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Yang H, Huang Z, Yue J, Chen J, Yu M, Qu C. Metabolomics reveals the mechanism of action of meropenem and amikacin combined in the treatment of Pseudomonas aeruginosa. Front Cell Infect Microbiol 2023; 13:1327452. [PMID: 38116135 PMCID: PMC10728327 DOI: 10.3389/fcimb.2023.1327452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/15/2023] [Indexed: 12/21/2023] Open
Abstract
The treatment of Pseudomonas aeruginosa infection often involves the combined use of β-lactam and aminoglycoside antibiotics. In this study, we employed metabolomic analysis to investigate the mechanism responsible for the synergistic activities of meropenem/amikacin combination therapy against multidrug-resistant P. aeruginosa strains harboring OXA-50 and PAO genes. Antibiotic concentrations for meropenem (2 mg/L) monotherapy, amikacin (16 mg/L) monotherapy, and meropenem/amikacin (2/16 mg/L) combination therapy were selected based on clinical breakpoint considerations. Metabolomic analysis revealed significant alterations in relevant metabolites involved in bacterial cell membrane and cell wall synthesis within 15 min of combined drug administration. These alterations encompassed various metabolic pathways, including fatty acid metabolism, peptidoglycan synthesis, and lipopolysaccharide metabolism. Furthermore, at 1 h and 4 h, the combination therapy exhibited significant interference with amino acid metabolism, nucleotide metabolism, and central carbon metabolism pathways, including the tricarboxylic acid cycle and pentose phosphate pathway. In contrast, the substances affected by single drug administration at 1 h and 4 h demonstrated a noticeable reduction. Meropenem/amikacin combination resulted in notable perturbations of metabolic pathways essential for survival of P. aeruginosa, whereas monotherapies had comparatively diminished impacts.
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Affiliation(s)
- Hai Yang
- Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, Qingdao, China
| | - Zhen Huang
- Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, Qingdao, China
| | - Jiali Yue
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, China
| | - Jianqi Chen
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, China
| | - Mingming Yu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao, China
| | - Chengming Qu
- Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital, Qingdao, China
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Ergün B, Esenkaya F, Küçük M, Yakar MN, Uzun Ö, Heybeli C, Hanci V, Ergan B, Cömert B, Gökmen AN. Amikacin-induced acute kidney injury in mechanically ventilated critically ill patients with sepsis. J Chemother 2023; 35:496-504. [PMID: 36469702 DOI: 10.1080/1120009x.2022.2153316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/04/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
In this retrospective cohort study, we aimed to evaluate the incidence, risk factors and outcomes of amikacin-induced acute kidney injury (AKI) in critically ill patients with sepsis. A total of 311 patients were included in the study. Of them, 83 (26.7%) had amikacin-induced AKI. In model 1, the multivariable analysis demonstrated concurrent use of colistin (OR 25.51, 95%CI 6.99-93.05, p< 0.001), presence of septic shock during amikacin treatment (OR 4.22, 95%CI 1.76-10.11, p=0.001), and Charlson Comorbidity Index (OR 1.14, 95%CI 1.02-1.28, p=0.025) as factors independently associated with an increased risk of amikacin-induced AKI. In model 2, the multivariable analysis demonstrated concurrent use of at least one nephrotoxic agent (OR 1.95, 95%CI 1.10-3.45; p=0.022), presence of septic shock during amikacin treatment (OR 3.48, 95%CI 1.61-7.53; p=0.002), and Charlson Comorbidity Index (OR 1.12, 95%CI 1.01-1.26; p=0.037) as factors independently associated with an increased risk of amikacin-induced AKI. In conclusion, before amikacin administration, the risk of AKI should be considered, especially in patients with multiple complicated comorbid diseases, septic shock, and those receiving colistin therapy.
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Affiliation(s)
- Bişar Ergün
- Department of Internal Medicine and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Fethiye Esenkaya
- Department of Internal Medicine, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Murat Küçük
- Department of Internal Medicine and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Mehmet Nuri Yakar
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Özcan Uzun
- Department of Internal Medicine and Nephrology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Cihan Heybeli
- Department of Internal Medicine and Nephrology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Volkan Hanci
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Begüm Ergan
- Department of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Bilgin Cömert
- Department of Internal Medicine and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Ali Necati Gökmen
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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Williams PG, Tabah A, Cotta MO, Sandaradura I, Kanji S, Scheetz MH, Imani S, Elhadi M, Luque-Pardos S, Schellack N, Sanches C, Timsit JF, Xie J, Farkas A, Wilks K, Roberts JA. International survey of antibiotic dosing and monitoring in adult intensive care units. Crit Care 2023; 27:241. [PMID: 37331935 DOI: 10.1186/s13054-023-04527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/07/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND In recent years, numerous dosing studies have been conducted to optimize therapeutic antibiotic exposures in patients with serious infections. These studies have led to the inclusion of dose optimization recommendations in international clinical practice guidelines. The last international survey describing dosing, administration and monitoring of commonly prescribed antibiotics for critically ill patients was published in 2015 (ADMIN-ICU 2015). This study aimed to describe the evolution of practice since this time. METHODS A cross-sectional international survey distributed through professional societies and networks was used to obtain information on practices used in the dosing, administration and monitoring of vancomycin, piperacillin/tazobactam, meropenem and aminoglycosides. RESULTS A total of 538 respondents (71% physicians and 29% pharmacists) from 409 hospitals in 45 countries completed the survey. Vancomycin was mostly administered as an intermittent infusion, and loading doses were used by 74% of respondents with 25 mg/kg and 20 mg/kg the most favoured doses for intermittent and continuous infusions, respectively. Piperacillin/tazobactam and meropenem were most frequently administered as an extended infusion (42% and 51%, respectively). Therapeutic drug monitoring was undertaken by 90%, 82%, 43%, and 39% of respondents for vancomycin, aminoglycosides, piperacillin/tazobactam, and meropenem, respectively, and was more frequently performed in high-income countries. Respondents rarely used dosing software to guide therapy in clinical practice and was most frequently used with vancomycin (11%). CONCLUSIONS We observed numerous changes in practice since the ADMIN-ICU 2015 survey was conducted. Beta-lactams are more commonly administered as extended infusions, and therapeutic drug monitoring use has increased, which align with emerging evidence.
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Affiliation(s)
- Paul G Williams
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia.
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia.
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
- Intensive Care Unit, Redcliffe Hospital, Redcliffe, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Menino Osbert Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Indy Sandaradura
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
- Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Sydney, NSW, Australia
| | - Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc H Scheetz
- Pharmacometric Center of Excellence, Departments of Pharmacy Practice and Pharmacology, College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Sahand Imani
- Nepean Blue Mountains Local Health District, Nepean Hospital, Sydney, NSW, Australia
| | | | - Sònia Luque-Pardos
- Pharmacy Department, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBER of Pharmacy, Saint Clare's Infectious Diseases (CIBERINFEC CB21/13/0002) Institute of Health Carlos III, Madrid, Spain
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Cristina Sanches
- Campus Centro Oeste Dona Lindu, Federal University of Sao João del Rei, Divinópolis, Minas Gerais, Brasil
| | - Jean-Francois Timsit
- Assistance Publique Hôpitaux de Paris - Bichat hospital Medical and infectious diseases ICU (MI2), 75018, Paris, France
- IAME U 1137 Université Paris-Cité Site Bichat, 75018, Paris, France
| | - Jiao Xie
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Andras Farkas
- Optimum Dosing Strategies, Bloomingdale, NJ, USA
- Department of Pharmacy, Saint Clare's Health, Denville, NJ, USA
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Alves J, Abreu B, Palma P, Alp E, Vieceli T, Rello J. Antimicrobial Stewardship on Patients with Neutropenia: A Narrative Review Commissioned by Microorganisms. Microorganisms 2023; 11:1127. [PMID: 37317101 DOI: 10.3390/microorganisms11051127] [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: 03/27/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 06/16/2023] Open
Abstract
The emergence of antibiotic resistance poses a global health threat. High-risk patients such as those with neutropenia are particularly vulnerable to opportunistic infections, sepsis, and multidrug-resistant infections, and clinical outcomes remain the primary concern. Antimicrobial stewardship (AMS) programs should mainly focus on optimizing antibiotic use, decreasing adverse effects, and improving patient outcomes. There is a limited number of published studies assessing the impact of AMS programs on patients with neutropenia, where early appropriate antibiotic choice can be the difference between life and death. This narrative review updates the current advances in strategies of AMS for bacterial infections among high-risk patients with neutropenia. Diagnosis, drug, dose, duration, and de-escalation (5D) are the core variables among AMS strategies. Altered volumes of distribution can make standard dose regimens inadequate, and developing skills towards a personalized approach represents a major advance in therapy. Intensivists should partner antibiotic stewardship programs to improve patient care. Assembling multidisciplinary teams with trained and dedicated professionals for AMS is a priority.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Betânia Abreu
- Pharmaceuticals Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Pedro Palma
- Infectious Diseases Department, Centro Hospitalar do Tâmega e Sousa, 4564-007 Penafiel, Portugal
| | - Emine Alp
- Infectious Diseases and Clinical Microbiology Department, Ankara Yıldırım Beyazıt University, 06760 Ankara, Turkey
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil
| | - Jordi Rello
- Clinical Research in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), 08035 Barcelona, Spain
- FOREVA Research Pôle, Centre Hôpitalaire Universitaire de Nîmes, 30900 Nîmes, France
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Vairo C, Villar Vidal M, Maria Hernandez R, Igartua M, Villullas S. Colistin- and amikacin-loaded lipid-based drug delivery systems for resistant gram-negative lung and wound bacterial infections. Int J Pharm 2023; 635:122739. [PMID: 36801363 DOI: 10.1016/j.ijpharm.2023.122739] [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: 11/14/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023]
Abstract
Antimicrobial resistance (AMR) is a global health issue, which needs to be tackled without further delay. The World Health Organization(WHO) has classified three gram-negative bacteria, Pseudomonas aeruginosa, Klebsiella pneumonia and Acinetobacter baumannii, as the principal responsible for AMR, mainly causing difficult to treat nosocomial lung and wound infections. In this regard, the need for colistin and amikacin, the re-emerged antibiotics of choice for resistant gram-negative infections, will be examined as well as their associated toxicity. Thus, current but ineffective clinical strategies designed to prevent toxicity related to colistin and amikacin will be reported, highlighting the importance of lipid-based drug delivery systems (LBDDSs), such as liposomes, solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs), as efficient delivery strategies for reducing antibiotic toxicity. This review reveals that colistin- and amikacin-NLCs are promising carriers with greater potential than liposomes and SLNs to safely tackle AMR, especially for lung and wound infections.
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Affiliation(s)
- Claudia Vairo
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain; NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain
| | | | - Rosa Maria Hernandez
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Manoli Igartua
- NanoBioCel Group, Laboratory of Pharmaceutics, University of the Basque Country (UPV/EHU), School of Pharmacy, Paseo de la Universidad 7, 01006 Vitoria-Gasteiz, Spain; Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Vitoria-Gasteiz, Spain; Bioaraba Health Research Institute, Vitoria-Gasteiz, Spain
| | - Silvia Villullas
- BioKeralty Research Institute AIE, Albert Einstein, 25-E3, 01510 Miñano, Spain.
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Coste A, Bellouard R, Deslandes G, Jalin L, Roger C, Ansart S, Dailly E, Bretonnière C, Grégoire M. Development of a Predictive Dosing Nomogram to Achieve PK/PD Targets of Amikacin Initial Dose in Critically Ill Patients: A Non-Parametric Approach. Antibiotics (Basel) 2023; 12:antibiotics12010123. [PMID: 36671324 PMCID: PMC9854650 DOI: 10.3390/antibiotics12010123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/10/2023] Open
Abstract
French guidelines recommend reaching an amikacin concentration of ≥8 × MIC 1 h after beginning infusion (C1h), with MIC = 8 mg/L for probabilistic therapy. We aimed to elaborate a nomogram guiding clinicians in choosing the right first amikacin dose for ICU patients in septic shock. A total of 138 patients with 407 observations were prospectively recruited. A population pharmacokinetic model was built using a non-parametric, non-linear mixed-effects approach. The total body weight (TBW) influenced the central compartment volume, and the glomerular filtration rate (according to the CKD-EPI formula) influenced its clearance. A dosing nomogram was produced using Monte Carlo simulations of the amikacin amount needed to achieve a C1h ≥ 8 × MIC. The dosing nomogram recommended amikacin doses from 1700 mg to 4200 mg and from 28 mg/kg to 49 mg/kg depending on the patient's TBW and renal clearance. However, a Cthrough ≤ 2.5 mg/L 24 h and 48 h after an optimal dose of amikacin was obtained with probabilities of 0.20 and 0.81, respectively. Doses ≥ 30 mg/kg are required to achieve a C1h ≥ 8 × MIC with MIC = 8 mg/L. Targeting a MIC = 8 mg/L should depend on local ecology.
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Affiliation(s)
- Anne Coste
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
- Correspondence:
| | - Ronan Bellouard
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | | | - Laurence Jalin
- Unité de Neuro-Anesthésie-Réanimation, Groupe Hospitalier Pitié-Salpétrière, AP-HP, 75013 Paris, France
| | - Claire Roger
- Département d’anesthésie et réanimation, douleur et médecine d’urgence, CHU Carémeau, 30029 Nîmes, France
- UR UM 103 IMAGINE, Faculté de Médecine, Montpellier Université, 30029 Nîmes, France
| | - Séverine Ansart
- Service de Maladies Infectieuses et Tropicales, CHU de Brest, 29200 Brest, France
- Laboratoire de Traitement de l’Information Médicale, INSERM, UMR1101, Brest Université, 29200 Brest, France
| | - Eric Dailly
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
| | - Cédric Bretonnière
- Service des Soins Intensifs de Pneumologie, CHU Nantes, 44000 Nantes, France
| | - Matthieu Grégoire
- Cibles et Médicaments des Infections et de l’Immunité, 9 IICiMed, UR1155, Nantes Université, 44000 Nantes, France
- Service de Pharmacologie Clinique, CHU Nantes, 44000 Nantes, France
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7
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When and How to Use MIC in Clinical Practice? Antibiotics (Basel) 2022; 11:antibiotics11121748. [PMID: 36551405 PMCID: PMC9774413 DOI: 10.3390/antibiotics11121748] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
Bacterial resistance to antibiotics continues to be a global public health problem. The choice of the most effective antibiotic and the use of an adapted dose in the initial phase of the infection are essential to limit the emergence of resistance. This will depend on (i) the isolated bacteria and its resistance profile, (ii) the pharmacodynamic (PD) profile of the antibiotic used and its level of toxicity, (iii) the site of infection, and (iv) the pharmacokinetic (PK) profile of the patient. In order to take account of both parameters to optimize the administered treatment, a minimal inhibitory concentration (MIC) determination associated with therapeutic drug monitoring (TDM) and their combined interpretation are required. The objective of this narrative review is thus to suggest microbiological, pharmacological, and/or clinical situations for which this approach could be useful. Regarding the microbiological aspect, such as the detection of antibiotic resistance and its level, the preservation of broad-spectrum β-lactams is particularly discussed. PK-PD profiles are relevant for difficult-to-reach infections and specific populations such as intensive care patients, cystic fibrosis patients, obese, or elderly patients. Finally, MIC and TDM are tools available to clinicians, who should not hesitate to use them to manage their patients.
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Glinka M, Filatova K, Kucińska-Lipka J, Šopík T, Domincová Bergerová E, Mikulcová V, Wasik A, Sedlařík V. Antibacterial Porous Systems Based on Polylactide Loaded with Amikacin. Molecules 2022; 27:molecules27207045. [PMID: 36296639 PMCID: PMC9609933 DOI: 10.3390/molecules27207045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
Three porous matrices based on poly(lactic acid) are proposed herein for the controlled release of amikacin. The materials were fabricated by the method of spraying a surface liquid. Description is given as to the possibility of employing a modifier, such as a silica nanocarrier, for prolonging the release of amikacin, in addition to using chitosan to improve the properties of the materials, e.g., stability and sorption capacity. Depending on their actual composition, the materials exhibited varied efficacy for drug loading, as follows: 25.4 ± 2.2 μg/mg (matrices with 0.05% w/v of chitosan), 93 ± 13 μg/mg (with 0.08% w/v SiO2 amikacin modified nanoparticles), and 96 ± 34 μg/mg (matrices without functional additives). An in vitro study confirmed extended release of the drug (amikacin, over 60 days), carried out in accordance with the mathematical Kosmyer–Pepas model for all the materials tested. The matrices were also evaluated for their effectiveness in inhibiting the growth of bacteria such as Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Concurrent research was conducted on the transdermal absorption, morphology, elemental composition, and thermogravimetric properties of the released drug.
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Affiliation(s)
- Marta Glinka
- Department of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, 11/12 G. Narutowicza Street, 80-233 Gdańsk, Poland
| | - Katerina Filatova
- Centre of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678 Street, 760 01 Zlín, Czech Republic
| | - Justyna Kucińska-Lipka
- Department of Polymer Technology, Faculty of Chemistry, Gdańsk University of Technology, 11/12 G. Narutowicza Street, 80-233 Gdańsk, Poland
| | - Tomáš Šopík
- Centre of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678 Street, 760 01 Zlín, Czech Republic
| | - Eva Domincová Bergerová
- Centre of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678 Street, 760 01 Zlín, Czech Republic
| | - Veronika Mikulcová
- Centre of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678 Street, 760 01 Zlín, Czech Republic
| | - Andrzej Wasik
- Department of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, 11/12 G. Narutowicza Street, 80-233 Gdańsk, Poland
- Correspondence:
| | - Vladimir Sedlařík
- Centre of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678 Street, 760 01 Zlín, Czech Republic
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9
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Koch BCP, Muller AE, Hunfeld NGM, de Winter BCM, Ewoldt TMJ, Abdulla A, Endeman H. Therapeutic Drug Monitoring of Antibiotics in Critically Ill Patients: Current Practice and Future Perspectives With a Focus on Clinical Outcome. Ther Drug Monit 2022; 44:11-18. [PMID: 34772892 DOI: 10.1097/ftd.0000000000000942] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Early initiation of antibiotics is essential for ameliorating infections in critically ill patients. The correct dosage of antibiotics is imperative to ensure their adequate exposure. Critically ill patients have altered pharmacokinetic parameters and are often infected by less susceptible microorganisms. Differences in drug disposition are not considered with standard doses of antibiotics. This can lead to suboptimal antibiotic exposure in critically ill patients. To overcome this problem of suboptimal dosing, therapeutic drug monitoring (TDM) is a strategy commonly used to support individualized dosing of antibiotics. It is routinely used for vancomycin and aminoglycosides in clinical practice. In recent years, it has become apparent that TDM may also be used in other antibiotics. METHODS This review summarizes the evidence for TDM of antibiotics in critically ill patients, focuses on clinical outcomes, and summarizes possibilities for optimized TDM in the future. RESULTS AND CONCLUSION After reviewing the literature, we can conclude that general TDM implementation is advised for glycopeptides and aminoglycosides, as evidence of the relationship between TDM and clinical outcome is present. For antibiotics, such as beta-lactams, fluoroquinolones, and linezolid, it seems rational to perform TDM in specific patient cases. TDM involving other antibiotics is supported by individual cases, specifically to decrease toxicity. When focusing on future possibilities to improve TDM of antibiotics in critically ill patients, implementation of model-informed precision dosing should be investigated because it can potentially streamline the TDM process. The logistics of TDM, such as turnaround time and available equipment, are challenging but may be overcome by rapid bioanalytical techniques or real-time monitoring of drug concentrations through biosensors in the future. Education, clinical information on targets, and clinical outcome studies are other important factors that facilitate TDM implementation.
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Affiliation(s)
- Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, the Netherlands; and
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Tim M J Ewoldt
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
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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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11
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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12
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Hurkacz M, Dobrek L, Wiela-Hojeńska A. Antibiotics and the Nervous System-Which Face of Antibiotic Therapy Is Real, Dr. Jekyll (Neurotoxicity) or Mr. Hyde (Neuroprotection)? Molecules 2021; 26:7456. [PMID: 34946536 PMCID: PMC8708917 DOI: 10.3390/molecules26247456] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/13/2022] Open
Abstract
Antibiotics as antibacterial drugs have saved many lives, but have also become a victim of their own success. Their widespread abuse reduces their anti-infective effectiveness and causes the development of bacterial resistance. Moreover, irrational antibiotic therapy contributes to gastrointestinal dysbiosis, that increases the risk of the development of many diseases, including neurological and psychiatric. One of the potential options for restoring homeostasis is the use of oral antibiotics that are poorly absorbed from the gastrointestinal tract (e.g., rifaximin alfa). Thus, antibiotic therapy may exert neurological or psychiatric adverse drug reactions which are often considered to be overlooked and undervalued issues. Drug-induced neurotoxicity is mostly observed after beta-lactams and quinolones. Penicillin may produce a wide range of neurological dysfunctions, including encephalopathy, behavioral changes, myoclonus or seizures. Their pathomechanism results from the disturbances of gamma-aminobutyric acid-GABA transmission (due to the molecular similarities between the structure of the β-lactam ring and GABA molecule) and impairment of the functioning of benzodiazepine receptors (BZD). However, on the other hand, antibiotics have also been studied for their neuroprotective properties in the treatment of neurodegenerative and neuroinflammatory processes (e.g., Alzheimer's or Parkinson's diseases). Antibiotics may, therefore, become promising elements of multi-targeted therapy for these entities.
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Affiliation(s)
- Magdalena Hurkacz
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
- Clinical Pharmacy Service, Jan Mikulicz-Radecki University Clinical Hospital, 50-556 Wroclaw, Poland
| | - Lukasz Dobrek
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
| | - Anna Wiela-Hojeńska
- Department of Clinical Pharmacology, Wroclaw Medical University, 50-556 Wroclaw, Poland; (M.H.); (L.D.)
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13
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Glinka M, Filatova K, Kucińska-Lipka J, Bergerova ED, Wasik A, Sedlařík V. Encapsulation of Amikacin into Microparticles Based on Low-Molecular-Weight Poly(lactic acid) and Poly(lactic acid- co-polyethylene glycol). Mol Pharm 2021; 18:2986-2996. [PMID: 34196555 PMCID: PMC8397404 DOI: 10.1021/acs.molpharmaceut.1c00193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
The aim of this study was to fabricate novel microparticles (MPs) for efficient and long-term delivery of amikacin (AMI). The emulsification method proposed for encapsulating AMI employed low-molecular-weight poly(lactic acid) (PLA) and poly(lactic acid-co-polyethylene glycol) (PLA-PEG), both supplemented with poly(vinyl alcohol) (PVA). The diameters of the particles obtained were determined as less than 30 μm. Based on an in-vitro release study, it was proven that the MPs (both PLA/PVA- and PLA-PEG/PVA-based) demonstrated long-term AMI release (2 months), the kinetics of which adhered to the Korsmeyer-Peppas model. The loading efficiencies of AMI in the study were determined at the followings levels: 36.5 ± 1.5 μg/mg for the PLA-based MPs and 106 ± 32 μg/mg for the PLA-PEG-based MPs. These values were relatively high and draw parallels with studies published on the encapsulation of aminoglycosides. The MPs provided antimicrobial action against the Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae bacterial strains. The materials were also comprehensively characterized by the following methods: differential scanning calorimetry; gel permeation chromatography; scanning electron microscopy; Fourier transform infrared spectroscopy-attenuated total reflectance; energy-dispersive X-ray fluorescence; and Brunauer-Emmett-Teller surface area analysis. The findings of this study contribute toward discerning new means for conducting targeted therapy with polar, broad spectrum antibiotics.
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Affiliation(s)
- Marta Glinka
- Department
of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, G. Narutowicza 11/12, Gdańsk 80-233, Poland
| | - Katerina Filatova
- Centre
of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678, Zlín 76001, Czech Republic
| | - Justyna Kucińska-Lipka
- Department
of Polymers Technology, Faculty of Chemistry, Gdańsk University of Technology, G. Narutowicza 11/12, Gdańsk 80-233, Poland
| | - Eva Domincova Bergerova
- Centre
of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678, Zlín 76001, Czech Republic
| | - Andrzej Wasik
- Department
of Analytical Chemistry, Faculty of Chemistry, Gdańsk University of Technology, G. Narutowicza 11/12, Gdańsk 80-233, Poland
| | - Vladimir Sedlařík
- Centre
of Polymer Systems, University Institute, Tomas Bata University in Zlín, Tomáše Bati 5678, Zlín 76001, Czech Republic
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14
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McAleenan A, Ambrose PG, Bhavnani SM, Drusano GL, Hope WW, Mouton JW, Higgins JPT, MacGowan AP. Methodological features of clinical pharmacokinetic-pharmacodynamic studies of antibacterials and antifungals: a systematic review. J Antimicrob Chemother 2021; 75:1374-1389. [PMID: 32083674 DOI: 10.1093/jac/dkaa005] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/17/2019] [Accepted: 01/02/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK)-pharmacodynamic (PD) indices relate measures of drug exposure to antibacterial effect. Clinical PK-PD studies aim to correlate PK-PD indices with outcomes in patients. Optimization of dosing based on pre-clinical studies means that PK-PD relationships are difficult to establish; therefore studies need to be designed and reported carefully to validate pre-clinical findings. OBJECTIVES To describe the methodological features of clinical antibacterial and antifungal PK-PD studies that reported the relationship between PK-PD indices and clinical or microbiological responses. METHODS Studies published between 1980 and 2015 were identified through systematic searches. Methodological features of eligible studies were extracted. RESULTS We identified 85 publications containing 97 PK-PD analyses. Most studies were small, with fewer than 100 patients. Around a quarter were performed on patients with infections due to a single specific pathogen. In approximately one-third of studies, patients received concurrent antibiotics/antifungals and in some other studies patients received other treatments that may confound the PK-PD-outcome relationship. Most studies measured antimicrobial concentrations in blood/serum and only four measured free concentrations. Most performed some form of regression, time-to-event analysis or used the Hill/Emax equation to examine the association between PK-PD index and outcome. Target values of PK-PD indices that predict outcomes were investigated in 52% of studies. Target identification was most commonly done using recursive partitioning or logistic regression. CONCLUSIONS Given the variability in conduct and reporting, we suggest that an agreed set of standards for the conduct and reporting of studies should be developed.
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Affiliation(s)
- Alexandra McAleenan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Paul G Ambrose
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - Sujata M Bhavnani
- Institute of Clinical Pharmacodynamics, 242 Broadway, Schenectady, New York 12305, USA
| | - George L Drusano
- Institute for Therapeutic Innovation, Department of Medicine, University of Florida, UF Research and Academic Center at Lake Nowa, 6550 Sanger Road, Orlando, Florida 32827, USA
| | - William W Hope
- Centre for Antimicrobial Pharmacodynamics, Institute of Translational Medicine, University of Liverpool, Liverpool L69 4BX, UK
| | - Johan W Mouton
- Department of Medical Microbiology & Infectious Diseases, Erasmus Medical Centre, s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation, Infection Sciences, Pathology Science Quarter, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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15
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Pérez-Blanco JS, Sáez Fernández EM, Calvo MV, Lanao JM, Martín-Suárez A. Amikacin initial dosage in patients with hypoalbuminaemia: an interactive tool based on a population pharmacokinetic approach. J Antimicrob Chemother 2021; 75:2222-2231. [PMID: 32363405 DOI: 10.1093/jac/dkaa158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To characterize amikacin population pharmacokinetics in patients with hypoalbuminaemia and to develop a model-based interactive application for amikacin initial dosage. METHODS A population pharmacokinetic model was developed using a non-linear mixed-effects modelling approach (NONMEM) with amikacin concentration-time data collected from clinical practice (75% hypoalbuminaemic patients). Goodness-of-fit plots, minimum objective function value, prediction-corrected visual predictive check, bootstrapping, precision and bias of parameter estimates were used for model evaluation. An interactive model-based simulation tool was developed in R (Shiny and R Markdown). Cmax/MIC ratio, time above MIC and AUC/MIC were used for optimizing amikacin initial dose recommendation. Probabilities of reaching targets were calculated for the dosage proposed. RESULTS A one-compartment model with first-order linear elimination best described the 873 amikacin plasma concentrations available from 294 subjects (model development and external validation groups). Estimated amikacin population pharmacokinetic parameters were CL (L/h) = 0.525 + 4.78 × (CKD-EPI/98) × (0.77 × vancomycin) and V (L) = 26.3 × (albumin/2.9)-0.51 × [1 + 0.006 × (weight - 70)], where CKD-EPI is calculated with the Chronic Kidney Disease Epidemiology Collaboration equation. AMKdose is a useful interactive model-based application for a priori optimization of amikacin dosage, using individual patient and microbiological information together with predefined pharmacokinetic/pharmacodynamic (PKPD) targets. CONCLUSIONS Serum albumin, total bodyweight, estimated glomerular filtration rate (using the CKD-EPI equation) and co-medication with vancomycin showed a significant impact on amikacin pharmacokinetics. A powerful interactive initial dose-finding tool has been developed and is freely available online. AMKdose could be useful for guiding initial amikacin dose selection before any individual pharmacokinetic information is available.
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Affiliation(s)
- Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Eva María Sáez Fernández
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - M Victoria Calvo
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.,Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - José M Lanao
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Ana Martín-Suárez
- Department of Pharmaceutical Sciences, University of Salamanca, Pharmacy Faculty, Campus Miguel de Unamuno, 37007 Salamanca, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Hospital Virgen de la Vega, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
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16
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Roger C, Louart B, Elotmani L, Barton G, Escobar L, Koulenti D, Lipman J, Leone M, Muller L, Boutin C, Amour J, Banakh I, Cousson J, Bourenne J, Constantin JM, Albanese J, Roberts JA, Lefrant JY. An international survey on aminoglycoside practices in critically ill patients: the AMINO III study. Ann Intensive Care 2021; 11:49. [PMID: 33740157 PMCID: PMC7979853 DOI: 10.1186/s13613-021-00834-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/05/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND While aminoglycosides (AG) have been used for decades, debate remains on their optimal dosing strategy. We investigated the international practices of AG usage specifically regarding dosing and therapeutic drug monitoring (TDM) in critically ill patients. We conducted a prospective, multicentre, observational, cohort study in 59 intensive-care units (ICUs) in 5 countries enrolling all ICU patients receiving AG therapy for septic shock. RESULTS We enrolled 931 septic ICU patients [mean ± standard deviation, age 63 ± 15 years, female 364 (39%), median (IQR) SAPS II 51 (38-65)] receiving AG as part of empirical (761, 84%) or directed (147, 16%) therapy. The AG used was amikacin in 614 (66%), gentamicin in 303 (33%), and tobramycin in 14 (1%) patients. The median (IQR) duration of therapy was 2 (1-3) days, the number of doses was 2 (1-2), the median dose was 25 ± 6, 6 ± 2, and 6 ± 2 mg/kg for amikacin, gentamicin, and tobramycin respectively, and the median dosing interval was 26 (23.5-43.5) h. TDM of Cmax and Cmin was performed in 437 (47%) and 501 (57%) patients, respectively, after the first dose with 295 (68%) patients achieving a Cmax/MIC > 8 and 353 (71%) having concentrations above Cmin recommended thresholds. The ICU mortality rate was 27% with multivariable analysis showing no correlation between AG dosing or pharmacokinetic/pharmacodynamic target attainment and clinical outcomes. CONCLUSION Short courses of high AG doses are mainly used in ICU patients with septic shock, although wide variability in AG usage is reported. We could show no correlation between PK/PD target attainment and clinical outcome. Efforts to optimize the first AG dose remain necessary. Trial registration Clinical Trials, NCT02850029, registered on 29th July 2016, retrospectively registered, https://www.clinicaltrials.gov.
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Affiliation(s)
- Claire Roger
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France. .,Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France.
| | - Benjamin Louart
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France.,Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France
| | - Loubna Elotmani
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France.,Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France
| | - Greg Barton
- St Helens and Knowsley Hospitals NHS Trust, Liverpool, UK
| | - Leslie Escobar
- Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Despoina Koulenti
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Second Critical Care Department, Attikon University Hospital, Athens, Greece
| | - Jeffrey Lipman
- Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France.,The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - Laurent Muller
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France.,Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France
| | - Caroline Boutin
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France
| | - Julien Amour
- Institute of Perfusion, Critical Care Medicine and Anesthesiology in Cardiac Surgery (IPRA), Hôpital Privé Jacques Cartier, Massy, France
| | | | - Joel Cousson
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Reims, Reims, France
| | - Jeremy Bourenne
- Department of Emergency and Intensive Care Medicine, University Hospital of Marseille, Hôpital de La Timone, Marseille, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jacques Albanese
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Marseille, Hôpital de La Conception, Marseille, France
| | - Jason A Roberts
- Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France.,The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jean-Yves Lefrant
- Department of Intensive Care Medicine, Division of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France.,Equipe D, Caractéristiques Féminines Des Interfaces Vasculaires (IMAGINE), Faculté de Médecine, Univ Montpellier, 2992, Montpellier, France
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Maheshwari ML, Memon N, Memon AA, Khuhawar MY, Memon AH. A rapid HPLC–DAD method for quantification of amikacin in pharmaceuticals and biological samples using pre-column derivatization with Hantzsch reagent. JOURNAL OF THE IRANIAN CHEMICAL SOCIETY 2021. [PMCID: PMC7478114 DOI: 10.1007/s13738-020-02046-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Amikacin (AMK) is an important member of aminoglycoside class, and its determination has therapeutic importance due to its matchless potency against gram –ve pathogens. Due to narrow therapeutic window, its monitoring in clinical samples is inevitable. Direct determination of AMK using HPLC with UV–visible detection is not possible because of its limited absorbance. Herein, Hantzsch reagent (mixture of acetylacetone, formaldehyde and acetate buffer) was used as pre-column derivatization for AMK. UV–visible detection was performed at 340 nm. Separation and identification of derivatized drug (amikacin) were carried out using C-18 column Kromasil 100 (15 cm × 0.46 mm, 5 μm) with isocratic mobile phase elution of pH 5 (acetate buffer 0.01 M):acetonitrile (30:70 v/v) with flow rate of 1 ml/min. The procedure was able to resolve AMK from endogenous compounds and from cephalosporin drug (most prescribed combination) with run time of 10 min. Under optimized conditions; calibration curve was linear in the range 0.10–25.0 µg/mL with LOD and LOQ values of 0.024 and 0.071 µg/mL. Method was also validated for reproducibility, ruggedness and accuracy. The procedure was found sensitive, robust and precise for the comprehensive analysis (qualitative and quantitative) that was applied for determination of AMK in pharmaceuticals, urine and blood samples.
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18
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Pérez-Blanco JS, Sáez Fernández EM, Calvo MV, Lanao JM, Martín-Suárez A. Evaluation of Current Amikacin Dosing Recommendations and Development of an Interactive Nomogram: The Role of Albumin. Pharmaceutics 2021; 13:pharmaceutics13020264. [PMID: 33672057 PMCID: PMC7919491 DOI: 10.3390/pharmaceutics13020264] [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] [Received: 12/22/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022] Open
Abstract
This study aimed to evaluate the potential efficacy and safety of the amikacin dosage proposed by the main guidelines and to develop an interactive nomogram, especially focused on the potential impact of albumin on initial dosage recommendation. The probability of target attainment (PTA) for each of the different dosing recommendations was calculated through stochastic simulations based on pharmacokinetic/pharmacodynamic (PKPD) criteria. Large efficacy and safety differences were observed for the evaluated amikacin dosing guidelines together with a significant impact of albumin concentrations on efficacy and safety. For all recommended dosages evaluated, efficacy and safety criteria of amikacin dosage proposed were not achieved simultaneously in most of the clinical scenarios evaluated. Furthermore, a significant impact of albumin was identified: The higher is the albumin, (i) the higher will be the PTA for maximum concentration/minimum inhibitory concentration (Cmax/MIC), (ii) the lower will be the PTA for the time period with drug concentration exceeding MIC (T>MIC) and (iii) the lower will be the PTA for toxicity (minimum concentration). Thus, accounting for albumin effect might be of interest for future amikacin dosing guidelines updates. In addition, AMKnom, an amikacin nomogram builder based on PKPD criteria, has been developed and is freely available to help evaluating dosing recommendations.
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Affiliation(s)
- Jonás Samuel Pérez-Blanco
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - Eva María Sáez Fernández
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Pharmacy Service, University Hospital of Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - María Victoria Calvo
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
| | - José M. Lanao
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
- Institute for Biomedical Research of Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain
- Correspondence: ; Tel.: +34-923294518
| | - Ana Martín-Suárez
- Department of Pharmaceutical Sciences, Pharmacy Faculty, University of Salamanca, 37007 Salamanca, Spain; (J.S.P.-B.); (E.M.S.F.); (M.V.C.); (A.M.-S.)
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Impact of Therapeutic Drug Monitoring on Once-Daily Regimen of Amikacin in Patients With Urinary Tract Infection: A Prospective Observational Study. Ther Drug Monit 2020; 42:841-847. [PMID: 32947556 DOI: 10.1097/ftd.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Amikacin is a semisynthetic antibiotic used in the treatment of gram-negative bacterial infections and has a narrow therapeutic index. Although therapeutic drug monitoring is recommended for amikacin, it is not routinely performed because of the use of a less toxic once-daily regimen. Only few studies have evaluated the role of therapeutic drug monitoring in patients treated with amikacin. The objective of our study was to find an association between the pharmacokinetic parameters of amikacin and the time required for a clinical cure, creatinine clearance, and frequency of ototoxicity in patients with urinary tract infection treated for 7 or more days. METHODS A prospective study was conducted on patients with urinary tract infections who were administered amikacin for 7 or more days. Blood samples were obtained from the patients to measure the maximum drug concentration (Cmax) and trough concentration (Ctrough). Minimum inhibitory concentration (MIC) values were determined for patients with positive urine cultures. Serum creatinine levels were estimated every 3 days. The auditory assessment was performed using pure tone audiometry at baseline and weekly until the patients were discharged. Levels of amikacin were analyzed using a validated liquid chromatography-tandem mass spectrometry method. RESULTS Of 125 patients analyzed, the median time required for a clinical cure was less in the group of patients who achieved a Cmax/MIC ratio ≥8 than it was in those who did not achieve this level [7 versus 8 days (P = 0.02)]. The Ctrough of amikacin was associated with the change in serum creatinine level (P = 0.01) and the incidence of nephrotoxicity (P = 0.004). CONCLUSIONS In patients receiving short-term amikacin therapy, Cmax/MIC value can be used to predict the time required for a clinical cure. Ctrough can be used to predict the occurrence of nephrotoxicity in patients receiving amikacin therapy.
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Combination Therapy with Aminoglycoside in Bacteremiasdue to ESBL-Producing Enterobacteriaceae in ICU. Antibiotics (Basel) 2020; 9:antibiotics9110777. [PMID: 33158238 PMCID: PMC7694250 DOI: 10.3390/antibiotics9110777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 01/21/2023] Open
Abstract
Objectives: Evaluation of the efficacy of empirical aminoglycoside in critically ill patients with bloodstream infections caused by extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-E BSI). Methods: Patients treated between 2011 and 2018 for ESBL-E BSI in the ICU of six French hospitals were included in a retrospective observational cohort study. The primary endpoint was mortality on day 30. Results: Among 307 patients, 169 (55%) were treated with empirical aminoglycoside. Death rate was 40% (43% with vs. 39% without aminoglycoside, p = 0.55). Factors independently associated with death were age ≥70 years (OR: 2.67; 95% CI: 1.09–6.54, p = 0.03), history of transplantation (OR 5.2; 95% CI: 1.4–19.35, p = 0.01), hospital acquired infection (OR 8.67; 95% CI: 1.74–43.08, p = 0.008), vasoactive drugs >48 h after BSI onset (OR 3.61; 95% CI: 1.62–8.02, p = 0.001), occurrence of acute respiratory distress syndrome (OR 2.42; 95% CI: 1.14–5.16, p = 0.02), or acute renal failure (OR 2.49; 95% CI: 1.14–5.47, p = 0.02). Antibiotherapy appropriateness was more frequent in the aminoglycoside group (91.7% vs. 77%, p = 0.001). Rate of renal impairment was similar in both groups (21% vs. 24%, p = 0.59). Conclusions: In intensive care unit (ICU) patients with ESBL-E BSI, empirical treatment with aminoglycoside was frequent. It demonstrated no impact on mortality, despite increasing treatment appropriateness.
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Ryan AC, Carland JE, McLeay RC, Lau C, Marriott DJE, Day RO, Stocker SL. Evaluation of amikacin use and comparison of the models implemented in two Bayesian forecasting software packages to guide dosing. Br J Clin Pharmacol 2020; 87:1422-1431. [PMID: 32881037 DOI: 10.1111/bcp.14542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/10/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022] Open
Abstract
AIMS Bayesian forecasting software can assist in guiding therapeutic drug monitoring (TDM)-based dose adjustments for amikacin to achieve therapeutic targets. This study aimed to evaluate amikacin prescribing and TDM practices, and to determine the suitability of the amikacin model incorporated into the DoseMeRx® software as a replacement for the previously available software (Abbottbase®). METHODS Patient demographics, pathology, amikacin dosing history, amikacin concentrations and Abbottbase® predicted TDM targets (area under the curve up to 24 hours, maximum concentration and trough concentration) were collected for adults receiving intravenous amikacin (2012-2017). Concordance with the Australian Therapeutic Guidelines was assessed. Observed and predicted amikacin concentrations were compared to determine the predictive performance (bias and precision) of DoseMeRx®. Amikacin TDM targets were predicted by DoseMeRx® and compared to those predicted by Abbottbase®. RESULTS Overall, guideline compliance for 63 courses of amikacin in 47 patients was suboptimal. Doses were often lower than recommended. For therapy >48 h, TDM sample collection timing was commonly discordant with recommendations, therapeutic target attainment low and 34% of dose adjustments inappropriate. DoseMeRx® under-predicted amikacin concentrations by 0.9 mg/L (95% confidence interval [CI] -1.4 to -0.5) compared with observed concentrations. However, maximum concentration values (n = 19) were unbiased (-1.7 mg/L 95%CI -5.8 to 0.8) and precise (8.6% 95%CI 5.4-18.1). Predicted trough concentration values (n = 7) were, at most, 1 mg/L higher than observed. Amikacin area under the curve values estimated using Abbottbase® (181 mg h/L 95%CI 161-202) and DoseMeRx® (176 mg h/L 95%CI 152-199) were similar (P = .59). CONCLUSION Amikacin dosing and TDM practice was suboptimal compared with guidelines. The model implemented by DoseMeRx® is satisfactory to guide amikacin dosing.
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Affiliation(s)
- Alice C Ryan
- The School of Medicine, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | | | - Cindy Lau
- Pharmacy Department, St Vincent's Hospital, Sydney, NSW, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Deborah J E Marriott
- St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital, Sydney, NSW, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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Logre E, Enser M, Tanaka S, Dubert M, Claudinon A, Grall N, Mentec H, Montravers P, Pajot O. Amikacin pharmacokinetic/pharmacodynamic in intensive care unit: a prospective database. Ann Intensive Care 2020; 10:75. [PMID: 32514769 PMCID: PMC7276966 DOI: 10.1186/s13613-020-00685-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/20/2020] [Indexed: 01/01/2023] Open
Abstract
Background Aminoglycosides have a concentration-dependent therapeutic effect when peak serum concentration (Cmax) reaches eight to tenfold the minimal inhibitory concentration (MIC). With an amikacin MIC of 8 mg/L, the Cmax should be 64–80 mg/L. This objective is based on clinical breakpoints and not on measured MIC. This study aimed to assess the proportion of patients achieving the pharmacokinetic/pharmacodynamic (PK/PD) target Cmax/MIC ≥ 8 using the measured MIC in critically ill patients treated for documented Gram-negative bacilli (GNB) infections. Methods Retrospective analysis from February 2016 to December 2017 of a prospective database conducted in 2 intensive care units (ICU). All patients with documented severe GNB infections treated with amikacin (single daily dose of 25 mg/kg of total body weight (TBW)) with both MIC and Cmax measurements at first day of treatment (D1) were included. Results are expressed in n (%) or median [min–max]. Results 93 patients with 98 GNB-documented infections were included. The median Cmax was 55.2 mg/L [12.2–165.7] and the median MIC was 2 mg/L [0.19–16]. Cmax/MIC ratio ≥ 8 was achieved in 87 patients (88.8%) while a Cmax ≥ 64 mg/L was achieved in only 38 patients (38.7%). Overall probability of PK/PD target attainment was 93%. No correlation was found between Cmax/MIC ratio and clinical outcome at D8 and D28. Conclusion According to PK/PD parameters observed in our study, single daily dose of amikacin 25 mg/kg of TBW appears to be sufficient in most critically ill patients treated for severe GNB infections.
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Affiliation(s)
- Elsa Logre
- CH Argenteuil, réanimation polyvalente, 69 rue du Lieutenant-Colonel Prudhon, Argenteuil, France.
| | - Maya Enser
- CH Argenteuil, réanimation polyvalente, 69 rue du Lieutenant-Colonel Prudhon, Argenteuil, France
| | - Sébastien Tanaka
- CHU Bichat, réanimation chirurgicale, Paris, France.,INSERM UMR1188 Diabète - Athérothrombose - Thérapies Réunion Océan Indien (DéTROI), Saint-Denis de la Réunion, Université de la Réunion, Réunion, France
| | - Marie Dubert
- CHU Bichat, maladies infectieuses et tropicales, Paris, France
| | | | | | - Hervé Mentec
- CH Argenteuil, réanimation polyvalente, 69 rue du Lieutenant-Colonel Prudhon, Argenteuil, France
| | | | - Olivier Pajot
- CH Argenteuil, réanimation polyvalente, 69 rue du Lieutenant-Colonel Prudhon, Argenteuil, France
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23
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 468] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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Cardoso P, Santos C, Rocha-Gonçalves F. Therapeutic Drug Monitoring by Pharmacists: Does It Reduce Costs. GLOBAL JOURNAL ON QUALITY AND SAFETY IN HEALTHCARE 2020; 3:69-71. [PMID: 37334151 PMCID: PMC10270549 DOI: 10.36401/jqsh-19-40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/25/2020] [Indexed: 06/20/2023]
Abstract
Therapeutic drug monitoring (TDM) has as its main objective to ensure that the plasma drug concentration remains within the appropriate range. Regarding the economic dimension of TDM, it is known that there are gains in health outcomes; however, there is still little evidence for the benefit of this procedure performed by pharmacists within the hospital context. With this project, we aimed to create a matrix of cost avoidance associated with TDM performed by pharmacists and to quantify the total avoided costs in 1 year, by implementing a TDM process in a tertiary hospital. For the studied period, we collected 362 pharmaceutical interventions related to TDM of antibiotics performed in adults. As a result, considering these data, the total cost avoidance in 1 year was 371,018 ($416,584.58) at one medical center. We conclude that TDM is highly cost-avoidant and that the implementation costs by pharmaceutical services is clearly lower than the benefit achieved.
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Population Pharmacokinetic Study of the Suitability of Standard Dosing Regimens of Amikacin in Critically Ill Patients with Open-Abdomen and Negative-Pressure Wound Therapy. Antimicrob Agents Chemother 2020; 64:AAC.02098-19. [PMID: 31964795 DOI: 10.1128/aac.02098-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/07/2020] [Indexed: 02/02/2023] Open
Abstract
The aim was to assess the appropriateness of recommended regimens for empirical MIC coverage in critically ill patients with open-abdomen and negative-pressure therapy (OA/NPT). Over a 5-year period, every critically ill patient who received amikacin and who underwent therapeutic drug monitoring (TDM) while being treated by OA/NPT was retrospectively included. A population pharmacokinetic (PK) modeling was performed considering the effect of 10 covariates (age, sex, total body weight [TBW], adapted body weight [ABW], body surface area [BSA], modified sepsis-related organ failure assessment [SOFA] score, vasopressor use, creatinine clearance [CLCR], fluid balance, and amount of fluids collected by the NPT over the sampling day) in patients who underwent continuous renal replacement therapy (CRRT) or did not receive CRRT. Monte Carlo simulations were employed to determine the fractional target attainment (FTA) for the PK/pharmacodynamic [PD] targets (maximum concentration of drug [C max]/MIC ratio of ≥8 and a ratio of the area under the concentration-time curve from 0 to 24 h [AUC0-24]/MIC of ≥75). Seventy critically ill patients treated by OA/NPT (contributing 179 concentration values) were included. Amikacin PK concentrations were best described by a two-compartment model with linear elimination and proportional residual error, with CLCR and ABW as significant covariates for volume of distribution (V) and CLCR for CL. The reported V) in non-CRRT and CRRT patients was 35.8 and 40.2 liters, respectively. In Monte Carlo simulations, ABW-adjusted doses between 25 and 35 mg/kg were needed to reach an FTA of >85% for various renal functions. Despite an increased V and a wide interindividual variability, desirable PK/PD targets may be achieved using an ABW-based loading dose of 25 to 30 mg/kg. When less susceptible pathogens are targeted, higher dosing regimens are probably needed in patients with augmented renal clearance (ARC). Further studies are needed to assess the effect of OA/NPT on the PK parameters of antimicrobial agents.
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Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020; 46:266-284. [PMID: 32047941 PMCID: PMC7223992 DOI: 10.1007/s00134-020-05950-6] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary—that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5–8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-to-date expert statements.
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Affiliation(s)
- Jean-François Timsit
- AP-HP, Hôpital Bichat, Medical and Infectious Diseases ICU, 75018, Paris, France. .,Université de Paris, IAME, INSERM, 75018, Paris, France.
| | - Etienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Hôpital Bichat, Bacteriology Laboratory, 75018, Paris, France
| | | | - Alexis Tabah
- ICU, Redcliffe Hospital, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino-IRCCS, Genoa, Italy
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Pitta RD, Gasparetto J, De Moraes TP, Telles JP, Tuon FF. Antimicrobial therapy with aminoglycoside or meropenem in the intensive care unit for hospital associated infections and risk factors for acute kidney injury. Eur J Clin Microbiol Infect Dis 2019; 39:723-728. [PMID: 31832808 DOI: 10.1007/s10096-019-03779-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/26/2019] [Indexed: 11/30/2022]
Abstract
There have historically been concerns of acute kidney injury (AKI) with the use of aminoglycosides. The present study aimed to compare the AKI incidence and mortality rate between critically ill patients treated with aminoglycoside or meropenem in the intensive care unit setting using a propensity score matching approach. This cross-sectional study was conducted at two university hospitals from January 2011 to October 2017. Clinical and laboratorial data were evaluated to exclude potential confounders and to calculate the Charlson index. AKI was classified according to the Acute Kidney Injury Network criteria. All tests were two-tailed, and a p value ≤ 0.05 was considered significant in the univariate and multivariate analyses. We included 494 patients, 95 and 399 of whom used meropenem and aminoglycoside, respectively. Patients in the subgroup that used meropenem were matched with controls (aminoglycoside). Among the 494 patients, 120 developed any grade of AKI (24.2%). After propensity score matching, there were no significant differences in AKI incidence and mortality rate between the aminoglycoside and meropenem groups (p = 0.324 and 0.464, respectively). Patients on the aminoglycoside regimen neither presented a higher AKI incidence nor mortality rate when compared with those on the meropenem regimen. Aminoglycosides may be a safe option for the treatment of critically ill patients on carbapenem sparing antimicrobial stewardship programs.
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Affiliation(s)
- Raphael Donadio Pitta
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil
| | - Juliano Gasparetto
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil
| | - Thyago Proença De Moraes
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil
| | - João Paulo Telles
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil
| | - Felipe Francisco Tuon
- Department of Medicine, School of Health and Biosciences, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil.
- Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Rua Imaculada Conceição, 1155, Curitiba, PR, 80215-901, Brazil.
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Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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In Vitro Activity of Imipenem-Relebactam Alone or in Combination with Amikacin or Colistin against Pseudomonas aeruginosa. Antimicrob Agents Chemother 2019; 63:AAC.00997-19. [PMID: 31262769 DOI: 10.1128/aac.00997-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/27/2019] [Indexed: 12/16/2022] Open
Abstract
Relebactam is a novel class A/C β-lactamase inhibitor that restores imipenem in vitro activity against multidrug-resistant and carbapenem-nonsusceptible Pseudomonas aeruginosa Time-kill analyses were performed to evaluate the potential role of imipenem-relebactam in combination with amikacin or colistin against P. aeruginosa Ten clinical P. aeruginosa isolates (9 imipenem nonsusceptible) with imipenem-relebactam MICs ranging from 1/4 to 8/4 μg/ml were included. The isolates had varied susceptibilities to imipenem (1 to 32 μg/ml), amikacin (4 to 128 μg/ml), and colistin (0.5 to 1 μg/ml). Duplicate 24-h time-kill studies were conducted using the average steady-state concentrations (Cssavg) observed after the administration of imipenem-relebactam at 500 mg/250 mg every 6 hours (q6h) alone and in combination with the Cssavg of 25 mg/kg of body weight/day amikacin and 360 mg/day colistin in humans. Imipenem-relebactam alone resulted in 24-h bacterial densities of -2.93 ± 0.38, -1.67 ± 0.29, +0.38 ± 0.96, and +0.15 ± 0.65 log10 CFU/ml at imipenem-relebactam MICs of 1/4, 2/4, 4/4, and 8/4 μg/ml, respectively. No synergy was demonstrated against the single imipenem-susceptible isolate. Against the imipenem-nonsusceptible isolates (n = 9), imipenem-relebactam combined with amikacin resulted in synergy (-2.61 ± 1.50 log10 CFU/ml) against all amikacin-susceptible isolates and in two of three amikacin-intermediate (i.e., MIC, 32 μg/ml) isolates (-2.06 ± 0.19 log10 CFU/ml). Synergy with amikacin was not observed when the amikacin MIC was >32 μg/ml. Imipenem-relebactam combined with colistin demonstrated synergy in eight out of the nine imipenem-resistant isolates (-3.17 ± 1.00 log10 CFU/ml). Against these 10 P. aeruginosa isolates, imipenem-relebactam combined with either amikacin or colistin resulted in synergistic activity against the majority of strains. Further studies evaluating combination therapy with imipenem-relebactam are warranted.
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Bassetti M, Giacobbe DR, Vena A, Brink A. Challenges and research priorities to progress the impact of antimicrobial stewardship. Drugs Context 2019; 8:212600. [PMID: 31516534 PMCID: PMC6726362 DOI: 10.7573/dic.212600] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial stewardship programmes have been playing an important role in patient care and hospital policies. These programmes are now recognised as formal strategies for curbing the upward trend in antibiotic resistance and for improving the appropriate antimicrobial and antifungal use. The role of such programs in the era of antimicrobial resistance presents several unique challenges and opportunities, most notably in the diagnostic and therapeutic setting. Controversies remain regarding the most effective interventions and the appropriate design to evaluate their impact. In this review, based on rounds of discussion, we explain the most important challenges faced by antibiotic stewardship and antifungal stewardship programmes. We also try to suggest areas for further research.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Largo R. Benzi, 10, 16132, Genoa, Italy.,Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Largo R. Benzi, 10, 16132, Genoa, Italy.,Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Italy
| | - Adrian Brink
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Pharmacodynamics of plazomicin and a comparator aminoglycoside, amikacin, studied in an in vitro pharmacokinetic model of infection. Int J Antimicrob Agents 2019; 54:626-632. [PMID: 31299297 DOI: 10.1016/j.ijantimicag.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022]
Abstract
The new aminoglycoside plazomicin shows in vitro potency against multidrug-resistant Enterobacteriales. The exposure-response relationship of plazomicin and the comparator aminoglycoside amikacin was determined for Escherichia coli, while for Klebsiella pneumoniae only plazomicin was tested. An in vitro pharmacokinetic model was used. Five E. coli strains (two meropenem-resistant) and five K. pneumoniae strains (two meropenem-resistant) with plazomicin MICs of 0.5-4 mg/L were used. Antibacterial effect was assessed by changes in bacterial load and bacterial population profile. The correlation between change in initial inoculum after 24 h of drug exposure and the AUC/MIC ratio was good (plazomicin R2 ≥ 0.8302; amikacin R2 ≥ 0.9520). Escherichia coli plazomicin AUC/MIC ratios for 24-h static, -1, -2 and -3 log drop were 36.1 ± 18.4, 39.3 ± 20.9, 41.2 ± 21.9 and 44.8 ± 24.3, respectively, and for amikacin were 49.5 ± 12.7, 55.7 ± 14.8, 64.1 ± 19.2 and 73.3 ± 25.3. Klebsiella pneumoniae plazomicin AUC/MIC ratios for 24-h static, -1, -2 and -3 log drop were 34.0 ± 15.2, 46.8 ± 27.8, 67.4 ± 46.5 and 144.3 ±129.8. Plazomicin AUC/MIC ratios >66 and amikacin AUC/MIC ratios >57.7 were associated with suppression of E. coli growth on 4 × or 8 × MIC recovery plates. The equivalent plazomicin AUC/MIC to suppress resistance emergence with K. pneumoniae was >132. The plazomicin AUC/MIC for 24-h static effect and -1 log reduction in E. coli and K. pneumoniae bacterial load was in the range 30-60. Plazomicin AUC/MIC targets aligned with those of amikacin for E. coli.
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Heffernan AJ, Sime FB, Lipman J, Roberts JA. Individualising Therapy to Minimize Bacterial Multidrug Resistance. Drugs 2019; 78:621-641. [PMID: 29569104 DOI: 10.1007/s40265-018-0891-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The scourge of antibiotic resistance threatens modern healthcare delivery. A contributing factor to this significant issue may be antibiotic dosing, whereby standard antibiotic regimens are unable to suppress the emergence of antibiotic resistance. This article aims to review the role of pharmacokinetic and pharmacodynamic (PK/PD) measures for optimising antibiotic therapy to minimise resistance emergence. It also seeks to describe the utility of combination antibiotic therapy for suppression of resistance and summarise the role of biomarkers in individualising antibiotic therapy. Scientific journals indexed in PubMed and Web of Science were searched to identify relevant articles and summarise existing evidence. Studies suggest that optimising antibiotic dosing to attain defined PK/PD ratios may limit the emergence of resistance. A maximum aminoglycoside concentration to minimum inhibitory concentration (MIC) ratio of > 20, a fluoroquinolone area under the concentration-time curve to MIC ratio of > 285 and a β-lactam trough concentration of > 6 × MIC are likely required for resistance suppression. In vitro studies demonstrate a clear advantage for some antibiotic combinations. However, clinical evidence is limited, suggesting that the use of combination regimens should be assessed on an individual patient basis. Biomarkers, such as procalcitonin, may help to individualise and reduce the duration of antibiotic treatment, which may minimise antibiotic resistance emergence during therapy. Future studies should translate laboratory-based studies into clinical trials and validate the appropriate clinical PK/PD predictors required for resistance suppression in vivo. Other adjunct strategies, such as biomarker-guided therapy or the use of antibiotic combinations require further investigation.
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Affiliation(s)
- A J Heffernan
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - F B Sime
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia
| | - J Lipman
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - J A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia.
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Building 71/918, Herston Rd, Herston, Queensland, 4029, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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Ben Romdhane H, Ben Fredj N, Chaabane A, Ben Aicha S, Chadly Z, Ben Fadhel N, Boughattas N, Aouam K. Interest of therapeutic drug monitoring of aminoglycosides administered by a monodose regimen. Nephrol Ther 2019; 15:110-114. [PMID: 30660586 DOI: 10.1016/j.nephro.2018.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the once-daily regimen of aminoglycosides (AG) is considered as predominantly used by many centers, the level of evidence of Therapeutic Drug Monitoring (TDM) of AG in cases of once-daily has not been clearly defined. The objective of this study is to evaluate the impact of TDM in achievement or maintaining target serum concentrations in patients receiving once-daily administration of AG. METHODS We performed a retrospective analysis of data from patients having received a once daily amikacin or gentamicin and underwent routine TDM. A longitudinal follow up was performed. Data were analyzed according to the adhesion or not to recommendations. A logistic regression was performed in order to evaluate the effect of covariates (age, gender, weight, creatinine clearance [CLcr], TDM-based dose adjustment, weighted dose of AG) on the achievement of non-toxic Cmin. RESULTS A total 437 blood samples issued from 324 patients were analyzed. The cut-off value of Clcr associated with a risk of toxic Cmin was≤41.66mL/min (OR: 11.29; 95%CI: 7.21-17.61; P<0.0001). Eighty-eight patients (27.1%) have at least two sampling points. The univariate analysis showed that the age, weight, CLcr and TDM-based dose adjustment were found to be significant factors in the achievement of non-toxic Cmin. In multivariate analysis, only TDM-based dose adjustment remains a significant factor in the achievement of non-toxic Cmin (OR: 6.66; 95%CI: 2.26-19.63; P=0.0006). CONCLUSION Our study demonstrates the usefulness of TDM-based dosing adjustment of AG antibiotics in achieving nontoxic trough concentrations, particularly in critically ill patients, as they are prone to a renal impairment.
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Affiliation(s)
- Haifa Ben Romdhane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Nadia Ben Fredj
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia.
| | - Amel Chaabane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Sana Ben Aicha
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Zohra Chadly
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Najeh Ben Fadhel
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Naceur Boughattas
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Karim Aouam
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
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How to optimize antibiotic pharmacokinetic/pharmacodynamics for Gram-negative infections in critically ill patients. Curr Opin Infect Dis 2018; 31:555-565. [DOI: 10.1097/qco.0000000000000494] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McCudden CR. Quality, origins and limitations of common therapeutic drug reference intervals. ACTA ACUST UNITED AC 2018; 5:47-61. [PMID: 29794249 DOI: 10.1515/dx-2018-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022]
Abstract
Therapeutic drug monitoring (TDM) is used to manage drugs with a narrow window between effective and toxic concentrations. TDM involves measuring blood concentrations of drugs to ensure effective therapy, avoid toxicity and monitor compliance. Common drugs for which TDM is used include aminoglycosides for infections, anticonvulsants to treat seizures, immunosuppressants for transplant patients and cardiac glycosides to regulate cardiac output and heart rate. An essential element of TDM is the provision of accurate and clinically relevant reference intervals. Unlike most laboratory reference intervals, which are derived from a healthy population, TDM reference intervals need to relate to clinical outcomes in the form of efficacy and toxicity. This makes TDM inherently more difficult to develop as healthy individuals are not on therapy, so there is no "normal value". In addition, many of the aforementioned drugs are old and much of the information regarding reference intervals is based on small trials using methods that have changed. Furthermore, individuals have different pharmacokinetics and drug responses, particularly in the context of combined therapies, which exacerbates the challenge of universal TDM targets. This focused review examines the origins and limitations of existing TDM reference intervals for common drugs, providing targets where possible based on available guidelines.
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Affiliation(s)
- Christopher R McCudden
- Department of Pathology and Laboratory Medicine, Division of Biochemistry, University of Ottawa, 501 Smyth Rd., Ottawa, ON K1H 8L6, Canada
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Population Pharmacokinetics of Amikacin in Adult Patients with Cystic Fibrosis. Antimicrob Agents Chemother 2018; 62:AAC.00877-18. [PMID: 30061295 DOI: 10.1128/aac.00877-18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/25/2018] [Indexed: 12/27/2022] Open
Abstract
Practitioners commonly use amikacin in patients with cystic fibrosis. Establishment of the pharmacokinetics of amikacin in adults with cystic fibrosis may increase the efficacy and safety of therapy. This study was aimed to establish the population pharmacokinetics of amikacin in adults with cystic fibrosis. We used serum concentration data obtained during routine therapeutic drug monitoring and explored the influence of patient covariates on drug disposition. We performed a retrospective chart review to collect the amikacin dosing regimens, serum amikacin concentrations, blood sampling times, and patient characteristics for adults with cystic fibrosis admitted for treatment of acute pulmonary exacerbations. Amikacin concentrations were retrospectively collected for 49 adults with cystic fibrosis, and 192 serum concentrations were available for analysis. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling with the first-order conditional estimation method. A two-compartment model with first-order elimination best described amikacin pharmacokinetics. Creatinine clearance and weight were identified as significant covariates for clearance and the volume of distribution, respectively, in the final model. Residual variability was modeled using a proportional error model. Typical estimates for clearance, central and peripheral volumes of distribution, and intercompartmental clearance were 3.06 liters/h, 14.4 liters, 17.1 liters, and 0.925 liters/h, respectively. The pharmacokinetics of amikacin in individuals with cystic fibrosis seems to differ from those in individuals without cystic fibrosis. However, further investigations are needed to confirm these results and, thus, the need for variations in amikacin dosing. Future pharmacodynamic studies will potentially establish the optimal amikacin dosing regimens for the treatment of acute pulmonary exacerbations in adult patients with CF.
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Abdul-Aziz MH, Driver E, Lipman J, Roberts JA. New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods. Expert Opin Drug Metab Toxicol 2018; 14:693-708. [PMID: 29865877 DOI: 10.1080/17425255.2018.1484452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.
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Affiliation(s)
- Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Elicia Driver
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Jeffrey Lipman
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,c Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics , The University of Queensland , Brisbane , Queensland , Australia
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Ruiz J, Ramirez P, Company MJ, Gordon M, Villarreal E, Concha P, Aroca M, Frasquet J, Remedios-Marqués M, Castellanos-Ortega Á. Impact of amikacin pharmacokinetic/pharmacodynamic index on treatment response in critically ill patients. J Glob Antimicrob Resist 2018; 12:90-95. [DOI: 10.1016/j.jgar.2017.09.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/20/2017] [Accepted: 09/28/2017] [Indexed: 11/30/2022] Open
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Machado AS, Oliveira MS, Sanches C, Silva Junior CVD, Gomez DS, Gemperli R, Santos SRCJ, Levin AS. Clinical Outcome and Antimicrobial Therapeutic Drug Monitoring for the Treatment of Infections in Acute Burn Patients. Clin Ther 2017; 39:1649-1657.e3. [PMID: 28705450 DOI: 10.1016/j.clinthera.2017.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In critical burn patients, the pharmacokinetic parameters (absorption, distribution, metabolism, and excretion) of many classes of drugs, including antibiotics, are altered. The aim of this study was to compare 2 groups of burn patients undergoing treatment for health care-associated infections with and without therapeutic drug monitoring. METHODS A retrospective analysis of a clinical intervention (ie, a before/after study) was conducted with patients with health care-associated pneumonia, burn infection, bloodstream infection, and urinary tract infection in the burn intensive care unit of a tertiary care hospital. The patients were divided into 2 groups: (1) those admitted from May 2005 to October 2008 who received conventional antimicrobial dose regimens; and (2) those admitted from November 2008 to June 2011 who received antibiotics (imipenem, meropenem, piperacillin, and vancomycin) with doses adjusted according to plasma monitoring and pharmacokinetic modeling. General characteristics of the groups were analyzed, as were clinical outcomes and 14-day and in-hospital mortality. FINDINGS Sixty-three patients formed the conventional treatment group, and 77 comprised the monitored treatment group. The groups were homogeneous, median age was 31 years (range: 1-90) and 66% were male. Improvement occurred in 60% of the patients under monitored treatment (vs 52% with conventional treatment); 14-day mortality was 16% vs 14%; and the in-hospital mortality was similar between groups (39% vs 36%). In the final multivariate models, variables significantly associated with in-hospital mortality were total burn surface area ≥30%, older age, and male sex. Treatment group did not affect the prognosis. IMPLICATIONS Therapeutic drug monitoring of antimicrobial treatment did not alter the prognosis of these burn patients. More trials are needed to support the use of therapeutic drug monitoring to optimize treatment in burn patients.
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Affiliation(s)
- Anna Silva Machado
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, and Department of Infectious Diseases, Laboratório de Investigação Médica-LIM 54 and Instituto de Medicina Tropical, Universidade de Sao Paulo, São Paulo, Brazil
| | - Maura S Oliveira
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, and Department of Infectious Diseases, Laboratório de Investigação Médica-LIM 54 and Instituto de Medicina Tropical, Universidade de Sao Paulo, São Paulo, Brazil
| | - Cristina Sanches
- Federal University of São João del Rei, Campus Centro Oeste, Divinópolis-MG, Brazil
| | | | - David S Gomez
- Division of Plastic Surgery and Burns, Hospitals das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Rolf Gemperli
- Division of Plastic Surgery and Burns, Hospitals das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Anna S Levin
- Department of Infection Control of Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, and Department of Infectious Diseases, Laboratório de Investigação Médica-LIM 54 and Instituto de Medicina Tropical, Universidade de Sao Paulo, São Paulo, Brazil.
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Pouzot-Nevoret C, Magnin M, Ayoub JY, Bourguignon L, Maire P, Wertz D, Goy-Thollot I, Barthélemy A, Boselli E, Allaouchiche B, Bonnet-Garin JM. Evaluation of haemodialysis as a protective technique for preventing high daily dose amikacin nephrotoxicity: an experimental study in an ovine model. Int J Antimicrob Agents 2017; 50:148-154. [PMID: 28689868 DOI: 10.1016/j.ijantimicag.2017.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/27/2017] [Accepted: 03/11/2017] [Indexed: 11/26/2022]
Abstract
Changes in pharmacokinetic parameters of critically ill patients make the treatment of infections challenging, particularly when multidrug-resistant bacteria are involved. The aim of this study was to evaluate the ability of haemodialysis to reduce the exposure to high dose amikacin and prevent nephrotoxicity. Amikacin 50 mg/kg was administered intravenously to six adult sheep once-daily for four days. The sheep were divided into two groups according to the implementation (group 1) or not (group 2) of haemodialysis. In group 1, haemodialysis was performed for 4 h, initiated 2 h after starting amikacin infusion. Amikacin area under the curve (AUC) and trough concentrations (Cmin) were used as markers of amikacin-induced nephrotoxicity. The median haemodialysis amikacin clearance was 2.14 L/h (35.6 mL/min), 14% of the mean total body clearance for 24 h. Haemodialysis reduced Cmin (group 1: 0.3 µg/mL [0.3-1.1]; group 2: 1.4 µg/mL [1.1-3.9]; P = 0.0003). A trend towards reduced AUC with haemodialysis was observed (group 1: 1450 µg/mL⋅h [1311-1716]; group 2: 3126 µg/mL⋅h [2581-3171]; P = 0.10). In conclusion, haemodialysis seems interesting in reducing AUC and Cmin after the injection of high-dose of amikacin, parameters known to be involved in its induced nephrotoxicity, in an experimental ovine model.
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Affiliation(s)
- Céline Pouzot-Nevoret
- Soins Intensifs, Anesthésiologie et Médecine d'Urgence (SIAMU), Univ Lyon, VetAgro Sup, F-69280 Marcy l'Etoile, France; Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France.
| | - Mathieu Magnin
- Soins Intensifs, Anesthésiologie et Médecine d'Urgence (SIAMU), Univ Lyon, VetAgro Sup, F-69280 Marcy l'Etoile, France; Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France
| | - Jean-Yves Ayoub
- Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Hôpital Antoine Charial, Service Pharmacie, 69340 Francheville, France
| | - Pascal Maire
- Hospices Civils de Lyon, Hôpital Antoine Charial, Service Pharmacie, 69340 Francheville, France
| | - Damien Wertz
- Centre Hospitalier Universitaire de Liège, Service de Soins Intensifs Généraux, B-4000 Liège, Belgium
| | - Isabelle Goy-Thollot
- Soins Intensifs, Anesthésiologie et Médecine d'Urgence (SIAMU), Univ Lyon, VetAgro Sup, F-69280 Marcy l'Etoile, France; Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France
| | - Anthony Barthélemy
- Soins Intensifs, Anesthésiologie et Médecine d'Urgence (SIAMU), Univ Lyon, VetAgro Sup, F-69280 Marcy l'Etoile, France; Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France
| | | | - Bernard Allaouchiche
- Univ Lyon, VetAgro Sup, APCSe, F-69280 Marcy l'Etoile, France; Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Service de Réanimation Médicale, 69310 Pierre-Bénite, France
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Abstract
PURPOSE OF REVIEW Infections are common complications in critically ill patients and are frequently treated with antibiotics. Unfortunately, delivery of optimal therapy is complicated because efficacy of antimicrobials is influenced by the timing of treatment initiation, the use of combination therapy, and the optimization of drug dosing. RECENT FINDINGS Early diagnosis of infection is mandatory to provide a rapid and appropriate antibiotic therapy. The presence of less susceptible strains, in particular for hospital-acquired infections, or patients with severe disease, such as the presence of septic shock, may need combination antibiotic therapy. Antibiotic pharmacokinetics, notably volume of distribution and total body clearance, are significantly altered in these critically ill patients and can influence the attainment of adequate circulating levels when standard dosage regimens are administered. Higher dosing should be considered in such patients, although in case of renal impairment and reduced clearance, drug accumulation could also result in some side-effects. Nebulized antibiotics may provide a better clinical response than systemic antibiotics in ventilator-associated pneumonia because of multidrug-resistant pathogens. SUMMARY The optimal use of antibiotics in the management of severe infections is an important challenge for ICU physicians. Antimicrobial therapy needs to be individualized according to specific patient characteristics, infecting organisms, and susceptibility patterns.
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Kovačević T, Avram S, Milaković D, Špirić N, Kovačević P. Therapeutic monitoring of amikacin and gentamicin in critically and noncritically ill patients. J Basic Clin Pharm 2016; 7:65-9. [PMID: 27330257 PMCID: PMC4910469 DOI: 10.4103/0976-0105.183260] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Therapeutic drug monitoring (TDM) enables individualization in the treatment to optimize clinical benefit and minimize drugs' side effects. Critically ill septic patients represent a challenge for antimicrobial treatment because of pathophysiological impact of sepsis on pharmacokinetics of drugs. The aim of this study was to assess the appropriateness of gentamicin and amikacin dosing in critically and noncritically ill patients, as well as to estimate the need for its regular therapeutic monitoring. SUBJECTS AND METHODS It was a prospective study which included 31 patients on gentamicin and 16 patients on amikacin from four different units who met the inclusion criteria. Trough concentrations of drugs were measured in serum just before third or fourth dose of antibiotic, whereas peak concentrations were measured in serum 1 h after the completion of drug administration (steady state). Relevant data on patients' clinical course of disease, comorbidities, and concomitant medication were collected from medical charts in order to identify their possible influence on drugs' concentrations. RESULTS Peak concentrations of amikacin were in reference range in 81.8% critically ill and in 80% of noncritically ill patients (P = 0.931). Peak concentrations of gentamicin were in reference range in 88.9% critically ill and in 77.3% of noncritically ill patients (P = 0.457). CONCLUSION Serum concentrations of aminoglycosides (amikacin and gentamicin) were in reference range in most of the patients in our study, suggesting that dosing of these drugs in the University Hospital Clinical Center, Banja Luka, was adequate. In patients without kidney or liver disease, regular TDM of aminoglycosides is not necessary.
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Affiliation(s)
- Tijana Kovačević
- Department of Pharmacy, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Sanja Avram
- Institute of Laboratory Diagnostics, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Dragana Milaković
- Department of Pharmacy, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Nikolina Špirić
- Department of Pharmacy, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
| | - Pedja Kovačević
- Medical Intensive Care Unit, University Clinical Centre Republic of Srpska, Banja Luka, Bosnia and Herzegovina
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Marsot A, Guilhaumou R, Riff C, Blin O. Amikacin in Critically Ill Patients: A Review of Population Pharmacokinetic Studies. Clin Pharmacokinet 2016; 56:127-138. [DOI: 10.1007/s40262-016-0428-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Allou N, Charifou Y, Augustin P, Galas T, Valance D, Corradi L, Martinet O, Vandroux D, Allyn J. A study to evaluate the first dose of gentamicin needed to achieve a peak plasma concentration of 30 mg/l in patients hospitalized for severe sepsis. Eur J Clin Microbiol Infect Dis 2016; 35:1187-93. [DOI: 10.1007/s10096-016-2652-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/18/2016] [Indexed: 12/25/2022]
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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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Roger C, Nucci B, Louart B, Friggeri A, Knani H, Evrard A, Lavigne JP, Allaouchiche B, Lefrant JY, Roberts JA, Muller L. Impact of 30 mg/kg amikacin and 8 mg/kg gentamicin on serum concentrations in critically ill patients with severe sepsis. J Antimicrob Chemother 2015; 71:208-12. [DOI: 10.1093/jac/dkv291] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 08/18/2015] [Indexed: 01/01/2023] Open
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49
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Optimizing the initial amikacin dosage in adults. Antimicrob Agents Chemother 2015; 59:7094-6. [PMID: 26282426 DOI: 10.1128/aac.01032-15] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/12/2015] [Indexed: 11/20/2022] Open
Abstract
We report on the pharmacokinetics (PK) and pharmacodynamics (PD) of high-dose (>15 mg/kg of body weight per day) amikacin. A mean (standard deviation [SD]) maximum drug concentration in the serum (Cmax) and 24-h area under the concentration-time curve (AUC24) of 101 (49.4) mg/liter and 600 (387) mg · h/liter, respectively, were observed (n = 73) with 28.0 (8.47) mg/kg/day doses. An initial amikacin dose of 2,500 mg in adults weighing 40 kg to 200 kg with therapeutic drug monitoring to adjust the maintenance dose will optimize its PK and PD.
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50
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Rech MA, Day SA, Kast JM, Donahey EE, Pajoumand M, Kram SJ, Erdman MJ, Peitz GJ, Allen JM, Palmer A, Kram B, Harris SA, Turck CJ. Major publications in the critical care pharmacotherapy literature: January-December 2013. Am J Health Syst Pharm 2015; 72:224-36. [PMID: 25596607 DOI: 10.2146/ajhp140241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Ten recently published articles with important implications for critical care pharmacotherapy are summarized. SUMMARY The Critical Care Pharmacotherapy Literature Update (CCPLU) group is a national assembly of experienced intensive care unit (ICU) pharmacists across the United States. Group members monitor 25 peer-reviewed journals on an ongoing basis to identify literature relevant to pharmacy practice in the critical care setting. After evaluation by CCPLU group members, selected articles are chosen for summarization and distribution to group members nationwide based on (1) applicability to critical care practice, (2) relevance to pharmacy practitioners, and (3) quality of evidence or research methodology. Hundreds of relevant articles were evaluated by the group during the period January-December 2013, of which 98 were summarized and disseminated nationally to CCPLU group members. Among those 98 publications, 10 deemed to be of particularly high utility to critical care practitioners were included in this review. The 10 articles address topics such as rapid lowering of blood pressure in patients with intracranial hemorrhage, adjunctive therapy to prevent renal injury due to acute heart failure, triple-drug therapy to improve neurologic outcomes after cardiac arrest, and continuous versus intermittent infusion of β-lactam antibiotics in severe sepsis. CONCLUSION There were many important additions to the critical care pharmacotherapy literature in 2013, including an updated guideline on the management of myocardial infarction and reports on advances in research focused on improving outcomes in patients with stroke or cardiac arrest and preventing the spread of drug-resistant pathogens in the ICU.
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Affiliation(s)
- Megan A Rech
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA.
| | - Sarah A Day
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Jenna M Kast
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Elisabeth E Donahey
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Mehrnaz Pajoumand
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Shawn J Kram
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Michael J Erdman
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Gregory J Peitz
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - John M Allen
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Allison Palmer
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Bridgette Kram
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Serena A Harris
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
| | - Charles J Turck
- Megan A. Rech, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Loyola University Medical Center, Maywood, IL. Sarah A. Day, Pharm.D., BCPS, is Clinical Pharmacist, Critical Care, Doctors Hospital, Columbus, OH. Jenna M. Kast, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Critical Care, Beaumont Hospital, Royal Oak, MI. Elisabeth E. Donahey, Pharm.D., BCPS, is Neurosciences Intensive Care Pharmacist, Loyola University Medical Center. Mehrnaz Pajoumand, Pharm.D., BCPS, is Clinical Specialist, Trauma Critical Care, University of Maryland Medical Center, Baltimore. Shawn J. Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital, Durham, NC. Michael J. Erdman, Pharm.D., BCPS, is Clinical Pharmacist, Neurocritical Care, University of Florida Health, Jacksonville. Gregory J. Peitz, Pharm.D., BCPS, is Clinical Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha. John M. Allen, Pharm.D., BCPS, is Assistant Professor, University of South Florida College of Pharmacy, Tampa. Allison Palmer, Pharm.D., BCPS, is Critical Care Clinical Pharmacist, John Peter Smith Hospital, Fort Worth, TX. Bridgette Kram, Pharm.D., BCPS, is Clinical Pharmacist, Duke University Hospital. Serena A. Harris, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Trauma and Surgical Critical Care, Eskenazi Health, Indianapolis, IN. Charles J Turck, Pharm.D., BCPS, is President and Chief Executive Officer, ScientiaCME, LLC, Mission Viejo, CA
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