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Bertram R, Naumann HT, Bartsch V, Hitzl W, Kinzig M, Haarmeyer GS, Baumgärtel M, Geise A, Muschner D, Nentwich J, John S, Sörgel F, Steinmann J, Höhl R. Clinical and demographic factors affecting trough levels of isavuconazole in critically ill patients with or without COVID-19. Mycoses 2023; 66:1071-1078. [PMID: 37700457 DOI: 10.1111/myc.13653] [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: 06/09/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The broad-spectrum antifungal isavuconazole is administered to treat invasive aspergillosis and mucormycosis. OBJECTIVES Isavuconazole plasma concentrations in critically ill ICU patients with or without COVID-19 and invasive fungal infection were determined, and factors for sub-therapeutic drug levels (<1 μg/mL) were evaluated. PATIENTS AND METHODS Isavuconazole plasma levels were measured as part of therapeutic drug monitoring (TDM) in ICUs of a tertiary hospital. Concentrations determined 20-28 h after previous dosing were defined as trough (Cmin ) levels. A total of 160 Cmin levels from 62 patients with invasive fungal infections were analysed, 30 of which suffering from COVID-19. Patient characteristics included into univariable and multivariable analyses were gender, age, COVID-19 status, body mass index (BMI), sepsis-related organ failure (SOFA) score, renal replacement therapy (RRT) and extracorporeal membrane oxygenation (ECMO) requirement. RESULTS The mean Cmin of isavuconazole in all patients was 1.64 μg/mL (interquartile range 0.83-2.24 μg/mL, total range 0.24-5.67 μg/mL). In total, 34.4% of the Cmin values (corresponding to 46.8% of patients) were below a threshold concentration of 1 μg/mL. Drug concentrations between patients with or without COVID-19 did not differ (p = .43). In contrast, levels were significantly lower in patients with female sex (p = .0007), age ≤ 65 years (p = .002), BMI > 25 (p = .006), SOFA score > 12 (p = .026), RRT (p = .017) and ECMO requirement (p = .001). CONCLUSIONS Isavuconazole plasma levels can be negatively affected by patients' risk factors, supportive renal replacement and ECMO therapy. Future prospective studies analysing the relevance of isavuconazole drug levels in ICU patient outcome are urgently needed.
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Affiliation(s)
- Ralph Bertram
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Hans-Theodor Naumann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Vanessa Bartsch
- Study Program in Human Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Wolfgang Hitzl
- Department of Research and Innovation Management, Biostatistics and publication of clinical trial studies, Paracelsus Medical University, Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University, Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Martina Kinzig
- Institute for Biomedical and Pharmaceutical Research, Nuremberg-Heroldsberg, Germany
| | - Golo-Sung Haarmeyer
- Department for Respiratory Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Matthias Baumgärtel
- Department for Respiratory Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Arnim Geise
- Department for Respiratory Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Dorothea Muschner
- Department for Respiratory Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Jens Nentwich
- Department of Cardiology, Intensive Care Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Stefan John
- Department of Cardiology, Intensive Care Medicine, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Fritz Sörgel
- Institute for Biomedical and Pharmaceutical Research, Nuremberg-Heroldsberg, Germany
- Institute of Pharmacology, West German Heart and Vascular Centre, University of Duisburg-Essen, Essen, Germany
| | - Joerg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Rainer Höhl
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
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Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
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Caputo R, Rozycki A, McClain M, Sobhanie MM, Coe K, Colburn N, Wardlow L. Clinical Outcomes with Ertapenem for Pneumonia in Obese versus Nonobese Patients. Antimicrob Agents Chemother 2022; 66:e0132521. [PMID: 34694873 PMCID: PMC8765228 DOI: 10.1128/aac.01325-21] [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: 07/01/2021] [Accepted: 10/16/2021] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to compare the rate of pneumonia resolution in obese (body mass index [BMI], ≥30 kg/m2) and nonobese (BMI, <30 kg/m2) patients treated with 1 gram ertapenem daily. In this retrospective cohort study, we evaluated patients treated at The Ohio State University Wexner Medical Center between 1 January 2015 and 31 August 2020. Patients were included if they were between 18 and 89 years old and received ertapenem for at least 48 hours for pneumonia treatment. Patients were excluded if they were pregnant, were incarcerated, had renal impairment, received antibiotics with Gram-negative activity for a significant period prior to or in addition to ertapenem, and had other concomitant deep-seated infections. The primary outcome of clinical resolution was defined as meeting any of the following three criteria in order of evaluations: discontinuation of antibiotics by day 8 of therapy, afebrile while on ertapenem in addition to a decrease in white blood cell count, or improvement on chest radiograph at day 7 of therapy. A multivariable logistic regression analysis was performed to examine the association between obesity and clinical resolution, while adjusting for proven confounders. There were 76 nonobese and 65 obese patients included. The median patient BMI was 23.7 kg/m2 (21.0 to 26.9) and 35.0 kg/m2 (32.8 to 39.8) for the nonobese and obese cohorts, respectively. Clinical resolution was achieved in 78% (59/76) of nonobese and 75% (49/65) of obese patients (P = 0.75) without an observed difference in the regression model. Outcomes were similar in obese and nonobese patients treated with 1 gram of ertapenem daily for pneumonia.
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Affiliation(s)
- Ryan Caputo
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alan Rozycki
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan McClain
- College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | - M. Mahdee Sobhanie
- Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kelci Coe
- Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nora Colburn
- Department of Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lynn Wardlow
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Demiroz D, Colak YZ, Iclek SK, Erdogan MA, Yagci NA, Durmus M, Gulhas N. Does Rocuroinum Dose Adjusted Due to Lean Body Weight Provide Adequate Intubation Conditions?: A Prospective Observational Study. Int J Clin Pract 2022; 2022:6840960. [PMID: 36263238 PMCID: PMC9556254 DOI: 10.1155/2022/6840960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/15/2022] [Indexed: 12/04/2022] Open
Abstract
METHODS This is a prospective, observational study. Patients between the ages of 18 and 65 with BMI of 18.5-34.9, who are expected to be under general anesthesia for less than 6 hours, were divided into 3 groups according to their BMI (Group 1 BMI = 18.5-24.9, Group 2 BMI = 25-29.9, Group 3 BMI = 30-34.9). These groups were randomly divided into 2 subgroups: Groups LBW; 1 LBW, 2 LBW, and 3 LBW were given rocuronium intubation dosages based on their LBW while control groups; 1K, 2K, and 3K were given 0.6 mg/kg rocuronium according to their total body weight. The data on the duration of action of rocuronium and its effects on the endotracheal intubation conditions were evaluated. RESULTS In Group 1, T1 time was found to be significantly longer (p=0.001). Intubation score and the use of additional rocuronium dose were found to be significantly higher in Group 1 LBW than in Group 1K (p=0.001). In Group 1, an additional rocuronium dose was needed to achieve optimal intubation conditions for subgroup 1 LBW. Rocuronium duration of action was found to be significantly longer in control groups 2 and 3, that received TBW-based dosage. CONCLUSION In adult patients with a BMI of 18.5 and 24.9 BMI, we report optimal intubation conditions with the LBW-adjusted rocuronium dosage. This trial is registered with NCT05476952.
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Affiliation(s)
- Duygu Demiroz
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
| | - Yusuf Ziya Colak
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
| | - Sumeyye Koc Iclek
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
| | - Mehmet Ali Erdogan
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
| | - Neslihan Altunkaya Yagci
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
| | - Mahmut Durmus
- Bezmialem Foundation University Medical Faculty Hospital, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Nurcın Gulhas
- Inonu University, School of Medicine, Department of Anesthesiology and Reanimation, Malatya, Turkey
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Wang P, Zhang Q, Feng M, Sun T, Yang J, Zhang X. Population Pharmacokinetics of Polymyxin B in Obese Patients for Resistant Gram-Negative Infections. Front Pharmacol 2021; 12:754844. [PMID: 34880755 PMCID: PMC8645997 DOI: 10.3389/fphar.2021.754844] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/08/2021] [Indexed: 01/31/2023] Open
Abstract
Polymyxin B is an effective but potentially nephrotoxic antibiotic that is commonly used to treat resistant Gram-negative infections. As a weight-based dosing drug, obese patients may be at a high risk of nephrotoxicity. However, the pharmacokinetics and dosing recommendations for this population are currently lacking. This study aimed to describe the polymyxin B population pharmacokinetics and to evaluate pharmacokinetic/pharmacodynamics (PK/PD) target attainment for obese patients. This study included 26 patients (body mass index, BMI >30) who received polymyxin B for ≥3 days. The total body weight (TBW) ranged from 75 to 125 kg, and the BMI ranged from 30.04 to 40.35. A two-compartment model adequately described the data using Phoenix NLME software. Monte Carlo simulation was used to assess polymyxin B exposure and the probability of target attainment (PTA). As a result, body weight had no significant effect on polymyxin B pharmacokinetics. According to model-based simulation, adjusted body weight (ABW)-based regimens had a high probability of achieving optimal exposure with minimal toxicity risk by comparing TBW and ideal body weight (IBW)-based regimens. The fixed dose of 125 mg or 150 mg q12h had a high toxicity risk. PTA results showed that TBW, IBW, and ABW-based regimens had similar PTA values. Therefore, for obese patients, ABW-based regimens but with a daily dose <250 mg have a high likelihood of achieving an AUCss,24h of 50-100 mg h/L and attaining PK/PD targets with the MIC ≤0.5 mg/L.
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Affiliation(s)
- Peile Wang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Min Feng
- Department of ICU, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- Department of General ICU, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Yang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xiaojian Zhang
- Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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Jang SM, Shaw AR, Mueller BA. Size Matters: The Influence of Patient Size on Antibiotics Exposure Profiles in Critically Ill Patients on Continuous Renal Replacement Therapy. Antibiotics (Basel) 2021; 10:antibiotics10111390. [PMID: 34827327 PMCID: PMC8615189 DOI: 10.3390/antibiotics10111390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/20/2022] Open
Abstract
(1) Purpose of this study: To determine whether patient weight influences the probability of target attainment (PTA) over 72 h of initial therapy with beta-lactam (cefepime, ceftazidime, piperacillin/tazobactam) and carbapenem (imipenem, ertapenem, meropenem) antibiotics in the critical care setting. This is the first paper to address the question of whether patient size affects antibiotic PTA in the ICU. (2) Methods: We performed a post hoc analysis of Monte Carlo simulations conducted in virtual critically ill patients receiving antibiotics and continuous renal replacement therapy. The PTA was calculated for each antibiotic on the following pharmacodynamic (PD) targets: (a) were above the target organism’s minimum inhibitory concentration (≥%fT≥1×MIC), (b) were above four times the MIC (≥%fT≥4×MIC), and (c) were always above the MIC (≥100%fT≥MIC) for the first 72 h of antibiotic therapy. The PTA was analyzed in patient weight quartiles [Q1 (lightest)-Q4 (heaviest)]. Optimal doses were defined as the lowest dose achieving ≥90% PTA. (3) Results: The PTA for fT≥1×MIC led to similarly high rates regardless of weight quartiles. Yet, patient weight influenced the PTA for higher PD targets (100%fT≥MIC and fT≥4×MIC) with commonly used beta-lactams and carbapenems. Reaching the optimal PTA was more difficult with a PD target of 100%fT≥MIC compared to fT≥4×MIC. (4) Conclusions: The Monte Carlo simulations showed patients in lower weight quartiles tended to achieve higher antibiotic pharmacodynamic target attainment compared to heavier patients.
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Affiliation(s)
- Soo-Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA 92350, USA
- Correspondence:
| | - Alex R. Shaw
- Medical Strategist, Ironwood Pharmaceuticals, Boston, MA 02110, USA;
| | - Bruce A. Mueller
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI 48109, USA;
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Pediatric obesity and perioperative medicine. Curr Opin Anaesthesiol 2021; 34:299-305. [PMID: 33935177 DOI: 10.1097/aco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action. RECENT FINDINGS Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur. SUMMARY Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.
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McCoy JA, Elovitz MA, Alby K, Koelper NC, Nissim I, Levine LD. Association of Obesity With Maternal and Cord Blood Penicillin Levels in Women With Group B Streptococcus Colonization. Obstet Gynecol 2020; 136:756-764. [PMID: 32925625 PMCID: PMC11106779 DOI: 10.1097/aog.0000000000004020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare maternal and cord blood penicillin concentrations in women with and without obesity who are receiving intrapartum group B streptococcus (GBS) prophylaxis. METHODS We performed a prospective cohort study of term women receiving intrapartum penicillin prophylaxis for GBS colonization (determined by antenatal rectovaginal culture). The following outcomes were compared between obese (body mass index [BMI] 35 or higher at delivery) and nonobese (BMI less than 30 at delivery) groups: penicillin concentration in maternal blood (after two penicillin doses) and umbilical cord blood, GBS rectovaginal colonization status on admission and after two completed doses, and neonatal GBS colonization (using a postnatal ear swab). Fifty-five women were needed to detect a 0.75 SD difference in cord blood penicillin concentrations. RESULTS Fifty-five women were enrolled and had all specimens collected; 49 had complete data for analysis (obese n=25, nonobese n=24). There was no difference in the median maternal penicillin concentration between groups (obese 4.2 micrograms/mL vs nonobese 4.0 micrograms/mL, P=.58). There was, however, a 60% lower median cord blood penicillin concentration in the obese compared with the nonobese group (2.7 micrograms/mL vs 6.7 micrograms/mL, respectively, P<.01), with no significant difference in time from last penicillin dose to delivery (obese 2.9 hours vs nonobese 1.7 hours, P=.07). The difference in cord blood concentrations remained significant after adjustment for nulliparity, hypertensive disorders, and time from last penicillin dose to delivery. Only 59.6% of women tested positive for GBS by rectovaginal culture on admission (obese 60.9% vs nonobese 58.3%, P=.86). CONCLUSION The median cord blood penicillin concentration was 60% lower in neonates born to women with obesity compared with those born to women without obesity. However, all concentrations exceeded the minimum inhibitory concentration. Maternal penicillin levels were not significantly different between groups. More than 40% of women who previously tested positive for GBS by antenatal culture tested negative for GBS on admission for delivery.
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Affiliation(s)
- Jennifer A McCoy
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, and the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, the Division of Genetics and Metabolism, Children's Hospital of Philadelphia, and the Department of Pediatrics, Biochemistry, and Biophysics, University of Pennsylvania, Philadelphia, Pennsylvania
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Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
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Narayanan N, Adams CD, Kubiak DW, Cheng S, Stoianovici R, Kagan L, Brunetti L. Evaluation of treatment options for methicillin-resistant Staphylococcus aureus infections in the obese patient. Infect Drug Resist 2019; 12:877-891. [PMID: 31114267 PMCID: PMC6490236 DOI: 10.2147/idr.s196264] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/12/2019] [Indexed: 12/30/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major cause of infection in both the hospital and community setting. Obesity is a risk factor for infection, and the prevalence of this disease has reached epidemic proportions worldwide. Treatment of infections in this special population is a challenge given the lack of data on the optimal antibiotic choice and dosing strategies, particularly for treatment of MRSA infections. Obesity is associated with various physiological changes that may lead to altered pharmacokinetic parameters. These changes include altered drug biodistribution, elimination, and absorption. This review provides clinicians with a summary of the literature pertaining to the pharmacokinetic and pharmacodynamic considerations when selecting antibiotic therapy for the treatment of MRSA infections in obese patients.
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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, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Christopher D Adams
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | - Serena Cheng
- Department of Pharmacy, VA San Diego Healthcare System, San Diego, CA, USA
| | - Robyn Stoianovici
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Leonid Kagan
- Department of Pharmacy Practice, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
- Department of Pharmaceutics, 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
- Department of Pharmaceutics, Rutgers University, Ernest Mario School of Pharmacy, Piscataway, NJ, USA
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A Perfect Storm: Increased Colonization and Failure of Vaccination Leads to Severe Secondary Bacterial Infection in Influenza Virus-Infected Obese Mice. mBio 2017; 8:mBio.00889-17. [PMID: 28928207 PMCID: PMC5605935 DOI: 10.1128/mbio.00889-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Obesity is a risk factor for developing severe disease following influenza virus infection; however, the comorbidity of obesity and secondary bacterial infection, a serious complication of influenza virus infections, is unknown. To fill this gap in knowledge, lean and obese C57BL/6 mice were infected with a nonlethal dose of influenza virus followed by a nonlethal dose of Streptococcus pneumoniae Strikingly, not only did significantly enhanced death occur in obese coinfected mice compared to lean controls, but also high mortality was seen irrespective of influenza virus strain, bacterial strain, or timing of coinfection. This result was unexpected, given that most influenza virus strains, especially seasonal human A and B viruses, are nonlethal in this model. Both viral and bacterial titers were increased in the upper respiratory tract and lungs of obese animals as early as days 1 and 2 post-bacterial infection, leading to a significant decrease in lung function. This increased bacterial load correlated with extensive cellular damage and upregulation of platelet-activating factor receptor, a host receptor central to pneumococcal invasion. Importantly, while vaccination of obese mice against either influenza virus or pneumococcus failed to confer protection, antibiotic treatment was able to resolve secondary bacterial infection-associated mortality. Overall, secondary bacterial pneumonia could be a widespread, unaddressed public health problem in an increasingly obese population.IMPORTANCE Worldwide obesity rates have continued to increase. Obesity is associated with increased severity of influenza virus infection; however, very little is known about respiratory coinfections in this expanding, high-risk population. Our studies utilized a coinfection model to show that obesity increases mortality from secondary bacterial infection following influenza virus challenge through a "perfect storm" of host factors that lead to excessive viral and bacterial outgrowth. In addition, we found that vaccination of obese mice against either virus or bacteria failed to confer protection against coinfection, but antibiotic treatment did alleviate mortality. Combined, these results represent an understudied and imminent public health concern in a weighty portion of the global population.
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Abstract
Obesity is an important risk factor for both community-acquired pneumonia (CAP) and healthcare-associated pneumonia. In striking contrast, emerging data suggest that obesity is associated with more favorable outcome of pneumonia, a protective effect coined 'the obesity paradox'. Areas covered: The aim of the present review is to summarize the existing evidence on the outcome of pneumonia in obese patients and to discuss the mechanisms underpinning the association between obesity and pneumonia outcome. Several observational studies showed that obesity is associated with better outcome of CAP. In contrast, obesity represents a risk factor for adverse outcome in patients infected with pandemic influenza. Very limited data exist on the association between obesity and the outcome of healthcare-associated pneumonia. The pathophysiological mechanisms contributing to these paradoxical findings are unclear. Expert commentary: It is possible that residual confounding might partly explain the better outcome of pneumonia in obese patients. On the other hand, obesity might indeed offer a survival advantage in patients with acute diseases, including pneumonia. Clearly, larger and well-designed studies are needed to clarify the pathogenetic links between obesity and pneumonia outcome, which might represent novel therapeutic targets in the management of infectious diseases.
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Affiliation(s)
- Marianthi Papagianni
- a First Propedeutic Department of Internal Medicine, Medical School , Aristotle University of Thessaloniki, AHEPA Hospital , Thessaloniki , Greece
| | - Konstantinos Tziomalos
- a First Propedeutic Department of Internal Medicine, Medical School , Aristotle University of Thessaloniki, AHEPA Hospital , Thessaloniki , Greece
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Abstract
PURPOSE OF REVIEW Recent studies suggest that contemporary antibiotic dosing is unlikely to achieve best outcomes for critically ill patients because of extensive pharmacokinetic variability and altered pharmacodynamics. Dose adaptation is considered quite challenging because of unpredictable dose-exposure relationships. Consequently, individualization of antibiotic dosing has been advocated. Herein, we describe recent developments in the optimization of antibiotic dosing in the critically ill. RECENT FINDINGS Conventional doses of many antibiotics frequently result in sub or supratherapeutic exposures in the critically ill. Clinical studies continue to illustrate that dose-exposure relationships are highly variable in severely ill patients. Dose optimization based on pharmacokinetic/pharmacodynamic principles can effectively improve antibiotic exposure. Therapeutic drug monitoring (TDM) with adaptive feedback is likely to be the most robust approach to optimize dosing for individual patients. This more accurate approach to dosing is made possible with the user-friendly dosing software that is emerging. SUMMARY The scope of TDM is broadening from the traditional focus on prevention of toxicity, to include optimization of antibiotic exposure thereby improving patient outcomes. However, the evidence relating TDM practice with improved clinical outcome remains limited. Well designed, multicentre, randomized controlled studies are warranted.
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Boyd SE, Charani E, Lyons T, Frost G, Holmes AH. Information provision for antibacterial dosing in the obese patient: a sizeable absence? J Antimicrob Chemother 2016; 71:3588-3592. [PMID: 27538956 DOI: 10.1093/jac/dkw324] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 07/04/2016] [Accepted: 07/12/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Obesity is on course to overtake being underweight as a global disease burden. Obesity alters antibacterial pharmacokinetics (PK) and pharmacodynamics (PD). Historically, drug PK/PD parameters have not been studied in obese populations. This means dose recommendations risk being sub-therapeutic in a population at increased risk of infection. Suboptimal antibacterial prescribing is widely associated with treatment failure, worse clinical outcomes, unnecessary escalation to broad-spectrum therapy and the emergence of antimicrobial resistance (AMR). OBJECTIVES To analyse current information provided by pharmaceutical companies, for the most commonly prescribed antibacterial agents in the UK, for evidence of dosing guidance for obese adults. METHODS We analysed the manufacturers' Summary of Product Characteristics (SPC) for 42 of the most clinically important and frequently prescribed antibacterial agents dispensed across both primary and secondary care. The manufacturer's SPC was reviewed, and cross-referenced with the online British National Formulary, to assess dosing guidance for obese adults. RESULTS No advice was provided to guide dosing for obese adults in 35 (83%) of 42 of the most clinically important and frequently prescribed antibacterial agents in the UK. Seven (17%) antibacterial agents (tigecycline, vancomycin, daptomycin, amikacin, gentamicin, tobramycin and teicoplanin) provided variable levels of advice. CONCLUSIONS There is a paucity of advice and evidence in the UK to guide dosing common antibacterial agents in the obese. The literature on antibacterial PK/PD studies in obese populations remains scarce. In the face of the increasing risks of AMR combined with the global rise of obesity there is an urgent need to address this significant research gap.
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Affiliation(s)
- Sara Elizabeth Boyd
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK .,Imperial College Healthcare NHS Trust, London, UK
| | - Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Tracy Lyons
- Imperial College Healthcare NHS Trust, London, UK
| | - Gary Frost
- Department of Medicine, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - Alison Helen Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, London, UK
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15
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Pharmacokinetic/pharmacodynamic considerations for the optimization of antimicrobial delivery in the critically ill. Curr Opin Crit Care 2016; 21:412-20. [PMID: 26348420 DOI: 10.1097/mcc.0000000000000229] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are very commonly used drugs in the intensive care setting. Extensive research has been conducted in recent years to describe their pharmacokinetics/pharmacodynamics in order to maximize the pharmacological benefit and patient outcome. Translating these new findings into clinical practice is encouraged. RECENT FINDINGS This article will discuss mechanistic data on factors causing changes in antimicrobial pharmacokinetics in critically ill patients, such as the phenomena of augmented renal clearance as well as the effects of hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Failure to achieve clinical cure has been correlated with pharmacokinetics/pharmacodynamics target nonattainment, and a recent meta-analysis suggests an association between dosing strategies aimed at optimizing antimicrobial pharmacokinetics/pharmacodynamics with improvement in clinical cure and survival. Novel dosing strategies including therapeutic drug monitoring are also now being tested to address challenges in the optimization of antimicrobial pharmacokinetics/pharmacodynamics. SUMMARY Optimization of antimicrobial dosing in accordance with pharmacokinetics/pharmacodynamics targets can improve survival and clinical cure. Dosing regimens for critically ill patients should aim for pharmacokinetics/pharmacodynamics target attainment by utilizing altered dosing strategies including adaptive feedback using therapeutic drug monitoring.
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16
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Multicentre prospective cohort study of body mass index and postoperative complications following gastrointestinal surgery. Br J Surg 2016; 103:1157-72. [PMID: 27321766 PMCID: PMC4973675 DOI: 10.1002/bjs.10203] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/18/2016] [Accepted: 03/29/2016] [Indexed: 12/13/2022]
Abstract
Background There is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications. Methods This was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4-month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30-day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital-level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.). Results Of 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30-day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147). Conclusion Overweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.
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Montravers P, Blot S, Dimopoulos G, Eckmann C, Eggimann P, Guirao X, Paiva JA, Sganga G, De Waele J. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 2016; 42:1234-47. [PMID: 26984317 DOI: 10.1007/s00134-016-4307-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/04/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria. METHODS A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients. RESULTS Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation. CONCLUSIONS The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.
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Affiliation(s)
- P Montravers
- APHP, CHU Bichat-Claude Bernard, Département d'Anesthésie Réanimation, Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Peine, Germany
| | - P Eggimann
- Department of Intensive Care Medicine and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - X Guirao
- Department of Endocrine and Head and Neck Surgery, Corporació Sanitaria del Parc Tauli, University Hospital, Sabadell, Barcelona, Spain
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - G Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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18
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Tafelski S, Yi H, Ismaeel F, Krannich A, Spies C, Nachtigall I. Obesity in critically ill patients is associated with increased need of mechanical ventilation but not with mortality. J Infect Public Health 2016; 9:577-85. [PMID: 26754202 DOI: 10.1016/j.jiph.2015.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/24/2015] [Accepted: 12/11/2015] [Indexed: 10/22/2022] Open
Abstract
Worldwide incidence of obesity is increasing and impaired outcome in postoperative patients has been described. Antibiotic prescribing is complicated by different pharmacology in this population. This study evaluates mortality and morbidity of obese postoperative patients and explores possible relation to antibiotic therapy. Therefore, data obtained in a prospective study in 2009-2010 were analysed. Postoperative patients on 5 ICUs were included with >48h of ICU treatment and documented body-mass-index (BMI). Altogether 451 non-obese patients (BMI<30kg/m(2)) were compared with 130 obese patients including propensity score matching. There was significant heterogeneity of baseline characteristics. ICU-mortality was 7.5% in non-obese and 7.7% in obese patients (p>0.999), but 65.4% of obese patients required mechanical ventilation compared with only 53.2% of non-obese patients (p=0.016). These findings were validated in multivariate regression analyses (adjusted OR for ICU-mortality for obese patients 0.53, 95%-CI 0.188-1.321, p=0.197; adjusted OR for mechanical ventilation 1.841, 95%-CI 1.113-3.076, p=0.018). Results were confirmed by propensity score matching. Therapeutic drug monitoring for vancomycin (TDM) showed that underdosing and overdosing occurred more often in obese patients and sufficient TDM levels were less often achieved. In conclusion, obesity is associated with increased morbidity but ICU mortality is equal compared with a non-obese population. Pharmacological differences might explain observed differences in antibiotic therapy and in obese patients TDM might be especially of importance.
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Affiliation(s)
- Sascha Tafelski
- Department of Anaesthesiology and Intensive Care, Charité - Universitaetsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Hailong Yi
- Department of Anaesthesiology and Intensive Care, Charité - Universitaetsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Fakher Ismaeel
- Department of Gynaecology, Campus Virchow Clinic, Charité Medical University Berlin, Augustenburger Platz 1, Berlin 13353, Germany
| | - Alexander Krannich
- Department of Biostatistics, Clinical Research Unit, Berlin Institute of Health, Charité - University Medicine Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care, Charité - Universitaetsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Irit Nachtigall
- Department of Anaesthesiology and Intensive Care, Charité - Universitaetsmedizin Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany.
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19
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De Pascale G, Fortuna S, Tumbarello M, Cutuli SL, Vallecoccia M, Spanu T, Bello G, Montini L, Pennisi MA, Navarra P, Antonelli M. Linezolid plasma and intrapulmonary concentrations in critically ill obese patients with ventilator-associated pneumonia: intermittent vs continuous administration. Intensive Care Med 2014; 41:103-10. [PMID: 25413377 DOI: 10.1007/s00134-014-3550-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/05/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE Clinical application of an antibiotic's pharmacokinetic/pharmacodynamic (PK/PD) properties may improve the outcome of severe infections. No data are available on the use of linezolid (LNZ) continuous infusion in critically ill obese patients affected by ventilator-associated pneumonia (VAP). METHODS We conducted a prospective randomized controlled trial to compare LNZ concentrations in plasma and epithelial lining fluid (ELF), when administered by intermittent and continuous infusion (II, CI), in obese critically ill patients affected by VAP. RESULTS Twenty-two critically ill obese patients were enrolled. At the steady state, in the II group, mean ± SD total and unbound maximum-minimum concentrations (C max/C max,u - C min/Cmin,u) were 10 ± 3.7/6.8 ± 2.6 mg/L and 1.7 ± 1.1/1.2 ± 0.8 mg/L, respectively. In the CI group, the mean ± SD total and unbound plasma concentrations (C ss and C ss,u) were 6.2 ± 2.3 and 4.3 ± 1.6 mg/L, respectively. Within a minimum inhibitory concentration (MIC) range of 1-4 mg/L, the median (IQR) time LNZ plasma concentration persisted above MIC (% T > MIC) was significantly higher in the CI than the II group [100 (100-100) vs 100 (89-100), p = 0.05; 100 (100-100) vs 82 (54.8-98.8), p = 0.009; 100 (74.2-100) vs 33 (30.2-78.5), p = 0.005; respectively]. Pulmonary penetration (%) was higher in the CI group, as confirmed by a Monte Carlo simulation [98.8 (IQR 93.8-104.3) vs 87.1 (IQR 78.7-95.4); p < 0.001]. CONCLUSIONS In critically ill obese patients affected by VAP, LNZ CI may overcome the limits of standard administration but these advantages are less evident with difficult to treat pathogens (MIC = 4 mg/L). These data support the usefulness of LNZ continuous infusion, combined with therapeutic drug monitoring (TDM), in selected critically ill populations.
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Affiliation(s)
- Gennaro De Pascale
- Department of Intensive Care and Anesthesiology, Agostino Gemelli Hospital, Catholic University of the Sacred Heart, Rome, Italy,
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Evans JD, Udeani G, Cole P, Friedland HD. Ceftaroline fosamil for the treatment of acute bacterial skin and skin structure infections in obese patients. Postgrad Med 2014; 126:128-34. [PMID: 25295657 DOI: 10.3810/pgm.2014.09.2807] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Ceftaroline fosamil is a broad-spectrum antibiotic approved by the US Food and Drug Administration (FDA) for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) and community-acquired bacterial pneumonia. The Clinical Assessment Program and Teflaro Utilization Registry (CAPTURE) is a multicenter registry study of patients treated with ceftaroline fosamil in the United States for ABSSSI or community-acquired bacterial pneumonia. OBJECTIVE To describe the clinical effectiveness of ceftaroline fosamil in the treatment of ABSSSI in obese patients [body mass index (BMI) ≥ 30] compared with patients with a normal BMI (18.5 to ≤ 24.9). METHODS Data were collected at US study centers by randomly ordered chart review. RESULTS Data from 261 patients with a normal BMI and 690 patients with an obese BMI were collected. The percentage of males was higher in the normal BMI than in the obese category (58.2% and 49.0%, respectively). The mean and median ages at baseline were similar. Most patients (91%) were treated on a general hospital ward, and the mean and median lengths of stay were similar between the 2 groups (approximately 11 days and 7 days, respectively). A total of 73.2% of normal BMI patients and 77.5% of obese patients were discharged to home. Rates of diabetes mellitus were 26.4% in the normal BMI group and 55.1% in the obese group. Methicillin-resistant Staphylococcus aureus was isolated from 26.1% of normal BMI patients and 20.5% of obese patients (16.4% morbidly obese subset). Mean treatment duration for all patients was 5.9 days. Of patients with a normal BMI, 57.5% received ceftaroline fosamil as monotherapy as did 63.3% of obese patients. Clinical success was high in both the normal BMI (85.1%) and the obese (89.0%) groups. CONCLUSION Ceftaroline fosamil is an effective treatment option for obese patients with ABSSSI with a similar clinical success rate, mean and median length of stay, and discharge destination to home when compared with normal BMI patients.
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Affiliation(s)
- John D Evans
- Director of Pharmacy Services, CHRISTUS Spohn Hospital-Alice, Alice, TX.
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