Stability of ceftazidime and vancomycin alone and in combination in heparinized and nonheparinized peritoneal dialysis solution

Culture-directed antibiotics in peritoneal dialysis solutions: a systematic review focused on stability and compatibility

BACKGROUND

This systematic review summarises the stability of less commonly prescribed antibiotics in different peritoneal dialysis solutions that could be used for culture-directed therapy of peritonitis, which would be especially useful in regions with a high prevalence of multidrug antibiotic-resistant strains.

METHODS

A literature search of Medline, Scopus, Embase and Google Scholar for articles published from inception to 25 January, 2023 was conducted. Only antibiotic stability studies conducted in vitro and not recently reviewed by So et al. were included. The main outcomes were chemical, physical, antimicrobial and microbial stability. This protocol was registered in PROSPERO (registration number CRD42023393366).

RESULTS

We screened 1254 abstracts, and 28 articles were included in the study. In addition to those discussed in a recent systematic review (So et al., Clin Kidney J 15(6):1071-1078, 2022), we identified 18 antimicrobial agents. Of these, 9 have intraperitoneal dosing recommendations in the recent International Society for Peritoneal Dialysis (ISPD) peritonitis guidelines, and 7 of the 9 had stability data applicable to clinical practice. They were cefotaxime, ceftriaxone, daptomycin, ofloxacin, and teicoplanin in glucose-based solutions, tobramycin in Extraneal solution only and fosfomycin in Extraneal, Nutrineal, Physioneal 1.36% and 2.27% glucose solutions.

CONCLUSIONS

Physicochemical stability has not been demonstrated for all antibiotics with intraperitoneal dosing recommendations in the ISPD peritonitis guidelines. Further studies are required to determine the stability of antibiotics, especially in icodextrin-based and low-glucose degradation products, pH-neutral solutions.

Stability of Drug Additives to Peritoneal Dialysate

Objective

The primary literature was reviewed to determine the stability of drug additives in peritoneal dialysis solutions.

Data Sources

A MEDLINE search and retrieval, covering the period 1981 to 1994, was undertaken to identify relevant original literature. Additional references were identified from citations within the original literature. Non-English literature was excluded unless an English abstract was provided.

Study Selection

Forty-nine studies were identified. Of these, 24 were directly related to drug stability, 13 were related to the clinical use of the drug additives but included no stability data, and 12 examined other, nonstability aspects of in vitroactivity of antibiotics, additives, or drug adsorption in peritoneal dialysis bags and tubing.

Data Extraction

Data included concentrations of drug additives and dialysate solutions, duration and temperatures of storage conditions, types of assay, and whether they were stability-indicating.

Results

Stability was defined as the duration of time that the drug concentration remained at 90% or more of the original concentration. Stability was examined under a large variety of conditions. Thirty-one drugs were identified from 20 manuscripts as single-drug additives. Most beta-Iactams were stable for 1 –2 weeks in a refrigerator and for several days at room temperature. Aminoglycosides were stable for 1 –2 days at room temperature. Glycopeptides were stable for several weeks refrigerated or at room temperature. Prolonged storage at room temperature resulted in instability of cefotaxime, ceftazidime, ceftriaxone, and miconazole. Eleven drugs were identified from seven manuscripts as drug combination studies and showed similar stability as single agents. Dialysate concentration appeared to have minimal effect on stability.

Conclusions

Drug additives in peritoneal dialysate, singly or combined, should be avoided unless data are available to support their stability. Additives should be made as close as possible to the time of the exchange. Alternatively, additives should be stored refrigerated, then warmed prior to use. The practice of preparing numerous bags at one time should be avoided. Finally, stability data do not indicate sterile integrity of the dialysate.

Short-Dwell Cycling Intraperitoneal Cefazolin plus Ceftazidime in Peritoneal Dialysis Patients

Background

Current guidelines suggest that intraperitoneal (IP) antibiotics should be administered only in a long peritoneal dialysis (PD) dwell (≥ 6 hours). The long dwell might result in low ultrafiltration and volume overload. We aim to examine plasma and dialysate concentration of cefazolin and ceftazidime after IP administration in a short-dwell (≤ 2 hours) automated cycling exchange.

Methods

Stable PD patients without peritonitis were invited to participate in the present study. Patients underwent 5 2-liter exchanges of PD fluid over 10 hours by the PD cycling machine without last fill or additional dwell. Cefazolin and ceftazidime (20 mg/kg each) were added to the first 5-liter bag of 2.5% dextrose PD fluid that was placed on the warmer of the PD cycling machine. Plasma samples were collected at 12 time-points over 24 hours. Dialysate samples from each exchange were also collected. Antibiotic concentrations in plasma and dialysate were then determined by high-performance liquid chromatography (HPLC).

Results

Six stable PD patients without peritonitis participated in the study. Dialysate cefazolin and ceftazidime were consistently high throughout the PD session in all patients (26 - 360 mg/L). Plasma cefazolin and ceftazidime exceeded the minimal inhibitory concentration (MIC) for susceptible organisms (≤ 8 mg/L) within 2 hours (cefazolin 28.5 ± 8.0 and ceftazidime 12.5 ± 3.4 mg/L), peak at 10 hours (51.1 ± 14.1 and 23.0 ± 5.2 mg/L) and sustained well above the MIC at 24 hours (42.0 ± 9.6 and 17.1 ± 3.1 mg/L).

Conclusions

The short-dwell cycling IP cefazolin and ceftazidime could provide adequate plasma concentration for up to 24 hours. Daily short-dwell cycling IP cefazolin and ceftazidime might be used to treat peritonitis in PD patients already using a PD cycling machine as well as selected continuous ambulatory PD (CAPD) patients who need shorter dwells during peritonitis due to increasing peritoneal solute transport.

Stability of Ceftazidime and Heparin in Four Different Types of Peritoneal Dialysis Solutions

BACKGROUND

Intraperitoneal (IP) administration of ceftazidime is recommended for the treatment of peritoneal dialysis-associated peritonitis (PDAP) from Pseudomonas. Patients with PDAP may also need IP heparin to overcome problems with drainage of turbid peritoneal dialysis (PD) fluids and blockage of catheters with fibrin. Physico-chemical stability of ceftazidime and heparin, and biological stability of heparin in many types of PD solutions is unknown. Therefore, we investigated the stability of ceftazidime and heparin in 4 types of PD solutions.

METHODS

A total of 12 PD bags (3 for each type of solution) containing ceftazidime and heparin were prepared and stored at 4°C for 120 hours, and then at 25°C for 6 hours, and finally at 37°C for 12 hours. An aliquot was withdrawn after predefined time points and analyzed for the concentration of ceftazidime and heparin using high-performance liquid-chromatography (HPLC). Samples were assessed for pH, color changes, particle content, and anticoagulant activity of heparin.

RESULTS

Ceftazidime and heparin retained more than 91% of their initial concentration when stored at 4°C for 120 hours followed by storage at 25°C for 6 hours and then at 37°C for 12 hours. Heparin retained more than 95% of its initial activity throughout the study period. Particle formation was not detected at any time under the storage conditions. The pH and color remained essentially unchanged throughout the study.

CONCLUSIONS

Ceftazidime-heparin admixture retains its stability over long periods of storage at different temperatures, allowing its potential use for PDAP treatment in outpatient and remote settings.

Intraperitoneal Administration of Drugs in Peritoneal Dialysis Patients: A Review of Compatibility and Guidance for Clinical Use

Peritoneal dialysis (PD) is an effective home-based therapy for end-stage renal failure. Intraperitoneal administration of drugs to PD patients is particularly important for the treatment of peritonitis. Clinicians need to know that the administered drug is compatible with both the PD solution and its container. A detailed literature search on drug compatibility and stability was performed and results of all published stability studies are presented for all drugs, PD solutions, and containers studied. These data will aid clinicians managing PD patients and provide a resource to demonstrate which drugs have been shown to be stable in various PD solutions and solution containers. This is important information to assist clinicians in applying effective treatments, in particular, for peritonitis.

Stability and compatibility of ceftazidime administered by continuous infusion to intensive care patients

The stability and compatibility of ceftazidime have been examined in the context of its potential use in concentrated solutions for continuous infusion in patients suffering from severe nosocomial pneumonia and receiving other intravenous medications by the same route. Ceftazidime stability in 4 to 12% solutions was found satisfactory (<10% degradation) for 24 h if kept at a temperature of 25 degrees C (77 degrees F) maximum. Studies mimicking the simultaneous administration of ceftazidime and other drugs as done in clinics showed physical incompatibilities with vancomycin, nicardipine, midazolam, and propofol and a chemical incompatibility with N-acetylcystein. Concentrated solutions (50 mg/ml) of erythromycin or clarithromycin caused the appearance of a precipitate, whereas gentamicin, tobramycin, amikacin, isepamicin, fluconazole, ketamine, sufentanil, valproic acid, furosemide, uradipil, and a standard amino acid solution were physically and chemically compatible.

Laboratory guidelines for monitoring of antimicrobial drugs

Few antimicrobial drugs meet the requirements for therapeutic drug monitoring. Those that are monitored include the aminoglycosides (gentamicin, tobramycin, and amikacin), chloramphenicol, and in some cases, vancomycin. For these drugs, there is evidence of a relationship between serum concentration, efficacy, and/or the incidence of adverse or toxic events. Monitoring begins with the appropriate timing of collection and continues through the analytical process to the integration of all data used to guide the clinician’s next decision.

Stability of vancomycin in plastic syringes measured by high-performance liquid chromatography

The shelf-life of vancomycin in infusion fluids was studied using high-performance liquid chromatographic (HPLC) methods. Vancomycin was stable (loss in potency less than 10%) for 47 days and 29 days, respectively, when dissolved in water-for-injections BP at 25 degrees C and stored in plastic syringes (Becton Dickinson Plastipak (three-piece) and B. Braun Medical Injekt (two-piece)). In sodium chloride solution (0.9%; pH 5.4) it was stable for 62 and 34 days, while in dextrose solution (5%; pH 4.2) it was stable for 55 and 33 days, respectively, at the same temperature. At 4 degrees C vancomycin was stable in all three infusion fluids and both types of syringe for at least 84 days.