the infection site drive antimicrobial effect, and efficacy predictions and dosing strategies should be based on these concentrations. We set out to review different translational pharmacokinetic-pharmacodynamic (PK/PD) approaches from a target site perspective. The most common approach involves calculating the probability of attaining animal-derived PK/PD index targets, which link PK parameters to antimicrobial susceptibility measures. This approach is time efficient but ignores some aspects of the shape of the PK profile and inter-species differences in drug clearance and distribution, and provides no information on the PD time-course. Time–kill curves, in contrast, depict bacterial response over time. In vitro dynamic time–kill setups allow for the evaluation of bacterial response to clinical PK profiles, but are not representative of the infection site environment. The translational value of in vivo time–kill experiments, conversely, is limited from a PK perspective. Computational PK/PD models, especially when developed using both in vitro and in vivo data and coupled to target site PK models, can bridge translational gaps in both PK and PD. Ultimately, clinical PK and experimental and computational tools should be combined to tailor antibiotic treatment strategies to the site of infection.
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9
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Edlinger-Stanger M, al Jalali V, Andreas M, Jäger W, Böhmdorfer M, Zeitlinger M, Hutschala D. Plasma and Lung Tissue Pharmacokinetics of Ceftaroline Fosamil in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: an In Vivo Microdialysis Study. Antimicrob Agents Chemother 2021; 65:e0067921. [PMID: 34280013 PMCID: PMC8448148 DOI: 10.1128/aac.00679-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/13/2021] [Indexed: 11/20/2022] Open
Abstract
Ceftaroline fosamil, a fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), is currently approved for the treatment of pneumonia and complicated skin and soft tissue infections. However, pharmacokinetics data on free lung tissue concentrations in critical patient populations are lacking. The aim of this study was to evaluate the pharmacokinetics of the high-dose regimen of ceftaroline in plasma and lung tissue in cardiac surgery patients during intermittent and continuous administration. Nine patients undergoing elective cardiac surgery on cardiopulmonary bypass were included in this study and randomly assigned to intermittent or continuous administration. Eighteen hundred milligrams of ceftaroline fosamil was administered intravenously as either 600 mg over 2 h every 8 h (q8h) (intermittent group) or 600 mg over 2 h (loading dose) plus 1,200 mg over 22 h (continuous group). Interstitial lung tissue concentrations were measured by in vivo microdialysis. Relevant pharmacokinetics parameters were calculated for each group. Plasma exposure levels during intermittent and continuous administration were comparable to those of previously published studies and did not differ significantly between the two groups. In vivo microdialysis demonstrated reliable and adequate penetration of ceftaroline into lung tissue during intermittent and continuous administration. The steady-state area under the concentration-time curve from 0 to 8 h (AUCss 0-8) and the ratio of AUCSS 0-8 in lung tissue and AUC in plasma (AUClung/plasma) were descriptively higher in the continuous group. Continuous administration of ceftaroline fosamil achieved a significantly higher proportion of time for which the free drug concentration remained above 4 times the minimal inhibitory concentration (MIC) during the dosing interval (% fT>4xMIC) than intermittent administration for pathogens with a MIC of 1 mg/liter. Ceftaroline showed adequate penetration into interstitial lung tissue of critically ill patients undergoing major cardiothoracic surgery, supporting its use for pneumonia caused by susceptible pathogens.
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Affiliation(s)
- M. Edlinger-Stanger
- Medical University of Vienna, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Vienna, Austria
| | - V. al Jalali
- Medical University of Vienna, Department of Clinical Pharmacology, Vienna, Austria
| | - M. Andreas
- Medical University of Vienna, Department of Surgery, Division of Cardiac Surgery, Vienna, Austria
| | - W. Jäger
- University of Vienna, Department of Pharmaceutical Chemistry, Vienna, Austria
| | - M. Böhmdorfer
- University of Vienna, Department of Pharmaceutical Chemistry, Vienna, Austria
| | - M. Zeitlinger
- Medical University of Vienna, Department of Clinical Pharmacology, Vienna, Austria
| | - D. Hutschala
- Medical University of Vienna, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Vienna, Austria
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10
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Dorn C, Petroff D, Stoelzel M, Kees MG, Kratzer A, Dietrich A, Kloft C, Zeitlinger M, Kees F, Wrigge H, Simon P. Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid. J Antimicrob Chemother 2021; 76:2114-2120. [PMID: 33969405 DOI: 10.1093/jac/dkab143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess plasma and tissue pharmacokinetics of cefazolin and metronidazole in obese patients undergoing bariatric surgery and non-obese patients undergoing intra-abdominal surgery. PATIENTS AND METHODS Fifteen obese and 15 non-obese patients received an IV short infusion of 2 g cefazolin and 0.5 g metronidazole for perioperative prophylaxis. Plasma and microdialysate from subcutaneous tissue were sampled until 8 h after dosing. Drug concentrations were determined by HPLC-UV. Pharmacokinetic parameters were calculated non-compartmentally. RESULTS In obese patients (BMI 39.5-69.3 kg/m2) compared with non-obese patients (BMI 18.7-29.8 kg/m2), mean Cmax of total cefazolin in plasma was lower (115 versus 174 mg/L) and Vss was higher (19.4 versus 14.2 L). The mean differences in t½ (2.7 versus 2.4 h), CL (5.14 versus 4.63 L/h) and AUC∞ (402 versus 450 mg·h/L) were not significant. The influence of obesity on the pharmacokinetics of metronidazole was similar (Cmax 8.99 versus 14.7 mg/L, Vss 73.9 versus 51.8 L, t½ 11.9 versus 9.1 h, CL 4.62 versus 4.13 L/h, AUC∞ 116 versus 127 mg·h/L). Regarding interstitial fluid (ISF), mean concentrations of cefazolin remained >4 mg/L until 6 h in both groups, and those of metronidazole up to 8 h in the non-obese group. In obese patients, the mean ISF concentrations of metronidazole were between 3 and 3.5 mg/L throughout the measuring interval. CONCLUSIONS During the time of surgery, cefazolin concentrations in plasma and ISF of subcutaneous tissue were lower in obese patients, but not clinically relevant. Regarding metronidazole, the respective differences were higher, and may influence dosing of metronidazole for perioperative prophylaxis in obese patients.
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Affiliation(s)
- Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany.,Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Melanie Stoelzel
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
| | - Martin G Kees
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Surgery, University of Leipzig, Leipzig, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
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11
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Schroepf S, Burau D, Muench HG, Derendorf H, Zeitlinger M, Genzel-Boroviczény O, Adam D, Kloft C. Microdialysis sampling to monitor target-site vancomycin concentrations in septic infants: a feasible way to close the knowledge gap. Int J Antimicrob Agents 2021; 58:106405. [PMID: 34289402 DOI: 10.1016/j.ijantimicag.2021.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
This work is dedicated to the memory of Hartmut Derendorf (1953-2020), a pioneer of modern pharmacokinetics and valued mentor of this project. OBJECTIVES Septic infants/neonates need effective antibiotic exposure, but dosing recommendations are challenging as the pharmacokinetics in this age are highly variable. For vancomycin, which is used as a standard treatment, comprehensive pharmacokinetic knowledge especially at the infection site is lacking. Hence, an exploratory clinical study was conducted to assess the feasibility and safety of microdialysis sampling for vancomycin monitoring at the target site. METHODS Nine infants/neonates with therapeutic indications for vancomycin treatment were administered 15 mg/kg as 1-hour infusions every 8-24 hours. Microdialysis catheters were implanted in the subcutaneous interstitial space fluid of the lateral thigh. Samples were collected every 30 minutes over 24 hours, followed by retrodialysis for catheter calibration. Prior in vitro investigations have evaluated impact factors on relative recovery and retrodialysis. RESULTS In vitro investigations showed the applicability of microdialysis for vancomycin monitoring. Microdialysis sampling was well tolerated in all infants/neonates (23-255 days) without major bleeding or other adverse events. Pharmacokinetic profiles were obtained and showed plausible vancomycin concentration-time courses. CONCLUSIONS Microdialysis as a minimally invasive technique for continuous longer-term sampling is feasible and safe in infants/neonates. Interstitial space fluid profiles were plausible and showed substantial interpatient variation. Hence, a larger microdialysis trial is warranted to further characterise the pharmacokinetics and variability of vancomycin at the target site and ultimately improve vancomycin dosing in these vulnerable patients.
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Affiliation(s)
- Sebastian Schroepf
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany.
| | - Daniela Burau
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Hans-Georg Muench
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | | | | | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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12
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Brasier N, Widmer A, Osthoff M, Mutke M, De Ieso F, Brasier-Lutz P, Brown K, Yao L, Broeckling CD, Prenni J, Eckstein J. The Detection of Vancomycin in Sweat: A Next-Generation Digital Surrogate Marker for Antibiotic Tissue Penetration: A Pilot Study. Digit Biomark 2021; 5:24-28. [PMID: 33615119 PMCID: PMC7879282 DOI: 10.1159/000512947] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Assuring adequate antibiotic tissue concentrations at the point of infection, especially in skin and soft tissue infections, is pivotal for an effective treatment and cure. Despite the global issue, a reliable AB monitoring test is missing. Inadequate antibiotic treatment leads to the development of antimicrobial resistances and toxic side effects. β-lactam antibiotics were already detected in sweat of patients treated with the respective antibiotics intravenously before. With the emergence of smartphone-based biosensors to analyse sweat on the spot of need, next-generation molecular digital biomarkers will be increasingly available for a non-invasive pharmacotherapy monitoring. OBJECTIVE Here, we investigated if the glycopeptide antibiotic vancomycin is detectable in sweat samples of in-patients treated with intravenous vancomycin. METHODS Eccrine sweat samples were collected using the Macroduct Sweat Collector®. Along every sweat sample, a blood sample was taken. Bio-fluid analysis was performed by Ultra-high Pressure Liquid Chromatograph-Tandem Quadrupole Mass Spectrometry coupled with tandem mass spectrometry. RESULTS A total of 5 patients were included. Results demonstrate that vancomycin was detected in 5 out of 5 sweat samples. Specifically, vancomycin concentrations ranged from 0.011 to 0.118 mg/L in sweat and from 4.7 to 8.5 mg/L in blood. CONCLUSION Our results serve as proof-of-concept that vancomycin is detectable in eccrine sweat and may serve as a surrogate marker for antibiotic tissue penetration. A targeted vancomycin treatment is crucial in patients with repetitive need for antibiotics and a variable antibiotic distribution such as in peripheral artery disease to optimize treatment effectiveness. If combined with on-skin smartphone-based biosensors and smartphone applications, the detection of antibiotic concentrations in sweat might enable a first digital, on-spot, lab-independent and non-invasive therapeutic drug monitoring in skin and soft tissue infections.
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Affiliation(s)
- Noé Brasier
- CMIO Research Group, Department of Digitalization and ICT, University Hospital Basel, Basel, Switzerland
| | - Andreas Widmer
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Basel, Basel, Switzerland
| | - Markus Mutke
- CMIO Research Group, Department of Digitalization and ICT, University Hospital Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Fiorangelo De Ieso
- CMIO Research Group, Department of Digitalization and ICT, University Hospital Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascale Brasier-Lutz
- Department of Gynaecology, Kantonsspital Luzern, Standort Wolhusen, Wolhusen, Switzerland
| | - Kitty Brown
- Analytical Resources Core, Bioanalysis and Omics Center, Colorado State University, Fort Collins, Colorado, USA
| | - Linxing Yao
- Analytical Resources Core, Bioanalysis and Omics Center, Colorado State University, Fort Collins, Colorado, USA
| | - Corey D. Broeckling
- Analytical Resources Core, Bioanalysis and Omics Center, Colorado State University, Fort Collins, Colorado, USA
| | - Jessica Prenni
- Department of Horticulture and Landscape, Colorado State University, Fort Collins, Colorado, USA
| | - Jens Eckstein
- CMIO Research Group, Department of Digitalization and ICT, University Hospital Basel, Basel, Switzerland
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
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13
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Early Antibiotic Prophylaxis Prior to Bypass Surgery Improves Tissue Penetration. Thorac Cardiovasc Surg 2019; 68:669-673. [PMID: 31491791 DOI: 10.1055/s-0039-1695780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND We previously identified preparation of the internal mammary artery as a risk factor significantly impairing antibiotic tissue penetration into the presternal subcutaneous tissue. We, therefore, adapted our dosing schema regarding preoperative timing to overcome this risk factor. METHODS Eight patients who underwent coronary artery bypass grafting with a left internal mammary artery and vein grafts were included in this clinical trial. Cefazolin (4 g) was administered twice (3 hours and 1 hour) prior to skin incision and once during skin closure (2 g). Antibiotic concentrations were measured with subcutaneous microdialysis probes on both sternal sides. Results were directly compared with the previously published patient cohort receiving the standard schema (4 g cefazolin prior to skin incision and 2 g during closure). RESULTS All patients (7 male, 1 female, 69 ± 7 years, 26.3 ± 3.9 kg/m2) survived the perioperative period. Mean area under the curve on the right and left sternal side was 117.0 ± 92.5 μg/mL and 114.5 ± 83.2 μg/mL, respectively (p = 0.95). This was well above the previously measured mean peak tissue concentrations without early preoperative antibiotic administration on the side of mammary artery harvesting (52.4 ± 48.5 μg/mL vs. 13.1 ± 5.8 μg/mL; p = 0.039). The %fT > minimal inhibitory concentration (MIC) for Staphylococcus epidermidis and Staphylococcus aureus during the first 10 hours in presternal tissue was ≥ 70% but did not differ compared with standard schema. CONCLUSIONS Early, additional preoperative administration of cefazolin was able to significantly increase peak tissue concentrations during surgery compared with the standard protocol. No difference, however, could be achieved in the percentage of time during which the concentration exceeded the MIC.
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14
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Nowak H, Weidemann C, Martini S, Oesterreicher ZA, Dorn C, Adamzik M, Kees F, Zeitlinger M, Rahmel T. Repeated determination of moxifloxacin concentrations in interstitial space fluid of muscle and subcutis in septic patients. J Antimicrob Chemother 2019; 74:2681-2689. [PMID: 31299075 DOI: 10.1093/jac/dkz259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/07/2019] [Accepted: 05/22/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For an effective antimicrobial treatment, it is crucial that antibiotics reach sufficient concentrations in plasma and tissue. Currently no data exist regarding moxifloxacin plasma concentrations and exposure levels in tissue under septic conditions. OBJECTIVES To determine the pharmacokinetics of moxifloxacin in plasma and interstitial space fluid over a prolonged period. PATIENTS AND METHODS Ten septic patients were treated with 400 mg of moxifloxacin once a day; on days 1, 3 and 5 of treatment plasma sampling and microdialysis in the subcutis and muscle of the upper thigh were performed to determine concentrations of moxifloxacin in different compartments. This trial was registered in the German Clinical Trials Register (DRKS, register number DRKS00012985). RESULTS Mean unbound fraction of moxifloxacin in plasma was 85.5±3.4%. On day 1, Cmax in subcutis and muscle was 2.8±1.8 and 2.5±1.3 mg/L, respectively, AUC was 24.8±15.1 and 21.3±10.5 mg·h/L, respectively, and fAUC0-24/MIC was 100.9±62.9 and 86.5±38.3 h, respectively. Cmax for unbound moxifloxacin in plasma was 3.5±0.9 mg/L, AUC was 23.5±7.5 mg·h/L and fAUC0-24/MIC was 91.6±24.8 h. Key pharmacokinetic parameters on days 3 and 5 showed no significant differences. Clearance was higher than in healthy adults, but tissue concentrations were comparable, most likely due to a lower protein binding. CONCLUSIONS Surprisingly, the first dose already achieved exposure comparable to steady-state conditions. The approved daily dose of 400 mg was adequate in our patient population. Thus, it seems that in septic patients a loading dose on the first day of treatment with moxifloxacin is not required.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Caroline Weidemann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Stefan Martini
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Zoe Anne Oesterreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Michael Adamzik
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
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15
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Hashemian SMR, Farhadi Z, Farhadi T. Fosfomycin: the characteristics, activity, and use in critical care. Ther Clin Risk Manag 2019; 15:525-530. [PMID: 30988619 PMCID: PMC6441553 DOI: 10.2147/tcrm.s199119] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fosfomycin (C3H7O4P) is a phosphonic acid derivative representing an epoxide class of antibiotics. The drug is a re-emerging bactericidal antibiotic with a wide range of actions against several Gram-positive and Gram-negative bacteria. Among the existing antibacterial agents, fosfomycin has the lowest molecular weight (138 Da), which is not structurally associated with other classes of antibiotics. In intensive care unit (ICU) patients, severe soft tissue infections (STIs) may lead to serious life-threatening problems, and therefore, appropriate antibiotic therapy and often intensive care management (ICM) coupled with surgical intervention are necessary. Fosfomycin is an antibiotic primarily utilized for the treatment of STIs in ICUs. Recently, fosfomycin has attracted renewed interest for the treatment of serious systemic infections caused by multidrug-resistant Enterobacteriaceae. In some countries, intravenous fosfomycin has been prescribed for various serious systemic infections, such as acute osteomyelitis, nosocomial lower respiratory tract infections, complicated urinary tract infections, bacterial meningitis, and bacteremia. Administration of intravenous fosfomycin can result in a sufficient concentration of the drug at different body regions. Dose modification is not required in hepatic deficiency because fosfomycin is not subjected to enterohepatic circulation.
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Affiliation(s)
- Seyed Mohammad Reza Hashemian
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran, .,Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zinat Farhadi
- Department of Microbiology, Shiraz Branch, Islamic Azad University, Shiraz, Iran
| | - Tayebeh Farhadi
- Chronic Respiratory Diseases Research Center (CRDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran,
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16
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Cefazolin tissue concentrations with a prophylactic dose administered before sleeve gastrectomy in obese patients: a single centre study in 116 patients. Br J Anaesth 2017; 120:1202-1208. [PMID: 29793587 DOI: 10.1016/j.bja.2017.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND In obese patients undergoing sleeve gastrectomy, the blood and fatty-tissue concentrations of cefazolin required for adequate antibiotic prophylaxis are uncertain. METHODS This was a single centre prospective study in obese (Group A: 40≤ BMI ≤50 kg m-2) and severely obese (Group B: 50< BMI ≤65 kg m-2) patients undergoing bariatric surgery. Blood and fatty-tissue samples were collected after a cefazolin 4 g i.v. injection. The primary aim was to compare cefazolin concentrations in subcutaneous fatty tissue with a targeted tissue concentration of 4 μg g-1 according to Staphylococcus aureus resistance breakpoint. RESULTS One hundred and sixteen patients were included: 79 in Group A and 37 in Group B. At the beginning of the surgery, cefazolin concentration in subcutaneous fatty tissue was 12.2 (5.4) μg g-1 in Group A and 12 (6.1) μg g-1 in Group B (P=0.7). At the end, cefazolin concentrations in subcutaneous fatty tissue were 9.0 (4.9) and 7.8 (4.2) μg g-1 in Groups A and B, respectively (P=0.2). The plasma concentration of free cefazolin during surgery was higher in Group A than in Group B (P<0.0001). Fatty-tissue concentrations of 95% and 83% patients in Groups A and B, respectively, were above S. aureus resistance breakpoint. CONCLUSIONS After a 4 g dose, the concentrations of cefazolin in fatty tissue were above the 4 μg g-1 tissue concentration target, providing adequate antibiotic tissue concentrations during bariatric surgery. As cefazolin concentration in fatty tissue is a surrogate endpoint, the results should be considered in conjunction with the results on free cefazolin concentrations in subcutaneous tissue. CLINICAL TRIAL REGISTRATION NCT01537380.
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17
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Impact of national policies on the microbial aetiology of surgical site infections in acute NHS hospitals in England: analysis of trends between 2000 and 2013 using multi-centre prospective cohort data. Epidemiol Infect 2016; 145:957-969. [PMID: 28027714 DOI: 10.1017/s0950268816003058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Our study aimed to evaluate changes in the epidemiology of pathogens causing surgical site infections (SSIs) in England between 2000 and 2013 in the context of intensified national interventions to reduce healthcare-associated infections introduced since 2006. National prospective surveillance data on target surgical procedures were used for this study. Data on causative organism were available for 72% of inpatient-detected SSIs meeting the standard case definitions for superficial, deep and organ-space infections (9767/13 531) which were analysed for trends. A multivariable logistic linear mixed model with hospital random effects was fitted to evaluate trends by pathogen. Staphylococcus aureus was the predominant cause of SSI between 2000 (41%) and 2009 (24%), decreasing from 2006 onwards reaching 16% in 2013. Data for 2005-2013 showed that the odds of SSI caused by S. aureus decreased significantly by 14% per year [adjusted odds ratio (aOR) 0·86, 95% confidence interval (CI) 0·83-0·89] driven by significant decreases in methicillin-resistant S. aureus (MRSA) (aOR 0·71, 95% CI 0·68-0·75). However a small significant increase in methicillin-sensitive S. aureus was identified (aOR 1·06, 95% CI 1·02-1·10). Enterobacteriaceae were stable during 2000-2007 (12% of cases overall), increasing from 2008 (18%) onwards, being present in 25% of cases in 2013; the model supported these increasing trends during 2007-2013 (aOR 1·12, 95% CI 1·07-1·18). The decreasing trends in S. aureus SSIs from 2006 and the increases in Enterobacteriaceae SSIs from 2008 may be related to intensified national efforts targeted at reducing MRSA bacteraemia combined with changes in antibiotic use aimed at controlling C. difficile infections.
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18
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Onufrak NJ, Forrest A, Gonzalez D. Pharmacokinetic and Pharmacodynamic Principles of Anti-infective Dosing. Clin Ther 2016; 38:1930-47. [PMID: 27449411 PMCID: PMC5039113 DOI: 10.1016/j.clinthera.2016.06.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/09/2016] [Accepted: 06/23/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE An understanding of the pharmacokinetic (PK) and pharmacodynamic (PD) principles that determine response to antimicrobial therapy can provide the clinician with better-informed dosing regimens. Factors influential on antibiotic disposition and clinical outcome are presented, with a focus on the primary site of infection. Techniques to better understand antibiotic PK and optimize PD are acknowledged. METHODS PubMed (inception-April 2016) was reviewed for relevant publications assessing antimicrobial exposures within different anatomic locations and clinical outcomes for various infection sites. FINDINGS A limited literature base indicates variable penetration of antibiotics to different target sites of infection, with drug solubility and extent of protein binding providing significant PK influences in addition to the major clearing pathway of the agent. PD indices derived from in vitro studies and animal models determine the optimal magnitude and frequency of dosing regimens for patients. PK/PD modeling and simulation has been shown an efficient means of assessing these PD endpoints against a variety of PK determinants, clarifying the unique effects of infection site and patient characteristics to inform the adequacy of a given antibiotic regimen. IMPLICATIONS Appreciation of the PK properties of an antibiotic and its PD measure of efficacy can maximize the utility of these life-saving drugs. Unfortunately, clinical data remain limited for a number of infection site-antibiotic exposure relationships. Modeling and simulation can bridge preclinical and patient data for the prescription of optimal antibiotic dosing regimens, consistent with the tenets of personalized medicine.
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Affiliation(s)
- Nikolas J Onufrak
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alan Forrest
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Abstract
Critical illness is accompanied by multiple physiologic alterations that affect the pharmacokinetics of antimicrobials. Although the pharmacokinetics of a number of antimicrobials have been studied in critically ill individuals, an understanding of the physiological alterations in critical illness and general pharmacokinetic principles of antimicrobials is imperative for appropriate selection, dosing, and prediction of toxicity.
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Affiliation(s)
- Aaron M. Cook
- Neurosurgery/Critical Care, University of Kentucky Chandler Medical Center, Lexington,
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20
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Bue M, Birke-Sørensen H, Thillemann TM, Hardlei TF, Søballe K, Tøttrup M. Single-dose pharmacokinetics of vancomycin in porcine cancellous and cortical bone determined by microdialysis. Int J Antimicrob Agents 2015; 46:434-8. [DOI: 10.1016/j.ijantimicag.2015.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/03/2015] [Accepted: 06/13/2015] [Indexed: 11/30/2022]
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Kiang TKL, Häfeli UO, Ensom MHH. A comprehensive review on the pharmacokinetics of antibiotics in interstitial fluid spaces in humans: implications on dosing and clinical pharmacokinetic monitoring. Clin Pharmacokinet 2015; 53:695-730. [PMID: 24972859 DOI: 10.1007/s40262-014-0152-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of the current review was to provide an updated and comprehensive summary on pharmacokinetic data describing the distribution of antimicrobials into interstitial fluid (ISF) by comparing drug concentration versus time profiles between ISF and blood/plasma in healthy individuals and/or diseased populations. An extensive literature search identified 55 studies detailing 87 individual comparisons. For each antibiotic (antibacterial) (or antibiotic class), we comment on dosing implications based on tissue ISF distribution characteristics and determine the suitability of conducting clinical pharmacokinetic monitoring (CPM) using a previously published scoring algorithm. Using piperacillin as an example, there is evidence supporting different degrees of drug penetration into the ISF of different tissues. A higher dose of piperacillin may be required to achieve an adequate ISF concentration in soft tissue infections. To achieve these higher doses, alternative administration regimens such as intravenous infusions may be utilized. Data also suggest that piperacillin can be categorized as a 'likely suitable' agent for CPM in ISF. Regression analyses of data from the published studies, including protein binding, molecular weight, and predicted partition coefficient (using XlogP3) as dependent variables, indicated that protein binding was the only significant predictor for the extent of drug distribution as determined by ratios of the area under the concentration-time curve between muscle ISF/total plasma (R (2) = 0.65, p < 0.001) and adipose ISF/total plasma (R (2) = 0.48, p < 0.004). Although recurrent limitations (i.e., small sample size, lack of statistical comparisons, lack of steady-state conditions, high individual variability) were identified in many studies, these data are still valuable and allowed us to generate general dosing guidelines and assess the suitability of using ISF for CPM.
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Affiliation(s)
- Tony K L Kiang
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
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22
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Azeredo FJ, Dalla Costa T, Derendorf H. Role of microdialysis in pharmacokinetics and pharmacodynamics: current status and future directions. Clin Pharmacokinet 2014; 53:205-212. [PMID: 24452811 DOI: 10.1007/s40262-014-0131-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diagnostic and therapeutic decisions in medical practice are still generally based on blood concentrations of drugs and/or biomolecules despite the knowledge that biochemical events and pharmacological effects usually take place in tissue rather than in the bloodstream. Microdialysis is a semi-invasive technique that is able to measure concentrations of the free, active drug or endogenous compounds in almost all human tissues and organs. It is currently being used to monitor brain metabolic processes and quantify tissue biomarkers, and determine transdermal drug distribution and tissue pharmacokinetics, confirming its importance as a widely used sampling technique in clinical drug monitoring and drug development as well as therapy and disease follow-up, contributing to rationalizing drug dosing regimens and influencing the clinical decision-making process.
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Affiliation(s)
| | - Teresa Dalla Costa
- Programa de Pós-Graduação em Ciências Farmacêuticas, UFRGS, Porto Alegre, Brazil
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA.
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Continuous versus short-term infusion of cefuroxime: assessment of concept based on plasma, subcutaneous tissue, and bone pharmacokinetics in an animal model. Antimicrob Agents Chemother 2014; 59:67-75. [PMID: 25313214 DOI: 10.1128/aac.03857-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The relatively short half-lives of most β-lactams suggest that continuous infusion of these time-dependent antimicrobials may be favorable compared to short-term infusion. Nevertheless, only limited solid-tissue pharmacokinetic data are available to support this theory. In this study, we randomly assigned 12 pigs to receive cefuroxime as either a short-term or continuous infusion. Measurements of cefuroxime were obtained every 30 min in plasma, subcutaneous tissue, and bone. For the measurements in solid tissues, microdialysis was applied. A two-compartment population model was fitted separately to the drug concentration data for the different tissues using a nonlinear mixed-effects regression model. Estimates of the pharmacokinetic parameters and time with concentrations above the MIC were derived using Monte Carlo simulations. Except for subcutaneous tissue in the short-term infusion group, the tissue penetration was incomplete for all tissues. For short-term infusion, the tissue penetration ratios were 0.97 (95% confidence interval [CI], 0.67 to 1.39), 0.61 (95% CI, 0.51 to 0.73), and 0.45 (95% CI, 0.36 to 0.56) for subcutaneous tissue, cancellous bone, and cortical bone, respectively. For continuous infusion, they were 0.53 (95% CI, 0.33 to 0.84), 0.38 (95% CI, 0.23 to 0.57), and 0.27 (95% CI, 0.13 to 0.48) for the same tissues, respectively. The absolute areas under the concentration-time curve were also lower in the continuous infusion group. Nevertheless, a significantly longer time with concentrations above the MIC was found for continuous infusion up until MICs of 4, 2, 2, and 0.5 μg/ml for plasma and the same three tissues mentioned above, respectively. For drugs with a short half-life, like cefuroxime, continuous infusion seems to be favorable compared to short-term infusion; however, incomplete tissue penetration and high MIC strains may jeopardize the continuous infusion approach.
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[Tissue penetration of antibiotics. Does the treatment reach the target site?]. Med Klin Intensivmed Notfmed 2014; 109:175-81. [PMID: 24691884 DOI: 10.1007/s00063-013-0309-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND For critically ill patients, infections still imply a major challenge for the treating physician. One key factor of successful treatment is sufficient exposure of the employed antimicrobial agent at the site of infection. In most cases, this is the interstitial space of the infected organ or a body cavity; much rarer vital bacteria are located within body cells. METHODS Different methods for assessment of tissue pharmacokinetics of antimicrobial agents in the human body are described, including tissue biopsy, bronchoalveolar lavage and microdialysis, and their implication on interpretation of obtained data are discussed. Tissue pharmacokinetics of the hydrophilic beta-lactam meropenem and the lipophilic fluoroquinolone levofloxacin are compared. RESULTS Differences in pharmacokinetics between plasma and tissue, healthy volunteers and critically ill patients but also between data obtained in the same organ by different methods are discussed. CONCLUSION In order to use pharmacokinetic data to optimize the treatment of critically ill patients, critical appraisal of the causative pathogen, the location of the infection, and the source of the used pharmacokinetic data is necessary.
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Pharmacokinetics of cefuroxime in porcine cortical and cancellous bone determined by microdialysis. Antimicrob Agents Chemother 2014; 58:3200-5. [PMID: 24663019 DOI: 10.1128/aac.02438-14] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Traditionally, the pharmacokinetics of antimicrobials in bone have been investigated using bone biopsy specimens, but this approach suffers from considerable methodological limitations. Consequently, new methods are needed. The objectives of this study were to assess the feasibility of microdialysis (MD) for measuring cefuroxime in bone and to obtain pharmacokinetic profiles for the same drug in porcine cortical and cancellous bone. The measurements were conducted in bone wax sealed and unsealed drill holes in cortical bone and in drill holes in cancellous bone and in subcutaneous tissue. As a reference, the free and total plasma concentrations were also measured. The animals received a bolus of 1,500 mg cefuroxime over 30 min. No significant differences were found between the key pharmacokinetic parameters for sealed and unsealed drill holes in cortical bone. The mean ± standard error of the mean area under the concentration-time curve (AUC) values from 0 to 5 h were 6,013 ± 1,339, 3,222 ± 1086, 2,232 ± 635, and 952 ± 290 min · μg/ml for free plasma, subcutaneous tissue, cancellous bone, and cortical bone, respectively (P < 0.01, analysis of variance). The AUC for cortical bone was also significantly different from that for cancellous bone (P = 0.04). This heterogeneous tissue distribution was also reflected in other key pharmacokinetic parameters. This study validates MD as a suitable method for measuring cefuroxime in bone. Cefuroxime penetration was impaired for all tissues, and bone may not be considered one distinct compartment.
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26
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Role of microdialysis in pharmacokinetics and pharmacodynamics: current status and future directions. Clin Pharmacokinet 2014. [PMID: 24452811 DOI: 10.1007/s40262–014-0131–8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
Diagnostic and therapeutic decisions in medical practice are still generally based on blood concentrations of drugs and/or biomolecules despite the knowledge that biochemical events and pharmacological effects usually take place in tissue rather than in the bloodstream. Microdialysis is a semi-invasive technique that is able to measure concentrations of the free, active drug or endogenous compounds in almost all human tissues and organs. It is currently being used to monitor brain metabolic processes and quantify tissue biomarkers, and determine transdermal drug distribution and tissue pharmacokinetics, confirming its importance as a widely used sampling technique in clinical drug monitoring and drug development as well as therapy and disease follow-up, contributing to rationalizing drug dosing regimens and influencing the clinical decision-making process.
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27
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Importance of relating efficacy measures to unbound drug concentrations for anti-infective agents. Clin Microbiol Rev 2013; 26:274-88. [PMID: 23554417 DOI: 10.1128/cmr.00092-12] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
For the optimization of dosing regimens of anti-infective agents, it is imperative to have a good understanding of pharmacokinetics (PK) and pharmacodynamics (PD). Whenever possible, drug efficacy needs to be related to unbound concentrations at the site of action. For anti-infective drugs, the infection site is typically located outside plasma, and a drug must diffuse through capillary membranes to reach its target. Disease- and drug-related factors can contribute to differential tissue distribution. As a result, the assumption that the plasma concentration of drugs represents a suitable surrogate of tissue concentrations may lead to erroneous conclusions. Quantifying drug exposure in tissues represents an opportunity to relate the pharmacologically active concentrations to an observed pharmacodynamic parameter, such as the MIC. Selection of an appropriate specimen to sample and the advantages and limitations of the available sampling techniques require careful consideration. Ultimately, the goal will be to assess the appropriateness of a drug and dosing regimen for a specific pathogen and infection.
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Roberts DJ, Hall RI. Drug absorption, distribution, metabolism and excretion considerations in critically ill adults. Expert Opin Drug Metab Toxicol 2013; 9:1067-84. [PMID: 23682923 DOI: 10.1517/17425255.2013.799137] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION All critically ill patients require medication to treat organ dysfunction. However, the pharmacokinetics of drugs used to treat these patients is complex due to frequent alterations in drug absorption, distribution, metabolism, and excretion (ADME). AREAS COVERED This review examines pharmacokinetic aspects of drug administration for adult intensive care unit (ICU) patients. Specifically, the authors examine the ADME changes that occur and which should be considered by clinicians when delivering drug therapy to critically ill patients. EXPERT OPINION Dosage pharmacokinetics determined from single-dose or limited-duration administration studies in healthy volunteers may not apply to critically ill patients. Organ dysfunction among these patients may be due to pre-existing disease or the effects of a systemic or locoregional inflammatory response precipitated by their illness. Alterations in pharmacokinetics observed among the critically ill include altered bioavailability after enteral administration, increased volume of distribution and blood-brain barrier permeability and changes in P-glycoprotein and cytochrome P450 enzyme function. However, the effect of these changes on clinically important outcomes remains uncertain and poorly studied. Future investigations should examine not only pharmacokinetic changes among the critically ill, but also whether recognition of these changes and alterations in drug therapy directed as a consequence of their observation alters patient outcomes.
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Affiliation(s)
- Derek J Roberts
- University of Calgary, Departments of Surgery and Community Health Sciences, Calgary, Alberta T2N 5A1, Canada
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Effect of cardiopulmonary bypass on regional antibiotic penetration into lung tissue. Antimicrob Agents Chemother 2013; 57:2996-3002. [PMID: 23587954 DOI: 10.1128/aac.02627-12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The use of cardiopulmonary bypass (CPB) during cardiac surgery causes regional ventilation-perfusion mismatch, contributing to regional disturbances in antibiotic penetration into lung tissue. Ventilation-perfusion mismatch is associated with postoperative pneumonia, a frequent and devastating complication after cardiac surgery. In this prospective clinical animal study, we performed in vivo microdialysis to determine the effect of CPB on regional penetration of levofloxacin (LVX) into lung tissue. Six pigs underwent surgery with CPB (CPB group), and another six pigs underwent surgery without CPB (off-pump coronary artery bypass grafting; OPCAB group). LVX (750 mg) was administered intravenously to all pigs immediately after surgery. For regional measurements of LVX in pulmonary concentrations, microdialysis probes were inserted in both lungs of each pig. Pigs were placed in the right lateral position. Time versus concentration profiles of unbound LVX were measured in the upper and lower lung tissue and plasma in all pigs. In all pigs, maximum concentrations (Cmax) of LVX were significantly lower in the upper lung than in the lower lung (OPCAB, P = 0.035; CPB, P < 0.001). Median Cmax of LVX showed a significant difference in the upper versus lower lung in the CPB group (P < 0.05). No significant difference was found in the median Cmax of LVX in the upper and the lower lung in the OPCAB group (P = 0.32). Our data indicate that CPB affects perioperative regional antibiotic penetration into lung tissue. Common clinical antibiotic dosing schemes should be reevaluated in patients undergoing coronary artery bypass grafting with CPB.
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30
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Blood, tissue, and intracellular concentrations of azithromycin during and after end of therapy. Antimicrob Agents Chemother 2013; 57:1736-42. [PMID: 23357769 DOI: 10.1128/aac.02011-12] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Although azithromycin is extensively used in the treatment of respiratory tract infections as well as skin and skin-related infections, pharmacokinetics of azithromycin in extracellular space fluid of soft tissues, i.e., one of its therapeutic target sites, are not yet fully elucidated. In this study, azithromycin concentration-time profiles in extracellular space of muscle and subcutaneous adipose tissue, but also in plasma and white blood cells, were determined at days 1 and 3 of treatment as well as 2 and 7 days after the end of treatment. Of all compartments, azithromycin concentrations were highest in white blood cells, attesting for intracellular accumulation. However, azithromycin concentrations in both soft tissues were markedly lower than in plasma both during and after treatment. Calculation of the area under the concentration-time curve from 0 to 24 h (AUC(0-24))/MIC(90) ratios for selected pathogens suggests that azithromycin concentrations measured in the present study are subinhibitory at all time points in both soft tissues and at the large majority of observed time points in plasma. Hence, it might be speculated that azithromycin's clinical efficacy relies not only on elevated intracellular concentrations but possibly also on its known pleotropic effects, including immunomodulation and influence on bacterial virulence factors. However, prolonged subinhibitory azithromycin concentrations at the target site, as observed in the present study, might favor the emergence of bacterial resistance and should therefore be considered with concern. In conclusion, this study has added important information to the pharmacokinetic profile of the widely used antibiotic drug azithromycin and evidentiates the need for further research on its potential for induction of bacterial resistance.
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Abstract
Critically ill patients admitted to the intensive care unit (ICU) are frequently treated with antimicrobials. The appropriate and judicious use of antimicrobial treatment in the ICU setting is a constant clinical challenge for healthcare staff due to the appearance and spread of new multiresistant pathogens and the need to update knowledge of factors involved in the selection of multiresistance and in the patient's clinical response. In order to optimize the efficacy of empirical antibacterial treatments and to reduce the selection of multiresistant pathogens, different strategies have been advocated, including de-escalation therapy and pre-emptive therapy as well as measurement of pharmacokinetic and pharmacodynamic (pK/pD) parameters for proper dosing adjustment. Although the theoretical arguments of all these strategies are very attractive, evidence of their effectiveness is scarce. The identification of the concentration-dependent and time-dependent activity pattern of antimicrobials allow the classification of drugs into three groups, each group with its own pK/pD characteristics, which are the basis for the identification of new forms of administration of antimicrobials to optimize their efficacy (single dose, loading dose, continuous infusion) and to decrease toxicity. The appearance of new multiresistant pathogens, such as imipenem-resistant Pseudomonas aeruginosa and/or Acinetobacter baumannii, carbapenem-resistant Gram-negative bacteria harbouring carbapenemases, and vancomycin-resistant Enterococcus spp., has determined the use of new antibacterials, the reintroduction of other drugs that have been removed in the past due to toxicity or the use of combinations with in vitro synergy. Finally, pharmacoeconomic aspects should be considered for the choice of appropriate antimicrobials in the care of critically ill patients.
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Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Dhanani J, Roberts JA, Chew M, Lipman J, Boots RJ, Paterson DL, Fraser JF. Antimicrobial chemotherapy and lung microdialysis: a review. Int J Antimicrob Agents 2010; 36:491-500. [PMID: 20952164 DOI: 10.1016/j.ijantimicag.2010.08.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 08/18/2010] [Indexed: 10/18/2022]
Abstract
Pneumonia is a form of lung infection that may be caused by various micro-organisms. The predominant site of infection in pneumonia is debatable. Advances in the fields of diagnostic and therapeutic medicine have had a less than optimal effect on the outcome of pneumonia and one of the many causes is likely to be inadequate antimicrobial concentrations at the site of infection in lung tissue. Traditional antimicrobial therapy guidelines are based on indirect modelling from blood antimicrobial levels. However, studies both in humans and animals have shown the fallacy of this concept in various tissues. Many different methods have been employed to study lung tissue antimicrobial levels with limited success, and each has limitations that diminish their utility. An emerging technique being used to study the pharmacokinetics of antimicrobial agents in lung tissue is microdialysis. Development of microdialysis catheters, along with improvement in analytical techniques, has improved the accuracy of the data. Unfortunately, very few studies have reported the use of microdialysis in lung tissue, and even fewer antimicrobial classes have been studied. These studies generally suggest that this technique is a safe and effective way of assessing the pharmacokinetics of antimicrobial agents in lung tissue. Further descriptive studies need to be conducted to study the pharmacokinetics and pharmacodynamics of different antimicrobial classes in lung tissue. Data emanating from these studies could inform decisions for appropriate dosing schedules of antimicrobial agents in pneumonia.
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Affiliation(s)
- Jayesh Dhanani
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.
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Zhang Y, Wang X, Lin X, Liu X, Tian B, Tang X. High azithromycin loading powders for inhalation and their in vivo evaluation in rats. Int J Pharm 2010; 395:205-14. [DOI: 10.1016/j.ijpharm.2010.05.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 05/14/2010] [Accepted: 05/27/2010] [Indexed: 10/19/2022]
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Abstract
The in vivo assessment of drug distribution has long been treated as a "forgotten relative" of pharmacokinetics, mainly due to a lack of appropriate methodology. Research was long restricted to the measurement of drug concentrations from biological specimens that are relatively easy to obtain, or to indirect modelling. However, data obtained by these approaches have resulted in considerable confusion about drug distribution and target site delivery, as their interpretation was flawed by several misconceptions, such as the lack of physiological input to pharmacokinetic models, the erroneous view that a tissue is a uniform matrix, and the notion that the entire drug fraction present in various tissue spaces exerts pharmacological activity. Today, drug distribution to the well defined tissue compartment -- "interstitial space fluid", the biophase for many drugs -- can be measured relatively cheaply, minimally invasively, and reproducibly, via microdialysis.
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Affiliation(s)
- Markus Müller
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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35
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Cohen J, Deans R, Dalley A, Lipman J, Roberts MS, Venkatesh B. Measurement of tissue cortisol levels in patients with severe burns: a preliminary investigation. Crit Care 2009; 13:R189. [PMID: 19943926 PMCID: PMC2811946 DOI: 10.1186/cc8184] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 10/07/2009] [Accepted: 11/27/2009] [Indexed: 11/28/2022] Open
Abstract
Introduction The assessment of adrenal function in critically ill patients is problematic, and there is evidence to suggest that measurement of tissue glucocorticoid activity may be more useful than estimation of plasma cortisol concentrations. Interstitial cortisol concentrations of cortisol represent the available pool of glucocorticoids able to enter the cell and bind to the glucocorticoid receptor. However the concentrations of plasma cortisol may not accurately reflect interstitial concentrations. We elected to perform a preliminary study into the feasibility of measuring interstitial cortisol by microdialysis, and to investigate the relationship between total plasma cortisol, free plasma cortisol and interstitial cortisol in patients with severe burns. Methods A prospective observational study carried out in a tertiary intensive care unit. Ten adult patients with a mean total burn surface area of 48% were studied. Interstitial cortisol was measured by microdialysis from patient-matched burnt and non-burnt tissue and compared with that of 3 healthy volunteers. Plasma sampling for estimations of total and free cortisol concentrations was performed concurrently. Results In the burn patients, mean total plasma and free plasma cortisol concentrations were 8.8 +/- 3.9, and 1.7 +/- 1.1 mcg/dL, (p < 0.001), respectively. Mean subcutaneous microdialysis cortisol concentrations in the burn and non-burn tissue were 0.80 +/- 0.31 vs 0.74 +/- 0.41 mcg/dL (p = 0.8), respectively, and were significantly elevated over the mean subcutaneous microdialysis cortisol concentrations in the healthy volunteers. There was no significant correlation between total plasma or free plasma and microdialysis cortisol concentrations. Plasma free cortisol was better correlated with total burn surface area than total cortisol. Conclusions In this preliminary study, interstitial cortisol concentrations measured by microdialysis in burnt and non-burnt skin from patients with severe thermal injury are significantly elevated over those from healthy volunteers. Plasma estimations of cortisol do not correlate with the microdialysis levels, raising the possibility that plasma cortisol may be an unreliable guide to tissue cortisol activity.
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Affiliation(s)
- Jeremy Cohen
- Burns Trauma and Critical Care Research Centre, University of Queensland, Herston 4006, Australia.
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Barbour A, Schmidt S, Rout WR, Ben-David K, Burkhardt O, Derendorf H. Soft tissue penetration of cefuroxime determined by clinical microdialysis in morbidly obese patients undergoing abdominal surgery. Int J Antimicrob Agents 2009; 34:231-5. [DOI: 10.1016/j.ijantimicag.2009.03.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 03/25/2009] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
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Szabó Z, Andersson R, Arnqvist H. Intraoperative muscle and fat metabolism in diabetic patients during coronary artery bypass grafting surgery: a parallel microdialysis and organ balance study. Br J Anaesth 2009; 103:166-72. [DOI: 10.1093/bja/aep105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Burkhardt O, Derendorf H, Jäger D, Kumar V, Madabushi R, Röhl K, Barth J. Moxifloxacin distribution in the interstitial space of infected decubitus ulcer tissue of patients with spinal cord injury measured by in vivo microdialysis. ACTA ACUST UNITED AC 2009; 38:904-8. [PMID: 17008236 DOI: 10.1080/00365540600664076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We investigated the distribution of moxifloxacin in the interstitial space of normal and infected subcutaneous tissue in patients with spinal cord injury and decubitus ulcers using in vivo microdialysis. Drug concentrations achieved in serum, saliva, normal and infected tissues showed approximately parallel time profiles. The interstitial tissue fluids reached bactericidal levels for common bacteria found in infected skin lesions. Our findings suggest that moxifloxacin exhibits good and similar penetration into the interstitial space fluid in normal subcutaneous tissue and infected decubitus ulcers in patients with spinal cord injury.
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Affiliation(s)
- Olaf Burkhardt
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA.
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&NA;. Cardiac surgery patients may have clinically relevant changes in the pharmacokinetics of frequently used drugs. DRUGS & THERAPY PERSPECTIVES 2009. [DOI: 10.2165/0042310-200925050-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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40
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Pea F, Pavan F, Furlanut M. Clinical relevance of pharmacokinetics and pharmacodynamics in cardiac critical care patients. Clin Pharmacokinet 2008; 47:449-62. [PMID: 18563954 DOI: 10.2165/00003088-200847070-00002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pharmacokinetics is a discipline aimed at predicting the best dosage and dosing regimen for each single drug in order to ensure and maintain therapeutically effective concentrations at the action sites. In cardiac critical care patients, various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs. Gastrointestinal drug absorption may be erratic and unpredictable in the early postoperative period, and so patients may be unresponsive to oral therapy; thus the intravenous route should be preferred for life-saving drugs whenever feasible. Variations in the extracellular fluid content as a response to the trauma of surgery and the fluid load or significant drug loss through thoracic drainages may significantly lower plasma concentrations of extracellularly distributed hydrophilic antimicrobials (beta-lactams, aminoglycosides and glycopeptides). Drug metabolism may be altered by the systemic inflammatory response and/or multiple organ failure and/or drug-drug pharmacokinetic interactions that can potentially occur during polytherapy, especially in immunosuppressed cardiac transplant patients. Instability of renal function may promote significant changes in body fluid concentrations of renally eliminated drugs, even in a brief period of hours. Finally, the application of extracorporeal circulation by means of cardiopulmonary bypass may significantly alter the disposition of several drugs during the operation because of acute haemodilution, hypoalbuminaemia, hypothermia and/or adsorption to the bypass equipment. Accordingly, to avoid either overexposure and the consequent increased risk of toxicity or underexposure and the consequent risk of therapeutic failure in critically ill cardiac patients, the dosing regimens of several drugs are expected to be significantly different from those suggested for clinically stable patients. Additionally, therapeutic drug monitoring may be helpful in the management of drug therapy and should be routinely used to guide individualized dose adjustments for (i) immunosuppressants whenever cytochrome P450 3A4 isoenzyme inhibitors (e.g. macrolide antibacterials, azole antifungals) or inducers (e.g. rifampicin [rifampin]) are added to or withdrawn from the regimen; and (ii) glycopeptide and aminoglycoside antibacterials whenever haemodynamically active agents (such as dopamine, dobutamine and furosemide [frusemide]) are added to or withdrawn from the regimen, and also whenever significant changes of haemodynamics and/or of renal function occur.
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Affiliation(s)
- Federico Pea
- Institute of Clinical Pharmacology & Toxicology, Department of Experimental and Clinical Pathology and Medicine, Medical School, University of Udine, Udine, Italy.
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Scaglione F, Paraboni L. Pharmacokinetics/pharmacodynamics of antibacterials in the Intensive Care Unit: setting appropriate dosing regimens. Int J Antimicrob Agents 2008; 32:294-301. [PMID: 18621508 DOI: 10.1016/j.ijantimicag.2008.03.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/26/2008] [Indexed: 12/18/2022]
Abstract
Patients admitted to Intensive Care Units (ICUs) are at very high risk of developing severe nosocomial infections. Consequently, antimicrobials are among the most important and commonly prescribed drugs in the management of these patients. Critically ill patients in ICUs include representatives of all age groups with a range of organ dysfunction related to severe acute illness that may complicate long-term illness. The range of organ dysfunction, together with drug interactions and other therapeutic interventions (e.g. haemodynamically active drugs and continuous renal replacement therapies), may strongly impact on antimicrobial pharmacokinetics in critically ill patients. In the last decade, it has become apparent that the intrinsic pharmacokinetic (PK) and pharmacodynamic (PD) properties are the major determinants of in vivo efficacy of antimicrobial agents. PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. In this review, we analyse the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach of the antimicrobial agent classes commonly utilised in the ICU setting.
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Affiliation(s)
- Francesco Scaglione
- Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, University of Milan, Milan, Italy.
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Pojar M, Mandak J, Malakova J, Jokesova I. TISSUE AND PLASMA CONCENTRATIONS OF ANTIBIOTIC DURING CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS - MICRODIALYSIS STUDY. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:139-45. [DOI: 10.5507/bp.2008.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tasso L, Bettoni CC, Oliveira LK, Costa TD. Evaluation of gatifloxacin penetration into skeletal muscle and lung by microdialysis in rats. Int J Pharm 2008; 358:96-101. [DOI: 10.1016/j.ijpharm.2008.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 02/19/2008] [Accepted: 02/20/2008] [Indexed: 11/25/2022]
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The impact of perioperative atelectasis on antibiotic penetration into lung tissue: an in vivo microdialysis study. Intensive Care Med 2008; 34:1827-34. [DOI: 10.1007/s00134-008-1122-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2007] [Accepted: 04/07/2008] [Indexed: 10/22/2022]
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Dahyot C, Marchand S, Bodin M, Debeane B, Mimoz O, Couet W. Application of basic pharmacokinetic concepts to analysis of microdialysis data: illustration with imipenem muscle distribution. Clin Pharmacokinet 2008; 47:181-9. [PMID: 18307372 DOI: 10.2165/00003088-200847030-00004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Microdialysis studies of antibacterial tissue distribution in critically ill patients have sometimes led to results that were spectacular but inconsistent with basic pharmacokinetic concepts. OBJECTIVE To conduct a study of imipenem distribution in the muscle of healthy volunteers and critical care patients in order to compare real-life data with theory. METHODS Microdialysis catheters were placed into the quadriceps, and probe recoveries were determined individually in vivo using a retrodialysis-by-drug method. Unbound imipenem concentrations were determined by high-performance liquid chromatography in plasma ultrafiltrates and muscle dialysates, and submitted to noncompartmental pharmacokinetic analysis. RESULTS Individual unbound imipenem concentrations in plasma and muscle extracellular fluid were virtually superimposed at any time, both in healthy volunteers and in critical care patients. CONCLUSION These new results are not consistent with previously published data obtained in similar conditions by another group, but they are in agreement with results previously obtained in rats, as well as being consistent with basic pharmacokinetic concepts.
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Engleman EA, Ingraham CM, Franklin KM, Keith CM, McClaren JA, Schultz JA, Morzorati SL, O'Connor S, Thielen RJ, Murphy JM, McBride WJ. In vivo time-course changes in ethanol levels sampled with subcutaneous microdialysis. Alcohol Clin Exp Res 2008; 32:435-42. [PMID: 18215218 DOI: 10.1111/j.1530-0277.2007.00587.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective of this study was to determine time-course changes in in vivo ethanol (EtOH) concentrations using a novel subcutaneous (s.c.) microdialysis sampling technique. The hypothesis to be tested was that EtOH concentrations in the s.c. fluid would reflect blood EtOH concentrations. If this is the case, then s.c. microdialysis could allow a more detailed analysis of changes in in vivo levels of EtOH under different drinking paradigms. METHODS Adult male and female Wistar rats and male alcohol-preferring (P) rats were used in this study. A loop-style microdialysis probe was designed for s.c. applications. After initial in vitro characterization, probes were implanted under the skin between the shoulder blades. Animals were allowed to recover 4 to 24 hours prior to microdialysis collection (2.0 microl/min flow rate with isotonic saline). In vivo microdialysis experiments were then conducted to determine (i) the extraction fraction (or clearance) using EtOH no-net-flux (NNF) coupled with the alcohol clamp method, (ii) the dose-response and time-course effects after systemic EtOH administration and to compare with blood EtOH levels, and (iii) the time-course changes in EtOH levels during and after an EtOH drinking episode. RESULTS In vivo probe recovery (extraction fraction) obtained using the alcohol clamp method was 69 +/- 3%, and was comparable to the in vitro recovery of 73 +/- 2%. For the EtOH dose-response experiment, rats injected i.p. with 0.5, 1.0, or 2.0 g/kg EtOH showed a clear dose-response effect in the s.c. dialysate samples. Peak concentrations (70, 123, and 203 mg%, respectively) were reached by 15 minutes after injection. In an experiment comparing levels of EtOH in s.c. dialysis and arterial blood samples in rats administered 1.0 g/kg EtOH, similar time-course changes in in vivo EtOH concentrations were observed with both i.g. and i.p. EtOH administration. In P rats drinking 15% EtOH during a 1-hour scheduled access period, EtOH levels in s.c. microdialysates rose rapidly over the session and peaked at approximately 50 mg% at 60 to 80 minutes. CONCLUSIONS Overall, these experiments indicate that s.c. EtOH and blood EtOH concentrations follow a similar time course. Moreover, s.c. microdialysis can be useful as an experimental approach for determining detailed time-course changes in in vivo EtOH concentrations associated with alcohol drinking episodes.
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Affiliation(s)
- Eric A Engleman
- Department of Psychiatry, Institute of Psychiatric Research, Indiana University School of Medicine, Indianapolis, IN 46220, USA.
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In Vivo Microdialysis to Measure Antibiotic Penetration Into Soft Tissue During Cardiac Surgery. Ann Thorac Surg 2007; 84:1605-10. [DOI: 10.1016/j.athoracsur.2007.06.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 06/16/2007] [Accepted: 06/19/2007] [Indexed: 11/22/2022]
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Plock N, Buerger C, Joukhadar C, Kljucar S, Kloft C. Does Linezolid Inhibit Its Own Metabolism?—Population Pharmacokinetics As a Tool to Explain the Observed Nonlinearity in Both Healthy Volunteers and Septic Patients. Drug Metab Dispos 2007; 35:1816-23. [PMID: 17639029 DOI: 10.1124/dmd.106.013755] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Few studies investigating the population pharmacokinetics of linezolid in critically ill patients have been reported, yielding controversial results. Therefore, a population pharmacokinetic analysis using NONMEM was performed to thoroughly understand the pharmacokinetics of unbound linezolid in plasma. Data were obtained from 10 healthy volunteers and 24 septic patients. Intensive sampling was performed after single and multiple dosing. The pharmacokinetics of unbound linezolid was best described by a two-compartment model with an absorption rate constant (K(A), 1.81 h(-1)), clearance (CL, 11.1 l/h), volumes of distribution (V(2) and V(3), 20.0 and 28.9 liters, respectively), and intercompartmental clearance Q, 75.0 l/h). However, clearance was inhibited over time to 76.4% of its original value, dependent on the concentration in an empirical inhibition compartment. Overall, imprecision of parameter estimates was low to moderate. Comparison of goodness of fit graphics and of the predictive performance revealed that the presented model was superior to previously published models using linear elimination or parallel linear and Michaelis-Menten elimination and also to other of our own investigated model alternatives. The observed nonlinearity in linezolid pharmacokinetics might be a result of an inhibition of the formation of the major linezolid metabolite due to the inhibition of respiratory chain enzyme activity. To our knowledge, this study presents the first attempt to mechanistically explain the observed nonlinearity in linezolid pharmacokinetics. Finally, simulations demonstrated that the model might also serve as a tool to predict concentration-time profiles of linezolid, thus providing a rationale for a more targeted antimicrobial therapy.
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Affiliation(s)
- N Plock
- Freie Universitaet Berlin, Institute of Pharmacy, Berlin, Germany
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Nguyen TH, Hoppe-Tichy T, Geiss HK, Rastall AC, Swoboda S, Schmidt J, Weigand MA. Factors influencing caspofungin plasma concentrations in patients of a surgical intensive care unit. J Antimicrob Chemother 2007; 60:100-6. [PMID: 17525052 DOI: 10.1093/jac/dkm125] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Co-morbidity, medical and surgical interventions often cause alterations to drug plasma concentrations and pharmacokinetic parameters in critically ill patients. In the present study, we investigated parameters influencing plasma caspofungin concentrations in patients of a surgical intensive care unit (SICU). METHODS In a monocentre open study, caspofungin trough concentrations (C(24)) were determined for a group of SICU patients. A linear-mixed model was then used to assess factors influencing caspofungin plasma concentrations. RESULTS A total of 40 SICU patients were enrolled. Age and body weight ranged from 22 to 76 years and 47 to 108 kg, respectively. All participants received a caspofungin loading dose of 70 mg and a maintenance dose of 50 mg/day. The median duration of therapy was 10 days. Caspofungin C(24) in SICU patients varied more than those determined for healthy subjects reported in previous studies (0.52-4.08 microg/mL versus 1.12-1.78 microg/mL). According to our model, caspofungin C(24) were predicted to be significantly higher in patients with body weight <75 kg (P=0.019) and patients with albumin concentration >23.6 g/L (P=0.030). CONCLUSIONS Our results show that body weight and albumin concentration influence caspofungin C(24) in SICU patients and should therefore be considered prognostic factors.
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Affiliation(s)
- T H Nguyen
- Pharmacy Department, University Hospital of Heidelberg, Im Neuenheimer Feld 670, D-69120 Heidelberg, Germany.
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Zeitlinger MA, Traunmüller F, Abrahim A, Müller MR, Erdogan Z, Müller M, Joukhadar C. A pilot study testing whether concentrations of levofloxacin in interstitial space fluid of soft tissues may serve as a surrogate for predicting its pharmacokinetics in lung. Int J Antimicrob Agents 2007; 29:44-50. [PMID: 17189094 DOI: 10.1016/j.ijantimicag.2006.08.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2006] [Revised: 08/31/2006] [Accepted: 08/31/2006] [Indexed: 10/23/2022]
Abstract
Recent observations indicate that pharmacokinetics of beta-lactam antibiotics in the lung can be predicted by the use of concentration versus time profiles in peripheral soft tissues. If this observation is transferred to other classes of antimicrobials, measurement of antimicrobial concentrations in peripheral tissues would enable prediction of the pharmacokinetics of antimicrobials at the site of the respiratory tract infection. We set out to test the hypothesis that concentrations of the fluoroquinolone levofloxacin in the respiratory tract can be predicted on the basis of knowledge of its pharmacokinetics in peripheral soft tissues. After administration of a single intravenous dose of 500mg of levofloxacin, microdialysis was used to describe the concentration versus time profiles of levofloxacin in the interstitial space fluid of lung tissue of patients (n=5) undergoing elective lung surgery. These data were compared with the concentration versus time courses in the interstitial space fluid of skeletal muscle and subcutaneous adipose tissue of healthy volunteers (n=7). The median AUC(0-infinity) of free levofloxacin in lung (2267mg x min/L, 1980-2355) was about 2-fold and 1.5-fold lower compared with skeletal muscle (4381mg x min/L, range 1720-8195) and adipose tissue (3492mg x min/L, range 1323-6420) of healthy controls, respectively. Concentrations in the interstitial space fluid of the lung were descriptively lower compared with corresponding concentrations in peripheral soft tissues. This is in contrast to previous observations made for the class of beta-lactam antibiotics, and indicates that pharmacokinetics of levofloxacin derived from soft tissues may not be used uncritically for prediction of levofloxacin concentrations in the interstitium of the lung.
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Affiliation(s)
- Markus A Zeitlinger
- Department of Clinical Pharmacology, Division of Clinical Pharmacokinetics, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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