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Luxton T, King N, Wälti C, Jeuken L, Sandoe J. A systematic review of the effect of therapeutic drug monitoring on patient health outcomes during treatment with penicillins. J Antimicrob Chemother 2022; 77:1532-1541. [PMID: 35355067 PMCID: PMC9155611 DOI: 10.1093/jac/dkac101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Dosing regimens guided by therapeutic drug monitoring (TDM) may be able to improve penicillin exposure in patients, which could result in improved patient health outcomes. OBJECTIVES This systematic review aims to describe the impact penicillin TDM has on health outcomes, including antimicrobial resistance (AMR). METHODS Studies measuring penicillins in patient samples that adjusted regimens according to the result, and reported health outcomes were selected. Study bias was assessed according to study type. Included study characteristics were tabulated and described by narrative synthesis. RESULTS Three randomized controlled trials (RCTs), 16 cohort studies, and 9 case studies were included. No RCTs showed statistically significant improvements in health outcomes. Five cohort studies showed improvement in at least one health outcome associated with target attainment. However, there was a high risk of bias in all studies for health outcomes. One study assessed the impact of penicillin TDM on AMR and found that improved target attainment was associated with suppression of resistance. No studies found a detrimental effect of penicillin TDM. CONCLUSIONS There is little evidence to suggest that TDM improves health outcomes, however neither health outcomes nor impact on AMR were adequately addressed. Variations in TDM implementation meant that a meta-analysis was not suitable. Penicillin TDM needs standardization, however there is currently no clear evidence of optimal conditions. Suitably powered studies are required to resolve the ambiguity surrounding the impact of TDM on clinical outcomes, including AMR. Further, standardized protocols and concentration targets need to be identified for TDM to be implemented successfully.
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Affiliation(s)
- Timothy Luxton
- School of Biomedical Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Christoph Wälti
- School of Electronic and Electrical Engineering, University of Leeds, Leeds LS2 9JT, UK
| | - Lars Jeuken
- Leeds Institute of Health Sciences, University of Leeds, Leeds LS2 9JT, UK
- Leiden Institute of Chemistry, Leiden University, PO Box 9502, 2300 RA, Leiden, The Netherlands
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Farrar JE, Mueller SW, Stevens V, Kiser TH, Taleb S, Reynolds PM. Correlation of antimicrobial fraction unbound and sieving coefficient in critically ill patients on continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2021; 77:310-319. [DOI: 10.1093/jac/dkab396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Fraction unbound has been used as a surrogate for antimicrobial sieving coefficient (SC) to predict extracorporeal clearance in critically ill patients on continuous renal replacement therapy (CRRT), but this is based largely on expert opinion.
Objectives
To examine relationships between package insert-derived fraction unbound (Fu-P), study-specific fraction unbound (Fu-S), and SC in critically ill patients receiving CRRT.
Methods
English-language studies containing patient-specific in vivo pharmacokinetic parameters for antimicrobials in critically ill patients requiring CRRT were included. The primary outcome included correlations between Fu-S, Fu-P, and SC. Secondary outcomes included correlations across protein binding quartiles, serum albumin, and predicted in-hospital mortality, and identification of predictors for SC through multivariable analysis.
Results
Eighty-nine studies including 32 antimicrobials were included for analysis. SC was moderately correlated to Fu-S (R2 = 0.55, P < 0.001) and Fu-P (R2 = 0.41, P < 0.001). SC was best correlated to Fu-S in first (<69%) and fourth (>92%) quartiles of fraction unbound and above median albumin concentrations of 24.5 g/L (R2 = 0.71, P = 0.07). Conversely, correlation was weaker in patients with mortality estimates greater than the median of 55% (R2 = 0.06, P = 0.84). SC and Fu-P were also best correlated in the first quartile of antimicrobial fraction unbound (R2 = 0.66, P < 0.001). Increasing Fu-P, flow rate, membrane surface area, and serum albumin, and decreasing physiologic charge significantly predicted increasing SC.
Conclusions
Fu-S and Fu-P were both reasonably correlated to SC. Caution should be taken when using Fu-S to calculate extracorporeal clearance in antimicrobials with 69%–92% fraction unbound or with >55% estimated in-hospital patient mortality. Fu-P may serve as a rudimentary surrogate for SC when Fu-S is unavailable.
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Affiliation(s)
- Julie E. Farrar
- Auburn University Harrison School of Pharmacy, 650 Clinic Dr, Mobile, AL 36688, USA
| | - Scott W. Mueller
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Victoria Stevens
- University of Colorado Hospital, 12505 E 16th Ave, Aurora, CO 80045, USA
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Sim Taleb
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
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Lonsdale DO, Kipper K, Baker EH, Barker CIS, Oldfield I, Philips BJ, Johnston A, Rhodes A, Sharland M, Standing JF. β-Lactam antimicrobial pharmacokinetics and target attainment in critically ill patients aged 1 day to 90 years: the ABDose study. J Antimicrob Chemother 2020; 75:3625-3634. [DOI: 10.1093/jac/dkaa363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/09/2020] [Indexed: 01/16/2023] Open
Abstract
Abstract
Background
The pharmacokinetics of β-lactam antibiotics in critical illness remain poorly characterized, particularly in neonates, children and the elderly. We undertook a pharmacokinetic study of commonly used β-lactam antibiotics in critically ill patients of all ages. The aims were to produce a whole-life β-lactam pharmacokinetic model and describe the extent to which standard doses achieve pharmacokinetic/pharmacodynamic targets associated with clinical cure.
Patients and methods
A total of 212 critically ill participants with an age range from 1 day (gestational age 24 weeks) to 90 years were recruited from a UK hospital, providing 1339 pharmacokinetic samples. Population pharmacokinetic analysis was undertaken using non-linear mixed-effects modelling (NONMEM) for each drug. Pooled data were used to estimate maturation and decline of β-lactam pharmacokinetics throughout life.
Results
Pharmacokinetic models for eight drugs were described, including what is thought to be the first benzylpenicillin model in critically ill adults. We estimate that 50% of adult β-lactam clearance is achieved by 43 weeks post-menstrual age (chronological plus gestational age). Fifty percent of decline from peak adult clearance occurs by 71 years. Paediatric participants were significantly less likely than adults to achieve pharmacokinetic/pharmacodynamic targets with standard antibiotic doses (P < 0.01).
Conclusions
We believe this to be the first prospective whole-life antibiotic pharmacokinetic study in the critically ill. The study provides further evidence that standard antibiotic doses fail to achieve pharmacokinetic/pharmacodynamic targets associated with clinical success in adults, children and neonates. Maturation and decline parameters estimated from this study could be adopted as a standard for future prospective studies.
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Affiliation(s)
- Dagan O Lonsdale
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- Institute of Chemistry, University of Tartu, Tartu, Estonia
- Analytical Services International Ltd, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Charlotte I S Barker
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Isobel Oldfield
- Institute for Infection and Immunity, St George’s, University of London, London, UK
| | | | - Atholl Johnston
- Analytical Services International Ltd, London, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andrew Rhodes
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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