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Chihara S, Ishigo T, Kazuma S, Matsumoto K, Morita K, Masuda Y. Association between Extended Meropenem Regimen and Achievement of Aggressive PK/PD in Patients Receiving Continuous Renal Replacement Therapy for Septic AKI. Antibiotics (Basel) 2024; 13:755. [PMID: 39200055 PMCID: PMC11350760 DOI: 10.3390/antibiotics13080755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/01/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024] Open
Abstract
Aggressive pharmacokinetic (PK)/pharmacodynamic (PD) targets have shown better microbiological eradication rates and a lower propensity to develop resistant strains than conservative targets. We investigated whether meropenem blood levels, including aggressive PK/PD, were acceptable in terms of efficacy and safety using a meropenem regimen of 1 g infusion every 8 h over 3 h in patients undergoing continuous renal replacement therapy (CRRT) for septic acute kidney injury (AKI). Aggressive PK/PD targets were defined as the percentage of time that the free concentration (%fT) > 4 × minimal inhibitory concentration (MIC), the toxicity threshold was defined as a trough concentration >45 mg/L, and the percentage of achievement at each MIC was evaluated. The 100% fT > 4 × MIC for a pathogen with an MIC of 0.5 mg/L was 89%, and that for a pathogen with an MIC of 2 mg/L was 56%. The mean steady-state trough concentration of meropenem was 11.9 ± 9.0 mg/L and the maximum steady-state trough concentration was 29.2 mg/L. Simulations using Bayesian estimation showed the probability of achieving 100% fT > 4 × MIC for up to an MIC of 2 mg/L for the administered administration via continuous infusion at 3 g/24 h. We found that an aggressive PK/PD could be achieved up to an MIC of 0.5 mg/L with a meropenem regimen of 1 g infused every 8 h over 3 h for patients receiving CRRT for septic AKI. In addition, the risk of reaching the toxicity range with this regimen is low. In addition, if the MIC was 1-2 mg/L, the simulation results indicated that aggressive PK/PD can be achieved by continuous infusion at 3 g/24 h without increasing the daily dose.
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Affiliation(s)
- Shinya Chihara
- Department of Intensive Care Medicine, Sapporo Medical University, School of Medicine, Sapporo 060-8543, Japan; (S.C.); (Y.M.)
- Department of Clinical Engineering, Japan Health Care University Faculty of Health Sciences, Sapporo 062-0053, Japan
| | - Tomoyuki Ishigo
- Department of Pharmacy, Sapporo Medical University Hospital, Sapporo 060-8543, Japan; (T.I.)
| | - Satoshi Kazuma
- Department of Intensive Care Medicine, Sapporo Medical University, School of Medicine, Sapporo 060-8543, Japan; (S.C.); (Y.M.)
| | - Kana Matsumoto
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women’s College of Liberal Arts, Kyotanabe 610-0395, Japan; (K.M.); (K.M.)
| | - Kunihiko Morita
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Doshisha Women’s College of Liberal Arts, Kyotanabe 610-0395, Japan; (K.M.); (K.M.)
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University, School of Medicine, Sapporo 060-8543, Japan; (S.C.); (Y.M.)
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Meng Q, Wang Y, Long Y, Wang Q, Gao Y, Tian J, Wu C, Xie B. The New Delhi metallo-β-lactamase-1 biosensor rapidly and accurately detected antibiotic plasma concentrations in cefuroxime-treated patients. Int J Antimicrob Agents 2024; 64:107229. [PMID: 38823493 DOI: 10.1016/j.ijantimicag.2024.107229] [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: 02/27/2024] [Revised: 05/05/2024] [Accepted: 05/28/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVES Therapeutic drug monitoring (TDM) of β-lactam antibiotics in critically ill patients may benefit dose optimisation, thus improving therapeutic outcomes. However, rapidly and accurately detecting these antibiotics in blood remains a challenge. This research group recently developed a thermometric biosensor called the New Delhi metallo-β-lactamase-1 (NDM-1) biosensor, which detects multiple classes of β-lactam antibiotics in spiked plasma samples. METHODS This study assessed the NDM-1 biosensor's effectiveness in detecting plasma concentrations of β-lactam antibiotics in treated patients. Seven patients receiving cefuroxime were studied. Plasma samples collected pre- and post-antibiotic treatment were analysed using the NDM-1 biosensor and compared with liquid chromatography coupled with ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). RESULTS The biosensor detected plasma samples without dilution, and a brief pre-treatment using a polyvinylidene fluoride filter significantly lowered matrix effects, reducing the running time to 5-8 minutes per sample. The assay's linear range for cefuroxime (6.25-200 mg/L) covered target concentrations during the trough phase of pharmacokinetics in critically ill patients. The pharmacokinetic properties of cefuroxime in treated patients determined by the NDM-1 biosensor and the UPLC-MS/MS were comparable, and the cefuroxime plasma concentrations measured by the two methods showed statistically good consistency. CONCLUSION These data demonstrate that the NDM-1 biosensor assay is a fast, sensitive, and accurate method for detecting cefuroxime plasma concentrations in treated patients and highlights the NDM-1 biosensor as a promising tool for on-site TDM of β-lactam antibiotics in critically ill patients.
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Affiliation(s)
- Qinglai Meng
- Institute of Biomedical Sciences, The Key Laboratory of Chemical Biology and Molecular Engineering of National Ministry of Education, Shanxi Provincial Key Laboratory of Medical Molecular Cell Biology, Shanxi University, Taiyuan, China.
| | - Yao Wang
- Institute of Biomedical Sciences, The Key Laboratory of Chemical Biology and Molecular Engineering of National Ministry of Education, Shanxi Provincial Key Laboratory of Medical Molecular Cell Biology, Shanxi University, Taiyuan, China
| | - Yali Long
- Hospital of Shanxi University, Shanxi University, Taiyuan, China
| | - Qi Wang
- Modern Research Center for Traditional Chinese Medicine, Shanxi University and Shanxi Key Laboratory of Active Constituents Research and Utilization of TCM, Shanxi University, Taiyuan, China
| | - Yajing Gao
- Institute of Biomedical Sciences, The Key Laboratory of Chemical Biology and Molecular Engineering of National Ministry of Education, Shanxi Provincial Key Laboratory of Medical Molecular Cell Biology, Shanxi University, Taiyuan, China
| | - Junsheng Tian
- Modern Research Center for Traditional Chinese Medicine, Shanxi University and Shanxi Key Laboratory of Active Constituents Research and Utilization of TCM, Shanxi University, Taiyuan, China
| | - Changxin Wu
- Institute of Biomedical Sciences, The Key Laboratory of Chemical Biology and Molecular Engineering of National Ministry of Education, Shanxi Provincial Key Laboratory of Medical Molecular Cell Biology, Shanxi University, Taiyuan, China.
| | - Bin Xie
- Pure and Applied Biochemistry, Department of Chemistry, Lund University, Lund, Sweden.
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Roger C. Understanding antimicrobial pharmacokinetics in critically ill patients to optimize antimicrobial therapy: A narrative review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:287-298. [PMID: 39035618 PMCID: PMC11258509 DOI: 10.1016/j.jointm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 07/23/2024]
Abstract
Effective treatment of sepsis not only demands prompt administration of appropriate antimicrobials but also requires precise dosing to enhance the likelihood of patient survival. Adequate dosing refers to the administration of doses that yield therapeutic drug concentrations at the infection site. This ensures a favorable clinical and microbiological response while avoiding antibiotic-related toxicity. Therapeutic drug monitoring (TDM) is the recommended approach for attaining these goals. However, TDM is not universally available in all intensive care units (ICUs) and for all antimicrobial agents. In the absence of TDM, healthcare practitioners need to rely on several factors to make informed dosing decisions. These include the patient's clinical condition, causative pathogen, impact of organ dysfunction (requiring extracorporeal therapies), and physicochemical properties of the antimicrobials. In this context, the pharmacokinetics of antimicrobials vary considerably between different critically ill patients and within the same patient over the course of ICU stay. This variability underscores the need for individualized dosing. This review aimed to describe the main pathophysiological changes observed in critically ill patients and their impact on antimicrobial drug dosing decisions. It also aimed to provide essential practical recommendations that may aid clinicians in optimizing antimicrobial therapy among critically ill patients.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Nîmes, France
- UR UM 103 IMAGINE (Initial Management and prévention of orGan failures IN critically ill patiEnts), Faculty of Medicine, Montpellier University, Montpellier, France
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4
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Barreto EF, Chang J, Rule AD, Mara KC, Meade LA, Paul J, Jannetto PJ, Athreya AP, Scheetz MH. Impact of Various Estimated Glomerular Filtration Rate Equations on the Pharmacokinetics of Meropenem in Critically Ill Adults. Crit Care Explor 2023; 5:e1011. [PMID: 38107538 PMCID: PMC10723891 DOI: 10.1097/cce.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
IMPORTANCE Meropenem dosing is typically guided by creatinine-based estimated glomerular filtration rate (eGFR), but creatinine is a suboptimal GFR marker in the critically ill. OBJECTIVES This study aimed to develop and qualify a population pharmacokinetic model for meropenem in critically ill adults and to determine which eGFR equation based on creatinine, cystatin C, or both biomarkers best improves model performance. DESIGN SETTING AND PARTICIPANTS This single-center study evaluated adults hospitalized in an ICU who received IV meropenem from 2018 to 2022. Patients were excluded if they had acute kidney injury, were on kidney replacement therapy, or were treated with extracorporeal membrane oxygenation. Two cohorts were used for population pharmacokinetic modeling: a richly sampled development cohort (n = 19) and an opportunistically sampled qualification cohort (n = 32). MAIN OUTCOMES AND MEASURES A nonlinear mixed-effects model was developed using parametric methods to estimate meropenem serum concentrations. RESULTS The best-fit structural model in the richly sampled development cohort was a two-compartment model with first-order elimination. The final model included time-dependent weight normalized to a 70-kg adult as a covariate for volume of distribution (Vd) and time-dependent eGFR for clearance. Among the eGFR equations evaluated, eGFR based on creatinine and cystatin C expressed in mL/min best-predicted meropenem clearance. The mean (se) Vd in the final model was 18.2 (3.5) liters and clearance was 11.5 (1.3) L/hr. Using the development cohort as the Bayesian prior, the opportunistically sampled cohort demonstrated good accuracy and low bias. CONCLUSIONS AND RELEVANCE Contemporary eGFR equations that use both creatinine and cystatin C improved meropenem population pharmacokinetic model performance compared with creatinine-only or cystatin C-only eGFR equations in adult critically ill patients.
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Affiliation(s)
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
- Department of Pharmacy, Northwestern Medicine, Chicago, IL
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Laurie A Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Johar Paul
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Arjun P Athreya
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
- Department of Pharmacy, Northwestern Medicine, Chicago, IL
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Kanji S, Roger C, Taccone FS, Muller L. Practical considerations for individualizing drug dosing in critically ill adults receiving renal replacement therapy. Pharmacotherapy 2023; 43:1194-1205. [PMID: 37491976 DOI: 10.1002/phar.2858] [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: 12/12/2022] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 07/27/2023]
Abstract
Critically ill patients with sepsis admitted to the intensive care unit (ICU) often present with or develop renal dysfunction requiring renal replacement therapy (RRT) in addition to antimicrobial therapy. While early and appropriate antimicrobials for sepsis have been associated with an increased probability of survival, adequate dosing is also required in these patients. Adequate dosing of antimicrobials refers to dosing strategies that achieve serum drug levels at the site of infection that are able to provide a microbiological and/or clinical response while avoiding toxicity from excessive antibiotic exposure. Therapeutic drug monitoring (TDM) is the recommended strategy to achieve this goal, however, TDM is not routinely available in all ICUs and for all antimicrobials. In the absence of TDM, clinicians are therefore required to make dosing decisions based on the clinical condition of the patient, the causative organism, the characteristics of RRT, and an understanding of the physicochemical properties of the antimicrobial. Pharmacokinetics (PK) of antimicrobials can be highly variable between critically ill patients and also within the same patient over the course of their ICU stay. The initiation of RRT, which can be in the form of intermittent hemodialysis, continuous, or prolonged intermittent therapy, further complicates the predictability of drug disposition. This variability highlights the need for individualized dosing. This review highlights the practical considerations for the clinician for antimicrobial dosing in critically ill patients receiving RRT.
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Affiliation(s)
- Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Claire Roger
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
- UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laurent Muller
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
- UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
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Pavia K, Hambrick HR, Paice K, Tang P, Punt N, Kaplan J, Goldstein SL, Vinks AA, Mizuno T, Tang Girdwood S. Cefepime pharmacokinetics in critically ill children and young adults undergoing continuous kidney replacement therapy. J Antimicrob Chemother 2023; 78:2140-2147. [PMID: 37466170 PMCID: PMC10477133 DOI: 10.1093/jac/dkad192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/05/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Cefepime is an antibiotic commonly used to treat sepsis and is cleared by renal excretion. Cefepime dosing requires adjustment in patients with decreased kidney function and in those receiving continuous kidney replacement therapy (CKRT). We aimed to characterize cefepime PK in a diverse cohort of critically ill paediatric patients on CKRT. METHODS Patients were identified from an ongoing pharmacokinetic/pharmacodynamic (PK/PD) study of beta-lactam antibiotics, and were included if they had received at least two cefepime doses in the ICU and were on CKRT for at least 24 h. PK parameters were estimated using MwPharm++ with Bayesian estimation and a paediatric population PK model. Target attainment was assessed as time of free cefepime concentrations above minimum inhibitory concentration (fT > 1× or 4 × MIC). RESULTS Seven patients were included in the study (ages 2 to 20 years). CKRT indications included liver failure (n = 1), renal failure (n = 4) and fluid overload (n = 2). Total effluent flow rates ranged from 1833 to 3115 (mean 2603) mL/1.73 m2/h, while clearance was 2.11-3.70 (mean 3.0) L/h/70 kg. Effluent flows were lower, but clearance and fT > MIC were similar to paediatric data published previously. Using Pseudomonas aeruginosa MIC breakpoints, all patients had 100% of dosing interval above MIC, but only one had 100% of dosing interval above 4× MIC. CONCLUSIONS Since most patients failed to attain stringent targets of 100% fT > 4× MIC, model-informed precision dosing may benefit such patients.
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Affiliation(s)
- Kathryn Pavia
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - H Rhodes Hambrick
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kelli Paice
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Tang
- Division of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nieko Punt
- University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, The Netherlands
- Medimatics, Maastricht, The Netherlands
| | - Jennifer Kaplan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sonya Tang Girdwood
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Behal ML, Flannery AH, Barreto EF. Medication Management in the Critically Ill Patient with Acute Kidney Injury. Clin J Am Soc Nephrol 2023; 18:1080-1088. [PMID: 36723347 PMCID: PMC10564345 DOI: 10.2215/cjn.0000000000000101] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
ABSTRACT AKI occurs frequently in critically ill patients. Patients with AKI, including those who require KRT, experience multiple pharmacokinetic and pharmacodynamic perturbations that dynamically influence medication effectiveness and safety. Patients with AKI may experience both subtherapeutic drug concentrations, which lead to ineffective therapy, and supratherapeutic drug concentrations, which increase the risk for toxicity. In critically ill patients with AKI not requiring KRT, conventional GFR estimation equations, especially those based on serum creatinine, have several limitations that can limit the accuracy when used for medication dosing. Alternative methods to estimate kidney function may be informative, including use of measured urinary creatinine clearance, kinetic eGFR, and equations that integrate novel kidney biomarkers. For critically ill patients with AKI requiring KRT, physicochemical properties of the drug, the KRT prescription and circuit configuration, and patient-specific factors each contribute to medication clearance. Evidence-based guidance for medication dosing during AKI requiring KRT is often limited. A working knowledge of the basic tenets of drug elimination during KRT can provide a framework for how to approach decision making when the literature is lacking. Iterative re-evaluation of a patient's progress toward therapeutic goals with a medication must occur over the arc of critical illness, including and especially in the setting of dynamic kidney function.
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Affiliation(s)
- Michael L. Behal
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
| | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky
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Schatz LM, Brinkmann A, Röhr A, Frey O, Greppmair S, Weinelt F, Zoller M, Scharf C, Hempel G, Liebchen U. Systematic Evaluation of Pharmacokinetic Models for Model-Informed Precision Dosing of Meropenem in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2023; 67:e0010423. [PMID: 37125925 DOI: 10.1128/aac.00104-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
The altered pharmacokinetics of renally cleared drugs such as meropenem in critically ill patients receiving continuous renal replacement therapy (CRRT) might impact target attainment. Model-informed precision dosing (MIPD) is applied to individualize meropenem dosing. However, most population pharmacokinetic (PopPK) models developed to date have not yet been evaluated for MIPD. Eight PopPK models based on adult CRRT patients were identified in a systematic literature research and encoded in NONMEM 7.4. A data set of 73 CRRT patients from two different study centers was used to evaluate the predictive performance of the models using simulation and prediction-based diagnostics for i) a priori dosing based on patient characteristics only and ii) Bayesian dosing by including the first measured trough concentration. Median prediction error (MPE) for accuracy within |20%| (95% confidence intervals including zero) and median absolute prediction error (MAPE) for precision ≤ 30% were considered clinically acceptable. For a priori dosing, most models (n = 5) showed accuracy and precision MPE within |20%| and MAPE <35%. The integration of the first measured meropenem concentration improved the predictive performance of all models (median MAPE decreased from 35.4 to 25.0%; median MPE decreased from 21.8 to 4.6%). The best predictive performance for intermittent infusion was observed for the O'Jeanson model, including residual diuresis as covariate (a priori and Bayesian dosing MPE within |2%|, MAPE <30%). Our study revealed the O'Jeanson model as the best-predicting model for intermittent infusion. However, most of the selected PopPK models are suitable for MIPD in CRRT patients when one therapeutic drug monitoring sample is available.
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Affiliation(s)
- Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka Röhr
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian Greppmair
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
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Teixeira JP, Neyra JA, Tolwani A. Continuous KRT: A Contemporary Review. Clin J Am Soc Nephrol 2023; 18:256-269. [PMID: 35981873 PMCID: PMC10103212 DOI: 10.2215/cjn.04350422] [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] [Indexed: 11/23/2022]
Abstract
AKI is a common complication of critical illness and is associated with substantial morbidity and risk of death. Continuous KRT comprises a spectrum of dialysis modalities preferably used to provide kidney support to patients with AKI who are hemodynamically unstable and critically ill. The various continuous KRT modalities are distinguished by different mechanisms of solute transport and use of dialysate and/or replacement solutions. Considerable variation exists in the application of continuous KRT due to a lack of standardization in how the treatments are prescribed, delivered, and optimized to improve patient outcomes. In this manuscript, we present an overview of the therapy, recent clinical trials, and outcome studies. We review the indications for continuous KRT and the technical aspects of the treatment, including continuous KRT modality, vascular access, dosing of continuous KRT, anticoagulation, volume management, nutrition, and continuous KRT complications. Finally, we highlight the need for close collaboration of a multidisciplinary team and development of quality assurance programs for the provision of high-quality and effective continuous KRT.
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Affiliation(s)
- J. Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Javier A. Neyra
- Division of Nephrology, Bone, and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita Tolwani
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Toy C, Stimes G, Moore M, Srivaths P, Arikan AA. Cefepime Dosing in a Critically Ill Neonate Receiving Continuous Renal Replacement Therapy With the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM). J Pediatr Pharmacol Ther 2023; 28:167-171. [PMID: 37139247 PMCID: PMC10150901 DOI: 10.5863/1551-6776-28.2.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/22/2022] [Indexed: 05/05/2023]
Abstract
We report on a former 27-week gestational age infant who was placed on the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) at 4 months post-menstrual age while receiving cefepime treatment for an Enterobacter cloacae bacteremia and persistent peritonitis secondary to an infected peritoneal dialysis catheter. Using therapeutic drug monitoring while assessing the clearance of cefepime on continuous renal replacement therapy (CRRT), we were able to successfully treat this patient's infection while also minimizing the risk of side effects from this medication. Current literature supports dosing in adult patients on all modalities of CRRT with effluent flow rates of 20 to 25 mL/kg/hr; however, pharmacokinetic data on cefepime dosing in pediatric CRRT are scant. This case report describes the successful dosing strategy used for this patient while on various rates of continuous veno-venous hemodialysis with CARPEDIEM. Therapeutic drug monitoring of cefepime should be considered in critically ill pediatric patients on CARPEDIEM receiving CRRT.
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Affiliation(s)
- Cynthia Toy
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Grant Stimes
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Megan Moore
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Renal Section (PS, AAA), Baylor College of Medicine, Houston, TX
| | - Ayse Akcan Arikan
- Department of Pediatrics, Renal Section (PS, AAA), Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Section of Critical Care Medicine (AAA), Baylor College of Medicine, Houston, TX
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11
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Pereira JG, Fernandes J, Duarte AR, Fernandes SM. β-Lactam Dosing in Critical Patients: A Narrative Review of Optimal Efficacy and the Prevention of Resistance and Toxicity. Antibiotics (Basel) 2022; 11:antibiotics11121839. [PMID: 36551496 PMCID: PMC9774837 DOI: 10.3390/antibiotics11121839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Antimicrobial prescription in critically ill patients represents a complex challenge due to the difficult balance between infection treatment and toxicity prevention. Underexposure to antibiotics and therapeutic failure or, conversely, drug overexposure and toxicity may both contribute to a worse prognosis. Moreover, changes in organ perfusion and dysfunction often lead to unpredictable pharmacokinetics. In critically ill patients, interindividual and intraindividual real-time β-lactam antibiotic dose adjustments according to the patient's condition are critical. The continuous infusion of β-lactams and the therapeutic monitoring of their concentration have both been proposed to improve their efficacy, but strong data to support their use are still lacking. The knowledge of the pharmacokinetic/pharmacodynamic targets is poor and is mostly based on observational data. In patients with renal or hepatic failure, selecting the right dose is even more tricky due to changes in drug clearance, distribution, and the use of extracorporeal circuits. Intermittent usage may further increase the dosing conundrum. Recent data have emerged linking overexposure to β-lactams to central nervous system toxicity, mitochondrial recovery delay, and microbiome changes. In addition, it is well recognized that β-lactam exposure facilitates resistance selection and that correct dosing can help to overcome it. In this review, we discuss recent data regarding real-time β-lactam antibiotic dose adjustment, options in special populations, and the impacts on mitochondria and the microbiome.
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Affiliation(s)
- João Gonçalves Pereira
- Hospital Vila Franca de Xira, 2600-009 Vila Franca de Xira, Portugal
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Correspondence: ; Tel.: +351-96-244-1546
| | - Joana Fernandes
- Centro Hospitalar de Trás-os-Montes e Alto Douro, 5000-508 Vila Real, Portugal
| | - Ana Rita Duarte
- Nova Medical School, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal
| | - Susana Mendes Fernandes
- Grupo de Investigação e Desenvolvimento em Infeção e Sépsis, 4450-681 Matosinhos, Portugal
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina, Universidade de Lisboa, 1649-004 Lisboa, Portugal
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12
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Pais GM, Chang J, Barreto EF, Stitt G, Downes KJ, Alshaer MH, Lesnicki E, Panchal V, Bruzzone M, Bumanglag AV, Burke SN, Scheetz MH. Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet 2022; 61:929-953. [PMID: 35764774 PMCID: PMC9345683 DOI: 10.1007/s40262-022-01137-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
Cefepime is a broad-spectrum fourth-generation cephalosporin with activity against Gram-positive and Gram-negative pathogens. It is generally administered as an infusion over 30-60 min or as a prolonged infusion with infusion times from 3 h to continuous administration. Cefepime is widely distributed in biological fluids and tissues with an average volume of distribution of ~ 0.2 L/kg in healthy adults with normal renal function. Protein binding is relatively low (20%), and elimination is mainly renal. About 85% of the dose is excreted unchanged in the urine, with an elimination half-life of 2-2.3 h. The pharmacokinetics of cefepime is altered under certain pathophysiological conditions, resulting in high inter-individual variability in cefepime volume of distribution and clearance, which poses challenges for population dosing approaches. Consequently, therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, or are infected with more resistant pathogens. Cefepime is generally safe and efficacious, with a goal exposure target of 70% time of the free drug concentration over the minimum inhibitory concentration for clinical efficacy. In recent years, reports of neurotoxicity have increased, specifically in patients with impaired renal function. This review summarizes the pharmacokinetics, pharmacodynamics, and toxicodynamics of cefepime contemporarily in the setting of increasing cefepime exposures. We explore the potential benefits of extended or continuous infusions and therapeutic drug monitoring in special populations.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | | | - Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Lesnicki
- College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Vaidehi Panchal
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Argyle V Bumanglag
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sara N Burke
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA.
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13
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Honore PM, Redant S, Djimafo P, Preseau T, Cismas BV, Kaefer K, Barreto Gutierrez L, Anane S, Gallerani A, Attou R. Letter to the Editor : "An optimal extended-infusion dosing of cefepime and ceftazidime in critically ill patients with continuous renal replacement therapy". J Crit Care 2022; 70:154058. [PMID: 35561558 DOI: 10.1016/j.jcrc.2022.154058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Patrick M Honore
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Sebastien Redant
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Pharan Djimafo
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Thierry Preseau
- ED Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | | | - Keitiane Kaefer
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | | | - Sami Anane
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Andrea Gallerani
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Rachid Attou
- ICU Dept, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
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Selig DJ, DeLuca JP, Chung KK, Pruskowski KA, Livezey JR, Nadeau RJ, Por ED, Akers KS. Pharmacokinetics of piperacillin and tazobactam in critically Ill patients treated with continuous kidney replacement therapy: A mini-review and population pharmacokinetic analysis. J Clin Pharm Ther 2022; 47:1091-1102. [PMID: 35352374 PMCID: PMC9544041 DOI: 10.1111/jcpt.13657] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/16/2022] [Accepted: 03/04/2022] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Timely and appropriate dosing of antibiotics is essential for the treatment of bacterial sepsis. Critically ill patients treated with continuous kidney replacement therapy (CKRT) often have physiologic derangements that affect pharmacokinetics (PK) of antibiotics and dosing may be challenging. We sought to aggregate previously published piperacillin and tazobactam (pip-tazo) pharmacokinetic data in critically ill patients undergoing CKRT to better understand pharmacokinetics of pip-tazo in this population and better inform dosing. METHODS The National Library of Medicine Database was searched for original research containing piperacillin or tazobactam clearance (CL) or volume of distribution (V) estimates in patients treated with CKRT. The search yielded 77 articles, of which 26 reported suitable estimates of CL or V. Of the 26 articles, 10 for piperacillin and 8 for tazobactam had complete information suitable for population pharmacokinetic modelling. Also included in the analysis was piperacillin and tazobactam PK data from 4 critically ill patients treated with CKRT in the Military Health System, 2 with burn and 2 without burn. RESULTS AND DISCUSSION Median and range of literature reported PK parameters for piperacillin (CL 2.76 L/hr, 1.4-7.92 L/hr, V 31.2 L, 16.77-42.27 L) and tazobactam (CL 2.34 L/hr, 0.72-5.2 L/hr, V 36.6 L, 26.2-58.87 L) were highly consistent with population estimates (piperacillin CL 2.7 L/hr, 95%CI 1.99-3.41 L/hr, V 25.83 22.07-29.59 L, tazobactam CL 2.49 L/hr, 95%CI 1.55-3.44, V 30.62 95%CI 23.7-37.54). The proportion of patients meeting pre-defined pharmacodynamic (PD) targets (median 88.7, range 71%-100%) was high despite significant mortality (median 44%, range 35%-60%). High mortality was predicted by baseline severity of illness (median APACHE II score 23, range 21-33.25). Choice of lenient or strict PD targets (ie 100%fT >MIC or 100%fT >4XMIC) had the largest impact on probability of target attainment (PTA), whereas presence or intensity of CKRT had minimal impact on PTA. WHAT IS NEW AND CONCLUSION Pip-tazo overexposure may be associated with increased mortality, although this is confounded by baseline severity of illness. Achieving adequate pip-tazo exposure is essential; however, risk of harm from overexposure should be considered when choosing a PD target and dose. If lenient PD targets are desired, doses of 2250-3375 mg every 6 h are reasonable for most patients receiving CKRT. However, if a strict PD target is desired, continuous infusion (at least 9000-13500 mg per day) may be required. However, some critically ill CKRT populations may need higher or lower doses and dosing strategies should be tailored to individuals based on all available clinical data including the specific critical care setting.
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Affiliation(s)
- Daniel J Selig
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Jesse P DeLuca
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kaitlin A Pruskowski
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,United States Army Institute of Surgical Research, US Army Burn Center, San Antonio, Texas, USA
| | - Jeffrey R Livezey
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Robert J Nadeau
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Elaine D Por
- Walter Reed Army Institute of Research, Experimental Therapeutics, Silver Spring, Maryland, USA
| | - Kevin S Akers
- United States Army Institute of Surgical Research, US Army Burn Center, San Antonio, Texas, USA
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15
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Gorham J, Taccone FS, Hites M. Ensuring target concentrations of antibiotics in critically ill patients through dose adjustment. Expert Opin Drug Metab Toxicol 2022; 18:177-187. [PMID: 35311440 DOI: 10.1080/17425255.2022.2056012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Antibiotics are commonly prescribed in critical care, and given the large variability of pharmacokinetic (PK) parameters in these patients, drug PK frequently varies during therapy with the risk of either treatment failure or toxicity. Therefore, adequate antibiotic dosing in critically ill patients is very important. AREAS COVERED This review provides an overview of the basic principles of PK and pharmacodynamics of antibiotics and the main patient and pathogen characteristics that may affect the dosage of antibiotics and different approaches to adjust doses. EXPERT OPINION Dose adjustment should be done for aminoglycosides and glycopeptides based on daily drug concentration monitoring. For glycopeptides, in particular vancomycin, the residual concentration (Cres) should be assessed daily. For beta-lactam antibiotics, a loading dose should be administered, followed by three different possible approaches, as TDM is rarely available in most centers: 1) antibiotic regimens should be adapted according to renal function and other risk factors; 2) nomograms or software can be used to calculate daily dosing; 3) TDM should be performed 24-48 h after the initiation of treatment; however, the results are required within 24 hours to appropriately adjust dosage regimens. Drug dosing should be reduced or increased according to the TDM results.
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Affiliation(s)
- Julie Gorham
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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16
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Sember AM, LoFaso ME, Lewis SJ. An optimal extended-infusion dosing of cefepime and ceftazidime in critically ill patients with continuous renal replacement therapy. J Crit Care 2022; 69:154011. [PMID: 35202996 DOI: 10.1016/j.jcrc.2022.154011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE This study aimed to determine optimal extended-infusion dosing regimens for cefepime and ceftazidime in critically ill patients receiving continuous renal replacement therapy using Monte Carlo Simulations (MCS). MATERIALS AND METHODS Pharmacokinetic models were built using published pharmacokinetic/demographic data to predict drug disposition in 5000 virtual critically ill patients receiving continuous venovenous hemofiltration (CVVH) with the standard (20-30 mL/kg/h) and a higher (40 mL/kg/h) effluent rates. MCS was performed to assess the probability of target attainment (PTA) of four cefepime and ceftazidime doses administered over 4-h with the target of ≥60% fT > 4×MIC. The lowest dose attaining PTA ≥90% during the first 48-h was considered optimal. Additionally, risk of drug toxicity was assessed at 48-h using suggested neurotoxicity thresholds. RESULTS Cefepime 2 g loading dose (LD), then extended-infusion of 2 g q8hr was optimal in CVVH at 20 mL/kg/h and the same ceftazidime dose was optimal in CVVH at 20-30 mL/kg/h. Higher cefepime and ceftazidime doses were required to be optimal at higher effluent rates. This optimal dose particularly for cefepime likely increases neurotoxicity risk in most virtual patients with all CVVH settings. CONCLUSIONS Cefepime and ceftazidime 2 g LD, followed by extended-infusion 2 g q8hr may be optimal in CVVH with standard effluent rates.
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Affiliation(s)
| | - Megan E LoFaso
- University of Findlay College of Pharmacy, Findlay, OH, USA
| | - Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA; Department of Pharmacy, Mercy Health - St. Anne Hospital, Toledo, OH, USA.
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17
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Lizza BD, Raush N, Micek ST. Antibiotic Optimization in the Intensive Care Unit. Semin Respir Crit Care Med 2022; 43:125-130. [PMID: 35172362 DOI: 10.1055/s-0041-1740972] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Effective antimicrobial therapy remains paramount to successful treatment of patients with critical illness, such as pneumonia and sepsis. Unfortunately, critically ill patients often exhibit altered pharmacokinetics and pharmacodynamics (PK/PD) that make this endeavor challenging. Particularly in sepsis, alterations in volume of distribution (Vd) and protein binding lead to unpredictable effects on serum levels of various antimicrobials. Additionally, metabolic pathways and excretion may be significantly impacted due to end-organ failure. These dynamic factors may increase the likelihood of deleterious effects such as treatment failure or toxicity. Meeting these challenging scenarios has led to various strategies meant to improve clinical cure without untoward consequences. Vancomycin and β-lactam antimicrobials are frequently utilized and have been the focus of dose optimization strategies including extended infusion (EI) or continuous infusion (CI). Available data suggests that administration of vancomycin by CI may reduce the risk of nephrotoxicity without increasing the risk of treatment failure, although retrospective data are largely utilized in supporting this method. Other efforts to optimize vancomycin have focused on transitioning from trough-based therapeutic drug monitoring (TDM) to area-under-the-curve: minimum inhibitory concentration (AUC:MIC) ratios. Despite the creation of more user-friendly methods of calculation and data suggesting reduced rates of nephrotoxicity, widespread implementation is limited, in part due to clinician comfort. Use of β-lactams in patients with sepsis is similarly problematic due to observational data demonstrating fluctuations in serum levels in the setting of critical illness. Implementing TDM of agents such as piperacillin-tazobactam, cefepime, and meropenem has been suggested as a method of improving time above MIC (T >MIC). This practice is limited by the lack of access to commercial assays and the failure of rigorous studies to demonstrate improved treatment success. Clinicians should be aware of these challenges and should refine their dosing strategies based on individualized patient factors to reduce treatment failure.
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Affiliation(s)
| | - Nick Raush
- Barnes Jewish Hospital, Saint Louis, Missouri.,Forrest General Hospital, Hattiesburg, Mississippi
| | - Scott T Micek
- Barnes Jewish Hospital, Saint Louis, Missouri.,University of Health Sciences and Pharmacy, Saint Louis, Missouri
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18
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Matusik E, Boidin C, Friggeri A, Richard JC, Bitker L, Roberts JA, Goutelle S. Therapeutic Drug Monitoring of Antibiotic Drugs in Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis: A Critical Review. Ther Drug Monit 2022; 44:86-102. [PMID: 34772891 DOI: 10.1097/ftd.0000000000000941] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM. METHODS Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines. RESULTS In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes. CONCLUSIONS Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.
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Affiliation(s)
- Elodie Matusik
- Pôle Pharmacie & Pôle Urgences-Réanimation-Anesthésie, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Pharmacie, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon 1, EA 3738 CICLY - Centre pour l'Innovation en Cancérologie de Lyon, Oullins
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service d'Anesthésie, Médecine Intensive et Réanimation, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon, Faculté de Médecine Lyon Sud-Charles Mérieux, Oullins
- UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, Laboratoire des Pathogènes Émergents
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Jason A Roberts
- Faculty of Medicine the University of Queensland, University of Queensland Centre for Clinical Research
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon ; and
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive Villeurbanne, France
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19
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Matusik E, Lemtiri J, Wabont G, Lambiotte F. Beta-lactam dosing during continuous renal replacement therapy: a survey of practices in french intensive care units. BMC Nephrol 2022; 23:48. [PMID: 35093011 PMCID: PMC8800323 DOI: 10.1186/s12882-022-02678-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/15/2022] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Little information is available on current practice in beta-lactam dosing during continuous renal replacement therapy (CRRT). Optimized dosing is essential for improving outcomes, and there is no consensus on the appropriate dose regimens. The objective of the present study was to describe current practice for beta-lactam dosing during CRRT in intensive care units (ICUs).
Methods
We conducted a nationwide survey by e-mailing an online questionnaire to physicians working in ICUs in France. The questionnaire included three sections: demographic characteristics, CRRT practices, and beta-lactam dosing regimens during CRRT.
Results
157 intensivists completed the questionnaire. Continuous venovenous hemofiltration was the most frequently used CRRT technique, and citrate was the most regularly used anticoagulant. The median prescribed dose at baseline was 30 mL/kg/h. The majority of prescribers (57%) did not reduce beta-lactam dosing during CRRT. The tools were used to adapt dosing regimens during CRRT included guidelines, therapeutic drug monitoring (TDM), and data from the literature. When TDM was used, 100% T > 4 time the MIC was the most common mentioned pharmacokinetic/pharmacodynamic target (53%). Pharmacokinetic software tools were rarely used. Prolonged or continuous infusions were widely used during CRRT (88%). Institutional guidelines on beta-lactam dosing during CRRT were rare. 41% of physicians sometimes consulted another specialist before adapting the dose of antibiotic during CRRT.
Conclusions
Our present results highlight the wide range of beta-lactam dosing practices adopted during CRRT. Personalized TDM and the implementation of Bayesian software appear to be essential for optimizing beta-lactam dosing regimens and improving patient outcomes.
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Caro Y, Van Strate P, Sartorio M, Cámara M, De Zan M. Application of the lifecycle approach to the development and validation of a chromatographic method for therapeutic drug monitoring of ceftazidime, meropenem, and piperacillin. Microchem J 2021. [DOI: 10.1016/j.microc.2021.106692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Applying cefepime population pharmacokinetics on critically ill patients receiving continuous renal replacement therapy. Antimicrob Agents Chemother 2021; 66:e0161121. [PMID: 34662194 DOI: 10.1128/aac.01611-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients admitted to the intensive care unit (ICU) may need continuous renal replacement therapy (CRRT) due to acute kidney injury or worsening of underlying chronic kidney disease. This will affect their antimicrobial exposure and may have a significant impact on the treatment. We aim to develop a cefepime pharmacokinetic (PK) model in CRRT ICU patients and generate the posterior predictions for a group and assess their therapy outcomes. Adult patients, admitted to the ICU, received cefepime, and had its concentration measured while on CRRT were included from three different datasets. In two datasets, samples were collected from the predialyzer, postdialyzer ports, and effluent fluid at different times within the same dosing interval. The third dataset had only cefepime plasma concentration measured as part of clinical service. Patients' demographics, cefepime regimens and concentration, CRRT parameters, and therapy outcomes were recorded. NPAG was used for population PK and posterior predictions. A total of 125 patients were included. Cefepime was described by a five-compartment model, and the CRRT flow rates described the rates of cefepime transfer between compartments. The posterior predictions were generated for the third dataset and the median (range) fT>MIC was 100% (27%-100%) and fT>4×MIC was 64% (0%-100%). The mortality rate was 53%. There was no difference in target attainment in terms of clinical cure and 30-day mortality. This model can be used as a precision dosing tool in CRRT patients. Future studies may address other PK/PD targets in a larger population.
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22
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Peck Palmer OM, Dasgupta A. Review of the Preanalytical Errors That Impact Therapeutic Drug Monitoring. Ther Drug Monit 2021; 43:595-608. [PMID: 33928931 DOI: 10.1097/ftd.0000000000000901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Preanalytical errors comprise the majority of testing errors experienced by clinical laboratories and significantly impact the accuracy of therapeutic drug monitoring (TDM). METHODS Specific preanalytical factors in sample timing, collection, transport, processing, and storage that lead to errors in TDM were reviewed. We performed a literature search using several scientific databases including PubMed, ScienceDirect, Scopus, Web of Science, and ResearchGate for human studies published in the English language from January 1980 to February 2021, reporting on TDM and the preanalytical phase. RESULTS Blood collection errors (ie, wrong anticoagulant/clot activator used, via an intravenous line, incorrect time after dosing) delay testing, cause inaccurate results, and adversely impact patient care. Blood collected in lithium heparin tubes instead of heparin sodium tubes produce supertoxic lithium concentrations, which can compromise care. Specimens collected in serum separator gel tubes cause falsely decreased concentrations due to passive absorption into the gel when samples are not processed and analyzed quickly. Dried blood spots are popular for TDM as they are minimally invasive, allowing for self-sampling and direct shipping to a clinical laboratory using regular mail. However, blood collection techniques, such as trauma to the collection site, filter paper fragility, and hematocrit (Hct) bias, can adversely affect the accuracy of the results. Volumetric absorptive microsampling is a potential alternative to dried blood spot that offers fast, volume-fixed sampling, low pain tolerance, and is not susceptible to Hct concentrations. CONCLUSIONS The identification of preanalytical factors that may negatively impact TDM is critical. Developing workflows that can standardize TDM practices, align appropriate timing and blood collection techniques, and specimen processing will eliminate errors.
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Affiliation(s)
- Octavia M Peck Palmer
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Amitava Dasgupta
- Department of Pathology and Laboratory Medicine, University of Texas McGovern Medical School at Houston, Texas
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Rapid Detection of Multiple Classes of β-Lactam Antibiotics in Blood Using an NDM-1 Biosensing Assay. Antibiotics (Basel) 2021; 10:antibiotics10091110. [PMID: 34572692 PMCID: PMC8468087 DOI: 10.3390/antibiotics10091110] [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: 08/05/2021] [Revised: 09/04/2021] [Accepted: 09/11/2021] [Indexed: 01/23/2023] Open
Abstract
Currently, assays for rapid therapeutic drug monitoring (TDM) of β-lactam antibiotics in blood, which might be of benefit in optimizing doses for treatment of critically ill patients, remain challenging. Previously, we developed an assay for determining the penicillin-class antibiotics in blood using a thermometric penicillinase biosensor. The assay eliminates sample pretreatment, which makes it possible to perform semicontinuous penicillin determinations in blood. However, penicillinase has a narrow substrate specificity, which makes it unsuitable for detecting other classes of β-lactam antibiotics, such as cephalosporins and carbapenems. In order to assay these classes of clinically useful antibiotics, a novel biosensor was developed using New Delhi metallo-β-lactamase-1 (NDM-1) as the biological recognition layer. NDM-1 has a broad specificity range and is capable of hydrolyzing all classes of β-lactam antibiotics in high efficacy with the exception of monobactams. In this study, we demonstrated that the NDM-1 biosensor was able to quantify multiple classes of β-lactam antibiotics in blood plasma at concentrations ranging from 6.25 mg/L or 12.5 mg/L to 200 mg/L, which covered the therapeutic concentration windows of the tested antibiotics used to treat critically ill patients. The detection of ceftazidime and meropenem was not affected by the presence of the β-lactamase inhibitors avibactam and vaborbactam, respectively. Furthermore, both free and protein-bound β-lactams present in the antibiotic-spiked plasma samples were detected by the NDM-1 biosensor. These results indicated that the NDM-1 biosensor is a promising technique for rapid TDM of total β-lactam antibiotics present in the blood of critically ill patients.
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Population Pharmacokinetic Analysis of Meropenem in Critically Ill Patients With Acute Kidney Injury Treated With Continuous Hemodiafiltration. Ther Drug Monit 2021; 42:588-594. [PMID: 32049890 DOI: 10.1097/ftd.0000000000000741] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of this study was to conduct a population pharmacokinetic (PK) analysis of meropenem and to explore the optimal dosing strategy for meropenem in critically ill patients with acute kidney injury receiving treatment with continuous hemodiafiltration (CHDF). METHODS Blood samples were obtained on days 1, 2, and 5 after the start of meropenem administration, immediately before dosing, and at 1, 2, 6, and 8 hours after dosing. Population PK model analysis was performed and concentration-time profiles were simulated using the Nonlinear Mixed Effects Model software. RESULTS Twenty-one patients receiving CHDF in our intensive care unit were enrolled and 350 serum concentration-time data points were obtained. The PKs of meropenem were best described using a 2-compartment model. Typical total and intercompartmental clearance values were 4.22 L/h and 7.84 L/h, respectively, whereas the central and peripheral compartment volumes of distribution were 14.82 L and 11.75 L, respectively. Estimated glomerular filtration rate was identified as a significant covariate of meropenem total clearance. In simulations of patients with renal failure receiving CHDF, the dose was affected by estimated glomerular filtration rate; a dose of 0.5 g every 8 hours or 1 g every 12 hours showed the probability of target attainment of achieving 100% time above the minimum inhibitory concentration for bacteria with a minimum inhibitory concentration ≤2 mg/L. CONCLUSIONS A population PK model was developed for meropenem in critically ill patients with acute kidney injury receiving CHDF. Our results indicated that a meropenem dosage of 0.5 g every 8 hours or 1 g every 12 hours was suitable in this population and for susceptible bacteria.
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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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Cefepime Population Pharmacokinetics and Target Attainment in Critically Ill Patients on Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2021; 65:AAC.00144-21. [PMID: 33722885 DOI: 10.1128/aac.00144-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/08/2021] [Indexed: 12/20/2022] Open
Abstract
Sepsis causes half of acute kidney injuries in the intensive care unit (ICU). ICU patients may need continuous renal replacement therapy (CRRT), which will affect their antimicrobial exposure. We aimed to build a cefepime population pharmacokinetic (PK) model in CRRT ICU patients and perform simulations to assess target attainment. Patients who were ≥18 years old, were admitted to the ICU, and received cefepime 2 g every 8 h as a 4-h infusion while on CRRT were enrolled prospectively. Samples were collected from the predialyzer ports, postdialyzer ports, and effluent fluid at 1, 2, 3, 4, and 8 h after the first dose and at steady state. Age, sex, weight, urine output, and CRRT parameters were recorded. Pmetrics was used for population PK and simulations. The target exposure was 100% of the dosing interval during which the free beta-lactam concentration is above the MIC (fT >MIC). Ten patients were included; their mean age was 53 years, and mean weight was 119 kg. Seventy percent were males. Cefepime was described by a five-compartment model. The downtime was applied to the CRRT flow rates, which were used to describe the rates of transfer between the compartments. At MICs of ≤8 mg/liter, intermittent infusion of 2 g cefepime every 8 h achieved good target attainment both early in therapy and at steady state. Only extended- and continuous-infusion regimens achieved good target attainment at MICs of 16 mg/liter. In conclusion, 2 g cefepime infused over 30 min followed by extended infusion of 2 g every 8 h achieved good target attainment at MICs of ≤16 mg/liter with different CRRT flow rates and may be considered in resistant bacterial infections.
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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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Steffens NA, Zimmermann ES, Nichelle SM, Brucker N. Meropenem use and therapeutic drug monitoring in clinical practice: a literature review. J Clin Pharm Ther 2021; 46:610-621. [PMID: 33533509 DOI: 10.1111/jcpt.13369] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/01/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Meropenem, a carbapenem antibiotic, is widely prescribed for the treatment of life-threatening infections. The main parameter associated with its therapeutic success is the percentage of time that the levels remain above the minimum inhibitory concentration. Inadequate levels of meropenem can lead to therapeutic failure and increase the possibility of microbial resistance. The employment of strategies involving dose regimens and drug pharmacodynamics has become increasingly important to optimize therapies. In the present study, we conducted a review with the purpose of assembling information about the clinical use of meropenem and therapeutic drug monitoring. METHODS A literature review emphasizing the application of therapeutic drug monitoring (TDM) of meropenem in clinical practice has been done. To identify articles related to the topic, we performed a standardized search from January 21, 2020 to December 21, 2020, using specific descriptors in PubMed, Lilacs and Embase. RESULTS AND DISCUSSION In total, 35 studies were included in the review. The daily dose of meropenem commonly ranged from 3 to 6 g/day. Critically ill patients and those with impaired renal function appear to be the most suitable patients for the application of meropenem TDM, in order to guide therapy. We observed that most of the studies recommend TDM and that, in nine locations, the TDM of meropenem and of other beta-lactams is a routine practice. TDM data can help to maximize the clinical outcomes of the treatment with meropenem. It can also improve the patient care by providing suitable levels of meropenem, guiding the most appropriate dose regimens, which is the main parameter associated with therapeutic success. WHAT IS NEW AND CONCLUSION The findings from this review suggest that the therapeutic monitoring of meropenem can be beneficial, since it adjusts the treatment and aids clinical outcomes. It does so by indicating the appropriate dosage and preventing failure, toxicity and possible antimicrobial resistance. The multidisciplinary effort, basic knowledge and communication among the medical team are also essential.
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Affiliation(s)
- Nadine A Steffens
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Estevan S Zimmermann
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida at Lake Nona, Orlando, FL, USA
| | - Sabrina M Nichelle
- Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Natália Brucker
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil.,Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
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[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]. ANNALES PHARMACEUTIQUES FRANÇAISES 2020; 79:346-360. [PMID: 33309603 DOI: 10.1016/j.pharma.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023]
Abstract
Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.
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Neyra JA, Yessayan L, Thompson Bastin ML, Wille KM, Tolwani AJ. How To Prescribe And Troubleshoot Continuous Renal Replacement Therapy: A Case-Based Review. KIDNEY360 2020; 2:371-384. [PMID: 35373031 PMCID: PMC8741005 DOI: 10.34067/kid.0004912020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/14/2020] [Indexed: 02/07/2023]
Abstract
Continuous RRT (CRRT) is the preferred dialysis modality for solute management, acid-base stability, and volume control in patients who are critically ill with AKI in the intensive care unit (ICU). CRRT offers multiple advantages over conventional hemodialysis in the critically ill population, such as greater hemodynamic stability, better fluid management, greater solute control, lower bleeding risk, and a more continuous (physiologic) approach of kidney support. Despite its frequent use, several aspects of CRRT delivery are still not fully standardized, or do not have solid evidence-based foundations. In this study, we provide a case-based review and recommendations of common scenarios and interventions encountered during the provision of CRRT to patients who are critically ill. Specific focus is on initial prescription, CRRT dosing, and adjustments related to severe hyponatremia management, concomitant extracorporeal membrane oxygenation support, dialysis catheter placement, use of regional citrate anticoagulation, and antibiotic dosing. This case-driven simulation is made as the clinical status of the patient evolves, and is on the basis of step-wise decisions made during the care of this patient, according to the specific patient's needs and the logistics available at the corresponding institution.
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Affiliation(s)
- Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lenar Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Melissa L. Thompson Bastin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Keith M Wille
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Chaijamorn W, Rungkitwattanakul D, Pattharachayakul S, Singhan W, Charoensareerat T, Srisawat N. Meropenem dosing recommendations for critically ill patients receiving continuous renal replacement therapy. J Crit Care 2020; 60:285-289. [PMID: 32949895 DOI: 10.1016/j.jcrc.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
PURPOSES To gather available meropenem pharmacokinetics and define drug dosing regimens for Asian critically ill patients receiving CRRT. METHODS All necessary pharmacokinetic and pharmacodynamic data from Asian population were gathered to develop mathematic models with first order elimination. Meropenem concentration-time profiles were calculated to evaluate efficacy based on the probability of target attainment (PTA) of 40%fT>4MIC. A group of 5000 virtual patients was created and tested using Monte Carlo simulations for each dose in the models. The optimal dosing regimens were defined as the doses achieved at least 90% of the PTA. RESULTS The recommended meropenem dosing regimen for Asian critically ill patients receiving CRRT with standard (20-25 mL/kg/h) and high (35 mL/kg/h) effluent rates was 750 mg q 8 h to manage Gram negative infections with expected MIC < 2 mg/L in virtual Asian patients. Some meropenem dosages from available clinical resources could not achieve the aforementioned target. The volume of distribution, body weights and nonrenal clearance significantly contributed to drug dosing adaptation especially in the specific population. CONCLUSIONS A meropenem regimen of 750 mg q 8 h was recommended for Asian critically ill patients receiving 2 different CRRT modalities with standard and high effluent rates. Clinical validation of these results is needed.
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Affiliation(s)
| | - Dhakrit Rungkitwattanakul
- Department of Clinical and Administrative Pharmacy and Sciences Howard University College of Pharmacy, Washington, DC, USA
| | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Wanchana Singhan
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | | | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Academic of Science, Royal Society of Thailand, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Center for Critical Care Nephrology, The CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Early Hemoglobin Status as a Predictor of Long-Term Mortality for Sepsis Patients in Intensive Care Units. Shock 2020; 55:215-223. [PMID: 33433167 DOI: 10.1097/shk.0000000000001612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES It is still not clear what influences hemoglobin has on the outcomes of patients with sepsis. The intention of this research is to investigate the impact of early hemoglobin levels on clinical outcomes for sepsis. METHODS In this single-center, cohort study, each patient was put into one of four groups dependent on hemoglobin levels of 70 g/L, 80 g/L, or 90 g/L in the first 48 h of being admitted to intensive care unit (ICU). Adjustments for baseline/confounding factors were made using the multiple Cox regression model. RESULTS In all, 235 septic patients were examined in this research. The non-survivors exhibited significantly higher levels for early hemoglobin status at or below 80 g/L (33.7% vs. 19.4%, P = 0.016) than survivors. Survival curve demonstrated that septic patients with early hemoglobin levels at or below 80 g/L survived at significantly lower rates than those with hemoglobin above 80 g/L. Multivariate Cox analysis demonstrated that levels of 1-year mortality rose as early hemoglobin levels fell in the first 48 h after ICU admission, with relative risks for 80 g/L to 90 g/L, 70 g/L to 80 g/L, and at or below 70 g/L being respectively 1.11 (95% CI: 0.654-1.882), 1.742 (95% CI: 0.969-3.133), 1.981 (95% CI: 1.124-3.492) times higher than those for hemoglobin levels above 90 g/L. CONCLUSIONS Hemoglobin levels at or below 80 g/L in the first 48 h after ICU admission are an alternative indicator for predicting long-term mortality of sepsis. Awareness should be encouraged of the importance of targeting early hemoglobin levels when treating sepsis to improve prognosis.
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Li L, Li X, Xia Y, Chu Y, Zhong H, Li J, Liang P, Bu Y, Zhao R, Liao Y, Yang P, Lu X, Jiang S. Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy. Front Pharmacol 2020; 11:786. [PMID: 32547394 PMCID: PMC7273837 DOI: 10.3389/fphar.2020.00786] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/12/2020] [Indexed: 12/13/2022] Open
Abstract
Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.
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Affiliation(s)
- Lu Li
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Li
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Yanzhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Haili Zhong
- Department of Pharmacy, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yishan Bu
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Rui Zhao
- School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yun Liao
- Department of Pharmacy, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Yang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Saiping Jiang
- Department of Pharmacy, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
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Crass RL, Rodvold KA, Mueller BA, Pai MP. Renal Dosing of Antibiotics: Are We Jumping the Gun? Clin Infect Dis 2020; 68:1596-1602. [PMID: 30219824 DOI: 10.1093/cid/ciy790] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022] Open
Abstract
Antibiotic renal dose adjustments are determined in patients with stable chronic kidney disease and may not translate to patients in late-phase trials and practice. Ceftolozane/tazobactam, ceftazidime/avibactam, and telavancin all carry precautionary statements for reduced clinical response in patients with baseline creatinine clearance of 30-50 mL/min, potentially due to unnecessary dose reduction in the setting of acute kidney injury (AKI). In this review, we discuss the regulatory landscape for antibiotics eliminated by the kidney and highlight the importance of the first 48 hours of therapy. Using a clinical database, we identified AKI on admission in a substantial proportion of patients with pneumonia (27.1%), intraabdominal (19.5%), urinary tract (20.0%), or skin and skin structure infections (9.7%) that resolved by 48 hours in 57.2% of cases. We suggest that deferred renal dose reduction of wide therapeutic index antibiotics could improve outcomes in patients with infectious diseases.
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Affiliation(s)
- Ryan L Crass
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
| | - Keith A Rodvold
- Departments of Pharmacy Practice and Medicine, Colleges of Pharmacy and Medicine, University of Illinois at Chicago
| | - Bruce A Mueller
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
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Onichimowski D, Będźkowska A, Ziółkowski H, Jaroszewski J, Borys M, Czuczwar M, Wiczling P. Population pharmacokinetics of standard-dose meropenem in critically ill patients on continuous renal replacement therapy: a prospective observational trial. Pharmacol Rep 2020; 72:719-729. [PMID: 32301057 PMCID: PMC7329797 DOI: 10.1007/s43440-020-00104-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 11/30/2022]
Abstract
Background The primary objective of this study was to develop a population pharmacokinetic model of meropenem, based on the population of critically ill adult patients undergoing CRRT. The secondary one was to examine the relationship between patient characteristics (covariates) and individual PK parameters. Finally, we aimed to perform Monte Carlo simulations to assess the probability of target attainment (PTA) of %T > MIC considering the uncertainty of PK parameters. Materials and methods The study population included 19 adult critically ill patients on CRRT, receiving 1 g of meropenem in 1-h infusions every 8 h. Blood samples were collected prior to (time zero) and 15, 30, 45, 60, 75, 90, 120, 180, 240 and 480 min after the start of meropenem administration. Population nonlinear mixed-effects modeling was conducted using NONMEM software, Fortran, and Wings for NONMEM. Results A two-compartment model was used to describe the available data. Typical values of the central and peripheral volume of distribution, and the CRRT and inter-compartmental clearance for a theoretical patient with 24.6 g/l albumin concertation were V1 = 27.9 l, V2 = 33.7 l, ClCRRT = 15.1 l/h, and Q = 21.1 l/h. A significant covariate relationship between V1 and albumin concentration was observed in the data that was described by a power relationship with − 2.87 exponent. Subsequently performed Monte Carlo simulations of the model allowed us to assess the impact of albumin concentration on PTA. The 40%T > 2 mg/l target was reached in more than 90% of subjects after 1-h infusion of 1000 mg q8h and steady-state conditions. The more stringent 100%T > 2 mg/l target requires higher doses and/or longer infusion durations that depend on the albumin concentration. Conclusions The population PK model was successfully developed to describe the time course of meropenem concentrations. The hypoalbuminemia was found to be associated with higher PTA in the CRRT patients after multiple short-term infusions. Electronic supplementary material The online version of this article (10.1007/s43440-020-00104-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dariusz Onichimowski
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Warmia and Mazury, Ul. Żołnierska 18, 10-900, Olsztyn, Poland.
| | - Anita Będźkowska
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Gdańsk, Poland
| | - Hubert Ziółkowski
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Jerzy Jaroszewski
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Michał Borys
- 2nd Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Mirosław Czuczwar
- 2nd Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Paweł Wiczling
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Gdańsk, Poland
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Caro Y, Cámara M, De Zan M. A review of bioanalytical methods for the therapeutic drug monitoring of β-lactam antibiotics in critically ill patients: Evaluation of the approaches used to develop and validate quality attributes. Talanta 2020; 210:120619. [DOI: 10.1016/j.talanta.2019.120619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022]
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Al-Sunaidar KA, Prof Abd Aziz N, Prof Hassan Y. Appropriateness of empirical antibiotics: risk factors of adult patients with sepsis in the ICU. Int J Clin Pharm 2020; 42:527-538. [PMID: 32144611 DOI: 10.1007/s11096-020-01005-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 02/22/2020] [Indexed: 12/29/2022]
Abstract
Background The appropriateness of antibiotics is the basis for improving the survival of patients with sepsis. Objective This study aimed to determine the appropriateness of empirical antibiotics, reasons for non-appropriate empirical antibiotics, risk factors of mortality, length of stay in intensive care unit (ICU-LOS) and Acute Physiology And Chronic Health Evaluation II (APACHE II) score predictors in adult patients with sepsis. Setting An adult ICU of a tertiary hospital in Malaysia. Methods A retrospective cohort study was conducted amongst patients with sepsis. Data were retrieved from the patients' files and computer system. Each case was reviewed for the appropriateness of empirical antibiotics based on ICU local guidelines, bacterial sensitivity, dose, frequency, creatinine clearance and time of administration of empirical antibiotics. Multivariable logistic and Cox regression modelling were performed to compute the adjusted association of receiving appropriate or inappropriate empirical antibiotics with ICU mortality. Multivariable linear regression modelling was performed using ICU-LOS and APACHE II scores. Main outcome measures were ICU mortality, severity score (APACHE II scores) and ICU-LOS. Results The total mortality rate amongst the 228 adult ICU patients was 84.6%. Males showed a higher mortality rate (119 [52.2%]) than females (74 [32.5%]). Inappropriate empirical antibiotics were significantly associated with mortality and ICU-LOS (P < 0.005). Results from multivariable logistic regression showed that the appropriateness of empirical antibiotics model was a potential predictor for survival (OR 0.395, 95% CI 0.184-0.850, P < 0.005). Results from simple linear regression indicated that the appropriateness of empirical antibiotics model was a remarkable predictor of decreasing ICU-LOS (R2 = 0.055, 95% CI - 7.184 to - 2.114, P < 0.001). Results from simple Cox regression suggested that the appropriateness of empirical antibiotics was a protective factor for ICU mortality (HR 0.610, 95% CI 0.433-0.858, P = 0.005). Multivariable Cox regression revealed that the administration of antibiotics exceeding the recommended dose based on creatinine clearance was a protective factor (HR 0.186, 95% CI 0.040-0.868, P = 0.032). Conclusion The appropriateness of empirical antibiotics is a good predictor for improving survival and decreasing ICU-LOS. Effective appropriateness of empirical antibiotics use and close adherence to the recommended dose can prevent the early mortality of patients with sepsis and acute renal failure.
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Affiliation(s)
- Khalid Ahmad Al-Sunaidar
- Faculty of Pharmacy-Universiti Teknologi Mara - Puncak Alam Campus, 42300, FF1, Level 10, Bandar Puncak Alam, Puncak Alam, Selangor, Malaysia.
| | - Noorizan Prof Abd Aziz
- Faculty of Pharmacy-Universiti Teknologi Mara - Puncak Alam Campus, 42300, FF1, Level 10, Bandar Puncak Alam, Puncak Alam, Selangor, Malaysia
| | - Yahaya Prof Hassan
- Faculty of Pharmacy-Universiti Teknologi Mara - Puncak Alam Campus, 42300, FF1, Level 10, Bandar Puncak Alam, Puncak Alam, Selangor, Malaysia
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Annoni F, Grimaldi D, Taccone FS. Individualized antibiotic therapy in the treatment of severe infections. Expert Rev Anti Infect Ther 2019; 18:27-35. [PMID: 31755789 DOI: 10.1080/14787210.2020.1696192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Sepsis is a frequent and life-threatening clinical entity and antibiotic treatment is one of the most important interventions, together with source control and hemodynamic resuscitation. Guidelines have highlighted the importance of an early (i.e. within 1-3 h from recognition) and appropriate (i.e. the pathogen is sensitive in vitro to the administered drug) antimicrobial therapy in this setting.Areas covered: Antibiotic therapy should be individualized according to several issues, including early pathogen identification, optimal drug regimens based on pharmacokinetic/pharmacodynamics (PK/PD) and adequate duration using both clinical and biological biomarkers. This narrative review has considered the most relevant studies evaluating these issues.Expert opinion: Rapid identification pathogen resistance profile (i.e. the minimal inhibitory concentration for the available antimicrobials), real-time measurement of drug concentrations with regimen adjustment on MIC and daily measurement of procalcitonin to guide duration of therapy are the main issues to individualize the antibiotic management in critically ill patients.
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Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Philpott CD, Droege CA, Droege ME, Healy DP, Courter JD, Ernst NE, Harger NJ, Foertsch MJ, Winter JB, Carter KE, Van Fleet SL, Athota K, Mueller EW. Pharmacokinetics and Pharmacodynamics of Extended-Infusion Cefepime in Critically Ill Patients Receiving Continuous Renal Replacement Therapy: A Prospective, Open-Label Study. Pharmacotherapy 2019; 39:1066-1076. [PMID: 31549737 DOI: 10.1002/phar.2332] [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] [Indexed: 02/05/2023]
Abstract
STUDY OBJECTIVE To evaluate extended-infusion (EI) cefepime pharmacokinetics (PK) and pharmacodynamic target attainment in critically ill patients receiving continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodialysis (CVVHD). DESIGN Prospective, open-label, PK study. SETTING Intensive care units at a large, academic, tertiary-care medical center. PATIENTS Ten critically ill adults who were receiving cefepime 2 g intravenously every 8 hours as a 4-hour infusion while receiving CVVH (eight patients) or CVVHD (two patients). INTERVENTION Two sets of five serum cefepime concentrations were collected for each patient to assess pharmacokinetics before and during presumed steady state. Concurrent serum and CRRT effluent samples were collected at hours 1, 2, 3, 4, and 8 after the first cefepime dose and after either the fourth, fifth, or sixth (steady-state) cefepime doses. MEASUREMENTS AND MAIN RESULTS Reversed-phase high-performance liquid chromatography was used to determine free cefepime concentrations. PK analyses included CRRT clearance, half-life, and sieving coefficient or saturation coefficient. Cefepime peak (4 hrs) concentrations, trough (8 hrs) concentrations (Cmin ), and minimum inhibitory concentration breakpoint of 8 µg/ml for the pathogen (MIC8 ) were used to evaluate attainment of pharmacodynamic targets: 100% of the dosing interval that free drug remains above MIC8 (100% fT > MIC8 ), 100% fT > 4 × MIC8 (optimal), percentage of time fT > 4 × MIC8 (%fT > 4 × MIC8 ) at steady state, and ratio of Cmin to MIC8 (fCmin /MIC8 ). Total CRRT effluent flow rate was a mean ± SD of 30.1 ± 5.4 ml/kg/hr, CRRT clearance was 39.6 ± 9.9 ml/min, and half-life was 5.3 ± 1.7 hours. Sieving coefficient or saturation coefficient were 0.83 ± 0.13 and 0.69 ± 0.22, respectively. First and steady-state dose Cmin were 23.4 ± 10.1 µg/ml and 45.2 ± 14.6 µg/ml, respectively. All patients achieved 100% fT > MIC8 on first and steady-state doses. First and steady-state dose 100% fT > 4 × MIC8 were achieved in 22% (2/9 patients) and 87.5% (7/8 patients) of patients, respectively. The mean %fT > 4 × MIC8 at steady state was 97.5%. The fCmin /MIC8 was 2.92 ± 1.26 for the first dose and 5.65 ± 1.83 at steady state. CONCLUSION Extended-infusion cefepime dosing in critically ill patients receiving CRRT successfully attained 100% fT > MIC8 in all patients and an appropriate fCmin /MIC8 for both first and steady-state doses. All but one patient achieved 100% fT > 4 × MIC8 at steady state. No significant differences were observed in PK properties between first and steady-state doses among or between patients. It may be reasonable to initiate an empiric or definitive regimen of EI cefepime in critically ill patients receiving concurrent CRRT who are at risk for resistant organisms. Further research is needed to identify the optimal dosing regimen of EI cefepime in this patient population.
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Affiliation(s)
- Carolyn D Philpott
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Christopher A Droege
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Molly E Droege
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Daniel P Healy
- University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | | | - Neil E Ernst
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Nicole J Harger
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Madeline J Foertsch
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Jessica B Winter
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Kristen E Carter
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Suzanne L Van Fleet
- University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio.,UC Health, West Chester Hospital, West Chester, Ohio
| | - Krishna Athota
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric W Mueller
- UC Health, University of Cincinnati Medical Center, Cincinnati, Ohio.,University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
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Therapeutic drug monitoring-guided continuous infusion of piperacillin/tazobactam significantly improves pharmacokinetic target attainment in critically ill patients: a retrospective analysis of four years of clinical experience. Infection 2019; 47:1001-1011. [PMID: 31473974 DOI: 10.1007/s15010-019-01352-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Standard dosing and intermittent bolus application (IB) are important risk factors for pharmacokinetic (PK) target non-attainment during empirical treatment with β-lactams in critically ill patients, particularly in those with sepsis and septic shock. We assessed the effect of therapeutic drug monitoring-guided (TDM), continuous infusion (CI) and individual dosing of piperacillin/tazobactam (PIP) on PK-target attainment in critically ill patients. METHODS This is a retrospective, single-center analysis of a database including 484 patients [933 serum concentrations (SC)] with severe infections, sepsis and septic shock who received TDM-guided CI of PIP in the intensive care unit (ICU) of an academic teaching hospital. The PK-target was defined as a PIP SC between 33 and 64 mg/L [fT > 2-4 times the epidemiological cutoff value (ECOFF) of Pseudomonas aeruginosa (PSA)]. RESULTS PK-target attainment with standard dosing (initial dose) was observed in 166 patients (34.3%), whereas only 49 patients (10.1%) demonstrated target non-attainment. The minimum PK-target of ≥ 33 mg/L was overall realized in 89.9% (n = 435/484) of patients after the first PIP dose including 146 patients (30.2%) with potentially harmful SCs ≥ 100 mg/L. Subsequent TDM-guided dose adjustments significantly enhanced PK-target attainment to 280 patients (62.4%) and significantly reduced the fraction of potentially overdosed (≥ 100 mg/L) patients to 4.5% (n = 20/449). Renal replacement therapy (RRT) resulted in a relevant reduction of PIP clearance (CLPIP): no RRT CLPIP 6.8/6.3 L/h (median/IQR) [SCs n = 752, patients n = 405], continuous veno-venous hemodialysis (CVVHD) CLPIP 4.3/2.6 L/h [SCs n = 160, n = 71 patients], intermittent hemodialysis (iHD) CLPIP 2.6/2.3 L/h [SCs n = 21, n = 8 patients]). A body mass index (BMI) of > 40 kg/m2 significantly increased CLPIP 9.6/7.7 L/h [SC n = 43, n = 18 patients] in these patients. Age was significantly associated with supratherapeutic PIP concentrations (p < 0.0005), whereas high CrCL led to non-target attainment (p < 0.0005). Patients with target attainment (33-64 mg/L) within the first 24 h exhibited the lowest hospital mortality rates (13.9% [n = 23/166], p < 0.005). Those with target non-attainment demonstrated higher mortality rates (≤ 32 mg/L; 20.8% [n = 10/49] ≥ 64 mg/L; 29.4% [n = 79/269]). CONCLUSION TDM-guided CI of PIP is safe in critically ill patients and improves PK-target attainment. Exposure to defined PK-targets impacts patient mortality while lower and higher than intended SCs may influence the outcome of critically ill patients. Renal function and renal replacement therapy are main determinants of PK-target attainment. These results are only valid for CI of PIP and not for prolonged or intermittent bolus administration of PIP.
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41
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Basic Principles of Antibiotics Dosing in Patients with Sepsis and Acute Kidney Damage Treated with Continuous Venovenous Hemodiafiltration. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2018-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Sepsis is the leading cause of acute kidney damage in patients in intensive care units. Pathophysiological mechanisms of the development of acute kidney damage in patients with sepsis may be hemodynamic and non-hemodynamic. Patients with severe sepsis, septic shock and acute kidney damage are treated with continuous venovenous hemodiafiltration. Sepsis, acute kidney damage, and continuous venovenous hemodiafiltration have a significant effect on the pharmacokinetics and pharmacodynamics of antibiotics. The impact dose of antibiotics is increased due to the increased volume of distribution (increased administration of crystalloids, hypoalbuminemia, increased capillary permeability syndrome toproteins). The dose of antibiotic maintenance depends on renal, non-renal and extracorporeal clearance. In the early stage of sepsis, there is an increased renal clearance of antibiotics, caused by glomerular hyperfiltration, while in the late stage of sepsis, as the consequence of the development of acute renal damage, renal clearance of antibiotics is reduced. The extracorporeal clearance of antibiotics depends on the hydrosolubility and pharmacokinetic characteristics of the antibiotic, but also on the type of continuous dialysis modality, dialysis dose, membrane type, blood flow rate, dialysis flow rate, net filtration rate, and effluent flow rate. Early detection of sepsis and acute kidney damage, early target therapy, early administration of antibiotics at an appropriate dose, and early extracorporeal therapy for kidney replacement and removal of the inflammatory mediators can improve the outcome of patients with sepsis in intensive care units.
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Chaijamorn W, Puchsaka P, Pattharachayakul S, Charoensareerat T, Srisawat N, Boonpeng A, Pummangura C. Doripenem dosing regimens in Asian critically ill patients with continuous renal replacement therapy. J Crit Care 2019; 52:233-236. [PMID: 31108327 DOI: 10.1016/j.jcrc.2019.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/13/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand.
| | | | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Apinya Boonpeng
- School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
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Li S, Xie F. Population pharmacokinetics and simulations of imipenem in critically ill patients undergoing continuous renal replacement therapy. Int J Antimicrob Agents 2018; 53:98-105. [PMID: 30626495 DOI: 10.1016/j.ijantimicag.2018.10.006] [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] [Received: 08/28/2018] [Revised: 10/02/2018] [Accepted: 10/20/2018] [Indexed: 01/08/2023]
Abstract
Various dose regimens of imipenem have been prescribed in critically ill patients undergoing continuous renal replacement therapy (CRRT) but there are limited information on its pharmacokinetics (PK) and treatment efficacy. The aim of this study was to describe the population PK of imipenem in patients receiving CRRT, and utilize this model to inform optimal dosing regimens using pharmacokinetics/pharmacodynamics (PK/PD) target as a surrogate marker for treatment efficacy. Population PK modelling was undertaken in 20 patients receiving CRRT to characterize variabilities and identify influential covariates. Monte Carlo simulations were performed to evaluate differences in probability of target attainment (PTA) between empirically used dosing regimens (0.5 g q6h, 1 g q8h, and 1 g q6h), and to explore the impact of CRRT intensity and identified covariates on target attainment. Imipenem concentration data were adequately described using a one-compartment model. Residual diuresis and burn injury were identified modifiers for imipenem endogenous clearance. The simulations showed that the impact of CRRT intensity on target attainment is clinically irrelevant, whereas urine output and burn injury influence PTA for pathogens with an MIC ≥ 4 mg/L. At an MIC ≤ 2 mg/L, satisfactory PTAs (>80%) were achieved for all three investigated dose regimens regardless of urine output, burn injury, and CRRT intensity. Our results indicate that from a safety perspective, 0.5 g q6h imipenem is optimal in these patients for pathogens with an MIC ≤ 2 mg/L, and 1 g q6h is recommended for non-burn patients with anuria against MIC 4-16 mg/L.
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Affiliation(s)
- Sanwang Li
- Ghent University, Department of Chemistry, Atomic and Mass Spectrometry Research Group (A&MS), Campus Sterre, Krijgslaan 281-S12, 9000 Ghent, Belgium
| | - Feifan Xie
- Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, B-9000 Ghent, Belgium.
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Chaijamorn W, Charoensareerat T, Srisawat N, Pattharachayakul S, Boonpeng A. Cefepime dosing regimens in critically ill patients receiving continuous renal replacement therapy: a Monte Carlo simulation study. J Intensive Care 2018; 6:61. [PMID: 30221005 PMCID: PMC6134777 DOI: 10.1186/s40560-018-0330-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/30/2018] [Indexed: 11/28/2022] Open
Abstract
Background Cefepime can be removed by continuous renal replacement therapy (CRRT) due to its pharmacokinetics. The purpose of this study is to define the optimal cefepime dosing regimens for critically ill patients receiving CRRT using Monte Carlo simulations (MCS). Methods The CRRT models of cefepime disposition during 48 h with different effluent rates were developed using published pharmacokinetic parameters, patient demographic data, and CRRT settings. Pharmacodynamic target was the cumulative percentage of a 48-h period of at least 70% that free cefepime concentration exceeds the four times susceptible breakpoint of Pseudomonas aeruginosa (minimum inhibitory concentration, MIC of 8). All recommended dosing regimens from available clinical resources were evaluated for the probability of target attainment (PTA) using MCS to generate drug disposition in a group of 5000 virtual patients for each dose. The optimal doses were defined as achieving the PTA at least 90% of virtual patients with lowest daily doses and the acceptable risk of neurotoxicity. Results Optimal cefepime doses in critically ill patients receiving CRRT with Kidney Disease: Improving Global Outcomes (KDIGO) recommended effluent rates were a regimen of 2 g loading dose followed by 1.5–1.75 g every 8 h for Gram-negative infections with a neurotoxicity risk of < 17%. Cefepime dosing regimens from this study were considerably higher than the recommended doses from clinical resources. Conclusion All recommended dosing regimens for patients receiving CRRT from available clinical resources failed to achieve the PTA target. The optimal dosing regimens were suggested based on CRRT modalities, MIC values, and different effluent rates. Clinical validation is warranted.
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Affiliation(s)
- Weerachai Chaijamorn
- 1Faculty of Pharmacy, Siam University, 38 Petkasem Road, Bangwa, Pasicharoen, Bangkok, 10160 Thailand
| | - Taniya Charoensareerat
- 1Faculty of Pharmacy, Siam University, 38 Petkasem Road, Bangwa, Pasicharoen, Bangkok, 10160 Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sutthiporn Pattharachayakul
- 3Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Apinya Boonpeng
- 4School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
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Bouglé A, Bombled C, Margetis D, Lebreton G, Vidal C, Coroir M, Hajage D, Amour J. Ventilator-associated pneumonia in patients assisted by veno-arterial extracorporeal membrane oxygenation support: Epidemiology and risk factors of treatment failure. PLoS One 2018; 13:e0194976. [PMID: 29652913 PMCID: PMC5898723 DOI: 10.1371/journal.pone.0194976] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/14/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is frequent in Intensive Care Unit (ICU) patients. In the specific case of patients treated with Veno-Arterial Extracorporeal Membrane Oxygenation Support (VA-ECMO), VAP treatment failures (VAP-TF) have been incompletely investigated. METHODS To investigate the risk factors of treatment failure (VAP-TF) in a large cohort of ICU patients treated with VA-ECMO, we conducted a retrospective study in a Surgical ICU about patients assisted with VA-ECMO between January 1, 2013, and December 31, 2014. Diagnosis of VAP was confirmed by a positive quantitative culture of a respiratory sample. VAP-TF was defined as composite of death attributable to pneumonia and relapse within 28 days of the first episode. RESULTS In total, 152 patients underwent ECMO support for > 48h. During the VA-ECMO support, 85 (55.9%) patients developed a VAP, for a rate of 60.6 per 1000 ECMO days. The main pathogens identified were Pseudomonas aeruginosa and Enterobacteriaceae. VAP-TF occurred in 37.2% of patients and was associated with an increased 28-day mortality (Hazard Ratio 3.05 [1.66; 5.63], P<0.001), and VA-ECMO assistance duration (HR 1.47 [1.05-2.05], P = 0.025). Risk factors for VAP-TF were renal replacement therapy (HR 13.05 [1.73; 98.56], P = 0.013) and documentation of Pseudomonas aeruginosa (HR 2.36 [1.04; 5.35], P = 0.04). CONCLUSIONS VAP in patients treated with VA-ECMO is associated with an increased morbidity and mortality. RRT and infection by Pseudomonas aeruginosa appear as strong risks factors of treatment failure. Further studies seem necessary to precise the best antibiotic management in these patients.
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Affiliation(s)
- Adrien Bouglé
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Camille Bombled
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Dimitri Margetis
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Thoracic and Cardiovascular Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles Vidal
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Marine Coroir
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - David Hajage
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Biostatistics, Public Health and Medical Information, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Paris Cité, UMR 1123 ECEVE, Université Paris Diderot, Paris, France
- INSERM, UMR 1123 ECEVE, Paris, France
| | - Julien Amour
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Anesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne Université, UMR INSERM 1166, IHU ICAN, Pitié-Salpêtrière Hospital, Paris, France
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[Dose adjustment of anti-infective drugs in patients with renal failure and renal replacement therapy in intensive care medicine : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:384-392. [PMID: 29546450 DOI: 10.1007/s00063-018-0416-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/27/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many anti-infective drugs require dose adjustments in critically ill patients with acute kidney injury (AKI) and renal replacement therapy, in order to achieve adequate therapeutic drug concentrations. OBJECTIVES The fundamental pharmacokinetic and pharmacodynamic principles of drug dose adjustment are presented. Recommendations on anti-infective drug dosage in intensive care are provided. MATERIALS AND METHODS We established dose recommendations of selected anti-infective drugs based on information in the summary of product characteristics, published studies and recommendations, pharmacokinetic and pharmacodynamic considerations, and the experience and expert opinion of the authors. RESULTS Out of a total of 37 anti-infective drugs (31 antibiotics, 2 antivirals, 4 antifungals) 8 can be administered independent of renal function. For 29 anti-infective drugs, a specific recommendation on drug dosage could be made in case of intermittent hemodialysis and for 24 anti-infective drugs in case of continuous hemo(dia)filtration. CONCLUSIONS Recommendations on dosing of important anti-infective drugs in critically ill patients with AKI and renal replacement therapy are provided.
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Determination of meropenem in endotracheal tubes by in-tube solid phase microextraction coupled to capillary liquid chromatography with diode array detection. J Pharm Biomed Anal 2018; 151:170-177. [DOI: 10.1016/j.jpba.2018.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/21/2017] [Accepted: 01/06/2018] [Indexed: 01/19/2023]
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Pharmacokinetics of meropenem in septic patients on sustained low-efficiency dialysis: a population pharmacokinetic study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:25. [PMID: 29382394 PMCID: PMC5791175 DOI: 10.1186/s13054-018-1940-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 01/02/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim of the study was to describe the population pharmacokinetics (PK) of meropenem in critically ill patients receiving sustained low-efficiency dialysis (SLED). METHODS Prospective population PK study on 19 septic patients treated with meropenem and receiving SLED for acute kidney injury. Serial blood samples for determination of meropenem concentrations were taken before, during and after SLED in up to three sessions per patient. Nonparametric population PK analysis with Monte Carlo simulations were used. Pharmacodynamic (PD) targets of 40% and 100% time above the minimal inhibitory concentration (f T > MIC) were used for probability of target attainment (PTA) and fractional target attainment (FTA) against Pseudomonas aeruginosa. RESULTS A two-compartment linear population PK model was most appropriate with residual diuresis supported as significant covariate affecting meropenem clearance. In patients without residual diuresis the PTA for both targets (40% and 100% f T > MIC) and susceptible P. aeruginosa (MIC ≤ 2 mg/L) was > 95% for a dose of 0.5 g 8-hourly. In patients with a residual diuresis of 300 mL/d 1 g 12-hourly and 2 g 8-hourly would be required to achieve a PTA of > 95% and 93% for targets of 40% f T > MIC and 100% f T > MIC, respectively. A dose of 2 g 8-hourly would be able to achieve a FTA of 97% for 100% f T > MIC in patients with residual diuresis. CONCLUSIONS We found a relevant PK variability for meropenem in patients on SLED, which was significantly influenced by the degree of residual diuresis. As a result dosing recommendations for meropenem in patients on SLED to achieve adequate PD targets greatly vary. Therapeutic drug monitoring may help to further optimise individual dosing. TRIAL REGISTRATION Clincialtrials.gov, NCT02287493 .
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Economou CJP, Wong G, McWhinney B, Ungerer JPJ, Lipman J, Roberts JA. Impact of β-lactam antibiotic therapeutic drug monitoring on dose adjustments in critically ill patients undergoing continuous renal replacement therapy. Int J Antimicrob Agents 2017; 49:589-594. [PMID: 28341612 DOI: 10.1016/j.ijantimicag.2017.01.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 12/29/2022]
Abstract
The objective of this study was to describe the effect of therapeutic drug monitoring (TDM) and dose adjustments of β-lactam antibiotics administered to critically ill patients undergoing continuous renal replacement therapy (CRRT) in a 30-bed tertiary intensive care unit (ICU). β-Lactam TDM data in our tertiary referral ICU were retrospectively reviewed. Clinical, demographic and dosing data were collected for patients administered β-lactam antibiotics while undergoing CRRT. The target trough concentration range was 1-10× the minimum inhibitory concentration (MIC). A total of 111 TDM samples from 76 patients (46 male) with a mean ± standard deviation age of 56.6 ± 15.9 years and weight of 89.1 ± 25.8 kg were identified. The duration of antibiotic therapy was between 2 days and 42 days. TDM identified a need for dose modification of β-lactam antibiotics in 39 (35%) instances; in 27 (24%) samples, TDM values resulted in decreasing the prescribed dose of β-lactam antibiotic whereas an increase in the prescribed dose occurred in 12 (11%) cases. In patients treated for hospital-acquired pneumonia and primary or secondary bacteraemia, the dose was required to be decreased in 10/25 (40%) and 7/46 (15%) cases, respectively, to attain target concentrations. β-Lactam TDM is a useful tool for guiding drug dosing in complex patients such as those receiving CRRT. Although over one-third of patients manifested concentrations outside the therapeutic range, most of these CRRT patients had excessive β-lactam concentrations.
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Affiliation(s)
- Caleb J P Economou
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Research, ICON Cancer Foundation, Brisbane, QLD, Australia
| | - Gloria Wong
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jason A Roberts
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, QLD, Australia.
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Abstract
PURPOSE OF REVIEW Infections are common complications in critically ill patients and are frequently treated with antibiotics. Unfortunately, delivery of optimal therapy is complicated because efficacy of antimicrobials is influenced by the timing of treatment initiation, the use of combination therapy, and the optimization of drug dosing. RECENT FINDINGS Early diagnosis of infection is mandatory to provide a rapid and appropriate antibiotic therapy. The presence of less susceptible strains, in particular for hospital-acquired infections, or patients with severe disease, such as the presence of septic shock, may need combination antibiotic therapy. Antibiotic pharmacokinetics, notably volume of distribution and total body clearance, are significantly altered in these critically ill patients and can influence the attainment of adequate circulating levels when standard dosage regimens are administered. Higher dosing should be considered in such patients, although in case of renal impairment and reduced clearance, drug accumulation could also result in some side-effects. Nebulized antibiotics may provide a better clinical response than systemic antibiotics in ventilator-associated pneumonia because of multidrug-resistant pathogens. SUMMARY The optimal use of antibiotics in the management of severe infections is an important challenge for ICU physicians. Antimicrobial therapy needs to be individualized according to specific patient characteristics, infecting organisms, and susceptibility patterns.
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