1
|
Lewis SJ, Mueller BA. Antibiotic dosing recommendations in critically ill patients receiving new innovative kidney replacement therapy. BMC Nephrol 2024; 25:73. [PMID: 38413858 PMCID: PMC10900833 DOI: 10.1186/s12882-024-03469-2] [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: 01/16/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The Tablo Hemodialysis System is a new innovative kidney replacement therapy (KRT) providing a range of options for critically ill patients with acute kidney injury. The use of various effluent rate and treatment durations/frequencies may clear antibiotics differently than traditional KRT. This Monte Carlo Simulation (MCS) study was to develop antibiotic doses likely to attain therapeutic targets for various KRT combinations. METHODS Published body weights and pharmacokinetic parameter estimates were used to predict drug exposure for cefepime, ceftazidime, imipenem, meropenem and piperacillin/tazobactam in virtual critically ill patients receiving five KRT regimens. Standard free β-lactam plasma concentration time above minimum inhibitory concentration targets (40-60%fT> MIC and 40-60%fT> MICx4) were used as efficacy targets. MCS assessed the probability of target attainment (PTA) and likelihood of toxicity for various antibiotic dosing strategies. The smallest doses attaining PTA ≥ 90% during 1-week of therapy were considered optimal. RESULTS MCS determined β-lactam doses achieving ∼90% PTA in all KRT options. KRT characteristics influenced antibiotic dosing. Cefepime and piperacillin/tazobactam regimens designed for rigorous efficacy targets were likely to exceed toxicity thresholds. CONCLUSION The flexibility offered by new KRT systems can influence β-lactam antibiotic dosing, but doses can be devised to meet therapeutic targets. Further clinical validations are warranted.
Collapse
Affiliation(s)
- Susan J Lewis
- Department of Pharmacy Practice, College of Pharmacy, University of Findlay, 1000 N. Main Street, 45840, Findlay, OH, USA.
- Department of Pharmacy, Mercy Health - St. Anne Hospital, 43623, Toledo, OH, USA.
| | - Bruce A Mueller
- Clinical Pharmacy Department, College of Pharmacy, University of Michigan, MI, 48109, Ann Arbor, USA
| |
Collapse
|
2
|
Schmid S, Koch C, Zimmermann K, Buttenschoen J, Mehrl A, Pavel V, Schlosser-Hupf S, Fleischmann D, Krohn A, Schilling T, Müller M, Kratzer A. Interprofessional Therapeutic Drug Monitoring of Carbapenems Improves ICU Care and Guideline Adherence in Acute-on-Chronic Liver Failure. Antibiotics (Basel) 2023; 12:1730. [PMID: 38136763 PMCID: PMC10740747 DOI: 10.3390/antibiotics12121730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing disease in patients with liver cirrhosis. Meropenem is crucial for treating severe infections. Therapeutic drug monitoring (TDM) offers an effective means to control drug dosages, especially vital for bactericidal antibiotics like meropenem. We aimed to assess the outcomes of implementing TDM for meropenem using an innovative interprofessional approach in ACLF patients on a medical intensive care unit (ICU). (2) Methods: The retrospective study was conducted on a medical ICU. The outcomes of an interprofessional approach comprising physicians, hospital pharmacists, and staff nurses to TDM for meropenem in critically ill patients with ACLF were examined in 25 patients. Meropenem was administered continuously via an infusion pump after the application of an initial loading dose. TDM was performed weekly using high-performance liquid chromatography (HPLC). Meropenem serum levels, implementation of the recommendations of the interprofessional team, and meropenem consumption were analyzed. (3) Results: Initial TDM for meropenem showed a mean meropenem serum concentration of 20.9 ± 9.6 mg/L in the 25 analyzed patients. Of note, in the initial TDM, only 16.0% of the patients had meropenem serum concentrations within the respective target range, while 84.0% exceeded this range. Follow-up TDM showed serum concentrations of 15.2 ± 5.7 mg/L (9.0-24.6) in Week 2 and 11.9 ± 2.3 mg/L (10.2-13.5) in Week 3. In Week 2, 41.7% of the patients had meropenem serum concentrations that were within the respective target range, while 58.3% of the patients were above this range. In Week 3, 50% of the analyzed serum concentrations of meropenem were within the targeted range, and 50% were above the range. In total, 100% of the advice given by the interprofessional team regarding meropenem dosing or a change in antibiotic therapy was implemented. During the intervention period, the meropenem application density was 37.9 recommended daily doses (RDD)/100 patient days (PD), compared to 42.1 RDD/100 PD in the control period, representing a 10.0% decrease. (4) Conclusions: Our interprofessional approach to TDM significantly reduced meropenem dosing, with all the team's recommendations being implemented. This method not only improved patient safety but also considerably decreased the application density of meropenem.
Collapse
Affiliation(s)
- Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Chiara Koch
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Katharina Zimmermann
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Jonas Buttenschoen
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Alexander Mehrl
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Vlad Pavel
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Sophie Schlosser-Hupf
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Daniel Fleischmann
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany; (D.F.); (A.K.)
| | - Alexander Krohn
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, 70174 Stuttgart, Germany; (A.K.); (T.S.)
| | - Tobias Schilling
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, 70174 Stuttgart, Germany; (A.K.); (T.S.)
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, 93053 Regensburg, Germany; (C.K.); (K.Z.); (J.B.); (A.M.); (V.P.); (S.S.-H.); (M.M.)
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany; (D.F.); (A.K.)
| |
Collapse
|
3
|
Dong J, Liu J, Liu Y, Yao J, Lu Y, Jiao Z, Li W. Physiologically based pharmacokinetic modeling to predict OAT3-mediated drug-drug interactions of meropenem in varying stages of chronic kidney disease. Eur J Pharm Sci 2023; 183:106395. [PMID: 36716979 DOI: 10.1016/j.ejps.2023.106395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/31/2022] [Accepted: 01/26/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Jing Dong
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jinyao Liu
- Ningxia Medical University, 1160 Shengli Street, Ningxia, Yinchuan 750004, PR China
| | - Yanhui Liu
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Jiachen Yao
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Yan Lu
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, 241 West Huaihai Road, Shanghai 200030, PR China.
| | - Wenyan Li
- Department of Pharmacy, Shanghai Pudong New Area Gongli Hospital, The Second Military Medical University, 219 Miaopu Road, Shanghai 200135, PR China.
| |
Collapse
|
4
|
Dubinsky S, Malik P, Hajducek DM, Edginton A. Determining the Effects of Chronic Kidney Disease on Organic Anion Transporter1/3 Activity Through Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2022; 61:997-1012. [PMID: 35508593 DOI: 10.1007/s40262-022-01121-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE The renal excretion of drugs via organic anion transporters 1 and 3 (OAT1/3) is significantly decreased in patients with renal impairment. This study uses physiologically based pharmacokinetic models to quantify the reduction in OAT1/3-mediated secretion of drugs throughout varying stages of chronic kidney disease. METHODS Physiologically based pharmacokinetic models were constructed for four OAT1/3 substrates in healthy individuals: acyclovir, meropenem, furosemide, and ciprofloxacin. Observed data from drug-drug interaction studies with probenecid, a potent OAT1/3 inhibitor, were used to parameterize the contribution of OAT1/3 to the renal elimination of each drug. The models were then translated to patients with chronic kidney disease by accounting for changes in glomerular filtration rate, kidney volume, renal blood flow, plasma protein binding, and hematocrit. Additionally, a relationship was derived between the estimated glomerular filtration rate and the reduction in OAT1/3-mediated secretion of drugs based on the renal extraction ratios of ƿ-aminohippuric acid in patients with varying degrees of renal impairment. The relationship was evaluated in silico by evaluating the predictive performance of each final model in describing the pharmacokinetics (PK) of drugs across stages of chronic kidney disease. RESULTS OAT1/3-mediated renal excretion of drugs was found to be decreased by 27-49%, 50-68%, and 70-96% in stage 3, stage 4, and stage 5 of chronic kidney disease, respectively. In support of the parameterization, physiologically based pharmacokinetic models of four OAT1/3 substrates were able to adequately characterize the PK in patients with different degrees of renal impairment. Total exposure after intravenous administration was predicted within a 1.5-fold error and 85% of the observed data points fell within a 1.5-fold prediction error. The models modestly under-predicted plasma concentrations in patients with end-stage renal disease undergoing intermittent hemodialysis. However, results should be interpreted with caution because of the limited number of molecules analyzed and the sparse sampling in observed chronic kidney disease pharmacokinetic studies. CONCLUSIONS A quantitative understanding of the reduction in OAT1/3-mediated excretion of drugs in differing stages of renal impairment will contribute to better predictive accuracy for physiologically based pharmacokinetic models in drug development, assisting with clinical trial planning and potentially sparing this population from unnecessary toxic exposures.
Collapse
Affiliation(s)
- Samuel Dubinsky
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Paul Malik
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada.
| |
Collapse
|
5
|
Alffenaar JWC, Stocker SL, Forsman LD, Garcia-Prats A, Heysell SK, Aarnoutse RE, Akkerman OW, Aleksa A, van Altena R, de Oñata WA, Bhavani PK, Van't Boveneind-Vrubleuskaya N, Carvalho ACC, Centis R, Chakaya JM, Cirillo DM, Cho JG, D Ambrosio L, Dalcolmo MP, Denti P, Dheda K, Fox GJ, Hesseling AC, Kim HY, Köser CU, Marais BJ, Margineanu I, Märtson AG, Torrico MM, Nataprawira HM, Ong CWM, Otto-Knapp R, Peloquin CA, Silva DR, Ruslami R, Santoso P, Savic RM, Singla R, Svensson EM, Skrahina A, van Soolingen D, Srivastava S, Tadolini M, Tiberi S, Thomas TA, Udwadia ZF, Vu DH, Zhang W, Mpagama SG, Schön T, Migliori GB. Clinical standards for the dosing and management of TB drugs. Int J Tuberc Lung Dis 2022; 26:483-499. [PMID: 35650702 PMCID: PMC9165737 DOI: 10.5588/ijtld.22.0188] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Optimal drug dosing is important to ensure adequate response to treatment, prevent development of drug resistance and reduce drug toxicity. The aim of these clinical standards is to provide guidance on 'best practice´ for dosing and management of TB drugs.METHODS: A panel of 57 global experts in the fields of microbiology, pharmacology and TB care were identified; 51 participated in a Delphi process. A 5-point Likert scale was used to score draft standards. The final document represents the broad consensus and was approved by all participants.RESULTS: Six clinical standards were defined: Standard 1, defining the most appropriate initial dose for TB treatment; Standard 2, identifying patients who may be at risk of sub-optimal drug exposure; Standard 3, identifying patients at risk of developing drug-related toxicity and how best to manage this risk; Standard 4, identifying patients who can benefit from therapeutic drug monitoring (TDM); Standard 5, highlighting education and counselling that should be provided to people initiating TB treatment; and Standard 6, providing essential education for healthcare professionals. In addition, consensus research priorities were identified.CONCLUSION: This is the first consensus-based Clinical Standards for the dosing and management of TB drugs to guide clinicians and programme managers in planning and implementation of locally appropriate measures for optimal person-centred treatment to improve patient care.
Collapse
Affiliation(s)
- J W C Alffenaar
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - S L Stocker
- School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Department of Clinical Pharmacology and Toxicology, St Vincent´s Hospital, Sydney, NSW, Australia, St Vincent´s Clinical Campus, University of NSW, Kensington, NSW, Australia
| | - L Davies Forsman
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, Sweden, Department of Infectious Diseases Karolinska University Hospital, Solna, Sweden
| | - A Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa, Department of Pediatrics, University of Wisconsin, Madison, WI
| | - S K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - R E Aarnoutse
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - O W Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, The Netherlands, University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord, Haren, The Netherlands
| | - A Aleksa
- Educational Institution "Grodno State Medical University", Grodno, Belarus
| | - R van Altena
- Asian Harm Reduction Network (AHRN) and Medical Action Myanmar (MAM) in Yangon, Myanmar
| | - W Arrazola de Oñata
- Belgian Scientific Institute for Public Health (Belgian Lung and Tuberculosis Association), Brussels, Belgium
| | - P K Bhavani
- Indian Council of Medical Research-National Institute for Research in Tuberculosis-International Center for Excellence in Research, Chennai, India
| | - N Van't Boveneind-Vrubleuskaya
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Department of Public Health TB Control, Metropolitan Public Health Services, The Hague, The Netherlands
| | - A C C Carvalho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos (LITEB), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - R Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| | - J M Chakaya
- Department of Medicine, Therapeutics and Dermatology, Kenyatta University, Nairobi, Kenya, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - D M Cirillo
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - J G Cho
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Parramatta Chest Clinic, Parramatta, NSW, Australia
| | - L D Ambrosio
- Public Health Consulting Group, Lugano, Switzerland
| | - M P Dalcolmo
- Reference Center Hélio Fraga, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - P Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - K Dheda
- Centre for Lung Infection and Immunity, Department of Medicine, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa, University of Cape Town Lung Institute & South African MRC Centre for the Study of Antimicrobial Resistance, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - G J Fox
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - A C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - H Y Kim
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, School of Pharmacy, The University of Sydney Faculty of Medicine and Health, Sydney, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia
| | - C U Köser
- Department of Genetics, University of Cambridge, Cambridge, UK
| | - B J Marais
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW, Australia, Department of Infectious Diseases and Microbiology, The Children´s Hospital at Westmead, Westmead, NSW, Australia
| | - I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A G Märtson
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Munoz Torrico
- Clínica de Tuberculosis, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, Mexico
| | - H M Nataprawira
- Division of Paediatric Respirology, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia
| | - C W M Ong
- Infectious Disease Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Institute for Health Innovation & Technology (iHealthtech), National University of Singapore, Singapore, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - R Otto-Knapp
- German Central Committee against Tuberculosis (DZK), Berlin, Germany
| | - C A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | - D R Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - R Ruslami
- TB/HIV Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - P Santoso
- Division of Respirology and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Indonesia
| | - R M Savic
- Department of Bioengineering and Therapeutic Sciences, Division of Pulmonary and Critical Care Medicine, Schools of Pharmacy and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - R Singla
- Department of TB & Respiratory Diseases, National Institute of TB & Respiratory Diseases, New Delhi, India
| | - E M Svensson
- Department of Pharmacy, Radboud Institute for Health Sciences & Radboudumc Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - A Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - D van Soolingen
- National Institute for Public Health and the Environment, TB Reference Laboratory (RIVM), Bilthoven, The Netherlands
| | - S Srivastava
- Department of Pulmonary Immunology, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - M Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - T A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Z F Udwadia
- P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - D H Vu
- National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - W Zhang
- Department of Infectious Diseases, National Medical Center for Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, People´s Republic of China
| | - S G Mpagama
- Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania, Kibong´oto Infectious Diseases Hospital, Sanya Juu, Siha, Kilimanjaro, United Republic of Tanzania
| | - T Schön
- Department of Infectious Diseases, Linköping University Hospital, Linköping, Sweden, Institute of Biomedical and Clinical Sciences, Division of Infection and Inflammation, Linköping University, Linköping, Sweden, Department of Infectious Diseases, Kalmar County Hospital, Kalmar, Linköping University, Linköping, Sweden
| | - G B Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Tradate, Italy
| |
Collapse
|
6
|
Minotti C, Barbieri E, Doni D, Impieri C, Giaquinto C, Donà D. Anti-infective Medicines Use in Children and Neonates With Pre-existing Kidney Dysfunction: A Systematic Review. Front Pediatr 2022; 10:868513. [PMID: 35558367 PMCID: PMC9087830 DOI: 10.3389/fped.2022.868513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background Dosing recommendations for anti-infective medicines in children with pre-existing kidney dysfunction are derived from adult pharmacokinetics studies and adjusted to kidney function. Due to neonatal/pediatric age and kidney impairment, modifications in renal clearance and drug metabolism make standard anti-infective dosing for children and neonates inappropriate, with a risk of drug toxicity or significant underdosing. The aim of this study was the systematic description of the use of anti-infective medicines in pediatric patients with pre-existing kidney impairment. Methods A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, Medline and Cochrane databases were searched on September 21st, 2021. Studies in all languages reporting data on pre-defined outcomes (pharmacokinetics-PK, kidney function, safety and efficacy) regarding the administration of anti-infective drugs in children up to 18 years with pre-existing kidney dysfunction were included. Results 29 of 1,792 articles were eligible for inclusion. There were 13 case reports, six retrospective studies, nine prospective studies and one randomized controlled trial (RCT), reporting data on 2,168 pediatric patients. The most represented anti-infective class was glycopeptides, with seven studies on vancomycin, followed by carbapenems, with five studies, mostly on meropenem. Antivirals, aminoglycosides and antifungals counted three articles, followed by combined antibiotic therapy, cephalosporins, lipopeptides with two studies, respectively. Penicillins and polymixins counted one study each. Nine studies reported data on patients with a decreased kidney function, while 20 studies included data on kidney replacement therapy (KRT). Twenty-one studies reported data on PK. In 23 studies, clinical outcomes were reported. Clinical cure was achieved in 229/242 patients. There were four cases of underdosing, one case of overdosing and 13 reported deaths. Conclusion This is the first systematic review providing evidence of the use of anti-infective medicines in pediatric patients with impaired kidney function or requiring KRT. Dosing size or interval adjustments in pediatric patients with kidney impairment vary according to age, critical illness status, decreased kidney function and dialysis type. Our findings underline the relevance of population PK in clinical practice and the need of developing predictive specific models for critical pediatric patients.
Collapse
Affiliation(s)
- Chiara Minotti
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Denis Doni
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Cristina Impieri
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| |
Collapse
|
7
|
Pharmacokinetics of Oral Tebipenem Pivoxil Hydrobromide in Subjects with Various Degrees of Renal Impairment. Antimicrob Agents Chemother 2022; 66:e0240721. [PMID: 35420493 PMCID: PMC9112917 DOI: 10.1128/aac.02407-21] [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] [Indexed: 11/23/2022] Open
Abstract
Tebipenem pivoxil hydrobromide (TBP-PI-HBr) is an oral carbapenem prodrug antimicrobial agent with broad-spectrum activity that includes multidrug-resistant (MDR) Enterobacterales. This study evaluated the safety, tolerability, and pharmacokinetics of TBP-PI-HBr in healthy subjects with normal renal function (cohort 1) and subjects with various degrees of renal impairment (RI [cohorts 2 to 4]) or end-stage renal disease (ESRD) receiving hemodialysis (HD) (cohort 5). Subjects in cohorts 1 to 4 received a single oral dose of TBP-PI-HBr (600 mg). Subjects in cohort 5 received single-dose administration (600 mg) in 2 separate periods: pre-HD (period 2) and post-HD (period 1). Pharmacokinetic (PK) parameters for TBP, the active moiety, were determined using noncompartmental analysis. Compared with cohort 1, the TBP plasma area under the curve (AUC) increased 1.4- to 4.5-fold among cohorts 2 to 4, the maximum concentration of drug in plasma (Cmax) increased up to 1.3-fold and renal clearance (CLR) decreased from 13.4 L/h to 2.4 L/h as the severity of RI increased. Plasma TBP concentrations decreased over 8 to 12 h in cohorts 1 to 4, and apparent total body clearance (CL/F) correlated (R2 = 0.585) with creatinine clearance (CLCR). TBP urinary excretion ranged from 38% to 64% of the administered dose for cohorts 1 to 4. Subjects in cohort 5 had an approximately 7-fold increase in TBP AUC and elimination half-life (t1/2) versus cohort 1. After 4 h of HD, mean TBP plasma exposure decreased by approximately 40%. Overall, TBP plasma exposure increased with increasing RI, highlighting the renal route importance in TBP elimination. A dose reduction of TBP-PI-HBr may be needed in patients with RI (CLCR of ≤50 mL/min) and those with ESRD on HD. TBP-PI-HBr was well tolerated across all cohorts. (This study has been registered at ClinicalTrials.gov under registration no. NCT04178577.).
Collapse
|
8
|
Methods for Determination of Meropenem Concentration in Biological Samples. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2022-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Measuring the concentration of antibiotics in biological samples allow implementation of therapeutic monitoring of these drugs and contribute to the adjustment of the dosing regimen in patients. This increases the effectiveness of antimicrobial therapy, reduces the toxicity of these drugs and prevents the development of bacterial resistance. This review article summarizes current knowledge on methods for determining concentration of meropenem, an antibiotic drug from the group of carbapenems, in different biological samples. It provides a brief discussion of the chemical structure, physicochemical and pharmacokinetic properties of meropenem, different sample preparation techniques, use of apparatus and equipment, knowledge of the advantages and limitations of available methods, as well as directions in which new methods should be developed. This review should facilitate clinical laboratories to select and apply one of the established methods for measuring of meropenem, as well as to provide them with the necessary knowledge to develop new methods for quantification of meropenem in biological samples according to their needs.
Collapse
|
9
|
Niibe Y, Suzuki T, Yamazaki S, Uchida M, Suzuki T, Takahashi N, Hattori N, Nakada TA, Ishii I. Identification of factors affecting meropenem pharmacokinetics in critically ill patients: Impact of inflammation on clearance. J Infect Chemother 2021; 28:532-538. [PMID: 34973877 DOI: 10.1016/j.jiac.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/02/2021] [Accepted: 12/22/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The purpose of this study was to explore factors influencing meropenem pharmacokinetics (PKs) in critically ill patients by developing a population PK model and to determine the optimal dosing strategy. METHODS This prospective observational study involved 12 critically ill patients admitted to the intensive care unit and treated with meropenem 1 g infused over 1 h every 8 h. Blood samples were collected on days 1, 2, and 5 immediately prior to dosing, and at 1, 2, 4, and 6 h after the start of infusion. Population PK parameters were estimated using nonlinear mixed-effects model software. RESULTS Meropenem PK was adequately described using a two-compartment model. Typical values of total and inter-compartmental clearance were 9.30 L/h and 9.70 L/h, respectively, and the central and peripheral compartment volumes of distribution were 12.61 L and 7.80 L, respectively. C-reactive protein (CRP) was identified as significant covariate affecting total meropenem clearance. The probability of target attainment (PTA) predicted by Monte Carlo simulations varied according to the patients' CRP. The PTA of 100% time above the minimum inhibitory concentration ≤2 mg/L for bacteria was achieved after a dose of 1 and 2 g infused over 4 h every 8 h in patients with CRP of 30 and 5 mg/dL, respectively. CONCLUSION The findings of this study suggest that CRP might be helpful in managing meropenem dosing in critically ill patients. Higher doses and extended infusion may be required to achieve optimal pharmacodynamic targets.
Collapse
Affiliation(s)
- Yoko Niibe
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan.
| | - Tatsuya Suzuki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Shingo Yamazaki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan
| | - Masashi Uchida
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan; Department of Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Takaaki Suzuki
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan; Department of Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Noriyuki Hattori
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Itsuko Ishii
- Division of Pharmacy, Chiba University Hospital, Chiba, Japan; Department of Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, Chiba University, Chiba, Japan
| |
Collapse
|
10
|
Lewis SJ, Bodenhorn D, Na EY, Jang SM. Comparison of antimicrobial dosing recommendations in patients receiving intermittent hemodialysis among drug information resources. J Clin Pharm Ther 2021; 47:628-635. [PMID: 34866202 DOI: 10.1111/jcpt.13583] [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: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tertiary drug information resources are frequently consulted for the optimal antimicrobial dosing in intermittent hemodialysis (IHD) patients. Yet, significant discrepancy may exist in dosing recommendations between resources. This study was to evaluate the consistency of antimicrobial dosing recommendations in IHD among four different drug information resources and the relevance of referenced pharmacokinetic studies. METHODS Dosing recommendations of 29 commonly prescribed antimicrobials in IHD patients were collected from Micromedex, LexiComp, Clinical Pharmacology and Drug Prescribing in Renal Impairment to compare dosing categorization and the total daily dose (TDD). Significant dosing discrepancies were defined as ≥30% difference. Referenced pharmacokinetic studies were evaluated for their relevance in current practice, using sample size, hemodialyzer types, the use of optimal pharmacodynamic targets and the consideration of different interdialytic dosing periods. RESULTS AND DISCUSSION A significant variation was found both in dosing categorization and recommended doses between resources. Seventeen drugs were compared for TDD with significant dosing discrepancy in 8 drugs. Among 42 referenced pharmacokinetic studies, 40 were evaluated. Mean patient numbers of pharmacokinetic studies were 13 ranging from 3 to 70. Sixty per cent of studies utilized contemporary hemodialyzers (e.g., high-flux and/or high efficiency). The optimal pharmacodynamic targets and the impact of different interdialytic intervals were assessed only in 27.5% and 7.5% respectively. WHAT IS NEW AND CONCLUSION Inconsistent antimicrobial dosing recommendations for IHD patients exist among four well-established resources. Many referenced pharmacokinetic studies utilized outdated or less pharmacodynamically relevant study methods. Newer studies are warranted to reflect contemporary dialysis practice and assess its impact on optimal antimicrobial dosing.
Collapse
Affiliation(s)
- Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, Ohio, USA.,Mercy Health - St. Anne Hospital, Toledo, Ohio, USA
| | | | - Eun-Young Na
- University of Findlay College of Pharmacy, Findlay, Ohio, USA
| | - Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, California, USA
| |
Collapse
|
11
|
Wang Y, Chen W, Huang Y, Wang G, Li Z, Yan G, Chen C, Lu G. Optimized Dosing Regimens of Meropenem in Septic Children Receiving Extracorporeal Life Support. Front Pharmacol 2021; 12:699191. [PMID: 34504424 PMCID: PMC8421735 DOI: 10.3389/fphar.2021.699191] [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: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
Objectives: To develop a population pharmacokinetic model of meropenem in children with sepsis receiving extracorporeal life support (ECLS) and optimize the dosage regimen based on investigating the probability of target attainment (PTA). Methods: The children with sepsis were prospectively enrolled in a pediatric intensive care unit from January 2018 to December 2019. The concentration-time data were fitted using nonlinear mixed effect model approach by NONMEM program. The stochastic simulation considering various scenarios based on proposed population pharmacokinetics model were conducted, and the PTAs were calculated to optimize the dosage regimens. Results: A total of 25 children with sepsis were enrolled, of whom13 received ECMO, 9 received CRRT, and 4 received ECMO combined with CRRT. 12 children received a two-step 3-h infusion and 13 children received 1-h infusion. Bodyweight and creatinine clearance had significant impacts on the PK parameters. ECMO intervention was not related to the PK properties. If 100%T > MIC was chosen as target, children receiving 40 mg/kg q8h over a 3 h-infusion only reached the PTA up to 77.4%. If bacteria with MIC 2 mg/L were to be treated with meropenem and the PTA target was 50%T > MIC, a dose of 40 mg/kg q8h for 1 h infusion would be necessary. Conclusions: The PK properties of meropenem in septic children receiving extracorporeal life support were best described. We recommended the opitimized dosing regimens for septic children receiving ECLS depending on the PTA of PK target 50%T > MIC and 100%T > MIC, for children with sepsis during ECLS with different body weight, estimated creatinine clearance (eCRCL) and MIC of bacteria.
Collapse
Affiliation(s)
- Yixue Wang
- Department of Pediatric Critical Care Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Weiming Chen
- Department of Pediatric Critical Care Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guangfei Wang
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Gangfeng Yan
- Department of Pediatric Critical Care Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Guoping Lu
- Department of Pediatric Critical Care Medicine, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| |
Collapse
|
12
|
Population Pharmacokinetics of Meropenem and Vaborbactam Based on Data from Noninfected Subjects and Infected Patients. Antimicrob Agents Chemother 2021; 65:e0260620. [PMID: 34097490 PMCID: PMC8370236 DOI: 10.1128/aac.02606-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Meropenem-vaborbactam is a broad-spectrum carbapenem–beta-lactamase inhibitor combination approved in the United States and Europe to treat patients with complicated urinary tract infections and in Europe for other serious bacterial infections, including hospital-acquired and ventilator-associated pneumonia. Population pharmacokinetic (PK) models were developed to characterize the time course of meropenem and vaborbactam using pooled data from two phase 1 and two phase 3 studies. Multicompartment disposition model structures with linear elimination processes were fit to the data using NONMEM 7.2. Since both drugs are cleared primarily by the kidneys, estimated glomerular filtration rate (eGFR) was evaluated as part of the base structural models. For both agents, a two-compartment model with zero-order input and first-order elimination best described the pharmacokinetic PK data, and a sigmoidal Hill-type equation best described the relationship between renal clearance and eGFR. For meropenem, the following significant covariate relationships were identified: clearance (CL) decreased with increasing age, CL was systematically different in subjects with end-stage renal disease, and all PK parameters increased with increasing weight. For vaborbactam, the following significant covariate relationships were identified: CL increased with increasing height, volume of the central compartment (Vc) increased with increasing body surface area, and CL, Vc, and volume of the peripheral compartment were systematically different between phase 1 noninfected subjects and phase 3 infected patients. Visual predictive checks demonstrated minimal bias, supporting the robustness of the final models. These models were useful for generating individual PK exposures for pharmacokinetic-pharmacodynamic (PK-PD) analyses for efficacy and Monte Carlo simulations to evaluate PK-PD target attainment.
Collapse
|
13
|
König C, Kluge S, Fuhrmann V, Jarczak D. Pharmacokinetics of meropenem during advanced organ support (ADVOS ®) and continuous renal replacement therapy. Int J Artif Organs 2021; 44:783-786. [PMID: 34144656 DOI: 10.1177/03913988211021101] [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: 01/11/2023]
Abstract
The advanced organ support (ADVOS) system allows to eliminate water-soluble as well as protein-bound molecules. Despite its clinical features, to date nothing is known about the elimination of clinically relevant drugs such as antiinfectives. Therefore, we report a case treated with ADVOS, continuous renal replacement therapy (CRRT), and meropenem (1 g 8-hourly) for empiric sepsis therapy monitored by meropenem drug levels. ADVOS showed more efficient elimination of meropenem compared to CRRT which has to be considered when evaluating dosing regimens.
Collapse
Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine, Evangelisches Klinikum Niederrhein, Duisburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
14
|
The Role of Non-Enzymatic Degradation of Meropenem-Insights from the Bottle to the Body. Antibiotics (Basel) 2021; 10:antibiotics10060715. [PMID: 34198482 PMCID: PMC8231794 DOI: 10.3390/antibiotics10060715] [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: 05/04/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 12/22/2022] Open
Abstract
Several studies have addressed the poor stability of meropenem in aqueous solutions, though not considering the main degradation product, the open-ring metabolite (ORM) form. In the present work, we elucidate the metabolic fate of meropenem and ORM from continuous infusion to the human bloodstream. We performed in vitro infusate stability tests at ambient temperature with 2% meropenem reconstituted in 0.9% normal saline, and body temperature warmed buffered human serum with 2, 10, and 50 mg/L meropenem, covering the therapeutic range. We also examined meropenem and ORM levels over several days in six critically ill patients receiving continuous infusions. Meropenem exhibited a constant degradation rate of 0.006/h and 0.025/h in normal saline at 22 °C and serum at 37 °C, respectively. Given that 2% meropenem remains stable for 17.5 h in normal saline (≥90% of the initial concentration), we recommend replacement of the infusate every 12 h. Our patients showed inter-individually highly variable, but intra-individually constant molar ORM/(meropenem + ORM) ratios of 0.21–0.52. Applying a population pharmacokinetic approach using the degradation rate in serum, spontaneous degradation accounted for only 6% of the total clearance.
Collapse
|
15
|
Jang SM, Awdishu L. Drug dosing considerations in continuous renal replacement therapy. Semin Dial 2021; 34:480-488. [PMID: 33939855 DOI: 10.1111/sdi.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, which is associated with increased in-hospital mortality. Delivering effective antibiotics to treat patients with sepsis receiving continuous renal replacement therapy (RRT) is complicated by variability in pharmacokinetics, dialysis delivery, lack of primary literature, and therapeutic drug monitoring. Pharmacokinetic alterations include changes in absorption, distribution, protein binding (PB), metabolism, and renal elimination. Drug absorption may be significantly changed due to alterations in gastric pH, perfusion, gastrointestinal motility, and intestinal atrophy. Volume of distribution for hydrophilic drugs may be increased due to volume overload. Estimation of renal clearance is challenged by the effective delivery of RRT. Drug characteristics such as PB, volume of distribution, and molecular weight impact removal of the drug by RRT. The totality of these alterations leads to reduced exposure. Despite our best knowledge, therapeutic drug monitoring of patients receiving continuous RRT demonstrates wide variability in antimicrobial concentrations, highlighting the need for expanded monitoring of all drugs. This review article will focus on changes in drug pharmacokinetics in AKI and dosing considerations to attain antibiotic pharmacodynamic targets in critically ill patients receiving continuous RRT.
Collapse
Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Linda Awdishu
- Clinical Pharmacy, UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| |
Collapse
|
16
|
Rakete S, Schuster C, Paal M, Vogeser M. An isotope-dilution LC-MS/MS method for the simultaneous quantification of meropenem and its open-ring metabolite in serum. J Pharm Biomed Anal 2021; 197:113944. [PMID: 33588299 DOI: 10.1016/j.jpba.2021.113944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of beta-lactam antibiotics and, among them, especially meropenem gains importance in the field of laboratory medicine. Meropenem is known to be unstable, resulting in a degradation product with an open beta-lactam ring. For a more comprehensive TDM of meropenem, the aim was to develop a LC-MS/MS method for the simultaneous quantification of meropenem and its main degradation product, the open-ring metabolite (ORM). METHODS The method involves a protein precipitation followed by chromatographic separation using a formic acid-ammonium formate methanol gradient on a pentafluorophenyl column. Multiple reaction monitoring in the positive ion mode and stable isotope labeled internal standards were used for quantification. Validation was performed according to the European Medicines Agency guideline. RESULTS Validation was successful performed within the linear drug concentration range of 1.0-100.0 mg/l for meropenem and 0.62-62.30 mg/l for the ORM. Investigation of selectivity, accuracy and precision showed good results and potential matrix effects were successfully compensated by the internal standards. The suitability of the method was shown by the comparison of 35 anonymized leftover serum samples from intensive care patients with routine analyses. CONCLUSION For the first time, we herein describe a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of meropenem and its ORM in human serum. The ratio of active to inactive compound provides valuable pharmaceutical and pharmacokinetic information, which may contribute to therapeutic efficacy.
Collapse
Affiliation(s)
- Sophie Rakete
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany.
| | - Carina Schuster
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| |
Collapse
|
17
|
Bastida C, Hernández-Tejero M, Aziz F, Espinosa C, Sanz M, Brunet M, López E, Fernández J, Soy D. Meropenem population pharmacokinetics in patients with decompensated cirrhosis and severe infections. J Antimicrob Chemother 2020; 75:3619-3624. [PMID: 32887993 DOI: 10.1093/jac/dkaa362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/25/2020] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Meropenem pharmacokinetics (PK) may be altered in patients with cirrhosis, hampering target attainment. We aimed to describe meropenem PK in patients with decompensated cirrhosis and severe bacterial infections, identify the sources of PK variability and assess the performance of different dosing regimens to optimize the PK/pharmacodynamic (PD) target. METHODS Serum concentrations and covariates were obtained from patients with severe infections under meropenem treatment. A population PK analysis was performed using non-linear mixed-effects modelling and the final model was used to simulate meropenem exposure to assess the PTA. RESULTS Fifty-four patients were enrolled in the study. Data were best described by a one-compartment linear model. The estimated typical mean value for clearance (CL) was 8.35 L/h and the estimated volume of distribution (V) was 28.2 L. Creatinine clearance (CLCR) and MELD score significantly influenced meropenem CL, and acute-on-chronic liver failure (ACLF) significantly affected V. Monte Carlo simulations showed that a lower meropenem dose would be needed as CLCR decreases and as the MELD score increases. Patients with ACLF would have lower peak meropenem concentrations but similar steady-state concentrations compared with patients with no ACLF. CONCLUSIONS Our study identified two new covariates that influence meropenem PK in patients with decompensated cirrhosis in addition to CLCR: MELD score and ACLF. Dosing regimens are recommended to reach several PK/PD targets considering these clinical variables and any MIC within the susceptibility range.
Collapse
Affiliation(s)
- Carla Bastida
- Pharmacy Department, Division of Medicines, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - María Hernández-Tejero
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Fátima Aziz
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Cristina Espinosa
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Miquel Sanz
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Centre, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Ester López
- Pharmacy Department, Division of Medicines, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Javier Fernández
- Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain.,European Foundation for the Study of Chronic Liver Failure (EF-Clif), EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Dolors Soy
- Pharmacy Department, Division of Medicines, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| |
Collapse
|
18
|
Jang SM, Lewis SJ, Mueller BA. Harmonizing antibiotic regimens with renal replacement therapy. Expert Rev Anti Infect Ther 2020; 18:887-895. [DOI: 10.1080/14787210.2020.1764845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Susan J. Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA
| | - Bruce A. Mueller
- Clinical Pharmacy Department, Michigan College of Pharmacy, Ann Arbor, MI, USA
| |
Collapse
|
19
|
Grensemann J, Busse D, König C, Roedl K, Jäger W, Jarczak D, Iwersen-Bergmann S, Manthey C, Kluge S, Kloft C, Fuhrmann V. Acute-on-chronic liver failure alters meropenem pharmacokinetics in critically ill patients with continuous hemodialysis: an observational study. Ann Intensive Care 2020; 10:48. [PMID: 32323030 PMCID: PMC7176801 DOI: 10.1186/s13613-020-00666-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infection and sepsis are a main cause of acute-on-chronic liver failure (ACLF). Adequate dosing of antimicrobial therapy is of central importance to improve outcome. Liver failure may alter antibiotic drug concentrations via changes of drug distribution and elimination. We studied the pharmacokinetics of meropenem in critically ill patients with ACLF during continuous veno-venous hemodialysis (CVVHD) and compared it to critically ill patients without concomitant liver failure (NLF). METHODS In this prospective cohort study, patients received meropenem 1 g tid short-term infusion (SI). Meropenem serum samples were analyzed by high-performance liquid chromatography. A population pharmacokinetic analysis was performed followed by Monte Carlo simulations of (A) meropenem 1 g tid SI, (B) 2 g loading plus 1 g prolonged infusion tid (C) 2 g tid SI, and (D) 2 g loading and continuous infusion of 3 g/day on days 1 and 7. Probability of target attainment (PTA) was assessed for 4× the epidemiological cut-off values for Enterobacterales (4 × 0.25 mg/L) and Pseudomonas spp. (4 × 2 mg/L). RESULTS Nineteen patients were included in this study. Of these, 8 patients suffered from ACLF. A two-compartment model with linear clearance from the central compartment described meropenem pharmacokinetics. The peripheral volume of distribution (V2) was significantly higher in ACLF compared to NLF (38.6L versus 19.7L, p = .05). PTA for Enterobacterales was achieved in 100% for all dosing regimens. PTA for Pseudomonas spp. in ACLF on day 1/7 was: A: 18%/80%, B: 94%/88%, C: 85%/98% D: 100%/100% and NLF: A: 48%/65%, B: 91%/83%, C: 91%/93%, D: 100%/100%. CONCLUSION ALCF patients receiving CVVHD had a higher V2 and may require a higher loading dose of meropenem. For Pseudomonas, high doses or continuous infusion are required to reach PTA in ACLF patients.
Collapse
Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Walter Jäger
- Department of Pharmaceutical Chemistry, University of Vienna, Althanstraße 14, 1090, Vienna, Austria
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefanie Iwersen-Bergmann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, 22529, Hamburg, Germany
| | - Carolin Manthey
- First Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Medicine B, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| |
Collapse
|
20
|
Drug Dosing Considerations in Critically Ill Patients Receiving Continuous Renal Replacement Therapy. PHARMACY 2020; 8:pharmacy8010018. [PMID: 32046092 PMCID: PMC7151686 DOI: 10.3390/pharmacy8010018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury is very common in critically ill patients requiring renal replacement therapy. Despite the advancement in medicine, the mortality rate from septic shock can be as high as 60%. This manuscript describes drug-dosing considerations and challenges for clinicians. For instance, drugs’ pharmacokinetic changes (e.g., decreased protein binding and increased volume of distribution) and drug property changes in critical illness affecting solute or drug clearance during renal replacement therapy. Moreover, different types of renal replacement therapy (intermittent hemodialysis, prolonged intermittent renal replacement therapy or sustained low-efficiency dialysis, and continuous renal replacement therapy) are discussed to describe how to optimize the drug administration strategies. With updated literature, pharmacodynamic targets and empirical dosing recommendations for commonly used antibiotics in critically ill patients receiving continuous renal replacement therapy are outlined. It is vital to utilize local epidemiology and resistance patterns to select appropriate antibiotics to optimize clinical outcomes. Therapeutic drug monitoring should be used, when possible. This review should be used as a guide to develop a patient-specific antibiotic therapy plan.
Collapse
|
21
|
Song X, Wu Y, Cao L, Yao D, Long M. Is Meropenem as a Monotherapy Truly Incompetent for Meropenem-Nonsusceptible Bacterial Strains? A Pharmacokinetic/Pharmacodynamic Modeling With Monte Carlo Simulation. Front Microbiol 2019; 10:2777. [PMID: 31849910 PMCID: PMC6895071 DOI: 10.3389/fmicb.2019.02777] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/14/2019] [Indexed: 01/28/2023] Open
Abstract
Infections due to meropenem-nonsusceptible bacterial strains (MNBSs) with meropenem minimum inhibitory concentrations (MICs) ≥ 16 mg/L have become an urgent problem. Currently, the optimal treatment strategy for these cases remains uncertain due to some limitations of currently available mono- and combination therapy regimens. Meropenem monotherapy using a high dose of 2 g every 8 h (q 8 h) and a 3-h traditional simple prolonged-infusion (TSPI) has proven to be helpful for the treatment of infections due to MNBSs with MICs of 4–8 mg/L but is limited for cases with higher MICs of ≥16 mg/L. This study demonstrated that optimized two-step-administration therapy (OTAT, i.e., a new administration model of i.v. bolus plus prolonged infusion) for meropenem, even in monotherapy, can resolve this problem and was thus an important approach of suppressing such highly resistant bacterial isolates. Herein, a pharmacokinetic (PK)/pharmacodynamic (PD) modeling with Monte Carlo simulation was performed to calculate the probabilities of target attainment (PTAs) and the cumulative fractions of response (CFRs) provided by dosage regimens and 39 OTAT regimens in five dosing models targeting eight highly resistant bacterial species with meropenem MICs ≥ 16 mg/L, including Acinetobacter baumannii, Acinetobacter spp., Enterococcus faecalis, Enterococcus faecium, Pseudomonas aeruginosa, Staphylococcus epidermidis, Staphylococcus haemolyticus, and Stenotrophomonas maltophilia, were designed and evaluated. The data indicated that meropenem monotherapy administered at a high dose of 2 g q 8 h and as an OTAT achieved a PTA of ≥90% for isolates with an MIC of up to 128 mg/L and a CFR of ≥90% for all of the targeted pathogen populations when 50% f T > MIC (50% of the dosing interval during which free drug concentrations remain above the MIC) is chosen as the PD target, with Enterococcus faecalis being the sole exception. Even though 50% f T > 5 × MIC is chosen as the PD target, the aforementioned dosage regimen still reached a PTA of ≥90% for isolates with an MIC of up to 32 mg/L and a CFR of ≥90% for Acinetobacter spp., Pseudomonas aeruginosa, and Klebsiella pneumoniae populations. In conclusion, meropenem monotherapy displays potential competency for infections due to such highly resistant bacterial isolates provided that it is administered as a reasonable OTAT but not as the currently widely recommended TSPI.
Collapse
Affiliation(s)
- Xiangqing Song
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yi Wu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Lizhi Cao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Dunwu Yao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Minghui Long
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| |
Collapse
|
22
|
Population pharmacokinetics of meropenem in critically ill children with different renal functions. Eur J Clin Pharmacol 2019; 76:61-71. [DOI: 10.1007/s00228-019-02761-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
|
23
|
Burger R, Guidi M, Calpini V, Lamoth F, Decosterd L, Robatel C, Buclin T, Csajka C, Marchetti O. Effect of renal clearance and continuous renal replacement therapy on appropriateness of recommended meropenem dosing regimens in critically ill patients with susceptible life-threatening infections. J Antimicrob Chemother 2019; 73:3413-3422. [PMID: 30304491 DOI: 10.1093/jac/dky370] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 08/20/2018] [Indexed: 12/15/2022] Open
Abstract
Background Meropenem plasma concentration above a pathogen's MIC over the whole dosing interval (100% ƒT>MIC) is a determinant of outcome in severe infections. Significant variability of meropenem pharmacokinetics is reported in ICU patients. Objectives To characterize meropenem pharmacokinetics in variable CLCR or renal replacement therapy and assess the appropriateness of recommended regimens for MIC coverage. Methods A pharmacokinetic analysis (NONMEM) was conducted with external model validation. Patient characteristics were tested on meropenem clearance estimates, differentiated according to the presence/absence of continuous renal replacement therapy (CRRT, CLCRRT or CLno-CRRT). Simulations evaluated the appropriateness of recommended dosing for achieving 100% fT>MIC in 90% of patients. Results A total of 101 patients were studied: median 63 years (range 49-70), 56% male, SAPS II 38 (27-48). 32% had a CLCR >60 mL/min, 49% underwent CRRT and 32% presented severe sepsis or septic shock. A total of 127 pathogens were documented: 76% Gram-negatives, 24% Gram-positives (meropenem MIC90 2 mg/L, corresponding to EUCAST susceptibility breakpoint). Three hundred and eighty plasma and 129 filtrate-dialysate meropenem concentrations were analysed: two-compartment modelling best described the data. Predicted meropenem CLno-CRRT was 59% lower in impaired (CLCR 30 mL/min) compared to normal (CLCR 100 mL/min) renal function. Simulations showed that recommended regimens appropriately cover MIC90 in patients with CLCR <60 mL/min. Patients with CLCR of 60 to <90 mL/min need 6 g/day to achieve appropriate coverage. In patients with CLCR ≥90 mL/min, appropriate exposure is achieved with increased dose, frequency of administration and infusion duration, or continuous infusion. Conclusions Recommended meropenem regimens are suboptimal in ICU patients with normal or augmented renal clearance. Modified dosing or infusion modalities achieve appropriate MIC coverage for optimized antibacterial efficacy in meropenem-susceptible life-threatening infections.
Collapse
Affiliation(s)
- Raphaël Burger
- Internal Medicine Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Monia Guidi
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Valérie Calpini
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratories, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Laurent Decosterd
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Corinne Robatel
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Thierry Buclin
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Chantal Csajka
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Oscar Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland
| |
Collapse
|
24
|
Minichmayr IK, Roberts JA, Frey OR, Roehr AC, Kloft C, Brinkmann A. Development of a dosing nomogram for continuous-infusion meropenem in critically ill patients based on a validated population pharmacokinetic model. J Antimicrob Chemother 2019; 73:1330-1339. [PMID: 29425283 DOI: 10.1093/jac/dkx526] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background Optimal antibiotic exposure is a vital but challenging prerequisite for achieving clinical success in ICU patients. Objectives To develop and externally validate a population pharmacokinetic model for continuous-infusion meropenem in critically ill patients and to establish a nomogram based on a routinely available marker of renal function. Methods A population pharmacokinetic model was developed in NONMEM® 7.3 based on steady-state meropenem concentrations (CSS) collected during therapeutic drug monitoring. Different serum creatinine-based markers of renal function were compared for their influence on meropenem clearance (the Cockcroft-Gault creatinine clearance CLCRCG, the CLCR bedside estimate according to Jelliffe, the Chronic Kidney Disease Epidemiology Collaboration equation and the four-variable Modification of Diet in Renal Disease equation). After validation of the pharmacokinetic model with independent data, a dosing nomogram was developed, relating renal function to the daily doses required to achieve selected target concentrations (4/8/16 mg/L) in 90% of the patients. Probability of target attainment was determined for efficacy (CSS ≥8 mg/L) and potentially increased likelihood of adverse drug reactions (CSS >32 mg/L). Results In total, 433 plasma concentrations (3.20-48.0 mg/L) from 195 patients (median/P0.05 - P0.95 at baseline: weight 77.0/55.0-114 kg, CLCRCG 63.0/19.6-168 mL/min) were used for model building. We found that CLCRCG best described meropenem clearance (CL = 7.71 L/h, CLCRCG = 80 mL/min). The developed model was successfully validated with external data (n = 171, 73 patients). According to the nomogram, daily doses of 910/1480/2050/2800/3940 mg were required to reach a target CSS = 8 mg/L in 90% of patients with CLCRCG = 20/50/80/120/180 mL/min, respectively. A low probability of adverse drug reactions (<0.5%) was associated with these doses. Conclusions A dosing nomogram was developed for continuous-infusion meropenem based on renal function in a critically ill population.
Collapse
Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany.,Graduate Research Training program PharMetrX, Freie Universitaet Berlin, Berlin, Germany, and Universitaet Potsdam, Potsdam, Germany
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Otto R Frey
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka C Roehr
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Alexander Brinkmann
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| |
Collapse
|
25
|
Hinderling PH, Yu Y. Quantitative Assessment of the Effect of Chronic Kidney Disease on the Nonrenal Clearance of 10 Drugs After Intravenous Administration. Clin Pharmacol Drug Dev 2018; 8:138-151. [PMID: 30589517 DOI: 10.1002/cpdd.635] [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: 09/07/2018] [Accepted: 10/26/2018] [Indexed: 11/09/2022]
Abstract
The investigation identified 10 publications that reported the individual values of total clearance (CL), renal clearance (CLr), nonrenal clearance (CLnr), and the glomerular filtration rate (GFR), in subjects with varying renal functions. We used these data to estimate extent and prevalence of changes in CLnr in chronic kidney disease (CKD) by examining the relationship between clearances and renal function. The investigation was restricted to drugs given intravenously and eliminated by mixed renal and nonrenal pathways. Six drugs showed a significant reduction of CLnr of 61% to 63% in subjects with severe renal impairment, suggesting that the decline of CLnr in advanced CKD can be clinically relevant and may not be uncommon. The decline of CLnr in CKD for these 6 drugs is linearly correlated with the decline of CLr. With 4 of the drugs studied, a significant reduction of CLnr in CKD was not seen. Renal clearance is a more reliable measure of renal function than GFR assessed by creatinine clearance. Chronic kidney disease affects the elimination more than the distribution of the 10 drugs.
Collapse
Affiliation(s)
- Peter H Hinderling
- Department of Pharmaceutics, School of Pharmacy, Virginia, Commonwealth University, Richmond, VA, USA
| | - Yichao Yu
- Department of Pharmaceutics, University of Florida, Gainesville, FL, USA
| |
Collapse
|
26
|
Hamanoue S, Suwabe T, Ubara Y, Kikuchi K, Hazue R, Mise K, Ueno T, Takaichi K, Matsumoto K, Morita K. Cyst infection in autosomal dominant polycystic kidney disease: penetration of meropenem into infected cysts. BMC Nephrol 2018; 19:272. [PMID: 30340529 PMCID: PMC6194587 DOI: 10.1186/s12882-018-1067-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/04/2018] [Indexed: 11/21/2022] Open
Abstract
Background Cyst infection is a common and serious complication of autosomal dominant polycystic kidney disease (ADPKD) that is often refractory. Carbapenems are frequently needed to treat to patients with refractory cyst infection, but little is known about the penetration of newer water-soluble carbapenems into cysts. This study investigated the penetration of meropenem (MEPM) into infected cysts in patients with ADPKD. Methods Between August 2013 and January 2014, 10 ADPKD patients (14 infected cysts) receiving MEPM at Toranomon Hospital underwent drainage of infected cysts and definite cyst infection was confirmed through detection of neutrophils by cyst fluid analysis. The serum concentration of MEPM was measured just after intravenous administration and was compared with that in fluid aspirated from infected cysts. Results In the patients undergoing cyst drainage, the mean serum MEPM concentration was 35.2 ± 12.2 μg/mL (range: 19.7 to 59.2 μg/mL, while the mean cyst fluid concentration of MEPM in the drained liver cysts (n = 12) or kidney cysts (n = 2) was 3.03 ± 2.6 μg/mL (range: 0 to 7.3 μg/mL). In addition, the mean cyst fluid/serum MEPM concentration ratio was 9.46 ± 7.19% (range: 0 to 18.8%). There was no relationship between the cyst fluid concentration of MEPM and the time until drainage after MEPM administration or between the cyst fluid/serum MEPM concentration ratio and the time until drainage. Conclusion These findings suggest that MEPM shows poor penetration into infected cysts in ADPKD patients. Trial registration This study was registered with the University Hospital Medical Information Network (UMIN) as “Penetration of meropenem into cysts in patients with autosomal dominant polycystic kidney disease (ADPKD)”, UMIN ID 000011292 on July 26th, 2013. Electronic supplementary material The online version of this article (10.1186/s12882-018-1067-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Satoshi Hamanoue
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Tatsuya Suwabe
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan.
| | - Yoshifumi Ubara
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Koichi Kikuchi
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Ryo Hazue
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Koki Mise
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Toshiharu Ueno
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Kenmei Takaichi
- Department of Nephrology, Toranomon Hospital Kajigaya, Kawasaki, Japan.,Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| | - Kunihiko Morita
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women's College of Liberal Arts, Kyoto, Japan
| |
Collapse
|
27
|
Schroeder T, Krueger W, Hansen M, Hoffmann E, Dieterich H, Unertl K. Elimination of Meropenem by Continuous Hemo(Dia) Filtration: An in Vitro One-Compartment Model. Int J Artif Organs 2018. [DOI: 10.1177/039139889902200503] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Meropenem is a carbapenem antibiotic with a wide spectrum of activity against most gram positive and gram negative bacteria including anaerobes. Dose adjustments are necessary during continuous renal replacement therapies of acute renal failure. This in vitro study was conducted to investigate the influence of different filter materials, surface areas (AN-69 0.6 m2 and 0.9 m2, polysulfone 0.75 m2, polyamide 0.6 m2), and increasing flow rates (from 3.3 - 26.7 ml/min) on the elimination of meropenem in an in vitro continuous hemo(dia)filtration model. Meropenem was measured using HPLC with UV-detection. While the clearance increased proportionally to increasing dialysate flow rates in filters with a surface area of 0.9 m2, a peak clearance was reached in the small filters at flow rates of 10.0 ml/min (polyamide 0.6 m2) and 18.3 ml/min (AN-69 0.6 m2), when tested under the same conditions. This indicated incomplete dialysate saturation due to the diminished time available for meropenem to equilibrate with the dialysate solution. No adsorption to either of the tested membranes was detected. Dosage recommendations derived from clinical studies might be appropriate when different filter materials, but similar operational settings of the continuous replacement therapy, are applied. Reduction of the recommended dose might be necessary, when renal replacement therapies with lower flow rates and/or filters with smaller surface areas are carried out.
Collapse
Affiliation(s)
- T.H. Schroeder
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| | - W.A. Krueger
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| | - M. Hansen
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| | - E. Hoffmann
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| | - H.J. Dieterich
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| | - K. Unertl
- Department of Anaesthesiology, Eberhard-Karls-University Tuebingen, Tuebingen - Germany
| |
Collapse
|
28
|
Pharmacokinetics of meropenem in septic patients on sustained low-efficiency dialysis: a population pharmacokinetic study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:25. [PMID: 29382394 PMCID: PMC5791175 DOI: 10.1186/s13054-018-1940-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 01/02/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim of the study was to describe the population pharmacokinetics (PK) of meropenem in critically ill patients receiving sustained low-efficiency dialysis (SLED). METHODS Prospective population PK study on 19 septic patients treated with meropenem and receiving SLED for acute kidney injury. Serial blood samples for determination of meropenem concentrations were taken before, during and after SLED in up to three sessions per patient. Nonparametric population PK analysis with Monte Carlo simulations were used. Pharmacodynamic (PD) targets of 40% and 100% time above the minimal inhibitory concentration (f T > MIC) were used for probability of target attainment (PTA) and fractional target attainment (FTA) against Pseudomonas aeruginosa. RESULTS A two-compartment linear population PK model was most appropriate with residual diuresis supported as significant covariate affecting meropenem clearance. In patients without residual diuresis the PTA for both targets (40% and 100% f T > MIC) and susceptible P. aeruginosa (MIC ≤ 2 mg/L) was > 95% for a dose of 0.5 g 8-hourly. In patients with a residual diuresis of 300 mL/d 1 g 12-hourly and 2 g 8-hourly would be required to achieve a PTA of > 95% and 93% for targets of 40% f T > MIC and 100% f T > MIC, respectively. A dose of 2 g 8-hourly would be able to achieve a FTA of 97% for 100% f T > MIC in patients with residual diuresis. CONCLUSIONS We found a relevant PK variability for meropenem in patients on SLED, which was significantly influenced by the degree of residual diuresis. As a result dosing recommendations for meropenem in patients on SLED to achieve adequate PD targets greatly vary. Therapeutic drug monitoring may help to further optimise individual dosing. TRIAL REGISTRATION Clincialtrials.gov, NCT02287493 .
Collapse
|
29
|
Ray VA, Hill PJ, Stover CK, Roy S, Sen CK, Yu L, Wozniak DJ, DiGiandomenico A. Anti-Psl Targeting of Pseudomonas aeruginosa Biofilms for Neutrophil-Mediated Disruption. Sci Rep 2017; 7:16065. [PMID: 29167572 PMCID: PMC5700069 DOI: 10.1038/s41598-017-16215-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 11/08/2017] [Indexed: 01/05/2023] Open
Abstract
Bacterial biofilms are recalcitrant to antibiotic therapy and a major cause of persistent and recurrent infections. New antibody-based therapies may offer potential to target biofilm specific components for host-cell mediated bacterial clearance. For Pseudomonas aeruginosa, human monoclonal antibodies (mAbs) targeting the Psl biofilm exopolysaccharide exhibit protective activity against planktonic bacteria in acute infection models. However, anti-Psl mAb activity against P. aeruginosa biofilms is unknown. Here, we demonstrate that anti-Psl mAbs targeting three distinct Psl epitopes exhibit stratified binding in mature in vitro biofilms and bind Psl within the context of a chronic biofilm infection. These mAbs also exhibit differential abilities to inhibit early biofilm events and reduce biomass from mature biofilms in the presence of neutrophils. Importantly, a mAb mixture with neutrophils exhibited the greatest biomass reduction, which was further enhanced when combined with meropenem, a common anti-Pseudomonal carbapenem antibiotic. Moreover, neutrophil-mediated killing of biofilm bacteria correlated with the evident mAb epitope stratification within the biofilm. Overall, our results suggest that anti-Psl mAbs might be promising candidates for adjunctive use with antibiotics to inhibit/disrupt P. aeruginosa biofilms as a result of chronic infection.
Collapse
Affiliation(s)
- Valerie A Ray
- Center for Microbial Interface Biology, Departments of Microbial Infection and Immunity, Microbiology, Ohio State University, Columbus, OH, 43210, USA
| | - Preston J Hill
- Center for Microbial Interface Biology, Departments of Microbial Infection and Immunity, Microbiology, Ohio State University, Columbus, OH, 43210, USA
| | - C Kendall Stover
- Department of Infectious Diseases, MedImmune, LLC, Gaithersburg, MD, 20878, USA
| | - Sashwati Roy
- Comprehensive Wound Center, Davis Heart and Lung Research Institute, Center for Regenerative Medicine and Cell Based Therapies, Ohio State University Medical Center, Columbus, OH, 43210, USA.,Department of Surgery, College of Veterinary Medicine, Ohio State University, Columbus, OH, 43210, USA
| | - Chandan K Sen
- Comprehensive Wound Center, Davis Heart and Lung Research Institute, Center for Regenerative Medicine and Cell Based Therapies, Ohio State University Medical Center, Columbus, OH, 43210, USA.,Department of Surgery, College of Veterinary Medicine, Ohio State University, Columbus, OH, 43210, USA
| | - Li Yu
- Translational Sciences, MedImmune, LLC, Gaithersburg, MD, 20878, USA
| | - Daniel J Wozniak
- Center for Microbial Interface Biology, Departments of Microbial Infection and Immunity, Microbiology, Ohio State University, Columbus, OH, 43210, USA
| | | |
Collapse
|
30
|
Ehmann L, Zoller M, Minichmayr IK, Scharf C, Maier B, Schmitt MV, Hartung N, Huisinga W, Vogeser M, Frey L, Zander J, Kloft C. Role of renal function in risk assessment of target non-attainment after standard dosing of meropenem in critically ill patients: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:263. [PMID: 29058601 PMCID: PMC5651591 DOI: 10.1186/s13054-017-1829-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/29/2017] [Indexed: 12/31/2022]
Abstract
Background Severe bacterial infections remain a major challenge in intensive care units because of their high prevalence and mortality. Adequate antibiotic exposure has been associated with clinical success in critically ill patients. The objective of this study was to investigate the target attainment of standard meropenem dosing in a heterogeneous critically ill population, to quantify the impact of the full renal function spectrum on meropenem exposure and target attainment, and ultimately to translate the findings into a tool for practical application. Methods A prospective observational single-centre study was performed with critically ill patients with severe infections receiving standard dosing of meropenem. Serial blood samples were drawn over 4 study days to determine meropenem serum concentrations. Renal function was assessed by creatinine clearance according to the Cockcroft and Gault equation (CLCRCG). Variability in meropenem serum concentrations was quantified at the middle and end of each monitored dosing interval. The attainment of two pharmacokinetic/pharmacodynamic targets (100%T>MIC, 50%T>4×MIC) was evaluated for minimum inhibitory concentration (MIC) values of 2 mg/L and 8 mg/L and standard meropenem dosing (1000 mg, 30-minute infusion, every 8 h). Furthermore, we assessed the impact of CLCRCG on meropenem concentrations and target attainment and developed a tool for risk assessment of target non-attainment. Results Large inter- and intra-patient variability in meropenem concentrations was observed in the critically ill population (n = 48). Attainment of the target 100%T>MIC was merely 48.4% and 20.6%, given MIC values of 2 mg/L and 8 mg/L, respectively, and similar for the target 50%T>4×MIC. A hyperbolic relationship between CLCRCG (25–255 ml/minute) and meropenem serum concentrations at the end of the dosing interval (C8h) was derived. For infections with pathogens of MIC 2 mg/L, mild renal impairment up to augmented renal function was identified as a risk factor for target non-attainment (for MIC 8 mg/L, additionally, moderate renal impairment). Conclusions The investigated standard meropenem dosing regimen appeared to result in insufficient meropenem exposure in a considerable fraction of critically ill patients. An easy- and free-to-use tool (the MeroRisk Calculator) for assessing the risk of target non-attainment for a given renal function and MIC value was developed. Trial registration Clinicaltrials.gov, NCT01793012. Registered on 24 January 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1829-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lisa Ehmann
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Barbara Maier
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian V Schmitt
- Institute of Pharmacy and Molecular Biotechnology, University of Heidelberg, Heidelberg, Germany
| | - Niklas Hartung
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Institute of Mathematics, Universitaet Potsdam, Potsdam, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, Universitaet Potsdam, Potsdam, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Lorenz Frey
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Zander
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.
| |
Collapse
|
31
|
Borella E, Poggesi I, Magni P. Prediction of the Effect of Renal Impairment on the Pharmacokinetics of New Drugs. Clin Pharmacokinet 2017; 57:505-514. [DOI: 10.1007/s40262-017-0574-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
32
|
Usman M, Frey OR, Hempel G. Population pharmacokinetics of meropenem in elderly patients: dosing simulations based on renal function. Eur J Clin Pharmacol 2016; 73:333-342. [PMID: 27966034 DOI: 10.1007/s00228-016-2172-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate different dosage regimens of meropenem in elderly patients in relation with renal function using a population pharmacokinetic (popPK) model. METHODS The data of 178 elderly patients treated with meropenem was collected from different sources. A popPK model was developed by using NONMEM® and the influence of different covariates on meropenem CL and V1 was observed. Monte Carlo dosing simulations were performed at steady state to observe the % T > MIC for targets of 40, 60 and 80% of dosage intervals at different levels of creatinine clearance (CLCR). RESULTS The data was described by a two-compartment model and the values of parameter estimates for CL, V1, Q and V2 were 5.27 L/h, 17.2 L, 9.92 L/h and 10.6 L, respectively. The CLCR, body weight and centre had a significant influence on meropenem CL while no direct influence of age was observed. Extended infusions had pharmacokinetic and pharmacodynamic (PK/PD) breakpoint one dilution greater than corresponding short infusion regimens for each target of % T > MIC. CONCLUSION Meropenem CL was significantly lower in the elderly compared to CL reported in younger patients due to the reduced renal function. An extended infusion of 1000 mg q8h can be considered for empirical treatment of infections in elderly patients when CLCR is ≤ 50 mL/min. A continuous infusion of 3000 mg daily dose is preferred if CLCR > 50 mL/min. However, a higher daily dose of meropenem would be required for resistant strains (MIC >8 mg/L) of bacteria if CLCR is >100 mL/min.
Collapse
Affiliation(s)
- Muhammad Usman
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Otto R Frey
- Department of Pharmacy, Hospital of Heidenheim, Heidenheim, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.
| |
Collapse
|
33
|
Byun SY, Jeong JW, Choi JH, Lee KP, Youn HY, Maeng HJ, Song KH, Koo TS, Seo KW. Pharmacokinetic study of meropenem in healthy beagle dogs receiving intermittent hemodialysis. J Vet Pharmacol Ther 2016; 39:560-565. [PMID: 27302674 DOI: 10.1111/jvp.12326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 04/20/2016] [Indexed: 11/30/2022]
Abstract
Meropenem, a second carbapenem antimicrobial agent with a broad spectrum of activity, is used to treat sepsis and resistant-bacterial infections in veterinary medicine. The objective of this study was to identify the pharmacokinetics of meropenem in dogs receiving intermittent hemodialysis (IHD) and to determine the proper dosing in renal failure patients receiving IHD. Five healthy beagle dogs were given a single i.v. dose of 24 mg/kg of meropenem and received IHD. The blood flow rate, dialysate flow, and ultrafiltration rate were maintained at 40 mL/min, 300 mL/min, and 40 mL/h, respectively. Blood samples were collected for 24 h from the jugular vein and from the extracorporeal arterial and venous line. Urine samples and dialysate were also collected. The concentrations of meropenem were assayed using HPLC/MS/MS determination. The peak plasma concentration was 116 ± 37 μg/mL at 15 min. The systemic clearance was 347 ± 117 mL/h/kg, and the steady-state volume of distribution was 223 ± 67 mL/kg. Dialysis clearance was 71.1 ± 34.3 mL/h/kg, and the extraction ratio by hemodialysis was 0.455 ± 0.150. The half-life (T1/2 ) in dogs with IHD decreased compared with those without IHD, and the reduction in T1/2 was greater in renal failure patients than in normal patients. Sixty-nine percent and 21% of the administered drug were recovered by urine and dialysate in the unchanged form, respectively. In conclusion, additional dosing of 24 mg/kg of meropenem after dialysis could be necessary according to the residual renal function of the patient based on the simulated data.
Collapse
Affiliation(s)
- S Y Byun
- College of Veterinary Medicine, Chungnam National University, Daejeon, Korea
| | - J W Jeong
- Graduate School of New Drug Discovery and Development, Chungnam National University, Daejeon, Korea
| | - J H Choi
- College of Veterinary Medicine, Chungnam National University, Daejeon, Korea
| | - K P Lee
- College of Veterinary Medicine, Chungnam National University, Daejeon, Korea
| | - H Y Youn
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Seoul National University, Seoul, Korea
| | - H J Maeng
- College of Pharmacy, Gachon University, Incheon, Korea
| | - K H Song
- College of Veterinary Medicine, Chungnam National University, Daejeon, Korea
| | - T S Koo
- Graduate School of New Drug Discovery and Development, Chungnam National University, Daejeon, Korea.
| | - K W Seo
- College of Veterinary Medicine, Chungnam National University, Daejeon, Korea.
| |
Collapse
|
34
|
Abstract
Hemodialysis is a life-sustaining chronic therapy for individuals with end stage renal disease (ESRD). It is also frequently used for days to weeks for patients with acute renal failure who are awaiting the recovery of their kidneys from the acute toxic or traumatic event. Both populations of patients often require complex pharmacotherapeutic regimens, and it is not uncommon for them to be receiving 10 or more concomitant medications. Optimization of care for these patients is dependent on the selection of the most appropriate drug as well as dosage regimen design, which accounts for the influence of hemodialysis therapy on drug disposition. During the last 10 to 15 years there have been several significant changes in the prescribed dose of dialysis and the composition and size of dialyzers available for use. Furthermore, reuse of dialyzers, which was rare in the early 1980s, is now common; it is employed with over 70% of patients with ESRD. The new synthetic dialyzers, which are now used for over 60% of ESRD patients in the United States, are uniformly associated with dramatic improvements in drug removal; dialysis clearance increases of 3 to 10 fold were common for the few drugs evaluated. The influence of these changes in hemodialysis therapy on drug disposition are discussed in a quantitative fashion, and a conceptual framework for drug therapy regimen decision making is presented. For the majority of the drugs reviewed, however, there were no data in the literature regarding dialyzability with currently available dialyzers. The generation of dialyzability data for old and new pharmacotherapeutic agents with state of the art dialysis procedures is clearly needed.
Collapse
Affiliation(s)
- Gary R. Matzke
- Department of Pharmacy and Therapeutics, School of Pharmacy, Division of Renal-Electrolyte Medicine at the School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,
| |
Collapse
|
35
|
Lewis SJ, Kays MB, Mueller BA. Use of Monte Carlo Simulations to Determine Optimal Carbapenem Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy. J Clin Pharmacol 2016; 56:1277-87. [DOI: 10.1002/jcph.727] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/08/2016] [Accepted: 02/16/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Susan J. Lewis
- Department of Clinical Pharmacy; University of Michigan College of Pharmacy; Ann Arbor MI USA
| | - Michael B. Kays
- Department of Pharmacy Practice; Purdue University College of Pharmacy; West Lafayette IN USA
| | - Bruce A. Mueller
- Department of Clinical Pharmacy; University of Michigan College of Pharmacy; Ann Arbor MI USA
| |
Collapse
|
36
|
Wilbaux M, Fuchs A, Samardzic J, Rodieux F, Csajka C, Allegaert K, van den Anker JN, Pfister M. Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates. J Clin Pharmacol 2016; 56:909-35. [PMID: 26766774 DOI: 10.1002/jcph.705] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 12/13/2022]
Abstract
Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.
Collapse
Affiliation(s)
- Mélanie Wilbaux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Aline Fuchs
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Frédérique Rodieux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Marc Pfister
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, CA, USA
| |
Collapse
|
37
|
Nehus EJ, Mizuno T, Cox S, Goldstein SL, Vinks AA. Pharmacokinetics of meropenem in children receiving continuous renal replacement therapy: Validation of clinical trial simulations. J Clin Pharmacol 2015. [PMID: 26222329 DOI: 10.1002/jcph.601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Meropenem is frequently prescribed in critically ill children receiving continuous renal replacement therapy (CRRT). We previously used clinical trial simulations to evaluate dosing regimens of meropenem in this population and reported that a dose of 20 mg/kg every 12 hours optimizes target attainment. Meropenem pharmacokinetics were investigated in this prospective, open-label study to validate our previous in silico predictions. Seven patients received meropenem (13.8-22 mg/kg) administered intravenously every 12 hours as part of standard care. A mean dose of 18.6 mg/kg of meropenem was administered, resulting in a mean peak concentration of 80.1 μg/mL. Meropenem volume of distribution was 0.35 ± 0.085 L/kg. CRRT clearance was 40.2 ± 6.6 mL/(min · 1.73 m(2) ) and accounted for 63.4% of the total clearance of 74.8 ± 36.9 mL/(min · 1.73 m(2) ). Simulations demonstrated that a dose of 20 mg/kg every 12 hours resulted in a time above the minimum inhibitory concentration (%fT > MIC) of 100% in 5 out of 7 subjects, with a %fT > MIC of 93% and 43% in the remaining 2 subjects. We conclude that CRRT contributed significantly to the total clearance of meropenem. A dosing regimen of 20 mg/kg achieved good target attainment in critically ill children receiving CRRT, which is consistent with our previously published in silico predictions.
Collapse
Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shareen Cox
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
38
|
Kees MG, Minichmayr IK, Moritz S, Beck S, Wicha SG, Kees F, Kloft C, Steinke T. Population pharmacokinetics of meropenem during continuous infusion in surgical ICU patients. J Clin Pharmacol 2015. [PMID: 26222202 DOI: 10.1002/jcph.600] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Continuous infusion of meropenem is a candidate strategy for optimization of its pharmacokinetic/pharmacodynamic profile. However, plasma concentrations are difficult to predict in critically ill patients. Steady-state concentrations of meropenem were determined prospectively during continuous infusion in 32 surgical ICU patients (aged 21-85 years, body weight 55-125 kg, APACHE II 5-29, measured creatinine clearance 22.7-297 mL/min). Urine was collected for the quantification of renal clearance of meropenem and creatinine. Cystatin C was measured as an additional marker of renal function. Population pharmacokinetic models were developed using NONMEM(®) , which described total meropenem clearance and its relationship with several estimates of renal function (measured creatinine clearance CLCR , Cockcroft-Gault formula CLCG , Hoek formula, 1/plasma creatinine, 1/plasma cystatin C) and other patient characteristics. Any estimate of renal function improved the model performance. The strongest association of clearance was found with CLCR (typical clearance = 11.3 L/h × [1 + 0.00932 × (CLCR - 80 mL/min)]), followed by 1/plasma cystatin C; CLCG was the least predictive covariate. Neither age, weight, nor sex was found to be significant. These models can be used to predict dosing requirements or meropenem concentrations during continuous infusion. The covariate CLCR offers the best predictive performance; if not available, cystatin C may provide a promising alternative to plasma creatinine.
Collapse
Affiliation(s)
- Martin G Kees
- Department of Anaesthesiology and Intensive Care, Charit, é, Universit, ä, tsmedizin Berlin-Campus Benjamin Franklin, 12200, Berlin, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Stefan Moritz
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), 06120, Halle (Saale), Germany
| | - Stefanie Beck
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, 93053, Regensburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Thomas Steinke
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), 06120, Halle (Saale), Germany
| |
Collapse
|
39
|
Karambelkar A, Kasekar R, Palevsky PM. Perioperative Pharmacologic Management of Patients with End Stage Renal Disease. Semin Dial 2015; 28:392-6. [PMID: 25876523 DOI: 10.1111/sdi.12384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The pharmacokinetics of numerous medications used in the perioperative period are altered in patients with end-stage renal disease. Clearance of drugs, or their metabolites, that are normally excreted by the kidney is markedly reduced in ESRD. In addition, patients with ESRD may also have alterations in gastrointestinal absorption, volume of distribution, protein binding, and metabolic clearance of pharmacologic agents. Finally, drug removal may be augmented during dialysis. All of these factors contribute to the need for dose adjustment of medications, including analgesics, anesthetics, neuromuscular blockers, and antimicrobial agents, which may be used in the perioperative management of the ESRD patient.
Collapse
Affiliation(s)
- Ameet Karambelkar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Riyaj Kasekar
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paul M Palevsky
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Renal Section, Medical Service, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| |
Collapse
|
40
|
Huttner A, Von Dach E, Renzoni A, Huttner BD, Affaticati M, Pagani L, Daali Y, Pugin J, Karmime A, Fathi M, Lew D, Harbarth S. Augmented renal clearance, low β-lactam concentrations and clinical outcomes in the critically ill: an observational prospective cohort study. Int J Antimicrob Agents 2015; 45:385-92. [PMID: 25656151 DOI: 10.1016/j.ijantimicag.2014.12.017] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 12/02/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
Abstract
Whilst augmented renal clearance (ARC) is associated with reduced β-lactam plasma concentrations, its impact on clinical outcomes is unclear. This single-centre prospective, observational, cohort study included non-pregnant, critically ill patients aged 18-60 years with presumed severe infection treated with imipenem, meropenem, piperacillin/tazobactam or cefepime and with creatinine clearance (CL(Cr)) ≥60 mL/min. Peak, intermediate and trough levels of β-lactams were drawn on Days 1-3 and 5. Concentrations were deemed 'subthreshold' if they did not meet EUCAST-defined non-species-related breakpoints. Primary and secondary endpoints were clinical response 28 days after inclusion, and ARC prevalence (CL(Cr)≥130 mL/min) and subthreshold and undetectable concentrations, respectively. Logistic regression was used to evaluate associations between ARC, antibiotic concentrations and clinical failure. From 2010 to 2013, 100 patients were enrolled (mean age, 45 years; median CL(Cr) at inclusion, 144.1 mL/min). ARC was present in 64 (64%) of the patients. Most patients received imipenem/cilastatin (54%). Moreover, 86% and 27% of patients had at least one subthreshold or undetectable trough level, respectively. Among imipenem and piperacillin trough levels, 77% and 61% were subthreshold, respectively, but intermediate levels of both antibiotics were largely above threshold. ARC strongly predicted undetectable trough concentrations (OR=3.3, 95% CI 1.11-9.94). A link between ARC and clinical failure (18/98; 18%) was not observed. ARC and subthreshold β-lactam antibiotic concentrations were widespread but were not associated with clinical failure. Larger studies are necessary to determine whether standard dosing regimens in the presence of ARC impact negatively on clinical outcome and antibiotic resistance.
Collapse
Affiliation(s)
- Angela Huttner
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland.
| | - Elodie Von Dach
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Adriana Renzoni
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Benedikt D Huttner
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Mathieu Affaticati
- University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Leonardo Pagani
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Yousef Daali
- Division of Pharmacology, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Jerôme Pugin
- Division of Critical Care Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Abderrahim Karmime
- Department of Laboratory Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Marc Fathi
- Department of Laboratory Medicine, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Daniel Lew
- Division of Infectious Diseases, Geneva University Hospitals and Medical School, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 4, Switzerland
| |
Collapse
|
41
|
Comparison of the accuracy and precision of pharmacokinetic equations to predict free meropenem concentrations in critically ill patients. Antimicrob Agents Chemother 2014; 59:1411-7. [PMID: 25512414 DOI: 10.1128/aac.04001-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Population pharmacokinetic analyses can be applied to predict optimized dosages for individual patients. The aim of this study was to compare the prediction performance of the published population pharmacokinetic models for meropenem in critically ill patients. We coded the published population pharmacokinetic models with covariate relationships into dosing software to predict unbound meropenem concentrations measured in a separate cohort of critically ill patients. The agreements between the observed and predicted concentrations were evaluated with Bland-Altman plots. The absolute and relative bias and precision of the models were determined. The clinical implications of the results were evaluated according to whether dose adjustments were required from the predictions to achieve a meropenem concentration of >2 mg/liter throughout the dosing interval. A total of 157 free meropenem concentrations from 56 patients were analyzed. Eight published population pharmacokinetic models were compared. The models showed an absolute bias in predicting the unbound meropenem concentrations from a mean percent difference (95% confidence interval [CI]) of -108.5% (-119.9% to -97.3%) to 19.9% (7.3% to 32.7%), while absolute precision ranged from -249.1% (-263.4% to -234.8%) to 31.9% (17.6% to 46.2%) and -178.9% (-196.9% to -160.9%) to 175.0% (157.0% to 193.0%). A dose change was required in 44% to 64% of the concentration results. Seven of the eight equations evaluated underpredicted free meropenem concentrations. In conclusion, the overall accuracy of these models supports their inclusion in dosing software and application for individualizing meropenem doses in critically ill patients to increase the likelihood of achievement of optimal antibiotic exposures.
Collapse
|
42
|
Ramon-Lopez A, Allen JM, Thomson AH, Dheansa BS, James SE, Hanlon GW, Stewart B, Davies JG. Dosing regimen of meropenem for adults with severe burns: a population pharmacokinetic study with Monte Carlo simulations. J Antimicrob Chemother 2014; 70:882-90. [PMID: 25362574 DOI: 10.1093/jac/dku429] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To develop a population model to describe the pharmacokinetics (PK) of intravenous meropenem in adult patients with severe burns and investigate potential relationships between dosage regimens and antimicrobial efficacy. PATIENTS AND METHODS A dose of 1 g every 8 h was administered to adult patients with total body surface area burns of ≥15%. Doses for subsequent courses were determined using results from the initial course and the patient's clinical condition. Five plasma meropenem concentrations were typically measured over the dosage interval on one to four occasions. An open, two-compartment PK model was fitted to the meropenem concentrations using NONMEM and the effect of covariates on meropenem PK was investigated. Monte Carlo simulations investigated dosage regimens to achieve a target T>MIC for ≥40%, ≥60% or ≥80% of the dose interval. RESULTS Data comprised 113 meropenem concentration measurements from 20 dosage intervals in 12 patients. The parameters were CL (L/h) = 0.196 L/h/kg × [1 - 0.023 × (age - 46)] × [1 - 0.049 × (albumin - 15)], V1 = 0.273 L/kg × [1 - 0.049 × (albumin - 15)], Q = 0.199 L/h/kg and V2 = 0.309 L/kg × [1 - 0.049 × (albumin - 15)]. For a target of ≥80% T>MIC, the breakpoint was 8 mg/L for doses of 1 g every 4 h and 2 g every 8 h given over 3 h, but only 4 mg/L if given over 5 min. CONCLUSIONS Although 1 g 8 hourly should be effective against Escherichia coli and CoNS, higher doses, ideally with a longer infusion time, would be more appropriate for empirical therapy, mixed infections and bacteria with MIC values ≥4 mg/L.
Collapse
Affiliation(s)
- Amelia Ramon-Lopez
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK Division of Pharmacy and Pharmaceutics, Department of Engineering, Miguel Hernandez University, Alicante, Spain
| | - Jane M Allen
- Pharmacy Department, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - Alison H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK Pharmacy Department, Western Infirmary, Glasgow, UK
| | - Bajlit S Dheansa
- Burns Centre, Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK
| | - S Elizabeth James
- School of Pharmacy & Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Geoff W Hanlon
- School of Pharmacy & Biomolecular Sciences, University of Brighton, Brighton, UK
| | - Bruce Stewart
- Department of Microbiology, Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - J Graham Davies
- Institute of Pharmaceutical Science, King's College London, London, UK
| |
Collapse
|
43
|
Abstract
BACKGROUND Meropenem is an effective β-lactam antibiotic that is frequently used to treat serious infections in both intensive care unit (ICU) and febrile neutropenic hematology/oncology (Hem/Onc) patients. Studies suggest that to be effective, meropenem concentrations must be maintained above the inhibitory concentrations for the majority of a dosing interval. However, the pharmacokinetics (PK) of meropenem seem to differ in critically ill patients compared with healthy or less ill subjects used to select labeled dosing regimens. OBJECTIVES This study was designed to investigate meropenem PK in critically ill patients and to see how often standard dosing regimens produced adequate plasma concentrations. A secondary objective was to investigate how achieved concentrations were related to outcomes (morbidity and mortality) in these patients. METHODS Meropenem plasma concentrations over time were measured using a high pressure liquid chromatography assay in febrile Hem/Onc and ICU patients who were treated with standard meropenem dosing schedules. Outcomes such as fever control and survival were assessed in these patients and compared with individual meropenem PK data and with recommended target concentrations. RESULTS A total of 25 subjects including 10 febrile Hem/Onc and 15 ICU patients with a variety of serious illnesses and baseline renal function were studied. Mean peak concentrations were less variable than were pre-dose concentrations. Post peak and trough concentrations were often below recommended minimum inhibitory concentrations. Both clearance and volumes of distribution were greater than reported in less ill subjects, only in part explained by increased renal clearance. Therefore, serum concentrations often did not exceed recommended concentration targets even for moderately sensitive organisms. Inadequate concentrations were especially common in the mostly ill, febrile neutropenic Hem/Onc subjects and seemed to explain at least some therapeutic failures. Conversely, drug accumulation occurred in ICU subjects with decreased renal function. CONCLUSIONS Standard meropenem dosing regimens were inadequate in many critically ill febrile, neutropenic Hem/Onc, and septic ICU patients. These data suggest a role for meropenem concentration monitoring in such patients.
Collapse
|
44
|
Optimal treatment schedule of meropenem for adult patients with febrile neutropenia based on pharmacokinetic–pharmacodynamic analysis. J Infect Chemother 2011; 17:831-41. [DOI: 10.1007/s10156-011-0271-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 06/07/2011] [Indexed: 11/25/2022]
|
45
|
Altucci P, Abbate G, Esposito S. Antibiotic treatment in patients with altered pathophysiological pathways. Arch Gerontol Geriatr 2009; 22 Suppl 1:429-36. [PMID: 18653072 DOI: 10.1016/0167-4943(96)86977-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The pharmacokinetics of antibiotics are reviewed under particular physiological (senescence) and pathological (renal failure, liver failure) conditions. As regards the antibiotic management in the elderly, the main problems are related to the "immunosenescence" and to kinetic modifications, occurring even in the absence of an evident renal impairment. If manifest renal failure is present, the main issue is the correct dosage, and a careful consideration of the interest of the patient when they have to undergo hemodialysis. In cases of liver failure, a number of factors impairing the kinetics of antibiotics are discussed, underlining how these are too often underestimated in therapeutical approaches. The paper is focused on the behavior of new molecules, with particular regard to Teicoplanin, Carbapenems and Fluoroquinolones.
Collapse
Affiliation(s)
- P Altucci
- Department of Internal Medicine, 2nd University of Naples, Via S. Pansini, 5, I-80131 Napoli, Italy
| | | | | |
Collapse
|
46
|
A systematic review of antibiotic dosing regimens for septic patients receiving continuous renal replacement therapy: do current studies supply sufficient data? J Antimicrob Chemother 2009; 64:929-37. [DOI: 10.1093/jac/dkp302] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
47
|
Vilay AM, Churchwell MD, Mueller BA. Clinical review: Drug metabolism and nonrenal clearance in acute kidney injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:235. [PMID: 19040780 PMCID: PMC2646335 DOI: 10.1186/cc7093] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Decreased renal drug clearance is an obvious consequence of acute kidney injury (AKI). However, there is growing evidence to suggest that nonrenal drug clearance is also affected. Data derived from human and animal studies suggest that hepatic drug metabolism and transporter function are components of nonrenal clearance affected by AKI. Acute kidney injury may also impair the clearance of formed metabolites. The fact that AKI does not solely influence kidney function may have important implications for drug dosing, not only of renally eliminated drugs but also of those that are hepatically cleared. A review of the literature addressing the topic of drug metabolism and clearance alterations in AKI reveals that changes in nonrenal clearance are highly complicated and poorly studied, but they may be quite common. At present, our understanding of how AKI affects drug metabolism and nonrenal clearance is limited. However, based on the available evidence, clinicians should be cognizant that even hepatically eliminated drugs and formed drug metabolites may accumulate during AKI, and renal replacement therapy may affect nonrenal clearance as well as drug metabolite clearance.
Collapse
Affiliation(s)
- A Mary Vilay
- Department of Clinical, Social and Administrative Sciences, University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109-1065, USA.
| | | | | |
Collapse
|
48
|
Nicolau D. Pharmacokinetic and Pharmacodynamic Properties of Meropenem. Clin Infect Dis 2008; 47 Suppl 1:S32-40. [DOI: 10.1086/590064] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
49
|
Chou YW, Yang YH, Chen JH, Kuo CC, Chen SH. Quantification of meropenem in plasma and cerebrospinal fluid by micellar electrokinetic capillary chromatography and application in bacterial meningitis patients. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 856:294-301. [PMID: 17625990 DOI: 10.1016/j.jchromb.2007.06.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 06/11/2007] [Accepted: 06/19/2007] [Indexed: 11/22/2022]
Abstract
A high-performance micellar electrokinetic capillary chromatography (MEKC) has been demonstrated for the determination of meropenem in human plasma and in cerebrospinal fluid (CSF) and application in meningitis patients after intravenous (IV) administration. Plasma sample was pretreated by means of solid-phase extraction (SPE) on C(18) cartridge and CSF sample was by direct injection without sample pretreatment, with subsequent quantitation by MEKC. The separation of meropenem was carried out in an untreated fused-silica capillary (40.2 cm x 50 microm I.D., effective length 30 cm) and was performed at 25 degrees C using a background electrolyte consisting of Tris buffer (40 mM, pH 8.0) solution with sodium dodecyl sulfate (SDS) as the running buffer and on-column detection at 300 nm. Several parameters affecting the separation and sensitivity of the drug were studied, including pH, the concentrations of Tris buffer and surfactant. Using cefotaxime as an internal standard (IS), the linear ranges of the method for the determination of meropenem in plasma and in CSF were all over 0.5-50 microg/mL; the detection limits (signal-to-noise ratio=3) of meropenem in plasma and in CSF were 0.2 microg/mL and 0.3 microg/mL, respectively.
Collapse
Affiliation(s)
- Yu-Wei Chou
- Graduate Institute of Pharmaceutical Sciences, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | | | | | | | | |
Collapse
|
50
|
Li C, Kuti JL, Nightingale CH, Nicolau DP. Population pharmacokinetic analysis and dosing regimen optimization of meropenem in adult patients. J Clin Pharmacol 2007; 46:1171-8. [PMID: 16988206 DOI: 10.1177/0091270006291035] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objectives of this study were to develop a meropenem population pharmacokinetic model using patient data and use it to explore alternative dosage regimens that could optimize the currently used dosing regimen to achieve higher likelihood of pharmacodynamic exposure against pathogenic bacteria. We gathered concentration data from 79 patients (ages 18-93 years) who received meropenem 0.5, 1, or 2 g over 0.5- or 3-hour infusion every 8 hours. Meropenem population pharmacokinetic analysis was performed using the NONMEM program. A 2-compartment model fit the data best. Creatinine clearance, age, and body weight were the most significant covariates to affect meropenem pharmacokinetics. Monte Carlo simulation was applied to mimic the concentration-time profiles while 1 g meropenem was administrated via infusion over 0.5, 1, 2, and 3 hours. The 3-hour prolonged infusion improved the likelihood of obtaining both bacteriostatic and bactericidal exposures most notably at the current susceptibility breakpoints.
Collapse
Affiliation(s)
- Chonghua Li
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06102, USA
| | | | | | | |
Collapse
|