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Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
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Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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He S, Cheng Z, Xie F. PK/PD guided gentamicin dosing in critically ill patients: a revisit of the Hartford nomogram. Int J Antimicrob Agents 2022; 59:106600. [DOI: 10.1016/j.ijantimicag.2022.106600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/29/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022]
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He S, Cheng Z, Xie F. Population Pharmacokinetics and Dosing Optimization of Gentamicin in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Drug Des Devel Ther 2022; 16:13-22. [PMID: 35023902 PMCID: PMC8747548 DOI: 10.2147/dddt.s343385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/23/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose Appropriate gentamicin dosing in continuous renal replacement therapy (CRRT) patients remains undefined. This study aimed to develop a population pharmacokinetic (PK) model of gentamicin in CRRT patients and to infer the optimal dosing regimen for gentamicin. Methods Fourteen CRRT patients dosed with gentamicin were included to establish a population PK model to characterize the variabilities and influential covariates of gentamicin. The pharmacokinetic/pharmacodynamic (PK/PD) target attainment and risk of toxicity for different combinations of gentamicin regimens (3–7 mg/kg q24h) and CRRT effluent doses (30–50 mL/h/kg) were evaluated by Monte Carlo simulation. The probability of target attainment (PTA) was determined for the PK/PD indices of the ratio of drug peak concentration/minimum inhibitory concentration (Cmax/MIC > 10) and the ratio of area under the drug concentration–time curve/MIC over 24 h (AUC0-24h/MIC > 100), and the risk of toxicity was estimated by drug trough concentration thresholds (1 and 2 mg/L). Results A one-compartment model adequately described the PK characteristics of gentamicin. Covariates including body weight, age, gender, and CRRT modality did not influence the PK parameters of gentamicin based on our dataset. All studied gentamicin regimens failed to achieve satisfactory PTAs for pathogens with an MIC ≥2 mg/L. A good balance of PK/PD target attainment and risk of toxicity (>2 mg/L) was achieved under 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose for an MIC ≤1 mg/L. CRRT dose intensity had a significant impact on the target attainment of AUC0-24h/MIC >100 and risk of toxicity. Conclusion A combination of 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose might be considered as a starting treatment option for CRRT patients, and drug monitoring is required to manage toxicity.
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Affiliation(s)
- Sha He
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Zeneng Cheng
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
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Matusik E, Boidin C, Friggeri A, Richard JC, Bitker L, Roberts JA, Goutelle S. Therapeutic Drug Monitoring of Antibiotic Drugs in Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis: A Critical Review. Ther Drug Monit 2022; 44:86-102. [PMID: 34772891 DOI: 10.1097/ftd.0000000000000941] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM. METHODS Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines. RESULTS In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes. CONCLUSIONS Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.
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Affiliation(s)
- Elodie Matusik
- Pôle Pharmacie & Pôle Urgences-Réanimation-Anesthésie, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Pharmacie, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon 1, EA 3738 CICLY - Centre pour l'Innovation en Cancérologie de Lyon, Oullins
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service d'Anesthésie, Médecine Intensive et Réanimation, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon, Faculté de Médecine Lyon Sud-Charles Mérieux, Oullins
- UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, Laboratoire des Pathogènes Émergents
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Jason A Roberts
- Faculty of Medicine the University of Queensland, University of Queensland Centre for Clinical Research
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon ; and
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive Villeurbanne, France
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Petejova N, Martinek A, Zadrazil J, Kanova M, Klementa V, Sigutova R, Kacirova I, Hrabovsky V, Svagera Z, Stejskal D. Acute Kidney Injury in Septic Patients Treated by Selected Nephrotoxic Antibiotic Agents-Pathophysiology and Biomarkers-A Review. Int J Mol Sci 2020; 21:ijms21197115. [PMID: 32993185 PMCID: PMC7583998 DOI: 10.3390/ijms21197115] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 12/28/2022] Open
Abstract
Acute kidney injury is a common complication in critically ill patients with sepsis and/or septic shock. Further, some essential antimicrobial treatment drugs are themselves nephrotoxic. For this reason, timely diagnosis and adequate therapeutic management are paramount. Of potential acute kidney injury (AKI) biomarkers, non-protein-coding RNAs are a subject of ongoing research. This review covers the pathophysiology of vancomycin and gentamicin nephrotoxicity in particular, septic AKI and the microRNAs involved in the pathophysiology of both syndromes. PubMED, UptoDate, MEDLINE and Cochrane databases were searched, using the terms: biomarkers, acute kidney injury, antibiotic nephrotoxicity, sepsis, miRNA and nephrotoxicity. A comprehensive review describing pathophysiology and potential biomarkers of septic and toxic acute kidney injury in septic patients was conducted. In addition, five miRNAs: miR-15a-5p, miR-192-5p, miR-155-5p, miR-486-5p and miR-423-5p specific to septic and toxic acute kidney injury in septic patients, treated by nephrotoxic antibiotic agents (vancomycin and gentamicin) were identified. However, while these are at the stage of clinical testing, preclinical and clinical trials are needed before they can be considered useful biomarkers or therapeutic targets of AKI in the context of antibiotic nephrotoxicity or septic injury.
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Affiliation(s)
- Nadezda Petejova
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
- Correspondence:
| | - Arnost Martinek
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Josef Zadrazil
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
| | - Marcela Kanova
- Department of Anesthesiology and Resuscitation, University Hospital Ostrava, 70852 Ostrava, Czech Republic;
| | - Viktor Klementa
- Department of Internal Medicine III—Nephrology, Rheumatology and Endocrinology, University Hospital and Faculty of Medicine and Dentistry, Palacky University Olomouc, 77900 Olomouc, Czech Republic; (J.Z.); (V.K.)
| | - Radka Sigutova
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Ivana Kacirova
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Institute of Clinical Pharmacology Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Vladimir Hrabovsky
- Department of Internal Medicine, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (A.M.); (V.H.)
- Department of Clinical Studies Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - Zdenek Svagera
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
| | - David Stejskal
- Department of Laboratory Diagnostics Institute of Clinical Biochemistry and Clinical Pharmacology, University Hospital Ostrava, 70852 Ostrava, Czech Republic; (R.S.); (I.K.); (Z.S.); (D.S.)
- Department of Biomedical Sciences Faculty of Medicine, University of Ostrava, 70300 Ostrava, Czech Republic
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Ruiz-Ramos J, Villarreal E, Gordon M, Martin-Cerezula M, Broch MJ, Remedios Marqués M, Poveda JL, Castellanos-Ortega Á, Ramírez P. Implication of Haemodiafiltration Flow Rate on Amikacin Pharmacokinetic Parameters in Critically Ill Patients. Blood Purif 2017; 45:88-94. [PMID: 29232669 DOI: 10.1159/000478969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/25/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND To analyse the effect of haemodiafiltration (CVVHDF) flow rate on amikacin pharmacokinetics and blood concentrations. METHODS Prospective observational study. Patients receiving CVVHDF and amikacin treatment were included. Pharmacokinetic parameters were calculated using Bayesian analysis. Spearman correlation test was used in order to assess the influence of CVVHDF flux on amikacin minimum concentration (Cmin) and plasma clearance. RESULTS Thirty patients undergoing CVVHDF procedures were included. The treatment with amikacin started at an initial mean dose of 12.4 (4.1) mg/kg/day. An association between the flow rate and Cmin value (r = 0.261; p = 0.161) and plasma clearance was found (r = 0.268; p = 0.152). Four patients (13.3%) were not able to achieve peak concentration over MIC value higher than 8. In 4 patients, amikacin had to be discontinued due to a high Cmin value. CONCLUSIONS Amikacin clearance in patients with CVVHDF is affected by the flow rate used. Therefore, CVVHDF dose should be taken into account when dosing amikacin.
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Affiliation(s)
- Jesús Ruiz-Ramos
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Esther Villarreal
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Mónica Gordon
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - María Martin-Cerezula
- Department of Pharmacy, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Maria Jesús Broch
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - María Remedios Marqués
- Department of Pharmacy, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Jose Luis Poveda
- Department of Pharmacy, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Álvaro Castellanos-Ortega
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
| | - Paula Ramírez
- Intensive Care Unit, Hospital Universitario y Politécnico La Fe, Avenida Fernando Abríl Martorell, Valencia, Spain
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Jager NGL, van Hest RM, Lipman J, Taccone FS, Roberts JA. Therapeutic drug monitoring of anti-infective agents in critically ill patients. Expert Rev Clin Pharmacol 2016; 9:961-79. [PMID: 27018631 DOI: 10.1586/17512433.2016.1172209] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Initial adequate anti-infective therapy is associated with significantly improved clinical outcomes for patients with severe infections. However, in critically ill patients, several pathophysiological and/or iatrogenic factors may affect the pharmacokinetics of anti-infective agents leading to suboptimal drug exposure, in particular during the early phase of therapy. Therapeutic drug monitoring (TDM) may assist to overcome this problem. We discuss the available evidence on the use of TDM in critically ill patient populations for a number of anti-infective agents, including aminoglycosides, β-lactams, glycopeptides, antifungals and antivirals. Also, we present the available evidence on the practices of anti-infective TDM and describe the potential utility of TDM to improve treatment outcome in critically ill patients with severe infections. For aminoglycosides, glycopeptides and voriconazole, beneficial effects of TDM have been established on both drug effectiveness and potential side effects. However, for other drugs, therapeutic ranges need to be further defined to optimize treatment prescription in this setting.
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Affiliation(s)
- Nynke G L Jager
- a Department of Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Reinier M van Hest
- a Department of Pharmacy , Academic Medical Center , Amsterdam , The Netherlands
| | - Jeffrey Lipman
- b Burns Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Departments of Pharmacy and Intensive Care , Royal Brisbane and Women's Hospital , Brisbane , Australia
| | - Fabio S Taccone
- d Department of Intensive Care, Hopital Erasme , Université Libre de Bruxelles (ULB) , Brussels , Belgium
| | - Jason A Roberts
- b Burns Trauma and Critical Care Research Centre , The University of Queensland , Brisbane , Australia.,c Departments of Pharmacy and Intensive Care , Royal Brisbane and Women's Hospital , Brisbane , Australia.,e School of Pharmacy , The University of Queensland , Brisbane , Australia
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Brasseur A, Hites M, Roisin S, Cotton F, Vincent JL, De Backer D, Jacobs F, Taccone FS. A high-dose aminoglycoside regimen combined with renal replacement therapy for the treatment of MDR pathogens: a proof-of-concept study. J Antimicrob Chemother 2016; 71:1386-94. [DOI: 10.1093/jac/dkv491] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 12/19/2015] [Indexed: 02/06/2023] Open
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How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy? Diagn Microbiol Infect Dis 2015; 82:92-103. [PMID: 25698632 DOI: 10.1016/j.diagmicrobio.2015.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 12/28/2014] [Accepted: 01/25/2015] [Indexed: 12/30/2022]
Abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
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Wong G, Sime FB, Lipman J, Roberts JA. How do we use therapeutic drug monitoring to improve outcomes from severe infections in critically ill patients? BMC Infect Dis 2014; 14:288. [PMID: 25430961 PMCID: PMC4289211 DOI: 10.1186/1471-2334-14-288] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/23/2014] [Indexed: 11/16/2022] Open
Abstract
High mortality and morbidity rates associated with severe infections in the critically ill continue to be a significant issue for the healthcare system. In view of the diverse and unique pharmacokinetic profile of drugs in this patient population, there is increasing use of therapeutic drug monitoring (TDM) in attempt to optimize the exposure of antibiotics, improve clinical outcome and minimize the emergence of antibiotic resistance. Despite this, a beneficial clinical outcome for TDM of antibiotics has only been demonstrated for aminoglycosides in a general hospital patient population. Clinical outcome studies for other antibiotics remain elusive. Further, there is significant variability among institutions with respect to the practice of TDM including the selection of patients, sampling time for concentration monitoring, methodologies of antibiotic assay, selection of PK/PD targets as well as dose optimisation strategies. The aim of this paper is to review the available evidence relating to practices of antibiotic TDM, and describe how TDM can be applied to potentially improve outcomes from severe infections in the critically ill.
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Affiliation(s)
| | | | | | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
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11
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D’Arcy DM, Corrigan OI, Deasy E, Gowing CM, Donnelly MB. Gentamicin pharmacokinetics in critically ill patients during treatment with continuous venovenous haemodiafiltration (CVVHDF). Eur J Clin Pharmacol 2014; 71:377-8. [DOI: 10.1007/s00228-014-1765-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/30/2014] [Indexed: 11/24/2022]
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Matthaiou DK, De Waele J, Dimopoulos G. What is new in the use of aminoglycosides in critically ill patients? Intensive Care Med 2014; 40:1553-5. [PMID: 24993463 DOI: 10.1007/s00134-014-3376-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Dimitrios K Matthaiou
- Department of Critical Care Medicine, University Hospital ATTIKON, Medical School, University of Athens, 1 Rimini Str, 12462, Haidari-Athens, Greece
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