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Dyer CJ, De Waele JJ, Roberts JA. Antibiotic dose optimisation in the critically ill: targets, evidence and future strategies. Curr Opin Crit Care 2024; 30:439-447. [PMID: 39150038 DOI: 10.1097/mcc.0000000000001187] [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: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the recent evidence for antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in enhancing patient outcomes in sepsis and septic shock. We also summarise the limitations of available data and describe future directions for research to support translation of antibiotic dose optimisation to the clinical setting. RECENT FINDINGS Sepsis and septic shock are associated with poor outcomes and require antibiotic dose optimisation, mostly due to significantly altered pharmacokinetics. Many studies, including some randomised controlled trials have been conducted to measure the clinical outcome effects of antibiotic dose optimisation interventions including use of therapeutic drug monitoring. Current data support antibiotic dose optimisation for the critically ill. Further investigation is required to evolve more timely and robust precision antibiotic dose optimisation approaches, and to clearly quantify whether any clinical and health-economic benefits support expanded use of this treatment intervention. SUMMARY Antibiotic dose optimisation appears to improve outcomes in critically ill patients with sepsis and septic shock, however further research is required to quantify the level of benefit and develop a stronger knowledge of the role of new technologies to facilitate optimised dosing.
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Affiliation(s)
- Christopher J Dyer
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital
- Dept of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jason A Roberts
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
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Wessel RJ, Rivera CG, Ausman SE, Martin N, Braga SA, Hagy NT, Moreland-Head LN, Abu Saleh OM, Gajic O, Jannetto PJ, Barreto EF. Use of the DMAIC Lean Six Sigma quality improvement framework to improve beta-lactam antibiotic adequacy in the critically ill. Int J Qual Health Care 2024; 36:mzae062. [PMID: 38955670 DOI: 10.1093/intqhc/mzae062] [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: 11/28/2023] [Revised: 04/12/2024] [Accepted: 07/01/2024] [Indexed: 07/04/2024] Open
Abstract
Beta-lactam antibiotics are widely used in the intensive care unit due to their favorable effectiveness and safety profiles. Beta-lactams given to patients with sepsis must be delivered as soon as possible after infection recognition (early), treat the suspected organism (appropriate), and be administered at a dose that eradicates the infection (adequate). Early and appropriate antibiotic delivery occurs in >90% of patients, but less than half of patients with sepsis achieve adequate antibiotic exposure. This project aimed to address this quality gap and improve beta-lactam adequacy using the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework. A multidisciplinary steering committee was formed, which completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention that included bundled education with the use of therapeutic drug monitoring (TDM; i.e. drug-level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill. The education and TDM intervention were deployed through a Plan, Do, Study, Act cycle. In the 3 months after "go-live," 54 episodes of beta-lactam TDM occurred in 41 unique intensive care unit patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. Ninety-four percent of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; P = .73). Application of the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.
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Affiliation(s)
- Rebecca J Wessel
- Strategy Department, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Christina G Rivera
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Sara E Ausman
- Department of Pharmacy, Mayo Clinic Health System, 733 W Clairemont Ave, Eau Claire, WI 54701, United States
| | - Nathaniel Martin
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Shienna A Braga
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Natalie T Hagy
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Lindsay N Moreland-Head
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN 46202, United States
| | - Omar M Abu Saleh
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
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Pai Mangalore R, Udy AA, Peel TN, Peleg AY, Ayton D. Implementation Strategies Addressing Stakeholder-Perceived Barriers and Enablers to the Establishment of a Beta-Lactam Antibiotic Therapeutic Drug Monitoring Program: A Qualitative Analysis. Ther Drug Monit 2024; 46:351-362. [PMID: 38018820 DOI: 10.1097/ftd.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of beta-lactam antibiotics (beta-lactams) is increasingly recommended for optimizing antibiotic exposure in intensive care patients with sepsis. However, limited data are available on the implementation of beta-lactam TDM in complex health care settings. Theory-based approaches were used to systematically explore barriers and enablers perceived by key stakeholders in the implementation of beta-lactam TDM in the intensive care unit. METHODS In this qualitative descriptive study, the authors interviewed key stakeholders (n = 40): infectious disease physicians, intensive care unit physicians, pharmacists, clinical leaders, scientists, and nurses. The data were thematically analyzed and coded using the theoretical domains framework, and the codes and themes were mapped to the relevant domains of the capability, opportunity, and motivation behavior-change wheel model. RESULTS Barriers included a lack of knowledge, experience, evidence, and confidence, which led to concerns about capability, lack of resources, and harm in straying from standard practice. Access to education and guidelines, on-site assays with short turnaround times, communication among teams, and workflow integration were identified as enablers. A focus on patient care, trust in colleagues, and endorsement by hospital leaders were strong motivators. Pharmacist and nursing stakeholder groups emerged as key targets in the implementation of strategies. CONCLUSIONS Using theory-based approaches, the authors identified the key barriers and enablers to establishing beta-lactam TDM. These data were used to identify strategies, policies, and key target groups for the implementation of interventions.
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Affiliation(s)
- Rekha Pai Mangalore
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Alexander Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and
| | - Trisha Nicole Peel
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anton Yariv Peleg
- Department of Infectious Diseases, The Alfred, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and
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Carland JE, Stojanova J, Lau C, Day RO, Marriott DJE. Crying Over Stark Differences: Resource Disparity and Therapeutic Drug Monitoring. Ther Drug Monit 2024; 46:415-416. [PMID: 38321597 DOI: 10.1097/ftd.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
| | - Jana Stojanova
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Cindy Lau
- Department of Pharmacy, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, NSW, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
- School of Medical Sciences, UNSW Sydney, NSW, Australia; and
| | - Deborah J E Marriott
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, UNSW Sydney, NSW, Australia
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Darlinghurst, NSW
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