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Sandes V, Figueras A, Lima EC. Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review. Antibiotics (Basel) 2024; 13:457. [PMID: 38786184 PMCID: PMC11117530 DOI: 10.3390/antibiotics13050457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.
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Affiliation(s)
- Valcieny Sandes
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
- National Cancer Institute, Pr. da Cruz Vermelha-23, Rio de Janeiro 20230-130, RJ, Brazil
| | | | - Elisangela Costa Lima
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
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Abonashey SG, Hassan HAFM, Shalaby MA, Fouad AG, Mobarez E, El-Banna HA. Formulation, pharmacokinetics, and antibacterial activity of florfenicol-loaded niosome. Drug Deliv Transl Res 2024; 14:1077-1092. [PMID: 37957473 DOI: 10.1007/s13346-023-01459-9] [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] [Accepted: 10/19/2023] [Indexed: 11/15/2023]
Abstract
The growing interest in employing nano-sized pharmaceutical formulations in veterinary medicine has prompted the exploration of the novel nanocarriers' ability to augment the therapeutic outcome. In this study, we harnessed niosomes, spherical nanocarriers formed through non-ionic surfactant self-assembly, to enhance the therapeutic efficacy of the broad-spectrum antibiotic florfenicol. Pre-formulation studies were conducted to identify the optimal parameters for preparing florfenicol-loaded niosomes (FLNs). These studies revealed that the formulation that consisted of Span 60, cholesterol, and dihexadecyl phosphate (DDP) at a molar ratio of 1:1:0.1 exhibited the highest entrapment efficiency (%EE) and uniform size distribution. In vitro antibacterial testing demonstrated the niosomal capacity to significantly reduce florfenicol minimum inhibitory concentration (MIC) against E. coli and S. aureus. Pharmacokinetic profiles of free florfenicol and FLN were assessed following oral administration of 30 mg florfenicol/kg body weight to healthy or E. coli-infected chickens. FLN exhibited a substantially higher maximum plasma concentration (Cmax) of florfenicol compared to free florfenicol. Furthermore, FLN showed significantly higher area under the curve (AUC0-t) than free florfenicol as revealed from the relative bioavailability studies. Lethal dose (LD) 50 values for both free florfenicol and FLN exceeded 5 g/kg of body weight, indicating high safety profile. Assessment of mortality protection in mice against lethal E. coli infections showed the significantly higher capability of FLN to improve the survival rate (75%) than free florfenicol (25%). Collectively, these findings demonstrate the niosomal ability to improve the oral bioavailability as well as the antibacterial activity of the incorporated veterinary antibiotic florfenicol.
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Affiliation(s)
- Shimaa G Abonashey
- Department of Biochemistry, Animal Health Research Institute, Dokki, Giza, Egypt
| | - Hatem A F M Hassan
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, 11562, Egypt.
- School of Life and Medical Sciences, University of Hertfordshire Hosted By Global Academic Foundation, New Administrative Capital, Cairo, Egypt.
| | - Mostafa A Shalaby
- Pharmacology Department, Faculty of Veterinary Medicine, Cairo University, Cairo, Egypt
| | - Amr Gamal Fouad
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Elham Mobarez
- Department of Biochemistry, Animal Health Research Institute, Dokki, Giza, Egypt
| | - Hossny A El-Banna
- Pharmacology Department, Faculty of Veterinary Medicine, Cairo University, Cairo, Egypt
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Matsuya S, Kawahata S, Takeda Y. Impact of physical build on serum vancomycin concentrations of patients undergoing hemodialysis: A retrospective cohort study at an acute care hospital. J Infect Chemother 2024:S1341-321X(24)00100-4. [PMID: 38552840 DOI: 10.1016/j.jiac.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 03/10/2024] [Accepted: 03/26/2024] [Indexed: 04/01/2024]
Abstract
INTRODUCTION Estimating the serum vancomycin (VCM) concentrations of lean and patients with obesity is challenging. Additionally, VCM dosing for Japanese patients undergoing hemodialysis remains particularly unclear. This study aimed to determine the impact of the physical build on serum VCM concentrations of Japanese patients undergoing hemodialysis. METHODS This retrospective cohort study included hospitalized patients undergoing hemodialysis, who received treatment with VCM between May 1, 2019, and December 31, 2021, at Kansai Rosai Hospital, which is a 642-bed acute care hospital in Japan. Patients were divided into the following three groups based on their body mass index (BMI): lean group (≤18.5 kg/m2), normal group (18.5-25 kg/m2), and obese group (≥25 kg/m2). The VCM dose and predialysis serum VCM concentration (PVC) were compared. RESULTS This study included 191 patients. There were 50 patients in the lean group, 85 in the normal group, and 56 in the obese group. The median loading doses per body weight were 24.0, 22.1, and 21.2 mg/kg for the lean, normal, and obese groups, respectively. The VCM dose per body weight decreased significantly with increasing BMI. The median PVCs of the lean and normal groups were approximately 15 mg/L (not significantly different). However, the median PVC of the obese group was 18.3 mg/L, which was significantly higher (P < 0.001). CONCLUSIONS The VCM dose per body weight for Japanese patients undergoing hemodialysis should be adjusted based on the BMI.
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Affiliation(s)
- Shota Matsuya
- Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki-shi, Hyogo-ken, 660-0064, Japan.
| | - Shunsuke Kawahata
- Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki-shi, Hyogo-ken, 660-0064, Japan
| | - Yoshiaki Takeda
- Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki-shi, Hyogo-ken, 660-0064, Japan
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Hansel J, Mannan F, Robey R, Kumarendran M, Bladon S, Mathioudakis AG, Ogungbenro K, Dark P, Felton TW. Covariates in population pharmacokinetic studies of critically ill adults receiving β-lactam antimicrobials: a systematic review and narrative synthesis. JAC Antimicrob Resist 2024; 6:dlae030. [PMID: 38410250 PMCID: PMC10895699 DOI: 10.1093/jacamr/dlae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/10/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Population pharmacokinetic studies of β-lactam antimicrobials in critically ill patients derive models that inform their dosing. In non-linear mixed-effects modelling, covariates are often used to improve model fit and explain variability. We aimed to investigate which covariates are most commonly assessed and which are found to be significant, along with global patterns of publication. Methods We conducted a systematic review, searching MEDLINE, Embase, CENTRAL and Web of Science on 01 March 2023, including studies of critically ill adults receiving β-lactam antimicrobials who underwent blood sampling for population pharmacokinetic studies. We extracted and categorized all reported covariates and assessed reporting quality using the ClinPK checklist. Results Our search identified 151 studies with 6018 participants. Most studies reported observational cohorts (120 studies, 80%), with the majority conducted in high-income settings (136 studies, 90%). Of the 1083 identified covariate instances, 237 were unique; the most common categories were patient characteristics (n = 404), biomarkers (n = 206) and physiological parameters (n = 163). Only seven distinct commonly reported covariates (CLCR, weight, glomerular filtration rate, diuresis, need for renal replacement, serum albumin and C-reactive protein) were significant more than 20% of the time. Conclusions Covariates are most commonly chosen based on biological plausibility, with patient characteristics and biomarkers the most frequently investigated. We developed an openly accessible database of reported covariates to aid investigators with covariate selection when designing population pharmacokinetic studies. Novel covariates, such as sepsis subphenotypes, have not been explored yet, leaving a research gap for future work.
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Affiliation(s)
- Jan Hansel
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Fahmida Mannan
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Rebecca Robey
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Mary Kumarendran
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Siân Bladon
- Division of Informatics, Imaging & Data Sciences, School of Health Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kayode Ogungbenro
- Division of Pharmacy & Optometry, School of Health Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- Critical Care Unit, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Greater Manchester M6 8HD, UK
| | - Timothy W Felton
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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Jiang X, Qin Y, Lei R, Han Y, Yang J, Zhang G, Liu J. A rapid and simple HPLC-MS/MS method for the therapeutic drug monitoring of six special-grade antimicrobials in pediatric patients. Heliyon 2024; 10:e24198. [PMID: 38226205 PMCID: PMC10788798 DOI: 10.1016/j.heliyon.2024.e24198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/17/2024] Open
Abstract
Meropenem, linezolid, fluconazole, voriconazole, posaconazole, and vancomycin are six important antimicrobials used for severe infections in critically ill patients listed in special-grade antimicrobials in China. The six antimicrobials' highly variable pharmacodynamics and pharmacokinetics in critically ill pediatric patients present significant challenges to clinicians in ensuring optimal therapeutic targets. Therefore, therapeutic drug monitoring of these antimicrobials in human plasma is necessary to obtain their plasma concentration. A rapid, simple, and sample-saving high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method was developed, which could simultaneously determine all six antimicrobials. It required only 10 μL of plasma and a one-step protein precipitation process. Chromatographic separation was achieved on a reversed-phase column (C18, 30 × 2.1 mm, 2.6 μm) via gradient elution using water and acetonitrile containing 0.1 % formic acid as mobile phase. The injection volume was 2 μL, and the total run time was only 2.5 min. Detection was done using a Triple Quad™ 4500MD tandem mass spectrometer coupled with an electrospray ionization (ESI) source in positive mode. The calibration curves ranged from 0.5 to 64 μg/mL for meropenem and fluconazole, 0.2-25.6 μg/mL for linezolid and voriconazole, 0.1-12.8 μg/mL for posaconazole and 1-128 μg/mL for vancomycin, with the coefficients of correlation all greater than 0.996. Furthermore, the method was validated rigorously according to the European Medicines Agency (EMA) guidelines, demonstrating excellent accuracy (from 93.0 % to 110.6 %) and precision (from 2.0 % to 12.8 %). Moreover, its applicability to various matrices (including serum, hemolytic plasma, and hyperlipidemic plasma) was evaluated. Thus, this method was successfully applied to routine therapeutic drug monitoring for critically ill pediatric patients and other patients in need.
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Affiliation(s)
- Xijuan Jiang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Yabin Qin
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Rong Lei
- Hebei Key Laboratory of Traditional Chinese Medicine Quality Evaluation and Standard Research, Hebei Institute for Drug and Medical Device Control, Shijiazhuang, Hebei, 050227, China
| | - Yu Han
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Jing Yang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Guying Zhang
- Department of Pharmacy, Hebei Children's Hospital, Shijiazhuang, Hebei, 050031, China
| | - Jianfang Liu
- Office of Clinical Trial Center, The First Affiliated Hospital of Hebei University of Chinese Medicine, Shijiazhuang, Hebei, 050017, China
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Alsultan A, Aldawsari MR, Alturaiq NK, Syed SA, Alsubai A, Kurdee Z, Alsubaie S, Alqahtani S, Abouelkheir M. Evaluation of pharmacokinetic pharmacodynamic target attainment of meropenem in pediatric patients. Pediatr Neonatol 2024:S1875-9572(23)00245-0. [PMID: 38218717 DOI: 10.1016/j.pedneo.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/27/2023] [Accepted: 09/08/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Meropenem is a widely used carbapenem for treating severe pediatric infections. However, few studies have assessed its pharmacokinetics/pharmacodynamics (PK/PD) in pediatric patients. This study aimed to evaluate the proportion of Saudi pediatric patients achieving the PK/PD target of meropenem. METHODS A prospective observational study was conducted at King Saud University Medical City from July to September 2022. Pediatric patients receiving meropenem for suspected or proven infections were included in the study. The primary outcome was the percentage of patients achieving the recommended PK/PD target for critically ill or non-critically ill pediatric patients. RESULTS The study included 30 patients (nine neonates and 21 older pediatric patients). All neonates were critically ill. Among them, 55 % achieved the PK/PD target of 100 % free time above the MIC. In older ICU pediatric patients, only 11 % attained this target, whereas 58 % of older pediatrics in the general wards achieved the PK/PD target of 50 % free time above the MIC. Augmented renal clearance (ARC) was identified in 57 % of our pediatric patient population, none of whom achieved the recommended PK/PD targets. The median trough concentrations in patients with and without ARC were 0.75 and 1.3 μg/mL, respectively (P < 0.05). CONCLUSIONS The majority of patients in our cohort did not achieve the PK/PD target for meropenem. ARC emerged as a major risk factor for target attainment failure in both critically ill and non-critically ill pediatric patients.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia.
| | - Maram R Aldawsari
- Department of Pharmacy, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Nujood Khaled Alturaiq
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Ali Syed
- Department of Pharmaceutical, Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alsubai
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Zeyad Kurdee
- Clinical Biochemistry Unit, Department of Pathology, College of Medicine, King Saud University, Saudi Arabia
| | - Sarah Alsubaie
- Pediatric Infectious Disease Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt.
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Lang M, Carvalho A, Baharoglu Z, Mazel D. Aminoglycoside uptake, stress, and potentiation in Gram-negative bacteria: new therapies with old molecules. Microbiol Mol Biol Rev 2023; 87:e0003622. [PMID: 38047635 PMCID: PMC10732077 DOI: 10.1128/mmbr.00036-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
SUMMARYAminoglycosides (AGs) are long-known molecules successfully used against Gram-negative pathogens. While their use declined with the discovery of new antibiotics, they are now classified as critically important molecules because of their effectiveness against multidrug-resistant bacteria. While they can efficiently cross the Gram-negative envelope, the mechanism of AG entry is still incompletely understood, although this comprehension is essential for the development of new therapies in the face of the alarming increase in antibiotic resistance. Increasing antibiotic uptake in bacteria is one strategy to enhance effective treatments. This review aims, first, to consolidate old and recent knowledge about AG uptake; second, to explore the connection between AG-dependent bacterial stress and drug uptake; and finally, to present new strategies of potentiation of AG uptake for more efficient antibiotic therapies. In particular, we emphasize on the connection between sugar transport and AG potentiation.
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Affiliation(s)
- Manon Lang
- Institut Pasteur, Université Paris Cité, CNRS UMR3525, Unité Plasticité du Génome Bactérien, Paris, France
| | - André Carvalho
- Institut Pasteur, Université Paris Cité, CNRS UMR3525, Unité Plasticité du Génome Bactérien, Paris, France
| | - Zeynep Baharoglu
- Institut Pasteur, Université Paris Cité, CNRS UMR3525, Unité Plasticité du Génome Bactérien, Paris, France
| | - Didier Mazel
- Institut Pasteur, Université Paris Cité, CNRS UMR3525, Unité Plasticité du Génome Bactérien, Paris, France
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Ryan CA, McNeal CD, Credille BC. Ceftiofur use and antimicrobial stewardship in the horse. Equine Vet J 2023; 55:944-961. [PMID: 36733237 DOI: 10.1111/evj.13930] [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: 01/26/2022] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
Equine practitioners require recommendations that support antimicrobial stewardship and avoid generating resistance to medically important antibiotics. This review examines current inadequacies in antimicrobial stewardship standards within the veterinary community, related to antimicrobial categorisation and prescribing practices. Resistance to cephalosporin antibiotics in horses is also described. Properties of cephalosporin antibiotics are outlined and equine-specific studies of ceftiofur, a third-generation cephalosporin antibiotic with medical importance, are detailed. Readers are provided with recommendations that encourage appropriate use of ceftiofur, citing the evidence available in horses.
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Affiliation(s)
- Clare A Ryan
- Department of Large Animal Medicine, University of Georgia, Athens, Georgia, USA
| | - Christina D McNeal
- Department of Large Animal Medicine, University of Georgia, Athens, Georgia, USA
| | - Brenton C Credille
- Department of Population Health, University of Georgia, Athens, Georgia, USA
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Nair VV, Smyth HDC. Inhalable Excipient-Free Dry Powder of Tigecycline for the Treatment of Pulmonary Infections. Mol Pharm 2023; 20:4640-4653. [PMID: 37606919 DOI: 10.1021/acs.molpharmaceut.3c00395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Tigecycline (TIG) is a broad-spectrum antibiotic that has been approved for the treatment of a number of complicated infections, including community-acquired bacterial pneumonia. Currently it is available only as an intravenous injection that undergoes rapid chemical degradation and limits the use to in-patient scenarios. The use of TIG as an inhaled dry powder inhaler may offer a promising treatment option for patients with multidrug-resistant respiratory tract infections, such as Stenotrophomonas maltophilia (S. maltophilia). This study explores the feasibility of engineering an inhaled powder formulation of TIG that could administer relevant doses at a wide range of inhalation flow rates while maintaining stability of this labile drug. Using air-jet milling, micronized TIG had excellent aerosolization efficiency, with over 80% of the device emitted dose being within the respirable range. TIG was also readily dispersed using different inhaler devices even when tested at different pressure drops and flow rates. Additionally, micronized TIG was stable for 6 months at 25 °C/60% RH and 40 °C/75% RH. Micronized TIG maintained a low minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) of 0.8 μM and >0.5 μM, respectively in S. maltophilia cultures in vitro. These results strongly suggest that the micronization of TIG results in a stable and respirable formulation that can be delivered via the pulmonary route for the treatment of lung infections.
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Affiliation(s)
- Varsha V Nair
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, 2409 University Ave, Austin, Texas 78712, United States
| | - Hugh D C Smyth
- Division of Molecular Pharmaceutics and Drug Delivery, College of Pharmacy, The University of Texas at Austin, 2409 University Ave, Austin, Texas 78712, United States
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Arain S, Khalawi F, Parakkal SA, AlHamad HS, Thorakkattil SA, Alghashmari FFJ, AlHarbi B, Bakhashwain N, Alzawad WM, AlHomoud A. Drug Utilization Evaluation and Impact of Pharmacist Interventions on Optimization of Piperacillin/Tazobactam Use: A Retrospective Analysis and Prospective Audit. Antibiotics (Basel) 2023; 12:1192. [PMID: 37508288 PMCID: PMC10376400 DOI: 10.3390/antibiotics12071192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Piperacillin/tazobactam is a broad-spectrum antimicrobial encompassing most Gram-positive and Gram-negative aerobic and anaerobic bacteria. The inappropriate use of such broad-spectrum antibiotics is an important contributor to the rising rates of antimicrobial drug resistance worldwide. Drug utilization evaluation studies and pharmacists' interventions are vital to assess, develop, and promote the rational use of antibiotics. This drug utilization study aimed to evaluate the current utilization practice of piperacillin/tazobactam in a hospital setting and assess the impact of pharmacist intervention in improving its appropriate use. (2) Methodology: In this study, we used a retrospective cohort and a prospective cohort, a cross-sectional, observational method. It included a retrospective (Cycle A/pre-intervention-CycA) phase followed by an educational interventional phase conducted by the pharmacists. During the 2 months of educational intervention, pharmacists used several methods, including workshops, lectures, oral presentations, and the development and reinforcement of clinical pathways to promote the judicious use of piperacillin/tazobactam. This was followed by a prospective (Cycle B/post-intervention-CycB) phase to improve piperacillin/tazobactam usage appropriateness. The appropriateness criteria for this drug utilization evaluation were established based on antimicrobial guidelines, the published literature, the institutional antibiogram, consultation from the antimicrobial stewardship committee, and the product monograph (Tazocin). The appropriateness of CycA and CycB patients was compared using the measurable elements, including indication and dose based on renal function, timely order for cultures, de-escalation, and use of extended infusion protocol. (3) Results: The study population comprised 100 patients in both CycA and CycB. The mean age of the patients was 66.28 ± 16.15 and 67.35 ± 17.98, and the ratios of men to women were found to be 49:51 and 61:39 in CycA and CycB, respectively. It was observed that inappropriate usage was high in CycA patients, and the appropriateness was improved in CycB patients. A total of 31% of inappropriate empirical broad-spectrum use was found in CycA, and it was reduced to 12% in CycB patients. The transition of appropriateness was observed in all measurable criteria, which includes the optimized dose according to the renal function (CycA = 49% to CycB = 94%), timely bacterial culture orders (CycA = 47% to CycB = 74%), prompt de-escalation (CycA = 31% to CycB = 53%), and adherence to extended infusion institutional guidelines (CycA = 34% to CycB = 86%). (4) Conclusions: The study highlighted important aspects of inappropriate piperacillin/tazobactam use. This can be considerably improved by proper education and timely interventions based on the pharmacists' vigilant approach. The study results emphasized the need for surveillance of piperacillin/tazobactam usage by conducting similar drug utilization evaluations and practice to improve quality and safety in healthcare organizations globally.
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Affiliation(s)
- Savera Arain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Fahad Khalawi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Sainul Abideen Parakkal
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Hassan S AlHamad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Shabeer Ali Thorakkattil
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | | | - Bader AlHarbi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Nujud Bakhashwain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Weaam Mustafa Alzawad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Ali AlHomoud
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
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Venuti F, Trunfio M, Martson AG, Lipani F, Audagnotto S, Di Perri G, Calcagno A. Extended and Continuous Infusion of Novel Protected β-Lactam Antibiotics: A Narrative Review. Drugs 2023:10.1007/s40265-023-01893-6. [PMID: 37314633 DOI: 10.1007/s40265-023-01893-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
Consolidated data from pharmacokinetic and pharmacodynamic studies support the administration of β-lactam antibiotics in prolonged infusion (i.e., extended or continuous) to optimize therapeutic efficacy by increasing the probability of attaining maximal bactericidal activity. This is the longest possible time during which the free drug concentrations are approximately four-fold the minimum inhibitory concentration between dosing intervals. In the context of antimicrobial stewardship strategies, achieving aggressive pharmacokinetic and pharmacodynamic targets is an important tool in the management of multi-drug resistant (MDR) bacterial infections and in the attainment of mutant preventing concentrations. However, prolonged infusion remains an unexploited resource. Novel β-lactam/β-lactamase inhibitor (βL/βLI) combinations (ceftolozane-tazobactam, ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-cilastatin-relebactam) have been released in recent years to face the emerging challenge of MDR Gram-negative bacteria. Pre-clinical and real-life evidence has confirmed the promising role of prolonged infusion of these molecules in specific settings and clinical populations. In this narrative review we have summarized available pharmacological and clinical data, future perspectives, and current limitations of prolonged infusion of the novel protected β-lactams, their application in hospital settings and in the context of outpatient parenteral antimicrobial therapy.
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Affiliation(s)
- Francesco Venuti
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy.
| | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Anne-Grete Martson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Pharmacology, University of Liverpool, Liverpool, UK
| | - Filippo Lipani
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Corso Svizzera 164, 10149, Turin, Italy
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Kanna G, Patodia S, Annigeri RA, Ramakrishnan N, Venkataraman R. Prevalence of Augmented Renal Clearance (ARC), Utility of Augmented Renal Clearance Scoring System (ARC score) and Augmented Renal Clearance in Trauma Intensive Care Scoring System (ARCTIC score) in Predicting ARC in the Intensive Care Unit: Proactive Study. Indian J Crit Care Med 2023; 27:433-443. [PMID: 37378369 PMCID: PMC10291663 DOI: 10.5005/jp-journals-10071-24479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
Objectives We aimed to study the prevalence of augmented renal clearance (ARC) and validate the utility of ARC and ARCTIC scores. We also aimed to assess the correlation and agreement between estimated GFR (eGFR-EPI) and 8-hour measured creatinine clearance (8 hr-mCLcr). Study design and methodology This was a prospective, observational study done in the mixed medical-surgical intensive care unit (ICU) and 90 patients were recruited. 8 hr-mCLcr, ARC, and ARCTIC scores and eGFR-EPI were calculated for all patients. ARC was said to be present if 8 hr-mCLcr was ≥ 130 mL/min. Results Four patients were excluded from the analysis. The prevalence of ARC was 31.4%. The sensitivity, specificity, and positive and negative predictive values of ARC and ARCTIC scores were found to be 55.6, 84.7, 62.5, 80.6, and 85.2, 67.8, 54.8, and 90.9 respectively. AUROC for ARC and ARCTIC scores were 0.802 and 0.765 respectively. A strong positive correlation and poor agreement were observed between eGFR-EPI and 8 hr-mCLcr. Conclusion The prevalence of ARC was significant and the ARCTIC score showed good potential as a screening tool to predict ARC. Lowering the cut-off of ARC score to ≥5 improved its utility in predicting ARC. Despite its poor agreement with 8 hr-mCLcr, eGFR-EPI with a cut-off ≥114 mL/min showed utility in predicting ARC. How to cite this article Kanna G, Patodia S, Annigeri RA, Ramakrishnan N, Venkataraman R. Prevalence of Augmented Renal Clearance (ARC), Utility of Augmented Renal Clearance Scoring System (ARC score) and Augmented Renal Clearance in Trauma Intensive Care Scoring System (ARCTIC score) in Predicting ARC in the Intensive Care Unit: Proactive Study. Indian J Crit Care Med 2023;27(6):433-443.
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Affiliation(s)
- Girish Kanna
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Sristi Patodia
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Rajeev A Annigeri
- Department of Nephrology, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
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13
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Vintila BI, Arseniu AM, Butuca A, Sava M, Bîrluțiu V, Rus LL, Axente DD, Morgovan C, Gligor FG. Adverse Drug Reactions Relevant to Drug Resistance and Ineffectiveness Associated with Meropenem, Linezolid, and Colistin: An Analysis Based on Spontaneous Reports from the European Pharmacovigilance Database. Antibiotics (Basel) 2023; 12:antibiotics12050918. [PMID: 37237821 DOI: 10.3390/antibiotics12050918] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Antimicrobial resistance is considered one of the major threats to public health and is an important factor that influences the patient's outcome in the intensive care unit. Pharmacovigilance can help raise awareness of potential drug resistance (DR) or ineffectiveness (DI) through adverse drug reaction reports that are submitted to different spontaneous reporting systems. Based on spontaneous Individual Case Safety Reports from EudraVigilance, we conducted a descriptive analysis of adverse drug reactions associated with meropenem, colistin, and linezolid, with a focus on DR and DI. Of the total adverse drug reactions (ADRs) reported for each analyzed antibiotic by 31 December 2022, between 2.38-8.42% and 4.15-10.14% of the reports were related to DR and DI, respectively. A disproportionality analysis was conducted to evaluate the frequency of reporting adverse drug reactions relevant to the DR and DI of the analyzed antibiotics compared to other antimicrobials. Based on the analysis of the collected data, this study underlines the importance of post-marketing drug safety monitoring in raising a warning signal regarding antimicrobial resistance, thereby potentially contributing to the reduction in antibiotic treatment failure in an intensive care setting.
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Affiliation(s)
- Bogdan Ioan Vintila
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Anca Maria Arseniu
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Anca Butuca
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Mihai Sava
- Clinical Surgical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
| | - Victoria Bîrluțiu
- County Clinical Emergency Hospital, 550245 Sibiu, Romania
- Clinical Medical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Luca Liviu Rus
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Dan Damian Axente
- Fifth Surgical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Claudiu Morgovan
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Felicia Gabriela Gligor
- Preclinical Department, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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15
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Vairo C, Villar Vidal M, Maria Hernandez R, Igartua M, Villullas S. Colistin- and amikacin-loaded lipid-based drug delivery systems for resistant gram-negative lung and wound bacterial infections. Int J Pharm 2023; 635:122739. [PMID: 36801363 DOI: 10.1016/j.ijpharm.2023.122739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
Antimicrobial resistance (AMR) is a global health issue, which needs to be tackled without further delay. The World Health Organization(WHO) has classified three gram-negative bacteria, Pseudomonas aeruginosa, Klebsiella pneumonia and Acinetobacter baumannii, as the principal responsible for AMR, mainly causing difficult to treat nosocomial lung and wound infections. In this regard, the need for colistin and amikacin, the re-emerged antibiotics of choice for resistant gram-negative infections, will be examined as well as their associated toxicity. Thus, current but ineffective clinical strategies designed to prevent toxicity related to colistin and amikacin will be reported, highlighting the importance of lipid-based drug delivery systems (LBDDSs), such as liposomes, solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs), as efficient delivery strategies for reducing antibiotic toxicity. This review reveals that colistin- and amikacin-NLCs are promising carriers with greater potential than liposomes and SLNs to safely tackle AMR, especially for lung and wound infections.
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Affiliation(s)
- Claudia Vairo
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain; NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain
| | | | - Rosa Maria Hernandez
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Manoli Igartua
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Silvia Villullas
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain.
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Nezamoleslami S, Fattahi A, Nemati H, Bagrezaie F, Pourmanouchehri Z, Kiaie SH. Electrospun sandwich-structured of polycaprolactone/gelatin-based nanofibers with controlled release of ceftazidime for wound dressing. Int J Biol Macromol 2023; 236:123819. [PMID: 36870631 DOI: 10.1016/j.ijbiomac.2023.123819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 06/24/2022] [Accepted: 02/19/2023] [Indexed: 03/06/2023]
Abstract
In the present work, sandwich-like polycaprolactone/gelatin/polycaprolactone electrospun multilayered mats were implemented to control the release of ceftazidime (CTZ). The outer layers were made from polycaprolactone nanofibers (NFs), and CTZ-loaded gelatin provided an internal layer. The release profile of CTZ from mats was compared with monolayer gelatin mats and chemically cross-linked GEL mats. All the constructs were characterized using scanning electron microscopy (SEM), mechanical properties, viscosity, electrical conductivity, X-ray diffraction (XRD), and Fourier transform-infrared spectroscopy (FT-IR). In vitro cytotoxicity against normal fibroblasts as well as antibacterial activity of CTZ-loaded sandwich-like NFs were investigated by the MTT assay. The results showed that the drug release rate from the polycaprolactone/gelatin/polycaprolactone mat was slower than that of gelatin monolayer NFs, and the rate of release can be adjusted by changing the thickness of hydrophobic layers. The NFs exhibited high activity against Pseudomonas aeruginosa and Staphylococcus aureus, while no significant cytotoxicity was observed against human normal cells. Altogether, the final mat as a predominant antibacterial scaffold can be used for controlled drug release of antibacterial drugs as the wound healing dressings in tissue engineering.
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Affiliation(s)
- Sadaf Nezamoleslami
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah 6734667149, Iran; Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Fattahi
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah 6734667149, Iran
| | - Houshang Nemati
- Fertility & Infertility Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fatemeh Bagrezaie
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah 6734667149, Iran
| | - Zahra Pourmanouchehri
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah 6734667149, Iran.
| | - Seyed Hossein Kiaie
- Nano Drug Delivery Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran; Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.
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17
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Cutuli SL, Cascarano L, Lazzaro P, Tanzarella ES, Pintaudi G, Grieco DL, De Pascale G, Antonelli M. Antimicrobial Exposure in Critically Ill Patients with Sepsis-Associated Multi-Organ Dysfunction Requiring Extracorporeal Organ Support: A Narrative Review. Microorganisms 2023; 11:microorganisms11020473. [PMID: 36838438 PMCID: PMC9965524 DOI: 10.3390/microorganisms11020473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023] Open
Abstract
Sepsis is a leading cause of disability and mortality worldwide. The pathophysiology of sepsis relies on the maladaptive host response to pathogens that fosters unbalanced organ crosstalk and induces multi-organ dysfunction, whose severity was directly associated with mortality. In septic patients, etiologic interventions aiming to reduce the pathogen load via appropriate antimicrobial therapy and the effective control of the source infection were demonstrated to improve clinical outcomes. Nonetheless, extracorporeal organ support represents a complementary intervention that may play a role in mitigating life-threatening complications caused by sepsis-associated multi-organ dysfunction. In this setting, an increasing amount of research raised concerns about the risk of suboptimal antimicrobial exposure in critically ill patients with sepsis, which may be worsened by the concomitant delivery of extracorporeal organ support. Accordingly, several strategies have been implemented to overcome this issue. In this narrative review, we discussed the pharmacokinetic features of antimicrobials and mechanisms that may favor drug removal during renal replacement therapy, coupled plasma filtration and absorption, therapeutic plasma exchange, hemoperfusion, extracorporeal CO2 removal and extracorporeal membrane oxygenation. We also provided an overview of evidence-based strategies that may help the physician to safely prescribe effective antimicrobial doses in critically ill patients with sepsis-associated multi-organ dysfunction who receive extracorporeal organ support.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-063-015-4490
| | - Laura Cascarano
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Paolo Lazzaro
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e Della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base Cliniche Intensivologiche e Perioperatorie, Universita’ Cattolica del Sacro Cuore, Rome, L.go F. Vito 1, 00168 Rome, Italy
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Jarrett P, Keogh S, Roberts JA, Wallis SC, Coyer FM. Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. Intensive Crit Care Nurs 2023:103403. [PMID: 36764903 DOI: 10.1016/j.iccn.2023.103403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To determine the percentage of drug remaining in discarded antibiotic vials after use. DESIGN Blinded prospective observational trial. SETTING 26-bed Australian metropolitan tertiary referral intensive care unit. MAIN OUTCOME MEASURES Percentage of labelled dose remaining in the vial after discard. METHOD Discarded antibiotic vials collected over a 7-day period in an adult intensive care unit were analysed. Each collected vial had any drug remnant washed out and made up to a known volume. A 1 ml aliquot of each vials washings was analysed using high performance liquid chromatography. From this concentration, the percentage of the drug remaining in the vial after discard was calculated. Additionally, each vial was weighed before and after washing to determine the weight of the remnant in each vial. RESULTS A total of 311 vials comprising of 11 different drugs and 14 individual vial types were collected. The median residual drug error across all vials was 3.7 %. The drug with the highest median was piperacillin at 6.1 % (IQR 4.3) and the lowest was amoxicillin 0.2 % (IQR 0.1). The single highest value for a given vial was vancomycin (500 mg) with 33.2 % and the lowest for a given vial was 0.1 % amoxicillin (1 g). These two drugs also exhibited the greatest range between the maximum and minimum value for any drug being 32 % and 0.9 % respectively. CONCLUSIONS Our study shows that up to a third of the intended dose may fail to reach the patient, highlighting a significant factor in the administration of antibiotics to the critically ill population. IMPLICATIONS FOR CLINICAL PRACTICE Residual drug often remains in antibiotic vials meaning that drug is not reaching the patient. There is considerable variation in the method by which medications are reconstituted in clinical settings. Two person checks should be completed after reconstitution in order to ensure that the medication is fully reconstituted and extracted from the vial.
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Affiliation(s)
- Paul Jarrett
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Brisbane, Queensland 4059. Australia; Department of Intensive Care Services, Royal Brisbane & Women's Hospital, Herston, Brisbane, Queensland 4029, Australia.
| | - Samantha Keogh
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Brisbane, Queensland 4059. Australia
| | - Jason A Roberts
- Department of Intensive Care Services, Royal Brisbane & Women's Hospital, Herston, Brisbane, Queensland 4029, Australia; University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4029, Australia
| | - Fiona M Coyer
- Queensland University of Technology (QUT), School of Nursing, Kelvin Grove, Brisbane, Queensland 4059. Australia; Department of Intensive Care Services, Royal Brisbane & Women's Hospital, Herston, Brisbane, Queensland 4029, Australia
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19
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Hou J, Li JF, Yan XJ, Zhang YL, Zhang MY, Zhang Y. The Effect of Clinical Pharmacist Intervention on Renal Function Impairment in Patients with Antimicrobial-Induced Acute Kidney Injury in ICU. Patient Prefer Adherence 2023; 17:711-718. [PMID: 36960183 PMCID: PMC10027847 DOI: 10.2147/ppa.s397873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/28/2023] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVE The purpose of this study was to analyze the improvement effect of clinical pharmacist intervention on renal function impairment in patients with antimicrobial-induced acute kidney injury (AKI). METHODS A total of 145 patients with AKI caused by antibiotics admitted to the ICU department were selected as the research subjects. The patients were divided into the control group (n=57) and the intervention group (n=88) according to whether there were ICU specialist clinical pharmacists involved in clinical treatment. The renal function outcome and infection control were evaluated in the two groups. RESULTS The proportion of renal function outcome in the intervention group was 88.6%, which was significantly higher than that in the control group. However, there was no statistically significant difference in infection control between the two groups. For the intervention group, the clinical pharmacists adopted three intervention methods: dose adjustment, drug replacement and CRRT treatment, respectively, according to the disease conditions of AKI patients. Among them, dose adjustment and drug replacement were the most frequently used intervention methods. In addition, the proportion of renal function outcome was higher in the group of patients who changed antibiotics and underwent CRRT, which were 93.1% and 100%, respectively. The adjusted-dose group had the highest infection control rate at 82.1%. However, there were no statistically significant differences in renal function outcomes and infection control among the three interventions. CONCLUSION Clinical pharmacists participating in the clinical treatment of patients with antimicrobial-induced AKI in ICU can effectively improve the renal function of patients.
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Affiliation(s)
- Jia Hou
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
| | - Jin-Feng Li
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
| | - Xiu-Juan Yan
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
| | - Yong-Liang Zhang
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
| | - Meng-Yu Zhang
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
| | - Yuan Zhang
- Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, People’s Republic of China
- Correspondence: Yuan Zhang, Department of Pharmacy, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, No. 70 Heping Road, Huancui District, Weihai City, Shandong Province, 264200, People’s Republic of China, Tel +86-18660377685, Email
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20
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Sequestration of Antimicrobial Agents in Xcoating and Heparin-Coated Extracorporeal Membrane Oxygenation Circuits: An In Vitro Study. ASAIO J 2023; 69:e23-e27. [PMID: 36583776 DOI: 10.1097/mat.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Limited data exist to guide antimicrobial therapy commonly prescribed to patients undergoing extracorporeal membrane oxygenation (ECMO). This study aimed to describe the kinetics of the cefazolin, doripenem, daptomycin, and levofloxacin in heparin-coated and Xcoating ECMO circuits. Circuits were primed with bovine whole blood and maintained at a physiological pH and temperature for 24 h. Each antimicrobial agent was added to the whole blood before priming. Equivalent doses of these drugs were added to glass jars containing fresh bovine whole blood as a control. Serial blood samples were collected from the ECMO circuits and controls over 24 h, and drug concentrations were quantified using validated assays. The concentrations of cefazolin, doripenem, daptomycin, and levofloxacin did not decrease significantly over 24 h. Collectively, these antimicrobial agents can be administered without the need to consider sequestration when using either heparin-coated or Xcoating circuits.
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21
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Baalbaki N, Blum S, Akerman M, Johnson D. Ceftriaxone 1 g Versus 2 g Daily for the Treatment of Enterobacterales Bacteremia: A Retrospective Cohort Study. J Pharm Technol 2022; 38:326-334. [PMID: 36311303 PMCID: PMC9608102 DOI: 10.1177/87551225221121252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background: Ceftriaxone is a commonly used antibiotic for the treatment of susceptible Enterobacterales infections. There is currently limited clinical data on the optimal dose of ceftriaxone for Enterobacterales bacteremia. Objectives: To evaluate the rate of clinical failure of ceftriaxone 1 g versus 2 g daily in patients with Enterobacterales bacteremia. Methods: This was a retrospective cohort study of patients admitted to any of the 3 New York University Hospitals: Long Island, Tisch, or Brooklyn, with ceftriaxone-susceptible Enterobacterales bacteremia, receiving ceftriaxone 1 or 2 g daily from October 2019 to September 2020. The primary outcome was 90-day rate of clinical failure. Clinical failure was defined as escalation of therapy, relapse of infection, or all-cause mortality. Results: A total of 124 patients, 58% in the 1-g group and 42% in the 2-g group, were included. There was no statistically significant difference found in the primary outcome. The 90-day rate of clinical failure was 16.7% versus 9.6%, P = 0.260. There were no statistically significant secondary outcomes, although infection relapse rates at 90 days were numerically greater in the 1-g group (11.1% vs 1.9%, P = 0.078). Hypoalbuminemia was the only variable associated with an increased risk of clinical failure (odds ratio = 4.03; 95% confidence interval [CI] = 1.12-14.50, P = 0.033). Conclusion: In our exploratory findings, there was no statistically significant difference with the 90-day rate of clinical failure between ceftriaxone 1 g versus 2 g daily, although there was a numeric trend toward an increased rate of infection relapse within the 1-g group. Hypoalbuminemia was associated with an increased risk of clinical failure. Prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Nadeem Baalbaki
- Department of Pharmacy, NYU Langone Hospital–Long Island, Mineola, NY, USA
| | - Sharon Blum
- Department of Pharmacy, NYU Langone Hospital–Long Island, Mineola, NY, USA
| | - Meredith Akerman
- Biostatistics Core, Division of Health Services Research, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Diane Johnson
- Department of Medicine, NYU Langone Hospital–Long Island, Mineola, NY, USA
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22
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Fortin É, Deceuninck G, Sirois C, Quach C, Simard M, Dionne M, Jean S, Irace-Cima A, Magali-Ufitinema N. Chronic diseases and compliance with provincial guidelines for outpatient antibiotic prescription in cases of otitis media and respiratory infections: a population-based study of linked data in Quebec, Canada, 2010-2017. CMAJ Open 2022; 10:E841-E847. [PMID: 36167419 PMCID: PMC9578749 DOI: 10.9778/cmajo.20210257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Quebec, antibiotic use is higher among outpatients with chronic diseases. We sought to measure compliance with provincial guidelines for the treatment of otitis media and common respiratory infections, and to measure variations in compliance according to the presence of certain chronic diseases. METHODS We conducted a population-based study of linked data on antibiotic dispensing covered by the public drug insurance plan between April 2010 and March 2017. We included patients who had consulted a primary care physician within 2 days before being dispensed an antibiotic for an infection targeted by provincial guidelines, including bronchitis in patients with chronic obstructive pulmonary disease, otitis media, pharyngitis, pneumonia and sinusitis. We computed proportions of prescriptions compliant with guidelines (use of recommended antibiotic for children, and use of recommended antibiotic and dosage for adults) by age group (children or adults) and chronic disease (respiratory, cardiovascular, diabetes, mental disorder or none). We measured the impact of chronic diseases on compliance using robust Poisson regression. RESULTS We analyzed between 14 677 and 198 902 prescriptions for each infection under study. Compliance was greater than 87% among children, but was lower among children with asthma (proportion ratios between 0.97 and 1.00). In adults, the chosen antibiotic was compliant for at least 73% of prescriptions, except for pharyngitis (≤ 61%). Accounting for dosage lowered compliance to between 31% and 61%. Compliance was lower in the presence of chronic diseases (proportion ratios between 0.94 and 0.98). INTERPRETATION It is possible that prescribing noncompliant prescriptions was sometimes appropriate, but the high frequency of noncompliance suggests room for improvement. Given that variations associated with chronic diseases were small, disease-specific guidelines for antibiotic prescriptions are likely to have a limited impact on compliance.
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Affiliation(s)
- Élise Fortin
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que.
| | - Geneviève Deceuninck
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Caroline Sirois
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Caroline Quach
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Marc Simard
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Marc Dionne
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Sonia Jean
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Alejandra Irace-Cima
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Nadine Magali-Ufitinema
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
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23
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Hemez C, Clarelli F, Palmer AC, Bleis C, Abel S, Chindelevitch L, Cohen T, Abel zur Wiesch P. Mechanisms of antibiotic action shape the fitness landscapes of resistance mutations. Comput Struct Biotechnol J 2022; 20:4688-4703. [PMID: 36147681 PMCID: PMC9463365 DOI: 10.1016/j.csbj.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 11/15/2022] Open
Abstract
Antibiotic-resistant pathogens are a major public health threat. A deeper understanding of how an antibiotic's mechanism of action influences the emergence of resistance would aid in the design of new drugs and help to preserve the effectiveness of existing ones. To this end, we developed a model that links bacterial population dynamics with antibiotic-target binding kinetics. Our approach allows us to derive mechanistic insights on drug activity from population-scale experimental data and to quantify the interplay between drug mechanism and resistance selection. We find that both bacteriostatic and bactericidal agents can be equally effective at suppressing the selection of resistant mutants, but that key determinants of resistance selection are the relationships between the number of drug-inactivated targets within a cell and the rates of cellular growth and death. We also show that heterogeneous drug-target binding within a population enables resistant bacteria to evolve fitness-improving secondary mutations even when drug doses remain above the resistant strain's minimum inhibitory concentration. Our work suggests that antibiotic doses beyond this "secondary mutation selection window" could safeguard against the emergence of high-fitness resistant strains during treatment.
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Affiliation(s)
- Colin Hemez
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Graduate Program in Biophysics, Harvard University, Boston, MA 02115, USA
- Corresponding authors at: Broad Institute, 75 Ames St, Room 3035, Cambridge, MA 02412, USA (C. Hemez). Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway (P. Abel zur Wiesch).
| | - Fabrizio Clarelli
- Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA 16802, USA
| | - Adam C. Palmer
- Department of Pharmacology, Computational Medicine Program, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Christina Bleis
- Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA 16802, USA
| | - Sören Abel
- Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA 16802, USA
- Division of Infection Control, Norwegian Institute of Public Health, Oslo 0318, Norway
| | - Leonid Chindelevitch
- Department of Infectious Disease Epidemiology, Imperial College, London SW7 2AZ, UK
| | - Theodore Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06520, USA
| | - Pia Abel zur Wiesch
- Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway
- Center for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA 16802, USA
- Division of Infection Control, Norwegian Institute of Public Health, Oslo 0318, Norway
- Corresponding authors at: Broad Institute, 75 Ames St, Room 3035, Cambridge, MA 02412, USA (C. Hemez). Department of Pharmacy, UiT – The Arctic University of Norway, 9019 Tromsø, Norway (P. Abel zur Wiesch).
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24
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Martinez MN, Miller RA, Martín-Jiménez T, Sharkey MJ. Application of pharmacokinetic/pharmacodynamic concepts to the development of treatment regimens for sporadic canine urinary tract infections: Challenges and paths forward. J Vet Pharmacol Ther 2022; 45:415-425. [PMID: 35906854 DOI: 10.1111/jvp.13088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
Antimicrobial efficacy can be predicted based on infection site exposure to the antimicrobial agent relative to the in vitro susceptibility of the pathogen to that agent. When infections occur in soft tissues (e.g., muscle, blood, and ligaments), exposure at the infection site is generally assumed to reflect an equilibrium between the unbound concentrations in plasma and that in the interstitial fluids. In contrast, for sporadic urinary tract infections (UTIs) in dogs and uncomplicated UTIs in humans, the primary site of infection is the bladder wall. Infection develops when bacteria invade the host bladder urothelium (specifically, the umbrella cells that form the urine-contacting layer of the stratified uroepithelium) within which these bacteria can avoid exposure to host defenses and antimicrobial agents. Traditionally, pathogen susceptibility has been estimated using standardized in vitro tests that measure the minimal concentration that will inhibit pathogen growth (MIC). When using exposure-response relationships during drug development to explore dose optimization, these relationships can either be based upon an assessment of a correlation between clinical outcome, drug exposure at the infection site, and pathogen MIC, or upon benchmark exposure-response relationships (i.e., pharmacokinetic/pharmacodynamic indices) typically used for the various drug classes. When using the latter approach, it is essential that the unbound concentrations at the infection site be considered relative to the MIC within the biological matrix to which the pathogen will be exposed. For soft tissue infections, this typically is the unbound plasma concentrations versus MICs determined in standardized media such as cation-adjusted Mueller Hinton broth, which is how many indices were originally established. However, for UTIs, it is the unbound drug concentrations within the urine versus the MICs in the actual urine biophase that needs to be considered. The importance of these relationships and how they are influenced by drug resistance, resilience, and inoculum are discussed in this review using fluoroquinolones and beta-lactams as examples.
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Affiliation(s)
- Marilyn N Martinez
- Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Ron A Miller
- Division of Human Food Safety, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Tomás Martín-Jiménez
- Division of Scientific Support, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
| | - Michele J Sharkey
- Division of Companion Animal Drugs, Food and Drug Administration, Center for Veterinary Medicine, Office of New Animal Drug Evaluation, Rockville, Maryland, USA
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25
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Guerra Valero YC, Dorofaeff T, Coulthard MG, Sparkes L, Lipman J, Wallis SC, Roberts JA, Parker SL. Optimal dosing of cefotaxime and desacetylcefotaxime for critically ill paediatric patients. Can we use microsampling? J Antimicrob Chemother 2022; 77:2227-2237. [PMID: 35678266 PMCID: PMC9333413 DOI: 10.1093/jac/dkac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To describe the population pharmacokinetics of cefotaxime and desacetylcefotaxime in critically ill paediatric patients and provide dosing recommendations. We also sought to evaluate the use of capillary microsampling to facilitate data-rich blood sampling. Methods Patients were recruited into a pharmacokinetic study, with cefotaxime and desacetylcefotaxime concentrations from plasma samples collected at 0, 0.5, 2, 4 and 6 h used to develop a population pharmacokinetic model using Pmetrics. Monte Carlo dosing simulations were tested using a range of estimated glomerular filtration rates (60, 100, 170 and 200 mL/min/1.73 m2) and body weights (4, 10, 15, 20 and 40 kg) to achieve pharmacokinetic/pharmacodynamic (PK/PD) targets, including 100% ƒT>MIC with an MIC breakpoint of 1 mg/L. Results Thirty-six patients (0.2–12 years) provided 160 conventional samples for inclusion in the model. The pharmacokinetics of cefotaxime and desacetylcefotaxime were best described using one-compartmental model with first-order elimination. The clearance and volume of distribution for cefotaxime were 12.8 L/h and 39.4 L, respectively. The clearance for desacetylcefotaxime was 10.5 L/h. Standard dosing of 50 mg/kg q6h was only able to achieve the PK/PD target of 100% ƒT>MIC in patients >10 kg and with impaired renal function or patients of 40 kg with normal renal function. Conclusions Dosing recommendations support the use of extended or continuous infusion to achieve cefotaxime exposure suitable for bacterial killing in critically ill paediatric patients, including those with severe or deep-seated infection. An external validation of capillary microsampling demonstrated skin-prick sampling can facilitate data-rich pharmacokinetic studies.
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Affiliation(s)
| | - Tavey Dorofaeff
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Mark G Coulthard
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia.,Mayne Academy of Paediatrics, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Louise Sparkes
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Jamieson Trauma Institute, Royal Brisbane & Women's Hospital, Herston, QLD 4029, Australia
| | - Steven C Wallis
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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26
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Weber F, Dübel L, Mikolajewska A, Uhrig A, Kiessling P, Huisinga W, Michelet R, Hennig S, Kloft C. Evaluation of a Meropenem and Piperacillin Monitoring Program in Intensive Care Unit Patients Calls for the Regular Assessment of Empirical Targets and Easy-to-Use Dosing Decision Tools. Antibiotics (Basel) 2022; 11:antibiotics11060758. [PMID: 35740164 PMCID: PMC9219867 DOI: 10.3390/antibiotics11060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 02/01/2023] Open
Abstract
The drug concentrations targeted in meropenem and piperacillin/tazobactam therapy also depend on the susceptibility of the pathogen. Yet, the pathogen is often unknown, and antibiotic therapy is guided by empirical targets. To reliably achieve the targeted concentrations, dosing needs to be adjusted for renal function. We aimed to evaluate a meropenem and piperacillin/tazobactam monitoring program in intensive care unit (ICU) patients by assessing (i) the adequacy of locally selected empirical targets, (ii) if dosing is adequately adjusted for renal function and individual target, and (iii) if dosing is adjusted in target attainment (TA) failure. In a prospective, observational clinical trial of drug concentrations, relevant patient characteristics and microbiological data (pathogen, minimum inhibitory concentration (MIC)) for patients receiving meropenem or piperacillin/tazobactam treatment were collected. If the MIC value was available, a target range of 1–5 × MIC was selected for minimum drug concentrations of both drugs. If the MIC value was not available, 8–40 mg/L and 16–80 mg/L were selected as empirical target ranges for meropenem and piperacillin, respectively. A total of 356 meropenem and 216 piperacillin samples were collected from 108 and 96 ICU patients, respectively. The vast majority of observed MIC values was lower than the empirical target (meropenem: 90.0%, piperacillin: 93.9%), suggesting empirical target value reductions. TA was found to be low (meropenem: 35.7%, piperacillin 50.5%) with the lowest TA for severely impaired renal function (meropenem: 13.9%, piperacillin: 29.2%), and observed drug concentrations did not significantly differ between patients with different targets, indicating dosing was not adequately adjusted for renal function or target. Dosing adjustments were rare for both drugs (meropenem: 6.13%, piperacillin: 4.78%) and for meropenem irrespective of TA, revealing that concentration monitoring alone was insufficient to guide dosing adjustment. Empirical targets should regularly be assessed and adjusted based on local susceptibility data. To improve TA, scientific knowledge should be translated into easy-to-use dosing strategies guiding antibiotic dosing.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Franz Weber
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Lucas Dübel
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | | | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50676
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Spangehl MJ, Clarke HD, Moore GA, Zhang M, Probst NE, Young SW. Higher Tissue Concentrations of Vancomycin Achieved With Low-Dose Intraosseous Injection Versus Intravenous Despite Limited Tourniquet Duration in Primary Total Knee Arthroplasty: A Randomized Trial. J Arthroplasty 2022; 37:857-863. [PMID: 35091036 DOI: 10.1016/j.arth.2022.01.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 12/30/2021] [Accepted: 01/20/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vancomycin use has been suggested in high risk patients undergoing total knee arthroplasty (TKA). Previous literature has shown that a lower dose (500 mg) of vancomycin given by intraosseous regional administration (IORA) achieves tissue concentrations 4-10 times higher than intravenous (IV) administration. There is increasing interest in performing TKA with limited tourniquet inflation time. The purpose of this study is to evaluate whether IORA of vancomycin can achieve effective tissue concentrations with limited tourniquet inflation time. METHODS Based on prior power calculations, 24 patients undergoing primary TKA were randomized into 2 groups. Group IV-Systemic received weight-based (15 mg/kg) vancomycin with the tourniquet inflated for cementation only. Group IORA received 500 mg vancomycin via IORA after tourniquet inflation which remained inflated for 10 minutes, then reinflated for cementation only. Vancomycin concentrations from tissue, serum, and drain fluid were compared between the 2 groups. RESULTS Median vancomycin concentrations in tissue were significantly higher (5-15 times) at all time points in the IORA group. Concentrations in fat at the time of wound closure, after the tourniquet had been deflated for most of the procedure, were 5.2 μg/g in Group IV-Systemic and 33.1 μg/g in Group IORA (P < .001). Median bone concentrations taken just prior to cementation were 7.9 μg/g in Group IV-Systemic and 21.8 μg/g in Group IORA (P = .006). There were no complications related to IORA. CONCLUSION For surgeons who wish to limit tourniquet time and when indicated to use vancomycin, low-dose vancomycin IORA achieves tissue concentrations 5-15 times higher than those achieved by IV administration. LEVEL OF EVIDENCE Level 1 therapeutic randomized trial.
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Affiliation(s)
| | | | - Grant A Moore
- Canterbury Health Laboratories, Toxicology, Christchurch, New Zealand
| | - Mei Zhang
- Canterbury Health Laboratories, Toxicology, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Nick E Probst
- Department of Orthopaedics, Mayo Clinic, Phoenix, AZ
| | - Simon W Young
- Department of Orthopaedics, North Shore Hospital, Auckland, New Zealand
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Ciprofloxacin in Patients Undergoing Extracorporeal Membrane Oxygenation (ECMO): A Population Pharmacokinetic Study. Pharmaceutics 2022; 14:pharmaceutics14050965. [PMID: 35631551 PMCID: PMC9145815 DOI: 10.3390/pharmaceutics14050965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/17/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is utilized to temporarily sustain respiratory and/or cardiac function in critically ill patients. Ciprofloxacin is used to treat nosocomial infections, but data describing the effect of ECMO on its pharmacokinetics is lacking. Therefore, a prospective, observational trial including critically ill adults (n = 17), treated with ciprofloxacin (400 mg 8–12 hourly) during ECMO, was performed. Serial blood samples were collected to determine ciprofloxacin concentrations to assess their pharmacokinetics. The pharmacometric modeling was performed (NONMEM®) and utilized for simulations to evaluate the probability of target attainment (PTA) to achieve an AUC0–24/MIC of 125 mg·h/L for ciprofloxacin. A two-compartment model most adequately described the concentration-time data of ciprofloxacin. Significant covariates on ciprofloxacin clearance (CL) were plasma bicarbonate and the estimated glomerular filtration rate (eGFR). For pathogens with an MIC of ≤0.25 mg/L, a PTA of ≥90% was attained. However, for pathogens with an MIC of ≥0.5 mg/L, plasma bicarbonate ≥ 22 mmol/L or eGFR ≥ 10 mL/min PTA decreased below 90%, steadily declining to 7.3% (plasma bicarbonate 39 mmol/L) and 21.4% (eGFR 150 mL/min), respectively. To reach PTAs of ≥90% for pathogens with MICs ≥ 0.5 mg/L, optimized dosing regimens may be required.
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Gude SS, Venu Gopal S, Marasandra Ramesh H, Vuppalapati S, Peddi NC, Gude SS. Unraveling the Nature of Antibiotics: Is It a Cure or a New Hurdle to the Patient Treatment? Cureus 2022; 14:e23955. [PMID: 35547462 PMCID: PMC9085652 DOI: 10.7759/cureus.23955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
Antimicrobial resistance is an increasing problem worldwide that has been exacerbated by antibiotic misuse worldwide. Growing antibiotic resistance can be attributed to as well as leads to severe infections, complications, prolonged hospital admissions, and higher mortality. One of the most important goals of administering antimicrobials is to avoid establishing antibiotic resistance during therapy. This can be done by drastically lowering worldwide antimicrobial usage, both in present and future. While current management methods to legislate antimicrobials and educate the healthcare community on the challenges are beneficial, they do not solve the problem of attaining an overall reduction in antimicrobial usage in humans. Application of rapid microbiological diagnostics for identification and antimicrobial susceptibility testing, use of inflammation markers to guide initiation and duration of therapies, reduction of standard antibiotic course durations, individualization of antibiotic treatments, and dosing considering pharmacokinetics are all possible strategies to optimize antibiotic use in everyday clinical practice and reduce the risk of inducing bacterial resistance. Furthermore, to remove any impediments to proper prescribing, strategies to improve antibiotic prescribing and antibiotic stewardship programs should enable clinical reasoning and enhance the prescribing environment. In addition, the well-established association between antimicrobial usage and resistance should motivate efforts to develop antimicrobial treatment regimens that facilitate the evolution of resistance. This review discusses the role of antibiotics, their current application in human medicine, and how the resistance has evolved to the existing antibiotics based on the existing literature.
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Ekhtiari Kolour SR, Shahrami B, Kargar M, Taghvaye Masoumi H, Amini S, Vaezi M, Hadjibabaie M, Mohammadi M, Sadeghi K. Adherence to practice guidelines for the management of febrile neutropenia in patients undergoing hematopoietic stem cell transplantation: An observational study in a referral center in Iran. J Oncol Pharm Pract 2022:10781552221092158. [PMID: 35392730 DOI: 10.1177/10781552221092158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Patients undergoing hematopoietic stem cell transplantation (HSCT) are suspected to develop febrile neutropenia (FN) and severe infections. Therefore, appropriate prescription of antibiotics in these patients is crucial to reduce the rates of morbidity, mortality, and antimicrobial resistance. The present study aimed to evaluate the physicians' prescription and adherence to the FN clinical guidelines among patients undergoing HSCT. METHODS This prospective observational single-center study was conducted during a 15-month period in a tertiary referral hospital in Iran. The patients with at least one episode of FN following HSCT were included in the current study. The physicians' adherence to the Infectious Diseases Society of America (IDSA) and National Comprehensive Cancer Network (NCCN) clinical guidelines for the management of FN was evaluated using prescription data and medical record reviews. RESULTS Two hundred and fifteen patients with 297 FN episodes were evaluated. The timing of antibiotics and the selection of the initial regimen were considered guideline-based therapy. However, antibiotic dosing and initial regimen modification were not followed in terms of the guideline recommendations in 58.1% of the patients. In particular, vancomycin was inappropriately given in 83.1% of patients. The overall adherence of physicians to the guidelines was 35.8%. CONCLUSION Non-adherence to clinical guidelines is high particularly in initial regimen modification and administration of vancomycin, which affects hospital stay and patient's outcome. Implementation of guideline-review sessions to raise the awareness of the physicians and to improve the rational use of antimicrobial agents may be crucial.
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Affiliation(s)
| | - Bita Shahrami
- Department of Clinical Pharmacy, School of Pharmacy, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Kargar
- Research Center for Rational Use of Drugs, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Taghvaye Masoumi
- Department of Clinical Pharmacy, School of Pharmacy, 37554Guilan University of Medical Sciences, Rasht, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, School of Pharmacy, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Vaezi
- Hematology-Oncology and Stem Cell Transplantation Research Center, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Molouk Hadjibabaie
- Department of Clinical Pharmacy, School of Pharmacy, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohammadi
- Department of Clinical Pharmacy, School of Pharmacy, 391934Alborz University of Medical Sciences, Karaj, Iran
| | - Kourosh Sadeghi
- Department of Clinical Pharmacy, School of Pharmacy, 48439Tehran University of Medical Sciences, Tehran, Iran
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31
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Jamrozik E, Heriot GS. Ethics and antibiotic resistance. Br Med Bull 2022; 141:4-14. [PMID: 35136968 PMCID: PMC8935610 DOI: 10.1093/bmb/ldab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION OR BACKGROUND Antibiotic resistance raises ethical issues due to the severe and inequitably distributed consequences caused by individual actions and policies. SOURCES OF DATA Synthesis of ethical, scientific and clinical literature. AREAS OF AGREEMENT Ethical analyses have focused on the moral responsibilities of patients to complete antibiotic courses, resistance as a tragedy of the commons and attempts to limit use through antibiotic stewardship. AREAS OF CONTROVERSY Each of these analyses has significant limitations and can result in self-defeating or overly narrow implications for policy. GROWING POINTS More complex analyses focus on ethical implications of ubiquitous asymptomatic carriage of resistant bacteria, non-linear outcomes within and between patients over time and global variation in resistant disease burdens. AREAS TIMELY FOR DEVELOPING RESEARCH Neglected topics include the harms of antibiotic use, including off-target effects on the human microbiome, and the lack of evidence guiding most antibiotic prescription decisions.
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Affiliation(s)
- Euzebiusz Jamrozik
- The Ethox Centre and Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, University of Oxford. Old Road Campus, Oxford OX3 7LF, UK.,Monash Bioethics Centre, Monash University, Wellington Rd, Clayton, 3800, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, 3050, Victoria, Australia
| | - George S Heriot
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, 3050, Victoria, Australia
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32
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Dubinsky S, Watt K, Saleeb S, Ahmed B, Carter C, Yeung CH, Edginton A. Pharmacokinetics of Commonly Used Medications in Children Receiving Continuous Renal Replacement Therapy: A Systematic Review of Current Literature. Clin Pharmacokinet 2022; 61:189-229. [PMID: 34846703 PMCID: PMC8816883 DOI: 10.1007/s40262-021-01085-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The use of continuous renal replacement therapy (CRRT) for renal support has increased substantially in critically ill children compared with intermittent modalities owing to its preferential effects on hemodynamic stability. With the expanding role of CRRT, the quantification of extracorporeal clearance and the effect on primary pharmacokinetic parameters is of the utmost importance. Within this review, we aimed to summarize the current state of the literature and compare published pharmacokinetic analyses of commonly used medications in children receiving CRRT to those who are not. METHODS A systematic search of the literature within electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Published studies that were included contained relevant information on the use of commonly administered medications to children, from neonates to adolescents, receiving CRRT. Pharmacokinetic parameters that were analyzed included volume of distribution, total clearance, extracorporeal clearance, area under the curve, and elimination half-life. Information regarding CRRT circuit, flow rates, and membrane components was analyzed to investigate differences in pharmacokinetics between each modality. RESULTS Forty-five studies met the final inclusion criteria within this systematic review, totaling 833 pediatric patients, with 586 receiving CRRT. Antimicrobials were the most common pharmacological class represented within the literature, representing 81% (35/43) of studies analyzed. Children receiving CRRT largely had similar volume of distribution and total clearance to critically ill children not receiving CRRT, suggesting reno-protective dose adjustments may lead to subtherapeutic dosing regimens in these patients. Overall, there was a tendency for hydrophilic agents, with a low protein binding to undergo elevated total clearance in these children. However, results should be interpreted with caution because of the large variability amongst patient populations and heterogeneity with CRRT modalities, flow rates, and use of extracorporeal membrane oxygenation within studies. This review was able to identify that variation in solute removal, or CRRT modalities, properties (i.e., flow rates), and membrane composition, may have differing effects on the pharmacokinetics of commonly administered medications. CONCLUSIONS The current state of the literature regarding medications administered to children receiving CRRT largely focuses on antimicrobials. Significant gaps remain with other commonly used medications such as sedatives and analgesics. Overall reporting of patient clinical characteristics, CRRT settings, and circuit composition was poor, with only 10% of articles including all relevant information to assess the impact of CRRT on total clearance. Changes in pharmacokinetics because of CRRT often required higher than labeled doses, suggesting renally adjusted or reno-protective doses may lead to subtherapeutic dosing regimens. A thorough understanding of the interplay between patient, drug, and CRRT-circuit factors are required to ensure adequate delivery of dosing regimens to this vulnerable population.
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Affiliation(s)
- Samuel Dubinsky
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Kevin Watt
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada;,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | - Caitlin Carter
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Cindy H.T. Yeung
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Andrea Edginton
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
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Quantitative Determination of Unbound Piperacillin and Imipenem in Biological Material from Critically Ill Using Thin-Film Microextraction-Liquid Chromatography-Mass Spectrometry. Molecules 2022; 27:molecules27030926. [PMID: 35164191 PMCID: PMC8839241 DOI: 10.3390/molecules27030926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
β-Lactam antibiotics are most commonly used in the critically ill, but their effective dosing is challenging and may result in sub-therapeutic concentrations that can lead to therapy failure and even promote antimicrobial resistance. In this study, we present the analytical tool enabling specific and sensitive determination of the sole biologically active fraction of piperacillin and imipenem in biological material from the critically ill. Thin-film microextraction sampling technique, followed by rapid liquid chromatography–tandem mass spectrometry (LC-MS/MS) analysis, was optimized and validated for the quantitative determination of antibiotics in blood and bronchoalveolar lavage (BAL) specimens collected from intensive care unit (ICU) patients suffering from ventilation-associated pneumonia (n = 18 and n = 9, respectively). The method was optimized and proved to meet the criteria of US Food and Drug Administration (FDA) guidelines for bioanalytical method validation. Highly selective, sensitive, accurate and precise analysis by means of thin-film microextraction–LC-MS/MS, which is not affected by matrix-related factors, was successfully applied in clinical settings, revealing poor penetration of piperacillin and imipenem from blood into BAL fluid (reflecting the site of bacterial infection), nonlinearity in antibiotic binding to plasma-proteins and drug-specific dependence on creatinine clearance. This work demonstrates that only a small fraction of biologically active antibiotics reach the site of infection, providing clinicians with a high-throughput analytical tool for future studies on personalized therapeutic drug monitoring when tailoring the dosing strategy to an individual patient.
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Tait JR, Bilal H, Rogers KE, Lang Y, Kim TH, Zhou J, Wallis SC, Bulitta JB, Kirkpatrick CMJ, Paterson DL, Lipman J, Bergen PJ, Roberts JA, Nation RL, Landersdorfer CB. Effect of Different Piperacillin-Tazobactam Dosage Regimens on Synergy of the Combination with Tobramycin against Pseudomonas aeruginosa for the Pharmacokinetics of Critically Ill Patients in a Dynamic Infection Model. Antibiotics (Basel) 2022; 11:antibiotics11010101. [PMID: 35052977 PMCID: PMC8772788 DOI: 10.3390/antibiotics11010101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 12/10/2022] Open
Abstract
We evaluated piperacillin-tazobactam and tobramycin regimens against Pseudomonas aeruginosa isolates from critically ill patients. Static-concentration time-kill studies (SCTK) assessed piperacillin-tazobactam and tobramycin monotherapies and combinations against four isolates over 72 h. A 120 h-dynamic in vitro infection model (IVM) investigated isolates Pa1281 (MICpiperacillin 4 mg/L, MICtobramycin 0.5 mg/L) and CR380 (MICpiperacillin 32 mg/L, MICtobramycin 1 mg/L), simulating the pharmacokinetics of: (A) tobramycin 7 mg/kg q24 h (0.5 h-infusions, t1/2 = 3.1 h); (B) piperacillin 4 g q4 h (0.5 h-infusions, t1/2 = 1.5 h); (C) piperacillin 24 g/day, continuous infusion; A + B; A + C. Total and less-susceptible bacteria were determined. SCTK demonstrated synergy of the combination for all isolates. In the IVM, regimens A and B provided initial killing, followed by extensive regrowth by 72 h for both isolates. C provided >4 log10 CFU/mL killing, followed by regrowth close to initial inoculum by 96 h for Pa1281, and suppressed growth to <4 log10 CFU/mL for CR380. A and A + B initially suppressed counts of both isolates to <1 log10 CFU/mL, before regrowth to control or starting inoculum and resistance emergence by 72 h. Overall, the combination including intermittent piperacillin-tazobactam did not provide a benefit over tobramycin monotherapy. A + C, the combination regimen with continuous infusion of piperacillin-tazobactam, provided synergistic killing (counts <1 log10 CFU/mL) of Pa1281 and CR380, and suppressed regrowth to <2 and <4 log10 CFU/mL, respectively, and resistance emergence over 120 h. The shape of the concentration–time curve was important for synergy of the combination.
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Affiliation(s)
- Jessica R. Tait
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Hajira Bilal
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Kate E. Rogers
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Yinzhi Lang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Tae-Hwan Kim
- College of Pharmacy, Daegu Catholic University, Gyeongsan 38430, Korea;
| | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Steven C. Wallis
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL 32827, USA; (Y.L.); (J.Z.); (J.B.B.)
| | - Carl M. J. Kirkpatrick
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - David L. Paterson
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
| | - Jeffrey Lipman
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
- Jamieson Trauma Institute, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Phillip J. Bergen
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (H.B.); (C.M.J.K.); (P.J.B.)
| | - Jason A. Roberts
- The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia; (S.C.W.); (D.L.P.); (J.L.); (J.A.R.)
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30900 Nîmes, France
| | - Roger L. Nation
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
| | - Cornelia B. Landersdorfer
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia; (J.R.T.); (K.E.R.); (R.L.N.)
- Correspondence: ; Tel.: +61-3-990-39011
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He S, Leanse LG, Feng Y. Artificial intelligence and machine learning assisted drug delivery for effective treatment of infectious diseases. Adv Drug Deliv Rev 2021; 178:113922. [PMID: 34461198 DOI: 10.1016/j.addr.2021.113922] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 07/14/2021] [Accepted: 08/09/2021] [Indexed: 12/23/2022]
Abstract
In the era of antimicrobial resistance, the prevalence of multidrug-resistant microorganisms that resist conventional antibiotic treatment has steadily increased. Thus, it is now unquestionable that infectious diseases are significant global burdens that urgently require innovative treatment strategies. Emerging studies have demonstrated that artificial intelligence (AI) can transform drug delivery to promote effective treatment of infectious diseases. In this review, we propose to evaluate the significance, essential principles, and popular tools of AI in drug delivery for infectious disease treatment. Specifically, we will focus on the achievements and key findings of current research, as well as the applications of AI on drug delivery throughout the whole antimicrobial treatment process, with an emphasis on drug development, treatment regimen optimization, drug delivery system and administration route design, and drug delivery outcome prediction. To that end, the challenges of AI in drug delivery for infectious disease treatments and their current solutions and future perspective will be presented and discussed.
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Affiliation(s)
- Sheng He
- Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Leon G Leanse
- Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Yanfang Feng
- Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
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Applying cefepime population pharmacokinetics on critically ill patients receiving continuous renal replacement therapy. Antimicrob Agents Chemother 2021; 66:e0161121. [PMID: 34662194 DOI: 10.1128/aac.01611-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients admitted to the intensive care unit (ICU) may need continuous renal replacement therapy (CRRT) due to acute kidney injury or worsening of underlying chronic kidney disease. This will affect their antimicrobial exposure and may have a significant impact on the treatment. We aim to develop a cefepime pharmacokinetic (PK) model in CRRT ICU patients and generate the posterior predictions for a group and assess their therapy outcomes. Adult patients, admitted to the ICU, received cefepime, and had its concentration measured while on CRRT were included from three different datasets. In two datasets, samples were collected from the predialyzer, postdialyzer ports, and effluent fluid at different times within the same dosing interval. The third dataset had only cefepime plasma concentration measured as part of clinical service. Patients' demographics, cefepime regimens and concentration, CRRT parameters, and therapy outcomes were recorded. NPAG was used for population PK and posterior predictions. A total of 125 patients were included. Cefepime was described by a five-compartment model, and the CRRT flow rates described the rates of cefepime transfer between compartments. The posterior predictions were generated for the third dataset and the median (range) fT>MIC was 100% (27%-100%) and fT>4×MIC was 64% (0%-100%). The mortality rate was 53%. There was no difference in target attainment in terms of clinical cure and 30-day mortality. This model can be used as a precision dosing tool in CRRT patients. Future studies may address other PK/PD targets in a larger population.
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Landmesser KB, Clark JA, Burgess DS. Time Above All Else: Pharmacodynamic Analysis of β-Lactams in Critically Ill Patients. J Clin Pharmacol 2021; 62:479-485. [PMID: 34614542 DOI: 10.1002/jcph.1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
β-Lactams are the most commonly used antibiotics in intensive care units (ICUs). As critically ill patients often experience pharmacokinetic aberrations, and rates of antimicrobial resistance vary between hospital settings, reliance on tertiary sources or package labeling to guide empiric dosing often results in suboptimal β-lactam exposure. The primary objective was to identify β-lactam regimens capable of achieving ≥90% cumulative fraction of response (CFR) against 7 Gram-negative pathogens within 4 ICUs at our institution. Unit-specific minimal inhibitory concentration (MIC) distribution data was used in combination with published pharmacokinetic parameters in critically ill patients to perform Monte Carlo simulations. The percentage of time for which the unbound concentration of antibiotic remained above the MIC (%ƒT > MIC) was used as the pharmacodynamic target: 70%ƒT >MIC for cefepime, 40%ƒT > MIC for meropenem, and 50%ƒT > MIC for piperacillin/tazobactam. Regimens were modeled to determine the likelihood of achieving ≥90% CFR. Overall, intermittently dosed cefepime, meropenem, and piperacillin/tazobactam failed to achieve ≥90% CFR for every organism. Cefepime 2 g intermittent bolus every 8 hours failed to achieve ≥90% CFR for Klebsiella pneumoniae or Enterobacter cloacae despite susceptibility rates exceeding 90%. Piperacillin/tazobactam 4.5 g prolonged infusion (PI) every 6 hours achieved <85% CFR for Pseudomonas aeruginosa and <50% CFR for Acinetobacter baumannii in every ICU. Meropenem 2 g PI every 8 hours and meropenem 2 g PI every 6 hours were the only regimens capable of achieving ≥90% CFR for P aeruginosa in all units. Use of Monte Carlo simulations, with incorporation of local MIC distribution data, provides a mechanism to effectively predict optimal agent and dose selection within specific hospital systems, thereby enhancing pharmacokinetic/pharmacodynamic optimization and improving clinical efficacy.
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Affiliation(s)
- Katie B Landmesser
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Department of Pharmacy Practice and Science, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Justin A Clark
- Department of Pharmacy Practice and Science, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - David S Burgess
- Department of Pharmacy Practice and Science, The University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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38
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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: 2] [Impact Index Per Article: 0.7] [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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39
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Eco-Friendly UPLC-MS/MS Quantitation of Delafloxacin in Plasma and Its Application in a Pharmacokinetic Study in Rats. SEPARATIONS 2021. [DOI: 10.3390/separations8090146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A novel UPLC-MS/MS assay was developed for rapid quantification of delafloxacin (a novel fluoroquinolone antibiotic in plasma samples by one step sample cleanup procedure. Delafloxacin (DFX) and internal standard (losartan) were separated on a UPLC BEH C18 column (50 × 2.1 mm; 1.7 μm) by using gradient programing of a mobile phase containing 0.1% formic acid in acetonitrile and 0.1% formic acid in water. The quantification was performed by a using triple-quadrupole mass detector at an electrospray ionization interface in positive mode. The precursor to the product ion transition of 441.1 → 379.1 for the qualifier and 441.1 → 423.1 for the quantifier was used for DFX monitoring, whereas 423.1 → 207.1 was used for the internal standard. The validation was performed as per guidelines of bioanalytical method validation, and the evaluated parameters were within the acceptable range. The greenness assessment of the method was evaluated by using AGREE software covering all 12 principles of green analytical chemistry. The final score obtained was 0.78, suggesting excellent greenness of the method. Moreover, Deming regression analysis showed an excellent linear relationship between this method and our previously reported method, and it is suitable for high-throughput analysis for routine application. The proposed method was effectively applied in a pharmacokinetic study of novel formulation (self-nanoemulsifying drug delivery systems) of DFX in rats.
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40
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Poźniak B, Tikhomirov M, Bobrek K, Jajor P, Świtała M. Tylosin Dosage Adjustment Based on Allometric Scaling in Male Turkeys. Antibiotics (Basel) 2021; 10:1057. [PMID: 34572639 PMCID: PMC8467158 DOI: 10.3390/antibiotics10091057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/18/2022] Open
Abstract
Turkeys' body weight (BW) increases 10-fold within only 2.5 months, leading to a change in the pharmacokinetics (PK) of drugs according to allometric principles. Thus, the same dosage may lead to age-dependent variability in efficacy, in particular, to treatment failure and/or selection for resistance. The study aimed to investigate whether a non-linear dosage based on a published allometric model for tylosin clearance, may optimize the internal exposure in growing turkeys. The single dose PK study was performed on turkeys aged 6, 9.5, 13 and 17 weeks (BW from 1.75 kg to 15.75 kg). Tylosin was administered intravenously (i.v.) or orally (p.o.) according to following protocols: Dose = 31.6 × BW0.58 or Dose = 158 × BW0.58, respectively. Plasma tylosin was measured using high-performance liquid chromatography and non-compartmental PK analysis was performed. The area under the curve (AUClast) after i.v. administration was 8.90 ± 1.01; 7.51 ± 1.11; 6.54 ± 1.20 and 8.01 ± 1.75 mg × h/L in 6-; 9.5-; 13- and 17-week-old turkeys, respectively. After p.o. administration AUClast was 4.80 ± 2.92; 4.60 ± 2.45; 3.00 ± 1.49 and 3.24 ± 2.00 mg × h/L in respective age groups indicating high variability. For i.v. administration, the non-linear dosage allowed to minimize the age-dependent variability in AUC. However, due to low oral bioavailability (8-12%) and resulting interindividual variability, the proposed approach may not improve tylosin efficacy in turkeys under farm conditions.
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Affiliation(s)
- Błażej Poźniak
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, ul. Norwida 31, 50-375 Wrocław, Poland; (M.T.); (P.J.); (M.Ś.)
| | - Marta Tikhomirov
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, ul. Norwida 31, 50-375 Wrocław, Poland; (M.T.); (P.J.); (M.Ś.)
| | - Kamila Bobrek
- Department of Epizootiology and Clinic of Birds and Exotic Animals, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, pl. Grunwaldzki 45, 50-366 Wrocław, Poland;
| | - Paweł Jajor
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, ul. Norwida 31, 50-375 Wrocław, Poland; (M.T.); (P.J.); (M.Ś.)
| | - Marcin Świtała
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences, ul. Norwida 31, 50-375 Wrocław, Poland; (M.T.); (P.J.); (M.Ś.)
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41
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Niederman MS, Baron RM, Bouadma L, Calandra T, Daneman N, DeWaele J, Kollef MH, Lipman J, Nair GB. Initial antimicrobial management of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:307. [PMID: 34446092 PMCID: PMC8390082 DOI: 10.1186/s13054-021-03736-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/08/2023]
Abstract
Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.
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Affiliation(s)
- Michael S Niederman
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, 425 East 61st St, New York, NY, 10065, USA.
| | - Rebecca M Baron
- Harvard Medical School; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Lila Bouadma
- AP-HP, Bichat Claude Bernard, Medical and Infectious Diseas ICU, University of Paris, Paris, France
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lusanne University Hospital, University of Lusanne, Lusanne, Switzerland
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jan DeWaele
- Department of Critical Care Medicine, Surgical Intensive Care Unit, Ghent University, Ghent, Belgium
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Lipman
- Royal Brisbane and Women's Hospital and Jamieson Trauma Institute, The University of Queensland, Brisbane, Australia.,Nimes University Hospital, University of Montpelier, Nimes, France
| | - Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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42
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Herbin SR, Barber KE, Isaacson AR, Dolman HS, McGee JD, Baylor AE, Tyburski JG, White MT, Faris J. When More is Still Not Enough: A Case of Ceftazidime-Avibactam Resistance in a Burn Patient. J Burn Care Res 2021; 43:474-478. [PMID: 34427655 DOI: 10.1093/jbcr/irab160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Burn patients have numerous risk factors for multidrug resistant organisms (MDROs) and altered pharmacokinetics, which both independently increase the risk of treatment failure. Data on appropriate antimicrobial dosing are limited in this population and therapeutic drug monitoring (TDM) for beta-lactams is impractical at most facilities. 1-3 Technology is available that can detect genetic markers of resistance, but they are not all encompassing, and often require specialized facilities that can detect less common genetic markers. 4-5 Newer antimicrobials can help combat MDROs, but additional resistance patterns may evolve during treatment. Considering drug shortages and antimicrobial formularies, clinicians must remain vigilant when treating infections. This case report describes the development of resistance to ceftazidime-avibactam in a burn patient. The patient was a 54- year-old burn victim with a 58% total body surface area (TBSA) thermal burn who underwent multiple courses of antibiotics for various Pseudomonal infections. The initial Pseudomonal wound infection was sensitive to cefepime, aminoglycosides, and meropenem. A subsequent resistant pseudomonal pneumonia was treated with ceftazidime-avibactam 2.5 grams every 6 hours due to the elevated MIC to cefepime (16mcg/mL) and meropenem (>8mcg/mL). Although, the patient improved over 7 days, the patient again spiked fevers and had increased white blood counts (WBC). Repeat blood cultures demonstrated a multidrug resistant (MDR) Pseudomonas with a minimum inhibitory concentration (MIC) to ceftazidime-avibactam of 16mcg/mL, which is above the Clinical and Laboratory Standards Institute (CLSI) breakpoint of 8mcg/mL. At first, resistance was thought to have occurred due to inadequate dosing, but genetic work demonstrated multiple genes encoding beta-lactamases.
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Affiliation(s)
| | - Katie E Barber
- University of Mississippi School of Pharmacy, Jackson MS
| | - Andrew R Isaacson
- Assistant Professor of Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit MI
| | - Heather S Dolman
- Assistant Professor of Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit MI
| | - Jessica D McGee
- Assistant Professor of Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit MI
| | - Alfred E Baylor
- Associate Professor of Surgery, Director of the Hyperbaric and Wound Care Center, Staff Surgeon, Wayne State University School of Medicine/Detroit Medical Center Affiliated Hospitals, Detroit Mi
| | - James G Tyburski
- Chief of Surgery, Detroit Receiving Hospital, Professor of Surgery, Wayne State University School of Medicine, Detroit MI
| | - Michael T White
- Medical Director of Burn Center, Detroit Receiving Hospital, Detroit MI, Assistant Professor of Surgery, Wayne State University School of Medicine, Detroit MI
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Han R, Sun D, Li S, Chen J, Teng M, Yang B, Dong Y, Wang T. Pharmacokinetic/Pharmacodynamic Adequacy of Novel β-Lactam/β-Lactamase Inhibitors against Gram-Negative Bacterial in Critically Ill Patients. Antibiotics (Basel) 2021; 10:antibiotics10080993. [PMID: 34439043 PMCID: PMC8389032 DOI: 10.3390/antibiotics10080993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/10/2021] [Accepted: 08/14/2021] [Indexed: 12/20/2022] Open
Abstract
The optimal regimens of novel β-lactam/β-lactamase inhibitors (BLBLIs), ceftazidime/avibactam, ceftolozane/tazobactam, and meropenem/vaborbactam, are not well defined in critically ill patients. This study was conducted to identify optimal regimens of BLBLIs in these patients. A Monte Carlo simulation was performed using the published data to calculate the joint probability of target attainment (PTA) and the cumulative fraction of response (CFR). For the target of β-lactam of 100% time with free drug concentration remains above minimal inhibitory concentrations, the PTAs of BLBLIs standard regimens were <90% at a clinical breakpoint for Enterobacteriaceae and Pseudomonas aeruginosa. For ceftazidime/avibactam, 2000 mg/500 mg/8 h by 4 h infusion achieved >90% CFR for Escherichia coli; even for 4000 mg/1000 mg/6 h by continuous infusion, CFR for Klebsiella pneumoniae was <90%; the CFRs of 3500 mg/875 mg/6 h by 4 h infusion and 4000 mg/1000 mg/8 h by continuous infusion were appropriate for Pseudomonas aeruginosa. For ceftolozane/tazobactam, the CFR of standard regimen was >90% for Escherichia coli, however, 2000 mg/1000 mg/6 h by continuous infusion achieved <90% CFRs for Klebsiella pneumoniae and Pseudomonas aeruginosa. For meropenem/vaborbactam, standard regimen achieved optimal attainments for Escherichia coli and Klebsiella pneumoniae; 2000 mg/2000 mg/6 h by 5 h infusion, 2500 mg /2500 mg/6 h by 4 h infusion, 3000 mg/3000 mg/6 h by 3 h infusion and 4000 mg/4000 mg/8 h by 5 h infusion achieved >90% CFRs for Pseudomonas aeruginosa. The CFRs of three BLBLIs were similar for Escherichia coli, but meropenem/vaborbactam were superior for Klebsiella pneumoniae and Pseudomonas aeruginosa.
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Jaworski R, Dzierzanowska-Fangrat K, Czajkowska A, Maruszewski B, Kansy A. Cefazolin prophylaxis in children undergoing cardiac surgery with the use of cardiopulmonary bypass-is the dosing correct? Eur J Cardiothorac Surg 2021; 61:27-33. [PMID: 34269390 DOI: 10.1093/ejcts/ezab251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To determine the recommended concentrations of cefazolin to be used for antibiotic prophylaxis during paediatric cardiac surgery with extracorporeal circulation (ECC). METHODS Twenty paediatric patients undergoing cardiac surgery with ECC and cefazolin antibiotic prophylaxis were included in the study. Blood samples for measurement of total cefazolin plasma concentration were collected at the following measurement time points: directly after skin incision, 15 min after ECC start, 5 min after ECC cessation and at skin closure. The target concentration was set for ≥40 mg/l, which corresponded to ≥8 mg/l of unbound cefazolin concentration. RESULTS The median total cefazolin plasma concentrations at the measurement time points were 62.8, 67.7, 45.8 and 34.2 mg/l, respectively, and target concentrations were achieved in 90%, 85%, 65% and 40% of children, respectively. Among patients who received ≥30 mg of cefazolin per 100 ml of ECC priming, target concentrations after ECC cessation were reached in 80% of patients, while in those with <30 mg cefazolin per 100 ml in 20% of patients (P = 0.031). CONCLUSIONS Direct extrapolation of antibiotic prophylaxis recommendations from adults to children may result in suboptimal antibiotic concentrations. An additional cefazolin dose to ECC priming appears necessary and the dosing should be based on ECC priming volume rather than on the weight of the patient.
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Affiliation(s)
- Radoslaw Jaworski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Agnieszka Czajkowska
- Department of Biochemistry, Radioimmunology and Experimental Medicine, Pharmacokinetics Laboratory, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan Maruszewski
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Kansy
- Department of Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
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45
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Narayanan N, Lin T, Vinarov D, Bucek T, Johnson L, Mathew C, Chaudhry S, Brunetti L. Relationship Between Multidrug-Resistant Enterobacterales and Obesity in Older Adults. Infect Drug Resist 2021; 14:2527-2532. [PMID: 34234480 PMCID: PMC8255648 DOI: 10.2147/idr.s317014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/01/2021] [Indexed: 01/23/2023] Open
Abstract
Purpose The objective of our study was to determine if obesity is associated with the presence of multidrug-resistant (MDR) bacteria among Enterobacterales. Patients and Methods This two-center cohort study included adult hospitalized patients with at least one specimen sampled from any site for bacterial culture yielding an Enterobacterales bacterial species from November 2016 to May 2017. Study groups were stratified by obesity status based on body mass index <30 kg/m2 (non-obese) and ≥30 kg/m2 (obese). The primary outcome was the presence of gram-negative MDR bacteria defined as presumptive extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales (ceftriaxone resistance) or carbapenem-resistant Enterobacterales (CRE). A multivariable logistic regression model was fit to estimate the adjusted odds ratio while controlling for potential confounders. Results A total of 366 patients, 238 non-obese and 128 obese, were included. The most common gram-negative bacterial species identified was Escherichia coli (64.2%). There was a higher proportion of gram-negative MDR bacteria in obese versus non-obese patients (18.8 versus 11.3%, P=0.057). Obesity was independently associated with gram-negative MDR bacteria after controlling for confounders (adjusted odds ratio, 1.92; 95% CI 1.03–3.60). The association did not significantly vary by diabetes status (interaction term P=0.792). Conclusion Among older adult hospitalized patients, obesity was independently associated with the presence of a gram-negative MDR bacteria (presumptive ESBL or CRE) in a culture.
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Affiliation(s)
- Navaneeth Narayanan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA.,Division of Infectious Diseases, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Tiffany Lin
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - David Vinarov
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Thomas Bucek
- Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
| | - Liya Johnson
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - Cheryl Mathew
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | | | - Luigi Brunetti
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA.,Center of Excellence in Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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A Retrospective, Observational Study on Antimicrobial Drug Use in Beef Fattening Operations in Northwestern Italy and Evaluation of Risk Factors Associated with Increased Antimicrobial Usage. Animals (Basel) 2021; 11:ani11071925. [PMID: 34203490 PMCID: PMC8300168 DOI: 10.3390/ani11071925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022] Open
Abstract
Simple Summary Antimicrobial usage in veterinary medicine is thought to be a source of antimicrobial resistance, with possible implications for human health. Certain antibiotics are considered critical for human health, and their use is being judiciously reduced in animal productions. The monitoring of antimicrobial consumption in animal production is key to lowering the risk of the development of antimicrobial resistance. With this study, we quantified antimicrobial usage in beef fattening operations in northwestern Italy before the implementation of a program intended to control antimicrobial usage in veterinary medicine. We found that antimicrobials defined as critical for human health (e.g., fluroquinolones) were often used also for metaphylactic treatment. Abstract The abuse or misuse of antimicrobials in animal production is thought to be a potential factor in the development of antimicrobial resistance in veterinary and human medicine. With this study, we wanted to quantify antimicrobial usage in beef fattening operations in northwestern Italy and to identify factors potentially influencing antimicrobial usage. The sample was composed of 26 beef fattening operations that import heifers and bulls from France. Data were extracted from the 2014 and 2015 treatment registers kept by the farmers. The mean (±SD) number of animal daily doses per animal (nADDa) per year for each farm was 3 (±2.1) during the study period (2014–2015). Group antimicrobial treatments (57.5% of all treatments) were often administered orally (70.5%) and consisted overwhelmingly of doxycycline (97%). Individual treatments (42.5% of all treatments) were administered parenterally (98.1%) and the most often used active substances were florfenicol (19.9%), marbofloxacin (19.5%), and tylosin (12.4%). There was a negative correlation between the nADDa for total and group treatments and average batch weight at arrival and between the amount of straw added per animal per day and the nADDa (p ≤ 0.05). Our data show that antimicrobials critical for human medicine were often used in beef fattening operations in northwestern Italy before the European guidelines for the prudent use of antimicrobials in veterinary medicine were issued. Additionally, the use of antimicrobials as a preventive group treatment was still widespread, mostly in lighter weight animals.
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Cefepime Population Pharmacokinetics and Target Attainment in Critically Ill Patients on Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2021; 65:AAC.00144-21. [PMID: 33722885 DOI: 10.1128/aac.00144-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/08/2021] [Indexed: 12/20/2022] Open
Abstract
Sepsis causes half of acute kidney injuries in the intensive care unit (ICU). ICU patients may need continuous renal replacement therapy (CRRT), which will affect their antimicrobial exposure. We aimed to build a cefepime population pharmacokinetic (PK) model in CRRT ICU patients and perform simulations to assess target attainment. Patients who were ≥18 years old, were admitted to the ICU, and received cefepime 2 g every 8 h as a 4-h infusion while on CRRT were enrolled prospectively. Samples were collected from the predialyzer ports, postdialyzer ports, and effluent fluid at 1, 2, 3, 4, and 8 h after the first dose and at steady state. Age, sex, weight, urine output, and CRRT parameters were recorded. Pmetrics was used for population PK and simulations. The target exposure was 100% of the dosing interval during which the free beta-lactam concentration is above the MIC (fT >MIC). Ten patients were included; their mean age was 53 years, and mean weight was 119 kg. Seventy percent were males. Cefepime was described by a five-compartment model. The downtime was applied to the CRRT flow rates, which were used to describe the rates of transfer between the compartments. At MICs of ≤8 mg/liter, intermittent infusion of 2 g cefepime every 8 h achieved good target attainment both early in therapy and at steady state. Only extended- and continuous-infusion regimens achieved good target attainment at MICs of 16 mg/liter. In conclusion, 2 g cefepime infused over 30 min followed by extended infusion of 2 g every 8 h achieved good target attainment at MICs of ≤16 mg/liter with different CRRT flow rates and may be considered in resistant bacterial infections.
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Rochman N, Wolf YI, Koonin EV. Substantial impact of post-vaccination contacts on cumulative infections during viral epidemics. F1000Res 2021; 10:315. [PMID: 34504684 PMCID: PMC8406440 DOI: 10.12688/f1000research.52341.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background: The start of 2021 was marked by the initiation of a global vaccination campaign against the novel coronavirus SARS-CoV-2. Formulating an optimal distribution strategy under social and economic constraints is challenging. Optimal distribution is additionally constrained by the potential emergence of vaccine resistance. Analogous to chronic low-dose antibiotic exposure, recently inoculated individuals who are not yet immune play an outsized role in the emergence of resistance. Classical epidemiological modelling is well suited to explore how the behavior of the inoculated population impacts the total number of infections over the entirety of an epidemic. Methods: A deterministic model of epidemic evolution is analyzed, with seven compartments defined by their relationship to the emergence of vaccine-resistant mutants and representing three susceptible populations, three infected populations, and one recovered population. This minimally computationally intensive design enables simulation of epidemics across a broad parameter space. The results are used to identify conditions minimizing the cumulative number of infections. Results: When an escape variant is only modestly less infectious than the originating strain within a naïve population, the cumulative number of infections does not monotonically decrease with the rate of vaccine distribution. Analysis of the model also demonstrates that inoculated individuals play a major role in the mitigation or exacerbation of vaccine-resistant outbreaks. Modulating the rate of host-host contact for the inoculated population by less than an order of magnitude can alter the cumulative number of infections by more than 20%. Conclusions: Mathematical modeling shows that limiting post-vaccination contacts can perceptibly affect the course of an epidemic. The consideration of limitations on post-vaccination contacts remains relevant for the entire duration of any vaccination campaign including the current status of SARS-CoV-2 vaccination.
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Affiliation(s)
- Nash Rochman
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
| | - Yuri I Wolf
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
| | - Eugene V Koonin
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
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Rochman N, Wolf YI, Koonin EV. Substantial impact of post-vaccination contacts on cumulative infections during viral epidemics. F1000Res 2021; 10:315. [PMID: 34504684 PMCID: PMC8406440 DOI: 10.12688/f1000research.52341.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2021] [Indexed: 07/20/2023] Open
Abstract
Background: The start of 2021 was marked by the initiation of a global vaccination campaign against the novel coronavirus SARS-CoV-2. Formulating an optimal distribution strategy under social and economic constraints is challenging. Optimal distribution is additionally constrained by the potential emergence of vaccine resistance. Analogous to chronic low-dose antibiotic exposure, recently inoculated individuals who are not yet immune play an outsized role in the emergence of resistance. Classical epidemiological modelling is well suited to explore how the behavior of the inoculated population impacts the total number of infections over the entirety of an epidemic. Methods: A deterministic model of epidemic evolution is analyzed, with seven compartments defined by their relationship to the emergence of vaccine-resistant mutants and representing three susceptible populations, three infected populations, and one recovered population. This minimally computationally intensive design enables simulation of epidemics across a broad parameter space. The results are used to identify conditions minimizing the cumulative number of infections. Results: When an escape variant is only modestly less infectious than the originating strain within a naïve population, there exists an optimal rate of vaccine distribution. Exceeding this rate increases the cumulative number of infections due to vaccine escape. Analysis of the model also demonstrates that inoculated individuals play a major role in the mitigation or exacerbation of vaccine-resistant outbreaks. Modulating the rate of host-host contact for the inoculated population by less than an order of magnitude can alter the cumulative number of infections by more than 20%. Conclusions: Mathematical modeling shows that optimization of the vaccination rate and limiting post-vaccination contacts can perceptibly affect the course of an epidemic. The consideration of limitations on post-vaccination contacts remains relevant for the entire duration of any vaccination campaign including the current status of SARS-CoV-2 vaccination.
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Affiliation(s)
- Nash Rochman
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
| | - Yuri I Wolf
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
| | - Eugene V Koonin
- National Center for Biotechnology Information, NIH, Bethesda, MD, 20894, USA
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Lykins V JD, Kuttab HI, Rourke EM, Hughes MD, Keast EP, Kopec JA, Ward BL, Pettit NN, Ward MA. The effect of delays in second-dose antibiotics on patients with severe sepsis and septic shock. Am J Emerg Med 2021; 47:80-85. [PMID: 33784532 DOI: 10.1016/j.ajem.2021.03.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early antibiotics are fundamental to sepsis management. Second-dose antibiotic delays were associated with increased mortality in a recent study. Study objectives include: 1) determine factors associated with delays in second-dose antibiotic administration; 2) evaluate if delays influence clinical outcomes. METHODS ED-treated adults (≥18 years; n = 1075) with severe sepsis or septic shock receiving ≥2 doses of intravenous antibiotics were assessed, retrospectively, for second-dose antibiotic delays (dose time > 25% of recommended interval). Predictors of delay and impact on outcomes were determined, controlling for MEDS score, 30 mL/kg fluids and antibiotics within three hours of sepsis onset, lactate, and renal failure, among others. RESULTS In total, 335 (31.2%) patients had delayed second-dose antibiotics. A total of 1864 second-dose antibiotics were included, with 354 (19.0%) delays identified by interval (delayed/total doses): 6-h (36/67) = 53.7%; 8-h (165/544) = 30.3%; 12-h (114/436) = 26.1%; 24-h (21/190) = 8.2%; 48-h (0/16) = 0%. In-hospital mortality in the timely group was 15.5% (shock-17.6%) and 13.7% in the delayed group (shock-16.9%). Increased odds of delay were observed for ED boarding (OR 2.54, 95% 1.81-3.55), shorter dosing intervals (6/8-h- OR 2.99, 95% CI 1.95-4.57; 12-h- OR 2.46, 95% CI 1.72-3.51), receiving 30 mL/kg fluids by three hours (OR 1.42, 95% CI 1.06-1.90), and renal failure (OR 2.57, 95% CI 1.50-4.39). Delays were not associated with increased mortality (OR 0.87, 95% CI 0.58-1.29) or other outcomes. CONCLUSIONS Factors associated with delayed second-dose antibiotics include ED boarding, antibiotics requiring more frequent dosing, receiving 30 mL/kg fluid, and renal failure. Delays in second-dose administration were not associated with mortality or other outcomes.
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Affiliation(s)
- Joseph D Lykins V
- Department of Emergency Medicine, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, VA 23298, United States
| | - Hani I Kuttab
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States.
| | - Erron M Rourke
- Section of Emergency Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Michelle D Hughes
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Eric P Keast
- Division of Emergency Medicine, NorthShore University HealthSystem, Evanston, IL 60201, United States
| | - Jason A Kopec
- Division of Emergency Medicine, Carle Foundation Hospital, Urbana, IL 61801, United States
| | - Brooke L Ward
- Department of Pharmacy, University of Wisconsin-Madison, Madison, WI 53705, United States
| | - Natasha N Pettit
- Department of Pharmacy, University of Chicago, Chicago, IL 60637, United States
| | - Michael A Ward
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI 53705, United States
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