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Oda K, Jono H, Kamohara H, Saito H. Population Pharmacokinetic Modeling of Unbound Meropenem in Patients Undergoing Continuous Renal Replacement Therapy: An Observational Cohort Study. Ther Drug Monit 2024:00007691-990000000-00227. [PMID: 38758632 DOI: 10.1097/ftd.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/15/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND The most effective dosing strategy of meropenem for patients undergoing continuous renal replacement therapy (CRRT) remains uncertain. This study aimed to analyze the population pharmacokinetics (popPKs) of unbound meropenem and establish an appropriate dosing approach. METHODS This prospective study involved 19 patients for the development of a popPK model and an additional 10 for its validation. Ethical approval was obtained. RESULTS The clearance of unbound meropenem was influenced by the sequential organ failure assessment (SOFA) score [=2.22 × (SOFA score/12)^1.88] and the effluent flow rate from the CRRT device, with an interindividual variability of 44.5%. The volume of distribution was affected by the simplified acute physiology score II [=23.1 × (simplified acute physiology score II/52)^1.54]. Monte Carlo simulations suggested meropenem doses ranging from 1.0 to 3.0 g/d using continuous infusion to achieve a target time above the 4 times of minimum inhibitory concentration of the unbound form (%fT>4×MIC) of 100% for definitive therapy. For empirical therapy, a dose of 1.0 g/d using continuous infusion was recommended to target %fT>MIC of 100%. CONCLUSIONS This study developed a popPK model for unbound meropenem in patients undergoing CRRT and formulated dosing guidelines. CLINICAL TRIAL REGISTRATION UMIN000024321.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan; and
| | - Hidenobu Kamohara
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Hideyuki Saito
- Department of Pharmacy, Kumamoto University Hospital, Kumamoto, Japan
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan; and
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El-Haffaf I, Marsot A, Hachemi D, Pesout T, Williams V, Smith MA, Albert M, Williamson D. Exposure levels and target attainment of piperacillin/tazobactam in adult patients admitted to the intensive care unit: a prospective observational study. Can J Anaesth 2024; 71:511-522. [PMID: 38243099 DOI: 10.1007/s12630-023-02689-8] [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: 03/13/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE The objective of this study was to evaluate the exposure and the pharmacodynamic target attainment of piperacillin/tazobactam (PTZ) in adult critically ill patients. METHODS We conducted a prospective observational study in the intensive care unit (ICU) of the Hôpital du Sacré-Cœur de Montréal (a Level I trauma centre in Montreal, QC, Canada) between January 2021 and June 2022. We included patients aged 18 yr or older admitted to the ICU who received PTZ by intravenous administration. Demographic and clinical characteristics were collected, and clinical scores were calculated. On study day 1 of antimicrobial therapy, three blood samples were collected at the following timepoints: one hour after PTZ dose administration and at the middle and at the end of the dosing interval. The sampling schedule was repeated on days 4 and 7 of therapy if possible. Samples were analyzed by ultra-high performance liquid chromatography with diode array detector to determine the total piperacillin concentration. Middle- and end-of-interval concentrations were used for target attainment analyses, and were defined as a concentration above the minimal inhibitory concentration of 16 mg·L-1, corresponding to the breakpoint of Enterobacteriaceae and Pseudomonas aeruginosa. RESULTS Forty-three patients were recruited and 202 blood samples were analyzed. The most prevalent dose was 3/0.375 g every six hours (n = 50/73 doses administered, 68%) with a 30-min infusion. We observed marked variability over the three sampling timepoints, and the median [interquartile range] piperacillin concentrations at peak, middle of interval, and end of interval were 109.4 [74.0-152.3], 59.3 [21.1-74.4], and 25.3 [6.8-44.6] mg·L-1, respectively. When assessing target attainment, 37% of patients did not reach the efficacy target of a trough concentration of 16 mg·L-1. The majority of patients who were underexposed were patients with normal to augmented renal clearance. CONCLUSION In this prospective observational study of adult ICU patients receiving intravenous PTZ, a large proportion had subtherapeutic concentrations of piperacillin. This was most notable in patients with normal to augmented renal clearance. More aggressive dosage regimens may be required for this subpopulation to ensure attainment of efficacy targets.
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Affiliation(s)
- Ibrahim El-Haffaf
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
| | - Djamila Hachemi
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Thomas Pesout
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Virginie Williams
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Marc-André Smith
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Martin Albert
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - David Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
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Wang Q, Li S, Chen J, Yang L, Qiu Y, Du Q, Wang C, Teng M, Wang T, Dong Y. A novel strategy for therapeutic drug monitoring: application of biosensors to quantify antimicrobials in biological matrices. J Antimicrob Chemother 2023; 78:2612-2629. [PMID: 37791382 DOI: 10.1093/jac/dkad289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Over the past few years, therapeutic drug monitoring (TDM) has gained practical significance in antimicrobial precision therapy. Yet two categories of mainstream TDM techniques (chromatographic analysis and immunoassays) that are widely adopted nowadays retain certain inherent limitations. The use of biosensors, an innovative strategy for rapid evaluation of antimicrobial concentrations in biological samples, enables the implementation of point-of-care testing (POCT) and continuous monitoring, which may circumvent the constraints of conventional TDM and provide strong technological support for individualized antimicrobial treatment. This comprehensive review summarizes the investigations that have harnessed biosensors to detect antimicrobial drugs in biological matrices, provides insights into the performance and characteristics of each sensing form, and explores the feasibility of translating them into clinical practice. Furthermore, the future trends and obstacles to achieving POCT and continuous monitoring are discussed. More efforts are necessary to address the four key 'appropriateness' challenges to deploy biosensors in clinical practice, paving the way for personalized antimicrobial stewardship.
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Affiliation(s)
- Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Sihan Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Chuhui Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
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Pai Mangalore R, Peel TN, Udy AA, Peleg AY. The clinical application of beta-lactam antibiotic therapeutic drug monitoring in the critical care setting. J Antimicrob Chemother 2023; 78:2395-2405. [PMID: 37466209 PMCID: PMC10566322 DOI: 10.1093/jac/dkad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Critically ill patients have increased variability in beta-lactam antibiotic (beta-lactam) exposure due to alterations in their volume of distribution and elimination. Therapeutic drug monitoring (TDM) of beta-lactams, as a dose optimization and individualization tool, has been recommended to overcome this variability in exposure. Despite its potential benefit, only a few centres worldwide perform beta-lactam TDM. An important reason for the low uptake is that the evidence for clinical benefits of beta-lactam TDM is not well established. TDM also requires the availability of specific infrastructure, knowledge and expertise. Observational studies and systematic reviews have demonstrated that TDM leads to an improvement in achieving target concentrations, a reduction in potentially toxic concentrations and improvement of clinical and microbiological outcomes. However, a small number of randomized controlled trials have not shown a mortality benefit. Opportunities for improved study design are apparent, as existing studies are limited by their inclusion of heterogeneous patient populations, including patients that may not even have infection, small sample size, variability in the types of beta-lactams included, infections caused by highly susceptible bacteria, and varied sampling, analytical and dosing algorithm methods. Here we review the fundamentals of beta-lactam TDM in critically ill patients, the existing clinical evidence and the practical aspects involved in beta-lactam TDM implementation.
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Affiliation(s)
- Rekha Pai Mangalore
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Andrew A Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
- Department of Infectious Diseases, Central Clinical School, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
- Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
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5
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Greppmair S, Brinkmann A, Roehr A, Frey O, Hagel S, Dorn C, Marsot A, El-Haffaf I, Zoller M, Saller T, Zander J, Schatz LM, Scharf C, Briegel J, Minichmayr IK, Wicha SG, Liebchen U. Towards model-informed precision dosing of piperacillin: multicenter systematic external evaluation of pharmacokinetic models in critically ill adults with a focus on Bayesian forecasting. Intensive Care Med 2023; 49:966-976. [PMID: 37439872 PMCID: PMC10425489 DOI: 10.1007/s00134-023-07154-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Inadequate piperacillin (PIP) exposure in intensive care unit (ICU) patients threatens therapeutic success. Model-informed precision dosing (MIPD) might be promising to individualize dosing; however, the transferability of published models to external populations is uncertain. This study aimed to externally evaluate the available PIP population pharmacokinetic (PopPK) models. METHODS A multicenter dataset of 561 ICU patients (11 centers/3654 concentrations) was used for the evaluation of 24 identified models. Model performance was investigated for a priori (A) predictions, i.e., considering dosing records and patient characteristics only, and for Bayesian forecasting, i.e., additionally including the first (B1) or first and second (B2) therapeutic drug monitoring (TDM) samples per patient. Median relative prediction error (MPE) [%] and median absolute relative prediction error (MAPE) [%] were calculated to quantify accuracy and precision. RESULTS The evaluation revealed a large inter-model variability (A: MPE - 135.6-78.3% and MAPE 35.7-135.6%). Integration of TDM data improved all model predictions (B1/B2 relative improvement vs. A: |MPE|median_all_models 45.1/67.5%; MAPEmedian_all_models 29/39%). The model by Kim et al. was identified to be most appropriate for the total dataset (A/B1/B2: MPE - 9.8/- 5.9/- 0.9%; MAPE 37/27.3/23.7%), Udy et al. performed best in patients receiving intermittent infusion, and Klastrup et al. best predicted patients receiving continuous infusion. Additional evaluations stratified by sex and renal replacement therapy revealed further promising models. CONCLUSION The predictive performance of published PIP models in ICU patients varied considerably, highlighting the relevance of appropriate model selection for MIPD. Our differentiated external evaluation identified specific models suitable for clinical use, especially in combination with TDM.
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Affiliation(s)
- Sebastian Greppmair
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Anka Roehr
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, University Hospital, Friedrich-Schiller-University Jena, 07747, Jena, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053, Regensburg, Germany
| | - Amélie Marsot
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Johannes Zander
- Laboratory Dr. Brunner, Laboratory Medical Care Center Konstanz GmbH, 78464, Constance, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, 48149, Muenster, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, 1090, Vienna, Austria
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146, Hamburg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Stašek J, Keller F, Kočí V, Klučka J, Klabusayová E, Wiewiorka O, Strašilová Z, Beňovská M, Škardová M, Maláska J. Update on Therapeutic Drug Monitoring of Beta-Lactam Antibiotics in Critically Ill Patients—A Narrative Review. Antibiotics (Basel) 2023; 12:antibiotics12030568. [PMID: 36978435 PMCID: PMC10044408 DOI: 10.3390/antibiotics12030568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Beta-lactam antibiotics remain one of the most preferred groups of antibiotics in critical care due to their excellent safety profiles and their activity against a wide spectrum of pathogens. The cornerstone of appropriate therapy with beta-lactams is to achieve an adequate plasmatic concentration of a given antibiotic, which is derived primarily from the minimum inhibitory concentration (MIC) of the specific pathogen. In a critically ill patient, the plasmatic levels of drugs could be affected by many significant changes in the patient’s physiology, such as hypoalbuminemia, endothelial dysfunction with the leakage of intravascular fluid into interstitial space and acute kidney injury. Predicting antibiotic concentration from models based on non-critically ill populations may be misleading. Therapeutic drug monitoring (TDM) has been shown to be effective in achieving adequate concentrations of many drugs, including beta-lactam antibiotics. Reliable methods, such as high-performance liquid chromatography, provide the accurate testing of a wide range of beta-lactam antibiotics. Long turnaround times remain the main drawback limiting their widespread use, although progress has been made recently in the implementation of different novel methods of antibiotic testing. However, whether the TDM approach can effectively improve clinically relevant patient outcomes must be proved in future clinical trials.
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Affiliation(s)
- Jan Stašek
- Department of Internal Medicine and Cardiology, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Filip Keller
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Veronika Kočí
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Eva Klabusayová
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Ondřej Wiewiorka
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Zuzana Strašilová
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Miroslava Beňovská
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Markéta Škardová
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Jan Maláska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, 620 00 Brno, Czech Republic
- Correspondence:
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Beijer G, Clarin L, Östervall J, Barclay V, Eliasson E. Reproducible Quantification of Unbound Fractions of Four Beta-Lactam Antibiotics: Ultrafiltration Versus Microdialysis of Spiked Healthy Donor Plasma. Ther Drug Monit 2023; 45:45-54. [PMID: 35971673 PMCID: PMC10321508 DOI: 10.1097/ftd.0000000000001016] [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: 03/01/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ultrafiltration (UF) is a conventional method for isolating the protein-unbound plasma fractions of therapeutic drugs. However, the ideal UF conditions for specific compounds remain largely unexplored. By comparing UF-derived unbound concentrations with the corresponding results obtained using a reference method, the authors sought to identify appropriate UF conditions for cefotaxime, cloxacillin, flucloxacillin, and piperacillin. METHODS In vitro microdialysis (MD) with a no-net-flux approach was used as a reference method for plasma protein separation, for which UF performance was assessed. Four levels of relative centrifugal force (2500-11,290 g ) and 2 levels of temperature (37 vs. 22°C) during 10 minutes of UF centrifugation were evaluated. Ultrafiltrates and reference microdialysates were analyzed using liquid chromatography-tandem mass spectrometry to obtain unbound concentrations. After identifying the appropriate UF conditions in the spiked plasma samples, exploratory analyses of clinical samples (n = 10 per analyte) were performed. RESULTS Of the evaluated UF alternatives, the best overall agreement with the MD-derived reference concentrations was obtained with 11,290 g UF performed at 22°C. For cloxacillin specifically, 37°C UF yielded better agreement than 22°C UF at 11,290 g. Clinical sample analyses indicated minimal differences between 22°C and 37°C at 11,290 g UF for cefotaxime and piperacillin. However, consistently lower levels of unbound cloxacillin (median: -23%, IQR: -19% to -24%) and flucloxacillin (median: -27%, IQR: -21 to -34%) were observed after UF at 22°C versus 37°C. CONCLUSIONS For the evaluated UF device, 10 minutes of 11,290 g UF at 22°C is appropriate for flucloxacillin, cefotaxime, and piperacillin, and can arguably be justified for cloxacillin as well for laboratory practice purposes. Maintenance of 37°C during high-centrifugal UF may lead to overestimation, particularly for unbound flucloxacillin.
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Affiliation(s)
- Gustaf Beijer
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet; and
- Medical Diagnostics Karolinska, Medical Unit of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Leona Clarin
- Medical Diagnostics Karolinska, Medical Unit of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Östervall
- Medical Diagnostics Karolinska, Medical Unit of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Victoria Barclay
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet; and
- Medical Diagnostics Karolinska, Medical Unit of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Eliasson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet; and
- Medical Diagnostics Karolinska, Medical Unit of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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Pajot O, Lakhal K, Lambert J, Gros A, Bruel C, Boulain T, Garot D, Das V, Timsit JF, Cerf C, Souweine B, Chaffaut C, Mentec H, Zahar JR, Mira JP, Jullien V. Empirical Antibiotic Therapy for Gram-Negative Bacilli Ventilator-Associated Pneumonia: Observational Study and Pharmacodynamic Assessment. Antibiotics (Basel) 2022; 11:antibiotics11111664. [PMID: 36421308 PMCID: PMC9686941 DOI: 10.3390/antibiotics11111664] [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: 10/13/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Strong evidence suggests a correlation between pharmacodynamics (PD) index and antibiotic efficacy while dose adjustment should be considered in critically ill patients due to modified pharmacokinetic (PK) parameters and/or higher minimum inhibitory concentrations (MICs). This study aimed to assess pharmacodynamic (PD) target attainment considering both antibiotics serum concentrations and measured MICs in these patients. Method: A multicentric prospective open-label trial conducted in 11 French ICUs involved patients with Gram-negative bacilli (GNB) ventilator-associated pneumonia (VAP) confirmed by quantitative cultures. Results: We included 117 patients. Causative GNBs were P. aeruginosa (40%), Enterobacter spp. (23%), E. coli (20%), and Klebsiella spp. (16%). Hence, 117 (100%) patients received β-lactams, 65 (58%) aminoglycosides, and two (1.5%) fluoroquinolones. For β-lactams, 83% of the patients achieved a Cmin/MIC > 1 and 70% had a Cmin/MIC > 4. In the case of high creatinine clearance (CrCL > 100 mL/min/1.73 m2), 70.4% of the patients achieved a Cmin/MIC ratio > 1 versus 91% otherwise (p = 0.041), and 52% achieved a Cmin/MIC ratio > 4 versus 81% (p = 0.018). For aminoglycosides, 94% of the patients had a Cmax/MIC ratio > 8. Neither β-lactams nor aminoglycosides PK/PD parameters were associated clinical outcomes, but our data suggest a correlation between β-lactams Cmin/MIC and microbiological success. Conclusion: In our ICU patients treated for GNB VAP, using recommended antibiotic dosage led in most cases to PK/PD targets attainment for aminoglycosides and β-lactams. High creatinine clearance should encourage clinicians to focus on PK/PD issues.
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Affiliation(s)
- Olivier Pajot
- Victor Dupouy Hospital, Intensive Care Unit, F-95100 Argenteuil, France
- Correspondence: ; Tel.: +33-134232455
| | - Karim Lakhal
- Service d’Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, F-44093 Nantes, France
| | - Jérome Lambert
- Department of Biostatistics and Medical Information, APHP, Saint-Louis Hospital, F-75010 Paris, France
| | - Antoine Gros
- Medical-Surgical Intensive Care Unit, André Mignot Hospital, F-78150 Le Chesnay, France
| | - Cédric Bruel
- Medical and Surgical Intensive Care Unit, Paris Saint-Joseph Hospital Network, F-75014 Paris, France
| | - Thierry Boulain
- Intensive Care Unit, Orleans Regional Hospital, 14 Avenue de L’Hôpital CS 86709, CEDEX 02, F-45067 Orléans, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, F-37000 Tours, France
| | - Vincent Das
- Service de Médecine Intensive Réanimation, Centre Hospitalier Intercommunal André Grégoire, F-93100 Montreuil, France
| | - Jean François Timsit
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit (MI2), F-75018 Paris, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, F-92150 Suresnes, France
| | - Bertrand Souweine
- CHU Clermont-Ferrand, Service de Réanimation Médicale, F-63000 Clermont-Ferrand, France
| | - Cendrine Chaffaut
- Department of Biostatistics and Medical Information, APHP, Saint-Louis Hospital, F-75010 Paris, France
| | - Hervé Mentec
- Victor Dupouy Hospital, Intensive Care Unit, F-95100 Argenteuil, France
| | - Jean Ralph Zahar
- AP-HP, Hôpital Avicenne, Prévention du Risque Infectieux, GH Paris Seine Saint-Denis, F-93000 Bobigny, France
| | - Jean Paul Mira
- Department of Medical Intensive Care, Cochin University Hospital, F-75014 Paris, France
| | - Vincent Jullien
- Pharmacology Unit, University Sorbonne Paris Nord, Groupe Hospitalier Paris Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, F-93140 Bondy, France
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9
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Bolcato L, Thiebaut-Bertrand A, Stanke-Labesque F, Gautier-Veyret E. Variability of Isavuconazole Trough Concentrations during Longitudinal Therapeutic Drug Monitoring. J Clin Med 2022; 11:jcm11195756. [PMID: 36233624 PMCID: PMC9573296 DOI: 10.3390/jcm11195756] [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: 08/10/2022] [Revised: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Isavuconazole (ISA), a triazole antifungal agent, is licensed for the treatment of invasive aspergillosis and mucormycosis. Therapeutic drug monitoring (TDM) is a cornerstone of treatment efficacy for triazole antifungals due to their pharmacokinetic variability, except for ISA, for which the utility of TDM is still uncertain. We performed a retrospective study that aimed to assess the inter- and intra-individual variability of ISA trough concentrations (Cmin) and to identify the determinants involved in such variability. ISA Cmin measured in adult patients at the Grenoble Alpes University Hospital between January 2018 and August 2020 were retrospectively analyzed. In total, 304 ISA Cmin for 33 patients were analyzed. The median ISA Cmin was 2.8 [25th−75th percentiles: 2.0−3.7] mg/L. The inter- and intra-individual variability was 41.5% and 30.7%, respectively. Multivariate analysis showed independent covariate effects of dose (β = 0.004 ± 3.56 × 10−4, p < 0.001), Aspartate aminotransférase (ASAT) (β = 0.002 ± 5.41 × 10−4, p = 0.002), and protein levels (β = 0.022 ± 0.004, p < 0.001) on ISA Cmin, whereas C reactive protein levels did not show any association. This study, conducted on a large number of ISA Cmin, shows that ISA exposure exhibits variability, explained in part by the ISA dose, and ASAT and protein levels.
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Affiliation(s)
- Léa Bolcato
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble Alpes University Hospital, 38000 Grenoble, France
| | - Anne Thiebaut-Bertrand
- Clinical Hematology Department, Grenoble Alpes University Hospital, 38000 Grenoble, France
| | - Françoise Stanke-Labesque
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble Alpes University Hospital, 38000 Grenoble, France
- Faculty of Medicine, University Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Elodie Gautier-Veyret
- Laboratory of Pharmacology, Pharmacogenetics and Toxicology, Grenoble Alpes University Hospital, 38000 Grenoble, France
- Faculty of Medicine, University Grenoble Alpes, Inserm, U1300, CHU Grenoble Alpes, 38000 Grenoble, France
- Correspondence: ; Tel.: +33-476-765492; Fax: +33-476-764664
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10
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Jongmans C, Muller AE, Van Den Broek P, Cruz De Almeida BDM, Van Den Berg C, Van Oldenrijk J, Bos PK, Koch BCP. An Overview of the Protein Binding of Cephalosporins in Human Body Fluids: A Systematic Review. Front Pharmacol 2022; 13:900551. [PMID: 35837288 PMCID: PMC9274189 DOI: 10.3389/fphar.2022.900551] [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: 03/20/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Protein binding can diminish the pharmacological effect of beta-lactam antibiotics. Only the free fraction has an antibacterial effect. The aim of this systematic literature review was to give an overview of the current knowledge of protein binding of cephalosporins in human body fluids as well as to describe patient characteristics influencing the level of protein binding. Method: A systematic literature search was performed in Embase, Medline ALL, Web of Science Core Collection and the Cochrane Central Register of Controlled Trials with the following search terms: “protein binding,” “beta-lactam antibiotic,” and “body fluid.” Only studies were included where protein binding was measured in humans in vivo. Results: The majority of studies reporting protein binding were performed in serum or plasma. Other fluids included pericardial fluid, blister fluid, bronchial secretion, pleural exudate, wound exudate, cerebrospinal fluid, dialysate, and peritoneal fluid. Protein binding differs between diverse cephalosporins and between different patient categories. For cefazolin, ceftriaxone, cefpiramide, and cefonicid a non-linear pattern in protein binding in serum or plasma was described. Several patient characteristics were associated with low serum albumin concentrations and were found to have lower protein binding compared to healthy volunteers. This was for critically ill patients, dialysis patients, and patients undergoing cardiopulmonary bypass during surgery. While mean/median percentages of protein binding are lower in these patient groups, individual values may vary considerably. Age is not likely to influence protein binding by itself, however limited data suggest that lower protein binding in newborns. Obesity was not correlated with altered protein binding. Discussion/Conclusion: Conclusions on protein binding in other body fluids than blood cannot be drawn due to the scarcity of data. In serum and plasma, there is a large variability in protein binding per cephalosporin and between different categories of patients. Several characteristics were identified which lead to a lower protein binding. The finding that some of the cephalosporins display a non-linear pattern of protein binding makes it even more difficult to predict the unbound concentrations in individual patients. Taken all these factors, it is recommended to measure unbound concentrations to optimize antibiotic exposure in individual patients. Systematic Review Registration: PROSPERO, identifier (CRD42021252776).
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Affiliation(s)
- C. Jongmans
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - A. E. Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, Netherlands
| | - P. Van Den Broek
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - C. Van Den Berg
- Department of Orthopedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - J. Van Oldenrijk
- Department of Orthopedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - P. K. Bos
- Department of Orthopedics and Sports Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - B. C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- *Correspondence: B. C. P. Koch,
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11
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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12
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Soeorg H, Sverrisdóttir E, Andersen M, Lund TM, Sessa M. The PHARMACOM-EPI Framework for Integrating Pharmacometric Modelling Into Pharmacoepidemiological Research Using Real-World Data: Application to Assess Death Associated With Valproate. Clin Pharmacol Ther 2021; 111:840-856. [PMID: 34860420 DOI: 10.1002/cpt.2502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/17/2021] [Indexed: 01/14/2023]
Abstract
In pharmacoepidemiology, it is usually expected that the observed association should be directly or indirectly related to the pharmacological effects of the drug/s under investigation. Pharmacological effects are, in turn, strongly connected to the pharmacokinetic and pharmacodynamic properties of a drug, which can be characterized and investigated using pharmacometric models. Recently, the use of pharmacometrics has been proposed to provide pharmacological substantiation of pharmacoepidemiological findings derived from real-world data. However, validated frameworks suggesting how to combine these two disciplines for the aforementioned purpose are missing. Therefore, we propose PHARMACOM-EPI, a framework that provides a structured approach on how to identify, characterize, and apply pharmacometric models with practical details on how to choose software, format dataset, handle missing covariates/dosing data, how to perform the external evaluation of pharmacometric models in real-world data, and how to provide pharmacological substantiation of pharmacoepidemiological findings. PHARMACOM-EPI was tested in a proof-of-concept study to pharmacologically substantiate death associated with valproate use in the Danish population aged ≥ 65 years. Pharmacological substantiation of death during a follow-up period of 1 year showed that in all individuals who died (n = 169) individual predictions were within the subtherapeutic range compared with 52.8% of those who did not die (n = 1,084). Of individuals who died, 66.3% (n = 112) had a cause of death possibly related to valproate and 33.7% (n = 57) with well-defined cause of death unlikely related to valproate. This proof-of-concept study showed that PHARMACOM-EPI was able to provide pharmacological substantiation for death associated with valproate use in the study population.
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Affiliation(s)
- Hiie Soeorg
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark.,Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Eva Sverrisdóttir
- Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Morten Andersen
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark
| | - Trine Meldgaard Lund
- Department of Drug Design and Pharmacology, Pharmacometrics Research Group, University of Copenhagen, Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, Pharmacovigilance Research Center, University of Copenhagen, Copenhagen, Denmark
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Optimal loading dose of meropenem before continuous infusion in critically ill patients: a simulation study. Sci Rep 2021; 11:17211. [PMID: 34446780 PMCID: PMC8390684 DOI: 10.1038/s41598-021-96744-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/05/2021] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate optimal loading doses prior to continuous infusion of meropenem in critically ill patients. A previously published and successfully evaluated pharmacokinetic model of critically ill patients was used for stochastic simulations of virtual patients. Maintenance doses administered as continuous infusion of 1.5–6 g/24 h with preceding loading doses (administered as 30 min infusion) of 0.15–2 g were investigated. In addition to the examination of the influence of individual covariates, a best-case and worst-case scenario were simulated. Dosing regimens were considered adequate if the 5th percentile of the concentration–time profile did not drop at any time below four times the S/I breakpoint (= 2 mg/L) of Pseudomonas aeruginosa according to the EUCAST definition. Low albumin concentrations, high body weight and high creatinine clearances increased the required loading dose. A maximum loading dose of 0.33 g resulted in sufficient plasma concentrations when only one covariate showed extreme values. If all three covariates showed extreme values (= worst-case scenario), a loading dose of 0.5 g was necessary. Higher loading doses did not lead to further improvements of target attainment. We recommend the administration of a loading dose of 0.5 g meropenem over 30 min immediately followed by continuous infusion.
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14
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Hosmann A, Ritscher L, Burgmann H, Al Jalali V, Wulkersdorfer B, Wölfl-Duchek M, Sanz Codina M, Jäger W, Poschner S, Plöchl W, Reinprecht A, Rössler K, Gruber A, Zeitlinger M. Meropenem concentrations in brain tissue of neurointensive care patients exceed CSF levels. J Antimicrob Chemother 2021; 76:2914-2922. [PMID: 34392352 DOI: 10.1093/jac/dkab286] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inadequate antibiotic exposure in cerebral infections might have detrimental effects on clinical outcome. Commonly, antibiotic concentrations within the CSF were used to estimate cerebral target levels. However, the actual pharmacological active unbound drug concentration beyond the blood-brain barrier is unknown. OBJECTIVES To compare meropenem concentrations in blood, CSF and cerebral microdialysate of neurointensive care patients. PATIENTS AND METHODS In 12 patients suffering subarachnoid haemorrhage, 2000 mg of meropenem was administered every 8 h due to an extracerebral infection. Meropenem concentrations were determined in blood, CSF and cerebral microdialysate at steady state (n = 11) and following single-dose administration (n = 5). RESULTS At steady state, the free AUC0-8 was 233.2 ± 42.7 mg·h/L in plasma, 7.8 ± 1.9 mg·h/L in CSF and 26.6 ± 14.0 mg·h/L in brain tissue. The brain tissue penetration ratio (AUCbrain/AUCplasma) was 0.11 ± 0.06, which was more than 3 times higher than in CSF (0.03 ± 0.01), resulting in an AUCCSF/AUCbrain ratio of 0.41 ± 0.16 at steady state. After single-dose administration similar proportions were achieved (AUCbrain/AUCplasma = 0.09 ± 0.08; AUCCSF/AUCplasma = 0.02 ± 0.00). Brain tissue concentrations correlated well with CSF concentrations (R = 0.74, P < 0.001), but only moderately with plasma concentrations (R = 0.51, P < 0.001). Bactericidal thresholds were achieved in both plasma and brain tissue for MIC values ≤16 mg/L. In CSF, bactericidal effects were only reached for MIC values ≤1 mg/L. CONCLUSIONS Meropenem achieves sufficient bactericidal concentrations for the most common bacterial strains of cerebral infections in both plasma and brain tissue, even in non-inflamed brain tissue. CSF concentrations would highly underestimate the target site activity of meropenem beyond the blood-brain barrier.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Lavinia Ritscher
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Heinz Burgmann
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Vienna, Austria
| | - Valentin Al Jalali
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Michael Wölfl-Duchek
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Maria Sanz Codina
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Walter Jäger
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Stefan Poschner
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Walter Plöchl
- Department of Anaesthesia, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Johannes Kepler University, Linz, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Measurement of Free Plasma Concentrations of Beta-Lactam Antibiotics: An Applicability Study in Intensive Care Unit Patients: Erratum. Ther Drug Monit 2021; 43:446. [PMID: 33973968 DOI: 10.1097/ftd.0000000000000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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