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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, 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; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Smeets TJL, de Geus HRH, Rietveld A, Rietdijk WJR, Koch BCP, Endeman H, Hunfeld NGM. Pursuing the Real Vancomycin Clearance during Continuous Renal Replacement Therapy in Intensive Care Unit Patients: Is There Adequate Target Attainment? Blood Purif 2023; 52:652-659. [PMID: 37311418 DOI: 10.1159/000530815] [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: 09/21/2022] [Accepted: 04/24/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Vancomycin is used in intensive care unit (ICU) patients for the treatment of infections caused by gram-positive bacteria. The vancomycin pharmacokinetic/pharmacodynamic index is a ratio of the area under the concentration to the minimum inhibitory concentration ≥400-600 h*mg/L. This target can generally be achieved by a plasma concentration of 20-25 mg/L. Together with the pathophysiological alterations and pharmacokinetic variability associated with critical illness, the use of continuous renal replacement therapy (CRRT) may complicate the attainment of adequate vancomycin concentrations. The primary objective was the prevalence of attainment of vancomycin concentrations 20-25 mg/L after 24 h in adult ICU patients receiving CRRT. Secondary outcomes were to evaluate target attainment at days 2 and 3 and to calculate vancomycin clearance (CL) by CRRT and residual diuresis. METHODS We performed a prospective observational study in adult ICU patients on CRRT, which received at least 24 h continuous infusion of vancomycin. Between May 2020 and February 2021, daily vancomycin residual blood gas and dialysate samples were collected from 20 patients, every 6 h and if possible vancomycin urine samples. Vancomycin was analysed with an immunoassay method. The CL by CRRT was calculated by a different approach correcting for the downtime and providing insight into the degree of filter patency. RESULTS The proportion of patients with vancomycin concentrations <20 mg/L was 50% 24 h after starting vancomycin (n = 10). No differences were observed in patient characteristics. The target vancomycin concentration 20-25 mg/L was only achieved in 30% of the patients. On days 2 and 3, despite the use of TDM and albeit in lower percentages, sub- and supratherapeutic levels were still observed. Taking downtime and filter patency into account resulted in lower vancomycin CL. CONCLUSIONS 50% of the studied ICU patients on CRRT showed subtherapeutic vancomycin concentrations 24 h after starting therapy. The results reveal that optimization of vancomycin dosage during CRRT therapy is needed.
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Affiliation(s)
- Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hilde R H de Geus
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anouk Rietveld
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nicole G M Hunfeld
- Department of Hospital Pharmacy, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Dai N, Jiang C, Wang Y. Relationship between vancomycin-induced nephrotoxicity and vancomycin trough concentration in older adults: A retrospective observational study. Indian J Pharmacol 2023; 55:155-161. [PMID: 37555409 PMCID: PMC10501546 DOI: 10.4103/ijp.ijp_634_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 04/10/2023] [Accepted: 07/13/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES The objective of the study is to investigate the risk factors of vancomycin-induced renal toxicity in older adults, especially in those with chronic kidney disease (CKD) Stages 3-5. METHODS In this retrospective observational study, serum vancomycin trough concentrations (VTCs) in patients aged g65 years treated with vancomycin were analyzed, and independent risk factors of vancomycin-induced nephrotoxicity (VIN) were determined by logistic regression analysis. RESULTS In total, 321 patients were included in this study. Serum VTC was an independent risk factor for vancomycin-induced renal toxicity in total cohort (odds ratio [OR], 1.07; P = 0.004) as well as in the cohort with CKD Stages 3-5 (OR, 1.09; P = 0.010). A daily dose of vancomycin and Charlson comorbidity index was an independent risk factor for vancomycin-induced renal toxicity in total cohort (OR, 3.63; P = 0.006) and in the cohort with CKD Stage 3-5 (OR, 1.83; P = 0.002), respectively. In older adults with CKD Stages 3a and 3b-5, the VTCs associated with higher risk for vancomycin-induced renal toxicity were 21.5 mg/L and 16.5 mg/L, respectively. CONCLUSIONS In older adults, serum VTC is an independent risk factor for VIN. VTCs over 21.5 mg/L and 16.5 mg/L are associated with increased risk of VIN in this population with CKD Stage 3a and 3b-5, respectively.
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Affiliation(s)
- Ning Dai
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chunyan Jiang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yunchao Wang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Codina MS, Bozkir HÖ, Jorda A, Zeitlinger M. Individualised antimicrobial dose optimisation: a systematic review and meta-analysis of randomised controlled trials. Clin Microbiol Infect 2023:S1198-743X(23)00134-9. [PMID: 36965694 DOI: 10.1016/j.cmi.2023.03.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Therapeutic drug management (TDM) and model-informed precision dosing (MIPD) allow dose individualisation to increase drug effectivity and reduce toxicity. OBJECTIVES Evaluate the available evidence on the clinical efficacy of individualised antimicrobial dosing optimisation. METHODS Data sources: Pubmed, Embase, Web of Science, and Cochrane Library databases from database inception to the 11th of November 2022. STUDY ELIGIBILITY CRITERIA Published peer-reviewed Randomised Controlled Trials (RCTs). PARTICIPANTS Human subjects aged ≥18 years receiving an antibiotic or antifungal drug. INTERVENTIONS Patients receiving individualised antimicrobial dose adjustment. Assessment of risk of bias: Cochrane risk-of-bias tool for randomised trials (RoB2). Methods of data synthesis: Primary outcome was the risk of mortality. Secondary outcomes included target attainment, treatment failure, clinical and microbiological cure, length of stay, treatment duration and adverse events. Effect sizes were pooled using a random-effects model. Statistical heterogeneity was assessed by inconsistency testing (I2). RESULTS Ten RCTs were included in the meta-analysis (1,241 participants; n= 624 in the TDM group, n = 617 in the control group). Individualised antimicrobial dose optimisation was associated with a numerical decrease in mortality (RR = 0.86; 95% CI 0.71-1.05), without reaching statistical significance. Moreover, it was associated with significantly higher target attainment rates (RR = 1.41; 95% CI, 1.13-1.76) and a significant decrease in treatment failure (RR = 0.70; 95% CI, 0.54-0.92). Individualised antimicrobial dose optimisation was also associated with improvement, but not significant in clinical cure (RR = 1.33; 95% CI, 0.94-1.33) and microbiological outcome (RR = 1.25; CI, 1.00-1.57), as well as with a significant decrease in the risk of nephrotoxicity (RR = 0.55; 95% CI, 0.31-0.97). CONCLUSIONS This meta-analysis demonstrates that target attainment, treatment failure, and nephrotoxicity were significantly improved in patients who underwent individualised antimicrobial dose optimisation. However, it did not show a significant decrease in mortality, clinical cure or microbiological outcome.
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Affiliation(s)
- Maria Sanz Codina
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Haktan Övul Bozkir
- Department of Nutritional Sciences, University of Vienna, Vienna, Austria
| | - Anselm Jorda
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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Shekar K, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Cho YJ, Corley A, Diehl A, Gilder E, Jakob SM, Kim HS, Levkovich BJ, Lim SY, McGuinness S, Parke R, Pellegrino V, Que YA, Reynolds C, Rudham S, Wallis SC, Welch SA, Zacharias D, Fraser JF, Roberts JA. Antimicrobial Exposures in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2023; 207:704-720. [PMID: 36215036 DOI: 10.1164/rccm.202207-1393oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Data suggest that altered antimicrobial concentrations are likely during extracorporeal membrane oxygenation (ECMO). Objectives: The primary aim of this analysis was to describe the pharmacokinetics (PKs) of antimicrobials in critically ill adult patients receiving ECMO. Our secondary aim was to determine whether current antimicrobial dosing regimens achieve effective and safe exposure. Methods: This study was a prospective, open-labeled, PK study in six ICUs in Australia, New Zealand, South Korea, and Switzerland. Serial blood samples were collected over a single dosing interval during ECMO for 11 antimicrobials. PK parameters were estimated using noncompartmental methods. Adequacy of antimicrobial dosing regimens were evaluated using predefined concentration exposures associated with maximal clinical outcomes and minimal toxicity risks. Measurements and Main Results: We included 993 blood samples from 85 patients. The mean age was 44.7 ± 14.4 years, and 61.2% were male. Thirty-eight patients (44.7%) were receiving renal replacement therapy during the first PK sampling. Large variations (coefficient of variation of ⩾30%) in antimicrobial concentrations were seen leading to more than fivefold variations in all PK parameters across all study antimicrobials. Overall, 70 (56.5%) concentration profiles achieved the predefined target concentration and exposure range. Target attainment rates were not significantly different between modes of ECMO and renal replacement therapy. Poor target attainment was observed across the most frequently used antimicrobials for ECMO recipients, including for oseltamivir (33.3%), piperacillin (44.4%), and vancomycin (27.3%). Conclusions: Antimicrobial PKs were highly variable in critically ill patients receiving ECMO, leading to poor target attainment rates. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000559819).
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Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
- St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Amanda Corley
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Eileen Gilder
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Stephan M Jakob
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Hyung-Sook Kim
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bianca J Levkovich
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Shay McGuinness
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Rachael Parke
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Yok-Ai Que
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Claire Reynolds
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - David Zacharias
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - John F Fraser
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Herbel S, Uhel F, Sibiude J, Charlier C. [Sepsis during pregnancy: Key points in 2022]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:134-142. [PMID: 36436821 DOI: 10.1016/j.gofs.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022]
Abstract
Sepsis is a severe affection, that requires an urgent and specific treatment sequence. Physiological changes occurring during pregnancy make the diagnosis of sepsis more challenging in this setting, with possible delay in treatment initiation, that in turn is responsible for poorer maternal and fetal outcome. This review aims to summarize current knowledge on the diagnosis and treatment of maternal sepsis, as well as persistent knowledge gaps in the field.
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Affiliation(s)
- S Herbel
- Département de maladies infectieuses et tropicales, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; Médecine intensive réanimation, DMU ESPRIT, hôpital Louis-Mourier, AP-HP, 92700 Colombes, France
| | - F Uhel
- Médecine intensive réanimation, DMU ESPRIT, hôpital Louis-Mourier, AP-HP, 92700 Colombes, France; UFR de médecine Paris Nord, université Paris Cité, 75018 Paris, France; Inserm U1151, Department of Immunology, Infectiology and Hematology, institut Necker-Enfants Malades (INEM), CNRS UMR 8253, université Paris-Cité, Paris, France
| | - J Sibiude
- UFR de médecine Paris Nord, université Paris Cité, 75018 Paris, France; Inserm U1151, Department of Immunology, Infectiology and Hematology, institut Necker-Enfants Malades (INEM), CNRS UMR 8253, université Paris-Cité, Paris, France; Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP, 178, rue des Renouillers, 92700 Colombes, France; Inserm, IAME, UMR 1137, Paris, France.
| | - C Charlier
- Département de maladies infectieuses et tropicales, hôpital Cochin, AP-HP, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France; UFR de médecine Paris Nord, université Paris Cité, 75018 Paris, France; Biology of Infection Unit, institut Pasteur, 28, rue du Docteur Roux, 75015 Paris, France; Institut Pasteur, French National Reference Center and WHO Collaborating Center Listeria, 28 rue du Docteur Roux, 75015 Paris, France; Inserm U1117, Paris, France.
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Oda K. Development of Novel Dosing Strategy According to the Area under the Concentration-Time Curve for Vancomycin. YAKUGAKU ZASSHI 2022; 142:1185-1190. [DOI: 10.1248/yakushi.22-00131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital
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8
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Roggeveen LF, Guo T, Fleuren LM, Driessen R, Thoral P, van Hest RM, Mathot RAA, Swart EL, de Grooth HJ, van den Bogaard B, Girbes ARJ, Bosman RJ, Elbers PWG. Right dose, right now: bedside, real-time, data-driven, and personalised antibiotic dosing in critically ill patients with sepsis or septic shock—a two-centre randomised clinical trial. Crit Care 2022; 26:265. [PMID: 36064438 PMCID: PMC9443636 DOI: 10.1186/s13054-022-04098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Adequate antibiotic dosing may improve outcomes in critically ill patients but is challenging due to altered and variable pharmacokinetics. To address this challenge, AutoKinetics was developed, a decision support system for bedside, real-time, data-driven and personalised antibiotic dosing. This study evaluates the feasibility, safety and efficacy of its clinical implementation. Methods In this two-centre randomised clinical trial, critically ill patients with sepsis or septic shock were randomised to AutoKinetics dosing or standard dosing for four antibiotics: vancomycin, ciprofloxacin, meropenem, and ceftriaxone. Adult patients with a confirmed or suspected infection and either lactate > 2 mmol/L or vasopressor requirement were eligible for inclusion. The primary outcome was pharmacokinetic target attainment in the first 24 h after randomisation. Clinical endpoints included mortality, ICU length of stay and incidence of acute kidney injury. Results After inclusion of 252 patients, the study was stopped early due to the COVID-19 pandemic. In the ciprofloxacin intervention group, the primary outcome was obtained in 69% compared to 3% in the control group (OR 62.5, CI 11.4–1173.78, p < 0.001). Furthermore, target attainment was faster (26 h, CI 18–42 h, p < 0.001) and better (65% increase, CI 49–84%, p < 0.001). For the other antibiotics, AutoKinetics dosing did not improve target attainment. Clinical endpoints were not significantly different. Importantly, higher dosing did not lead to increased mortality or renal failure. Conclusions In critically ill patients, personalised dosing was feasible, safe and significantly improved target attainment for ciprofloxacin. Trial registration: The trial was prospectively registered at Netherlands Trial Register (NTR), NL6501/NTR6689 on 25 August 2017 and at the European Clinical Trials Database (EudraCT), 2017-002478-37 on 6 November 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04098-7.
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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Xu J, Duan L, Li J, Chen F, Xu X, Lu J, Zhuang Z, Cao Y, Yuan Y, Liu X, Sun J, Zhou Q, Shi L, Tang L. Continuous infusion versus intermittent infusion of vancomycin in critically ill patients undergoing continuous venovenous hemofiltration: a prospective interventional study. BMC Infect Dis 2022; 22:667. [PMID: 35918657 PMCID: PMC9344630 DOI: 10.1186/s12879-022-07618-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prospective interventional study comparing outcomes in critically ill patients receiving intermittent infusion (II) or continuous infusion (CI) of vancomycin during continuous venovenous hemofiltration (CVVH) is lacking. The objective of this study was to compare the pharmacokinetic/pharmacodynamics (PK/PD) target attainment, therapeutic efficacy and safety among critically ill patients who received CI or II of vancomycin in a prospective interventional trial and to explore the correlations of effluent flow rate (EFR) with PK/PD indices. METHODS This prospective interventional study was conducted in two independent intensive care units (ICUs) from February 2021 to January 2022. Patients in one ICU were assigned to receive CI (intervention group) of vancomycin, whereas patients in the other ICU were assigned to receive II regimen (control group). The primary outcome was to compare the PK/PD target attainment, including target concentration and target area under the curve over 24 h to minimum inhibitory concentration (AUC24/MIC). RESULTS Overall target attainment of PK/PD indices was higher with CI compared with II, irrespective of target concentration (78.7% vs. 40.5%; P < 0.05) or AUC24/MIC (53.2% vs. 28.6%; P < 0.05). There were no significant differences in clinical success (72.2% vs. 50.0%; P = 0.183) and microbiological success (83.3% vs. 75.0%, P = 0.681) between the patients treated with CI or II of vancomycin. Adverse reactions occurred at similar rates (0.0% vs. 4.4%; P = 0.462), and mortality between the two modalities was also not significant different (21.7% vs. 17.9%; P = 0.728). Correlation analysis showed a weak to moderately inverse correlation of EFR with observed concentration (r = - 0.3921, P = 0.01) and AUC24/MIC (r = - 0.3811, P = 0.013) in the II group, whereas the correlation between EFR and observed concentration (r = - 0.5711, P < 0.001) or AUC24/MIC (r = - 0.5458, P < 0.001) in the CI group was stronger. CONCLUSION As compared to II, CI of vancomycin in critically ill patients undergoing CVVH was associated with improved attainment of PK/PD indices. Furthermore, the inverse correlation of PK/PD indices with EFR was stronger among patients treated with CI of vancomycin. Trial registration The trial was registered in the Chinese clinical trial registration center (21/01/2021-No. ChiCTR2100042393).
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Affiliation(s)
- Jinhui Xu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Lufen Duan
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Jiahui Li
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Fang Chen
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Xiaowen Xu
- Emergent Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Jian Lu
- Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Zhiwei Zhuang
- Emergent Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Yifei Cao
- Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Yunlong Yuan
- Medical Laboratory, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Xin Liu
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Jiantong Sun
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Qin Zhou
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China
| | - Lu Shi
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China.
| | - Lian Tang
- Department of Pharmacy, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 215002, China.
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11
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Biomarkers Predicting Tissue Pharmacokinetics of Antimicrobials in Sepsis: A Review. Clin Pharmacokinet 2022; 61:593-617. [PMID: 35218003 PMCID: PMC9095522 DOI: 10.1007/s40262-021-01102-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 02/07/2023]
Abstract
The pathophysiology of sepsis alters drug pharmacokinetics, resulting in inadequate drug exposure and target-site concentration. Suboptimal exposure leads to treatment failure and the development of antimicrobial resistance. Therefore, we seek to optimize antimicrobial therapy in sepsis by selecting the right drug and the correct dosage. A prerequisite for achieving this goal is characterization and understanding of the mechanisms of pharmacokinetic alterations. However, most infections take place not in blood but in different body compartments. Since tissue pharmacokinetic assessment is not feasible in daily practice, we need to tailor antibiotic treatment according to the specific patient’s pathophysiological processes. The complex pathophysiology of sepsis and the ineffectiveness of current targeted therapies suggest that treatments guided by biomarkers predicting target-site concentration could provide a new therapeutic strategy. Inflammation, endothelial and coagulation activation markers, and blood flow parameters might be indicators of impaired tissue distribution. Moreover, hepatic and renal dysfunction biomarkers can predict not only drug metabolism and clearance but also drug distribution. Identification of the right biomarkers can direct drug dosing and provide timely feedback on its effectiveness. Therefore, this might decrease antibiotic resistance and the mortality of critically ill patients. This article fills the literature gap by characterizing patient biomarkers that might be used to predict unbound plasma-to-tissue drug distribution in critically ill patients. Although all biomarkers must be clinically evaluated with the ultimate goal of combining them in a clinically feasible scoring system, we support the concept that the appropriate biomarkers could be used to direct targeted antibiotic dosing.
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12
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Shipkova M, Jamoussi H. Therapeutic Drug Monitoring of Antibiotic Drugs: The Role of the Clinical Laboratory. Ther Drug Monit 2022; 44:32-49. [PMID: 34726200 DOI: 10.1097/ftd.0000000000000934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-infective drugs is an increasingly complex field, given that in addition to the patient and drug as 2 usual determinants, its success is driven by the pathogen. Pharmacodynamics is related both to the patient (toxicity) and bacterium (efficacy or antibiotic susceptibility). The specifics of TDM of antimicrobial drugs stress the need for multidisciplinary knowledge and expertise, as in any other field. The role and the responsibility of the laboratory in this interplay are both central and multifaceted. This narrative review highlights the role of the clinical laboratory in the TDM process. METHODS A literature search was conducted in PubMed and Google Scholar, focusing on the past 5 years (studies published since 2016) to limit redundancy with previously published review articles. Furthermore, the references cited in identified publications of interest were screened for additional relevant studies and articles. RESULTS The authors addressed microbiological methods to determine antibiotic susceptibility, immunochemical and chromatographic methods to measure drug concentrations (primarily in blood samples), and endogenous clinical laboratory biomarkers to monitor treatment efficacy and toxicity. The advantages and disadvantages of these methods are critically discussed, along with existing gaps and future perspectives on strategies to provide clinicians with as reliable and useful results as possible. CONCLUSIONS Although interest in the field has been the driver for certain progress in analytical technology and quality in recent years, laboratory professionals and commercial providers persistently encounter numerous unresolved challenges. The main tasks that need tackling include broadly and continuously available, easily operated, and cost-effective tests that offer short turnaround times, combined with reliable and easy-to-interpret results. Various fields of research are currently addressing these features.
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Affiliation(s)
- Maria Shipkova
- Competence Center for Therapeutic Drug Monitoring, SYNLAB Holding Germany GmbH, SYNLAB MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
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13
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Chen J, Huang X, Lin Z, Li C, Ding H, Du J, Li L. Case Report: Monitoring Vancomycin Concentrations and Pharmacokinetic Parameters in Continuous Veno-Venous Hemofiltration Patients to Guide Individualized Dosage Regimens: A Case Analysis. Front Pharmacol 2021; 12:763575. [PMID: 34955835 PMCID: PMC8695924 DOI: 10.3389/fphar.2021.763575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
There are limited pharmacokinetic (PK) studies on vancomycin in patients treated with continuous renal replacement therapy (CRRT), and the results have been inconsistent. Because of individual differences, proposing a definite recommendation for the clinical regimen is not possible. Rapidly reaching target vancomycin concentrations will facilitate effective treatment for critically ill patients treated with CRRT. In this study, to understand the dynamic change in drug clearance rates in vivo, analyze the effect of PK changes on drug concentrations, and recommend loading and maintenance dosage regimens, we monitored the blood concentrations of vancomycin and calculated the area under the curve in two critically ill patients treated with vancomycin and continuous veno-venous hemofiltration (CVVH). On the basis of real-time therapeutic drug monitoring results and PK parameters, an individualized vancomycin regimen was developed for patients with CVVH. Good clinical efficacy was achieved, which provided support and reference for empirical vancomycin therapy in these patients.
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Affiliation(s)
- Jihui Chen
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyan Lin
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chao Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haoshu Ding
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Junming Du
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lixia Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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14
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Garreau R, Falquet B, Mioux L, Bourguignon L, Ferry T, Tod M, Wallet F, Friggeri A, Richard JC, Goutelle S. Population Pharmacokinetics and Dosing Simulation of Vancomycin Administered by Continuous Injection in Critically Ill Patient. Antibiotics (Basel) 2021; 10:1228. [PMID: 34680809 PMCID: PMC8532763 DOI: 10.3390/antibiotics10101228] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Vancomycin is widely used for empirical antimicrobial therapy in critically ill patients with sepsis. Continuous infusion (CI) may provide more stable exposure than intermittent infusion, but optimal dosing remains challenging. The aims of this study were to perform population pharmacokinetic (PK) analysis of vancomycin administered by CI in intensive care unit (ICU) patients to identify optimal dosages. Methods: Patients who received vancomycin by CI with at least one measured concentration in our center over 16 months were included, including those under continuous renal replacement therapy (CRRT). Population PK was conducted and external validation of the final model was performed in a dataset from another center. Simulations were conducted with the final model to identify the optimal loading and maintenance doses for various stages of estimated creatinine clearance (CRCL) and in patients on CRRT. Target exposure was defined as daily AUC of 400-600 mg·h/L on the second day of therapy (AUC24-48 h). Results: A two-compartment model best described the data. Central volume of distribution was allometrically scaled to ideal body weight (IBW), whereas vancomycin clearance was influenced by CRRT and CRCL. Simulations performed with the final model suggested a loading dose of 27.5 mg/kg of IBW. The maintenance dose ranged from 17.5 to 30 mg/kg of IBW, depending on renal function. Overall, simulation showed that 55.8% (95% CI; 47-64%) of patients would achieve the target AUC with suggested dosages. Discussion: A PK model has been validated for vancomycin administered by CI in ICU patients, including patients under CRRT. Our model-informed precision dosing approach may help for early optimization of vancomycin exposure in such patients.
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Affiliation(s)
- Romain Garreau
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
| | - Benoît Falquet
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
| | - Lisa Mioux
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
| | - Tristan Ferry
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, 69004 Lyon, France
| | - Michel Tod
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
| | - Florent Wallet
- Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Critical Care, 69495 Pierre-Bénite, France
| | - Arnaud Friggeri
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Critical Care, 69495 Pierre-Bénite, France
- Centre International de Recherche en Infectiologie (CIRI) Inserm, Public Health, Epidemiology and Evolutionary Ecology of Infectious Diseases (PHE3ID), U1111, UCBL Lyon 1, CNRS, UMR5308, ENS de Lyon, 69364 Lyon, France
| | - Jean-Christophe Richard
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service de Médecine Intensive-Réanimation, 69004 Lyon, France
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, 69005 Lyon, France
- Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, UMR CNRS 5558, 69100 Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Université Lyon 1, 69008 Lyon, France
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15
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Bouajram RH, Awdishu L. A Clinician's Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy. Kidney Int Rep 2021; 6:2033-2048. [PMID: 34386653 PMCID: PMC8343808 DOI: 10.1016/j.ekir.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is a common complication in critical illness and has a significant impact on pharmacokinetic factors determining drug exposure, including absorption, distribution, transport, metabolism, and clearance. In this review, we provide a practical guide to drug dosing considerations in critically ill patients undergoing CRRT, focusing on the most commonly used analgesic, anticonvulsant, and psychotropic medications in the clinical care of critically ill patients. A literature search was conducted to identify articles in which drug dosing was evaluated in adult patients receiving CRRT between the years 1980 and 2020. We included articles with pharmacokinetic/pharmacodynamic analyses and those that described medication clearance via CRRT. A summary of the data focused on practical pharmacokinetic and pharmacodynamic principles is presented, with recommendations for drug dosing of analgesics, anticonvulsants, and psychotropic medications. Pharmacokinetic and pharmacodynamic studies to guide drug dosing of analgesics, anticonvulsants, and psychotropic medications in critically ill patients receiving CRRT are sparse. Considering the widespread use of these medications, narrow therapeutic index of these drug classes, and risks of over- and underdosing, additional studies in patients receiving CRRT are needed to inform drug dosing.
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Affiliation(s)
- Rima H. Bouajram
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California, USA
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16
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Sridharan K, Abbasi MY, Mulubwa M. Population Pharmacokinetics and Dose Optimization of Vancomycin in Critically Ill Children. Eur J Drug Metab Pharmacokinet 2021; 46:539-546. [PMID: 34156647 DOI: 10.1007/s13318-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Critically ill children may exhibit varied vancomycin pharmacokinetic parameters mainly due to altered protein binding, extracellular volume, and renal elimination. The objective of this study was to assess the pharmacokinetics of vancomycin in critically ill children and determine the optimum dose regimen. METHODS This was a cross-sectional study of critically ill children admitted to a pediatric intensive care unit. They received vancomycin dose of 15 mg/kg every 8 h for mild infections or every 6 h if infection was moderate or severe. A nonlinear mixed-effects modeling approach was applied in estimating pharmacokinetic parameters using Monolix 2019R2®. We performed Monte Carlo simulations to assess and optimize the dosing regimen using Simulx®. We used the ratio of the area under the concentration-time curve up to 24 h to minimum inhibitory concentration (AUC0-24/MIC) ≥ 400 as the pharmacokinetic-pharmacodynamic target. RESULTS Fifty-eight critically ill children with 145 concentrations were included in the present study. A one-compartment pharmacokinetic model with linear elimination described the concentration-time profile well. The estimated median (95% confidence intervals) volume of distribution (Vd) was 13.3 (10.8-16.5) l and clearance (CL) was 1.23 (1.03-1.45) l/h. Creatinine clearance significantly affected the CL of vancomycin. Monte Carlo simulations revealed that a dose of either 15 mg/kg 6 hourly or 20 mg/kg 8 hourly was likely to result into most critically ill children attaining the vancomycin lead pharmacokinetic-pharmacodynamic target. CONCLUSION We established pharmacokinetic parameters of vancomycin for critically ill children. We also observed that the current dosing regimen practiced in the intensive care unit was inadequate for achieving the pharmacokinetic-pharmacodynamic target. We recommend vancomycin dose escalation in critically ill pediatric patients from 15 mg/kg 8 hourly (current dosing regimen) to either 6 hourly or 20 mg/kg 8 hourly with intense therapeutic drug monitoring for adverse effects.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Mohammad Yaseen Abbasi
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Mwila Mulubwa
- Drug Discovery and Development Centre (H3D), Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
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17
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Jang SM, Awdishu L. Drug dosing considerations in continuous renal replacement therapy. Semin Dial 2021; 34:480-488. [PMID: 33939855 DOI: 10.1111/sdi.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, which is associated with increased in-hospital mortality. Delivering effective antibiotics to treat patients with sepsis receiving continuous renal replacement therapy (RRT) is complicated by variability in pharmacokinetics, dialysis delivery, lack of primary literature, and therapeutic drug monitoring. Pharmacokinetic alterations include changes in absorption, distribution, protein binding (PB), metabolism, and renal elimination. Drug absorption may be significantly changed due to alterations in gastric pH, perfusion, gastrointestinal motility, and intestinal atrophy. Volume of distribution for hydrophilic drugs may be increased due to volume overload. Estimation of renal clearance is challenged by the effective delivery of RRT. Drug characteristics such as PB, volume of distribution, and molecular weight impact removal of the drug by RRT. The totality of these alterations leads to reduced exposure. Despite our best knowledge, therapeutic drug monitoring of patients receiving continuous RRT demonstrates wide variability in antimicrobial concentrations, highlighting the need for expanded monitoring of all drugs. This review article will focus on changes in drug pharmacokinetics in AKI and dosing considerations to attain antibiotic pharmacodynamic targets in critically ill patients receiving continuous RRT.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Linda Awdishu
- Clinical Pharmacy, UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
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18
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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19
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Godi I, Lorenzin A, De Rosa S, Golino G, Knust M, Gaspar A, Sandini A, Fiorin F, de Cal M, Navalesi P, Ronco C. Vancomycin Adsorption During in vitro Model of Hemoperfusion with HA380 Cartridge. Nephron Clin Pract 2021; 145:157-163. [PMID: 33567447 DOI: 10.1159/000513122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION A critical point for using blood purification during sepsis may be the potential interaction with antimicrobial therapy, the mainstay of sepsis treatment. The aim of our study was to investigate the vancomycin removal during hemoperfusion (HP) using HA380 cartridge. METHODS This is an experimental study, in which 500 mL of solution was circulated in a closed-circuit (blood flow of 250 mL/min) simulating HP ran using HA380. Vancomycin was added to reach a through concentration or a very high concentration to evaluate the removal ratio (RR) during 120 min of HP. Comparison between blood-crystalloid solution and balanced solution was performed by using Kruskal-Wallis test. The kinetics of vancomycin removal and the adsorption isotherm were evaluated. RESULTS We found a complete removal of vancomycin at baseline through concentration of 23.0 ± 7.4 mg/L. Using extremely high concentration (baseline 777.0 ± 62.2 mg/L), RR was 90.1 ± 0.6% at 5 min and 99.2 ± 0.6% at 120 min. No difference in terms of RR was found between blood-crystalloid mixture and balanced solution. The kinetics of the vancomycin reduction followed an exponential decay. Repeated boluses (total amount of 2,000 mg) resulted in cumulative adsorption of 1,919.4 mg with RR of 96.6 ± 1.4%, regardless of the amount injected (100 vs. 500 mg). Vancomycin adsorption onto HA380 followed the Langmuir isotherm model. CONCLUSIONS A considerable amount of vancomycin was rapidly removed during in vitro HP with HA380. Clinical studies are needed to determine whether this may lead to underdosing. Drug therapeutic monitoring is highly recommended when using HA380 for blood purification in patients receiving vancomycin.
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Affiliation(s)
- Ilaria Godi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy, .,International renal Research Institute of Vicenza, Vicenza, Italy,
| | - Anna Lorenzin
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Silvia De Rosa
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Anesthesia and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Gianlorenzo Golino
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy.,International renal Research Institute of Vicenza, Vicenza, Italy
| | - Maira Knust
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Ana Gaspar
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Alessandra Sandini
- Department of Transfusional Medicine, San Bortolo Hospital, Vicenza, Italy
| | - Francesco Fiorin
- Department of Transfusional Medicine, San Bortolo Hospital, Vicenza, Italy
| | - Massimo de Cal
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Paolo Navalesi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Claudio Ronco
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine - DIMED, University of Padova, Padova, Italy
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20
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Wang M, Jiang L, Zhu B, Li W, Du B, Kang Y, Weng L, Qin T, Ma X, Zhu D, Wang Y, Zhan Q, Duan M, Li W, Sun B, Cao X, Ai Y, Li T, Zhu X, Jia J, Zhou J, He Y, Xi X. The Prevalence, Risk Factors, and Outcomes of Sepsis in Critically Ill Patients in China: A Multicenter Prospective Cohort Study. Front Med (Lausanne) 2020; 7:593808. [PMID: 33392219 PMCID: PMC7774866 DOI: 10.3389/fmed.2020.593808] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/16/2020] [Indexed: 02/05/2023] Open
Abstract
Background: Sepsis is a main cause of morbidity and mortality in critically ill patients. The epidemiology of sepsis in high-income countries is well-known, but information on sepsis in middle- or low-income countries is still deficient, especially in China. The purpose of this study was to explore the prevalence, characteristics, risk factors, treatment, and outcomes of sepsis in critically ill patients in tertiary hospitals in China. Methods: A multicenter prospective observational cohort study was performed with consecutively collected data from adults who stayed in any intensive care unit (ICU) for at least 24 h; data were collected from 1 January 2014 to 31 August 2015, and patients were followed until death or discharge from the hospital. Results: A total of 4,910 patients were enrolled in the study. Of these, 2,086 (42.5%) presented with sepsis or septic shock on admission to the ICU or within the first 48 h after admission to the ICU. ICU mortality was higher in patients with sepsis (13.1%) and septic shock (39.0%) and varied according to geographical region. Acinetobacter, Pseudomonas, and Staphylococcus infections were associated with increased ICU mortality. In addition, age, Acute Physiology, and Chronic Health Evaluation II (APACHE II) scores, pre-existing cardiovascular diseases, malignant tumors, renal replacement therapy (RRT), and septic shock were independent risk factors for mortality in patients with sepsis. The prompt administration of antibiotics (OR 0.65, 95% CI 0.46-0.92) and 30 mL/kg of initial fluid resuscitation during the first 3 h (OR 0.43, 95% CI 0.30-0.63) improved the outcome in patients with septic shock. Conclusions: Sepsis was common and was associated with a high mortality rate in critically ill patients in tertiary hospitals in China. The prompt administration of antibiotics and 30 mL/kg fluid resuscitation decreased the risk of mortality.
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Affiliation(s)
- Meiping Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bo Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Wen Li
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Weng
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Tiehe Qin
- Department of Critical Care Medicine, Guangdong Geriatric Institute, Guangdong General Hospital, Guangdong, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Duming Zhu
- Surgical Intensive Care Unit, Department of Anaesthesiology, ZhongShan Hospital, FuDan University, Shanghai, China
| | - Yushan Wang
- Intensive Care Unit, The First Hospital of Jilin University, Changchun, China
| | - Qingyuan Zhan
- Department of Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenxiong Li
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Bing Sun
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiangyuan Cao
- Department of Critical Care Medicine, General Hospital of Ningxia Medical University, Ningxia, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Tong Li
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xi Zhu
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Jianguo Jia
- Surgical Intensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan He
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
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21
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Zhou Q, Zhao F, Wang M. An individualized administration model of vancomycin in elderly patients with sepsis and factors influencing augmented renal clearance. J Clin Pharm Ther 2020; 46:447-453. [PMID: 33210363 DOI: 10.1111/jcpt.13304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Vancomycin efficacy is dependent on appropriate dosing, which should aim to achieve a target serum trough level. The purpose of this study was to determine the variables that predicted vancomycin serum trough concentrations in elderly patients with sepsis. METHODS This retrospective cohort study, which was conducted in the medical ICU of a university-affiliated teaching hospital in China, included 87 medical patients with sepsis who were enrolled from January 2014 to December 2017. RESULTS AND DISCUSSION All the patients were at least 60 years old (mean age = 74.8 ± 8.2 years), and 51.7% (n = 45) of them were male. The most common primary site of infection was the lungs (67.8%), followed by the abdomen (12.6%). Patients with septic shock accounted for 21.8% (n = 19) of the cases. The proportion of patients with vancomycin serum trough concentrations reaching target concentrations (≥15 mg/L) was 47.1% (41 cases). Multivariate linear regression showed that the creatinine clearance rate (CCR) and the daily dosage of vancomycin were independent predictors of vancomycin serum trough concentrations (both p's < 0.05), and the model for predicting vancomycin trough concentrations should be: serum trough concentration (mg/L) = 15.942 - 0.101 × CCR (mL/min) + 0.347 × vancomycin daily doses (mg/kg/d). Augmented renal clearance (ARC) was present in 13 patients (14.9%), and logistic regression revealed body mass index (OR = 1.420, p = .002) and serum creatinine level (OR = 0.883, p = .002) were independent predictors of ARC. WHAT IS NEW AND CONCLUSION The CCR and daily dosage of vancomycin were significantly correlated with vancomycin serum trough concentrations in elderly patients with sepsis, and the individualized administration model should be verified through further clinical trials. BMI and serum creatinine level were identified to be independent predictors of ARC in elderly patients.
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Affiliation(s)
- Qingtao Zhou
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Feifan Zhao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Meng Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
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Helset E, Nordøy I, Sporsem H, Bakke VD, Bugge JF, Gammelsrud KW, Zucknick M, Lippe E. Factors increasing the risk of inappropriate vancomycin therapy in ICU patients: A prospective observational study. Acta Anaesthesiol Scand 2020; 64:1295-1304. [PMID: 32578201 DOI: 10.1111/aas.13658] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/28/2020] [Accepted: 06/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vancomycin trough levels are frequently subtherapeutic in intensive care unit (ICU) patients. The aim of this study was to identify patients at risk of therapeutic failure defined as vancomycin area-under-the-curve0-24 /minimum inhibitory concentration (AUC0-24 /MIC) <400, and to examine possible effects of different MICs, the variability in renal clearance and continuous renal replacement therapy (CRRT), and the relevance of vancomycin therapy. METHODS A prospective observational study of ICU patients ≥ 18 years at initiation of vancomycin therapy was conducted from May 2013 to October 2015. The patients were divided into four groups according to renal function and CRRT-mode as follows: normal- or augmented renal clearance and continuous venovenous hemodialysis or -hemofiltration. Vancomycin peak and trough levels were measured at 24, 48, and 72 hours after therapy initiation. Relevance of vancomycin therapy was retrospectively evaluated based on microbiological results. RESULTS Eighty-three patients were included, median age 54.5 years, 74.5% male, SAPS II score 46, and 90 day mortality 28%. Vancomycin therapy was initiated on ICU-day 8 (IQR, 5-12), with a median treatment time of 7.5 (IQR, 5-12) days. AUC0-24 /MIC > 400 was reached in 81% and 8% with MIC = 1 and 2 mg/L respectively. The CRRT groups had higher AUC0-24 /MIC-ratios than the non-CRRT groups (P < .001). Augmented renal clearance increased the risk of AUC0-24 /MIC < 400, independent of MIC-value. Initiation of vancomycin therapy was retrospectively considered relevant in 28 patients (34%). CONCLUSION A MIC-value >1 mg/L and augmented renal clearance, were factors increasing the risk of therapeutic failure. Vancomycin treatments could have been omitted or shortened in most of these patients.
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Affiliation(s)
- Elin Helset
- Division of Critical care and Emergency Medicine Oslo University Hospital Oslo Norway
| | - Ingvild Nordøy
- Section for Clinical Immunology and Infectious diseases Oslo University Hospital Oslo Norway
- Research Institute for Internal Medicine University of Oslo Oslo Norway
| | | | | | - Jan F. Bugge
- Division of Critical care and Emergency Medicine Oslo University Hospital Oslo Norway
| | | | - Manuela Zucknick
- Oslo Center for Biostatistics and Epidemiology Department of Biostatistics Faculty of Medicine University of Oslo Oslo Norway
| | - Elisabeth Lippe
- Department of Infectious Diseases Oslo University Hospital Oslo Norway
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The ONTAI study - a survey on antimicrobial dosing and the practice of therapeutic drug monitoring in German intensive care units. J Crit Care 2020; 60:260-266. [PMID: 32932111 DOI: 10.1016/j.jcrc.2020.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Optimization of antibiotic therapy is still urgently needed in critically ill patients. The aim of the ONTAI survey (online survey on the use of Therapeutic Drug Monitoring of antibiotics in intensive care units) was to evaluate which strategies intensive care physicians in Germany use to improve the quality of antibiotic therapy and what role a Therapeutic Drug Monitoring (TDM) plays. METHODS Among the members of the German Society for Anaesthesiology and the German Society for Medical Intensive Care Medicine and Emergency Medicine, a national cross-sectional survey was conducted using an online questionnaire. RESULTS The questionnaire was completely answered by 398 respondents. Without TDM, prolonged infusion was judged to be the most appropriate dosing regimen for beta lactams. A TDM for piperacillin, meropenem and vancomycin was performed in 17, 22 and 75% of respondents, respectively. For all beta lactams, a TDM was requested more often than it was available. There was great uncertainty as to the optimal pharmacokinetic/pharmacodynamic index for beta-lactams. 86% of the respondents who received minimal inhibitory concentrations adapted the therapy accordingly. CONCLUSION German intensive care physicians are convinced of TDM for dose optimization. However, practical implementation, the determination of MICs and defined target values are still lacking.
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Rello J, Tejada S, Xu E, Solé-Lleonart C, Campogiani L, Koulenti D, Ferreira-Coimbra J, Lipman J. Quality of evidence supporting Surviving Sepsis Campaign Recommendations. Anaesth Crit Care Pain Med 2020; 39:497-502. [PMID: 32650126 PMCID: PMC7340061 DOI: 10.1016/j.accpm.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 01/06/2023]
Abstract
Introduction The Surviving Sepsis Campaign (SSC) guidelines, released in 2017, are a combination of expert opinion and evidence-based medicine, adopted by many institutions as a standard of practice. The aim was to analyse the quality of evidence supporting recommendations on the management of sepsis. Methods The strength and quality of evidence (high, moderate, low-very low and best practice statements) of each recommendation were extracted. Randomised controlled trials were required to qualify as high-quality evidence. Results A total of 96 recommendations were formulated, and 87 were included. Among thirty-one (43%) strong recommendations, only 15.2% were supported by high-quality evidence. Overall, thirty-seven (42.5%) recommendations were based on low-quality evidence, followed by 28 (32.2%) based on moderate-quality, 15 (17.2%) were best practice statements and only seven (8.0%) were supported by high-quality evidence. Randomised controlled trials supported 21.4%, 9.5% and 8.6% recommendations on mechanical ventilation, resuscitation, and management/adjuvant therapy, respectively. In contrast, none high-quality evidence recommendation supported antimicrobial/source control (82.4% were low-very low evidence or best practice statements), and nutrition. Conclusions In the SSC guidelines most recommendations were informed by indirect evidence and non-systematic observations. While awaiting trials results, Delphi-like approaches or multi-criteria decision analyses should guide recommendations.
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Affiliation(s)
- Jordi Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Scientifical Research, CHU Nîmes, University Montpellier-Nîmes, Nîmes, France
| | - Sofia Tejada
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain; Centro de Investigacion Biomedica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Elena Xu
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | | | - Laura Campogiani
- Clinical Infectious Diseases, Department of System Medicine, Tor Vergata University, Rome, Italy
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Critical Care II, Attikon University Hospital, Athens, Greece
| | - João Ferreira-Coimbra
- Internal Medicine Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jeff Lipman
- Scientifical Research, CHU Nîmes, University Montpellier-Nîmes, Nîmes, France; UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
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Escobar MF, Echavarría MP, Zambrano MA, Ramos I, Kusanovic JP. Maternal sepsis. Am J Obstet Gynecol MFM 2020; 2:100149. [PMID: 33345880 DOI: 10.1016/j.ajogmf.2020.100149] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/16/2020] [Accepted: 05/23/2020] [Indexed: 12/11/2022]
Abstract
Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia.
| | - María Paula Echavarría
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - María Andrea Zambrano
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia; Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Juan Pedro Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Department of Obstetrics and Gynecology, Hospital Sótero del Río, Santiago, Chile; Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Xia H, Gao J, Xiu M, Li D. Community-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus in a Chinese adult: A case report. Medicine (Baltimore) 2020; 99:e20914. [PMID: 32590802 PMCID: PMC7329007 DOI: 10.1097/md.0000000000020914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Methicillin-resistant Staphylococcus aureus (MRSA) has been established as an important cause of severe community-acquired pneumonia (CAP) with very high mortality. Panton-Valentine leukocidin (PVL) producing MRSA has been reported to be associated with necrotizing pneumonia and worse outcome. The incidence of community-acquired MRSA (CA-MRSA) pneumonia is very low, as only a few CA-MRSA pneumonia cases were reported in the last few years. We present a case of severe CAP caused by PVL-positive MRSA with ensuing septic shock. PATIENT CONCERNS A 68-year-old male with no concerning medical history had developed a fever that reached 39.0°C, a productive cough that was sustained for 5 days, and hypodynamia. He was treated with azithromycin and alexipyretic in a nearby clinic for 2 days in which the symptoms were alleviated. However, 1 day later, the symptoms worsened, and he was taken to a local Chinese medicine hospital for traditional medicine treatment. However, his clinical condition deteriorated rapidly, and he then developed dyspnea and hemoptysis. DIAGNOSIS CA-MRSA pneumonia and septic shock. The sputum culture showed MRSA. Polymerase chain reaction of MRSA isolates was positive for PVL genes. INTERVENTIONS Mechanical ventilation, fluid resuscitation, and antibiotic therapy were performed. Antibiotic therapy included mezlocillin sodium/sulbactam sodium, linezolid, and oseltamivir. OUTCOMES He died after 12 hours of treatment. LESSONS This is a report of severe pneumonia due to PVL-positive CA-MRSA in a healthy adult. CA-MRSA should be considered a pathogen of severe CAP, especially when combined with septic shock in previously healthy individuals.
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Affiliation(s)
- Huan Xia
- Department of Respiratory Medicine
| | | | - Ming Xiu
- Department of Intensive Care Unit Group One, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Dan Li
- Department of Respiratory Medicine
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Ter Heine R, Keizer RJ, van Steeg K, Smolders EJ, van Luin M, Derijks HJ, de Jager CPC, Frenzel T, Brüggemann R. Prospective validation of a model-informed precision dosing tool for vancomycin in intensive care patients. Br J Clin Pharmacol 2020; 86:2497-2506. [PMID: 32415710 PMCID: PMC7688533 DOI: 10.1111/bcp.14360] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/24/2020] [Accepted: 05/01/2020] [Indexed: 02/04/2023] Open
Abstract
AIMS Vancomycin is an important antibiotic for critically ill patients with Gram-positive bacterial infections. Critically ill patients typically have severely altered pathophysiology, which leads to inefficacy or toxicity. Model-informed precision dosing may aid in optimizing the dose, but prospectively validated tools are not available for this drug in these patients. We aimed to prospectively validate a population pharmacokinetic model for purpose model-informed precision dosing of vancomycin in critically ill patients. METHODS We first performed a systematic evaluation of various models on retrospectively collected pharmacokinetic data in critically ill patients and then selected the best performing model. This model was implemented in the Insight Rx clinical decision support tool and prospectively validated in a multicentre study in critically ill patients. The predictive performance was obtained as mean prediction error and relative root mean squared error. RESULTS We identified 5 suitable population pharmacokinetic models. The most suitable model was carried forward to a prospective validation. We found in a prospective multicentre study that the selected model could accurately and precisely predict the vancomycin pharmacokinetics based on a previous measurement, with a mean prediction error and relative root mean squared error of respectively 8.84% (95% confidence interval 5.72-11.96%) and 19.8% (95% confidence interval 17.47-22.13%). CONCLUSION Using a systematic approach, with a retrospective evaluation and prospective verification we showed the suitability of a model to predict vancomycin pharmacokinetics for purposes of model-informed precision dosing in clinical practice. The presented methodology may serve a generic approach for evaluation of pharmacometric models for the use of model-informed precision dosing in the clinic.
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Affiliation(s)
- Rob Ter Heine
- Radboud Institute for Health Sciences, Department of Pharmacy, Radboud university medical center, Nijmegen, The Netherlands
| | | | - Krista van Steeg
- Department of Clinical Pharmacy, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Elise J Smolders
- Department of Pharmacy, Isala Hospital, Zwolle, The Netherlands & Department of Pharmacy, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands/Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cornelis P C de Jager
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger Brüggemann
- Radboud Institute for Health Sciences, Department of Pharmacy, Radboud university medical center, Nijmegen, The Netherlands
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Roggeveen LF, Guo T, Driessen RH, Fleuren LM, Thoral P, van der Voort PHJ, Girbes ARJ, Bosman RJ, Elbers P. Right Dose, Right Now: Development of AutoKinetics for Real Time Model Informed Precision Antibiotic Dosing Decision Support at the Bedside of Critically Ill Patients. Front Pharmacol 2020; 11:646. [PMID: 32499697 PMCID: PMC7243359 DOI: 10.3389/fphar.2020.00646] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Antibiotic dosing in critically ill patients is challenging because their pharmacokinetics (PK) are altered and may change rapidly with disease progression. Standard dosing frequently leads to inadequate PK exposure. Therapeutic drug monitoring (TDM) offers a potential solution but requires sampling and PK knowledge, which delays decision support. It is our philosophy that antibiotic dosing support should be directly available at the bedside through deep integration into the electronic health record (EHR) system. Therefore we developed AutoKinetics, a clinical decision support system (CDSS) for real time, model informed precision antibiotic dosing. Objective To provide a detailed description of the design, development, validation, testing, and implementation of AutoKinetics. Methods We created a development framework and used workflow analysis to facilitate integration into popular EHR systems. We used a development cycle to iteratively adjust and expand AutoKinetics functionalities. Furthermore, we performed a literature review to select and integrate pharmacokinetic models for five frequently prescribed antibiotics for sepsis. Finally, we tackled regulatory challenges, in particular those related to the Medical Device Regulation under the European regulatory framework. Results We developed a SQL-based relational database as the backend of AutoKinetics. We developed a data loader to retrieve data in real time. We designed a clinical dosing algorithm to find a dose regimen to maintain antibiotic pharmacokinetic exposure within clinically relevant safety constraints. If needed, a loading dose is calculated to minimize the time until steady state is achieved. Finally, adaptive dosing using Bayesian estimation is applied if plasma levels are available. We implemented support for five extensively used antibiotics following model development, calibration, and validation. We integrated AutoKinetics into two popular EHRs (Metavision, Epic) and developed a user interface that provides textual and visual feedback to the physician. Conclusion We successfully developed a CDSS for real time model informed precision antibiotic dosing at the bedside of the critically ill. This holds great promise for improving sepsis outcome. Therefore, we recently started the Right Dose Right Now multi-center randomized control trial to validate this concept in 420 patients with severe sepsis and septic shock.
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Affiliation(s)
- Luca F Roggeveen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Tingjie Guo
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ronald H Driessen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Patrick Thoral
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rob J Bosman
- Intensive Care Unit, OLVG Oost, Amsterdam, Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Sridharan K, Al Daylami A, Ajjawi R, Al-Ajooz H, Veeramuthu S. Clinical Pharmacokinetics of Vancomycin in Critically Ill Children. Eur J Drug Metab Pharmacokinet 2020; 44:807-816. [PMID: 31301023 DOI: 10.1007/s13318-019-00568-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Critically ill children exhibit altered pharmacokinetic parameters of vancomycin, mainly due to altered renal excretion and volume of distribution (as a result of altered plasma protein concentrations). We assessed the pharmacokinetic parameters of vancomycin in this subpopulation. METHODS Vancomycin trough concentrations in critically ill children were obtained following first dose and at steady state. Using a one-compartment model, clearance (CL), volume of distribution (Vd), elimination half-life (t1/2), and area under the time-concentration curve for 24 h (AUC0-24) were estimated. Subgroup analyses were carried out, with patients differentiated based on age, renal clearance, outcome, and renal dysfunction. Protein-free vancomycin concentrations were calculated using a previously reported formula. RESULTS Twenty-two samples were evaluated for first-dose and 182 for steady-state pharmacokinetics, and similar pharmacokinetic parameter values were observed at first dose and at steady state. Only 36.4% and 47.3% of the samples attained the recommended AUC0-24 (mg·hr/L) of > 400 at first dose and at steady state, while 62.5% of the patients with renal dysfunction achieved this target. Nearly 40% of the patients had augmented renal clearance (ARC), which was associated with higher CL, shorter t1/2, and lower AUC values. Amongst the patients with ARC, none had AUC0-24 (mg·hr/L) > 400 at first dose, while 16% achieved this target at steady state. Volume of distribution was significantly higher in infants and a decreasing trend was observed in toddlers, children, and older children at steady state. Children with renal dysfunction had lower CL, prolonged t1/2, and higher AUC values than patients with normal renal clearance at first dose. A good correlation was observed between trough concentration and AUC0-24, as corroborated by the area under the receiver operating characteristic curve. The median fraction of protein-free vancomycin was around 77%. CONCLUSION Vancomycin dosing strategies in younger children should be revisited, and increased doses should be considered for critically ill children with ARC in order to achieve therapeutic concentrations of AUC0-24.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain.
| | - Amal Al Daylami
- Department of Pediatrics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain.,Pediatric Intensive Care Unit, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain
| | - Reema Ajjawi
- Pediatric Intensive Care Unit, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain
| | - Husain Al-Ajooz
- Pediatric Intensive Care Unit, Salmaniya Medical Complex, Ministry of Health, Manama, Bahrain
| | - Sindhan Veeramuthu
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
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Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective calculated antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed infection and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account during the selection of anti-infective treatment. Many pathophysiologic alterations influence the pharmacokinetics (PK) of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of β‑lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM, but for continuous infusion, TDM is generally necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug-resistant (MDR) pathogens in the intensive care unit. For effective treatment, antibiotic stewardship teams (ABS teams) are becoming more established. Interdisciplinary cooperation of the ABS team with infectious disease (ID) specialists, microbiologists, and clinical pharmacists leads not only to rational administration of antibiotics, but also has a positive influence on treatment outcome. The gold standards for pathogen identification are still culture-based detection and microbiologic resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction(PCR)-based procedures for pathogen identification and resistance determination are currently only an adjunct to routine sepsis diagnostics, due to the limited number of studies, high costs, and limited availability. In complicated septic courses with multiple anti-infective therapies or recurrent sepsis, PCR-based procedures can be used in addition to treatment monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically (still) absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation). (Contribution available free of charge by "Free Access" [ https://link.springer.com/article/10.1007/s00101-017-0396-z ].).
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Chu Y, Luo Y, Quan X, Jiang M, Zhou B. Intermittent vs. continuous vancomycin infusion for gram-positive infections: A systematic review and meta-analysis. J Infect Public Health 2020; 13:591-597. [DOI: 10.1016/j.jiph.2019.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/15/2018] [Accepted: 09/03/2019] [Indexed: 01/29/2023] Open
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Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, Gogtay NJ, Thatte UM. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. Indian J Crit Care Med 2020; 23:497-502. [PMID: 31911739 PMCID: PMC6900889 DOI: 10.5005/jp-journals-10071-23275] [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] [Indexed: 11/23/2022] Open
Abstract
Aims and objectives Vancomycin is a drug of choice for various gram-positive bacterial (GPB) infections and is largely prescribed to pediatric intensive care unit (PICU) patients. Despite the different pathophysiology of these patients, limited data are available on pharmacokinetics of vancomycin. There are lack of data for critically ill Indian children; hence, study was conducted to assess the steady-state pharmacokinetics in children admitted to PICU. Materials and methods Twelve subjects (seven males, five females) aged 1–12 years were enrolled. Vancomycin (dose of 20 mg/kg per 8 hours) was infused for over 1 hour and steady-state pharmacokinetics was performed on day 3. Vancomycin concentrations were measured by the validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). Results The steady-state mean Cssmax was 40.94 μg/mL (±15.07), and mean AUC0–8 hours was 124.15 μg/mL (±51.27). The mean t1/2 was 4.82 hours (±2.71), Vd was 12.48 L (±4.43), and Cl was 2.08 mL/minute (±0.89). The mean AUC0–24 among 12 subjects was 372.44 μg/mL (±153.82). Among 35 measured trough concentrations, 23 (65.71%) were below, 11 (31.43%) were within, and 1 (2.86%) was above the recommended range. Conclusion The pharmacokinetic parameters of vancomycin were comparable with previously reported studies. However, recommended trough levels (10–20 μg/mL) were not achievable with current recommended dosing of 60 mg/kg/day. How to cite this article Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, et al. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. IJCCM 2019;23(11):497–502.
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Affiliation(s)
- Nitin B Mali
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Milind S Tullu
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Poorwa P Wandalkar
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Vinod C Ingale
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Chandrahas T Deshmukh
- Department of Pediatrics, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
| | - Urmila M Thatte
- Department of Clinical Pharmacology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
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Mali NB, Deshpande SP, Wandalkar PP, Gupta VA, Karnik ND, Gogtay NJ, Nataraj G, Mehta PR, Thatte U. Single-dose and Steady-state Pharmacokinetics of Vancomycin in Critically Ill Patients Admitted to Medical Intensive Care Unit of India. Indian J Crit Care Med 2020; 23:513-517. [PMID: 31911742 PMCID: PMC6900894 DOI: 10.5005/jp-journals-10071-23289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Rationale Vancomycin remains the standard of care for gram-positive bacterial infections, though there are significant developments in newer antibacterial agents. Efficacy can be improved by linking pharmacokinetic with pharmacodynamic principles, thus leading to optimum antibiotic exposure. There is scarcity of pharmacokinetic data in Indian intensive care unit (ICU) population. Materials and methods Fifteen subjects with suspected or proven gram-positive bacterial infection of either gender between 18 years and 65 years of age were enrolled. Vancomycin at the dose of 1 g every 12 hours was administered over 1-hour period and pharmacokinetic assessments performed on blood samples collected on days 1 and 3. Vancomycin concentrations were measured on validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). Results The mean Cmax, elimination half-life, AUC0–12hours, volume of distribution, and clearance of single dose were 36.46 μg/mL (±14.87), 3.98 hours (±1.31), 113.51 μg/mL (±49.51), 52.01 L (±31.31), and 8.90 mL/minute (±3.29), respectively, and at steady state were 40.87 μg/mL (±19.29), 6.27 hours (±3.39), 147.94 μg/mL (±72.89), 56.39 L (±42.13), and 6.98 mL/minute (±4.48), respectively. The elimination half-life increased almost two-fold at steady state. The steady state mean AUC0–24 was 295.89 µg/mL (±153.82). Out of 45 trough levels, 32 (71.11%) concentrations were below recommended range. Conclusion Recommended AUC0–24hours and trough concentrations were not achieved in majority of patients with current dosing, suggesting reevaluation of current vancomycin dosing. Individualized treatment based on close monitoring of vancomycin serum concentrations in critically ill patients is imperative. How to cite this article Mali NB, Deshpande SP, Wandalkar PP, Gupta VA, Karnik ND, Gogtay NJ, et al. Single-dose and Steady-state Pharmacokinetics of Vancomycin in Critically Ill Patients Admitted to Medical Intensive Care Unit of India. IJCCM 2019;23(11):513–517.
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Affiliation(s)
- Nitin B Mali
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Siddharth P Deshpande
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Poorwa P Wandalkar
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Vishal A Gupta
- Department of Medicine, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Niteen D Karnik
- Department of Medicine, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Gita Nataraj
- Department of Microbiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Preeti R Mehta
- Department of Microbiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Urmila Thatte
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
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Talaie H, Mousavizadeh A, Emami H, Gachkar L, Barari B, Alijanzadeh MH. High sensitivity versus low level of vancomycin needs to be concern for another alternative anti- Staphylococcus aureus as the first- line antibiotic. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:498-503. [PMID: 31910175 PMCID: PMC7233789 DOI: 10.23750/abm.v90i4.7646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/23/2019] [Indexed: 11/23/2022]
Abstract
Background and aim: Vancomycin has been the first-line therapy for MRSA infection disease for many years. According to standard guidelines, the therapeutic vancomycin trough concentration should be above 10 mg/L and optimally between 15-20 mg/L. The aim of this study was to evaluate vancomycin trough level concentration in patients infected with MRSA.Methods: This cross- sectional study included a sample of 170 patients admitted to the ICU of Loghman hospital. We used a standard questionnaire, then applied appropriate statistical tests. All collected data had been analyzed and interpreted by IBM SPSS Statistics 19.0.Results: Among this study population, 71.8% was male. Just 20.8% of the patients can reach the therapeutic level trough even after changing the dose. It should be noted that a significant percentage of toxicity was observed after increasing the dose. Conclusions: Even though high sensitivity against vancomycin disc has been seen in antibiogram tests, sufficient efficiency has not been distinguished, in the sense that, just a few patients by low trough level concentration, reached to therapeutic level after the dose change. Based on some sources, because of the side effects and limited safe range of vancomycin, we should consider a new approach to the alternative antibiotics. (www.actabiomedica.it)
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Affiliation(s)
- Haleh Talaie
- Toxicological Research Center, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran..
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Roggeveen LF, Fleuren LM, Guo T, Thoral P, de Grooth HJ, Swart EL, Klausch TLT, van der Voort PHJ, Girbes ARJ, Bosman RJ, Elbers PWG. Right Dose Right Now: bedside data-driven personalized antibiotic dosing in severe sepsis and septic shock - rationale and design of a multicenter randomized controlled superiority trial. Trials 2019; 20:745. [PMID: 31852491 PMCID: PMC6921499 DOI: 10.1186/s13063-019-3911-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/15/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Antibiotic exposure is often inadequate in critically ill patients with severe sepsis or septic shock and this is associated with worse outcomes. Despite markedly altered and rapidly changing pharmacokinetics in these patients, guidelines and clinicians continue to rely on standard dosing schemes. To address this challenge, we developed AutoKinetics, a clinical decision support system for antibiotic dosing. By feeding large amounts of electronic health record patient data into pharmacokinetic models, patient-specific predicted future plasma concentrations are displayed graphically. In addition, a tailored dosing advice is provided at the bedside in real time. To evaluate the effect of AutoKinetics on pharmacometric and clinical endpoints, we are conducting the Right Dose Right Now multicenter, randomized controlled, two-arm, parallel-group, non-blinded, superiority trial. METHODS All adult intensive care patients with a suspected or proven infection and having either lactatemia or receiving vasopressor support are eligible for inclusion. Randomization to the AutoKinetics or control group is initiated at the bedside when prescribing at least one of four commonly administered antibiotics: ceftriaxone, ciprofloxacin, meropenem and vancomycin. Dosing advice is available for patients in the AutoKinetics group, whereas patients in the control group receive standard dosing. The primary outcome of the study is pharmacometric target attainment during the first 24 h. Power analysis revealed the need for inclusion of 42 patients per group per antibiotic. Thus, a total of 336 patients will be included, 168 in each group. Secondary pharmacometric endpoints include time to target attainment and fraction of target attainment during an entire antibiotic course. Secondary clinical endpoints include mortality, clinical cure and days free from organ support. Several other exploratory and subgroup analyses are planned. DISCUSSION This is the first randomized controlled trial to assess the effectiveness and safety of bedside data-driven automated antibiotic dosing advice. This is important as adequate antibiotic exposure may be crucial to treat severe sepsis and septic shock. In addition, the trial could prove to be a significant contribution to clinical pharmacometrics and serve as a stepping stone for the use of big data and artificial intelligence in the field. TRIAL REGISTRATION Netherlands Trial Register (NTR), NL6501/NTR6689. Registered on 25 August 2017. European Clinical Trials Database (EudraCT), 2017-002478-37. Registered on 6 November 2017.
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Affiliation(s)
- Luca F. Roggeveen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Lucas M. Fleuren
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Tingjie Guo
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Patrick Thoral
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Harm Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Eleonora L. Swart
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Thomas L. T. Klausch
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | | | - Armand R. J. Girbes
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Rob J. Bosman
- Intensive Care Unit, OLVG Oost, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Williams P, Beall G, Cotta MO, Roberts JA. Antimicrobial dosing in critical care: A pragmatic adult dosing nomogram. Int J Antimicrob Agents 2019; 55:105837. [PMID: 31722224 DOI: 10.1016/j.ijantimicag.2019.10.018] [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: 02/11/2019] [Revised: 10/08/2019] [Accepted: 10/27/2019] [Indexed: 11/27/2022]
Abstract
Standard dosing of antimicrobials derived from product information is considered to have limited application in critically ill patients given the pharmacokinetic and pharmacodynamic changes often seen in these patients relative to other groups in the hospital. Dosing nomograms that account for the altered needs of critically ill patients are needed to minimise the likelihood of antimicrobial underdosing (risk of treatment failure) and overdosing (risk of toxicity) in these patients. The aim of this paper is to present a pragmatic, evidence-based, adult dosing nomogram for a selection of antimicrobials frequently prescribed to treat infections in critically ill patients.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.
| | - Gareth Beall
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Queensland, 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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Colin PJ, Jonckheere S, Struys MMRF. Target-Controlled Continuous Infusion for Antibiotic Dosing: Proof-of-Principle in an In-silico Vancomycin Trial in Intensive Care Unit Patients. Clin Pharmacokinet 2019; 57:1435-1447. [PMID: 29512049 PMCID: PMC6182490 DOI: 10.1007/s40262-018-0643-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES In this in-silico study, we investigate the clinical utility of target-controlled infusion for antibiotic dosing in an intensive care unit setting using vancomycin as a model compound. We compared target-controlled infusion and adaptive target-controlled infusion, which combines target-controlled infusion with data from therapeutic drug monitoring, with conventional (therapeutic drug monitoring-based) vancomycin dosing strategies. METHODS A clinical trial simulation was conducted. This simulation was based on a comprehensive database of clinical records of intensive care unit patients and a systematic review of currently available population-pharmacokinetic models for vancomycin in intensive care unit patients. Dosing strategies were compared in terms of the probability of achieving efficacious concentrations as well as the potential for inducing toxicity. RESULTS Adaptive target-controlled infusion outperforms rule-based dosing guidelines for vancomycin. In the first 48 h of treatment, the probability of target attainment is significantly higher for adaptive target-controlled infusion than for the second-best method (Cristallini). Probability of target attainments of 54 and 72% and 47 and 59% for both methods after 24 and 48 h, respectively. Compared to the Cristallini method, which is characterized by a probability of attaining concentrations above 30 mg.L-1 > 65% in the first few hours of treatment, adaptive target-controlled infusion shows negligible time at risk and a probability of attaining concentrations above 30 mg.L-1 not exceeding 25%. Finally, in contrast to the other methods, the performance of target-controlled infusion is consistent across subgroups within the population. CONCLUSIONS Our study shows that adaptive target-controlled infusion has the potential to become a practical tool for patient-tailored antibiotic dosing in the intensive care unit.
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Affiliation(s)
- Pieter J Colin
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
- Department of Anesthesiology, Groningen University, University Medical Center Groningen, Groningen, The Netherlands.
| | - Stijn Jonckheere
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
- Department of Anesthesiology, Groningen University, University Medical Center Groningen, Groningen, The Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, Groningen University, University Medical Center Groningen, Groningen, The Netherlands
- Department of Anesthesiology and Peri-operative Medicine, Ghent University, Ghent, Belgium
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Risk stratification and treatment of ICU-acquired pneumonia caused by multidrug- resistant/extensively drug-resistant/pandrug-resistant bacteria. Curr Opin Crit Care 2019; 24:385-393. [PMID: 30156569 DOI: 10.1097/mcc.0000000000000534] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Describe the risk factors and discuss the management of multidrug-resistant (MDR) bacteria responsible for pneumonia among critically ill patients, including methicillin-resistant Staphylococcus aureus, extended spectrum beta-lactamase-producing Enterobactericeae, carbapenem-resistant Enterobactericeae, multidrug resistant Pseudomonas aeruginosa, and Acinetobacter baumannii. RECENT FINDINGS Multiple factors have been associated with infections because of MDR bacteria, including prolonged hospital stay, presence of invasive devices, mechanical ventilation, colonization with resistant pathogens, and use of broad-spectrum antibiotics. Management of these infections includes the prompt use of appropriate antimicrobial therapy, implementation of antimicrobial stewardship protocols, and targeted active microbiology surveillance. Combination therapy and novel molecules have been used for the treatment of severe infections caused by resistant bacteria. SUMMARY The exponential increase of antimicrobial resistance among virulent pathogens currently represents one of the main challenges for clinicians in the intensive care unit. Knowledge of the local epidemiology, patient risk stratification, and infection-control policies remain key elements for the management of MDR infections. Results from clinical trials on new molecules are largely awaited.
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Molina KC, Hall ST, Barletta JF, Mangram AJ, Dzandu JK, Huang V. Utilization of Augmented Renal Clearance in Trauma Intensive Care Scoring System to Improve Vancomycin Dosing in Trauma Patients at Risk for Augmented Renal Clearance. Surg Infect (Larchmt) 2019; 21:43-47. [PMID: 31335259 DOI: 10.1089/sur.2019.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scoring system is a validated system to predict augmented renal clearance in trauma patients. This study examined the ability of the ARCTIC score to identify patients at risk for subtherapeutic vancomycin trough concentrations relative to estimated creatinine clearance (eCrCl) alone. Methods: Trauma patients admitted to the intensive care unit from September 2012 to December 2017 who received vancomycin and had a vancomycin trough concentration recorded were included. Patients were excluded if their serum creatinine concentration was >1.3 mg/dL, if they had received vancomycin doses <30 mg/kg per day, an improperly timed trough concentration measurement, or renal replacement therapy. The primary endpoint was an initial subtherapeutic vancomycin trough concentration (<10 mg/L). Classification and regression tree (CART) analysis was used to identify thresholds for the ARCTIC score and other continuous data where subtherapeutic troughs were more common. A step-wise logistic regression analysis was performed to control for confounders for subtherapeutic troughs whereby inclusion of ARCTIC was modeled sequentially after eCrCl. Results: A total of 119 patients with a mean age of 42 ± 17 years and eCrCl 142 ± 39 mL/min met the inclusion criteria. The mean daily vancomycin dose was 44 ± 9 mg/kg, and the incidence of subtherapeutic trough concentration was 46%. The CART analysis identified two variables creating three groups where subtherapeutic trough concentrations differed: eCrCl >105 mL/min and ARCTIC score ≥7, eCrCl >105 mL/min and ARCTIC score <7, and eCrCl ≤105 mL/min. The base logistic regression model identified eCrCl >105 mL/min and pelvic fracture as risk factors for subtherapeutic trough values. The final model included the addition of ARCTIC score ≥7, which improved the model significantly (p = 0.009). Predictors of subtherapeutic trough concentrations were (odds ratio [95% confidence interval]): eCrCl >105 mL/min (6.5 [1.66-25.07]), ARCTIC score ≥7 (3.26 [1.31-8.09]), and pelvic fracture (4.36 [1.27-14.93]). Conclusion: The ARCTIC score is useful when applied in conjunction with eCrCl. Patients with a eCrCl >105 mL/min and an ARCTIC score ≥7 may require a more aggressive dosing strategy.
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Affiliation(s)
- Kyle C Molina
- Department of Pharmacy, Scripps Mercy Hospital, San Diego, California.,Department of Pharmacy, HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona.,Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
| | - Scott T Hall
- Department of Pharmacy, HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
| | - Alicia J Mangram
- Trauma Services and Acute Care Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona
| | - James K Dzandu
- Trauma Services and Acute Care Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, Arizona
| | - Vanthida Huang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
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Abstract
Objective: Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis. Data Sources: We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection. Study Selection: We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics. Results: By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci. Conclusions: This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.
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Malaeb DN, Fahs IM, Salameh P, Hallit S, Saad M, Bourji J, Hallit R. Assessment of vancomycin utilization among Lebanese hospitals. Saudi Med J 2019; 40:152-157. [PMID: 30723860 PMCID: PMC6402470 DOI: 10.15537/smj.2019.2.23872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives: To assess the appropriateness of vancomycin dosing and monitoring at Lebanese hospitals. Methods: This was a multicenter retrospective study conducted at 3 Lebanese hospitals between January and March 2018. Patients 18 years of age and older treated with vancomycin for a systemic infection or prophylaxis were eligible for study enrollment. Consistency with the Infectious Diseases Society of America guidelines was evaluated to determine whether the dose of vancomycin was appropriate, as well as for the time of trough measurement, and the target concentration obtained. Results: From a total of 120 patients who met the inclusion criteria, only 11 (12%) were given the appropriate maintenance dose of vancomycin with respect to actual body weight. The trough levels were monitored for 67 (55.8%) patients, with 20 (29.9%) of these patients achieving appropriate therapeutic trough levels of 15-20 mg/l. The trough concentration time measurement before the fourth dose was only carried out in 28 (41.8%) of the 67 patients. Conclusion: This study reveals a gap between the appropriate utilization of vancomycin with respect to the international guidelines in the studied Lebanese hospitals. It highlights the need for dosing and monitoring protocols suitable for vancomycin utilization in these hospitals.
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Affiliation(s)
- Diana N Malaeb
- Department of Clinical Practice, Lebanese International University, Mouseitbah, Lebanon. E-mail.
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Claisse G, Zufferey PJ, Trone JC, Maillard N, Delavenne X, Laporte S, Ollier E. Predicting the dose of vancomycin in ICU patients receiving different types of RRT therapy: a model-based meta-analytic approach. Br J Clin Pharmacol 2019; 85:1215-1226. [PMID: 30768726 DOI: 10.1111/bcp.13904] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/28/2019] [Accepted: 02/10/2019] [Indexed: 11/28/2022] Open
Abstract
AIM Previous pharmacokinetic (PK) studies have proposed various dosing regimens for vancomycin in intensive care unit (ICU) patients undergoing renal replacement therapy (RRT), but all are restricted to specific RRT modalities. To be useful in practice, a population PK model would need to predict vancomycin clearance during any RRT modality. Development of such a model is feasible using meta-analysis of published summarized estimates of vancomycin PK parameters. Our aims were: (i) to develop and validate a population PK model for vancomycin that takes into account any RRT modalities, and (ii) to predict vancomycin dosing for RRT patients in ICU. METHODS Vancomycin pharmacokinetics were assumed to be two-compartmental, total body clearance being the sum of non-RRT clearance and RRT-induced clearance. Drug disposition and non-RRT clearance parameters were estimated by systematic review and meta-analysis of previously published parameter estimates. The relationship between RRT-induced clearance and RRT flowrate settings was assessed using a model-based meta-analysis. Prediction performances of the PK model were assessed using external data. RESULTS The meta-analyses of disposition parameters, non-RRT clearance and RRT-induced clearance included 11, 6 and 38 studies (84 RRT clearance measurements) respectively. The model performed well in predicting external individual PK data. Individual vancomycin concentrations during RRT were accurately predicted using Bayesian estimation based solely on pre-RRT measurements. CONCLUSIONS The PK model allowed accurate prediction of the vancomycin pharmacokinetics during RRT in ICU patients. Based on the model of RRT-induced clearance, an appropriate adjustment of the vancomycin dosing regimen could be proposed for any kind of flowrate settings.
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Affiliation(s)
- Guillaume Claisse
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, Saint-Etienne, France
| | - Paul J Zufferey
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,Département d'Anesthésie-Réanimation, Hôpital Nord, Saint-Etienne, France
| | - Jane C Trone
- Département de radiothérapie, Institut de Cancérologie Lucien Neuwirth, Saint Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Nicolas Maillard
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, Saint-Etienne, France.,Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Silvy Laporte
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
| | - Edouard Ollier
- Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, Saint-Etienne, France.,INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Etienne, France
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43
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Liu TT, Pang HM, Jing L, Wei WX, Qin XL, Guo Q, Lu H, Cheng DH, Jiang WZ. A population pharmacokinetic model of vancomycin for dose individualization based on serum cystatin C as a marker of renal function. ACTA ACUST UNITED AC 2019; 71:945-955. [PMID: 30873627 DOI: 10.1111/jphp.13071] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/19/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study aimed to establish a vancomycin population pharmacokinetics (PPK) model based on serum cystatin C and to optimize dosing for achieving targeted steady-state trough concentrations (Css ) of 10-15 and 15-20 mg/l. METHODS Patients aged ≥18 years were prospectively enrolled. A vancomycin PPK model was built with glomerular filtration rate (GFR) as a renal covariate estimated by cystatin C. A new group of patients were used for external evaluation. PPK analysis and Monte Carlo simulations were performed using nonlinear mixed effect modelling programme. KEY FINDINGS Two hundreds of patients with 514 samples were included. The final model was CL (L/h) = (5.07 × (GFR/105.5)0.524 × (AGE/48.5)-0.309 × (WT/60)0.491 ); V (l) = 46.3. Internal and external evaluations demonstrated good stability and predictability. The average probability of target attainment (PTA) of optimal dosing regimens for targeted Css achieving 10-15 and 15-20 mg/l were 51.2% and 40.6%, respectively. An average PTA ≥71% for targeted concentration of 10-20 mg/l was obtained. CONCLUSIONS A vancomycin PPK model with cystatin C as the renal marker has good stability and predictability. The new proposed dosing regimens were predicted to achieve a good PTA.
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Affiliation(s)
- Tao-Tao Liu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hui-Mei Pang
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Li Jing
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wen-Xing Wei
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao-Ling Qin
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qing Guo
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hua Lu
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Dao-Hai Cheng
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wei-Zhe Jiang
- Department of Pharmacology, Guangxi Medical University, Nanning, Guangxi, China
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44
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Tian Y, Huang X, Wu LJ, Yi L, Li M, Gu SC, Guo DJ, Zhan QY. Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus: Vancomycin or Linezolid? Chin Med J (Engl) 2019; 131:2002-2004. [PMID: 30082534 PMCID: PMC6085849 DOI: 10.4103/0366-6999.238139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ye Tian
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Xu Huang
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Li-Juan Wu
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Li Yi
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Min Li
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Si-Chao Gu
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Dong-Jie Guo
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qing-Yuan Zhan
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
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45
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Kidd JM, Abdelraouf K, Nicolau DP. Comparative efficacy of human-simulated epithelial lining fluid exposures of tedizolid, linezolid and vancomycin in neutropenic and immunocompetent murine models of staphylococcal pneumonia. J Antimicrob Chemother 2018; 74:970-977. [DOI: 10.1093/jac/dky513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/05/2018] [Accepted: 11/13/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- James M Kidd
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Kamilia Abdelraouf
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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46
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Goti V, Chaturvedula A, Fossler MJ, Mok S, Jacob JT. Hospitalized Patients With and Without Hemodialysis Have Markedly Different Vancomycin Pharmacokinetics: A Population Pharmacokinetic Model-Based Analysis. Ther Drug Monit 2018; 40:212-221. [PMID: 29470227 DOI: 10.1097/ftd.0000000000000490] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite being in clinical use for about 6 decades, vancomycin dosing remains perplexing and complex. METHODS A population pharmacokinetic modeling and simulation approach was used to evaluate the efficiency of the current nomogram-based dosing of vancomycin. Serum vancomycin concentrations were obtained as a part of routine therapeutic drug monitoring from two 500-bed academic medical centers. A population pharmacokinetic model was first built using these therapeutic drug monitoring data. Population pharmacokinetic modeling was conducted using NONMEM (7.2 and 7.3). The forward addition-backward elimination approach was used to test the covariate effects. Appropriate numerical and visual criteria were used as model diagnostics for checking model appropriateness and model qualification. The current nomogram efficiency was evaluated by determining the percentage of subjects in the therapeutic range (10-20 mg/L). RESULTS A 2-compartment model with between-subject variability on clearance (CL), central volume of distribution (Vc), and peripheral volume of distribution best fit the data. Blood urea nitrogen, age, creatinine clearance, and hemodialysis status were significant covariates on clearance. Hemodialysis status was a significant covariate on Vc and peripheral volume of distribution. In the final model, creatinine clearance was retained as a covariate on CL whereas hemodialysis status was retained as covariate on both CL and Vc. Using Monte Carlo simulations, the current nomogram was optimized by the addition of a loading dose and reducing the maintenance doses. The current nomogram is suboptimal. Optimization of the nomogram resulted in >40% subjects consistently being in the therapeutic range at troughs collected after the first 6 doses. CONCLUSIONS CL and Vc differ markedly between patients undergoing hemodialysis and those not undergoing hemodialysis. Dosing nomogram based on these covariate relationships may potentially help in accurate dosing of vancomycin.
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Affiliation(s)
- Vineet Goti
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia
| | - Ayyappa Chaturvedula
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia.,Department of Pharmacotherapy, University of North Texas Health Science Center, Fort Worth, Texas
| | - Michael J Fossler
- Department of Pharmaceutical Sciences, Mercer University, Atlanta, Georgia.,Clinical Operations & Quantitative Sciences, Trevena Inc, King of Prussia, Pennsylvania
| | - Steve Mok
- Department of Pharmacy, Emory Healthcare
| | - Jesse T Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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47
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Effects of pharmacist intervention in Vancomycin treatment for patients with bacteremia due to Methicillin-resistant Staphylococcus aureus. PLoS One 2018; 13:e0203453. [PMID: 30188918 PMCID: PMC6126860 DOI: 10.1371/journal.pone.0203453] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 08/21/2018] [Indexed: 11/23/2022] Open
Abstract
Objective We conducted a retrospective study based on composite endpoints for treatment failure to evaluate the effect of pharmacist-led VCM initial dose planning for Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia patients. Methods A retrospective cohort study was performed between pharmacist intervention and non-intervention groups. In this study, four types of failure were defined as the composite endpoint. When any one of the following failures occurred: 1) Death within 30 days from the start of VCM therapy, 2) Positive blood culture 7 days after the start of VCM therapy, 3) Change of VCM to another anti-MRSA agent, and 4) Development of nephrotoxicity, we considered that VCM treatment had failed. Survival time analysis was conducted with the Kaplan-Meier method and Cox’s proportional hazard model that included seven predefined parameters: pharmacist intervention, age, sex, weight, baseline VCM trough concentration, Charlson Comorbidity Index (CCI), and Pitt Bacteremia score (PBS). The effect of pharmacist intervention was studied as the survival probability estimated from the period of time from the start of VCM administration to the earliest failure. Results The survival rate at 30 days after starting VCM therapy, at the end of follow-up, was 53.1 and 82.1% in the non-intervention and intervention groups, respectively. A significant survival time prolongation was noted in the intervention group (p = 0.011, log rank test). Among the seven parameters, only pharmacist intervention was significantly different and its hazard ratio was 0.26 (p = 0.014). The survival probability of the intervention group was higher than that of the non-intervention group for the time to each failure. In subgroup analyses, a significant difference was noted in male patients between the intervention and non-intervention groups (p = 0.005). Age was categorized into those under and over 65 years old. For those over 65 years old, a significant difference was shown between the groups (p = 0.018). Conclusion To our knowledge, this is the first study to evaluate the failure of VCM treatment based on the composite endpoint. Pharmacist intervention through the initial VCM dose planning could maintain a balance between the efficacy and safety of VCM treatment and might avoid treatment failure for patients with MRSA bacteremia. Further investigations with large sample sizes are required to confirm our findings.
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48
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Richter DC, Heininger A, Brenner T, Hochreiter M, Bernhard M, Briegel J, Dubler S, Grabein B, Hecker A, Krüger WA, Mayer K, Pletz MW, Störzinger D, Pinder N, Hoppe-Tichy T, Weiterer S, Zimmermann S, Brinkmann A, Weigand MA, Lichtenstern C. [Bacterial sepsis : Diagnostics and calculated antibiotic therapy]. Anaesthesist 2018; 66:737-761. [PMID: 28980026 DOI: 10.1007/s00101-017-0363-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).
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Affiliation(s)
- D C Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - A Heininger
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Hochreiter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - J Briegel
- Klinik für Anästhesiologie, Klinikum der Universität München, München, Deutschland
| | - S Dubler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B Grabein
- Stabsstelle "Klinische Mikrobiologie und Krankenhaushygiene", Klinikum der Universität München, München, Deutschland
| | - A Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und operative Intensivmedizin, Gesundheitsverbund Landkreis Konstanz, Klinikum Konstanz, Konstanz, Deutschland
| | - K Mayer
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - M W Pletz
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Jena, Deutschland
| | - D Störzinger
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - N Pinder
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - T Hoppe-Tichy
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Zimmermann
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Heidenheim, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - Christoph Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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Truong J, Smith SR, Veillette JJ, Forland SC. Individualized Pharmacokinetic Dosing of Vancomycin Reduces Time to Therapeutic Trough Concentrations in Critically Ill Patients. J Clin Pharmacol 2018; 58:1123-1130. [PMID: 29957824 DOI: 10.1002/jcph.1273] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 05/14/2018] [Indexed: 11/06/2022]
Abstract
Dosing vancomycin in critically ill patients often results in subtherapeutic and supratherapeutic trough concentrations. In this retrospective study, we compared the time to goal trough attainment and incidence of acute kidney injury in intensive care unit (ICU) patients whose vancomycin was dosed by a pharmacy pharmacokinetic (PK) dosing and monitoring service to the standard of care. Three-hundred fifty adult ICU patients at a Level 1 trauma, teaching hospital who received vancomycin for >24 hours from February 1, 2016, to November 30, 2016, were screened. Patients were included in the PK group if consecutive serum concentrations were used to calculate individualized PK and determine a dosing regimen. Patients who were dosed using troughs only were then matched 1-to-1 to the PK group by date of vancomycin initiation and included in the traditional group. Fifty patients were included in each group. Baseline characteristics were similar, except the PK group had more patients under the care of the neuromedical ICU service (42% vs 18%; P = .02) and fewer patients with a corrected creatinine clearance <30 mL/min/1.73 m2 (22% vs 46%; P = .02). Attainment of goal trough concentrations for the PK and traditional groups were 84.4% and 29.4% by 48 hours (P = .0001), 88.4% and 60.7% by 72 hours (P = .009), and 92.9% and 77.8% by 96 hours (P = .1), respectively. Incidence of acute kidney injury between the PK and traditional groups was not statistically significant (8.3% vs 14%; P = .5). Utilization of individualized pharmacokinetic dosing of vancomycin in critically ill patients resulted in faster goal trough attainment without an increase in nephrotoxicity.
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Affiliation(s)
- James Truong
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Shawn R Smith
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - John J Veillette
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Steven C Forland
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.,Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA, USA.,Loma Linda University School of Medicine, Loma Linda, CA, USA
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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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