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Prinz C, Streit F, Schumann C, Dudakova A, Lanckohr C, Schanz J, Bohn M, Groß U, Meissner K, Moerer O, Harnisch LO. Feasibility of Continuous Infusion of Cefiderocol in Conjunction with the Establishment of Therapeutic Drug Monitoring in Patients with Extensively Drug-Resistant Gram-Negative Bacteria. Clin Drug Investig 2023; 43:307-314. [PMID: 37017874 PMCID: PMC10075148 DOI: 10.1007/s40261-023-01257-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Resistance to antibacterial substances is a huge and still emerging issue, especially with regard to Gram-negative bacteria and in critically ill patients. We report a study in six patients infected with extensively drug-resistant Gram-negative bacteria in a limited outbreak who were successfully managed with a quasi-continuous infusion of cefiderocol. METHODS Patients were initially treated with prolonged infusions of cefiderocol over 3 h every 8 h, and the application mode was then switched to a quasi-continuous infusion of 2 g over 8 h, i.e. 6 g in 24 h. Therapeutic drug monitoring (TDM) was established using an in-house liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. RESULTS Determined trough plasma concentrations were a median of 50.00 mg/L [95% confidence interval (CI) 27.20, 74.60] and steady-state plasma concentrations were a median of 90.96 mg/L [95% CI 37.80, 124]. No significant differences were detected with respect to acute kidney injury/continuous renal replacement therapy. Plasma concentrations determined from different modes of storage were almost equal when frozen or cooled, but markedly reduced when stored at room temperature. CONCLUSIONS (Quasi) continuous application of cefiderocol 6 g/24 h in conjunction with TDM is a feasible mode of application; the sample for TDM should either be immediately analyzed, cooled, or frozen prior to analysis.
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Affiliation(s)
- Carolin Prinz
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Frank Streit
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratories, University of Göttingen Medical Center, Robert-Koch-Str.40, 37099, Göttingen, Germany
| | - Christian Schumann
- Pharmacy, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Anna Dudakova
- Institute for Medical Microbiology and Virology, University of Göttingen Medical Center, Kreuzbergring 57, 37075, Göttingen, Germany
| | - Christian Lanckohr
- Institute of Hygiene, University Medical Center Münster, Robert-Koch-Str. 41, 48149, Münster, Germany
| | - Julie Schanz
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratories, University of Göttingen Medical Center, Robert-Koch-Str.40, 37099, Göttingen, Germany
| | - Matthias Bohn
- Pharmacy, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Uwe Groß
- Institute for Medical Microbiology and Virology, University of Göttingen Medical Center, Kreuzbergring 57, 37075, Göttingen, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Lars-Olav Harnisch
- Department of Anaesthesiology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37099, Göttingen, Germany.
- Department of Anaesthesiology, Georg-August University of Göttingen, University Medical Center, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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Simner PJ, Patel R. Cefiderocol Antimicrobial Susceptibility Testing Considerations: the Achilles' Heel of the Trojan Horse? J Clin Microbiol 2020; 59:e00951-20. [PMID: 32727829 PMCID: PMC7771437 DOI: 10.1128/jcm.00951-20] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cefiderocol (formerly S-649266) is a novel siderophore-conjugated cephalosporin with activity against a broad array of multidrug-resistant (MDR), aerobic Gram-negative bacilli. The siderophore component binds iron and uses active iron transport for drug entry into the bacterial periplasmic space. The cephalosporin moiety is the active antimicrobial component, structurally resembling a hybrid between ceftazidime and cefepime. Like other β-lactam agents, the principal bactericidal activity of cefiderocol occurs via inhibition of bacterial cell wall synthesis by binding of penicillin-binding proteins (PBPs) and inhibiting peptidoglycan synthesis, leading to cell death. Iron concentrations need to be taken into consideration when in vitro antimicrobial susceptibility to cefiderocol is determined. Broth microdilution (BMD) and disk diffusion methods have been developed to determine in vitro activity of cefiderocol. For BMD, cation-adjusted Mueller-Hinton broth (CAMHB) requires iron depletion to provide MICs predictive of in vivo activity. A method to prepare iron-depleted CAMHB (ID-CAMHB) has been described by the Clinical and Laboratory Standards Institute (CLSI). For disk diffusion, standard Mueller-Hinton agar is recommended, presumably because iron is bound in the medium. Currently, clinical FDA and European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints and investigational (research-use-only) CLSI breakpoints exist for interpreting cefiderocol susceptibility results for certain Gram-negative bacilli. Cefiderocol does not have clinically relevant activity against Gram-positive or anaerobic organisms. FDA or EUCAST breakpoints should be applied to interpret results for Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter baumannii complex for patient care until the investigational status has been removed from CLSI breakpoints. Further clinical outcome data are required to assess the effectiveness of cefiderocol for treatment of other Acinetobacter species (non-baumannii complex) and Stenotrophomonas maltophilia at this time, and, as such, antimicrobial susceptibility testing of these organisms should be limited to research use in the scenario of limited treatment options.
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Affiliation(s)
- Patricia J Simner
- Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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