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Richter DC, Dietrich M, Lalev LD, Schmitt FCF, Fiedler MO, Bruckner T, Stoerzinger D, Chiriac U, Klein S, Hackert T, Brenner T, Brinkmann A, Weigand MA. Prolonged Infusion of β-Lactams Decreases Mortality in Patients with Septic Shock: A Retrospective before-and-after Study. Antibiotics (Basel) 2021; 10:antibiotics10060687. [PMID: 34201244 PMCID: PMC8229114 DOI: 10.3390/antibiotics10060687] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/04/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023] Open
Abstract
Septic shock substantially alters the pharmacokinetic properties of β-lactams with a subsequently high risk of insufficiently low serum concentrations and treatment failure. Considering their pharmacokinetic (PK)/pharmacodynamic (PD) index, prolonged infusions (PI) of β-lactams extend the time that the unbound fraction of the drug remains above the minimal inhibitory concentration MIC (ft >MIC) and may improve patient survival. The present study is a monocentric, retrospective before-and-after analysis of septic shock patients treated with β-lactams. Patients of the years 2015–2017 received intermittent bolus application whereas patients of 2017–2020 received PI of β-lactams. The primary outcome was mortality at day 30 and 90 after diagnosis of septic shock. Mortality rates in the PI group were significantly lower on day 30 (PI: 41%, n = 119/290 vs. IB: 54.8%, n = 68/114; p = 0.0097) and day 90 (PI: 47.9%, n = 139/290 vs. IB: 62.9%, n = 78/124; p = 0.005). After propensity-score matching, 30- and 90-day mortality remained lower for the PI group (−10%, p = 0.14). PI was further associated with a reduction in the duration of invasive ventilation and a stronger decrease in SOFA scores within a 14 day-observation period. PI of β-lactams was associated with a significant reduction of mortality in patients with septic shock and may have beneficial effects on invasive ventilation and recovery from sepsis-related organ failure.
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Affiliation(s)
- Daniel Christoph Richter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
- Correspondence: (D.C.R.); (M.D.)
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
- Correspondence: (D.C.R.); (M.D.)
| | - Lazar Detelinov Lalev
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Mascha Onida Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
| | - Thomas Bruckner
- Institute of Medical Biometry & Biostatistics, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany;
| | - Dominic Stoerzinger
- Department of Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany; (D.S.); (U.C.)
| | - Ute Chiriac
- Department of Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany; (D.S.); (U.C.)
| | - Sabrina Klein
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany;
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany;
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany;
| | - Alexander Brinkmann
- Department of Anesthesiology, Heidenheim Hospital, Schloßhaustraße 100, 89522 Heidenheim, Germany;
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (L.D.L.); (F.C.F.S.); (M.O.F.); (M.A.W.)
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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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Jang SM, Gharibian KN, Lewis SJ, Fissell WH, Tolwani AJ, Mueller BA. A Monte Carlo Simulation Approach for Beta-Lactam Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy. J Clin Pharmacol 2018; 58:1254-1265. [PMID: 29746711 DOI: 10.1002/jcph.1137] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/23/2018] [Indexed: 11/05/2022]
Abstract
Cefepime, ceftazidime, and piperacillin/tazobactam are commonly used beta-lactam antibiotics in the critical care setting. For critically ill patients receiving prolonged intermittent renal replacement therapy (PIRRT), limited pharmacokinetic data are available to inform clinicians on the dosing of these agents. Monte Carlo simulations (MCS) can be used to guide drug dosing when pharmacokinetic trials are not feasible. For each antibiotic, MCS using previously published pharmacokinetic data derived from critically ill patients was used to evaluate multiple dosing regimens in 4 different prolonged intermittent renal replacement therapy effluent rates and prolonged intermittent renal replacement therapy duration combinations (4 L/h × 10 hours or 5 L/h × 8 hours in hemodialysis and hemofiltration modes). Antibiotic regimens were also modeled depending on whether drugs were administered during or well before prolonged intermittent renal replacement therapy therapy commenced. The probability of target attainment (PTA) was calculated using each antibiotic's pharmacodynamic target during the first 48 hours of therapy. Optimal doses were defined as the smallest daily dose achieving ≥90% probability of target attainment in all prolonged intermittent renal replacement therapy effluent and duration combinations. Cefepime 1 g every 6 hours following a 2 g loading dose, ceftazidime 2 g every 12 hours, and piperacillin/tazobactam 4.5 g every 6 hours attained the desired pharmacodynamic target in ≥90% of modeled prolonged intermittent renal replacement therapy patients. Alternatively, if an every 6-hours cefepime regimen is not desired, the cefepime 2 g pre-prolonged intermittent renal replacement therapy and 3 g post-prolonged intermittent renal replacement therapy regimen also met targets. For ceftazidime, 1 g every 6 hours or 3 g continuous infusion following a 2 g loading dose also met targets. These recommended doses provide simple regimens that are likely to achieve the pharmacodynamics target while yielding the least overall drug exposure, which should result in lower toxicity rates. These findings should be validated in the clinical setting.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda School of Pharmacy, Loma Linda, CA, USA
| | - Katherine N Gharibian
- Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA
| | - Susan J Lewis
- Department of Pharmacy Practice, University of Findlay College of Pharmacy, Findlay, OH, USA
| | - William H Fissell
- Nephrology and Hypertension Division, Vanderbilt University, School of Medicine and School of Engineering, Nashville, TN, USA
| | - Ashita J Tolwani
- Division of Nephrology, University of Alabama-Birmingham, School of Medicine, Birmingham, AL, USA
| | - Bruce A Mueller
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Rawson TM, O’Hare D, Herrero P, Sharma S, Moore LSP, de Barra E, Roberts JA, Gordon AC, Hope W, Georgiou P, Cass AEG, Holmes AH. Delivering precision antimicrobial therapy through closed-loop control systems. J Antimicrob Chemother 2018; 73:835-843. [PMID: 29211877 PMCID: PMC5890674 DOI: 10.1093/jac/dkx458] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
| | - D O’Hare
- Department of Bioengineering, Imperial College London, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - S Sharma
- College of Engineering, Swansea University, Swansea, UK
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
| | - E de Barra
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Centre for Translational Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - A C Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
| | - W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - A E G Cass
- Department of Chemistry & Institute of Biomedical Engineering, Imperial College London, Kensington Campus, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, Acton, UK
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Cross VJ, Parker JT, Law Min MCYL, Bourne RS. Pharmacist prescribing in critical care: an evaluation of the introduction of pharmacist prescribing in a single large UK teaching hospital. Eur J Hosp Pharm 2018; 25:e2-e6. [PMID: 31157059 PMCID: PMC6457156 DOI: 10.1136/ejhpharm-2017-001267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the introduction of pharmacist independent prescribing activity across three general critical care units within a single large UK teaching hospital. To identify the prescribing demographics including total of all prescriptions, number prescribed by pharmacists, reason for pharmacist prescription, range of medications prescribed, pharmacist prescribing error rate and the extent of pharmacist second 'clinical check'. METHODS Retrospective evaluation of e-prescribing across all general critical care units of a single large UK teaching hospital. All prescribing data were downloaded over a 1-month period (May to June 2016) with analysis of pharmacist prescribing activity including rate, indication, therapeutic class and error rate. RESULTS In total, 5374 medicines were prescribed in 193 patients during the evaluated period. Prescribing pharmacists were available on the units on 60.4% (58/96) of days, during their working hours and accounted for 576/5374 (10.7%) of medicines prescribed in 65.2% (126/193) of patients. The majority (342/576) of pharmacist prescriptions were for new medicines. Infections, central nervous system, and nutrition/blood were the top three British National Formulary (BNF) therapeutic categories, accounting for 63.4% (349/576) of all pharmacist prescriptions. The critical care pharmacist prescribing error rate was 0.18% (1/550). CONCLUSIONS Pharmacist independent prescribers demonstrated a high degree and wide-ranging scope of prescribing activity in general critical care patients. Pharmacists contributed a significant proportion of total prescribing, despite less than full service coverage. Prescribing activity was also safe with a very low error rate recorded.
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Affiliation(s)
- Verity J Cross
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - James T Parker
- Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Marie-Christine Y L Law Min
- Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Richard S Bourne
- Departments of Pharmacy and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
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Naicker S, Guerra Valero YC, Ordenez Meija JL, Lipman J, Roberts JA, Wallis SC, Parker SL. A UHPLC-MS/MS method for the simultaneous determination of piperacillin and tazobactam in plasma (total and unbound), urine and renal replacement therapy effluent. J Pharm Biomed Anal 2017; 148:324-333. [PMID: 29080413 DOI: 10.1016/j.jpba.2017.10.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/29/2017] [Accepted: 10/22/2017] [Indexed: 11/17/2022]
Abstract
Piperacillin-tazobactam is a beta-lactam/beta-lactamase combination antibiotic used in patients with moderate to severe infection. Dosing of piperacillin-tazobactam requires an understanding of this patient group to maximise the effectiveness of this antibiotic and limit a further emergence of resistant pathogens. This is the first method that measures piperacillin and tazobactam simultaneously, across this range of clinically-relevant biological matrices. The calibration line was linear across the concentration range of 0.5-500μg/mL for piperacillin and 0.625-62.5μg/mL for tazobactam. All validation testing for matrix effects, precision and accuracy, specificity and stability were within 15%. A calibration equivalence study was performed to investigate the suitability of applying calibration curves prepared in an alternative matrix, with a mean bias of -10.8% identified for the application of a calibration line prepared for tazobactam in plasma only. Bias for all other calibration lines prepared in alternate matrices was within the 5% acceptance criteria. The method was successfully applied to a pharmacokinetic study of a critically ill patient receiving renal replacement therapy, with the results included.
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Affiliation(s)
- Saiyuri Naicker
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Centre of Translational Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.
| | - Yarmarly C Guerra Valero
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jenny L Ordenez Meija
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre of Translational Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Suzanne L Parker
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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