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Miao S, Yin J, Liu S, Zhu Q, Liao C, Jiang G. Maternal-Fetal Exposure to Antibiotics: Levels, Mother-to-Child Transmission, and Potential Health Risks. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2024; 58:8117-8134. [PMID: 38701366 DOI: 10.1021/acs.est.4c02018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Due to its widespread applications in various fields, antibiotics are continuously released into the environment and ultimately enter the human body through diverse routes. Meanwhile, the unreasonable use of antibiotics can also lead to a series of adverse outcomes. Pregnant women and developing fetuses are more susceptible to the influence of external chemicals than adults. The evaluation of antibiotic exposure levels through questionnaire surveys or prescriptions in medical records and biomonitoring-based data shows that antibiotics are frequently prescribed and used by pregnant women around the world. Antibiotics may be transmitted from mothers to their offspring through different pathways, which then adversely affect the health of offspring. However, there has been no comprehensive review on antibiotic exposure and mother-to-child transmission in pregnant women so far. Herein, we summarized the exposure levels of antibiotics in pregnant women and fetuses, the exposure routes of antibiotics to pregnant women, and related influencing factors. In addition, we scrutinized the potential mechanisms and factors influencing the transfer of antibiotics from mother to fetus through placental transmission, and explored the adverse effects of maternal antibiotic exposure on fetal growth and development, neonatal gut microbiota, and subsequent childhood health. Given the widespread use of antibiotics and the health threats posed by their exposure, it is necessary to comprehensively track antibiotics in pregnant women and fetuses in the future, and more in-depth biological studies are needed to reveal and verify the mechanisms of mother-to-child transmission, which is crucial for accurately quantifying and evaluating fetal health status.
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Affiliation(s)
- Shiyu Miao
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jia Yin
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shuang Liu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Qingqing Zhu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Chunyang Liao
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- Hubei Key Laboratory of Environmental and Health Effects of Persistent Toxic Substances, School of Environment and Health, Jianghan University, Wuhan 430056, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Guibin Jiang
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- Hubei Key Laboratory of Environmental and Health Effects of Persistent Toxic Substances, School of Environment and Health, Jianghan University, Wuhan 430056, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
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Mackeen AD, Sullivan MV, Berghella V. Evidence-based cesarean delivery: preoperative management (part 7). Am J Obstet Gynecol MFM 2024; 6:101362. [PMID: 38574855 DOI: 10.1016/j.ajogmf.2024.101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.
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Affiliation(s)
- A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan).
| | - Maranda V Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan)
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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Downing J, Sjeklocha L. Trauma in Pregnancy. Emerg Med Clin North Am 2023; 41:223-245. [PMID: 37024160 DOI: 10.1016/j.emc.2022.12.001] [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: 04/08/2023]
Abstract
Trauma is the leading cause of nonobstetric maternal death. Pregnant patients have a similar spectrum of traumatic injuries with a noted increase in interpersonal violence. A structured approach to trauma evaluation and management is recommended with several guidelines expanding on ATLS principles; however, evidence is limited. Optimal management requires understanding of physiologic changes in pregnancy, a team-based approach, and preparation for interventions that may including neonatal resuscitation. The principles of trauma management are the same in pregnancy with a systematic approach and initial maternal focused resuscitation..
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Affiliation(s)
- Jessica Downing
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Lucas Sjeklocha
- Department of Emergency Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Moreira FDL, Benzi JRDL, Pinto L, Thomaz MDL, Duarte G, Lanchote VL. Optimizing Therapeutic Drug Monitoring in Pregnant Women: A Critical Literature Review. Ther Drug Monit 2023; 45:159-172. [PMID: 36127797 DOI: 10.1097/ftd.0000000000001039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 06/18/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND More than 90% of pregnant women take at least one drug during pregnancy. Drug dose adjustments during pregnancy are sometimes necessary due to various pregnancy-induced physiological alterations frequently associated with lower plasma concentrations. However, the clinical relevance or benefits of therapeutic drug monitoring (TDM) in pregnant women have not been specifically studied. Clinical pharmacokinetic studies in pregnant women are incredibly challenging for many reasons. Despite this, regulatory agencies have made efforts to encourage the inclusion of this population in clinical trials to achieve more information on the pharmacotherapy of pregnant women. This review aims to provide support for TDM recommendations and dose adjustments in pregnant women. METHODS The search was conducted after a predetermined strategy on PubMed and Scopus databases using the MeSH term "pregnancy" alongside other terms such as "Pregnancy and dose adjustment," "Pregnancy and therapeutic drug monitoring," "Pregnancy and PBPK," "Pregnancy and pharmacokinetics," and "Pregnancy and physiological changes." RESULTS The main information on TDM in pregnant women is available for antiepileptics, antipsychotics, antidepressants, antibiotics, antimalarials, and oncologic and immunosuppressive drugs. CONCLUSIONS More data are needed to support informed benefit-risk decision making for the administration of drugs to pregnant women. TDM and/or pharmacokinetic studies could ensure that pregnant women receive an adequate dosage of an active drug. Mechanistic modeling approaches potentially could increase our knowledge about the pharmacotherapy of this special population, and they could be used to better design dosage regimens.
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Affiliation(s)
- Fernanda de Lima Moreira
- Department of Clinical Analysis, Food Science and Toxicology, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo; and
| | - Jhohann Richard de Lima Benzi
- Department of Clinical Analysis, Food Science and Toxicology, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo; and
| | - Leonardo Pinto
- Department of Clinical Analysis, Food Science and Toxicology, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo; and
| | - Matheus de Lucca Thomaz
- Department of Clinical Analysis, Food Science and Toxicology, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo; and
| | - Geraldo Duarte
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Vera Lucia Lanchote
- Department of Clinical Analysis, Food Science and Toxicology, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo; and
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Black M, Kothari A, Chawla G, Pelecanos A, Zahumensky A, McDermott L, O'Connor H, Kalma B, Eley V. Attitudes and awareness of Australian women regarding peripartum antibiotic use: A multicentre survey. Aust N Z J Obstet Gynaecol 2022; 63:171-177. [PMID: 35856134 DOI: 10.1111/ajo.13587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peripartum antibiotics are commonly administered. Little is known of the attitudes of pregnant women toward peripartum antibiotics. AIM We aimed to assess the awareness of and attitudes toward peripartum antibiotic use in Australian women. MATERIALS AND METHODS We surveyed post-partum women at three hospitals over six months. Women reported if they received antibiotics 48 h either side of delivery and responded to statements assessing attitudes to peripartum antibiotic use. Administered antibiotics were recorded. We reported the proportion receiving antibiotics and the proportion aware of receiving them. Participants responded on five-point Likert scales and selected side effects of concern. RESULTS Participants responding were 248 of 299 (83%, Royal Brisbane and Women's Hospital), 56 of 106 (53%, Caboolture Hospital) and 17 (Redcliffe Hospital, denominator not recorded). Of 183 (57%) receiving antibiotics, 134 (73%) received them pre-delivery only, 18 (10%) post-delivery only and 31 (17%) pre- and post-delivery. Pre-delivery, the most common indication was pre-incisional prophylaxis for caesarean delivery (93 of 160 responses, 58%). Seventy-nine (51%, 156 responses) of those receiving pre-delivery antibiotics were aware. Of 49 women receiving post-delivery antibiotics, 36 (73%) were aware. Most agreed they were worried that pre-delivery antibiotics would affect their baby (198, 62%) and 160 (50%) were concerned about effects on their own microbiome. Most (204, 65%) agreed they would rather not take antibiotics while breastfeeding. CONCLUSION Many women were unaware of receiving pre-delivery antibiotics. Most had concerns about side effects. Improved communication regarding peripartum antibiotic use would improve patient-centred care.
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Affiliation(s)
- Matthew Black
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alka Kothari
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Obstetrics and Gynaecology, Redcliffe Hospital, Moreton Bay Region, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Moreton Bay Region, Queensland, Australia
| | - Anita Pelecanos
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Amanda Zahumensky
- Department of Anaesthesia, Caboolture Hospital, Moreton Bay Region, Queensland, Australia
| | - Laura McDermott
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Hannah O'Connor
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Benjamin Kalma
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Application of a Physiologically Based Pharmacokinetic Model to Predict Cefazolin and Cefuroxime Disposition in Obese Pregnant Women Undergoing Caesarean Section. Pharmaceutics 2022; 14:pharmaceutics14061162. [PMID: 35745736 PMCID: PMC9229966 DOI: 10.3390/pharmaceutics14061162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 12/10/2022] Open
Abstract
Intravenous (IV) cefuroxime and cefazolin are used prophylactically in caesarean sections (CS). Currently, there are concerns regarding sub-optimal dosing in obese pregnant women compared to lean pregnant women prior to CS. The current study used a physiologically based pharmacokinetic (PBPK) approach to predict cefazolin and cefuroxime pharmacokinetics in obese pregnant women at the time of CS as well as the duration that these drug concentrations remain above a target concentration (2, 4 or 8 µg/mL or µg/g) in plasma or adipose tissue. Cefazolin and cefuroxime PBPK models were first built using clinical data in lean and in obese non–pregnant populations. Models were then used to predict cefazolin and cefuroxime pharmacokinetics data in lean and obese pregnant populations. Both cefazolin and cefuroxime models sufficiently described their total and free levels in the plasma and in the adipose interstitial fluid (ISF) in non–pregnant and pregnant populations. The obese pregnant cefazolin model predicted adipose exposure adequately at different reference time points and indicated that an IV dose of 2000 mg can maintain unbound plasma and adipose ISF concentration above 8 µg/mL for 3.5 h post dose. Predictions indicated that an IV 1500 mg cefuroxime dose can achieve unbound plasma and unbound ISF cefuroxime concentration of ≥8 µg/mL up to 2 h post dose in obese pregnant women. Re-dosing should be considered if CS was not completed within 2 h post cefuroxime administration for both lean or obese pregnant if cefuroxime concentrations of ≥8 µg/mL is required. A clinical study to measure cefuroxime adipose concentration in pregnant and obese pregnant women is warranted.
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Kim KM, Jung J, Lee JM, Yang HS, Bang J, Lee E, Choi B, Noh G. The expected advantage of administering prophylactic antibiotics using target‐ concentration controlled infusion: Development of a new pharmacokinetic model of cefazolin. Clin Exp Pharmacol Physiol 2022; 49:731-739. [DOI: 10.1111/1440-1681.13648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/29/2022] [Accepted: 04/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Jong Min Lee
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Hong Seuk Yang
- Department of Anesthesiology and Pain Medicine Daejeon Eulji University Hospital Eulji University School of Medicine Daejeon Korea
| | - Ji‐Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Eun‐Kyung Lee
- Department of Statistics Ewha Womans University Seoul South Korea
| | - Byung‐Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Gyu‐Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
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Gilliot S, Ducloy-Bouthors AS, Loingeville F, Hennart B, Allorge D, Lebuffe G, Odou P. Pharmacokinetics of Curative Tranexamic Acid in Parturients Undergoing Cesarean Delivery. Pharmaceutics 2022; 14:pharmaceutics14030578. [PMID: 35335955 PMCID: PMC8952437 DOI: 10.3390/pharmaceutics14030578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this study was to evaluate the population pharmacokinetics of tranexamic acid (TXA) administered intravenously at a single dose of 0.5 or 1 g in parturients undergoing active hemorrhagic cesarean delivery and to evaluate the influence of patient variables on TXA pharmacokinetics. Subjects from three recruiting centers were included in this PK sub-study if randomized in the experimental group (i.v TXA 0.5 g or 1 g over one minute) of the TRACES study. Blood samples and two urinary samples were collected within 6 h after TXA injection. Parametric non-linear mixed-effect modeling (Monolix v2020R1) was computed. The final covariate model building used 315 blood and 117 urinary concentrations from seventy-nine patients. A two-compartment model with a double first-order elimination from the central compartment best described the data. The population estimates of clearance (CL), central volume of distribution (V1), and half-life for a typical 70 kg patient with an estimated renal clearance of 150 mL/min (Cockroft–Gault) were 0.14 L/h, 9.25 L, and 1.8 h. A correlation between estimated creatinine clearance and CL, body weight before pregnancy, and V1 was found and partly explained the PK variability. The final model was internally validated using a 500-run bootstrap. The first population pharmacokinetic model of TXA in active hemorrhagic caesarean section was successfully developed and internally validated.
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Affiliation(s)
- Sixtine Gilliot
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
- Correspondence:
| | - Anne-Sophie Ducloy-Bouthors
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Florence Loingeville
- ULR2694—METRICS—Evaluation des Technologies de Santé et des Pratiques Médicales, Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France;
| | - Benjamin Hennart
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
| | - Delphine Allorge
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
- ULR 4483-IMPECS-IMPact de l’Environnement Chimique sur la Santé, Faculté de Médecine-Pôle Recherche, Université de Lille, 1 Place de Verdun, F-59045 Lille, France
| | - Gilles Lebuffe
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Pascal Odou
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
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Abduljalil K, Ning J, Pansari A, Pan X, Jamei M. Prediction of Maternal and Fetoplacental Concentrations of Cefazolin, Cefuroxime and Amoxicillin during Pregnancy using bottom-up Physiologically based Pharmacokinetic Models. Drug Metab Dispos 2022; 50:386-400. [DOI: 10.1124/dmd.121.000711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
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10
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Understanding the pharmacokinetics of antibiotics in pregnancy: Is there a role for therapeutic drug monitoring? A narrative review. Ther Drug Monit 2021; 44:50-64. [PMID: 34897239 DOI: 10.1097/ftd.0000000000000950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Antibiotics are commonly used during pregnancy. However, physiological changes during pregnancy can affect the pharmacokinetics of drugs, including antibiotics, used during this period. Pharmacokinetic evaluations have shed light on how antibiotics are affected during pregnancy and have influenced dosing recommendations in this context. Methods: A narrative review was conducted and included reports providing data reflecting drug distribution and exposure in the context of pregnancy. Results: Pharmacokinetic parameters of antibiotics in pregnancy and transplacental passage of antibiotics are comprehensively presented. Conclusion: Knowledge about the impact on pharmacokinetics and fetal exposure is especially helpful for complicated or severe infections, including intra-amniotic infection and sepsis in pregnancy, where both mother and fetus are at risk. Further studies are warranted to consolidate the role of therapeutic drug monitoring in complicated or severe infections in pregnant patients.
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Shirvany A, Rezayan AH, Alvandi H, Barshan Tashnizi M, Sabahi H. Preparation and Evaluation of a Niosomal Drug Delivery System Containing Cefazolin and Study of Its Antibacterial Activity. IRANIAN JOURNAL OF MEDICAL MICROBIOLOGY 2021. [DOI: 10.30699/ijmm.15.6.638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Elkayal O, Allegaert K, Spriet I, Smits A, Seghaye MC, Charlier C, Dreesen E. Population pharmacokinetics of cefazolin in maternal and umbilical cord plasma, and simulated exposure in term neonates. J Antimicrob Chemother 2021; 76:3229-3236. [PMID: 34499720 DOI: 10.1093/jac/dkab329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/14/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intra-partum cefazolin is used to prevent group B Streptococcus (GBS) vertical transmission in mothers allergic to penicillin without a history of anaphylaxis. OBJECTIVES To investigate the maternal cefazolin dose-exposure relationship and subsequent maternal and neonatal target attainment at delivery. METHODS Data were obtained from 24 healthy, GBS-colonized pregnant women (20-41 years), undergoing vaginal delivery (gestational age ≥37 weeks). During labour, all women received a 2 g cefazolin IV infusion. Eight hours later, eight women received another 1 g in the event of delayed (>8 h) delivery. Next to maternal plasma concentrations (up to 10 per dosing interval, until delivery), venous and arterial umbilical cord concentrations were determined at delivery. Target attainment in maternal/neonatal plasma was set at 1 mg/L for 60% of the dosing interval (unbound cefazolin, worst-case clinical breakpoint). A population pharmacokinetic (popPK) model was built (NONMEM 7.4). ClinicalTrials.gov Identifier: NCT01295606. RESULTS At delivery, maternal blood and arterial umbilical cord unbound cefazolin concentrations were >1 mg/L in 23/24 (95.8%) and 11/12 (91.7%), respectively. The popPK of cefazolin in pregnant women was described by a two-compartment model with first-order elimination. Two additional compartments described the venous and arterial umbilical cord concentration data. Cefazolin target attainment was adequate in the studied cohort, where delivery occurred no later than 6.5 h after either the first or the second dose. PopPK simulations showed adequate maternal and umbilical cord exposure for 12 h following the first dose. CONCLUSIONS PopPK simulations showed that standard pre-delivery maternal cefazolin dosing provided adequate target attainment up to the time of delivery.
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Affiliation(s)
- Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | | | - Corinne Charlier
- Department of Toxicology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
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13
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Roset Bahmanyar E, Out HJ, van Duin M. Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed. Am J Obstet Gynecol 2021; 225:43-50. [PMID: 34215353 DOI: 10.1016/j.ajog.2021.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022]
Abstract
Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.
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Szeto KX, Le Merdy M, Dupont B, Bolger MB, Lukacova V. PBPK Modeling Approach to Predict the Behavior of Drugs Cleared by Kidney in Pregnant Subjects and Fetus. AAPS JOURNAL 2021; 23:89. [PMID: 34169370 PMCID: PMC8225528 DOI: 10.1208/s12248-021-00603-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/27/2021] [Indexed: 12/21/2022]
Abstract
The purpose of this study was to develop a physiologically based pharmacokinetic (PBPK) model predicting the pharmacokinetics (PK) of different compounds in pregnant subjects. This model considers the differences in tissue sizes, blood flow rates, enzyme expression levels, glomerular filtration rates, plasma protein binding, and other factors affected during pregnancy in both the maternal and fetal models. The PBPKPlus™ module in GastroPlus® was used to model the PK of cefuroxime and cefazolin. For both compounds, the model was first validated against PK data in healthy non-pregnant volunteers and then applied to predict pregnant groups PK. The model accurately described the PK in both non-pregnant and pregnant groups and explained well differences in the plasma concentration due to pregnancy. The fetal plasma and amniotic fluid concentrations were also predicted reasonably well at different stages of pregnancy. This work describes the use of a PBPK approach for drug development and demonstrates the ability to predict differences in PK in pregnant subjects and fetal exposure for compounds excreted renally. The prediction for pregnant groups is also improved when the model is calibrated with postpartum or non-pregnant female group if such data are available.
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Affiliation(s)
- Ke Xu Szeto
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Maxime Le Merdy
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Benjamin Dupont
- PhinC Development, 36 Rue Victor Basch, 91300, Massy, France
| | - Michael B Bolger
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA
| | - Viera Lukacova
- Simulations Plus, Inc., 42505 10th Street West, Lancaster, California, 93534, USA.
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15
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Effectiveness of antimicrobial prophylaxis at 30 versus 60 min before cesarean delivery. Sci Rep 2021; 11:8401. [PMID: 33863969 PMCID: PMC8052330 DOI: 10.1038/s41598-021-87846-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
This study aimed to examine the effect of antibiotic prophylaxis (AP) given within 30 compared to 30–60 min before skin incision on the incidence of infectious morbidity after cesarean delivery (CD). A retrospective cohort study was conducted at a single institution on data between 2014 and 2018. Women who delivered by CD were divided into two groups according to AP timing before skin incision: group 1 within 30 min, and group 2 from 30 to 60 min. The primary outcome was the incidence of any infectious morbidity. Overall, 2989 women were eligible: 2791 in group 1 and 198 in group 2. The primary composite outcome occurred in 125 women (4.48%) in group 1 and 8 women (4.04%) in group 2 (OR, 1.11; 95% CI 0.54–2.31; P = 0.77). The rate of surgical site infection only, was 1.08% in group 1 and 0.51% in group 2 (OR, 2.13; 95% CI 0.29–15.70; P = 0.72). The incidence was comparable between the groups in a separate sub-analysis restricted to laboring CDs and obese women. The rate of infectious morbidity was similar among women who received AP within 30 min and from 30 to 60 min before skin incision.
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16
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Allegaert K, Muller AE, Russo F, Schoenmakers S, Deprest J, Koch BCP. Pregnancy-related pharmacokinetics and antimicrobial prophylaxis during fetal surgery, cefazolin and clindamycin as examples. Prenat Diagn 2020; 40:1178-1184. [PMID: 32441341 DOI: 10.1002/pd.5753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 11/09/2022]
Abstract
Antimicrobial prophylaxis during surgery aims to prevent post-operative site infections. For fetal surgery, this includes the fetal and amniotic compartments. Both are deep compartments as drug equilibrium with maternal blood is achieved relatively late. Despite prophylaxis, chorio-amnionitis or endometritis following ex utero intrapartum treatment or fetoscopy occur in 4.13% and 1.45% respectively of the interventions. This review summarizes the observations on two commonly administered antimicrobials (cefazolin, clindamycin) for surgical prophylaxis during pregnancy, with emphasis on the deep compartments. For both compounds, antimicrobial exposure is on target when we consider the maternal and fetal plasma compartment. In contrast, amniotic fluid concentrations-time profiles display a delayed and much more blunted pattern, behaving as deep compartment. For cefazolin, there are data that document further dilution in the setting of polyhydramnios. Along this deep compartment concept, there is some accumulation during repeated administration, modeled for cefazolin and observed for clindamycin. The relative underexposure to antimicrobials in amniotic fluid may be reflected in the pattern of maternal-fetal complications after fetal surgery, and suggest that antimicrobial prophylaxis practices for fetal surgery should be reconsidered. Further studies should be designed by a multidisciplinary team (fetal surgeons, clinical pharmacologists and microbiologists) to facilitate efficient evaluation of antimicrobial prophylaxis.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden MC, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Woman's Health, University College London, London, UK
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Dallmann A, Mian P, Van den Anker J, Allegaert K. Clinical Pharmacokinetic Studies in Pregnant Women and the Relevance of Pharmacometric Tools. Curr Pharm Des 2020; 25:483-495. [PMID: 30894099 DOI: 10.2174/1381612825666190320135137] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/18/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND In clinical pharmacokinetic (PK) studies, pregnant women are significantly underrepresented because of ethical and legal reasons which lead to a paucity of information on potential PK changes in this population. As a consequence, pharmacometric tools became instrumental to explore and quantify the impact of PK changes during pregnancy. METHODS We explore and discuss the typical characteristics of population PK and physiologically based pharmacokinetic (PBPK) models with a specific focus on pregnancy and postpartum. RESULTS Population PK models enable the analysis of dense, sparse or unbalanced data to explore covariates in order to (partly) explain inter-individual variability (including pregnancy) and to individualize dosing. For population PK models, we subsequently used an illustrative approach with ketorolac data to highlight the relevance of enantiomer specific modeling for racemic drugs during pregnancy, while data on antibiotic prophylaxis (cefazolin) during surgery illustrate the specific characteristics of the fetal compartments in the presence of timeconcentration profiles. For PBPK models, an overview on the current status of reports and papers during pregnancy is followed by a PBPK cefuroxime model to illustrate the added benefit of PBPK in evaluating dosing regimens in pregnant women. CONCLUSIONS Pharmacometric tools became very instrumental to improve perinatal pharmacology. However, to reach their full potential, multidisciplinary collaboration and structured efforts are needed to generate more information from already available datasets, to share data and models, and to stimulate cross talk between clinicians and pharmacometricians to generate specific observations (pathophysiology during pregnancy, breastfeeding) needed to further develop the field.
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Affiliation(s)
- André Dallmann
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel 4056, Switzerland
| | - Paola Mian
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Johannes Van den Anker
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel 4056, Switzerland.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, United States
| | - Karel Allegaert
- Organ Systems, KU Leuven, Department of Development and Regeneration, Leuven, Belgium.,Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
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Brooks Peterson M, Cohen MN, O'Neill BR, Garg S, Child J, Henthorn TK, Galinkin JG. Preoperative Vancomycin Administration for Surgical Site Prophylaxis: Plasma and Soft-Tissue Concentrations in Pediatric Neurosurgical and Orthopedic Patients. Anesth Analg 2019; 130:1435-1444. [PMID: 31397701 DOI: 10.1213/ane.0000000000004340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Vancomycin is used for antibiotic prophylaxis in pediatric surgical patients without a complete understanding of plasma and soft-tissue pharmacokinetics. Guidelines recommend incision within 60 minutes after administration; however, tissue vancomycin concentrations at that early time may not be therapeutic. We conducted a study of plasma and skin concentrations in pediatric neurosurgical and orthopedic patients to characterize intraoperative vancomycin pharmacokinetics. METHODS Patients (0.1-18.8 years of age) undergoing posterior spinal fusion (n = 30) or ventriculoperitoneal shunt placement (n = 30) received intravenous vancomycin 15 mg/kg (maximum 1000 mg) over 1 hour. Skin was biopsied at incision and skin closure. Blood samples were collected at incision, at 2 and 4 hours intraoperatively, and at closure. Population pharmacokinetic analysis was performed to characterize pharmacokinetic parameter estimates and to develop a model of intraoperative plasma and skin vancomycin concentrations versus time. RESULTS Pharmacokinetic analysis included data from 59 subjects, 130 plasma samples, and 107 skin samples. A 2-compartment model, volume of the central (Vc) and volume of the peripheral compartment (V2), proved to have the best fit. Stepwise covariate selection yielded a significant relationship for body surface area on elimination clearance and body weight on V2. Skin vancomycin concentrations rose continuously during surgery. Modeling predicted that equilibration of skin and plasma vancomycin concentrations took ≥5 hours. CONCLUSIONS Skin vancomycin concentrations immediately after a preoperative dose are relatively low compared with concentrations at the end of surgery. It may be advisable to extend the time between dose and incision if higher skin concentrations are desired at the start of surgery.
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Affiliation(s)
| | | | | | - Sumeet Garg
- Department of Orthopedic Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado
| | - Thomas K Henthorn
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado
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Theis KR, Romero R, Winters AD, Greenberg JM, Gomez-Lopez N, Alhousseini A, Bieda J, Maymon E, Pacora P, Fettweis JM, Buck GA, Jefferson KK, Strauss JF, Erez O, Hassan SS. Does the human placenta delivered at term have a microbiota? Results of cultivation, quantitative real-time PCR, 16S rRNA gene sequencing, and metagenomics. Am J Obstet Gynecol 2019; 220:267.e1-267.e39. [PMID: 30832984 DOI: 10.1016/j.ajog.2018.10.018] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The human placenta has been traditionally viewed as sterile, and microbial invasion of this organ has been associated with adverse pregnancy outcomes. Yet, recent studies that utilized sequencing techniques reported that the human placenta at term contains a unique microbiota. These conclusions are largely based on the results derived from the sequencing of placental samples. However, such an approach carries the risk of capturing background-contaminating DNA (from DNA extraction kits, polymerase chain reaction reagents, and laboratory environments) when low microbial biomass samples are studied. OBJECTIVE To determine whether the human placenta delivered at term in patients without labor who undergo cesarean delivery harbors a resident microbiota ("the assemblage of microorganisms present in a defined niche or environment"). STUDY DESIGN This cross-sectional study included placentas from 29 women who had a cesarean delivery without labor at term. The study also included technical controls to account for potential background-contaminating DNA, inclusive in DNA extraction kits, polymerase chain reaction reagents, and laboratory environments. Bacterial profiles of placental tissues and background technical controls were characterized and compared with the use of bacterial culture, quantitative real-time polymerase chain reaction, 16S ribosomal RNA gene sequencing, and metagenomic surveys. RESULTS (1) Twenty-eight of 29 placental tissues had a negative culture for microorganisms. The microorganisms retrieved by culture from the remaining sample were likely contaminants because corresponding 16S ribosomal RNA genes were not detected in the same sample. (2) Quantitative real-time polymerase chain reaction did not indicate greater abundances of bacterial 16S ribosomal RNA genes in placental tissues than in technical controls. Therefore, there was no evidence of the presence of microorganisms above background contamination from reagents in the placentas. (3) 16S ribosomal RNA gene sequencing did not reveal consistent differences in the composition or structure of bacterial profiles between placental samples and background technical controls. (4) Most of the bacterial sequences obtained from metagenomic surveys of placental tissues were from cyanobacteria, aquatic bacteria, or plant pathogens, which are microbes unlikely to populate the human placenta. Coprobacillus, which constituted 30.5% of the bacterial sequences obtained through metagenomic sequencing of placental samples, was not identified in any of the 16S ribosomal RNA gene surveys of these samples. These observations cast doubt as to whether this organism is really present in the placenta of patients at term not in labor. CONCLUSION With the use of multiple modes of microbiologic inquiry, a resident microbiota could not be identified in human placentas delivered at term from women without labor. A consistently significant difference in the abundance and/or presence of a microbiota between placental tissue and background technical controls could not be found. All cultures of placental tissue, except 1, did not yield bacteria. Incorporating technical controls for potential sources of background-contaminating DNA for studies of low microbial biomass samples, such as the placenta, is necessary to derive reliable conclusions.
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20
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Applying surgical antimicrobial standards in cesarean deliveries. Am J Obstet Gynecol 2018; 218:416.e1-416.e4. [PMID: 29353029 DOI: 10.1016/j.ajog.2018.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/04/2018] [Accepted: 01/10/2018] [Indexed: 11/21/2022]
Abstract
Antimicrobial prophylaxis practices are critical to surgical site infection risk-reduction strategies. Included in these practices is antibiotic redosing following prolonged procedures or after large blood losses. Guidelines have been published by several professional associations, with most endorsing repeat antibiotic administration after an estimated blood loss of 1500 mL or following 2 half-lives of the select agent. These conventions have been widely adopted by surgeons with the exception of obstetricians at the time of cesarean delivery. This Viewpoint explores existing guidelines, reviews the data for these recommendations, and questions the tradition of abstinence from redosing in cesarean deliveries despite the burden of infection in this cohort.
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21
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Surgical site infections following caesarean operations at a Jordanian teaching hospital: Frequency and implicated factors. Sci Rep 2017; 7:12210. [PMID: 28939862 PMCID: PMC5610177 DOI: 10.1038/s41598-017-12431-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/08/2017] [Indexed: 12/11/2022] Open
Abstract
Surgical site infections (SSIs) following caesarean surgeries are common. The present study aimed to evaluate the frequency of SSIs following caesareans at Jordan University Hospital during the 30 postoperative days and to identify factors associated with increased SSIs risk. Data regarding the occurrence of SSIs were collected both prospectively via follow-up phone calls and retrospectively via reviewing wound culture results and clinical notes. SSI cases were subsequently determined utilizing predefined criteria. Data relating to possible risk factors of SSIs were collected from patient interviews and hospital records. Risk factors for SSIs were identified via logistic regression. A high rate of SSIs (14.4%) was detected; implicated factors included body mass index ≥36 kg/m2 prior to pregnancy odds ratio (OR) 3.8, 95% confidence interval (95% CI) 1.6-9.4, hospital stay longer than 3.5 days OR 2.3, 95% CI 1.4-3.6, having the operation at a gestational age greater than 40 weeks OR 2.2, 95% CI 1.3-3.9. Receiving a higher weight-adjusted dose of the prophylactic antibiotic cefazolin was associated with lower SSIs risk OR 0.967, 95% CI 0.94-0.99.In conclusion, a high rate of SSIs following caesareans was detected, and modifiable risk factors of SSIs should be incorporated into targeted policies aiming to reduce the rate of SSIs.
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22
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Body Mass Index 50 kg/m2 and Beyond: Perioperative Care of Pregnant Women With Superobesity Undergoing Cesarean Delivery. Obstet Gynecol Surv 2017; 72:500-510. [DOI: 10.1097/ogx.0000000000000469] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Groff SM, Fallatah W, Yang S, Murphy J, Crutchfield C, Marzinke M, Kurtzberg J, Lee CKK, Burd I, Farzin A. Effect of Maternal Obesity on Maternal-Fetal Transfer of Preoperative Cefazolin at Cesarean Section. J Pediatr Pharmacol Ther 2017. [PMID: 28638306 DOI: 10.5863/1551-6776-22.3.227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES American Congress of Obstetricians and Gynecologists recommends a single dose of antibiotic prophylaxis before all cesarean sections (C/S). This recommendation is based on pharmacokinetic studies that include only non-obese patients. We sought to evaluate 1) cefazolin plasma concentrations among obese and non-obese patients after administration of a 2-g cefazolin dose for prevention of surgical wound infections, and 2) whether cefazolin concentration in fetal circulation may be protective against pathogens that cause early onset neonatal sepsis. METHODS Maternal and fetal cefazolin plasma concentrations were compared between obese (body mass index [BMI] ≥ 30 kg/m2) and non-obese (BMI < 25 kg/m2) healthy, term pregnant women undergoing scheduled C/S. Liquid chromatographic-tandem mass spectrometric (LC-MS/MS) methods were used for quantification of total and free cefazolin concentrations in maternal blood (MB) and umbilical cord blood (UCB). RESULTS Eight women were screened and consented. There was no difference between groups in MB total and free cefazolin concentrations. All MB samples had total and free cefazolin concentrations greater than the minimum inhibitory concentration 90 (MIC90) for Group B Streptococcus (GBS), Staphylococcus aureus, and Escherichia coli. All UCB samples had total and free cefazolin concentrations greater than MIC90 for GBS and S aureus, even when administered as briefly as 18 minutes before delivery. A lower concentration of total cefazolin was detected in UCB of neonates of obese women compared to non-obese women (p > 0.05). CONCLUSIONS Administration of 2 g of cefazolin to women undergoing scheduled C/S might be an adequate prophylactic dose for surgical wound infection in both non-obese and obese patients; and cefazolin concentration in fetal circulation may be protective against GBS and S aureus.
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24
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Duffield A, Sultan P, Riley ET, Carvalho B. Optimal administration of cefazolin prophylaxis for cesarean delivery. J Perinatol 2017; 37:16-20. [PMID: 28050017 DOI: 10.1038/jp.2016.210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/07/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Affiliation(s)
- A Duffield
- Department of Anesthesiology, Sentara Martha Jefferson Hospital, Charlottesville, VA, USA
| | - P Sultan
- Department of Anaesthesia and Perioperative Medicine, University College London Hospital, London, UK
| | - E T Riley
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - B Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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25
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Grupper M, Kuti JL, Swank ML, Maggio L, Hughes BL, Nicolau DP. Population Pharmacokinetics of Cefazolin in Serum and Adipose Tissue From Overweight and Obese Women Undergoing Cesarean Delivery. J Clin Pharmacol 2016; 57:712-719. [DOI: 10.1002/jcph.851] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/07/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Mordechai Grupper
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
| | | | | | - Brenna L. Hughes
- Division of Maternal-Fetal Medicine; Department of Obstetrics & Gynecology; Women & Infants Hospital of Rhode Island; Warren Alpert Medical School of Brown University; Providence RI, USA
| | - David P. Nicolau
- Center for Anti-Infective Research and Development; Hartford Hospital; Hartford CT, USA
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26
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Kiriazopoulos E, Zaharaki S, Vonaparti A, Vourna P, Panteri-Petratou E, Gennimata D, Lombardo K, Panderi I. Quantification of three beta-lactam antibiotics in breast milk and human plasma by hydrophilic interaction liquid chromatography/positive-ion electrospray ionization mass spectrometry. Drug Test Anal 2016; 9:1062-1072. [DOI: 10.1002/dta.2104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 10/02/2016] [Accepted: 10/04/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Evaggelos Kiriazopoulos
- National and Kapodistrian University of Athens; Faculty of Pharmacy; Laboratory of Pharmaceutical Analysis; Athens Greece
| | - Sabina Zaharaki
- National and Kapodistrian University of Athens; Faculty of Pharmacy; Laboratory of Pharmaceutical Analysis; Athens Greece
| | - Ariadni Vonaparti
- National and Kapodistrian University of Athens; Faculty of Pharmacy; Laboratory of Pharmaceutical Analysis; Athens Greece
- Qatar Doping Analysis Laboratory; Doha Qatar
| | - Panagiota Vourna
- General - Maternity District Hospital Elena Venizelou; Milk Bank and Maternal Breast-feeding Department; Athens Greece
| | | | - Dimitra Gennimata
- General Hospital ‘Korgialenio-Benakio National Red Cross’; Athens Greece
| | - Kara Lombardo
- Brown University; Warren Alpert Medical School; Department of Pathology; Rhode Island Hospital; Providence RI USA
| | - Irene Panderi
- National and Kapodistrian University of Athens; Faculty of Pharmacy; Laboratory of Pharmaceutical Analysis; Athens Greece
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27
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Boldenow E, Gendrin C, Ngo L, Bierle C, Vornhagen J, Coleman M, Merillat S, Armistead B, Whidbey C, Alishetti V, Santana-Ufret V, Ogle J, Gough M, Srinouanprachanh S, MacDonald JW, Bammler TK, Bansal A, Liggitt HD, Rajagopal L, Adams Waldorf KM. Group B Streptococcus circumvents neutrophils and neutrophil extracellular traps during amniotic cavity invasion and preterm labor. Sci Immunol 2016; 1:1/4/eaah4576. [PMID: 27819066 DOI: 10.1126/sciimmunol.aah4576] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Preterm birth is a leading cause of neonatal morbidity and mortality. Although microbial invasion of the amniotic cavity (MIAC) is associated with the majority of early preterm births, the temporal events that occur during MIAC and preterm labor are not known. Group B Streptococci (GBS) are β-hemolytic, gram-positive bacteria, which commonly colonize the vagina but have been recovered from the amniotic fluid in preterm birth cases. To understand temporal events that occur during MIAC, we utilized a unique chronically catheterized nonhuman primate model that closely emulates human pregnancy. This model allows monitoring of uterine contractions, timing of MIAC and immune responses during pregnancy-associated infections. Here, we show that adverse outcomes such as preterm labor, MIAC, and fetal sepsis were observed more frequently during infection with hemolytic GBS when compared to nonhemolytic GBS. Although MIAC was associated with systematic progression in chorioamnionitis beginning with chorionic vasculitis and progressing to neutrophilic infiltration, the ability of the GBS hemolytic pigment toxin to induce neutrophil cell death and subvert killing by neutrophil extracellular traps (NETs) in placental membranes in vivo facilitated MIAC and fetal injury. Furthermore, compared to maternal neutrophils, fetal neutrophils exhibit decreased neutrophil elastase activity and impaired phagocytic functions to GBS. Collectively, our studies demonstrate how a unique bacterial hemolytic lipid toxin enables GBS to circumvent neutrophils and NETs in placental membranes to induce fetal injury and preterm labor.
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Affiliation(s)
- Erica Boldenow
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Claire Gendrin
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Lisa Ngo
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Craig Bierle
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Jay Vornhagen
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America; Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Michelle Coleman
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Sean Merillat
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Blair Armistead
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America; Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Christopher Whidbey
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America; Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Varchita Alishetti
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Veronica Santana-Ufret
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Jason Ogle
- Washington National Primate Center, University of Washington, Seattle, Washington, United States of America
| | - Michael Gough
- Washington National Primate Center, University of Washington, Seattle, Washington, United States of America
| | - Sengkeo Srinouanprachanh
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - James W MacDonald
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - Theo K Bammler
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, United States of America
| | - Aasthaa Bansal
- Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - H Denny Liggitt
- Department of Comparative Medicine, University of Washington, Seattle, Washington, United States of America
| | - Lakshmi Rajagopal
- Department of Pediatric Infectious Diseases, University of Washington and Seattle Children's Research Institute, Seattle, Washington, United States of America; Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Kristina M Adams Waldorf
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, United States of America
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Patil AS, Sheng JS, Dotters-Katz SK, Schmoll MS, Onslow ML. Principles of Anti-infective Dosing in Pregnancy. Clin Ther 2016; 38:2006-15. [DOI: 10.1016/j.clinthera.2016.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 01/25/2023]
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Lillico R, Sayre CL, Sitar DS, Davies NM, Baron CM, Lakowski TM. Quantification of cefazolin in serum and adipose tissue by ultra high performance liquid chromatography-Tandem mass spectrometry (UHPLC-MS/MS): application to a pilot study of obese women undergoing cesarean delivery. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1031:94-98. [PMID: 27469905 DOI: 10.1016/j.jchromb.2016.07.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/13/2016] [Accepted: 07/17/2016] [Indexed: 11/18/2022]
Abstract
Higher doses of cefazolin are required in obese patients for preoperative antibiotic prophylaxis, owing to its low lipophilicity. An ultra high performance liquid chromatography-tandem mass spectrometry method was developed to quantify cefazolin in serum and adipose tissue from 6 obese patients undergoing cesarean delivery, and using stable-isotope labeled cefazolin as an internal standard. The method has a 2μg/g lower limit of quantitation. The concentration in adipose tissue was 3.4±1.6μg/mL, which is less than half of the reported minimum inhibitory concentration of 8μg/mL for cefazolin. Serum cefazolin concentrations were more than 30-fold higher than in adipose tissue.
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Affiliation(s)
- Ryan Lillico
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Casey L Sayre
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada; College of Pharmacy, Roseman University of Health Sciences, South Jordan, UT, USA
| | - Daniel S Sitar
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada; Clinical Pharmacology Section, The Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Neal M Davies
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Cynthia M Baron
- Department of Anesthesia, The Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ted M Lakowski
- The Rady Faculty of Health Sciences, College of Pharmacy, Pharmaceutical Analysis Laboratory, University of Manitoba, Winnipeg, Manitoba, Canada.
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Affiliation(s)
- Marie-Pierre Bonnet
- Department of Anaesthesia and Intensive Care, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, AP-HP, Paris Descartes University, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France; Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, 53, avenue de l'Observatoire, 75014 Paris, France; DHU Risks in pregnancy, 53, avenue de l'Observatoire, 75014 Paris, France.
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Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition. Anesth Analg 2016; 122:786-804. [DOI: 10.1213/ane.0000000000001143] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Crutchfield CA, Marzinke MA. Bioanalytical development and validation of liquid chromatographic-tandem mass spectrometric methods for the quantification of total and free cefazolin in human plasma and cord blood. Pract Lab Med 2015; 1:12-21. [PMID: 28932794 PMCID: PMC5597705 DOI: 10.1016/j.plabm.2015.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/13/2015] [Accepted: 03/03/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Cefazolin is a commonly prescribed β-lactam antibiotic for prophylaxis against skin infections following surgery, including caesarean sections. Assessment of maternal and neonatal exposure is important for correlating drug concentrations to clinical outcomes. Thus, bioanalytical methods for the quantification of both total and free cefazolin in maternal plasma and cord blood can assist in the comprehensive evaluation of cefazolin exposure. DESIGN AND METHODS Specimen preparation for the measurement of total cefazolin was performed via protein precipitation with acetonitrile containing the internal standard cloxacillin. Ultrafiltration was used to isolate free cefazolin. Processed samples were analyzed on a Prelude SPLC system coupled to a TSQ triple quadrupole Vantage mass spectrometer. Methods were validated following FDA bioanalytical guidelines. RESULTS The analytical measuring ranges of these methods were 0.48-480 µg/mL and 0.048-48 µg/mL for total and free drug, respectively. Calibration curves were generated using 1/x2 weighted linear regression analysis. Total cefazolin demonstrated inter- and intra-assay precision of ≤20% at the LLOQ and ≤11.2% at other levels. Free cefazolin demonstrated inter- and intra-assay precision of ≤18.5% at the LLOQ and ≤12.6% at other levels, respectively. Accuracy (%DEV), carryover, matrix effects, recovery and stability studies were also acceptable based on FDA recommendations. Furthermore, it was demonstrated that samples prepared in cord blood can be accurately quantified from an adult plasma calibration curve, with recoveries ≤9.1% DIF and ≤11.9% DIF for total and free cefazolin, respectively. CONCLUSIONS The described LC-MS/MS methods allow for the measurement of total and free cefazolin in both plasma and cord blood.
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Affiliation(s)
| | - Mark A Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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