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Gandéga H, Poujol H, Mezzarobba M, Muller L, Boyer JC, Lefrant JY, Leguelinel G, Roger C. Determinants of beta-lactam PK/PD target attainment in critically ill patients: A single center retrospective study. J Crit Care 2024; 83:154828. [PMID: 38759580 DOI: 10.1016/j.jcrc.2024.154828] [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: 01/22/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE We aimed to identify factors associated with achieving target BL plasma concentrations and describe real world data for therapeutic drug monitoring (TDM). METHODS A retrospective single center study was conducted. We collected data from patients admitted to ICU with at least one BL TDM. We assessed the proportion of patients attaining the recommended plasma concentrations (i.e 100%fT > 4 to 8 MIC). Univariate and multivariate analyses was performed to identify the determinants of BL target attainment. RESULTS 156 patients were included. At the first dosing, 34% achieved target BL plasma concentrations, 50% were overdosed, and 16% were underdosed. Median time for 1st TDM were 4 (SD = 2.9) days. Multivariate analysis revealed that CKD-EPI estimated glomerular filtration rate (OR = 1.02; CI [1.01; 1.03]; p < 0.0001) and total body weight (OR = 1.03; CI [1.01; 1.04]; p = 0.0048) were the main determinant of BL target attainment. Conversely, Continuous Renal Replacement Therapy (OR = 0.28; CI [0.09; 0.89]; p = 0.0318) and meropenem use (OR = 0.31; CI [0.14; 0.69]; p = 0.0041) were identified as risk factors for overdosing. No factor was associated with underdosing. CONCLUSION Achieving target BL plasma concentrations remains challenging in ICUs. Identifying predictive factors of BL target attainment would favor implementing rapid dosing optimization strategies in both under and overdosing high risk patients.
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Affiliation(s)
- H Gandéga
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France
| | - H Poujol
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - M Mezzarobba
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University of Montpellier, Nîmes, France
| | - L Muller
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - J C Boyer
- Department of toxicity and biochemistry, Nimes University Hospital, Nimes, France
| | - J Y Lefrant
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France
| | - G Leguelinel
- Department of Pharmacy, Nimes University Hospital, University of Montpellier, Nimes, France; Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES, EA 2415, University of Montpellier, Montpellier, France
| | - C Roger
- UR-UM103 IMAGINE, Univ Montpellier, Division of Anesthesia and Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Montpellier, France.
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2
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Huang J, Wu T, Tan R, Dai Y, Qiu Y, Lu H, Cao X, Liu J, Qu H, Wang X. Population pharmacokinetics and dosing simulations of meropenem in septic critically ill patients with complicated intra-abdominal infection or pneumonia. J Pharm Sci 2024:S0022-3549(24)00420-9. [PMID: 39313153 DOI: 10.1016/j.xphs.2024.09.011] [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: 06/27/2024] [Revised: 09/19/2024] [Accepted: 09/19/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVES Meropenem pharmacokinetics (PK) may be altered in septic critically ill patients with complicated intra-abdominal infections (cIAI) and pneumonia. We aimed to evaluate the covariates affecting meropenem PK and the performance of different dosing regimens to optimize the PK/pharmacodynamic target. METHODS Population PK analysis was performed using non-linear mixed-effects modeling. The final model was validated and used to simulate meropenem exposure to assess the probability of attaining the 100%ƒT>MIC target. RESULTS Forty-six and 14 patients were respectively enrolled for PK analysis and external validation. A one-compartment linear model adequately described the data of 226 concentrations. The typical clearance (CL) and volume of distribution (Vd) were 9.69 L/h and 27.4 L, respectively. Septic shock from cIAI (cIASS) and actual body weight were significant covariates for meropenem Vd in addition to the influential covariates of creatinine clearance (CLCR-CG) and augmented renal clearance for CL. External validation showed the robustness and accuracy of this model. Simulation results proposed continuous infusion (CI) dosing regimens of meropenem against pathogens with MICs ≥ 2 mg/L in patients with cIASS and CLCR-CG ≥ 60 mL/min. CONCLUSIONS For the patients with cIASS and CLCR-CG ≥ 60 mL/min, CI meropenem is proposed for treatment of less sensitive pathogens with MICs ≥ 2 mg/L.
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Affiliation(s)
- Jingjing Huang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Tong Wu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Ruoming Tan
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Yunqi Dai
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Yuzhen Qiu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Haiwen Lu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200025 Shanghai, China
| | - Xiaoli Cao
- Department of clinical laboratory, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, 200025 Shanghai, China
| | - Jialin Liu
- Department of Geriatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China.
| | - Hongping Qu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China.
| | - Xiaoli Wang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China.
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3
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Gras-Martín L, Plaza-Diaz A, Zarate-Tamames B, Vera-Artazcoz P, Torres OH, Bastida C, Soy D, Ruiz-Ramos J. Risk Factors Associated with Antibiotic Exposure Variability in Critically Ill Patients: A Systematic Review. Antibiotics (Basel) 2024; 13:801. [PMID: 39334976 PMCID: PMC11428266 DOI: 10.3390/antibiotics13090801] [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: 07/19/2024] [Revised: 08/15/2024] [Accepted: 08/22/2024] [Indexed: 09/30/2024] Open
Abstract
(1) Background: Knowledge about the behavior of antibiotics in critically ill patients has been increasing in recent years. Some studies have concluded that a high percentage may be outside the therapeutic range. The most likely cause of this is the pharmacokinetic variability of critically ill patients, but it is not clear which factors have the greatest impact. The aim of this systematic review is to identify risk factors among critically ill patients that may exhibit significant pharmacokinetic alterations, compromising treatment efficacy and safety. (2) Methods: The search included the PubMed, Web of Science, and Embase databases. (3) Results: We identified 246 observational studies and ten clinical trials. The most studied risk factors in the literature were renal function, weight, age, sex, and renal replacement therapy. Risk factors with the greatest impact included renal function, weight, renal replacement therapy, age, protein or albumin levels, and APACHE or SAPS scores. (4) Conclusions: The review allows us to identify which critically ill patients are at a higher risk of not reaching therapeutic targets and helps us to recognize the extensive number of risk factors that have been studied, guiding their inclusion in future studies. It is essential to continue researching, especially in real clinical practice and with clinical outcomes.
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Affiliation(s)
- Laura Gras-Martín
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Adrián Plaza-Diaz
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
| | - Borja Zarate-Tamames
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
| | - Paula Vera-Artazcoz
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Intensive Care Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Olga H Torres
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Geriatric Unit, Internal Medicine Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Carla Bastida
- Pharmacy Department, Division of Medicines, Hospital Clinic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
- Department of Pharmacology, Toxicology and Therapeutical Chemistry, Faculty of Pharmacy, Universitat de Barcelona, Campus Diagonal, Av. de Joan XXIII, 27-31, 08028 Barcelona, Spain
| | - Dolors Soy
- Pharmacy Department, Division of Medicines, Hospital Clinic of Barcelona, Villarroel 170, 08036 Barcelona, Spain
- Department of Pharmacology, Toxicology and Therapeutical Chemistry, Faculty of Pharmacy, Universitat de Barcelona, Campus Diagonal, Av. de Joan XXIII, 27-31, 08028 Barcelona, Spain
| | - Jesús Ruiz-Ramos
- Pharmacy Department, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
- Institut de Recerca Sant Pau (IR SANT PAU), Sat Quintí 77-79, 08041 Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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Shi HY, Zhang W, Cao W, van den Anker J, Chen XY, Zhao W. Meropenem Clearance in a Child With End-stage Renal Disease Undergoing Prolonged Intermittent Renal Replacement Therapy: A Case Report and Literature Review. Pediatr Infect Dis J 2023; 42:1073-1076. [PMID: 37725827 DOI: 10.1097/inf.0000000000004077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND Meropenem is frequently used to treat severe infections in critically ill children. However, pharmacokinetic data on meropenem in children with end-stage renal disease (ESRD) undergoing prolonged intermittent renal replacement therapy (PIRRT) is limited. Our objectives were to evaluate meropenem clearance in a child with ESRD with and without PIRRT, compare the results to previous continuous renal replacement therapy studies in children, toddlers and neonates, and assess whether the currently used dose of meropenem is sufficient. CASE DESCRIPTION A 5-year-old girl with an estimated glomerular filtration rate of 12.8 mL/min/1.73 m 2 was diagnosed with pulmonary infection and treated with 300 mg meropenem once a day. PIRRT was performed for 8 hours every 2 days. We used WinNonlin to evaluate meropenem clearance with and without PIRRT. RESULTS Our case showed that PIRRT increased the clearance of meropenem from 1.39 (1.3) to 2.42 L/h (2.3 mL/kg/min) and caught up 42.6% of the total clearance. This result is in accordance with previous studies in children but slightly less than seen in toddlers and neonates under continuous renal replacement therapy. The current dose of 300 mg once a day is not sufficient to reach the therapeutic target. CONCLUSIONS Predicting meropenem clearance in children with ESRD undergoing PIRRT is difficult as clearance will be affected by renal function, PIRRT settings and other factors. Further studies are needed to explore the individual variability of meropenem clearance and optimize the dosing regimen.
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Affiliation(s)
- Hai-Yan Shi
- From the Department of Clinical Pharmacy, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wei Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Cao
- Department of Nephrology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Institute of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC
- Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC
- Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, University of Basel, Switzerland
| | - Xiao-Yu Chen
- Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Third Hospital of Hebei Medical University, Shijiazhuang, China
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5
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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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6
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Williams P, Cotta MO, Abdul‐Aziz MH, Wilks K, Farkas A, Roberts JA. In silico evaluation of a beta-lactam dosing guideline among adults with serious infections. Pharmacotherapy 2023; 43:1121-1130. [PMID: 36567467 PMCID: PMC10946580 DOI: 10.1002/phar.2753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 12/27/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to compare the achievement of therapeutic pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for beta-lactam antibiotics using product information dosing or guideline-based dosing for the treatment of serious infections. DESIGN In silico study. DATA SOURCE ID-ODSTM (Individually Designed Optimum Dosing Strategies). PATIENTS AND INTERVENTION None. MEASUREMENTS AND MAIN RESULTS In silico product information and guideline-based dosing simulations for cefepime, ceftazidime, flucloxacillin, meropenem, and piperacillin/tazobactam were performed using pharmacokinetic models from seriously ill patient populations. The median simulated concentration at 48 and 96 h was used to measure the probability of target attainment (PTA) to achieve predefined therapeutic and toxicity PK-PD targets. A multiple linear regression model was constructed to identify the effect of guideline-based dosing covariates on achieving pre-defined therapeutic targets. In total, 480 dosing simulations were performed. The PTA percentage with guideline-based dosing at 48 and 96 h was 80% and 68%, respectively, yielding significantly higher results when compared to product information dosing (48.45% and 49%, respectively), p < 0.001 at both time points. At 48 h, predefined toxicity thresholds were exceeded in 4.7% and 0% of simulations for guideline-based and product information-based dosing, respectively (p = 0.002). eGFR was significantly associated with the % PTA by guideline-based dosing, with eGFR values of 20 and 50 ml/min both statistically significant in leading to an increase in PTA. CONCLUSIONS Our study demonstrated that achievement of PK-PD exposures associated with an increased likelihood of effectiveness was more likely to occur with guideline-based dosing; especially at 48 h.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Pharmacy DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Mohd H. Abdul‐Aziz
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
| | - Kathryn Wilks
- Infectious Diseases DepartmentSunshine Coast University HospitalBirtinyaQueenslandAustralia
- School of Public HealthThe University of QueenslandBrisbaneQueenslandAustralia
| | - Andras Farkas
- Department of PharmacyMount Sinai WestNew YorkNew YorkUSA
- Optimum Dosing StrategiesBloomingdaleNew JerseyUSA
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), The University of QueenslandBrisbaneQueenslandAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Pharmacy DepartmentRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
- Division of Anaesthesiology Critical Care Emergency and Pain MedicineNîmes University Hospital, University of MontpellierNîmesFrance
- Herston Infectious Diseases Institute (HeIDI)BrisbaneQueenslandAustralia
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7
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Barreto EF, Chang J, Bjergum MW, Gajic O, Jannetto PJ, Mara KC, Meade LA, Rule AD, Vollmer KJ, Scheetz MH. Adequacy of cefepime concentrations in the early phase of critical illness: A case for precision pharmacotherapy. Pharmacotherapy 2023; 43:1112-1120. [PMID: 36648390 PMCID: PMC10350476 DOI: 10.1002/phar.2766] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE In critically ill patients, adequacy of early antibiotic exposure has been incompletely evaluated. This study characterized factors associated with inadequate cefepime exposure in the first 24 h of critical illness. DESIGN Prospective cohort study. SETTING Academic Medical Center. PATIENTS Critically ill adults treated with cefepime. Patients with acute kidney injury or treated with kidney replacement therapy or extracorporeal membrane oxygenation were excluded. INTERVENTION None. MEASUREMENTS A nonlinear mixed-effects pharmacokinetic (PK) model was developed to estimate cefepime concentrations for each patient over time. The percentage of time the free drug concentration exceeded 8 mg/L during the first 24 h of therapy was calculated (%ƒT>8; appropriate for the susceptible breakpoint for Pseudomonas aeruginosa). Factors predictive of low %ƒT>8 were explored with multivariable regression. MAIN RESULTS In the 100 included patients, a one-compartment PK model was developed with first-order elimination with covariates for weight and estimated glomerular filtration rate based on creatinine and cystatin C (eGFRSCr-CysC). The median (interquartile range) %ƒT>8 for cefepime in the first 24 h of therapy based on this model was 85% (66%, 100%). Less than 100% ƒT>8 during first 24 h of therapy occurred in 70 (70%) individuals. Lower Sequential Organ Failure Assessment score (p = 0.032) and higher eGFRSCr-CysC (p < 0.001) predicted a lower %ƒT>8. Central nervous system infection source was protective (i.e., associated with a higher %ƒT>8; p = 0.008). CONCLUSIONS During early critical illness, cefepime concentrations were inadequate in a significant proportion of patients. Antimicrobial optimization is needed to improve the precision of pharmacotherapy in the critically ill patients.
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Affiliation(s)
- Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Northwestern Medicine, Department of Pharmacy, Chicago, Illinois, USA
| | - Matthew W. Bjergum
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ognjen Gajic
- Division of Pulmonary Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J. Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C. Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Laurie A. Meade
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Minnesota, USA
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn J. Vollmer
- Rutgers Institute for Pharmaceutical Industry Fellowships, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA
| | - Marc H. Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Northwestern Medicine, Department of Pharmacy, Chicago, Illinois, USA
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8
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Angelini J, Giuliano S, Flammini S, Pagotto A, Lo Re F, Tascini C, Baraldo M. Meropenem PK/PD Variability and Renal Function: "We Go Together". Pharmaceutics 2023; 15:2238. [PMID: 37765207 PMCID: PMC10534409 DOI: 10.3390/pharmaceutics15092238] [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: 07/28/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Meropenem is a carbapenem antibiotic widely employed for serious bacterial infections. Therapeutic drug monitoring (TDM) is a strategy to optimize dosing, especially in critically ill patients. This study aims to show how TDM influences the management of meropenem in a real-life setting, not limited to intensive care units. METHODS From December 2021 to February 2022, we retrospectively analyzed 195 meropenem serum concentrations (Css). We characterized patients according to meropenem exposure, focusing on the renal function impact. RESULTS A total of 36% (n = 51) of the overall observed patients (n = 144) were in the therapeutic range (8-16 mg/L), whereas 64% (n = 93) required a meropenem dose modification (37 patients (26%) underexposed; 53 (38%) overexposed). We found a strong relationship between renal function and meropenem concentrations (correlation coefficient = -0.7; p-value < 0.001). We observed different dose-normalized meropenem exposure (Css/D) among renal-impaired (severe and moderate), normal, and hyperfiltrating patients, with a median (interquartile range) of 13.1 (10.9-20.2), 7.9 (6.1-9.5), 3.8 (2.6-6.0), and 2.4 (1.6-2.7), respectively (p-value < 0.001). CONCLUSIONS Meropenem TDM in clinical practice allows modification of dosing in patients inadequately exposed to meropenem to maximize antibiotic efficacy and minimize the risk of antibiotic resistance, especially in renal alterations despite standard dose adaptations.
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Affiliation(s)
- Jacopo Angelini
- Clinical Pharmacology and Toxicology Institute, University Hospital Friuli Centrale ASUFC, 33100 Udine, Italy; (F.L.R.); (M.B.)
- Department of Medicine, University of Udine (UNIUD), 33100 Udine, Italy;
| | - Simone Giuliano
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.G.); (S.F.); (A.P.)
| | - Sarah Flammini
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.G.); (S.F.); (A.P.)
| | - Alberto Pagotto
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.G.); (S.F.); (A.P.)
| | - Francesco Lo Re
- Clinical Pharmacology and Toxicology Institute, University Hospital Friuli Centrale ASUFC, 33100 Udine, Italy; (F.L.R.); (M.B.)
- Department of Medicine, University of Udine (UNIUD), 33100 Udine, Italy;
| | - Carlo Tascini
- Department of Medicine, University of Udine (UNIUD), 33100 Udine, Italy;
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.G.); (S.F.); (A.P.)
| | - Massimo Baraldo
- Clinical Pharmacology and Toxicology Institute, University Hospital Friuli Centrale ASUFC, 33100 Udine, Italy; (F.L.R.); (M.B.)
- Department of Medicine, University of Udine (UNIUD), 33100 Udine, Italy;
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9
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Gan Y, Meng X, Lei N, Yu H, Zeng Q, Huang Q. Meropenem Pharmacokinetics and Target Attainment in Critically Ill Patients. Infect Drug Resist 2023; 16:3989-3997. [PMID: 37366501 PMCID: PMC10290838 DOI: 10.2147/idr.s408572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
Purpose This study aimed to investigate the pharmacokinetics and target attainment of meropenem and compare the effect of meropenem dosing regimens in critically ill patients. Patients and Methods Thirty-seven critically ill patients who were administered meropenem in intensive care units were analyzed. Patients were classified according to their renal function. Pharmacokinetic parameters were assessed based on Bayesian estimation. The target attainment of 40%fT > MIC (fraction time that the free concentration exceeds the minimum inhibitory concentration) and 100%fT > MIC with the pathogen MIC of 2 mg/L and 8 mg/L were specially focused. Furthermore, the effects of standard dosing (1g meropenem, 30 min intravenous infusion every 8h) and non-standard dosing (dosage regimens except standard dosing) were compared. Results The results showed that the values of meropenem clearance (CL), central volume of distribution (V1), intercompartmental clearance (Q), and peripheral volume of distribution (V2) were 3.3 L/h, 9.2 L, 20.1 L/h and 12.8 L, respectively. The CL of the patients among renal function groups was significantly different (p < 0.001). The tow targets attainment for the pathogen MIC of 2 mg/L and 8 mg/L were 89%, 73%, 49% and 27%, respectively. The severe renal impairment group has higher fraction of target attainment than the other group. The standard dosing achieved the target of 40%fT > 2/8 mg/L (85.7% and 81%, respectively) and patients with severe renal impairment achieved the target fraction of 100% for 40%fT > MIC. Additionally, there was no significant difference between standard and non-standard dosing group in target attainment. Conclusion Our findings indicate that renal function is an important covariate for both meropenem pharmacokinetics parameters and target attainment. The target attainment between standard and non-standard dosing group was not comparable. Therefore, therapeutic drug monitoring is indispensable in the dosing adjustment for critically ill patients if it is available.
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Affiliation(s)
- Yuhong Gan
- Department of Clinical Pharmacy, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Xiaobin Meng
- Department of Clinical Pharmacy, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Nanfeng Lei
- Department of Clinical Pharmacy, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Hong Yu
- Department of Clinical Pharmacy, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Qingkao Zeng
- Department of Intensive Care Unit, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
| | - Qingyan Huang
- Center for Precision Medicine, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
- Guangdong Provincial Engineering and Technology Research Center for Clinical Molecular Diagnostics and Antibody Therapeutics, Meizhou People’s Hospital, Meizhou Academy of Medical Sciences, Meizhou, People’s Republic of China
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10
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Fukumoto S, Ohbayashi M, Okada A, Kohyama N, Tamatsukuri T, Inoue H, Kato A, Kotani T, Sagara H, Dohi K, Kogo M. Population Pharmacokinetic Model and Dosing Simulation of Meropenem Using Measured Creatinine Clearance for Patients with Sepsis. Ther Drug Monit 2023; 45:392-399. [PMID: 36253888 PMCID: PMC10168112 DOI: 10.1097/ftd.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/28/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Creatinine clearance (CCr) and pharmacokinetic parameters are markedly affected by pathophysiological changes in patients with sepsis. However, only a few reports have assessed renal function in patients with sepsis using the measured CCr. Furthermore, the administration regimen has not been sufficiently evaluated using a population PK (PPK) model across renal function broad ranges. Therefore, this study was performed to construct a meropenem PPK model for patients with sepsis using the measured CCr and evaluate the optimized meropenem dosing regimen based on the CCr. METHODS Patients with sepsis who received intravenous meropenem at the Showa University Hospital were enrolled in this prospective observational study. The PPK model was constructed using blood samples and clinical information of patients. The probability of target attainment (PTA) indicates the likelihood of achieving 50% time above the minimum inhibitory concentration (% T > MIC) based on 10,000 virtual patients using Monte Carlo simulations. The PTA for each meropenem regimen was 50% T > MIC based on different renal functions using the Monte Carlo simulation. RESULTS One hundred samples were collected from 31 patients. The final PPK model incorporating the measured CCr as a covariate in CL displayed the best fit. The recommended dosing regimen to achieve a PTA of 50% T > MIC of 4 mcg/mL was 1 g every 8 hours as a 3-hour prolonged infusion for patients with CCr 85-130 mL/min and 1 g every 8 hours as an 8-hour continuous infusion for patients with CCr ≥ 130 mL/min. CONCLUSIONS This model precisely predicted meropenem concentrations in patients with sepsis by accurately evaluating renal function using the measured CCr. Extended dosing was demonstrated to be necessary to achieve a PTA of 50% T > MIC for patients with CCr ≥ 85 mL/min. Meropenem effectiveness can be maximized in patients with sepsis by selecting the appropriate dosing regimen based on renal function and the MIC.
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Affiliation(s)
- Shiori Fukumoto
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy
| | - Masayuki Ohbayashi
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy
| | - Akira Okada
- Laboratory of Regulatory Science, Faculty of Pharmacy, Musashino University
| | - Noriko Kohyama
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy
| | | | - Hideki Inoue
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University School of Medicine
| | - Akihito Kato
- Department of Emergency, Disaster and Critical Care Medicine, Showa University; and
| | - Toru Kotani
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hironori Sagara
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University School of Medicine
| | - Kenji Dohi
- Department of Emergency, Disaster and Critical Care Medicine, Showa University; and
| | - Mari Kogo
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy
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11
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Wu YE, Kou C, Li X, Tang BH, Yao BF, Hao GX, Zheng Y, van den Anker J, You DP, Shen AD, Zhao W. Developmental Population Pharmacokinetics-Pharmacodynamics of Meropenem in Chinese Neonates and Young Infants: Dosing Recommendations for Late-Onset Sepsis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1998. [PMID: 36553441 PMCID: PMC9777159 DOI: 10.3390/children9121998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/07/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022]
Abstract
The pharmacokinetic (PK) studies of meropenem in Chinese newborns with late-onset sepsis (LOS) are still lacking. Causative pathogens of LOS and their susceptibility patterns in China differ from the data abroad. We, therefore, conducted a developmental population pharmacokinetic−pharmacodynamic analysis in Chinese newborns with the goal to optimize meropenem dosing regimens for LOS therapy. An opportunistic sampling strategy was used to collect meropenem samples, followed by model building and validation. A Monte Carlo simulation was performed to show the probability of target attainment (PTA) for various dosages. The information from 78 newborns (postmenstrual age: 27.4−46.1 weeks) was compiled and had a good fit to a 1-compartment model that had first order elimination. The median (range) values of estimated weight−normalized volume of distribution (V)and clearance (CL) were 0.60 (0.51−0.69) L/kg and 0.16 (0.04−0.51) L/h/kg, respectively. Covariate analysis revealed that postnatal age (PNA), gestational age (GA) and current weight (CW) were the most important factors in describing meropenem PK. Simulation results showed for LOS with a minimal inhibitory concentration (MIC) of 8 mg/L, the doses of 30 mg/kg 3 times daily (TID) as a 1-h infusion for newborns with GA ≤ 37 weeks and 40 mg/kg TID as a 3-h infusion for those with GA > 37 weeks were optimal, with PTA of 71.71% and 75.08%, respectively. In conclusion, we proposed an evidence-based dosing regimen of meropenem for LOS in Chinese newborns by using the population pharmacokinetic−pharmacodynamic analysis, based on domestic common pathogens and their susceptibility patterns.
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Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Chen Kou
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100020, China
| | - Xue Li
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC 20010, USA
- Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC 20052, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, 4056 Basel, Switzerland
| | - Dian-Ping You
- Pediatric Research Institute, Children’s Hospital of Hebei Province Affiliated to Hebei Medical University, Shijiazhuang 050000, China
| | - A-Dong Shen
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
- Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou 450018, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Qilu Hospital of Shandong University, Shandong University, Jinan 250012, China
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12
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Schatz LM, Zoller M, Scharf C, Liebchen U. [Therapeutic drug monitoring and pharmacokinetic models as a strategy for rational antibiotic therapy in intensive care patients]. DIE ANAESTHESIOLOGIE 2022; 71:495-501. [PMID: 35925054 DOI: 10.1007/s00101-022-01150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Antibiotic dosing in intensive care patients is complex due to pharmacokinetic (PK) alterations. The aim of this article is to illustrate the role of therapeutic drug monitoring (TDM) and PK models to individualize antibiotic dosing. MATERIAL AND METHODS Guidelines and recommendations are discussed in the context of clinical practice and the prerequisites for routine TDM of different antibiotics are presented. In addition, the benefits and limitations of TDM are discussed. The advantages and disadvantages of TDM and PK models are described and the resulting future options are presented. RESULTS In the clinical routine, the peak or trough concentrations of antibiotics in blood are measured depending on the antibiotic class. Prerequisites for a purposeful TDM are a coordinated blood sampling and a prompt reporting of findings. As target ranges are not uniformly defined following rules, dosage adjustments are difficult. The PK models offer a valid possibility to individualize the antibiotic therapy of intensive care patients. Areas of application are the calculation of the loading dose and the combination with TDM for treatment control. For whom and how often TDM is necessary and how it can best be combined with PK models or even replace them should be investigated in the future, in addition to evaluation of the optimal target area. CONCLUSION The routine use of TDM for antibiotics in intensive care patients is only effective under the abovementioned conditions. By combination with PK models the treatment could be optimized in the future.
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Affiliation(s)
- Lea Marie Schatz
- Institut für Klinische Pharmazie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland
| | - Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Christina Scharf
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland.
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Hefny F, Sambhi S, Morris C, Kung JY, Stuart A, Mahmoud SH. Drug Dosing in Critically Ill Adult Patients with Augmented Renal Clearance. Eur J Drug Metab Pharmacokinet 2022; 47:607-620. [PMID: 35763238 DOI: 10.1007/s13318-022-00779-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
Abstract
Augmented renal clearance (ARC) is a phenomenon of enhanced renal function seen in critically ill patients. ARC alters the disposition of renally eliminated medications currently used in the intensive care unit, resulting in underdosing and potential therapy failure. Our review addresses the rising concern of inadequate dosing in patients with ARC by summarizing the currently available evidence. To our knowledge, this guide is the first to provide clinicians with dose recommendation insights for renally eliminated agents in adult critically ill patients with ARC. A comprehensive literature search using MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and ProQuest Dissertations and Theses Global was conducted until 3 November 2021. Screening and data extraction were conducted in two steps: title and abstract screening followed by full-text review. Full text review resulted in a total of 51 studies included in this review. The results demonstrated the need for higher-than-standard doses for meropenem, imipenem, and vancomycin and reduced dosing intervals for ceftriaxone in patients with ARC. The potential need for increased dosing frequency in patients with ARC was also found for both enoxaparin and levetiracetam. In conclusion, ARC has been shown to influence the probability of target attainment in several medications requiring dosing changes to mitigate the risk of therapeutic failure.
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Affiliation(s)
- Fatma Hefny
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Sukhvir Sambhi
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Cassidy Morris
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Janice Y Kung
- Public Services Librarian, John W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Anna Stuart
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada
| | - Sherif Hanafy Mahmoud
- Katz Group Centre for Pharmacy and Health Research, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-142H, Edmonton, AB, T6G 2E1, Canada.
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14
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Weber F, Dübel L, Mikolajewska A, Uhrig A, Kiessling P, Huisinga W, Michelet R, Hennig S, Kloft C. Evaluation of a Meropenem and Piperacillin Monitoring Program in Intensive Care Unit Patients Calls for the Regular Assessment of Empirical Targets and Easy-to-Use Dosing Decision Tools. Antibiotics (Basel) 2022; 11:antibiotics11060758. [PMID: 35740164 PMCID: PMC9219867 DOI: 10.3390/antibiotics11060758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 02/01/2023] Open
Abstract
The drug concentrations targeted in meropenem and piperacillin/tazobactam therapy also depend on the susceptibility of the pathogen. Yet, the pathogen is often unknown, and antibiotic therapy is guided by empirical targets. To reliably achieve the targeted concentrations, dosing needs to be adjusted for renal function. We aimed to evaluate a meropenem and piperacillin/tazobactam monitoring program in intensive care unit (ICU) patients by assessing (i) the adequacy of locally selected empirical targets, (ii) if dosing is adequately adjusted for renal function and individual target, and (iii) if dosing is adjusted in target attainment (TA) failure. In a prospective, observational clinical trial of drug concentrations, relevant patient characteristics and microbiological data (pathogen, minimum inhibitory concentration (MIC)) for patients receiving meropenem or piperacillin/tazobactam treatment were collected. If the MIC value was available, a target range of 1–5 × MIC was selected for minimum drug concentrations of both drugs. If the MIC value was not available, 8–40 mg/L and 16–80 mg/L were selected as empirical target ranges for meropenem and piperacillin, respectively. A total of 356 meropenem and 216 piperacillin samples were collected from 108 and 96 ICU patients, respectively. The vast majority of observed MIC values was lower than the empirical target (meropenem: 90.0%, piperacillin: 93.9%), suggesting empirical target value reductions. TA was found to be low (meropenem: 35.7%, piperacillin 50.5%) with the lowest TA for severely impaired renal function (meropenem: 13.9%, piperacillin: 29.2%), and observed drug concentrations did not significantly differ between patients with different targets, indicating dosing was not adequately adjusted for renal function or target. Dosing adjustments were rare for both drugs (meropenem: 6.13%, piperacillin: 4.78%) and for meropenem irrespective of TA, revealing that concentration monitoring alone was insufficient to guide dosing adjustment. Empirical targets should regularly be assessed and adjusted based on local susceptibility data. To improve TA, scientific knowledge should be translated into easy-to-use dosing strategies guiding antibiotic dosing.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Franz Weber
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, Freie Universitaet Berlin/Universität Potsdam, 12169 Berlin, Germany
| | - Lucas Dübel
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | - Alexander Uhrig
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 13353 Berlin, Germany; (M.S.S.); (F.P.); (S.A.); (A.M.); (A.U.)
| | | | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany; (F.A.W.); (L.D.); (F.W.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50676
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C/MIC > 4: A Potential Instrument to Predict the Efficacy of Meropenem. Antibiotics (Basel) 2022; 11:antibiotics11050670. [PMID: 35625314 PMCID: PMC9137711 DOI: 10.3390/antibiotics11050670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
This prospective study aimed to explore the determinants of meropenem trough concentration (Ctrough) in patients with bacterial pneumonia and to investigate the association between its concentration and efficacy. From January 2019 to December 2019, patients with pulmonary infections were prospectively enrolled from the intensive care unit. Factors affecting the meropenem trough concentration were analyzed, and a multiple linear regression model was constructed. Logistic regression analyses were used to investigate the relationship between Ctrough and clinical efficacy. A total of 64 patients were enrolled, in whom 210 meropenem concentrations were measured. Of the total, 60.9% (39/64) were considered clinically successful after treatment. Ctrough may increase with increased blood urea nitrogen, albumin, and concomitant antifungal use. By contrast, concentration may decrease with increased endogenous creatinine clearance rate. Six variables, including Ctrough/minimum inhibitory concentration (MIC) > 4, were associated with the efficacy of meropenem. There was an independent correlation between Ctrough/MIC > 4 and efficacy after fully adjusting for confounding factors. Based upon renal function indexes, it is possible to predict changes in meropenem concentration and adjust the dosage precisely and individually. Ctrough/MIC > 4 is a potential instrument to predict successful treatment with meropenem.
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Berry AV, Kuti JL. Pharmacodynamic Thresholds for Beta-Lactam Antibiotics: A Story of Mouse Versus Man. Front Pharmacol 2022; 13:833189. [PMID: 35370708 PMCID: PMC8971958 DOI: 10.3389/fphar.2022.833189] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/24/2022] [Indexed: 01/20/2023] Open
Abstract
Beta-lactams remain a critical member of our antibiotic armamentarium and are among the most commonly prescribed antibiotic classes in the inpatient setting. For these agents, the percentage of time that the free concentration remains above the minimum inhibitory concentration (%fT > MIC) of the pathogen has been shown to be the best predictor of antibacterial killing effects. However, debate remains about the quantity of fT > MIC exposure needed for successful clinical response. While pre-clinical animal based studies, such as the neutropenic thigh infection model, have been widely used to support dosing regimen selection for clinical development and susceptibility breakpoint evaluation, pharmacodynamic based studies in human patients are used validate exposures needed in the clinic and for guidance during therapeutic drug monitoring (TDM). For the majority of studied beta-lactams, pre-clinical animal studies routinely demonstrated the fT > MIC should exceed approximately 40–70% fT > MIC to achieve 1 log reductions in colony forming units. In contrast, clinical studies tend to suggest higher exposures may be needed, but tremendous variability exists study to study. Herein, we will review and critique pre-clinical versus human-based pharmacodynamic studies aimed at determining beta-lactam exposure thresholds, so as to determine which targets may be best suited for optimal dosage selection, TDM, and for susceptibility breakpoint determination. Based on our review of murine and clinical literature on beta-lactam pharmacodynamic thresholds, murine based targets specific to each antibiotic are most useful during dosage regimen development and susceptibility breakpoint assessment, while a range of exposures between 50 and 100% fT > MIC are reasonable to define the beta-lactam TDM therapeutic window for most infections.
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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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Prevalence and Risk Factors of Augmented Renal Clearance: A Systematic Review and Meta-Analysis. Pharmaceutics 2022; 14:pharmaceutics14020445. [PMID: 35214177 PMCID: PMC8878755 DOI: 10.3390/pharmaceutics14020445] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Kidney function assessment in the critically ill overlooks the possibility for hyperfunctioning kidneys, known as augmented renal clearance (ARC), which could contribute to therapeutic failures in the intensive care unit (ICU). The aim of this research is to conduct a systematic review and meta-analysis of prevalence and risk factors of ARC in the critically ill. MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations and Theses Global databases were searched on 27 October 2020. We included studies conducted in critically ill adults who reported the prevalence and/or risk factors of ARC. We evaluated study quality using the Joanna Briggs Institute appraisal tool. Case reports, reviews, editorials and commentaries were excluded. We generated a random-effects meta-analytic model using the inverse variance method and visualized the pooled estimates using forest plots. Seventy studies were included. The pooled prevalence (95% CI) was 39% (34.9–43.3). Prevalence for neuro, trauma, mixed and sepsis ICUs were 74 (55–87), 58 (48–67), 36 (31–41) and 33 (21–48), respectively. Age, male sex and trauma were associated with ARC with pooled OR (95% CI) of 0.95 (0.93–0.96), 2.36 (1.28–4.36), 2.60 (1.21–5.58), respectively. Limitations included variations in ARC definition, inclusion and exclusion criteria and studies design. In conclusion, ARC is prevalent in critically ill patients, especially those in the neurocritical care and trauma ICU population. Young age, male sex and trauma are risk factors for ARC in those with apparently normal renal function. Further research on optimal dosing of drugs in the setting of ARC is warranted. (Prospero registration: CRD42021246417).
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Gijsen M, Elkayal O, Annaert P, Van Daele R, Meersseman P, Debaveye Y, Wauters J, Dreesen E, Spriet I. Meropenem Target Attainment and Population Pharmacokinetics in Critically Ill Septic Patients with Preserved or Increased Renal Function. Infect Drug Resist 2022; 15:53-62. [PMID: 35035223 PMCID: PMC8754504 DOI: 10.2147/idr.s343264] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/14/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Critically ill patients with preserved or increased renal function have been shown to be at risk of underexposure to meropenem. Although many meropenem population pharmacokinetic (PK) models have been published, there is no large prospective population PK study with rich sampling focusing on patients most at risk of suboptimal pharmacokinetic/pharmacodynamic (PK/PD) target attainment. Therefore, the aim of the present study was to evaluate PK/PD target attainment and to perform a thorough covariate screening using population PK modelling of meropenem in septic patients with preserved or increased renal function. Patients and Methods A single-centre prospective observational PK study was performed in the intensive care unit (ICU) of the University Hospitals Leuven. Patients with severe sepsis or septic shock and treated with meropenem in the ICU were screened for inclusion. Patients were excluded if they received renal replacement therapy or had an estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology collaboration equation <70 mL/min/1.73m2 on the day of PK sampling. Successful PK/PD target attainment was defined as an unbound meropenem trough concentration above 2 mg/L or 8 mg/L. Population PK modelling was performed with NONMEM7.4. Results In total, 58 patients were included, contributing 345 plasma samples over 70 dosing intervals. The 2 mg/L and 8 mg/L targets were successfully attained in 46% and 11% of all dosing intervals, respectively. A two-compartment population PK model with linear elimination and interindividual variability on clearance best described meropenem PK. The estimated creatinine clearance according to the Cockcroft-Gault equation was the only covariate retained during population PK analysis. Conclusion This study provided detailed insight into meropenem PK in critically ill patients with preserved or increased renal function. We observed poor PK/PD target attainment, for which renal function was the only significant covariate. Trial Registration This study is registered at ClinicalTrials.gov (NCT03560557).
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Affiliation(s)
- Matthias Gijsen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Omar Elkayal
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,BioNotus, Niel, Belgium
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | | | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Joost Wauters
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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20
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Lan J, Wu Z, Wang X, Wang Y, Yao F, Zhao BX, Wang Y, Chen J, Chen C. Population pharmacokinetics analysis and dosing simulations of meropenem in critically ill patients with pulmonary infection. J Pharm Sci 2022; 111:1833-1842. [DOI: 10.1016/j.xphs.2022.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 01/02/2023]
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21
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Weinelt FA, Stegemann MS, Theloe A, Pfäfflin F, Achterberg S, Schmitt L, Huisinga W, Michelet R, Hennig S, Kloft C. Development of a Model-Informed Dosing Tool to Optimise Initial Antibiotic Dosing-A Translational Example for Intensive Care Units. Pharmaceutics 2021; 13:pharmaceutics13122128. [PMID: 34959409 PMCID: PMC8708464 DOI: 10.3390/pharmaceutics13122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022] Open
Abstract
The prevalence and mortality rates of severe infections are high in intensive care units (ICUs). At the same time, the high pharmacokinetic variability observed in ICU patients increases the risk of inadequate antibiotic drug exposure. Therefore, dosing tailored to specific patient characteristics has a high potential to improve outcomes in this vulnerable patient population. This study aimed to develop a tabular dosing decision tool for initial therapy of meropenem integrating hospital-specific, thus far unexploited pathogen susceptibility information. An appropriate meropenem pharmacokinetic model was selected from the literature and evaluated using clinical data. Probability of target attainment (PTA) analysis was conducted for clinically interesting dosing regimens. To inform dosing prior to pathogen identification, the local pathogen-independent mean fraction of response (LPIFR) was calculated based on the observed minimum inhibitory concentrations distribution in the hospital. A simple, tabular, model-informed dosing decision tool was developed for initial meropenem therapy. Dosing recommendations achieving PTA > 90% or LPIFR > 90% for patients with different creatinine clearances were integrated. Based on the experiences during the development process, a generalised workflow for the development of tabular dosing decision tools was derived. The proposed workflow can support the development of model-informed dosing tools for initial therapy of various drugs and hospital-specific conditions.
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Affiliation(s)
- Ferdinand Anton Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Miriam Songa Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Anja Theloe
- Pharmacy Department, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany;
| | - Frieder Pfäfflin
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
- Antimicrobial Stewardship, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany
| | - Stephan Achterberg
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, Berlin Institute of Health, 10117 Berlin, Germany; (M.S.S.); (F.P.); (S.A.)
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
| | - Stefanie Hennig
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane 4000, Australia
- Certara, Inc., Princeton, NJ 08540, USA
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (F.A.W.); (L.S.); (R.M.); (S.H.)
- Correspondence: ; Tel.: +49-30-838-50656
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Combination of pharmacokinetic and pathogen susceptibility information to optimize meropenem treatment of gram-negative infections in critically ill patients. Antimicrob Agents Chemother 2021; 66:e0183121. [PMID: 34871092 DOI: 10.1128/aac.01831-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Meropenem is one of the most frequently used antibiotics to treat life-threatening infections in critically ill patients. This study aimed to develop a meropenem dosing algorithm for the treatment of gram-negative infections based on intensive care unit (ICU)-specific resistance data. Methods: Antimicrobial susceptibility testing of gram-negative bacteria obtained from critically ill patients was carried out from 2016 to 2020 at a tertiary care hospital. Based on the observed minimal inhibitory concentration (MIC) distribution, stochastic simulations (n=1000) of an evaluated pharmacokinetic meropenem model and a defined pharmacokinetic/pharmacodynamic target (100%T>4xMIC while minimum concentrations <44.5 mg/L), dosing recommendations for patients with varying renal function were derived: Pathogen-specific MIC distributions were used to calculate the cumulative fraction of response (CFR) and the overall MIC distribution was used to calculate the local pathogen-independent mean fraction of response (LPIFR) for the investigated dosing regimens. A CFR/LPIFR >90% was considered adequate. Results: The observed MIC distribution significantly differed from the EUCAST database. Based on the 6520 MIC values included, a three-level dosing algorithm was developed. If the pathogen causing the infection is unknown (level 1), known (level 2), known to be neither Pseudomonas aeruginosa nor Acinetobacter baumannii or classified as susceptible (level 3), a continuous infusion of 1.5 g daily reached sufficient target attainment independent of renal function. In all other cases dosing needs to be adjusted based on renal function. Conclusion: ICU-specific susceptibility data should be assessed regularly and integrated into dosing decisions. The presented workflow may serve as a blueprint for other antimicrobial settings. (250 words).
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Personalized Antibiotic Therapy for the Critically Ill: Implementation Strategies and Effects on Clinical Outcome of Piperacillin Therapeutic Drug Monitoring-A Descriptive Retrospective Analysis. Antibiotics (Basel) 2021; 10:antibiotics10121452. [PMID: 34943664 PMCID: PMC8698194 DOI: 10.3390/antibiotics10121452] [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: 10/30/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 12/29/2022] Open
Abstract
Therapeutic drug monitoring (TDM) is increasingly relevant for an individualized antibiotic therapy and subsequently a necessary tool to reduce multidrug-resistant pathogens, especially in light of diminishing antimicrobial capabilities. Critical illness is associated with profound pharmacokinetic and pharmacodynamic alterations, which challenge dose finding and the application of particularly hydrophilic drugs such as β-lactam antibiotics. Methods: Implementation strategy, potential benefit, and practicability of the developed standard operating procedures were retrospectively analyzed from January to December 2020. Furthermore, the efficacy of the proposed dosing target of piperacillin in critically ill patients was evaluated. Results: In total, 160 patients received piperacillin/tazobactam therapy and were subsequently included in the study. Of them, 114 patients received piperacillin/tazobactam by continuous infusion and had at least one measurement of piperacillin serum level according to the standard operating procedure. In total, 271 measurements were performed with an average level of 79.0 ± 46.0 mg/L. Seventy-one piperacillin levels exceeded 100 mg/L and six levels were lower than 22.5 mg/L. The high-level and the low-level group differed significantly in infection laboratory parameters (CRP (mg/dL) 20.18 ± 11.71 vs. 5.75 ± 5.33) and renal function [glomerular filtration rate (mL/min/1.75 m2) 40.85 ± 26.74 vs. 120.50 ± 70.48]. Conclusions: Piperacillin levels are unpredictable in critically ill patients. TDM during piperacillin/tazobactam therapy is highly recommended for all patients. Although our implementation strategy was effective, further strategies implemented into the daily clinical workflow might support the health care staff and increase the clinicians' alertness.
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Liebchen U, Paal M, Bucher V, Vogeser M, Irlbeck M, Schroeder I, Zoller M, Scharf C. Trough concentrations of meropenem and piperacillin during slow extended dialysis in critically ill patients with intermittent and continuous infusion: A prospective observational study. J Crit Care 2021; 67:26-32. [PMID: 34628123 DOI: 10.1016/j.jcrc.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/28/2022]
Abstract
Beta-lactam dosing is challenging in critically ill patients with slow extended daily dialysis (SLEDD). This prospective observational study aimed to investigate meropenem and piperacillin concentrations and half-lives during SLEDD and in SLEDD-free intervals. Critically ill patients with SLEDD-therapy and meropenem or piperacillin therapy were included. Breakpoints of target attainment were defined as 2 and 20.8 mg/L for meropenem and piperacillin, respectively. Daily TDM was performed and therapies were adapted based on the measured concentrations. Elimination rate constants were determined by using nonlinear regression analysis. Seventeen patients were included (48 SLEDD intervals; median SLEDD-duration: 7.25 h). The median antibiotic trough concentrations and half-lives were significantly (p < 0.001) lower during and after the SLEDD-therapy compared to SLEDD-free intervals (median meropenem: 22.3 (IQR: 12.8, 25.6) vs. 28.3 mg/L (IQR: 16.9, 37.4); median piperacillin: 55.8 (IQR: 45.1, 84.9) vs. 130 mg/L (IQR: 91.5, 154.5); relative change: -48.0% each, IQR meropenem: -33.3, -58.5%; IQR piperacillin: -36.3, -52.1%). However, none of the measured trough concentrations were subtherapeutic during SLEDD. SLEDD leads to a reduction in meropenem and piperacillin concentrations of approximately 50% independently of the initial concentration. If the concentration is twice as high as the breakpoint of target attainment before SLEDD-therapy, subtherapeutic levels can be avoided.
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Affiliation(s)
- Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Veronika Bucher
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany.
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Wang Y, Chen W, Huang Y, Wang G, Li Z, Yan G, Chen C, Lu G. Optimized Dosing Regimens of Meropenem in Septic Children Receiving Extracorporeal Life Support. Front Pharmacol 2021; 12:699191. [PMID: 34504424 PMCID: PMC8421735 DOI: 10.3389/fphar.2021.699191] [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: 04/23/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
Objectives: To develop a population pharmacokinetic model of meropenem in children with sepsis receiving extracorporeal life support (ECLS) and optimize the dosage regimen based on investigating the probability of target attainment (PTA). Methods: The children with sepsis were prospectively enrolled in a pediatric intensive care unit from January 2018 to December 2019. The concentration-time data were fitted using nonlinear mixed effect model approach by NONMEM program. The stochastic simulation considering various scenarios based on proposed population pharmacokinetics model were conducted, and the PTAs were calculated to optimize the dosage regimens. Results: A total of 25 children with sepsis were enrolled, of whom13 received ECMO, 9 received CRRT, and 4 received ECMO combined with CRRT. 12 children received a two-step 3-h infusion and 13 children received 1-h infusion. Bodyweight and creatinine clearance had significant impacts on the PK parameters. ECMO intervention was not related to the PK properties. If 100%T > MIC was chosen as target, children receiving 40 mg/kg q8h over a 3 h-infusion only reached the PTA up to 77.4%. If bacteria with MIC 2 mg/L were to be treated with meropenem and the PTA target was 50%T > MIC, a dose of 40 mg/kg q8h for 1 h infusion would be necessary. Conclusions: The PK properties of meropenem in septic children receiving extracorporeal life support were best described. We recommended the opitimized dosing regimens for septic children receiving ECLS depending on the PTA of PK target 50%T > MIC and 100%T > MIC, for children with sepsis during ECLS with different body weight, estimated creatinine clearance (eCRCL) and MIC of bacteria.
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Affiliation(s)
- Yixue Wang
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Weiming Chen
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yidie Huang
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Guangfei Wang
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Zhiping Li
- Department of Clinical Pharmacy, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Gangfeng Yan
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Chao Chen
- Department of Neonatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Guoping Lu
- Department of Pediatric Critical Care Medicine, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
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Pařízková RČ, Martínková J, Havel E, Šafránek P, Kaška M, Astapenko D, Bezouška J, Chládek J, Černý V. Impact of cumulative fluid balance on the pharmacokinetics of extended infusion meropenem in critically ill patients with sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:251. [PMID: 34274013 PMCID: PMC8285835 DOI: 10.1186/s13054-021-03680-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/06/2021] [Indexed: 12/29/2022]
Abstract
Background Meropenem dosing for septic critically patients is difficult due to pathophysiological changes associated with sepsis as well as supportive symptomatic therapies. A prospective single-center study assessed whether fluid retention alters meropenem pharmacokinetics and the achievement of the pharmacokinetic/pharmacodynamic (PK/PD) targets for efficacy. Methods Twenty-five septic ICU patients (19 m, 6f) aged 32–86 years with the mean APACHE II score of 20.2 (range 11–33), suffering mainly from perioperative intra-abdominal or respiratory infections and septic shock (n = 18), were investigated over three days after the start of extended 3-h i.v. infusions of meropenem q8h. Urinary creatinine clearance (CLcr) and cumulative fluid balance (CFB) were measured daily. Plasma meropenem was measured, and Bayesian estimates of PK parameters were calculated. Results Eleven patients (9 with peritonitis) were classified as fluid overload (FO) based on a positive day 1 CFB of more than 10% body weight. Compared to NoFO patients (n = 14, 11 with pneumonia), the FO patients had a lower meropenem clearance (CLme 8.5 ± 3.2 vs 11.5 ± 3.5 L/h), higher volume of distribution (V1 14.9 ± 3.5 vs 13.5 ± 4.1 L) and longer half-life (t1/2 1.4 ± 0.63 vs 0.92 ± 0.54 h) (p < 0.05). Over three days, the CFB of the FO patients decreased (11.7 ± 3.3 vs 6.7 ± 4.3 L, p < 0.05) and the PK parameters reached the values comparable with NoFO patients (CLme 12.4 ± 3.8 vs 11.5 ± 2.0 L/h, V1 13.7 ± 2.0 vs 14.0 ± 5.1 L, t1/2 0.81 ± 0.23 vs 0.87 ± 0.40 h). The CLcr and Cockroft–Gault CLcr were stable in time and comparable. The correlation with CLme was weak to moderate (CLcr, day 3 CGCLcr) or absent (day 1 and 2 CGCLcr). Dosing with 2 g meropenem q8h ensured adequate concentrations to treat infections with sensitive pathogens (MIC 2 mg/L). The proportion of pre-dose concentrations exceeding the MIC 8 mg/L and the fraction time with a target-exceeding concentration were higher in the FO group (day 1–3 f Cmin > MIC: 67 vs 27%, p < 0.001; day 1%f T > MIC: 79 ± 17 vs 58 ± 17, p < 0.05). Conclusions These findings emphasize the importance of TDM and a cautious approach to augmented maintenance dosing of meropenem to patients with FO infected with less susceptible pathogens, if guided by population covariate relationships between CLme and creatinine clearance. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03680-9.
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Affiliation(s)
- Renata Černá Pařízková
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jiřina Martínková
- Department of Surgery, University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Eduard Havel
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Petr Šafránek
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Milan Kaška
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - David Astapenko
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jan Bezouška
- Department of Surgery, University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Jaroslav Chládek
- Department of Pharmacology, Charles University, Faculty of Medicine in Hradec Králové, Šimkova 870, 50003, Hradec Králové, Czech Republic.
| | - Vladimír Černý
- Department of Anesthesiology, Resuscitation and Intensive Medicine, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Sokolská 581, 50005, Hradec Králové, Czech Republic
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Gijsen M, Dreesen E, Annaert P, Nicolai J, Debaveye Y, Wauters J, Spriet I. Meropenem Pharmacokinetics and Target Attainment in Critically Ill Patients Are Not Affected by Extracorporeal Membrane Oxygenation: A Matched Cohort Analysis. Microorganisms 2021; 9:microorganisms9061310. [PMID: 34208553 PMCID: PMC8234236 DOI: 10.3390/microorganisms9061310] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022] Open
Abstract
Existing evidence is inconclusive whether meropenem dosing should be adjusted in patients receiving extracorporeal membrane oxygenation (ECMO). Therefore, the aim of this observational matched cohort study was to evaluate the effect of ECMO on pharmacokinetic (PK) variability and target attainment (TA) of meropenem. Patients admitted to the intensive care unit (ICU) simultaneously treated with meropenem and ECMO were eligible. Patients were matched 1:1, based on renal function and body weight, with non-ECMO ICU patients. Meropenem blood sampling was performed over one or two dosing intervals. Population PK modelling was performed using NONMEM7.5. TA was defined as free meropenem concentrations >2 or 8 mg/L (i.e., 1 or 4× minimal inhibitory concentration, respectively) throughout the whole dosing interval. In total, 25 patients were included, contributing 27 dosing intervals. The overall TA was 56% and 26% for the 2 mg/L and 8 mg/L target, respectively. Population PK modelling identified estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology equation and body weight, but not ECMO, as significant predictors. In conclusion, TA of meropenem was confirmed to be poor under standard dosing in critically ill patients but was not found to be influenced by ECMO. Future studies should focus on applying dose optimisation strategies for meropenem based on renal function, regardless of ECMO.
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Affiliation(s)
- Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (P.A.); (J.N.)
- BioNotus, 2845 Niel, Belgium
| | - Johan Nicolai
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (P.A.); (J.N.)
- Development Science, UCB Biopharma SRL, 1420 Braine-l’Alleud, Belgium
| | - Yves Debaveye
- Laboratory for Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium;
| | - Joost Wauters
- Medical Intensive Care Unit, UZ Leuven, 3000 Leuven, Belgium;
- Laboratory for Clinical Infectious and Inflammatory Diseases, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
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The Role of Non-Enzymatic Degradation of Meropenem-Insights from the Bottle to the Body. Antibiotics (Basel) 2021; 10:antibiotics10060715. [PMID: 34198482 PMCID: PMC8231794 DOI: 10.3390/antibiotics10060715] [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: 05/04/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 12/22/2022] Open
Abstract
Several studies have addressed the poor stability of meropenem in aqueous solutions, though not considering the main degradation product, the open-ring metabolite (ORM) form. In the present work, we elucidate the metabolic fate of meropenem and ORM from continuous infusion to the human bloodstream. We performed in vitro infusate stability tests at ambient temperature with 2% meropenem reconstituted in 0.9% normal saline, and body temperature warmed buffered human serum with 2, 10, and 50 mg/L meropenem, covering the therapeutic range. We also examined meropenem and ORM levels over several days in six critically ill patients receiving continuous infusions. Meropenem exhibited a constant degradation rate of 0.006/h and 0.025/h in normal saline at 22 °C and serum at 37 °C, respectively. Given that 2% meropenem remains stable for 17.5 h in normal saline (≥90% of the initial concentration), we recommend replacement of the infusate every 12 h. Our patients showed inter-individually highly variable, but intra-individually constant molar ORM/(meropenem + ORM) ratios of 0.21–0.52. Applying a population pharmacokinetic approach using the degradation rate in serum, spontaneous degradation accounted for only 6% of the total clearance.
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30
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Bjergum MW, Barreto EF, Scheetz MH, Rule AD, Jannetto PJ. Stability and Validation of a High-Throughput LC-MS/MS Method for the Quantification of Cefepime, Meropenem, and Piperacillin and Tazobactam in Serum. J Appl Lab Med 2021; 6:1202-1212. [PMID: 34086904 DOI: 10.1093/jalm/jfab036] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The class of antibiotics known as β-lactams are a commonly used due to their effectiveness and safety. Therapeutic drug monitoring has been proposed but requires an accurate assay along with well-characterized preanalytic stability, as β-lactams are known to be relatively unstable. METHODS A high-throughput LC-MS/MS assay validation and stability study was performed for cefepime, meropenem, and piperacillin and tazobactam in serum. Patient samples, standards, and QCs were crashed with acetonitrile containing internal standard. Following centrifugation, an aliquot of the supernatant was diluted with clinical laboratory reagent water and analyzed by LC-MS/MS. RESULTS The assay showed linearity between 0.5 and 60 µg/mL for each analyte. The intra- and interassay reproducibility at 3 different concentrations (approximately 2, 25, and 40 µg/mL) was <5% for each analyte. Accuracy studies for each analyte were compared using linear regression and demonstrated: slope = 1.0 ± 0.1; r2 ≥ 0.980; and y intercept 95% CI that included zero. Minimal ion suppression or enhancement was observed, and no significant carryover was observed up to 500 µg/mL of each analyte. Stability studies demonstrated significant loss in serum for each analyte at ambient and refrigerated temperatures (2-8 °C) and at -20 °C over days or weeks. In contrast, when stored at -80 °C, no significant loss was observed. CONCLUSIONS The LC-MS/MS assay showed acceptable performance characteristics for quantitation of β-lactams. With well-characterized stability, this assay can be used with residual specimens for pharmacokinetic modeling, which may lead to individualized dosing and improved patient care.
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Affiliation(s)
- Matthew W Bjergum
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Marc H Scheetz
- Departments of Pharmacy and Pharmacology, Midwestern University, Colleges of Pharmacy and Graduate Studies, Pharmacometrics Center of Excellence, Downers Grove, IL USA.,Northwestern Memorial Hospital, Chicago, IL, USA
| | - Andrew D Rule
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Barreto EF, Webb AJ, Pais GM, Rule AD, Jannetto PJ, Scheetz MH. Setting the Beta-Lactam Therapeutic Range for Critically Ill Patients: Is There a Floor or Even a Ceiling? Crit Care Explor 2021; 3:e0446. [PMID: 34136822 PMCID: PMC8202642 DOI: 10.1097/cce.0000000000000446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Beta-lactam antibiotics exhibit high interindividual variability in drug concentrations in patients with critical illness which led to an interest in the use of therapeutic drug monitoring to improve effectiveness and safety. To implement therapeutic drug monitoring, it is necessary to define the beta-lactam therapeutic range-in essence, what drug concentration would prompt a clinician to make dose adjustments up or down. This objective of this narrative review was to summarize evidence for the "floor" (for effectiveness) and "ceiling" (for toxicity) for the beta-lactam therapeutic range to be used with individualized therapeutic drug monitoring. DATA SOURCES Research articles were sourced from PubMed using search term combinations of "pharmacokinetics," "pharmacodynamics," "toxicity," "neurotoxicity," "therapeutic drug monitoring," "beta-lactam," "cefepime," "meropenem," "piperacillin/tazobactam," "ICU," and "critical illness." STUDY SELECTION Articles were selected if they included preclinical, translational, or clinical data on pharmacokinetic and pharmacodynamic thresholds for effectiveness and safety for beta-lactams in critical illness. DATA SYNTHESIS Experimental data indicate a beta-lactam concentration above the minimum inhibitory concentration of the organism for greater than or equal to 40-60% of the dosing interval is needed, but clinical data indicate that higher concentrations may be preferrable. In the first 48 hours of critical illness, a free beta-lactam concentration at or above the susceptibility breakpoint of the most likely pathogen for 100% of the dosing interval would be reasonable (typically based on Pseudomonas aeruginosa). After 48 hours, the lowest acceptable concentration could be tailored to 1-2× the observed minimum inhibitory concentration of the organism for 100% of the dosing interval (often a more susceptible organism). Neurotoxicity is the primary dose-dependent adverse effect of beta-lactams, but the evidence remains insufficient to link a specific drug concentration to greater risk. CONCLUSIONS As studies advance the understanding of beta-lactam exposure and response in critically ill patients, it is essential to clearly define the acceptable therapeutic range to guide regimen selection and adjustment.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Andrew J Webb
- Department of Pharmacy, Oregon Health and Science University, Portland, OR
| | - Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Paul J Jannetto
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL
- Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL
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Liebchen U, Klose M, Paal M, Vogeser M, Zoller M, Schroeder I, Schmitt L, Huisinga W, Michelet R, Zander J, Scharf C, Weinelt FA, Kloft C. Evaluation of the MeroRisk Calculator, A User-Friendly Tool to Predict the Risk of Meropenem Target Non-Attainment in Critically Ill Patients. Antibiotics (Basel) 2021; 10:468. [PMID: 33924047 PMCID: PMC8074046 DOI: 10.3390/antibiotics10040468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The MeroRisk-calculator, an easy-to-use tool to determine the risk of meropenem target non-attainment after standard dosing (1000 mg; q8h), uses a patient's creatinine clearance and the minimum inhibitory concentration (MIC) of the pathogen. In clinical practice, however, the MIC is rarely available. The objectives were to evaluate the MeroRisk-calculator and to extend risk assessment by including general pathogen sensitivity data. METHODS Using a clinical routine dataset (155 patients, 891 samples), a direct data-based evaluation was not feasible. Thus, in step 1, the performance of a pharmacokinetic model was determined for predicting the measured concentrations. In step 2, the PK model was used for a model-based evaluation of the MeroRisk-calculator: risk of target non-attainment was calculated using the PK model and agreement with the MeroRisk-calculator was determined by a visual and statistical (Lin's concordance correlation coefficient (CCC)) analysis for MIC values 0.125-16 mg/L. The MeroRisk-calculator was extended to include risk assessment based on EUCAST-MIC distributions and cumulative-fraction-of-response analysis. RESULTS Step 1 showed a negligible bias of the PK model to underpredict concentrations (-0.84 mg/L). Step 2 revealed a high level of agreement between risk of target non-attainment predictions for creatinine clearances >50 mL/min (CCC = 0.990), but considerable deviations for patients <50 mL/min. For 27% of EUCAST-listed pathogens the median cumulative-fraction-of-response for the observed patients receiving standard dosing was < 90%. CONCLUSIONS The MeroRisk-calculator was successfully evaluated: For patients with maintained renal function it allows a reliable and user-friendly risk assessment. The integration of pathogen-based risk assessment substantially increases the applicability of the tool.
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Affiliation(s)
- Uwe Liebchen
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Marian Klose
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Graduate Research Training Program PharMetrX, Freie Universität Berlin, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Universität Potsdam, 14476 Potsdam, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, Universität Potsdam, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
| | - Johannes Zander
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.P.); (M.V.); (J.Z.)
- Laboratory Dr. Brunner, Luisenstr. 7e, 78464 Konstanz, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (M.Z.); (I.S.); (C.S.)
| | - Ferdinand A. Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
- Graduate Research Training Program PharMetrX, Freie Universität Berlin, 12169 Berlin, Germany
- Graduate Research Training Program PharMetrX, Universität Potsdam, 14476 Potsdam, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; (U.L.); (M.K.); (L.S.); (R.M.); (F.A.W.)
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Westermann I, Gastine S, Müller C, Rudolph W, Peters F, Bloos F, Pletz M, Hagel S. Population pharmacokinetics and probability of target attainment in patients with sepsis under renal replacement therapy receiving continuous infusion of meropenem: Sustained low-efficiency dialysis and continuous veno-venous haemodialysis. Br J Clin Pharmacol 2021; 87:4293-4303. [PMID: 33818823 DOI: 10.1111/bcp.14846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/16/2021] [Accepted: 03/27/2021] [Indexed: 01/01/2023] Open
Abstract
AIMS To describe the population pharmacokinetics (PK) and probability of target attainment (PTA) of continuous infusion (CI) of meropenem in septic patients receiving renal replacement therapy (RRT). METHODS Fifteen patients without RRT, 13 patients receiving sustained low-efficiency dialysis and 12 patients receiving continuous veno-venous haemodialysis were included. Population PK analysis with Monte Carlo simulations for different dosing regimens was performed. For minimum inhibitory concentration 2 mg/L was chosen. The target was set as 50% time ≥4× minimum inhibitory concentration. RESULTS The PK of meropenem was best described by a 1-compartment model with linear elimination. Serum creatinine, residual diuresis and time on RRT, with no difference between sustained low-efficiency dialysis and continuous veno-venous haemodialysis, were found to be significant covariates affecting clearance, explaining >20% of the clearance between subject variability. PTA analysis showed that in patients with RRT, 2 g/24 h, meropenem CI achieved a PTA of 95%. In patients without RRT, the target was achieved with 3 g/24 h CI or prolonged infusion of 1 g meropenem over 8 hours but not with bolus application of 1 g meropenem for 8 hours. Only 2 patients (both without RRT) had meropenem concentrations below the target level. However, approximately half of the patients with RRT receiving CI 3 g/24 h meropenem had toxic concentrations. CONCLUSION We found relevant PK variability for meropenem CI in septic patients with or without RRT, leading to a substantial risk for overdosing in patients with RRT. This finding highlights the strong demand for personalized dosing in critically ill patients.
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Affiliation(s)
- Isabella Westermann
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Silke Gastine
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Carsten Müller
- Centre of Pharmacology, Department of Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Wiebke Rudolph
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Peters
- Institute of Forensic Medicine, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Therapy, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany.,Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
| | - Stefan Hagel
- Center for Sepsis Control and Care - Friedrich Schiller University Jena, Jena, Germany.,Institute for Infectious Diseases and Infection Control, Jena University Hospital - Friedrich Schiller University Jena, Jena, Germany
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Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy 2021; 41:220-233. [PMID: 33480024 DOI: 10.1002/phar.2505] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/13/2022]
Abstract
Therapeutic drug monitoring (TDM) opens the door to personalized medicine, yet it is infrequently applied to β-lactam antibiotics, one of the most commonly prescribed drug classes in the hospital setting. As we continue to understand more about β-lactam pharmacodynamics (PD) and wide inter- and intra-patient variability in pharmacokinetics (PK), the utility of TDM has become increasingly apparent. For β-lactams, the time that free concentrations remain above the minimum inhibitory concentration (MIC) as a function of the dosing interval (%fT>MIC) has been shown to best predict antibacterial effect. Many studies have shown that β-lactam %fT>MIC exposures are often suboptimal across a wide variety of disease states and clinical settings. A limitation to implementing this practice is the general lack of understanding on how to best operationalize this intervention and interpret the results. The instrumentation and expertise needed to quantify β-lactams for TDM is rarely available locally, but certain laboratories advertise these services and perform them regularly. Familiarity with the modalities and nuances of antimicrobial susceptibility testing is crucial to establishing β-lactam concentration targets that meet the relevant exposure thresholds. Evaluation of these concentrations is best accomplished using population PK software and Bayesian modeling, for which a multitude of programs are available. While TDM of β-lactams has shown an ability to increase the rate of target attainment, there is currently limited evidence to suggest that it leads to improved clinical outcomes. Although consensus guidelines for β-lactam TDM do not exist in the United States, guidance would help to promote this important practice and better standardize the approach across institutions. Herein, we discuss the basis for β-lactam TDM, review supporting evidence, and provide guidance for implementation in specific patient populations.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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35
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Abdulla A, Ewoldt TMJ, Purmer IM, Muller AE, Gommers D, Endeman H, Koch BCP. A narrative review of predictors for β-lactam antibiotic exposure during empirical treatment in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:359-368. [PMID: 33463382 DOI: 10.1080/17425255.2021.1879049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION : Emerging studies suggest that antibiotic pharmacokinetics (PK) are difficult to predict in critically ill patients. The high intra- and inter-patient PK variability makes it challenging to accurately predict the appropriate dosage required for a given patient. Identifying patients at risk could help clinicians to consider more individualized dosing regimens and perform therapeutic drug monitoring. We provide an overview of relevant predictors associated with target (non-)attainment of β-lactam antibiotics in critically ill patients. AREAS COVERED : This narrative review summarizes patient and clinical characteristics that can help to predict the attainment of target serum concentrations and to provide guidance on antimicrobial dose optimization. Literature was searched using Embase and Medline database, focusing on β-lactam antibiotics in critically ill patients. EXPERT OPINION : Adequate concentration attainment can be anticipated in critically ill patients prior to initiating empiric β-lactam antibiotic therapy based on readily available demographic and clinical factors. Male gender, younger age, and augmented renal clearance were the most significant predictors for target non-attainment and should be considered in further investigations to develop dosing algorithms for optimal β-lactam therapy.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Eisert A, Lanckohr C, Frey J, Frey O, Wicha SG, Horn D, Ellger B, Schuerholz T, Marx G, Simon TP. Comparison of two empirical prolonged infusion dosing regimens for meropenem in patients with septic shock: A two-center pilot study. Int J Antimicrob Agents 2021; 57:106289. [PMID: 33515688 DOI: 10.1016/j.ijantimicag.2021.106289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Due to high pharmacokinetic variability, standard doses of meropenem are frequently inadequate in septic patients. Therapeutic drug monitoring of meropenem is not widely available; therefore, improved empiric dosing recommendations are needed. OBJECTIVES This study aimed to compare the attainment of pharmacologic targets for two common empirical dosing regimens for meropenem in patients with septic shock. METHODS Two empiric dosing schemes for meropenem were compared using extended infusions (120 minutes) in 32 patients with septic shock in the intensive care units at two different hospitals. One regimen was 3 × 2 g meropenem/24 h for two days, followed by 3 × 1 g meropenem/24 h; the other regimen was 4 × 1 g meropenem/24 h. Serum meropenem concentrations were measured for the first 72 h of therapy, and pharmacokinetic modelling was performed to define the percentage of time the free drug concentration was above various target MICs for each regimen (%fT>MIC). RESULTS Both regimens led to a sufficiently high %fT>MIC for pathogens with target MICs < 4 mg/L. When higher MICs were targeted, the %fT>MIC of 4 × 1 g meropenem decreased faster than that of 3 × 2 g meropenem. At high MICs of 32 mg/L, both dosing regimens failed to provide appropriate drug concentrations. Renal function was a significant covariate of target attainment. CONCLUSIONS The results of this study can guide clinicians in their choice of an empirical dosing regimen for meropenem. If pathogens with low MICs (< 4 mg/L) are targeted, both dosing regimens are adequate, whereas more resistant strains require higher doses.
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Affiliation(s)
- Albrecht Eisert
- Department of Pharmacy, University Hospital Aachen RWTH Aachen, Aachen, Germany; Institute of Clinical Pharmacology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Janina Frey
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital Muenster, Muenster, Germany
| | - Bjoern Ellger
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Tobias Schuerholz
- Department of Anaesthesia and Intensive Care, University of Rostock, Rostock, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive and Intermediate Care, University Hospital RWTH Aachen, Aachen, Germany.
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Scharf C, Liebchen U, Paal M, Taubert M, Vogeser M, Irlbeck M, Zoller M, Schroeder I. The higher the better? Defining the optimal beta-lactam target for critically ill patients to reach infection resolution and improve outcome. J Intensive Care 2020; 8:86. [PMID: 33292582 PMCID: PMC7686672 DOI: 10.1186/s40560-020-00504-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Beta-lactam antibiotics are often subject to therapeutic drug monitoring, but breakpoints of target attainment are mostly based on expert opinions. Studies that show a correlation between target attainment and infection resolution are missing. This analysis investigated whether there is a difference in infection resolution based on two breakpoints of target attainment. METHODS An outcome group out of 1392 critically ill patients treated with meropenem or piperacillin-tazobactam was formed due to different selection criteria. Afterwards, three groups were created: group 1=free drug concentration (f) was < 100% of the time (T) above the minimal inhibitory concentration (MIC) (< 100% fT > MIC), group 2=100% fT > MIC < 4xMIC, and group 3=100% fT > 4xMIC. Parameters for infection control, renal and liver function, and estimated and observed in-hospital mortality were compared between those groups. Statistical analysis was performed with one-way analysis of variance, Tukey post hoc test, U test, and bivariate logistic regression. RESULTS The outcome group consisted of 55 patients (groups 1-3, 17, 24, and 14 patients, respectively). Patients allocated to group 2 or 3 had a significantly faster reduction of the C-reactive protein in contrast to patients allocated to group 1 (p = 0.033 and p = 0.026). Patients allocated to group 3 had a worse renal function, a higher Acute Physiology and Chronic Health Evaluation (APACHE II) score, were older, and had a significantly higher in-hospital mortality compared to group 1 (p = 0.017) and group 2 (p = 0.001). The higher mortality was significantly influenced by worse liver function, higher APACHE II, and higher Sequential Organ Failure Assessment (SOFA) score and norepinephrine therapy. CONCLUSION Achieving the target 100% fT > MIC leads to faster infection resolution in the critically ill. However, there was no benefit for patients who reached the highest target of 100% fT > 4xMIC, although the mortality rate was higher possibly due to confounding effects. In conclusion, we recommend the target 100% fT > MIC < 4xMIC for critically ill patients. TRIAL REGISTRATION NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Max Taubert
- Department I of Pharmacology, Centre for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Garzón V, Bustos RH, G. Pinacho D. Personalized Medicine for Antibiotics: The Role of Nanobiosensors in Therapeutic Drug Monitoring. J Pers Med 2020; 10:E147. [PMID: 32993004 PMCID: PMC7712907 DOI: 10.3390/jpm10040147] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 01/01/2023] Open
Abstract
Due to the high bacterial resistance to antibiotics (AB), it has become necessary to adjust the dose aimed at personalized medicine by means of therapeutic drug monitoring (TDM). TDM is a fundamental tool for measuring the concentration of drugs that have a limited or highly toxic dose in different body fluids, such as blood, plasma, serum, and urine, among others. Using different techniques that allow for the pharmacokinetic (PK) and pharmacodynamic (PD) analysis of the drug, TDM can reduce the risks inherent in treatment. Among these techniques, nanotechnology focused on biosensors, which are relevant due to their versatility, sensitivity, specificity, and low cost. They provide results in real time, using an element for biological recognition coupled to a signal transducer. This review describes recent advances in the quantification of AB using biosensors with a focus on TDM as a fundamental aspect of personalized medicine.
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Affiliation(s)
- Vivian Garzón
- PhD Biosciences Program, Universidad de La Sabana, Chía 140013, Colombia;
| | - Rosa-Helena Bustos
- Therapeutical Evidence Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia;
| | - Daniel G. Pinacho
- Therapeutical Evidence Group, Clinical Pharmacology, Universidad de La Sabana, Chía 140013, Colombia;
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39
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The ONTAI study - a survey on antimicrobial dosing and the practice of therapeutic drug monitoring in German intensive care units. J Crit Care 2020; 60:260-266. [PMID: 32932111 DOI: 10.1016/j.jcrc.2020.08.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE Optimization of antibiotic therapy is still urgently needed in critically ill patients. The aim of the ONTAI survey (online survey on the use of Therapeutic Drug Monitoring of antibiotics in intensive care units) was to evaluate which strategies intensive care physicians in Germany use to improve the quality of antibiotic therapy and what role a Therapeutic Drug Monitoring (TDM) plays. METHODS Among the members of the German Society for Anaesthesiology and the German Society for Medical Intensive Care Medicine and Emergency Medicine, a national cross-sectional survey was conducted using an online questionnaire. RESULTS The questionnaire was completely answered by 398 respondents. Without TDM, prolonged infusion was judged to be the most appropriate dosing regimen for beta lactams. A TDM for piperacillin, meropenem and vancomycin was performed in 17, 22 and 75% of respondents, respectively. For all beta lactams, a TDM was requested more often than it was available. There was great uncertainty as to the optimal pharmacokinetic/pharmacodynamic index for beta-lactams. 86% of the respondents who received minimal inhibitory concentrations adapted the therapy accordingly. CONCLUSION German intensive care physicians are convinced of TDM for dose optimization. However, practical implementation, the determination of MICs and defined target values are still lacking.
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Delattre IK, Hites M, Laterre PF, Dugernier T, Spapen H, Wallemacq PE, Jacobs F, Taccone FS. What is the optimal loading dose of broad-spectrum β-lactam antibiotics in septic patients? Results from pharmacokinetic simulation modelling. Int J Antimicrob Agents 2020; 56:106113. [PMID: 32721604 DOI: 10.1016/j.ijantimicag.2020.106113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/25/2020] [Accepted: 07/19/2020] [Indexed: 01/15/2023]
Abstract
Optimal loading doses of β-lactams to rapidly achieve adequate drug concentrations in critically ill patients are unknown. This was a post-hoc analysis of a prospective study that evaluated broad-spectrum β-lactams [piperacillin (PIP), ceftazidime (CAZ), cefepime (FEP) and meropenem (MEM)] pharmacokinetics (PKs) in patients with sepsis or septic shock (n = 88). Monte Carlo simulation was performed for 1000 virtual patients using specific sets of covariates for various dosing regimens and different durations of administration. Pharmacodynamic (PD) targets were considered as drug concentrations exceeding at least 50% of time above four times the minimum inhibitory concentration (T>4 × MIC) of Pseudomonas aeruginosa, according to EUCAST criteria, for PIP, 70%T>4 × MIC for CAZ and FEP and 40%T>4 × MIC for MEM. The probability of target attainment (PTA) was derived by calculating the percentage of patients who attained the PK/PD target at each MIC. The optimal loading dose was defined as the one associated with a ≥90% probability to achieve the PD targets. Our simulation model identified an optimal loading dose for PIP of 8 g given as a 3-h infusion (PTA of 96.2%), for CAZ and FEP of 4 g given as a 3-h infusion (PTA of 96.5% and 98.4%, respectively), and for MEM of 2 g given as a 30-min infusion (PTA of 93.4%), with the following antibiotic dose administered 6 h thereafter regardless of the drug. A higher first dose of broad-spectrum β-lactams should be given to adequately treat less-susceptible pathogens in septic patients. These findings need to be validated in a prospective study.
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Affiliation(s)
- Isabelle K Delattre
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain (UCL), Brussels, Belgium; Louvain Drug Research Institute, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Maya Hites
- Department of Infectious Diseases, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre-Francois Laterre
- Department of Intensive Care, Cliniques Universitaires St Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Thierry Dugernier
- Department of Intensive Care, Clinique St-Pierre, Ottignies, Belgium
| | - Herbert Spapen
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Pierre E Wallemacq
- Louvain Centre for Toxicology and Applied Pharmacology, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Frédérique Jacobs
- Department of Infectious Diseases, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Cliniques Universitaires de Bruxelles Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Cattaneo D, Corona A, De Rosa FG, Gervasoni C, Kocic D, Marriott DJ. The management of anti-infective agents in intensive care units: the potential role of a 'fast' pharmacology. Expert Rev Clin Pharmacol 2020; 13:355-366. [PMID: 32320302 DOI: 10.1080/17512433.2020.1759413] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of 'fast microbiology.' Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents. AREAS COVERED We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles. EXPERT OPINION Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a 'fast pharmacology' at the bedside.
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Affiliation(s)
- Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Alberto Corona
- Intensive Care Unit, ASST Fatebenefratelli Sacco, University Hospital , Milan, Italy
| | | | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy.,Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital , Milan, Italy
| | - Danijela Kocic
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney , Sydney, Australia
| | - Deborah Je Marriott
- Department of Clinical Microbiology and Infectious Diseases, St Vincent's Hospital , Sydney, Australia
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42
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Grensemann J, Busse D, König C, Roedl K, Jäger W, Jarczak D, Iwersen-Bergmann S, Manthey C, Kluge S, Kloft C, Fuhrmann V. Acute-on-chronic liver failure alters meropenem pharmacokinetics in critically ill patients with continuous hemodialysis: an observational study. Ann Intensive Care 2020; 10:48. [PMID: 32323030 PMCID: PMC7176801 DOI: 10.1186/s13613-020-00666-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/13/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infection and sepsis are a main cause of acute-on-chronic liver failure (ACLF). Adequate dosing of antimicrobial therapy is of central importance to improve outcome. Liver failure may alter antibiotic drug concentrations via changes of drug distribution and elimination. We studied the pharmacokinetics of meropenem in critically ill patients with ACLF during continuous veno-venous hemodialysis (CVVHD) and compared it to critically ill patients without concomitant liver failure (NLF). METHODS In this prospective cohort study, patients received meropenem 1 g tid short-term infusion (SI). Meropenem serum samples were analyzed by high-performance liquid chromatography. A population pharmacokinetic analysis was performed followed by Monte Carlo simulations of (A) meropenem 1 g tid SI, (B) 2 g loading plus 1 g prolonged infusion tid (C) 2 g tid SI, and (D) 2 g loading and continuous infusion of 3 g/day on days 1 and 7. Probability of target attainment (PTA) was assessed for 4× the epidemiological cut-off values for Enterobacterales (4 × 0.25 mg/L) and Pseudomonas spp. (4 × 2 mg/L). RESULTS Nineteen patients were included in this study. Of these, 8 patients suffered from ACLF. A two-compartment model with linear clearance from the central compartment described meropenem pharmacokinetics. The peripheral volume of distribution (V2) was significantly higher in ACLF compared to NLF (38.6L versus 19.7L, p = .05). PTA for Enterobacterales was achieved in 100% for all dosing regimens. PTA for Pseudomonas spp. in ACLF on day 1/7 was: A: 18%/80%, B: 94%/88%, C: 85%/98% D: 100%/100% and NLF: A: 48%/65%, B: 91%/83%, C: 91%/93%, D: 100%/100%. CONCLUSION ALCF patients receiving CVVHD had a higher V2 and may require a higher loading dose of meropenem. For Pseudomonas, high doses or continuous infusion are required to reach PTA in ACLF patients.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Walter Jäger
- Department of Pharmaceutical Chemistry, University of Vienna, Althanstraße 14, 1090, Vienna, Austria
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefanie Iwersen-Bergmann
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, 22529, Hamburg, Germany
| | - Carolin Manthey
- First Department of Internal Medicine and Gastroenterology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169, Berlin, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Medicine B, Münster University Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Lertwattanachai T, Montakantikul P, Tangsujaritvijit V, Sanguanwit P, Sueajai J, Auparakkitanon S, Dilokpattanamongkol P. Clinical outcomes of empirical high-dose meropenem in critically ill patients with sepsis and septic shock: a randomized controlled trial. J Intensive Care 2020; 8:26. [PMID: 32318268 PMCID: PMC7158081 DOI: 10.1186/s40560-020-00442-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background Appropriate antimicrobial dosing is challenging because of changes in pharmacokinetics (PK) parameters and an increase in multidrug-resistant (MDR) organisms in critically ill patients. This study aimed to evaluate the effects of an empirical therapy of high-dose versus standard-dose meropenem in sepsis and septic shock patients. Methods We performed a prospective randomized open-label study to compare the changes of modified sequential organ failure assessment (mSOFA) score and other clinical outcomes of the high-dose meropenem (2-g infusion over 3 h every 8 h) versus the standard-dose meropenem (1-g infusion over 3 h every 8 h) in sepsis and septic shock patients. Patients' characteristics, clinical and microbiological outcomes, 14 and 28-day mortality, vasopressor- and ventilator-free days, intensive care unit (ICU) and hospital-free days, percent of the time of antibiotic concentrations above the minimum inhibitory concentration (%T>MIC), and safety were assessed. Results Seventy-eight patients were enrolled. Median delta mSOFA was comparable between two groups (- 1 in the high-dose group vs. - 1 in the standard-dose group; P value = 0.75). There was no difference between the two groups regarding clinical and microbiological cure, 14- and 28-day mortality, vasopressor- and ventilator-free days, and ICU- and hospital-free days. In patients admitted from the emergency department (ED) with a mSOFA score ≥ 7, the high-dose group demonstrated significantly better microbiological cure compared with the standard-dose group (75% (9/12 patients) vs. 20% (2/10 patients); P value = 0.03). Likewise, the high-dose group presented higher microbiological cure rate in patients admitted from ED who had either APACHE II score > 20 (83.3% (10/12) vs. 28.6% (2/7); P value = 0.045) or on mechanical ventilator (87.5% (7/8) vs. 23.1% (3/13); P value = 0.008) than the standard-dose group. Adverse events were comparable between the two groups. Conclusions Empirical therapy with the high-dose meropenem presented comparable clinical outcomes to the standard-dose meropenem in sepsis and septic shock patients. Besides, subgroup analysis manifested superior microbiological cure rate in sepsis or septic shock patients admitted from ED. Trial registration ClinicalTrials.gov, NCT03344627, registered on November 17, 2017.
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Affiliation(s)
- Tospon Lertwattanachai
- 1Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, 10400 Thailand
| | - Preecha Montakantikul
- 1Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, 10400 Thailand
| | - Viratch Tangsujaritvijit
- 2Department of Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Piyavate Hospital, Bangkok, Thailand
| | - Pitsucha Sanguanwit
- 4Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jetjamnong Sueajai
- 5Toxicology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Saranya Auparakkitanon
- 5Toxicology Laboratory, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Scharf C, Paal M, Schroeder I, Vogeser M, Draenert R, Irlbeck M, Zoller M, Liebchen U. Therapeutic Drug Monitoring of Meropenem and Piperacillin in Critical Illness-Experience and Recommendations from One Year in Routine Clinical Practice. Antibiotics (Basel) 2020; 9:antibiotics9030131. [PMID: 32245195 PMCID: PMC7148485 DOI: 10.3390/antibiotics9030131] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/19/2022] Open
Abstract
Various studies have reported insufficient beta-lactam concentrations in critically ill patients. The extent to which therapeutic drug monitoring (TDM) in clinical practice can reduce insufficient antibiotic concentrations is an ongoing matter of investigation. We retrospectively evaluated routine meropenem and piperacillin measurements in critically ill patients who received antibiotics as short infusions in the first year after initiating a beta-lactam TDM program. Total trough concentrations above 8.0 mg/L for meropenem and above 22.5 mg/L for piperacillin were defined as the breakpoints for target attainment. We included 1832 meropenem samples and 636 piperacillin samples. We found that 39.3% of meropenem and 33.6% of piperacillin samples did not reach the target concentrations. We observed a clear correlation between renal function and antibiotic concentration (meropenem, r = 0.53; piperacillin, r = 0.63). Patients with renal replacement therapy or creatinine clearance (CrCl) of <70 mL/min had high rates of target attainment with the standard dosing regimens. There was a low number of patients with a CrCl >100 mL/min that achieved the target concentrations with the maximum recommended dosage. Patients with impaired renal function only required TDM if toxic side effects were noted. In contrast, patients with normal renal function required different dosage regimens and TDM-guided therapy to reach the breakpoints of target attainment.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
- Correspondence: ; Fax: +49-89-4400-78886
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Rika Draenert
- Section Clinical Infectious Diseases, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
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Therapeutic drug monitoring-guided high dose meropenem therapy of a multidrug resistant Acinetobacter baumannii - A case report. Respir Med Case Rep 2019; 29:100966. [PMID: 31871885 PMCID: PMC6909205 DOI: 10.1016/j.rmcr.2019.100966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/27/2019] [Accepted: 11/11/2019] [Indexed: 12/30/2022] Open
Abstract
Background Infections with multidrug resistant Acinetobacter baumannii in immunocompromised patients are life-threatening. Therapeutic options are rare in this context, but patients are dependent on an effective antibiotic therapy. Thus, new antibiotic strategies are deemed necessary. Case presentation This case report recounts the therapeutic drug monitoring-guided meropenem therapy of a 32 years old patient admitted with acute exacerbation of cystic fibrosis. Veno-venous extracorporeal membrane oxygenation was initiated on the first day of admission to the intensive care unit. The patient showed insufficient serum trough levels of meropenem despite the maximum approved dose (2g every 8h) was administered which was due to augmented renal clearance. Through continuous infusion of the same cumulative dose, target levels were reached. On day 17 of admission, the patient underwent successful double-lung-transplant surgery and extracorporeal membrane oxygenation was ended. Unfortunately, the donor's lung was colonized with a multidrug resistant Acinetobacter baumannii that was positive for OXA-23 carbapenemase. Hence a combination therapy of intravenous sulbactam, tigecycline, meropenem and inhalative colistin was established, with a known minimal inhibitory concentration for meropenem of 32 mg/l. Under continuous infusion of 8 g meropenem/day, serum levels exceeded 32 mg/l over 12 days. The patient was transferred from the intensive care unit to a general ward without any signs of infection. Conclusions Therapeutic drug monitoring-guided meropenem may be a sound new therapeutic option in eradicating multidrug resistant Acinetobacter and offer a novel therapeutic option in the field of personalized medicine.
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Burger R, Guidi M, Calpini V, Lamoth F, Decosterd L, Robatel C, Buclin T, Csajka C, Marchetti O. Effect of renal clearance and continuous renal replacement therapy on appropriateness of recommended meropenem dosing regimens in critically ill patients with susceptible life-threatening infections. J Antimicrob Chemother 2019; 73:3413-3422. [PMID: 30304491 DOI: 10.1093/jac/dky370] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 08/20/2018] [Indexed: 12/15/2022] Open
Abstract
Background Meropenem plasma concentration above a pathogen's MIC over the whole dosing interval (100% ƒT>MIC) is a determinant of outcome in severe infections. Significant variability of meropenem pharmacokinetics is reported in ICU patients. Objectives To characterize meropenem pharmacokinetics in variable CLCR or renal replacement therapy and assess the appropriateness of recommended regimens for MIC coverage. Methods A pharmacokinetic analysis (NONMEM) was conducted with external model validation. Patient characteristics were tested on meropenem clearance estimates, differentiated according to the presence/absence of continuous renal replacement therapy (CRRT, CLCRRT or CLno-CRRT). Simulations evaluated the appropriateness of recommended dosing for achieving 100% fT>MIC in 90% of patients. Results A total of 101 patients were studied: median 63 years (range 49-70), 56% male, SAPS II 38 (27-48). 32% had a CLCR >60 mL/min, 49% underwent CRRT and 32% presented severe sepsis or septic shock. A total of 127 pathogens were documented: 76% Gram-negatives, 24% Gram-positives (meropenem MIC90 2 mg/L, corresponding to EUCAST susceptibility breakpoint). Three hundred and eighty plasma and 129 filtrate-dialysate meropenem concentrations were analysed: two-compartment modelling best described the data. Predicted meropenem CLno-CRRT was 59% lower in impaired (CLCR 30 mL/min) compared to normal (CLCR 100 mL/min) renal function. Simulations showed that recommended regimens appropriately cover MIC90 in patients with CLCR <60 mL/min. Patients with CLCR of 60 to <90 mL/min need 6 g/day to achieve appropriate coverage. In patients with CLCR ≥90 mL/min, appropriate exposure is achieved with increased dose, frequency of administration and infusion duration, or continuous infusion. Conclusions Recommended meropenem regimens are suboptimal in ICU patients with normal or augmented renal clearance. Modified dosing or infusion modalities achieve appropriate MIC coverage for optimized antibacterial efficacy in meropenem-susceptible life-threatening infections.
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Affiliation(s)
- Raphaël Burger
- Internal Medicine Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Monia Guidi
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Valérie Calpini
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frédéric Lamoth
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Institute of Microbiology, Department of Laboratories, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Laurent Decosterd
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Corinne Robatel
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Thierry Buclin
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Chantal Csajka
- Clinical Pharmacology Service, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Oscar Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland
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Minichmayr IK, Roberts JA, Frey OR, Roehr AC, Kloft C, Brinkmann A. Development of a dosing nomogram for continuous-infusion meropenem in critically ill patients based on a validated population pharmacokinetic model. J Antimicrob Chemother 2019; 73:1330-1339. [PMID: 29425283 DOI: 10.1093/jac/dkx526] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022] Open
Abstract
Background Optimal antibiotic exposure is a vital but challenging prerequisite for achieving clinical success in ICU patients. Objectives To develop and externally validate a population pharmacokinetic model for continuous-infusion meropenem in critically ill patients and to establish a nomogram based on a routinely available marker of renal function. Methods A population pharmacokinetic model was developed in NONMEM® 7.3 based on steady-state meropenem concentrations (CSS) collected during therapeutic drug monitoring. Different serum creatinine-based markers of renal function were compared for their influence on meropenem clearance (the Cockcroft-Gault creatinine clearance CLCRCG, the CLCR bedside estimate according to Jelliffe, the Chronic Kidney Disease Epidemiology Collaboration equation and the four-variable Modification of Diet in Renal Disease equation). After validation of the pharmacokinetic model with independent data, a dosing nomogram was developed, relating renal function to the daily doses required to achieve selected target concentrations (4/8/16 mg/L) in 90% of the patients. Probability of target attainment was determined for efficacy (CSS ≥8 mg/L) and potentially increased likelihood of adverse drug reactions (CSS >32 mg/L). Results In total, 433 plasma concentrations (3.20-48.0 mg/L) from 195 patients (median/P0.05 - P0.95 at baseline: weight 77.0/55.0-114 kg, CLCRCG 63.0/19.6-168 mL/min) were used for model building. We found that CLCRCG best described meropenem clearance (CL = 7.71 L/h, CLCRCG = 80 mL/min). The developed model was successfully validated with external data (n = 171, 73 patients). According to the nomogram, daily doses of 910/1480/2050/2800/3940 mg were required to reach a target CSS = 8 mg/L in 90% of patients with CLCRCG = 20/50/80/120/180 mL/min, respectively. A low probability of adverse drug reactions (<0.5%) was associated with these doses. Conclusions A dosing nomogram was developed for continuous-infusion meropenem based on renal function in a critically ill population.
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Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany.,Graduate Research Training program PharMetrX, Freie Universitaet Berlin, Berlin, Germany, and Universitaet Potsdam, Potsdam, Germany
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Otto R Frey
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka C Roehr
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Alexander Brinkmann
- Department of Pharmacy and Department of Anaesthesia and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
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Ehmann L, Zoller M, Minichmayr IK, Scharf C, Huisinga W, Zander J, Kloft C. Development of a dosing algorithm for meropenem in critically ill patients based on a population pharmacokinetic/pharmacodynamic analysis. Int J Antimicrob Agents 2019; 54:309-317. [PMID: 31229669 DOI: 10.1016/j.ijantimicag.2019.06.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/30/2019] [Accepted: 06/15/2019] [Indexed: 12/21/2022]
Abstract
Effective antibiotic dosing is vital for therapeutic success in critically ill patients. This work aimed to develop an algorithm to identify appropriate meropenem dosing in critically ill patients. Population pharmacokinetic (PK) modelling was performed in NONMEM®7.3 based on densely sampled meropenem serum samples (npatients = 48; nsamples = 1376) and included a systematic analysis of 27 pre-selected covariates to identify factors influencing meropenem exposure. Using Monte Carlo simulations newly considering the uncertainty of PK parameter estimates, standard meropenem dosing was evaluated with respect to attainment of the pharmacokinetic/pharmacodynamic (PK/PD) target and was compared with alternative infusion regimens (short-term, prolonged, continuous; daily dose, 2000-6000 mg). Subsequently, a dosing algorithm was developed to identify appropriate dosing regimens. The two-compartment population PK model included three factors influencing meropenem pharmacokinetics: the Cockcroft-Gault creatinine clearance (CLCRCG) on meropenem clearance; and body weight and albumin on the central and peripheral volume of distribution, respectively; of these, only CLCRCG was identified as a vital influencing factor on PK/PD target attainment. A three-level dosing algorithm was developed (considering PK parameter uncertainty), suggesting dosing regimens depending on renal function and the level (L) of knowledge about the infecting pathogen (L1, pathogen unknown; L2, pathogen known; L3(-MIC), pathogen and susceptibility known; L3(+MIC), MIC known). Whereas patients with higher CLCRCG and lower pathogen susceptibility required mainly intensified dosing regimens, lower than standard doses appeared sufficient for highly susceptible pathogens. In conclusion, a versatile meropenem dosing algorithm for critically ill patients is proposed, indicating appropriate dosing regimens based on patient- and pathogen-specific information.
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Affiliation(s)
- Lisa Ehmann
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; Graduate Research Training Program PharMetrX
| | - Michael Zoller
- Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany; Graduate Research Training Program PharMetrX
| | - Christina Scharf
- Department of Anaesthesiology, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Johannes Zander
- Institute of Laboratory Medicine, Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany.
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Fleuren LM, Roggeveen LF, Guo T, Waldauf P, van der Voort PHJ, Bosman RJ, Swart EL, Girbes ARJ, Elbers PWG. Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient: a cross-sectional study. Crit Care 2019; 23:185. [PMID: 31118061 PMCID: PMC6532162 DOI: 10.1186/s13054-019-2438-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antibiotic exposure in intensive care patients with sepsis is frequently inadequate and is associated with poorer outcomes. Antibiotic dosing is challenging in the intensive care, as critically ill patients have altered and fluctuating antibiotic pharmacokinetics that make current one-size-fits-all regimens unsatisfactory. Real-time bedside dosing software is not available yet, and therapeutic drug monitoring is typically used for few antibiotic classes and only allows for delayed dosing adaptation. Thus, adequate and timely antibiotic dosing continues to rely largely on the level of pharmacokinetic expertise in the ICU. Therefore, we set out to assess the level of knowledge on antibiotic pharmacokinetics among these intensive care professionals. METHODS In May 2018, we carried out a cross-sectional study by sending out an online survey on antibiotic dosing to more than 20,000 intensive care professionals. Questions were designed to cover relevant topics in pharmacokinetics related to intensive care antibiotic dosing. The preliminary pass mark was set by members of the examination committee for the European Diploma of Intensive Care using a modified Angoff approach. The final pass mark was corrected for clinical relevance as assessed for each question by international experts on pharmacokinetics. RESULTS A total of 1448 respondents completed the survey. Most of the respondents were intensivists (927 respondents, 64%) from 97 countries. Nearly all questions were considered clinically relevant by pharmacokinetic experts. The pass mark corrected for clinical relevance was 52.8 out of 93.7 points. Pass rates were 42.5% for intensivists, 36.1% for fellows, 24.8% for residents, and 5.8% for nurses. Scores without correction for clinical relevance were worse, indicating that respondents perform better on more relevant topics. Correct answers and concise clinical background are provided. CONCLUSIONS Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient. This should be addressed given the importance of adequate antibiotic exposure in critically ill patients with sepsis. Solutions include improved education, intensified pharmacy support, therapeutic drug monitoring, or the use of real-time bedside dosing software. Questions may provide useful for teaching purposes.
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Affiliation(s)
- Lucas M. Fleuren
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Luca F. Roggeveen
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tingjie Guo
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Eleonora L. Swart
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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50
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Kim YK, Lee DH, Jeon J, Jang HJ, Kim HK, Jin K, Lim SN, Lee SS, Park BS, Kim YW, Shin JG, Kiem S. Population Pharmacokinetic Analysis of Meropenem After Intravenous Infusion in Korean Patients With Acute Infections. Clin Ther 2018; 40:1384-1395. [PMID: 30093133 DOI: 10.1016/j.clinthera.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 07/03/2018] [Accepted: 07/03/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this study was to investigate the population pharmacokinetic (PK) profile of meropenem in Korean patients with acute infections. METHODS The study included 37 patients with a creatinine clearance ≤50 or >50 mL/min who received a 500- or 1000-mg dose of meropenem, respectively, infused intravenously over 1 hour every 8 hours. Blood samples were collected before and at 1, 1.5, and 5 hours after the start of the fourth infusion. The population PK analysis was conducted by using nonlinear mixed effect modeling software (NONMEM). Monte-Carlo simulations were performed to identify optimal dosing regimens. FINDINGS Thirty-seven subjects completed the study. Meropenem PK variables were well described by using a one-compartment model. The typical values (relative SE) for weight-normalized clearance (CL) and Vd were 0.266 L/h/kg (12.29%) and 0.489 L/kg (11.01%), respectively. Meropenem CL was significantly influenced by the serum creatinine level, which explained 11% of the interindividual CK variability. The proposed equation to estimate meropenem CL in Korean patients was as follows: CL (L/h) = 0.266 × weight × [serum creatinine/0.74]-1.017. The simulation results indicate that the current meropenem dosing regimen may be suboptimal in patients infected with normal or augmented renal function. IMPLICATIONS Prolonged infusions of meropenem over at least 2 hours should be considered, especially in patients with augmented renal function and those infected with pathogens for which the minimum inhibitory meropenem concentration is >1 μg/mL. Our results suggest an individualized meropenem dosing regimen for patients with abnormal renal function and those infected with pathogens with decreased in vitro susceptibility.
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Affiliation(s)
- Yong Kyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Dong-Hwan Lee
- Hallym Institute for Clinical Medicine, Hallym University Medical Center, Anyang, Republic of Korea
| | - Jaehyun Jeon
- Department of Infectious Diseases, Division of Intensive Care Medicine, Sheikh Khalifa Specialty Hospital, North Ras Al Khaimah, United Arab Emirates
| | - Hang-Jea Jang
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Hyeon-Kuk Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Kyubok Jin
- Division of Nephrology, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sung-Nam Lim
- Division of Hemato-Oncology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Sung Sook Lee
- Division of Hemato-Oncology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Bong Soo Park
- Division of Nephrology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Yang Wook Kim
- Division of Nephrology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jae-Gook Shin
- Department of Clinical Pharmacology, Inje University College of Medicine, Busan, Republic of Korea
| | - Sungmin Kiem
- Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea.
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