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Liu T, Yuan Y, Wang C, Wu J, Wang Y, Na P, Chen X, Rao W, Zhao J, Wang D, Wang H, Duan Z, Xie F, Fang X, Xie L, Li H. Therapeutic drug monitoring of linezolid and exploring optimal regimens and a toxicity-related nomogram in elderly patients: a multicentre, prospective, non-interventional study. J Antimicrob Chemother 2024; 79:1938-1950. [PMID: 38873816 PMCID: PMC11290878 DOI: 10.1093/jac/dkae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/22/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND The concentrations of linezolid, its optimal regimen and the associated side effects in elderly patients remain unclear. METHODS In this multicentre, prospective study, elderly patients receiving linezolid at four tertiary hospitals in Beijing between May 2021 and December 2022 were included. Linezolid concentrations and haematological toxicity were monitored dynamically. Risk factors for linezolid overexposure and moderate-to-severe linezolid-induced thrombocytopenia (M/S LIT) were analysed, and a predictive model of M/S LIT was developed. RESULTS A total of 860 linezolid concentrations were measured in 313 patients. The median trough concentrations of linezolid were 24.4 (15.3, 35.8) mg/L at 36-72 h and 26.1 (17.0, 38.1) mg/L at 5-10 days (P = 0.132). Severe linezolid exposure was independently associated with age, estimated glomerular filtration rate (eGFR) and the worst SOFA score (SOFA1), and we further recommended dose regimens for elderly patients based on these findings. The incidences of linezolid-induced thrombocytopenia(LIT) and M/S LIT were 73.5% and 47.6%, respectively. M/S LIT was independently correlated with treatment duration, average trough concentration (TDMa), baseline platelet count, eGFR and baseline SOFA score (SOFA0). The developed nomogram predicted M/S LIT with an area under the curve of 0.767 (95% CI 0.715-0.820), a sensitivity of 71.1% and a specificity of 73.2%. CONCLUSIONS Linezolid trough concentrations increased dramatically in the elderly, by about 10 mg/L in patients aged 65-80 years, followed by a further increase of 10 mg/L for every 10 years of age. Therapeutic drug monitoring is recommended in elderly patients receiving linezolid. The developed nomogram may predict M/S LIT and guide dosage adjustments of linezolid. Clinical trial registration number: ChiCTR2100045707.
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Affiliation(s)
- Tingting Liu
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Medical School, Beijing 100853, China
| | - Yaping Yuan
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Medical School, Beijing 100853, China
| | - Chao Wang
- Chinese PLA Medical School, Beijing 100853, China
- Department of Pulmonary and Critical Care Medicine, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jionghe Wu
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
- Chinese PLA Medical School, Beijing 100853, China
| | - Yajuan Wang
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Peng Na
- Chinese PLA Medical School, Beijing 100853, China
| | | | - Weiqiao Rao
- BGI Genomics Co., Ltd, Shenzhen 518083, China
| | - Jing Zhao
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Dan Wang
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Haiyan Wang
- Department of Pulmonary and Critical Care Medicine, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhimei Duan
- Department of Pulmonary and Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Fei Xie
- College of Pulmonary and Critical Care Medicine, The Eighth Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiangqun Fang
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Lixin Xie
- College of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Hongxia Li
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
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Bulitta JB, Fang E, Stryjewski ME, Wang W, Atiee GJ, Stark JG, Hafkin B. Population pharmacokinetic rationale for intravenous contezolid acefosamil followed by oral contezolid dosage regimens. Antimicrob Agents Chemother 2024; 68:e0140023. [PMID: 38415667 PMCID: PMC10989001 DOI: 10.1128/aac.01400-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Abstract
Contezolid is a novel oxazolidinone antibiotic with a promising safety profile. Oral contezolid and its intravenous (IV) prodrug contezolid acefosamil (CZA) are in development for treatment of diabetic foot and acute bacterial skin and skin structure infections (ABSSSI). The prodrug CZA is converted to active contezolid via intermediate MRX-1352. This study aimed to provide the pharmacokinetic rationale for safe, effective, and flexible dosage regimens with initial IV CZA followed by oral contezolid. We simultaneously modeled plasma concentrations from 110 healthy volunteers and 74 phase 2 patients with ABSSSI via population pharmacokinetics (using the importance sampling estimation algorithm), and optimized dosage regimens by Monte Carlo simulations. This included data on MRX-1352, contezolid, and its metabolite MRX-1320 from 66 healthy volunteers receiving intravenous CZA (150-2400 mg) for up to 28 days, and 74 patients receiving oral contezolid [800 mg every 12 h (q12h)] for 10 days. The apparent total clearance for 800 mg oral contezolid with food was 16.0 L/h (23.4% coefficient of variation) in healthy volunteers and 17.7 L/h (53.8%) in patients. CZA was rapidly converted to MRX-1352, which subsequently transformed to contezolid. The proposed dosage regimen used an IV CZA 2000 mg loading dose with 1000 mg IV CZA q12h as maintenance dose(s), followed by 800 mg oral contezolid q12h (with food). During each 24-h period, Monte Carlo simulations predicted this regimen to achieve consistent areas under the curve of 91.9 mg·h/L (range: 76.3-106 mg·h/L) under all scenarios. Thus, this regimen was predicted to reliably achieve efficacious contezolid exposures independent of timing of switch from IV CZA to oral contezolid.IMPORTANCEThis study provides the population pharmacokinetic rationale for the dosage regimen of the intravenous (IV) prodrug contezolid acefosamil (CZA) followed by oral contezolid. We developed the first integrated population model for the pharmacokinetics of the MRX-1352 intermediate prodrug, active contezolid, and its main metabolite MRX-1320 based on data from three clinical studies in healthy volunteers and phase 2 patients. The proposed regimen was predicted to reliably achieve efficacious contezolid exposures independent of timing of switch from IV CZA to oral contezolid.
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Affiliation(s)
- Jürgen B. Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, Florida, USA
| | - Edward Fang
- MicuRx Pharmaceuticals, Inc., Foster City, California, USA
| | - Martin E. Stryjewski
- Department of Medicine, Division of Infectious Diseases, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | - Wen Wang
- MicuRx Pharmaceuticals, Inc., Foster City, California, USA
| | | | | | - Barry Hafkin
- MicuRx Pharmaceuticals, Inc., Foster City, California, USA
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Patel A, Doernberg SB, Zack T, Butte AJ, Radtke KK. Predictive Modeling of Drug-Related Adverse Events with Real-World Data: A Case Study of Linezolid Hematologic Outcomes. Clin Pharmacol Ther 2024; 115:847-859. [PMID: 38345264 DOI: 10.1002/cpt.3201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/29/2024] [Indexed: 03/21/2024]
Abstract
Electronic health records (EHRs) provide meaningful knowledge of drug-related adverse events (AEs) that are not captured in standard drug development and postmarketing surveillance. Using variables obtained from EHR data in the University of California San Francisco de-identified Clinical Data Warehouse, we aimed to evaluate the potential of machine learning to predict two hematological AEs, thrombocytopenia and anemia, in a cohort of patients treated with linezolid for 3 or more days. Features for model input were extracted at linezolid initiation (index), and outcomes were characterized from index to 14 days post-treatment. Random forest classification (RFC) was used for AE prediction, and reduced feature models were evaluated using cumulative importance (cImp) for feature selection. Grade 3+ thrombocytopenia and anemia occurred in 31% of 2,171 and 56% of 2,170 evaluable patients, respectively. Of the total 53 features, as few as 7 contributed at least 50% cImp, resulting in prediction accuracies of 70% or higher and area under the receiver operating characteristic curves of 0.886 for grade 3+ thrombocytopenia and 0.759 for grade 3+ anemia. Sensitivity analyses in strictly defined patient subgroups revealed similarly high predictive performance in full and reduced feature models. A logistic regression model with the same 50% cImp features showed similar predictive performance as RFC and good concordance with RFC probability predictions after isotonic calibration, adding interpretability. Collectively, this work demonstrates potential for machine learning prediction of AE risk in real-world patients using few variables regularly available in EHRs, which may aid in clinical decision making and/or monitoring.
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Affiliation(s)
- Anu Patel
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Travis Zack
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Atul J Butte
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
- University of California Health, University of California, Office of the President, Oakland, California, USA
| | - Kendra K Radtke
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA
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Qin Y, Chen Z, Gao S, Shen Y, Ye Y. Development and validation of a risk prediction model for linezolid-induced thrombocytopenia in elderly patients. Eur J Hosp Pharm 2024; 31:94-100. [PMID: 35477677 PMCID: PMC10895188 DOI: 10.1136/ejhpharm-2022-003258] [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: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Linezolid is the first oxazolidinone antimicrobial agent developed for treating multi-drug-resistant gram-positive bacterial infections. The study aimed to investigate the risk factors of linezolid (LI)-induced thrombocytopenia (LI-TP) and to develop and validate a risk prediction model to identify elderly patients at high risk of developing LI-TP during linezolid therapy. METHODS A retrospective cohort study was performed at Zhongshan Hospital, FuDan University, China. The study involved elderly Chinese patients aged ≥65 years administered with linezolid (600 mg) twice a day between January 2015 and April 2021. We collected the patients' clinical characteristics and demographic data from electronic medical records, and compared the differences between LI-TP patients and those who had not developed thrombocytopenia (NO-TP) after linezolid treatment. The risk prediction model was developed based on the regression coefficient generated from logistic regression model. RESULTS A total of 343 inpatients were enrolled from January 2015 to August 2020 and were used as the training set. Among them, 67 (19.5%) developed LI-TP. Multivariate logistic regression analysis revealed that baseline platelet counts <150×109·L-1 (odds ratio (OR)=3.576; p<0.001), age ≥75 years (OR=2.258; p=0.009), estimated glomerular filtration rate (eGFR <60 mL·(min·1.73 m2)-1 (OR=2.553; p=0.002), duration of linezolid therapy ≥10 d (OR=3.218; p<0.001), intensive care unit (ICU) admittance (OR=2.682; p=0.004), concomitant piperacillin-tazobactam (OR=3.863; p=0.006) were independent risk factors for LI-TP in elderly patients. The LI-TP risk prediction model was established using a scoring method based on the regression coefficient and exhibited a good discriminative power, with an area under the curve (AUC) of 0.795 (95% confidence interval (CI) 0.740 to 0.851) and 0.849 (95% CI 0.760 to 0.939) in the training set (n=343) and validation set (n=90) respectively. CONCLUSIONS These findings indicate that duration of linezolid therapy, age, eGFR, ICU admittance, baseline platelet counts, concomitant piperacillin-tazobactam were significantly associated with LI-TP in elderly patients. A risk prediction model based on these risk factors showed a good discriminative performance and may be useful for clinicians to identify patients at high risk of developing LI-TP.
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Affiliation(s)
- Yan Qin
- Department of Pharmacy, Zhongshan Hospital FuDan Univeristy, Shanghai, China
| | - Zhe Chen
- Department of Pharmacy, Zhongshan Hospital FuDan Univeristy, Shanghai, China
| | - Shuai Gao
- Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Yun Shen
- Department of Pharmacy, Zhongshan Hospital FuDan Univeristy, Shanghai, China
| | - Yanrong Ye
- Department of Pharmacy, Zhongshan Hospital FuDan Univeristy, Shanghai, China
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Thirot H, Fage D, Leonhardt A, Clevenbergh P, Besse-Hammer T, Yombi JC, Cornu O, Briquet C, Hites M, Jacobs F, Wijnant GJ, Wicha SG, Cotton F, Tulkens PM, Spinewine A, Van Bambeke F. Towards a better detection of patients at-risk of linezolid toxicity in clinical practice: a prospective study in three Belgian hospital centers. Front Pharmacol 2024; 15:1310309. [PMID: 38313312 PMCID: PMC10834751 DOI: 10.3389/fphar.2024.1310309] [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: 10/17/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction: Linezolid is a last-resort antibiotic for infections caused by multidrug-resistant microorganisms. It is widely used for off-label indications and for longer than recommended treatment durations, exposing patients at higher risk of adverse drug reactions (ADRs), notably thrombocytopenia. This study aimed to investigate ADR incidence and risk factors, identify thrombocytopenia-related trough levels based on treatment duration, and evaluate the performance of predictive scores for ADR development. Methods: Adult in- and outpatients undergoing linezolid therapy were enrolled in three hospitals and ADRs and linezolid trough levels prospectively monitored over time. A population pharmacokinetic (pop-PK model) was used to estimate trough levels for blood samples collected at varying times. Results: A multivariate analysis based on 63 treatments identified treatment duration ≥10 days and trough levels >8 mg/L as independent risk factors of developing thrombocytopenia, with high trough values correlated with impaired renal function. Five patients treated for >28 days did not develop thrombocytopenia but maintained trough values in the target range (<8 mg/L). The Buzelé predictive score, which combines an age-adjusted Charlson comorbidity index with treatment duration, demonstrated 77% specificity and 67% sensitivity to predict the risk of ADR. Conclusion: Our work supports the necessity of establishing guidelines for dose adjustment in patients with renal insufficiency and the systematic use of TDM in patients at-risk in order to keep trough values ≤8 mg/L. The Buzelé predictive score (if ≥7) may help to detect these at-risk patients, and pop-PK models can estimate trough levels based on plasma samples collected at varying times, reducing the logistical burden of TDM in clinical practice.
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Affiliation(s)
- Hélène Thirot
- Pharmacologie cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Clinical Pharmacy, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - David Fage
- Department of Clinical Chemistry, Laboratoire hospitalier universitaire de Bruxelles (LHUB-ULB), Brussels, Belgium
| | - Antonia Leonhardt
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hambourg, Germany
| | | | | | - Jean Cyr Yombi
- Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Olivier Cornu
- Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Caroline Briquet
- Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Maya Hites
- Hôpitaux universitaires de Bruxelles-Erasme (HUB), Université libre de Bruxelles, Brussels, Belgium
| | - Frédérique Jacobs
- Hôpitaux universitaires de Bruxelles-Erasme (HUB), Université libre de Bruxelles, Brussels, Belgium
| | - Gert-Jan Wijnant
- Pharmacologie cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hambourg, Germany
| | - Frédéric Cotton
- Department of Clinical Chemistry, Laboratoire hospitalier universitaire de Bruxelles (LHUB-ULB), Brussels, Belgium
| | - Paul M Tulkens
- Pharmacologie cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Anne Spinewine
- Clinical Pharmacy, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
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6
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Bock M, Van Hasselt JGC, Schwartz F, Wang H, Høiby N, Fuursted K, Ihlemann N, Gill S, Christiansen U, Bruun NE, Elming H, Povlsen JA, Køber L, Høfsten DE, Fosbøl EL, Pries-Heje MM, Christensen JJ, Rosenvinge FS, Torp-Pedersen C, Helweg-Larsen J, Tønder N, Iversen K, Bundgaard H, Moser C. Rifampicin reduces plasma concentration of linezolid in patients with infective endocarditis. J Antimicrob Chemother 2023; 78:2840-2848. [PMID: 37823408 DOI: 10.1093/jac/dkad316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Linezolid in combination with rifampicin has been used in treatment of infective endocarditis especially for patients infected with staphylococci. OBJECTIVES Because rifampicin has been reported to reduce the plasma concentration of linezolid, the present study aimed to characterize the population pharmacokinetics of linezolid for the purpose of quantifying an effect of rifampicin cotreatment. In addition, the possibility of compensation by dosage adjustments was evaluated. PATIENTS AND METHODS Pharmacokinetic measurements were performed in 62 patients treated with linezolid for left-sided infective endocarditis in the Partial Oral Endocarditis Treatment (POET) trial. Fifteen patients were cotreated with rifampicin. A total of 437 linezolid plasma concentrations were obtained. The pharmacokinetic data were adequately described by a one-compartment model with first-order absorption and first-order elimination. RESULTS We demonstrated a substantial increase of linezolid clearance by 150% (95% CI: 78%-251%), when combined with rifampicin. The final model was evaluated by goodness-of-fit plots showing an acceptable fit, and a visual predictive check validated the model. Model-based dosing simulations showed that rifampicin cotreatment decreased the PTA of linezolid from 94.3% to 34.9% and from 52.7% to 3.5% for MICs of 2 mg/L and 4 mg/L, respectively. CONCLUSIONS A substantial interaction between linezolid and rifampicin was detected in patients with infective endocarditis, and the interaction was stronger than previously reported. Model-based simulations showed that increasing the linezolid dose might compensate without increasing the risk of adverse effects to the same degree.
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Affiliation(s)
- Magnus Bock
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Johan G C Van Hasselt
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Franziska Schwartz
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hengzhuang Wang
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Kurt Fuursted
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Nikolaj Ihlemann
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Sabine Gill
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Niels Eske Bruun
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Elming
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Jonas A Povlsen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Lars Køber
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dan E Høfsten
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mia M Pries-Heje
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Jørgen Christensen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Regional Department of Clinical Microbiology, Region Zealand, Slagelse, Denmark
| | - Flemming S Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Microbiology, University of Southern Denmark, Odense, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niels Tønder
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Kasper Iversen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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Keutzer L, Mockeliunas L, Sturkenboom MGG, Bolhuis MS, Akkerman OW, Simonsson USH. Derivation and Clinical Utility of Safety Targets for Linezolid-Related Adverse Events in Drug-Resistant Tuberculosis Treatment. Pharmaceuticals (Basel) 2023; 16:1575. [PMID: 38004440 PMCID: PMC10674798 DOI: 10.3390/ph16111575] [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: 10/12/2023] [Revised: 11/02/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Long-term usage of linezolid can result in adverse events such as peripheral neuropathy, anemia and thrombocytopenia. Therapeutic drug monitoring data from 75 drug-resistant tuberculosis patients treated with linezolid were analyzed using a time-to-event (TTE) approach for peripheral neuropathy and anemia and indirect response modelling for thrombocytopenia. Different time-varying linezolid pharmacokinetic exposure indices (AUC0-24h,ss, Cav, Cmax and Cmin) and patient characteristics were investigated as risk factors. A treatment duration shorter than 3 months was considered dropout and was modelled using a TTE approach. An exposure-response relationship between linezolid Cmin and both peripheral neuropathy and anemia was found. The exposure index which best described the development of thrombocytopenia was AUC0-24h. The final TTE dropout model indicated an association between linezolid Cmin and dropout. New safety targets for each adverse event were proposed which can be used for individualized linezolid dosing. According to the model predictions at 6 months of treatment, a Cmin of 0.11 mg/L and 1.4 mg/L should not be exceeded to keep the cumulative probability to develop anemia and peripheral neuropathy below 20%. The AUC0-24h should be below 111 h·mg/L or 270 h·mg/L to prevent thrombocytopenia and severe thrombocytopenia, respectively. A clinical utility assessment showed that the currently recommended dose of 600 mg once daily is safer compared to a 300 mg BID dosing strategy considering all four safety endpoints.
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Affiliation(s)
- Lina Keutzer
- Department of Pharmaceutical Biosciences, Uppsala University, 751 24 Uppsala, Sweden
| | - Laurynas Mockeliunas
- Department of Pharmaceutical Biosciences, Uppsala University, 751 24 Uppsala, Sweden
| | - Marieke G. G. Sturkenboom
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Mathieu S. Bolhuis
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Onno W. Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- Tuberculosis Center Beatrixoord, University Medical Center Groningen, University of Groningen, 9751 ND Groningen, The Netherlands
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8
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de Kretser D, Mora J, Bloomfield M, Campbell A, Cheng MP, Guy S, Hensgens M, Kalimuddin S, Lee TC, Legg A, Mahar RK, Marks M, Marsh J, McGlothlin A, Morpeth SC, Sud A, Ten Oever J, Yahav D, Tong SY, Davis JS, Walls G, Goodman AL, Bonten M. Early oral antibiotic switch in Staphylococcus aureus bacteraemia: The Staphylococcus aureus Network Adaptive Platform (SNAP) Trial Early Oral Switch Protocol. Clin Infect Dis 2023:ciad666. [PMID: 37921609 DOI: 10.1093/cid/ciad666] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/07/2023] [Accepted: 10/20/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Staphylococcus aureus bloodstream infection (bacteraemia) is traditionally treated with at least two weeks of IV antibiotics in adults, 3-7 days in children, and often longer for those with complicated disease. The current practice of treating S. aureus bacteraemia (SAB) with prolonged IV antibiotics (rather than oral antibiotics) is based on historical observational research and expert opinion. Prolonged IV antibiotic therapy has significant disadvantages for patients and healthcare systems, and there is growing interest in whether a switch to oral antibiotics following an initial period of IV therapy is a safe alternative for clinically stable patients. PROTOCOL The early oral switch (EOS) domain of the S. aureus Network Adaptive Platform (SNAP) trial will assess early switch to oral antibiotics compared with continued IV treatment in clinically stable patients with SAB. The primary endpoint is 90-day all-cause mortality. Hospitalised SAB patients are assessed at platform day 7 +/- 2 (uncomplicated SAB) and day 14 +/-2 (complicated SAB) to determine their eligibility for randomisation to EOS (intervention) or continued IV treatment (current standard of care). DISCUSSION Recruitment is occurring to the EOS domain of the SNAP trial. As of August 2023, 21% of all SNAP participants had been randomised to the EOS domain, a total of 264 participants across 77 centres, with an aim to recruit at least 1000 participants. We describe challenges and facilitators to enrolment in this domain to aid those planning similar trials.
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Affiliation(s)
- Dana de Kretser
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Jocelyn Mora
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Max Bloomfield
- Department of Infection Services, Wellington Regional Hospital, New Zealand
| | - Anita Campbell
- Telethon Kids Institute, Wesfarmers Centre of Infectious Diseases and Vaccines, The University of Western Australia, Perth, Australia
| | - Matthew P Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Canada
| | - Stephen Guy
- Department of Infectious Diseases, Eastern Health, Box Hill, 3128, Australia
- Monash University (including Australian and New Zealand Intensive Care Research Centre), Clayton, 3800, Australia, Australia
| | - Marjolein Hensgens
- UMC Utrecht, Utrecht University, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, 169608, Singapore, Singapore
- Program in Emerging Infectious Diseases, Duke-NUS Medical School, 169857, Singapore, Singapore
| | - Todd C Lee
- Clinical Practice Assessment Unit and Division of Infectious Diseases, McGill University, Montreal, Canada
| | - Amy Legg
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, Australia
| | - Robert K Mahar
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Australia
| | - Michael Marks
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospital, London
- Division of Infection and Immunity, University College London, London
| | - Julie Marsh
- Telethon Kids Institute &/Department of Infectious Diseases &/Wesfarmers Centre for Vaccines and Infectious Diseases, Perth Children's Hospital, Perth, Australia
| | | | | | - Archana Sud
- Department of Infectious Diseases, University of Sydney, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Steven Yc Tong
- Department of Infectious Diseases University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Joshua S Davis
- School of Medicine and Public Health and Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | | | - Anna L Goodman
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
- Department of Infectious Diseases, Guy's and St Thomas' Foundation NHS Trust, London, UK
| | - Marc Bonten
- UMC Utrecht, Utrecht University, Utrecht, the Netherlands
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9
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Zhang L, Yan Y, Liao R, Dong H. Effect of Platelet Parameters on Linezolid-Related Thrombocytopenia in Hospitalized Patients. Infect Drug Resist 2023; 16:6145-6154. [PMID: 37719650 PMCID: PMC10505032 DOI: 10.2147/idr.s408102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background Linezolid-induced thrombocytopenia incidence varies considerably. Linezolid-related thrombocytopenia in patients has received few studies which have investigated risk factors including platelet parameters except for platelet counts. The study aims to analyze the effect of platelet parameters, including mean platelet volume and platelet large cell ratio, on linezolid-related thrombocytopenia in patients. Methods The effect of platelet parameters on linezolid-related thrombocytopenia was identified by univariate and multivariate logistic regressions. A Kaplan-Meier survival analysis was carried out to compare the survival of patients who developed linezolid-related thrombocytopenia with patients who did not. Results Thrombocytopenia occurred at a rate of 41.5% (66/159) after linezolid therapy in hospitalized patients. Platelet parameters, including the difference in mean platelet volume (MPV/fL=0.08 (-1.2-0.9)vs-0.5 (-1.5-0.3), (OR, 0.459; P = 0.001), the difference in platelet large cell ratio (PLCR/fL=0.9 (-5.1-6.2)vs-3.8 (-8.6-2.4), (OR, 1.156; P = 0.001), baseline platelet counts (OR, 0.995; P = 0.006) and duration of linezolid therapy≥10d (OR, 1.346; P = 0.007), were significantly associated with linezolid-related thrombocytopenia in hospitalized patients. In addition, other risk factors which also are associated with linezolid-related thrombocytopenia include baseline red blood cells, co-medication with parecoxib and co-medication with caspofungin. Accumulated in-hospital mortality of patients with thrombocytopenia was significantly higher than that of patients without thrombocytopenia during linezolid treatment (19.7% vs 8.6%, P = 0.003). Conclusion The difference in mean platelet volume, the difference in large platelet ratio, baseline platelet counts and duration of linezolid therapy≥10d significantly affected the development of linezolid-related thrombocytopenia in hospitalized patients.
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Affiliation(s)
- Lu Zhang
- Department of Pharmacy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Yan Yan
- Department of Pharmacy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Ru Liao
- Department of Pharmacy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
| | - Haiyan Dong
- Department of Pharmacy, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710061, People’s Republic of China
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10
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Liu Y, Wang J, Liu T, Xiao K, Yan P, Fang X, Xie L. Nomogram prediction model called "ADPLCP" for predicting linezolid-associated thrombocytopenia in elderly individuals. JOURNAL OF INTENSIVE MEDICINE 2023; 3:268-274. [PMID: 37533813 PMCID: PMC10391562 DOI: 10.1016/j.jointm.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/17/2022] [Accepted: 12/28/2022] [Indexed: 08/04/2023]
Abstract
Background Linezolid-associated thrombocytopenia (LAT) leads to drug withdrawal associated with a poor prognosis. Some risk factors for LAT have been identified; however, the sample size of previous studies was small, data from elderly individuals are limited, and a simple risk score scale was not established to predict LAT at an early stage, making it difficult to identify and intervene in LAT at an early stage. Methods In this single-center retrospective case-control study, we enrolled elderly patients treated with linezolid in the intensive care unit from January 2015 to December 2020. All the data of enrolled patients, including demographic information and laboratory findings at baseline, were collected. We analyzed the incidence and risk factors for LAT and established a nomogram risk prediction model for LAT in the elderly population. Results A total of 428 elderly patients were enrolled, and the incidence of LAT was 35.5% (152/428). Age ≥80 years old (OR=1.980; 95% CI: 1.179-3.325; P=0.010), duration of linezolid ≥ 10 days (OR=1.100; 95% CI: 1.050-1.152; P <0.0001), platelet count at baseline (100-149×109/L vs. ≥200×109/L, OR=8.205, 95% CI: 4.419-15.232, P <0.0001; 150-199 ×109/L vs. ≥200×109/L, OR=3.067, 95% CI: 1.676-5.612, P <0.001), leukocyte count at baseline ≥16×109/L (OR=2.580; 95% CI: 1.523-4.373; P <0.0001), creatinine clearance <50 mL/min (OR=2.323; 95% CI: 1.388-3.890; P=0.001), and total protein <60 g/L (OR=1.741; 95% CI: 1.039-2.919; P=0.035) were associated with LAT. The nomogram prediction model called "ADPLCP" (age, duration, platelet, leukocyte, creatinine clearance, protein) was established based on logistic regression. The area under the curve (AUC) of ADPLCP was 0.802 (95% CI: 0.748-0.856; P <0.0001), with 78.9% sensitivity and 69.2% specificity (cut-off was 108). Risk stratification for LAT was performed based on "ADPLCP." Total points of <100 were defined as low risk, and the possibility of LAT was <32.0%. Total points of 100-150 were defined as medium risk, and the possibility of LAT was 32.0-67.5%. A total point >150 was defined as high risk, and the probability of LAT was >67.5%. Conclusions We created the ADPLCP risk score scale to predict the occurrence of LAT in elderly individuals. ADPLCP is simple and feasible and is helpful for the early determination of LAT to guide drug withdrawal or early intervention.
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Affiliation(s)
- Yanxin Liu
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Jiang Wang
- Centre of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Tingting Liu
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Kun Xiao
- Centre of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Peng Yan
- Centre of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiangqun Fang
- Department of Pulmonary and Critical Care Medicine, The Second Medical Center, National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China
| | - Lixin Xie
- Centre of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
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11
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Zanfardino A, Di Napoli M, Migliore F, Hay Mele B, Soriente A, De Rosa M, Notomista E, Varcamonti M. Characterization of Linezolid-Analogue L3-Resistance Mutation in Staphylococcus aureus. Microorganisms 2023; 11:microorganisms11030700. [PMID: 36985273 PMCID: PMC10054786 DOI: 10.3390/microorganisms11030700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
In a previous study, a linezolid analogue, called 10f, was synthesized. The 10f molecule has an antimicrobial activity comparable to that of the parental compound. In this study, we isolated a Staphylococcus aureus (S. aureus) strain resistant to 10f. After sequencing the 23S rRNA and the ribosomal proteins L3 (rplC) and L4 (rplD) genes, we found that the resistant phenotype was associated with a single mutation G359U in rplC bearing to the missense mutation G120V in the L3 protein. The identified mutation is far from the peptidyl transferase center, the oxazolidinone antibiotics binding site, thus suggesting that we identified a new and interesting example of a long-range effect in the ribosome structure.
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Affiliation(s)
- Anna Zanfardino
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
| | - Michela Di Napoli
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
| | - Federica Migliore
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
| | - Bruno Hay Mele
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
| | - Annunziata Soriente
- Department of Chemistry and Biology “Zambelli”, University of Salerno, Via Giovanni Paolo II, 132, 84084 Fisciano, Italy
| | - Margherita De Rosa
- Department of Chemistry and Biology “Zambelli”, University of Salerno, Via Giovanni Paolo II, 132, 84084 Fisciano, Italy
| | - Eugenio Notomista
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
| | - Mario Varcamonti
- Department of Biology, University of Naples Federico II, Via Cintia, 80126 Naples, Italy
- Correspondence:
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12
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Cattaneo D, Marriott DJ, Gervasoni C. Hematological toxicities associated with linezolid therapy in adults: key findings and clinical considerations. Expert Rev Clin Pharmacol 2023; 16:219-230. [PMID: 36787631 DOI: 10.1080/17512433.2023.2181160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Linezolid can cause serious adverse effects including thrombocytopenia and anemia. Here, we focus specifically on linezolid-related hematological toxicity in adult patients requiring prolonged drug treatment. AREAS COVERED We review the available evidence on the likelihood of hematological toxicity in adult patients treated with linezolid, with a focus on the main risk factors and strategies to prevent this adverse event. A MEDLINE PubMed search for articles published from January 2000 to May 2022 was completed matching the terms linezolid, hematology, hematological toxicity, anemia, and thrombocytopenia. Moreover, additional studies were identified from the reference lists of retrieved articles. EXPERT OPINION Thrombocytopenia is the major concern with administration of linezolid for Gram-positive infections, whereas anemia is more common in patients with tuberculosis. The important clinical risk factors for the development of linezolid-related thrombocytopenia are aging, renal dysfunction, low baseline platelet count, duration of treatment, and linezolid plasma trough concentrations >8 mg/L. Patients receiving linezolid for extended periods of time or patient populations with increased risk of altered drug pharmacokinetics would benefit from therapeutic drug monitoring or from the availability of toxico-dynamic predictive models to optimize linezolid dosing.
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Affiliation(s)
- Dario Cattaneo
- Department of Infectious Diseases, Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Department of Laboratory Medicine, Unit of Clinical Pharmacology ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, Australia
| | - Cristina Gervasoni
- Department of Infectious Diseases, Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Department of Infectious Diseases ASST Fatebenefratelli Sacco University Hospital, IIIrd Division of Infectious DiseasesMilan, Italy
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13
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Onita T, Ishihara N, Ikebuchi A, Yano T, Nishimura N, Tamaki H, Ikawa K, Morikawa N, Naora K. Pharmacokinetic and pharmacodynamic simulation for the quantitative risk assessment of linezolid-associated thrombocytopenia. J Clin Pharm Ther 2022; 47:2041-2048. [PMID: 35893441 DOI: 10.1111/jcpt.13747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/10/2022] [Accepted: 07/10/2022] [Indexed: 12/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Linezolid (LZD) may cause thrombocytopenia, which can result in discontinuation of treatment. In this study, the blood LZD trough concentration was estimated based on population pharmacokinetic (PK) parameters derived from two previously published models in the Japanese population to determine the rate of achieving the target trough value when the risk of thrombocytopenia is low and to clarify its relationship with the onset of thrombocytopenia. METHODS This study included adult patients hospitalized at Shimane University Hospital, who received LZD treatment for at least 4 days from January 2010 to December 2017. Patients whose platelet count fell below 70% before LZD administration were categorized as the thrombocytopenic group. Patient PK parameters were calculated based on the population PK models described by Matsumoto et al. and Sasaki et al., and these parameters were designated A and B, respectively. Based on these parameters, the rate of achieving an LZD trough concentration of less than 8 μg/ml, which is the safety target achievement rate, was calculated using a random simulation for each patient. We further analysed the association between the incidence of thrombocytopenia and patient factors, including safety target achievement rate, through univariate, multivariate, and receiver operating characteristic (ROC) analyses. RESULTS AND DISCUSSION Patients (n = 77) aged 72 ± 11 years and weighing 56.7 ± 10.9 kg, with a creatinine clearance (CLcr ) of 60.5 ± 47.2 ml/min and a cirrhosis prevalence of 9.1%, were analysed. All patients received LZD at a dose of 600 mg twice daily for a total of 10.9 ± 8.9 days. Univariate analyses revealed significant differences (p < 0.05) in the duration of LZD therapy, serum creatinine, creatinine clearance, LZD clearance, and the safety target achievement rate for parameters A and B between the thrombocytopenic and non-thrombocytopenic groups. A multivariate analysis of these factors stratified with the cutoff values obtained by ROC analysis revealed that the duration of LZD therapy and the safety target achievement rates for parameters A and B were significant factors (odds ratios for duration of LZD therapy: 7.436 [95% confidence interval (CI): 1.918-28.831] and 4.712 [95% CI: 1.567-14.163]; odds ratio for safety target achievement rate: 0.060 [95% CI: 0.016-0.232] and 0.167 [95% CI: 0.056-0.498] for parameters A and B, respectively). When the safety target achievement rates for patients treated with LZD were compared between the thrombocytopenic and non-thrombocytopenic groups, the safety target achievement rate was higher in the non-thrombocytopenic group in both the patients treated with LZD for less than 10 days and those for 10 days or more. Therefore, the safety target achievement rate estimated by the PK/PD simulation may represent to be an important index for risk assessment of LZD-induced thrombocytopenia. WHAT IS NEW AND CONCLUSION The risk of LZD-induced thrombocytopenia, which increased with the duration of LZD therapy, may be predicted using the safety target achievement rate obtained by the blood concentration simulation.
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Affiliation(s)
- Tetsushu Onita
- Department of Pharmacy, Shimane University Hospital, Izumo, Japan.,Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan
| | | | - Amika Ikebuchi
- Department of Pharmacy, Shimane University Hospital, Izumo, Japan
| | - Takahisa Yano
- Department of Pharmacy, Shimane University Hospital, Izumo, Japan
| | - Nobuhiro Nishimura
- School of Pharmacy at Fukuoka, International University of Health and Welfare, Fukuoka, Japan
| | - Hiroki Tamaki
- Department of Pharmacy, Shimane University Hospital, Izumo, Japan
| | - Kazuro Ikawa
- Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan
| | - Norifumi Morikawa
- Department of Clinical Pharmacotherapy, Hiroshima University, Hiroshima, Japan
| | - Kohji Naora
- Department of Pharmacy, Shimane University Hospital, Izumo, Japan
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14
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Zuo M, Sun Y, Zhao X, Xu G, Wang N, Chen J, Zhu L, Yang W, Zhao M. Evaluating linezolid dose regimens against methicillin-resistant Staphylococcus aureus based on renal function in populations with different body weight. J Clin Pharm Ther 2022; 47:2162-2169. [PMID: 36053892 DOI: 10.1111/jcpt.13765] [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: 05/17/2022] [Revised: 07/18/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Linezolid is an alternative first-line agent for MRSA pneumonia. This study assessed whether dose adjustments of linezolid against methicillin-resistant Staphylococcus aureus (MRSA) infections were needed based on renal function in populations with different body weight. METHODS Monte Carlo simulations were conducted to evaluate renal function in relation to the probability of target attainment (PTA) in three population groups with different body weight. Area under the concentration time curve (AUC)/ minimum inhibitory concentration (MIC) ratio and percentage of time above the MIC (%T > MIC) were regarded as pharmacokinetic/pharmacodynamic targets. The PTA and cumulative fractions of response (CFR) were calculated to assess the efficacy. Regarding safety, trough plasma concentration (Cmin ) > 8 mg/L was used as target for toxicity. RESULTS AND DISCUSSION Using AUC/MIC >100 as the target pharmacodynamic (PD) index, the CFR of linezolid at the standard dose (600 mg every 12 h [q12h]) were 57.01%, 93.22%, and 99.93% in patients with normal renal function, patients with renal dysfunction and low body weight patients with renal dysfunction, respectively. Using 100%T > MIC as the target PD index, all the CFR of three population groups were more than 90% at the standard dose. The percentages of Cmin > 8 mg/L at the standard dose of linezolid were 24.16%, 53.24%, and 90.10% in three population groups on day 7. WHAT IS NEW AND CONCLUSION The risk of thrombocytopenia of linezolid was extremely higher in low body weight patients with renal impairment when receiving standard linezolid dose compared with patients with normal renal function. 450 mg q12h and 300 mg q12h might be effective and safe against MRSA infection in patients with renal dysfunction and low body weight patients with renal dysfunction, respectively.
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Affiliation(s)
- Meiling Zuo
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Yuxuan Sun
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Xianmei Zhao
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Gaoqi Xu
- The Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Nan Wang
- Pharmacy Department, Tianjin Third Central Hospital, Tianjin, China
| | - Jingtao Chen
- School of Statistics and Data Science, Nankai University, Tianjin, China
| | - Liqin Zhu
- Pharmaceutical College, Tianjin Medical University, Tianjin, China.,Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Wenjie Yang
- Infection Department, Tianjin First Central Hospital, Tianjin, China
| | - Mingfeng Zhao
- Hematology Department, Tianjin First Central Hospital, Tianjin, China
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15
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Liu X, Aoki M, Osa S, Ito C, Saiki R, Nagai T, Enoki Y, Taguchi K, Matsumoto K. Safety of linezolid in patients with decreased renal function and trough monitoring: a systematic review and meta-analysis. BMC Pharmacol Toxicol 2022; 23:89. [PMID: 36451204 PMCID: PMC9714190 DOI: 10.1186/s40360-022-00628-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/16/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Linezolid causes hematological toxicity, mostly thrombocytopenia, which leads to treatment discontinuation and failure. Recent studies revealed that during linezolid therapy, the incidence of treatment-related hematological toxicity is significantly higher in patients with decreased renal function (DRF) than in those with normal renal function. Linezolid monitoring is necessary due to the high frequency of hematological toxicity in patients with DRF and the relationship between blood concentration and safety. We performed a systematic review and meta-analysis to evaluate the safety correlation between DRF and trough monitoring. METHODS Articles published before June 24, 2022, on MEDLINE, Web of Sciences, Cochrane Register of Controlled Trials, and ClinicalTrials.gov were systematically analyzed. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method and the variable effects model. RESULTS The incidence of hematological toxicity was significantly higher in patients with DRF than in those without DRF (OR = 2.37; p < 0.001). Subgroup analysis, performed according to hematotoxicity classification, including thrombocytopenia, anemia, and pancytopenia, revealed a significantly higher incidence of thrombocytopenia (OR = 2.45; p < 0.001) and anemia (OR = 2.31; p = 0.006) in patients with DRF than in those without; pancytopenia (OR = 1.41; p = 0.80) incidences were not significantly higher. Based on a systematic review, linezolid trough concentrations > 6-7 μg/mL may be associated with an increased incidence of thrombocytopenia. However, no confidential threshold values for the development of thrombocytopenia were found in the area under the concentration curve values for children or adults. CONCLUSION We observed a high frequency of hematological toxicity during linezolid therapy in patients with DRF. To ensure safety, linezolid trough concentrations should be ≤6-7 μg/mL.
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Affiliation(s)
- Xiaoxi Liu
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Mari Aoki
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Sumika Osa
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Chihiro Ito
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Reika Saiki
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Tomoya Nagai
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Yuki Enoki
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Kazuaki Taguchi
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
| | - Kazuaki Matsumoto
- grid.26091.3c0000 0004 1936 9959Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30, Shibakoen, Minato-ku, Tokyo, 105-8512 Japan
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16
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Matsumoto K, Samura M, Tashiro S, Shishido S, Saiki R, Takemura W, Misawa K, Liu X, Enoki Y, Taguchi K. Target Therapeutic Ranges of Anti-MRSA Drugs, Linezolid, Tedizolid and Daptomycin, and the Necessity of TDM. Biol Pharm Bull 2022; 45:824-833. [PMID: 35786589 DOI: 10.1248/bpb.b22-00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The target therapeutic ranges of vancomycin, teicoplanin, and arbekacin have been determined, and therapeutic drug monitoring (TDM) is performed in clinical practice. However, TDM is not obligatory for daptomycin, linezolid, or tedizolid. In this study, we examined whether TDM will be necessary for these 3 drugs in the future. There was no significant difference in therapeutic effects on acute bacterial skin and skin structure infection between linezolid and tedizolid by meta-analysis. Concerning the therapeutic effects on pneumonia, the rate of effectiveness after treatment with tedizolid was significantly lower than with linezolid. With respect to safety, the incidences of gastrointestinal adverse events and blood/lymphatic system disorders related to tedizolid were significantly lower than those related to linezolid. Linezolid exhibits potent therapeutic effects on pneumonia, but the appearance of adverse reactions is indicated as a problem. There was a dose-dependent decrease in the platelet count, and the target trough concentration (Ctrough) was estimated to be 4-6 or 2-7 µg/mL in accordance with the patient's condition. The efficacy of linezolid may be obtained while minimizing the appearance of adverse reactions by performing TDM. The target therapeutic range of tedizolid cannot be achieved in immunocompromised or severe patients. Therefore, we concluded that TDM was unnecessary, considering step-down therapy with oral drugs, use in non-severe patients, and high-level safety. Concerning daptomycin, high-dose administration is necessary to achieve an area under the curve (AUC) of ≥666 as an index of efficacy. To secure its safety, Ctrough (<20 µg/mL) monitoring is important. Therefore, TDM is necessary.
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Affiliation(s)
| | - Masaru Samura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Sho Tashiro
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Shino Shishido
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Reika Saiki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Wataru Takemura
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Kana Misawa
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Xiaoxi Liu
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Yuki Enoki
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
| | - Kazuaki Taguchi
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy
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17
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Abstract
In recent years, many studies on population pharmacokinetics of linezolid have been conducted. This comprehensive review aimed to summarize population pharmacokinetic models of linezolid, by focusing on dosage optimization to maximize the probability of attaining a certain pharmacokinetic-pharmacodynamic parameter in special populations. We searched the PubMed and EMBASE databases for population pharmacokinetic analyses of linezolid using a parametric non-linear mixed-effect approach, including both observational and prospective trials. Of the 32 studies, 26 were performed in adults, four in children, and one in both adults and children. High between-subject variability was determined in the majority of the models, which was in line with the variability of linezolid concentrations previously detected in observational studies. Some studies found that patients with renal impairment, hepatic failure, advanced age, or low body weight had higher exposure and adverse reactions rates. In contrast, lower concentrations and therapeutic failure were associated with obese patients, young patients, and patients who had undergone renal replacement techniques. In critically ill patients, the inter-individual and intra-individual variability was even greater, suggesting that this population is at an even higher risk of underexposure and overexposure. Therapeutic drug monitoring may be warranted in a large proportion of patients given that the Monte Carlo simulations demonstrated that the one-size-fits-all labeled dosing of 600 mg every 12 h could lead to toxicity or therapeutic failure for high values of the minimum inhibitory concentration of the target pathogen. Further research on covariates, including renal function, hepatic function, and drug–drug interactions related to P-glycoprotein could help to explain variability and improve linezolid dosing regimens.
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18
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Bu X, Zhou J. Effects of linezolid on the haematological system in very low birth weight infants: A single‐centre retrospective study. J Clin Pharm Ther 2022; 47:1181-1185. [PMID: 35312093 DOI: 10.1111/jcpt.13652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Xinghe Bu
- Department of Neonatology Children’s Hospital of Fudan University National Children’s Medical Center Shanghai China
| | - Jianguo Zhou
- Department of Neonatology Children’s Hospital of Fudan University National Children’s Medical Center Shanghai China
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19
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Population pharmacokinetics and toxicodynamics of continuously infused linezolid in critically-ill patients. Int J Antimicrob Agents 2022; 59:106572. [DOI: 10.1016/j.ijantimicag.2022.106572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 03/07/2022] [Accepted: 03/13/2022] [Indexed: 11/23/2022]
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20
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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21
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Dose Optimization of Combined Linezolid and Fosfomycin against Enterococcus by Using an In Vitro Pharmacokinetic/Pharmacodynamic Model. Microbiol Spectr 2021; 9:e0087121. [PMID: 34851157 PMCID: PMC8635129 DOI: 10.1128/spectrum.00871-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The rapid spread of antibiotic resistance among Enterococcus has prompted considerable interest in determining the dosage regimen of linezolid combined with fosfomycin. A checkerboard assay was employed to evaluate whether linezolid combined with fosfomycin had a synergistic effect on Enterococcus isolates from the hospital, including three drug-resistant strains (MIC of linezolid [MICLZD], ≥8 mg/L; MIC of fosfomycin [MICFOF], ≥256 mg/L). The in vitro static time-kill assay, dynamic pharmacokinetic (PK)/pharmacodynamic (PD) model, and semimechanistic PK/PD model were used to explore and predict effective combined dosage regimens. The checkerboard assay and in vitro static time-kill assay demonstrated that linezolid combined with fosfomycin has a synergistic effect on drug-resistant and sensitive Enterococcus. In the in vitro PK/PD model, the dosage regimen of linezolid (8 mg/L or 12 mg/L, steady-state concentration) combined with fosfomycin (6 g or 8 g) via a 0.5-h infusion every 8 h effectively suppressed bacterial growth at 24 h with a 3 log10 CFU/mL decrease compared with the initial inocula against two resistant and one sensitive Enterococcus isolates. The semimechanistic PK/PD model predicted that linezolid (more than 16 mg/L) combined with fosfomycin (6 g or 10 g) via a 0.5-h infusion every 8 h was required to achieve a 4 log10 CFU/mL decrease at 24 h against Enterococcus isolates (MICLZD ≥ 8 mg/L and MICFOF ≥ 256 mg/L). According to the prediction of the semimechanical PK/PD model, the effect of the combination was driven by linezolid, with fosfomycin enhancing the effect. Our study is the first to explore the synergistic effects of these two drugs from a qualitative and quantitative perspective and provides a simulation tool for future studies. IMPORTANCE In this study, we found that linezolid combined with fosfomycin could kill Enterococcus in vitro and that the administered dose was significantly lower after the combination treatment, which could reduce adverse effects and the development of drug resistance. The potential mechanism of the two-drug combination against Enterococcus was revealed from a quantitative perspective, which is an important step toward dose optimization in simulated humans. We hope that our research will help build a better relationship between clinicians and patients as we work together to address the challenges of antibiotic resistance in the 21st century.
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22
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Linezolid Population Pharmacokinetics in South African Adults with Drug-Resistant Tuberculosis. Antimicrob Agents Chemother 2021; 65:e0138121. [PMID: 34543098 DOI: 10.1128/aac.01381-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Linezolid is widely used for drug-resistant tuberculosis (DR-TB) but has a narrow therapeutic index. To inform dose optimization, we aimed to characterize the population pharmacokinetics of linezolid in South African participants with DR-TB and explore the effect of covariates, including HIV coinfection, on drug exposure. Data were obtained from pharmacokinetic substudies in a randomized controlled trial and an observational cohort study, both of which enrolled adults with drug-resistant pulmonary tuberculosis. Participants underwent intensive and sparse plasma sampling. We analyzed linezolid concentration data using nonlinear mixed-effects modeling and performed simulations to estimate attainment of putative efficacy and toxicity targets. A total of 124 participants provided 444 plasma samples; 116 were on the standard daily dose of 600 mg, while 19 had dose reduction to 300 mg due to adverse events. Sixty-one participants were female, 71 were HIV-positive, and their median weight was 56 kg (interquartile range [IQR], 50 to 63). In the final model, typical values for clearance and central volume were 3.57 liters/h and 40.2 liters, respectively. HIV coinfection had no significant effect on linezolid exposure. Simulations showed that 600-mg dosing achieved the efficacy target (area under the concentration-time curve for the free, unbound fraction of the drug [[Formula: see text] at a MIC level of 0.5 mg/liter) with 96% probability but had 56% probability of exceeding safety target ([Formula: see text]. The 300-mg dose did not achieve adequate efficacy exposures. Our model characterized population pharmacokinetics of linezolid in South African patients with DR-TB and supports the 600-mg daily dose with safety monitoring.
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23
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Fang J, Zhang XS, Zhang CH, Zhou ZY, Han L, Wang YX, He XS, Bian XL, Lin GY, Jiao Z, Dai Y, Yu XB, Pan JY. Model Based Identification of Linezolid Exposure-toxicity Thresholds in Hospitalized Patients. Front Pharmacol 2021; 12:732503. [PMID: 34675806 PMCID: PMC8525462 DOI: 10.3389/fphar.2021.732503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Evidence supports linezolid therapeutic drug monitoring as the exposure-response relationship has been identified for toxicity among patients receiving linezolid, but the data to establish the upper limit are limited and the published toxicity thresholds range widely. The purpose of this study was to determine the linezolid exposure-toxicity thresholds to improve the safety of linezolid. This is a multicenter retrospective study of adult patients treated with linezolid from 2018 to 2019. The population pharmacokinetic model of linezolid was established based on 270 plasma concentrations in 152 patients, which showed creatinine clearance and white cell count are covariates affecting the clearance of linezolid, and serum albumin is the covariate affecting the volume of distribution. Classification and regression tree analysis was used to determine the linezolid exposure thresholds associated with an increased probability of toxicity. Among 141 patients included for toxicity analysis, the rate of occurring toxicity was significantly higher among patients with an AUC0-24, d1 ≥163 mg h/L, AUC0-24, d2 ≥207 mg h/L, AUC0-24, ss ≥210 mg h/L, and Cmin,d2 ≥6.9 mg/L, Cmin,ss ≥6.9 mg/L, while no threshold was discovered for Cmin, d1. Those exposure thresholds and duration of linezolid treatment were independently associated with linezolid-related toxicity in the logistic regression analyses. In addition, the predictive performance of the AUC0-24 and Cmin thresholds at day 2 and steady state were close. Considering that the AUC estimation is cumbersome, Cmin threshold at 48 h and steady state with a value of ≥6.9 mg/L is recommended to improve safety, especially for patients with renal insufficiency and patients with low serum albumin.
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Affiliation(s)
- Jie Fang
- Department of Pharmacy, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Shan Zhang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China.,Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chun-Hong Zhang
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zi-Ye Zhou
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lu Han
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Ye-Xuan Wang
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, China
| | - Xiao-Shuang He
- Department of Pharmacy, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Lan Bian
- Department of Pharmacy, School of Medicine, Ruijin Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Guan-Yang Lin
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Dai
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xu-Ben Yu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jing-Ye Pan
- Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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24
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Tietjen AK, Kroemer N, Cattaneo D, Baldelli S, Wicha SG. Population pharmacokinetics and target attainment analysis of linezolid in multidrug-resistant tuberculosis patients. Br J Clin Pharmacol 2021; 88:1835-1844. [PMID: 34622478 DOI: 10.1111/bcp.15102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 01/02/2023] Open
Abstract
AIM This study investigates the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of linezolid in patients infected with multidrug-resistant (MDR) tuberculosis (TB). METHODS A pharmacometric model was developed including 244 timed linezolid concentration samples from 39 patients employing NONMEM 7.4. The probability of target attainment (PTA, PK/PD target: unbound (f) area-under-the-concentration-time-curve (AUC)/minimal inhibitory concentration (MIC) of 119) as well as a region-specific cumulative fraction of response (CFR) were estimated for different dosing regimens. RESULTS A one-compartment model with linear elimination with a clearance (CL) of 7.69 L/h (interindividual variability 34.1%), a volume of distribution (Vd) of 45.2 L and an absorption constant (KA) of 0.679 h-1 (interoccasion variability 143.7%) allometric scaled by weight best described the PK of linezolid. The PTA at an MIC of 0.5 mg/L was 55% or 97% if patients receiving 300 or 600 mg twice daily, respectively. CFRs varied greatly among populations and geographic regions. A desirable global CFR of ≥90% was achieved if linezolid was administered at a dose of 600 mg twice daily but not at a dose of 300 mg twice daily. CONCLUSION This study showed that a dose of 300 mg twice daily of linezolid might not be sufficient to treat MDR-TB patients from a PK/PD perspective. Thus, it might be recommendable to start with a higher dose of 600 mg twice daily to ensure PK/PD target attainment. Hereby, therapeutic drug monitoring and MIC determination should be performed to control PK/PD target attainment as linezolid shows high variability in its PK in the TB population.
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Affiliation(s)
- Anna K Tietjen
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.,University of Lübeck, Lübeck, Germany
| | - Niklas Kroemer
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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25
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Imperial MZ, Nedelman JR, Conradie F, Savic RM. Proposed linezolid dosing strategies to minimize adverse events for treatment of extensively drug-resistant tuberculosis. Clin Infect Dis 2021; 74:1736-1747. [PMID: 34604901 PMCID: PMC9155613 DOI: 10.1093/cid/ciab699] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We evaluated clinical trial data (Nix-TB, NCT02333799) to provide data-driven dosing recommendations to potentially minimize linezolid toxicity in patients with extensively drug-resistant tuberculosis. METHODS Based on 104 participants, a pharmacokinetic model and toxicodynamic models for peripheral neuropathy, hemoglobin, and platelets were developed. Simulations compared safety outcomes for daily linezolid of 1200 and 600 mg, with and without dose adjustments for toxicity. Severe neuropathy was based on symptom scores from the Brief Peripheral Neuropathy Screen. Severe anemia and thrombocytopenia were defined as ≥grade 3 adverse events according to the Division of Microbiology and Infectious Disease Adult Toxicity table. RESULTS Predicted individual concentration-time profiles were a major predictor in all three toxicodynamic models. Simulations showed higher percentages of patients with severe neuropathy (median: 19% (90%CI: 17-22%) vs 5% (4-7%)) and severe anemia (15% (12-17%) vs 1% (0-2%)) between 1200 and 600 mg daily linezolid. No differences in severe thrombocytopenia were observed (median: <1% for both daily doses). Generally, neuropathy occurred after 3 to 6 months of treatment and, with protocol-specified management, reversed within 15 months after onset. Simulations indicated that a >10% decrease from pretreatment in hemoglobin level after 4 weeks of treatment would have maximum sensitivity (82%) and specificity (84%) for predicting severe anemia. Reducing dose from 1200 to 600 mg triggered by this marker may prevent 60% (90%CI: 45-72) of severe anemia. CONCLUSIONS Simple neuropathy symptom and hemoglobin monitoring may guide linezolid dosing to avoid toxicities, but prospective testing is needed to confirm benefit-to-risk ratio.
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Affiliation(s)
- Marjorie Z Imperial
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy, University of California, San Francisco, CA, USA
| | | | - Francesca Conradie
- Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Rada M Savic
- Department of Bioengineering and Therapeutic Sciences, Schools of Pharmacy, University of California, San Francisco, CA, USA
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26
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Tsuji Y. Hospital Pharmacometrics for Optimal Individual Administration of Antimicrobial Agents for Anti-methicillin-resistant Staphylococcus aureus Infected Patients. Biol Pharm Bull 2021; 44:1174-1183. [PMID: 34471044 DOI: 10.1248/bpb.b21-00002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Therapeutic drug monitoring and target concentration intervention based on population pharmacokinetic and pharmacodynamic models has been strongly recommended for anti-methicillin-resistant Staphylococcus aureus (MRSA) agents in order to provide appropriate antimicrobial chemotherapy to each individual patient, and pharmacokinetic and pharmacodynamic analyses in hospitalized patients have been actively conducted, as evidenced with vancomycin. Teicoplanin, daptomycin, and linezolid have been the most studied antibiotics, using population pharmacokinetics of patients with MRSA. Infections caused by MRSA have higher severity and fatality rates than other antimicrobial-susceptible infections. Therefore, many medical facilities have been implementing infection control programs based on antimicrobial stewardship to prevent nosocomial infections and drug-resistant strains. Studies detailing pharmacometrics for these antibiotics have been reported to elucidate the pharmacokinetic and pharmacodynamic properties, to determine significant factors influencing variabilities between individuals, and to develop target concentration interventions and dosing regimens for adults, the elderly, patients with renal insufficiency including those on continuous renal replacement therapies, patients with low body weight, obese patients, and pediatric patients. This review presents the details of our recent research on the optimal dosing design of antimicrobial agents for the treatment of MRSA infection based on hospital pharmacometrics. In addition, the prospect of using modeling and simulation has shown major advantages in supporting dosing regimen selection.
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Affiliation(s)
- Yasuhiro Tsuji
- Center for Pharmacist Education, School of Pharmacy, Nihon University
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27
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Shi C, Xia J, Ye J, Xie Y, Jin W, Zhang W, Wang L, Ding X, Lin N, Wang L. Effect of renal function on the risk of thrombocytopenia in patients receiving linezolid therapy: a systematic review and meta-analysis. Br J Clin Pharmacol 2021; 88:464-475. [PMID: 34192814 PMCID: PMC9292275 DOI: 10.1111/bcp.14965] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/03/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022] Open
Abstract
Aims The association of renal function and linezolid‐induced thrombocytopaenia (LIT) remains controversial. We performed a meta‐analysis to determine whether impaired renal function is associated with an increased LIT risk. Methods We conducted a systematic search of PubMed, EMBASE and the Cochrane Library from inception to February 2021 for eligible studies evaluating the relationship between renal function and LIT. Indicators of renal function included renal impairment (RI), severe RI, haemodialysis status, creatinine clearance rate (Ccr) and estimated glomerular filtration rate (eGFR). Unadjusted and adjusted estimates and 95% confidence intervals (CIs) were calculated separately using a random‐effect model. Results A total of 24 studies with 3580 patients were included in the meta‐analysis. RI patients had an increased LIT risk compared to non‐RI patients in both the unadjusted (OR 3.54; 95% CI 2.27, 5.54; I2 = 77.7%) and adjusted analyses (OR 2.51; 95% CI 1.82, 3.45; I2 = 17.9%). This association persisted in the subset of studies involving only patients receiving a fixed conventional dose (600 mg every 12 h) and other subgroup analyses by ethnicity, sample size and study quality. Moreover, the LIT risk was significantly higher in patients with severe RI and haemodialysis than in patients without severe RI and haemodialysis. The eGFR and Ccr were significantly lower in LIT patients than in non‐LIT patients. Conclusions Impaired renal function is associated with an increased risk of LIT. A reduced linezolid dose may be considered in RI patients at a low risk of treatment failure, ideally guided by therapeutic drug monitoring.
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Affiliation(s)
- Changcheng Shi
- Department of Clinical Pharmacy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junbo Xia
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian Ye
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaping Xie
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weizhong Jin
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Zhang
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liusheng Wang
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xuping Ding
- Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Nengming Lin
- Department of Clinical Pharmacy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Limin Wang
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Respiratory Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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28
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Alraish R, Wicha SG, Frey OR, Roehr AC, Pratschke J, Stockmann M, Wuensch T, Kaffarnik M. Liver function, quantified by the LiMAx test, as a predictor for the clinical outcome of critically ill patients treated with linezolid. Technol Health Care 2021; 30:309-321. [PMID: 34180433 DOI: 10.3233/thc-191847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Critically ill patients commonly suffer from infections that require antimicrobial therapy. In previous studies, liver dysfunction was shown to have an essential impact on the dose selection in these patients. This pilot study aims to assess the influence of liver dysfunction, measured by the novel LiMAx test, on clinical outcomes in critically ill patients treated with linezolid. METHODS Twenty-nine critically ill patients were included and treated with linezolid. Indications for linezolid therapy were secondary or tertiary peritonitis (46.7%), bloodstream infection (6.7%) and 46.7% were other infections with gram-positive bacteria. Linezolid Cmin, maximal liver function capacity (LiMAx test) and plasma samples were collected while linezolid therapy was in a steady-state condition. Furthermore, potential factors for the clinical outcome were investigated using logistic regression analysis. Clinical cure was defined as the resolution or significant improvement of clinical symptoms without using additional antibiotic therapy or intervention. RESULTS Cured patients presented lower median linezolid Cmin yet a significantly higher mean LiMAx-value compared to the clinical failure group (1.9 mg/L vs. 5.1 mg/L) (349 μg/kg/h vs. 131 μg/kg/h). In the logistic regression model, LiMAx < 178 μg/kg/h was the only independent predictor of clinical failure with a sensitivity of 77% and specificity of 93%. CONCLUSIONS The LiMAx test predicts clinical failure more precisely than linezolid trough levels in critically ill surgical patients. Therefore liver failure may have a stronger impact on the outcome of critically ill surgical patients than low linezolid Cmin. While linezolid Cmin failed to predict patient's outcome, LiMAx results were the only independent predictor of clinical failure.
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Affiliation(s)
- Rawan Alraish
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany
| | - Otto R Frey
- Klinikum Heidenheim, Clinical Pharmacy, 89522 Heidenheim, Germany
| | - Anka C Roehr
- Klinikum Heidenheim, Clinical Pharmacy, 89522 Heidenheim, Germany
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Martin Stockmann
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Tilo Wuensch
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Magnus Kaffarnik
- Charité - Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte/Campus Virchow-Klinikum, 13353 Berlin, Germany
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29
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Wang Y, Gu EM, Du X, Xu RA, Lin G. A Novel UPLC-MS/MS Assay for the Measurement of Linezolid and its Metabolite PNU-142300 in Human Serum and its Application to Patients With Renal Insufficiency. Front Pharmacol 2021; 12:641872. [PMID: 34093181 PMCID: PMC8173121 DOI: 10.3389/fphar.2021.641872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/05/2021] [Indexed: 12/29/2022] Open
Abstract
The contribution of the metabolites of linezolid to the associated myelosuppression is unknown in patients who are renal impairment. In this research, the purpose of our experiment was to explore and develop a quick and robust ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) assay for the determination of linezolid and its metabolite PNU-142300 in human serum simultaneously. The analytes were prepared using a simple and convenient approach with acetonitrile for protein crash, and then separated from the matrix on a Waters Acquity Ultra performance liquid chromatography (UPLC) BEH C18 (2.1 mm × 50 mm, 1.7 μm) column in a program of gradient elution, where the mobile phase was consisted of water with 0.1% formic acid and acetonitrile, and was placed at 0.40 ml/min flow rate. Multiple reaction monitoring (MRM) was employed and conducted for UPLC-MS/MS detection with ion transitions at m/z 338.01 → 296.03 for linezolid, m/z 369.96 → 327.98 for PNU-142300 and m/z 370.98 → 342.99 for tedizolid (Internal standard, IS), respectively. This method had good linearity respectively in the calibration range of 0.01–20 μg/ml for linezolid, and 0.05–100 μg/ml for PNU-142300. In the intra- and inter-day, the precision of linezolid and PNU-142300 was below 14.2%, and the accuracy in this method was determined to be from −9.7 to 12.8%. In addition, recovery and matrix effect of the analytes were all found to be acceptable, and the analytes during the assay and storage in serum samples were observed to be stable. The novel optimized UPLC-MS/MS assay was also successfully employed to determine the concentration levels of linezolid and PNU-142300 in human serum. The results showed that linezolid-associated myelosuppression occurs more frequently in patients with renal insufficiency, and the metabolite-to-parent concentration ratio of PNU-142300 is predicted to reduce this toxicity of myelosuppression.
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Affiliation(s)
- Yingying Wang
- Department of pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Er-Min Gu
- The First People's Hospital of Jiashan, Jiaxing, China
| | - Xiaoxiang Du
- Department of pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ren-Ai Xu
- Department of pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Guanyang Lin
- Department of pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Dosage Individualization of Linezolid: Precision Dosing of Linezolid To Optimize Efficacy and Minimize Toxicity. Antimicrob Agents Chemother 2021; 65:AAC.02490-20. [PMID: 33820765 DOI: 10.1128/aac.02490-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/18/2021] [Indexed: 01/02/2023] Open
Abstract
The high interindividual variability in the pharmacokinetics (PK) of linezolid has been described, which results in an unacceptably high proportion of patients with either suboptimal or potentially toxic concentrations following the administration of a fixed regimen. The aim of this study was to develop a population pharmacokinetic model of linezolid and use this to build and validate alogorithms for individualized dosing. A retrospective pharmacokinetic analysis was performed using data from 338 hospitalized patients (65.4% male, 65.5 [±14.6] years) who underwent routine therapeutic drug monitoring for linezolid. Linezolid concentrations were analyzed by using high-performance liquid chromatography. Population pharmacokinetic modeling was performed using a nonparametric methodology with Pmetrics, and Monte Carlo simulations were employed to calculate the 100% time >MIC after the administration of a fixed regimen of 600 mg administered every 12 h (q12h) intravenously (i.v.). The dose of linezolid needed to achieve a PTA ≥ 90% for all susceptible isolates classified according to EUCAST was estimated to be as high as 2,400 mg q12h, which is 4 times higher than the maximum licensed linezolid dose. The final PK model was then used to construct software for dosage individualization, and the performance of the software was assessed using 10 new patients not used to construct the original population PK model. A three-compartment model with an absorptive compartment with zero-order i.v. input and first-order clearance from the central compartment best described the data. The dose optimization software tracked patients with a high degree of accuracy. The software may be a clinically useful tool to adjust linezolid dosages in real time to achieve prespecified drug exposure targets. A further prospective study is needed to examine the potential clinical utility of individualized therapy.
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Rao GG, Konicki R, Cattaneo D, Alffenaar JW, Marriott DJE, Neely M. Therapeutic Drug Monitoring Can Improve Linezolid Dosing Regimens in Current Clinical Practice: A Review of Linezolid Pharmacokinetics and Pharmacodynamics. Ther Drug Monit 2021; 42:83-92. [PMID: 31652190 DOI: 10.1097/ftd.0000000000000710] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Linezolid is an antibiotic used to treat infections caused by drug-resistant gram-positive organisms, including vancomycin-resistant Enterococcus faecium, multi-drug resistant Streptococcus pneumoniae, and methicillin-resistant Staphylococcus aureus. The adverse effects of linezolid can include thrombocytopenia and neuropathy, which are more prevalent with higher exposures and longer treatment durations. Although linezolid is traditionally administered at a standard 600 mg dose every 12 hours, the resulting exposure can vary greatly between patients and can lead to treatment failure or toxicity. The efficacy and toxicity of linezolid are determined by the exposure achieved in the patient; numerous clinical and population pharmacokinetics (popPK) studies have identified threshold measurements for both parameters. Several special populations with an increased need for linezolid dose adjustments have also been identified. Therapeutic Drug Monitoring (TDM) is a clinical strategy that assesses the response of an individual patient and helps adjust the dosing regimen to maximize efficacy while minimizing toxicity. Adaptive feedback control and model-informed precision dosing are additional strategies that use Bayesian algorithms and PK models to predict patient-specific drug exposure. TDM is a very useful tool for patient populations with sparse clinical data or known alterations in pharmacokinetics, including children, patients with renal insufficiency or those receiving renal replacement therapy, and patients taking co-medications known to interact with linezolid. As part of the clinical workflow, clinicians can use TDM with the thresholds summarized from the current literature to improve linezolid dosing for patients and maximize the probability of treatment success.
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Affiliation(s)
- Gauri G Rao
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Robyn Konicki
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Jan-Willem Alffenaar
- University of Sydney, Faculty of Medicine and Health, School of Pharmacy.,Westmead Hospital, Sydney, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Deborah J E Marriott
- Department of Clinical Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael Neely
- Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children's Hospital Los Angeles; and.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Ogami C, Tsuji Y, Nishi Y, Kawasuji H, To H, Yamamoto Y. External Evaluation of Population Pharmacokinetics and Pharmacodynamics in Linezolid-Induced Thrombocytopenia: The Transferability of Published Models to Different Hospitalized Patients. Ther Drug Monit 2021; 43:271-278. [PMID: 33009290 DOI: 10.1097/ftd.0000000000000816] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The objective of this study was to perform an external evaluation of published linezolid population pharmacokinetic and pharmacodynamic models, to evaluate the predictive performance using an independent data set. Another aim was to offer an elegant environment for display and simulation of both the concentration and platelet count after linezolid administration. METHODS We performed a systematic literature search in PubMed for all studies evaluating the population pharmacokinetic and pharmacodynamic parameters of linezolid in patients and selected the models to be used for the external validation. The bias of predictions was visually evaluated by plotting prediction errors (PEs) and relative PEs. The precision of prediction was evaluated by calculating the mean absolute error (MAE), root mean squared error (RMSE), and mean relative error (MRE). RESULTS Three articles (models A, B, and C) provided linezolid-induced platelet dynamic models using population pharmacokinetic and pharmacodynamic modeling approaches. The PE and relative PE of both linezolid concentrations and platelet counts for models A and C showed similar predictive distributions. With respect to the prediction accuracy of total linezolid concentration, the MAE, RMSE, and MRE of population prediction values for model C was the smallest. The comparison of the MAE, RMSE, and MRE of patient-individual prediction values for the 3 pharmacodynamic models revealed no large differences. CONCLUSIONS We confirmed the transferability of published population pharmacokinetic and pharmacodynamic models and showed that they were suitable for extrapolation to other hospitals and/or patients. This study also introduced application software based on model C for the therapeutic drug monitoring of linezolid.
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Affiliation(s)
- Chika Ogami
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama
| | - Yasuhiro Tsuji
- Center for Pharmacist Education, School of Pharmacy, Nihon University, Funabashi, Chiba
| | - Yoshifumi Nishi
- Division of Hospital Safety Management, Kyorin University Hospital, Mitaka
- Department of Pharmaceutical Sciences, International University of Health and Welfare, Otawara; and
| | - Hitoshi Kawasuji
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Hideto To
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
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Kawasuji H, Tsuji Y, Ogami C, Kimoto K, Ueno A, Miyajima Y, Kawago K, Sakamaki I, Yamamoto Y. Proposal of initial and maintenance dosing regimens with linezolid for renal impairment patients. BMC Pharmacol Toxicol 2021; 22:13. [PMID: 33663616 PMCID: PMC7934392 DOI: 10.1186/s40360-021-00479-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/21/2021] [Indexed: 01/15/2023] Open
Abstract
Background Linezolid is administered as a fixed dose to all patients despite evidence of overexposure and thrombocytopenia in renal impairment. The aims of this study were to evaluate the risk of thrombocytopenia and the utility of therapeutic drug monitoring (TDM), and to propose alternate dosing regimens in patients with renal impairment. Methods We retrospectively reviewed patients ≥13 years old for whom serum linezolid trough concentration (Cmin) was measured during linezolid treatment. Patients with episodes of infection were divided into groups by presence of renal impairment (RI group) or absence of renal impairment (non-RI group), and by use of Cmin-based TDM (TDM group) or not (non-TDM group) during linezolid treatment. Results In the 108 patients examined by multivariable analyses, renal impairment was independently associated with increased risk of thrombocytopenia (OR 3.17, 95%CI 1.10–9.12) and higher Cmin. Analysis of the utility of TDM in the RI group showed that clinical failure rate was significantly lower in the TDM subgroup than in the non-TDM subgroup. Furthermore, in the RI group, dosage adjustments were needed in 90.5% of the TDM subgroup. All episodes administered a reduced dose of 300 mg every 12 h in the RI group showed Cmin ≥ 2.0 mg/L. Additional analysis of 53 episodes in which Cmin was measured within 48 h after starting administration showed that the initial standard dose for 2 days was sufficient to rapidly reach an effective therapeutic concentration in the RI group. Conclusions Empirical dose reduction to 300 mg every 12 h after administration of the initial fixed dose for 2 days and Cmin-based TDM may improve safety outcomes while maintaining appropriate efficacy among patients with renal impairment. Supplementary Information The online version contains supplementary material available at 10.1186/s40360-021-00479-w.
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Affiliation(s)
- Hitoshi Kawasuji
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yasuhiro Tsuji
- Center for Pharmacist Education, School of Pharmacy, Nihon University, 7-7-1 Narashinodai, Chiba, 274-8555, Japan
| | - Chika Ogami
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kou Kimoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Akitoshi Ueno
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yuki Miyajima
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Koyomi Kawago
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Ippei Sakamaki
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, 2630 Sugitani, Toyama, 930-0194, Japan.
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Chua HC, Tse A, Smith NM, Mergenhagen KA, Cha R, Tsuji BT. Combatting the Rising Tide of Antimicrobial Resistance: Pharmacokinetic/Pharmacodynamic Dosing Strategies for Maximal Precision. Int J Antimicrob Agents 2021; 57:106269. [PMID: 33358761 DOI: 10.1016/j.ijantimicag.2020.106269] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/09/2020] [Accepted: 12/13/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Antimicrobial pharmacokinetics/pharmacodynamics (PK/PD) principles and PK/PD models have been essential in characterizing the mechanism of antibiotic bacterial killing and determining the most optimal dosing regimen that maximizes clinical outcomes. This review summarized the fundamentals of antimicrobial PK/PD and the various types of PK/PD experiments that shaped the utilization and dosing strategies of antibiotics today. METHODS Multiple databases - including PubMed, Scopus, and EMBASE - were searched for published articles that involved PK/PD modelling and precision dosing. Data from in vitro, in vivo and mechanistic PK/PD models were reviewed as a basis for compiling studies that guide dosing regimens used in clinical trials. RESULTS Literature regarding the utilization of exposure-response analyses, mathematical modelling and simulations that were summarized are able to provide a better understanding of antibiotic pharmacodynamics that influence translational drug development. Optimal pharmacokinetic sampling of antibiotics from patients can lead to personalized dosing regimens that attain target concentrations while minimizing toxicity. Thus the development of a fully integrated mechanistic model based on systems pharmacology can continually adapt to data generated from clinical responses, which can provide the framework for individualized dosing regimens. CONCLUSIONS The promise of what PK/PD can provide through precision dosing for antibiotics has not been fully realized in the clinical setting. Antimicrobial resistance, which has emerged as a significant public health threat, has forced clinicians to empirically utilize therapies. Future research focused on implementation and translation of PK/PD-based approaches integrating novel approaches that combine knowledge of combination therapies, systems pharmacology and resistance mechanisms are necessary. To fully realize maximally precise therapeutics, optimal PK/PD strategies are critical to maximize antimicrobial efficacy against extremely-drug-resistant organisms, while minimizing toxicity.
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Affiliation(s)
- Hubert C Chua
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA; VA Western New York Healthcare System, Buffalo, NY, USA
| | - Andy Tse
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Nicholas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | | | - Raymond Cha
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA; New York State Center for Excellence in Life Sciences and Bioinformatics, Buffalo, NY, USA.
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Classification Tree Analysis Based On Machine Learning for Predicting Linezolid-Induced Thrombocytopenia. J Pharm Sci 2021; 110:2295-2300. [PMID: 33609520 DOI: 10.1016/j.xphs.2021.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/30/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
Linezolid-induced thrombocytopenia is related to linezolid exposure, baseline platelet count and patient background. Although the relationship usually reflects the time of onset of thrombocytopenia, if the platelet maturation process is taken into account, the platelet decrease can be considered to have started at the beginning of treatment. To predict linezolid-induced thrombocytopenia, classification and regression tree (CART) analysis based on machine learning has been applied to identify predictive factors and cutoff values. We examined 74 patient data with or without linezolid-induced thrombocytopenia. Linezolid concentration and platelet count change, baseline platelet count, age, body weight and creatinine clearance estimate were evaluated as predictive factors for linezolid-induced thrombocytopenia. CART analysis selected the final tree containing two cutoff values: a platelet count reduction to less than 2.3% from baseline at 96 h after the initial dose and a linezolid concentration greater than or equal to 13.5 mg/L at 96 h after the initial dose. The targets for therapeutic intervention were concluded to be the linezolid concentration and the platelet change from baseline at 96 h after the initial dose. These cutoff values occur prior to the onset of thrombocytopenia and should be monitored to avoid linezolid-induced thrombocytopenia.
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Dai Y, Jiang S, Chen X, Han L, Zhang C, Yu X, Zhang X. Analysis of the risk factors of linezolid-related haematological toxicity in Chinese patients. J Clin Pharm Ther 2021; 46:807-813. [PMID: 33555057 DOI: 10.1111/jcpt.13359] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Haematological toxicity including thrombocytopenia, anaemia and leucopenia is the main adverse events of linezolid (LZD) therapy. This study aimed to investigate the risk factors for LZD-induced haematological toxicity and define the threshold of plasma trough concentration to minimize the haematological toxicity. METHODS 145 patients who received LZD for more than 10 days were retrospectively reviewed to determine the incidence of LZD-induced haematological toxicity. Meanwhile, the risk factors of haematological toxicity were confirmed by univariate and multivariate logistic regression analysis. RESULTS AND DISCUSSION 9 (6.2%) patients developed leucopenia, while 52 (35.9%) and 26 (17.9%) patients developed thrombocytopenia and anaemia, respectively. The estimated glomerular filtration rate (eGFR) <90 ml/min/1.73 m2 (OR, 2.744; 95% CI, 1.117-6.734; p = 0.028) and baseline platelet count <200 × 109 /L (OR, 6.817; 95% CI, 2.870-16.193; p < 0.0001) were found to be significant risk factors for LZD-related thrombocytopenia. Aspartate aminotransferase (AST) >80 U/L (OR, 4.844; 95% CI, 1.207-19.451; p = 0.026) and eGFR <90 ml/min/1.73 m2 (OR, 7.132; 95% CI, 2.088-24.357; p = 0.002) were the risk factors for LZD-related anaemia. However, no significant risk factors were identified for LZD-related leucopenia. Moreover, LZD plasma trough concentration >8 mg/L [OR, 3.047; 95% CI, 1.233-7.539; p = 0.016] could be a predictor for the development of thrombocytopenia and anaemia. WHAT IS NEW AND CONCLUSION Hepatic and/or renal dysfunction are the risk factors for LZD-related haematological toxicity, while the target plasma trough concentration within 8 mg/L via dose reduction could minimize the haematological toxicity induced by LZD.
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Affiliation(s)
- Ying Dai
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of National Drug Cinical Trial Institute, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Shuying Jiang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of Pharmacy, Taizhou Municipal Central Hospital, Taizhou, Zhejiang, China
| | - Xiaoou Chen
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Lu Han
- Department of Pharmacy, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Chunhong Zhang
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xuben Yu
- Department of Pharmacy, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of National Drug Cinical Trial Institute, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiuhua Zhang
- Department of National Drug Cinical Trial Institute, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.,Department of Pharmacy, Wenzhou Medical University, Wenzhou, Zhejiang, China
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Evaluation of Linezolid Pharmacokinetics in Critically Ill Obese Patients with Severe Skin and Soft Tissue Infections. Antimicrob Agents Chemother 2021; 65:AAC.01619-20. [PMID: 33257446 DOI: 10.1128/aac.01619-20] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/04/2020] [Indexed: 11/20/2022] Open
Abstract
Linezolid standard dosing is fixed at 600 mg every 12 h (q12h) for adults. Literature suggests critically ill, obese patients require higher doses. The study aim is 2-fold: (i) to describe linezolid pharmacokinetics (PK), and (ii) to evaluate if PK/pharmacodynamic (PD) target attainment is achieved with standard dosing in critically ill, obese patients with severe skin and soft tissue infections (SSTIs). Adult patients with a body mass index (BMI) of ≥30 kg/m2 and receiving intravenous (i.v.) linezolid from August 2018 to April 2019 were eligible for consent in this prospective study. Severe SSTIs were defined as necrotizing fasciitis, myonecrosis, or SSTI with sepsis syndrome. Four blood samples were collected at steady state at 1, 3, 5 h postinfusion and as a trough. Target attainment was defined as achieving area under the concentration-time curve from 0 to 24 h to MIC (AUC0-24h/MIC) of ≥100 h*mg/liter. Monte Carlo simulations were used to determine the probability of target attainment (PTA). Eleven patients were included in the study. The median BMI was 45.7 kg/m2, and median total body weight (TBW) was 136.0 kg. Seven patients received standard linezolid doses, and four received 600 mg q8h. A one-compartment model described linezolid PK. Based on AUC0-24h/MIC targets, for noncirrhotic patients at 140 kg, the PTA with standard linezolid doses was 100%, 98.8%, 34.1%, and 0% for MICs of 0.5, 1, 2, and 4 mg/liter, respectively. In conclusion, target attainment of ≥90% is not achieved with standard linezolid doses for noncirrhotic patients ≥140 kg with MICs of ≥2 mg/liter. This study adds to accumulating evidence that standard linezolid doses may not be adequate for all patients.
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Long-Term Use of Tedizolid in Osteoarticular Infections: Benefits among Oxazolidinone Drugs. Antibiotics (Basel) 2021; 10:antibiotics10010053. [PMID: 33429902 PMCID: PMC7826593 DOI: 10.3390/antibiotics10010053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background: To evaluate the efficacy and safety of long-term use of tedizolid in osteoarticular infections. Methods: Multicentric retrospective study (January 2017–March 2019) of osteoarticular infection cases treated with tedizolid. Failure: clinical worsening despite antibiotic treatment or the need of suppressive treatment. Results: Cases (n = 51; 59% women, mean age of 65 years) included osteoarthritis (n = 27, 53%), prosthetic joint infection (n = 17, 33.3%), and diabetic foot infections (n = 9, 18%); where, 59% were orthopedic device-related. Most frequent isolates were Staphylococcus spp. (65%, n = 47; S. aureus, 48%). Reasons for choosing tedizolid were potential drug-drug interaction (63%) and cytopenia (55%); median treatment duration was 29 days (interquartile range -IQR- 15–44), 24% received rifampicin (600 mg once daily) concomitantly, and adverse events were scarce (n = 3). Hemoglobin and platelet count stayed stable throughout treatment (from 108.6 g/L to 116.3 g/L, p = 0.079; and 240 × 109/L to 239 × 109/L, p = 0.942, respectively), also in the subgroup of cases with cytopenia. Among device-related infections, 33% were managed with implant retention. Median follow-up was 630 days and overall cure rate 83%; among failures (n = 8), 63% were device-related infections. Conclusions: Long-term use of tedizolid was effective, showing a better safety profile with less myelotoxicity and lower drug-drug interaction than linezolid. Confirmation of these advantages could make tedizolid the oxazolidinone of choice for most of osteoarticular infections.
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Zou D, Xu P, Zhang Y, Lu C, Wang J, Leng B, Zhang W. The first case of teeth discoloration induced by linezolid in children in China Mainland. J Infect Chemother 2020; 26:1062-1065. [DOI: 10.1016/j.jiac.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022]
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Cojutti PG, Merelli M, Bassetti M, Pea F. Proactive therapeutic drug monitoring (TDM) may be helpful in managing long-term treatment with linezolid safely: findings from a monocentric, prospective, open-label, interventional study. J Antimicrob Chemother 2020; 74:3588-3595. [PMID: 31504570 DOI: 10.1093/jac/dkz374] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/25/2019] [Accepted: 07/30/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Thrombocytopenia may be a dose-dependent adverse effect of linezolid therapy. OBJECTIVES To assess whether proactive therapeutic drug monitoring (TDM) could be helpful in preventing and/or in recovering from the occurrence of linezolid-induced thrombocytopenia during long-term treatment. METHODS This was a monocentric, prospective, open-label, interventional study conducted between June 2015 and December 2017 among adult patients receiving >10 days of linezolid therapy and undergoing proactive TDM (desired trough level 2-8 mg/L) and platelet count assessment at day 3-5 and then once weekly up to the end of treatment. RESULTS Sixty-one patients were included. Twenty-eight (45.9%) always had desired trough level (group A) and 33 (54.1%) experienced linezolid overexposure (group B) [29/33 transiently (subgroup B1) and 4/33 persistently (subgroup B2)]. No patient experienced linezolid underexposure. Median duration of treatment for the different groups ranged between 19 and 54 days. Thrombocytopenia occurred overall in 14.8% of cases (9/61). The incidence rate of thrombocytopenia was significantly lower (P=0.012) in both group A (10.7%; 3/28) and subgroup B1 (10.3%; 3/29) than in subgroup B2 (75.0%; 3/4). Thrombocytopenic patients belonging to both group A and group B1 recovered from thrombocytopenia without the need for discontinuing therapy. Multivariate linear regression analysis revealed that thrombocytopenia was independently associated with baseline platelet count and with median linezolid trough concentrations. CONCLUSIONS Proactive TDM of linezolid may be beneficial either in preventing or in recovering from dose-dependent thrombocytopenia, even when treatment lasts for more than 28 days. Larger prospective studies are warranted to confirm our findings.
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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
| | - Maria Merelli
- Clinic of Infectious Diseases, Santa Maria della Misericordia University Hospital of Udine, ASUIUD, Udine, Italy
| | - Matteo Bassetti
- Department of Medicine, University of Udine, Udine, Italy.,Clinic of Infectious Diseases, 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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Yulin Z, Lingti K, Shan G, Yong Z. A possible interaction between linezolid and digoxin: A case report of therapeutic drug monitoring. Saudi Pharm J 2020; 28:1408-1410. [PMID: 33250647 PMCID: PMC7679430 DOI: 10.1016/j.jsps.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/08/2020] [Indexed: 11/06/2022] Open
Abstract
Drug-drug interactions lead to altered clinical effects, including adverse reactions. Therapeutic drug monitoring of digoxin is necessary due to its narrow therapeutic range. Linezolid can cause variable exposures in patients hospitalized in the intensive care unit owing to its possibility of drug-drug interactions. We present a patient with pneumonia and heart failure who experienced a possible drug interaction between linezolid and digoxin, resulting in high serum concentrations of both drugs. Also, the patient developed thrombocytopenia likely related to linezolid. The linezolid dose required to maintain sufficient levels had to reduce to 50% of the usual linezolid dose. A quarter dose of the standard digoxin dose was needed. Although the underlying mechanism of the drug interaction is unclear, we recommend conducting therapeutic drug monitoring when linezolid and digoxin are administered concurrently.
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Affiliation(s)
- Zhu Yulin
- Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China.,Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Kong Lingti
- Department of Pharmacy, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Gao Shan
- Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Zhang Yong
- Pulmonary and Critical Care Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
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42
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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43
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Evaluation of the relationship between linezolid exposure and hyponatremia. J Infect Chemother 2020; 27:165-171. [PMID: 32933858 DOI: 10.1016/j.jiac.2020.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/12/2020] [Accepted: 08/23/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Aims of this study were (a) to assess the development ratio of hyponatremia during treatment with linezolid and (b) to evaluate the relationship between the risk of hyponatremia and linezolid exposure and patient background. METHOD Clinical data including linezolid serum concentrations and serum sodium values were collected at Toyama University Hospital and Kyorin University Hospital. Data from 89 patients were used for the analysis, and a nadir serum sodium level ≤130 mmol/L during the treatment with linezolid was defined as hyponatremia. Mann-Whitney's U test was used to evaluate the effects of the area under the time-concentration curve (AUC) of linezolid at the nadir sodium level, clinical characteristics (e.g. laboratory data), and baseline serum sodium levels on the development of hyponatremia. RESULTS The hyponatremia was occurred in 21 of 89 patients (23.6%). Data are compared for baseline and nadir serum sodium levels of patients with and without hyponatremia. In both groups, nadir serum sodium levels were significantly different from those of the baseline values (P < 0.05). The values of AUC0-12, accumulated AUC, baseline serum sodium levels and age were significantly different between patients with and without hyponatremia (P < 0.05). CONCLUSIONS Linezolid exposure, age, and baseline sodium levels were detected as the risk factors for linezolid-related hyponatremia. Our findings suggest that regular monitoring of serum sodium levels is desirable during treatment with linezolid, especially for the elderly and patients with low serum sodium levels before the start of linezolid administration.
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Lee BJ, Vu BN, Seddon AN, Hodgson HA, Wang SK. Treatment Considerations for CNS Infections Caused by Vancomycin-Resistant Enterococcus faecium: A Focused Review of Linezolid and Daptomycin. Ann Pharmacother 2020; 54:1243-1251. [DOI: 10.1177/1060028020932513] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: To review the current literature describing pharmacology, pharmacokinetics/pharmacodynamics (PK/PD), efficacy, and safety of linezolid and daptomycin for the treatment of central nervous system (CNS) infections caused by vancomycin-resistant Enterococcus (VRE) faecium. Data Sources: A literature search of PubMed/MEDLINE databases was conducted (from 1950 to April 2020) utilizing the following key terms: vancomycin-resistant Enterococcus, VRE, meningitis, ventriculitis, CNS infection, daptomycin, and linezolid. Study Selection and Data Extraction: All relevant studies and case reports describing the treatment of VRE faecium from the CNS with linezolid or daptomycin were included. Data Synthesis: A total of 17 reports describing 22 cases were identified. There were 15 of 19 cases involving linezolid that reported clinical cure, of which 53.3% were monotherapy. Only 5 of 9 cases involving intravenous (IV) daptomycin resulted in cure; all 4 cases reporting daptomycin administration via the intrathecal or intraventricular route achieved clearance from the cerebrospinal fluid (CSF). Relevance to Patient Care and Clinical Practice: The preferred treatment option for VRE faecium infections involving the CNS remains unclear. Supporting evidence through observational case reports have described varying outcomes with linezolid and daptomycin. This review compares reported outcomes between the 2 agents and provides a thorough discussion on drug- and patient-specific variables to consider. Conclusions: Linezolid monotherapy appears to be safe and effective for the treatment of susceptible-VRE faecium CNS infections, with consideration of therapeutic drug monitoring in special populations and with prolonged treatment duration. Daptomycin is an effective treatment option via intrathecal or intraventricular administration when neurosurgical access is available. The role of IV daptomycin remains inconclusive.
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Affiliation(s)
- Benjamin J. Lee
- University of California Irvine Health, Orange, CA, USA
- University of Southern California, Los Angeles, CA, USA
| | - Betty N. Vu
- Rush University Medical Center, Chicago, IL, USA
- Chicago State University College of Pharmacy, Chicago, IL, USA
| | - Amanda N. Seddon
- Rush University Medical Center, Chicago, IL, USA
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
| | | | - Sheila K. Wang
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Chicago, IL, USA
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Population Pharmacokinetics and Dosage Optimization of Linezolid in Patients with Liver Dysfunction. Antimicrob Agents Chemother 2020; 64:AAC.00133-20. [PMID: 32253210 DOI: 10.1128/aac.00133-20] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/27/2020] [Indexed: 12/22/2022] Open
Abstract
Linezolid is the first synthetic oxazolidone agent to treat infections caused by Gram-positive pathogens. Infected patients with liver dysfunction (LD) are more likely to suffer from adverse reactions, such as thrombocytopenia, when standard-dose linezolid is used than patients with LD who did not use linezolid. Currently, pharmacokinetics data of linezolid in patients with LD are limited. This study aimed to characterize pharmacokinetics parameters of linezolid in patients with LD, identify the factors influencing the pharmacokinetics, and propose an optimal dosage regimen. We conducted a prospective study and established a population pharmacokinetics model with the Phoenix NLME software. The final model was evaluated by goodness-of-fit plots, bootstrap analysis, and prediction corrected-visual predictive check. A total of 163 concentration samples from 45 patients with LD were adequately described by a one-compartment model with first-order elimination along with prothrombin activity (PTA) and creatinine clearance as significant covariates. Linezolid clearance (CL) was 2.68 liters/h (95% confidence interval [CI], 2.34 to 3.03 liters/h); the volume of distribution (V) was 58.34 liters (95% CI, 48.00 to 68.68 liters). Model-based simulation indicated that the conventional dose was at risk for overexposure in patients with LD or severe renal dysfunction; reduced dosage (300 mg/12 h) would be appropriate to achieve safe (minimum steady-state concentration [C min,ss] at 2 to 8 μg/ml) and effective targets (the ratio of area under the concentration-time curve from 0 to 24 h [AUC0-24] at steady state to MIC, 80 to 100). In addition, for patients with severe LD (PTA, ≤20%), the dosage (400 mg/24 h) was sufficient at an MIC of ≤2 μg/ml. This study recommended therapeutic drug monitoring for patients with LD. (This study has been registered in the Chinese Clinical Trial Registry under no. ChiCTR1900022118.).
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Abstract
PURPOSE OF REVIEW Prosthetic joint infections (PJIs) represent one of the most disastrous complications in prosthetic surgery, requiring long hospitalization, prolonged antimicrobial treatment and repeated surgical interventions. No gold standard test to formulate diagnosis exist. A combination of high index of suspicion, physical examination, microbiological and biohumoral investigations is required. Therapeutical approach should be based on a multidisciplinary team. In our center, a two-stage approach is preferred. As regards the choice of the empirical antibiotic backbone, individual risk factors for multiple-drug resistant (MDR) pathogens should be considered. Several studies enhance the possibility to shorten the length of antibiotic couses. RECENT FINDINGS Some interesting improvements have been made in the setting of PJIs management. As regards diagnosis, novel biomarkers and nuclear imaging are acquiring more importance. Molecular biology techniques also offer the possibility to formulate rapid microbiological identification. The pattern of PJIs is evolving towards higher rates of MDR causes. During the last decade, a number of new antibiotic molecules with activity against MDRs have been approved. Some of them are also available either in oral formulation or as long-acting compounds, offering the opportunity for early patient's discharge, with expected healthcare costs saving. SUMMARY Management of PJIs still represents a major threat for clinicians. Improvements in surgical techniques and antibiotic pipeline promise to revolutionize the approach in next years. Despite data from our experience confirm the efficacy of shorter antibiotic courses and the value of new molecules, randomized clinical trials are lacking. More data are needed in order to modify the routine clinical practice.
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Dou L, Meng D, Dong Y, Chen L, Han X, Fan D, Dong H. Dosage regimen and toxicity risk assessment of linezolid in sepsis patients. Int J Infect Dis 2020; 96:105-111. [PMID: 32251797 DOI: 10.1016/j.ijid.2020.03.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 02/19/2020] [Accepted: 03/23/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Significant alterations in the pharmacokinetic characteristics of linezolid are often seen in sepsis patients. The study aimed to identify a target pharmacokinetics/pharmacodynamics (PK/PD) index of the efficacy of linezolid treatment, and to estimate the optimum dosage regimen of linezolid in sepsis patients. METHODS The PK data were modeled using the one-compartment model, which determined the target PK/PD index for successful treatment by logistic regression. The probability of thrombocytopenia was identified by establishing a logistic model. Different dosing regimens were evaluated using Monte Carlo simulation. RESULTS Reaching 80% bacterial eradication required an AUC24/MIC of 100, which defined the therapeutic target. The proposed regimen to attain a cumulative fraction of response ≥80% was 800 mg/12 h (safety probability 66.8%) for sepsis patients with normal renal function or mild kidney damage. By contrast, the target cumulative fraction of response was attained with a standard dosing regimen in sepsis patients on continuous renal replacement therapy [600 mg/12 h (safety probability 49.7%)]. CONCLUSIONS This study identified different dosing strategies to achieve target linezolid PK/PD values according to whether sepsis patients were treated with continuous renal replacement therapy. Due to the high incidence of thrombocytopenia in sepsis patients on continuous renal replacement therapy, therapeutic drug monitoring should be encouraged for optimizing linezolid exposure in sepsis patients.
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Affiliation(s)
- Linjie Dou
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Dandan Meng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Lihong Chen
- Department of International Medical Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xinyan Han
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Di Fan
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Haiyan Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
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Fang J, Chen C, Wu Y, Zhang M, Zhang Y, Shi G, Yao Y, Chen H, Bian X. Does the conventional dosage of linezolid necessitate therapeutic drug monitoring?-Experience from a prospective observational study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:493. [PMID: 32395537 PMCID: PMC7210126 DOI: 10.21037/atm.2020.03.207] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background The objectives of the present prospective observational study conducted in patients receiving conventional dosage of linezolid was to define the pharmacodynamic range of linezolid exposure, to assess the inter-individual variability in linezolid concentrations, and to define if therapeutic drug monitoring (TDM) of linezolid may be necessary for Chinese population. Methods Patients included in this study underwent linezolid TDM trough concentration (Cmin) during treatment with a standard regimen in the period between January 2019 and October 2019. Linezolid Cmin was analyzed with high-performance liquid chromatography (HPLC) method. Logistic regression was used to define the desired range of linezolid Cmin. Linear regression and univariate logistic regression analysis were carried out to investigate variables associated with inappropriate linezolid plasma exposure. Results A total of 84 patients who had 153 linezolid Cmin assessed were included in the study. Median linezolid Cmin was 3.43 mg/L (IQR 1.59–5.93). The estimated probability of thrombocytopenia was 50% in the presence of Cmin of 7.85 mg/L. Approximately 57.52% (88/153) of the samples fell within the desired range of linezolid Cmin (2–8 mg/L) while 31.37% (48/153) experienced underexposure, and overexposure occurred in 11.11% (17/153) of the patients. No significant linear relationships between either body weight or estimated creatinine clearance (CrCL) and Cmin were detected. Estimated CrCL ≥100 mL/min was significantly associated with linezolid underexposure (OR 4.121; 95% CI, 1.945–8.731; P<0.001). Estimated CrCL ≤40 mL/min was significantly associated with linezolid overexposure (OR 3.761; 95% CI, 1.324–10.681; P=0.013). Conclusions Our results suggest that the pharmacodynamic range of linezolid Cmin can be defined as 2–8 mg/L for the Chinese population. Renal function partially accounts for the inter-interindividual variability of exposure. The application of TDM might be especially valuable in optimizing linezolid exposure in the majority of patients to avoid therapeutic failure and/or dose-dependent adverse reactions.
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Affiliation(s)
- Jie Fang
- Department of Pharmacy, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China
| | - Congqin Chen
- Department of Pharmacy, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian 361000, China
| | - Yan Wu
- Department of Pharmacy, Chinese and Western Medicine Hospital of Kun Shan, Suzhou 215300, China
| | - Min Zhang
- Department of Pharmacy Services, Boston Medical Center, Boston, MA, USA
| | - Ying Zhang
- Department of Pharmacy, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou 215000, China
| | - Guochao Shi
- Department of Respiration and Critical Care Disease, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China.,Institute of Respiratory Diseases, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China
| | - Yijin Yao
- Department of Respiration and Critical Care Disease, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China.,Institute of Respiratory Diseases, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China
| | - Hong Chen
- Department of Respiration and Critical Care Disease, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China.,Institute of Respiratory Diseases, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China
| | - Xiaolan Bian
- Department of Pharmacy, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200003, China
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Fourteen-Day Bactericidal Activity, Safety, and Pharmacokinetics of Linezolid in Adults with Drug-Sensitive Pulmonary Tuberculosis. Antimicrob Agents Chemother 2020; 64:AAC.02012-19. [PMID: 31988102 PMCID: PMC7179319 DOI: 10.1128/aac.02012-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/03/2020] [Indexed: 01/24/2023] Open
Abstract
Linezolid is increasingly used for the treatment of tuberculosis resistant to first-line agents, but the most effective dosing strategy is yet unknown. From November 2014 to November 2016, we randomized 114 drug-sensitive treatment-naive pulmonary tuberculosis patients from Cape Town, South Africa, to one of six 14-day treatment arms containing linezolid at 300 mg once daily (QD), 300 mg twice daily (BD), 600 mg QD, 600 mg BD, 1,200 mg QD, 1,200 mg three times per week (TIW), or a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Sixteen-hour sputum samples were collected overnight, and bactericidal activity was characterized by the daily percentage change in time to positivity (TTP) and the daily rate of change in log10(CFU). We also assessed the safety and pharmacokinetics of the study treatments. We found that bactericidal activity increased with increasing doses of linezolid. Based on the daily percentage change in TTP, activity was highest for 1,200 mg QD (4.5%; 95% Bayesian confidence interval [BCI], 3.3 to 5.6), followed by 600 mg BD (4.1%; BCI, 2.5 to 5.7), 600 mg QD (4.1%; BCI, 2.9 to 5.3), 300 mg BD (3.3%; BCI, 1.9 to 4.7), 300 mg QD (2.3%; BCI, 1.1 to 3.5), and 1,200 mg TIW (2.2%; BCI, 1.1 to 3.3). Similar results were seen with bactericidal activity characterized by the daily rate of change in CFU count. Antimycobacterial activity correlated positively with plasma drug exposure and percentage time over MIC. There were no unexpected adverse events. All linezolid doses showed bactericidal activity. For the same total daily dose, once-daily dosing proved to be at least as effective as a divided twice-daily dose. An intermittent dosing regimen, with 1,200 mg given three times weekly, showed the least activity. (This study has been registered at ClinicalTrials.gov under identifier NCT02279875.).
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50
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Alsultan A. Determining therapeutic trough ranges for linezolid. Saudi Pharm J 2019; 27:1061-1063. [PMID: 31885465 PMCID: PMC6921164 DOI: 10.1016/j.jsps.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 09/22/2019] [Indexed: 11/29/2022] Open
Abstract
Linezolid (LZD) is an oxazolidinone approved for the treatment of gram-positive infections. Therapeutic drug monitoring is increasingly used to optimize LZD dosing. The therapeutic target for LZD is to achieve an area under the concentration-time curve over 24 h divided by the MIC (AUC/MIC) > 100. In this study, we determined the trough ranges associated with this therapeutic AUC. Concentration-time profiles for 999 virtual patients were simulated using a previously published pharmacokinetic model for LZD. AUC was estimated for each virtual patient using the trapezoidal method. We determined the trough ranges that achieve the therapeutic target of AUC/MIC > 100 at different MIC values of 1, 2 and 4 μg/mL. Trough samples correlated well with LZD AUC (R2 = 0.87). For trough concentration of 2–5 μg/mL, 99% had an AUC0–24 > 100 µg⋅h⋅ml−1, 23% had an AUC0–24 > 200 µg⋅h⋅ml−1 and none had an AUC0–24 > 400 µg⋅h⋅ml−1. For trough concentrations of 5–8 µg/ml, 87% of the patients had an AUC0–24 > 200 µg⋅h⋅ml−1 and none had an AUC0–24 > 400 µg⋅h⋅ml−1 To achieve the therapeutic target of an AUC/MIC > 100, it is suggested that trough ranges be set at 2–5 µg/ml if the MIC < 2 and 5–8 µg/ml if the MIC = 2; however, at an MIC of 4 µg/ml, it is difficult to achieve an AUC/MIC > 100 without increasing the risk of LZD toxicity.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
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