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Troisi C, Cojutti PG, Rinaldi M, Laici C, Siniscalchi A, Viale P, Pea F. Measuring Creatinine Clearance Is the Most Accurate Way for Calculating the Proper Continuous Infusion Meropenem Dose for Empirical Treatment of Severe Gram-Negative Infections among Critically Ill Patients. Pharmaceutics 2023; 15:pharmaceutics15020551. [PMID: 36839872 PMCID: PMC9967919 DOI: 10.3390/pharmaceutics15020551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Assessment of glomerular filtration rate (GFR) is necessary for dose adjustments of beta-lactam that are excreted by the kidneys, such as meropenem. The aim of this study was to compare the daily dose of 24 h-continuous infusion (CI) meropenem when GFR was calculated by means of measured creatinine clearance (mCLCR) or estimated by the CKDEPI (eGFRCKDEPI), Cockcroft-Gault (eGFRCG), and MDRD (eGFRMDRD) equations. Adult critically ill patients who underwent therapeutic drug monitoring (TDM) for the assessment of 24 h-CI meropenem steady state concentration (Css) and for whom a 24 h-urine collection was performed were retrospectively enrolled. Meropenem clearance (CLM) was regressed against mCLCR, and meropenem daily dose was calculated based on the equation infusion rate = daily dose/CLM. eGFRCKDEPI, eGFRCG, and eGFRCKDEPI were regressed against mCLCR in order to estimate CLM. Forty-six patients who provided 133 meropenem Css were included. eGFRCKDEPI overestimated mCLCR up to 90 mL/min, then mCLCR was underestimated. eGFRCG and eGFRMDRD overestimated mCLCR across the entire range of GFR. In critically ill patients, dose adjustments of 24 h-CI meropenem should be based on mCLCR. Equations for estimation of GFR may lead to gross under/overestimates of meropenem dosages. TDM may be highly beneficial, especially for critically ill patients with augmented renal clearance.
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Affiliation(s)
- Carla Troisi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
| | - Pier Giorgio Cojutti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence:
| | - Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Cristiana Laici
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Antonio Siniscalchi
- Division of Anesthesiology, Department of Anesthesia and Intensive Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138 Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Kadralinova A, Bekniyazova AZ, Konkayeva ME, Yeltayeva AA, Konkayev AK. Case report: Successful experience using continuous infusion of meropenem in a geriatric patient with hip fracture complicated by sepsis. Front Med (Lausanne) 2023; 10:1148555. [PMID: 37181364 PMCID: PMC10174454 DOI: 10.3389/fmed.2023.1148555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
This article highlights a clinical case of successful treatment of a 79-year-old multimorbid patient with a hip fracture resulting from a household injury. On the first day, the patient's injury was complicated by infection and pneumonia. As a result, arterial hypotension, tachysystole, and respiratory failure progressed. With manifestations of sepsis, the patient was transferred to the intensive care unit. Surgical treatment in such a situation was contraindicated due to the high operational and anesthesiological risks, the unstable severe condition of the patient, as well as the presence of concomitant pathology in the form of coronary heart disease, obesity, and schizophrenia. According to the new sepsis management guideline, it was decided to use a continuous 24-h infusion of meropenem in addition to the complex treatment of sepsis. The use of continuous infusion of meropenem in this clinical situation may have caused the patient's clinical improvement, which increased her quality of life and decreased the length of ICU stay and total hospital stay, despite an unfavorable cumulative prognosis and a high risk of in-hospital mortality.
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Affiliation(s)
- Assiya Kadralinova
- Department of Anesthesiology and Intensive Care, Astana Medical University, Astana, Kazakhstan
- *Correspondence: Assiya Kadralinova,
| | - Assema Zh. Bekniyazova
- Department of Anesthesiology and Intensive Care, Astana Medical University, Astana, Kazakhstan
- Department of Anesthesiology and Intensive Care, National Scientific Center of Traumatology and Orthopedics named after Academician N.D. Batpenov, Astana, Kazakhstan
| | - Maiya E. Konkayeva
- Department of Anesthesiology and Intensive Care, Astana Medical University, Astana, Kazakhstan
| | - Aigerim A. Yeltayeva
- Department of Anesthesiology and Intensive Care, Astana Medical University, Astana, Kazakhstan
- Department of Anesthesiology and Intensive Care, National Scientific Center of Traumatology and Orthopedics named after Academician N.D. Batpenov, Astana, Kazakhstan
| | - Aidos K. Konkayev
- Department of Anesthesiology and Intensive Care, Astana Medical University, Astana, Kazakhstan
- Department of Anesthesiology and Intensive Care, National Scientific Center of Traumatology and Orthopedics named after Academician N.D. Batpenov, Astana, Kazakhstan
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Luxton TN, King N, Wälti C, Jeuken LJC, Sandoe JAT. A Systematic Review of the Effect of Therapeutic Drug Monitoring on Patient Health Outcomes during Treatment with Carbapenems. Antibiotics (Basel) 2022; 11:antibiotics11101311. [PMID: 36289971 PMCID: PMC9598625 DOI: 10.3390/antibiotics11101311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Adjusting dosing regimens based on measurements of carbapenem levels may improve carbapenem exposure in patients. This systematic review aims to describe the effect carbapenem therapeutic drug monitoring (TDM) has on health outcomes, including the emergence of antimicrobial resistance (AMR). Four databases were searched for studies that reported health outcomes following adjustment to dosing regimens, according to measurements of carbapenem concentration. Bias in the studies was assessed with risk of bias analysis tools. Study characteristics and outcomes were tabulated and a narrative synthesis was performed. In total, 2 randomised controlled trials (RCTs), 17 non-randomised studies, and 19 clinical case studies were included. Significant variation in TDM practice was seen; consequently, a meta-analysis was unsuitable. Few studies assessed impacts on AMR. No significant improvement on health outcomes and no detrimental effects of carbapenem TDM were observed. Five cohort studies showed significant associations between achieving target concentrations and clinical success, including suppression of resistance. Studies in this review showed no obvious improvement in clinical outcomes when TDM is implemented. Optimisation and standardisation of carbapenem TDM practice are needed to improve intervention success and enable study synthesis. Further suitably powered studies of standardised TDM are required to assess the impact of TMD on clinical outcomes and AMR.
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Affiliation(s)
- Timothy N. Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
- Correspondence:
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars J. C. Jeuken
- Leiden Institute of Chemistry, Leiden University, P.O. Box 9502, 2300 RA Leiden, The Netherlands
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Maimongkol P, Yonwises W, Anugulruengkitt S, Sophonphan J, Treyaprasert W, Wacharachaisurapol N. Therapeutic drug monitoring of meropenem and pharmacokinetic-pharmacodynamic target assessment in critically ill pediatric patients from a prospective observational study. Int J Infect Dis 2022; 120:96-102. [PMID: 35489632 DOI: 10.1016/j.ijid.2022.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To compare the unbound plasma meropenem concentrations at mid-dosing intervals (Cmid, 50%fT), end-dosing intervals (Ctrough, 100%fT), and proportions of patients achieving 50%fT and 100%fT above MIC (50%fT>MIC and 100%fT>MIC) between extended infusion (EI) and intermittent bolus (IB) administration in a therapeutic drug monitoring (TDM) program in children. METHODS A prospective observational study was conducted in children aged 1 month to 18 years receiving meropenem every 8 h by either EI or IB. Meropenem Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC were compared. RESULTS TDM data from 72 patients with a median age (IQR) of 12 months (3-37) were used. Meropenem dose was 120 and 60 mg/kg/day in EI and IB groups, respectively. Geometric mean (95% CI) Cmid of EI versus IB was 17.3 mg/L (13.7-21.8) versus 3.4 mg/L (1.7-6.7) (P<0.001). Geometric mean (95% CI) Ctrough of EI versus IB was 2.3 mg/L (1.6-3.4) versus 0.8 mg/L (0.4-1.5) (P=0.005). Greater proportions of patients achieving 50%fT>MIC and 100%fT>MIC were observed in the EI group. CONCLUSIONS A meropenem dose of 20 mg/kg/dose given by IB should not be used in critically ill children, even if they are not suspected of having a CNS infection. A dose of 40 mg/kg/dose given by EI resulted in higher Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC.
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Affiliation(s)
- Passara Maimongkol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wanlika Yonwises
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jiratchaya Sophonphan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Wanchai Treyaprasert
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Imburgia TA, Kussin ML. A Review of Extended and Continuous Infusion Beta-Lactams in Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:214-227. [PMID: 35350159 DOI: 10.5863/1551-6776-27.3.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
Intravenous beta-lactam antibiotics are the most prescribed antibiotic class in US hospitalized patients of all ages; therefore, optimizing their dosing is crucial. Bactericidal killing is best predicted by the time in which beta-lactam drug concentrations are maintained above the organism's minimum inhibitory concentration (MIC), rather than achievement of a high peak concentration. As such, administration of beta-lactam antibiotics via extended or continuous infusions over a minimum of 3 hours, rather than standard infusions over approximately 30 minutes, has been associated with improved achievement of pharmacodynamic targets and improved clinical outcomes in adult medical literature. This review summarizes the pediatric medical literature. Applicable studies include pharmacodynamic models, case series, retrospective analyses, and prospective studies on the use of extended infusion and continuous infusion penicillins, cephalosporins, carbapenems, and monobactams in neonates, infants, children, and adolescents. Specialized patient populations with unique pharmacokinetics and high-risk infections (neonates, critically ill, febrile neutropenia, cystic fibrosis) are also reviewed. While more studies are needed to confirm prospective clinical outcomes, the current body of evidence suggests extended and continuous infusions of beta-lactam antibiotics are well tolerated in children and improve achievement of pharmacokineticpharmacodynamic targets with similar or superior clinical outcomes, particularly in infections associated with high MICs.
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Affiliation(s)
- Taylor A Imburgia
- Department of Pharmacy (TAI), WVU Medicine Children's, Morgantown, WV
| | - Michelle L Kussin
- Department of Pharmacy (MLK), Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, IN
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Zhou P, Zhang Y, Wang Z, Ying Y, Xing Y, Tong X, Zhai S. Extended or Continuous Infusion of Carbapenems in Children with Severe Infections: A Systematic Review and Narrative Synthesis. Antibiotics (Basel) 2021; 10:antibiotics10091088. [PMID: 34572670 PMCID: PMC8470113 DOI: 10.3390/antibiotics10091088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 01/08/2023] Open
Abstract
We systematically reviewed the efficacy and safety of an extended or continuous infusion (EI/CI) versus short-term infusion (STI) of carbapenems in children with severe infections. Databases, including PubMed, Embase, the Cochrane Library, Clinicaltrials.gov, China National Knowledge Infrastructure, WanFang Data, and SinoMed, were systematically searched from their inceptions to 10 August 2020, for all types of studies (such as randomized controlled trials (RCTs), retrospective studies, and pharmacokinetic or population pharmacokinetic (PK/PPK) studies) comparing EI/CI versus STI in children with severe infection. There was no limitation on language, and a manual search was also conducted. The data were screened, evaluated, extracted, and reviewed by two researchers independently. Quantitative (meta-analysis) or qualitative analyses of the included studies were performed. Twenty studies (including two RCTs, one case series, six case reports, and 11 PK/PPK studies) were included in this review (CRD42020162845). The RCTs’ quality evaluation results revealed a risk of selection and concealment bias. Qualitative analysis of RCTs demonstrated that, compared with STI, an EI (3 to 4 h) of meropenem in late-onset neonatal sepsis could improve the clinical effectiveness and microbial clearance rates, and reduce the rates of mortality; however, the differences in the incidence of other adverse events were not statistically significant. Retrospective studies showed that children undergoing an EI of meropenem experienced satisfactory clinical improvement. In addition, the results of the PK/PPK study showed that an EI (3 or 4 h)/CI of carbapenems in severely infected children was associated with a more satisfactory goal achievement rate (probability of target attainment) and a cumulative fraction of response than STI therapy. In summary, the EI/CI of carbapenems in children with severe infection has a relatively sufficient PK or pharmacodynamic (PD) basis and satisfactory efficacy and safety. However, due to the limited quantity and quality of studies, the EI/CI therapy should not be used routinely in severely infected children. This conclusion should be further verified by more high-quality controlled clinical trials or observational studies based on PK/PD theories.
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Affiliation(s)
- Pengxiang Zhou
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China; (P.Z.); (Y.Z.); (Y.Y.)
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China
| | - Yahui Zhang
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China; (P.Z.); (Y.Z.); (Y.Y.)
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China;
| | - Zhenhuan Wang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China;
- Department of Pharmacy, First Hospital of Tsinghua University, Beijing 100016, China
| | - Yingqiu Ying
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China; (P.Z.); (Y.Z.); (Y.Y.)
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China;
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing 100191, China;
- Correspondence: (X.T.); (S.Z.); Tel.: +86-(010)-82267671 (X.T.); +86-(010)-82266686 (S.Z.)
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China; (P.Z.); (Y.Z.); (Y.Y.)
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing 100191, China
- Correspondence: (X.T.); (S.Z.); Tel.: +86-(010)-82267671 (X.T.); +86-(010)-82266686 (S.Z.)
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Cojutti PG, Lazzarotto D, Candoni A, Dubbini MV, Zannier ME, Fanin R, Pea F. Real-time TDM-based optimization of continuous-infusion meropenem for improving treatment outcome of febrile neutropenia in oncohaematological patients: results from a prospective, monocentric, interventional study. J Antimicrob Chemother 2021; 75:3029-3037. [PMID: 32681168 PMCID: PMC7678894 DOI: 10.1093/jac/dkaa267] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022] Open
Abstract
Objectives To assess the role that real-time therapeutic drug monitoring (TDM)-guided optimization of continuous-infusion (CI) meropenem may have in maximizing empirical treatment and in preventing breakthrough infection and/or colonization with carbapenem-resistant Enterobacteriaceae (CRE) among oncohaematological patients with febrile neutropenia (FN). Methods A monocentric, interventional, prospective study was conducted. The pharmacodynamic (PD) target was a steady-state meropenem concentration-to-MIC ratio (Css/MIC) of 4–8. The primary endpoint was 14 day all-cause mortality. The secondary endpoint was the prevalence of CRE colonization in rectal swabs of patients rehospitalized within 3 months. Results Among the 75 patients enrolled, most (56%) had AML, almost half (37/75, 49.3%) underwent HSCT and one-third (32%) received meropenem as monotherapy. Meropenem dosages were adjusted in 30.1% of TDM reassessments. Gram-negative infections were microbiologically documented in 20.0% of patients. All of the 12 patients having infections caused by in vitro meropenem-susceptible pathogens attained the desired PD target and were cured. Three patients had infections caused by in vitro meropenem-resistant pathogens. Two of these achieved a Css/MIC target of 1 and were cured; the other one achieved a suboptimal PD target (0.59) and died. The 14 day all-cause mortality (10.7%) was significantly associated, at multivariate regression, with HSCT (OR 0.086, 95% CI 0.008–0.936, P = 0.044) and with augmented renal clearance (OR 10.846, 95% CI 1.534–76.672, P = 0.017). None of the patients who had hospital readmissions in the 3 month follow-up (63/75) had CRE colonization in rectal swabs. Conclusions Real-time TDM-guided CI meropenem may be a useful approach for attaining adequate exposure and preventing CRE emergence in FN oncohaematological patients.
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Affiliation(s)
- Pier Giorgio Cojutti
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Davide Lazzarotto
- Division of Haematology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Anna Candoni
- Division of Haematology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Maria Vittoria Dubbini
- Division of Haematology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Maria Elena Zannier
- Division of Haematology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Renato Fanin
- Department of Medicine, University of Udine, Udine, Italy.,Division of Haematology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Federico Pea
- Department of Medicine, University of Udine, Udine, Italy.,Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
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Population Pharmacokinetics and Pharmacodynamics of Meropenem in Critically Ill Pediatric Patients. Antimicrob Agents Chemother 2021; 65:AAC.01909-20. [PMID: 33199385 DOI: 10.1128/aac.01909-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/27/2022] Open
Abstract
This study investigates the optimal meropenem (MEM) dosing regimen for critically ill pediatric patients, for which there is a lack of pharmacokinetic (PK) studies. We conducted a retrospective single-center PK and pharmacodynamic (PD) analysis of 34 pediatric intensive care unit patients who received MEM. Individual PK parameters were determined by a two-compartment analysis. The median (range) age and body weight were 1.4 (0.03 to 14.6) years and 8.9 (2.7 to 40.9) kg, respectively, and eight (23.5%) patients received continuous renal replacement therapy (CRRT), three of whom received extracorporeal membrane oxygenation. Renal function, the systemic inflammatory response syndrome (SIRS) score for the clearance (CL), and the use of CRRT for the central volume of distribution (V c) were identified as significant covariates. The mean CL, V c, and peripheral volume of distribution (V p) were 0.45 liters/kg/h, 0.49 liters/kg, and 0.34 liters/kg, respectively. The mean population CL of MEM increased by 35% in patients with SIRS and V c increased by 66% in patients on CRRT in the final model. Dosing simulations suggested that the standard dosing regimen provided insufficient PD exposures of a 100% free time above the MIC, and higher doses (40 to 80 mg/kg of body weight/dose every 8 h) with a prolonged 3-h infusion were required to ensure the appropriate PD exposures for patients with SIRS. Our PK model indicated that critically ill pediatric patients are at risk of subtherapeutic exposure under the standard dosing regimen of MEM. A larger, prospective investigation confirming the safety and efficacy of higher concentrations and prolonged infusion of MEM is necessary.
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Cojutti PG, Candoni A, Lazzarotto D, Filì C, Zannier M, Fanin R, Pea F. Population Pharmacokinetics of Continuous-Infusion Meropenem in Febrile Neutropenic Patients with Hematologic Malignancies: Dosing Strategies for Optimizing Empirical Treatment against Enterobacterales and P. aeruginosa. Pharmaceutics 2020; 12:pharmaceutics12090785. [PMID: 32825109 PMCID: PMC7560225 DOI: 10.3390/pharmaceutics12090785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 12/20/2022] Open
Abstract
A population pharmacokinetic analysis of continuous infusion (CI) meropenem was conducted in a prospective cohort of febrile neutropenic (FN) patients with hematologic malignancies. A non-parametric approach with Pmetrics was used for pharmacokinetic analysis and covariate evaluation. Monte Carlo simulations were performed for identifying the most appropriate dosages for empirical treatment against common Enterobacterales and P. aeruginosa. The probability of target attainment (PTA) of steady-state meropenem concentration (Css)-to-minimum inhibitory concentration (MIC) ratio (Css/MIC) ≥1 and ≥4 at the European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoint of 2 mg/L were calculated. Cumulative fraction of response (CFR) against Enterobacterales and P. aeruginosa were assessed as well. PTAs and CFRs ≥ 90% were considered optimal. A total of 61 patients with 178 meropenem Css were included. Creatinine clearance (CLCR) was the only covariate associated with meropenem clearance. Monte Carlo simulations showed that dosages of meropenem ranging between 1 g q8h and 1.25 g q6h by CI may grant optimal PTAs of Css/MIC ≥4 at the EUCAST clinical breakpoint. Optimal CFRs may be granted with these dosages against the Enterobacterales at Css/MIC ≥ 4 and against P. aeruginosa at Css/MIC ≥ 1. When dealing against P. aeruginosa at Css/MIC ≥ 4, only a dosage of 1.5 g q6h by CI may grant quasi-optimal CFR (around 80–87%). In conclusion, our findings suggest that dosages of meropenem ranging between 1 g q8h and 1.25 g q6h by CI may maximize empirical treatment against Enterobacterales and P. aeruginosa among FN patients with hematologic malignancies having different degree of renal function.
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Affiliation(s)
- Pier Giorgio Cojutti
- Department of Medicine, University of Udine, 33100 Udine, Italy; (P.G.C.); (R.F.)
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
| | - Anna Candoni
- Division of Haematology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy; (A.C.); (D.L.); (C.F.); (M.Z.)
| | - Davide Lazzarotto
- Division of Haematology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy; (A.C.); (D.L.); (C.F.); (M.Z.)
| | - Carla Filì
- Division of Haematology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy; (A.C.); (D.L.); (C.F.); (M.Z.)
| | - Maria Zannier
- Division of Haematology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy; (A.C.); (D.L.); (C.F.); (M.Z.)
| | - Renato Fanin
- Department of Medicine, University of Udine, 33100 Udine, Italy; (P.G.C.); (R.F.)
- Division of Haematology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy; (A.C.); (D.L.); (C.F.); (M.Z.)
| | - Federico Pea
- Department of Medicine, University of Udine, 33100 Udine, Italy; (P.G.C.); (R.F.)
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University-Hospital of Udine, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), 33100 Udine, Italy
- Correspondence: ; Tel.: +39-432-559830
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Lonsdale DO, Baker EH, Kipper K, Barker C, Philips B, Rhodes A, Sharland M, Standing JF. Scaling beta-lactam antimicrobial pharmacokinetics from early life to old age. Br J Clin Pharmacol 2018; 85:316-346. [PMID: 30176176 DOI: 10.1111/bcp.13756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Beta-lactam dose optimization in critical care is a current priority. We aimed to review the pharmacokinetics (PK) of three commonly used beta-lactams (amoxicillin ± clavulanate, piperacillin-tazobactam and meropenem) to compare PK parameters reported in critically and noncritically ill neonates, children and adults, and to investigate whether allometric and maturation scaling principles could be applied to describe changes in PK parameters through life. METHODS A systematic review of PK studies of the three drugs was undertaken using MEDLINE and EMBASE. PK parameters and summary statistics were extracted and scaled using allometric principles to 70 kg individual for comparison. Pooled data were used to model clearance maturation and decline using a sigmoidal (Hill) function. RESULTS A total of 130 papers were identified. Age ranged from 29 weeks to 82 years and weight from 0.9-200 kg. PK parameters from critically ill populations were reported with wider confidence intervals than those in healthy volunteers, indicating greater PK variability in critical illness. The standard allometric size and sigmoidal maturation model adequately described increasing clearance in neonates, and a sigmoidal model was also used to describe decline in older age. Adult weight-adjusted clearance was achieved at approximately 2 years postmenstrual age. Changes in volume of distribution were well described by the standard allometric model, although amoxicillin data suggested a relatively higher volume of distribution in neonates. CONCLUSIONS Critical illness is associated with greater PK variability than in healthy volunteers. The maturation models presented will be useful for optimizing beta-lactam dosing, although a prospective, age-inclusive study is warranted for external validation.
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Affiliation(s)
- Dagan O Lonsdale
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George's, University of London, London, UK.,Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International Ltd
| | - Charlotte Barker
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Barbara Philips
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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11
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Kong L, Tang Y, Zhang X, Lu G, Yu M, Shi Q, Wu X. Pharmacokinetic/Pharmacodynamic Analysis of Meropenem for the Treatment of Nosocomial Pneumonia in Intracerebral Hemorrhage Patients by Monte Carlo Simulation. Ann Pharmacother 2017; 51:970-975. [PMID: 28677407 DOI: 10.1177/1060028017719715] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Nosocomial pneumonia (NP) is a frequent complication among patients with intracerebral hemorrhage (ICH). However, there are currently no pharmacokinetic (PK) and pharmacodynamic (PD) data to guide meropenem dosing in these patients. OBJECTIVE To investigate the PK/PD properties of meropenem in these patients and whether the usual dosing regimens of meropenem (2-hour infusion, 1 g, every 8 hours) was suitable. METHODS A total of 11 patients with a diagnosis of ICH complicated with NP were selected in the emergency internal medicine and treated with a 1-g/2-hours extended infusion model. The plasma concentrations of meropenem were determined by high-performance liquid chromatography. PK parameters were estimated by plasma concentration versus time profile using WinNonlin software. The probability of target attainments (PTAs) of meropenem at different minimum inhibitory concentrations (MICs) based on percentage time that concentrations were above the minimum inhibitory concentration (%T>MIC) value were performed by Monte Carlo simulation. RESULTS The volume of distribution and total body clearance of meropenem were 55.55 L/kg and 22.89 L/h, respectively. Using 40%T>MIC, PTA was >90% at MICs ≤4 µg/mL. Using 80% or 100%T>MIC, PTA was >90% only at MICs ≤1 µg/mL. CONCLUSIONS The PK/PD profile of dosing regimens tested will assist in selecting the appropriate meropenem regimens for these patients. At a target of 40%T>MIC, the usual dosing regimens can provide good coverage for pathogens with MICs of ≤4 µg/mL. However, when a higher target (80% or 100%) is desired for difficult-to-treat infections, larger doses, prolonged infusions, shorter intervals, and/or combination therapy may be required.
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Affiliation(s)
- Lingti Kong
- 1 Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yan Tang
- 2 Department of Emergency Internal Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xiaohua Zhang
- 2 Department of Emergency Internal Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Guoyu Lu
- 2 Department of Emergency Internal Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Meiling Yu
- 1 Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Qingping Shi
- 1 Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xiaofei Wu
- 2 Department of Emergency Internal Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, China
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12
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Zhou QT, He B, Shen N, Liang Y, Sun LN. Meropenem Dosing Based on a Population Pharmacokinetic–Pharmacodynamic Model in Elderly Patients with Infection of the Lower Respiratory Tract. Drugs Aging 2017; 34:115-121. [DOI: 10.1007/s40266-016-0431-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Colin P, Eleveld DJ, Jonckheere S, Van Bocxlaer J, De Waele J, Vermeulen A. What about confidence intervals? A word of caution when interpreting PTA simulations. J Antimicrob Chemother 2016; 71:2502-8. [PMID: 27147302 DOI: 10.1093/jac/dkw150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 04/05/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES In the field of antimicrobial chemotherapy, readers are increasingly confronted with population pharmacokinetic models and the ensuing simulation results with the purpose to improve the efficiency of currently used therapeutic regimens. One such type of analysis is Monte Carlo (MC) simulations in support of dose selection. At the moment, results of these MC simulations consist of predictions for the typical individual/population only. The uncertainty associated with the parameters, from which the simulations are derived, is completely ignored. Here, we highlight the importance of and the need to include parameter uncertainty in PTA simulations. METHODS Using MC simulation with parameter uncertainty, we estimated CIs around PTA curves. The added benefit of this approach was illustrated using, on the one hand, a population pharmacokinetic model developed in-house for a β-lactam antibiotic and, on the other hand, results from a previously published PTA analysis. RESULTS Our examples illustrate that proper clinical decision-making requires more than the typical PTA curve. Therefore, authors should be encouraged to provide an estimate of the uncertainty along with their simulations and to take this into account when interpreting the results. We feel that CIs around PTA curves provide this information in a comprehensive manner without requiring advanced knowledge on the underlying modelling approaches from the reader. CONCLUSIONS We believe that this approach should be advocated by all stakeholders in antibiotic stewardship programmes to safeguard the quality of clinical decision-making in the future.
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Affiliation(s)
- Pieter Colin
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Douglas J Eleveld
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Jan Van Bocxlaer
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - An Vermeulen
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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