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El Nekidy WS, Ghazal I, Abidi E, Malaeb D, Ghazi IM, El Lababidi R, Mooty M, Malik A, Ghosn M, Mallat J. Efficacy and safety of ertapenem dosing in patients with ESBL producing Enterobacterales infections utilizing renal replacement therapies. Int J Artif Organs 2024:3913988241264463. [PMID: 39076040 DOI: 10.1177/03913988241264463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
PURPOSE The clinical efficacy and safety of ertapenem use in patients undergoing renal replacement therapies (RRT) are not well-documented. Therefore, we aimed to investigate the safety and efficacy of ertapenem in patients with sepsis secondary to Enterobacterales who are undergoing RRT. METHODS A retrospective cohort study was conducted on patients who met the inclusion criteria at our hospital between May 2015 and December 2021. The primary endpoint was 30-day mortality. Secondary endpoints included clinical cure, microbiologic cure, recurrence rate, and incidence of seizures. RESULTS During the study period, 158 patients met the inclusion criteria. Of these, 86 were male (54.4%), the mean age was 66.4 ± 13.8 years, and the mean weight was 77 ± 22.4 kg. The most common diagnosis was bacteremia in 48 (30.4%) subjects, followed by urinary tract infection in 39 (24.7%) subjects, and pneumonia in 35 (22.2%) patients. The most isolated pathogens were Escherichia coli, followed by Klebsiella species. The median ertapenem dose was 0.5 g intravenously (IV) daily in those who received intermittent hemodialysis (IHD) and 1 g IV daily for those who received continuous veno-venous hemofiltration (CVVH). The 30-day mortality rate was 24%, the clinical cure rate was 89.2%, the microbiologic cure rate was 82%, the 30-day recurrence rate was 41.1%, and the incidence of seizures was 2.5%. Multivariate logistic regression analysis indicated that age (OR 1.04 [95% CI: 1.003-1.075]), being critically ill at therapy initiation (OR 2.9 [95% CI: 1.1-7.5]), and Enterobacterales other than Klebsiella species and Escherichia coli (OR 3.8 [95% CI: 1.1-12.5]) were significant independent risk factors associated with mortality in this population. Ertapenem dose was not associated with mortality. CONCLUSION Our findings suggest that the commonly used doses of ertapenem in patients undergoing IHD and CVVH are clinically effective but may pose a higher risk of seizures. A comprehensive pharmacokinetic study is needed to determine the most effective and safe dose for this population.
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Affiliation(s)
- Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Iyad Ghazal
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- College of Pharmacy, Gulf Medical University, Ajman, UAE
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Diana Malaeb
- College of Pharmacy, Gulf Medical University, Ajman, UAE
| | - Islam M Ghazi
- Arnold and Marie Schwartz College of Pharmacy, Long Island University, NY, USA
| | | | | | - Amir Malik
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | - Jihad Mallat
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
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Joynt GM, Ling L, Wong WT, Lipman J. Therapeutic drug monitoring of carbapenem antibiotics in critically ill patients: an overview of principles, recommended dosing regimens, and clinical outcomes. Expert Rev Clin Pharmacol 2023; 16:703-714. [PMID: 36942827 DOI: 10.1080/17512433.2023.2194629] [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: 11/28/2022] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION The importance of antibiotic treatment for sepsis in critically ill septic patients is well established. Consistently achieving the dose of antibiotics required to optimally kill bacteria, minimize the development of resistance, and avoid toxicity is challenging. The increasing understanding of the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of antibiotics, and the effects of critical illness on key PK/PD parameters, is gradually re-shaping how antibiotics are dosed in critically ill patients. AREAS COVERED The PK/PD characteristics of commonly used carbapenem antibiotics, the principles of the application of therapeutic drug monitoring (TDM), and current as well as future methods of utilizing TDM to optimally devise dosing regimens will be reviewed. The limitations and evidence-base supporting the use of carbapenem TDM to improve outcomes in critically ill patients will be examined. EXPERT OPINION It is important to understand the principles of TDM in order to correctly inform dosing regimens. Although the concept of TDM is attractive, and the ability to utilize PK software to optimize dosing in the near future is expected to rapidly increase clinicians' ability to meet pre-defined PK/PD targets more accurately, current evidence provides only limited support for the use of TDM to guide carbapenem dosing in critically ill patients.
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Affiliation(s)
- Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Jeffrey Lipman
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesia Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Wang C, Zhou Y, Zhou Y, Ye C. Ertapenem-Induced Neurotoxicity: A Literature Review of Clinical Characteristics and Treatment Outcomes. Infect Drug Resist 2023; 16:3649-3658. [PMID: 37313264 PMCID: PMC10259588 DOI: 10.2147/idr.s406852] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/17/2023] [Indexed: 06/15/2023] Open
Abstract
Background Neurotoxicity is a rare adverse event for ertapenem. Given the limited evidence, large patient data are needed to aid in the identification and management of this fatal complication. Aim of the review, we summarize the characteristics, risk factors, and treatment of ertapenem-induced neurotoxicity. Methods Pubmed, Web of Science, Embase, Cochrane library, Wanfang, CNKI, China VIP database were searched up from 31 October 2001 to 31 December 2022. All articles concerning neurotoxicity induced by ertapenem were included. The retrieved articles were screened by two experienced clinicians by reading the titles, abstracts, and full texts. Results A total of 66 patients were included, with a median age of 71.5 years (range 40-92), of whom 45 (68.2%) were male. Twelve patients (18.2%) received irrational doses (exceeding the recommended dose), and 30 patients (45.5%) had chronic renal insufficiency. The median time to symptom onset was 5 (range 1-14). Epileptiform seizures (42.4%), visual hallucinations (36.4%), altered mental status (25.8%), and confusion (22.7%) were the most common symptoms of ertapenem-induced neurotoxicity. Of the 29 patients with reported albumin levels, 25 had serum albumin <3.5 g/dl. Ertapenem was discontinued in 95.5% of patients, and 90.9% recovered completely. Median time to symptom recovery was 7 days (range 1-42) after intervention including antiepileptic administration, or hemodialysis. Conclusion Neurotoxicity is a rare adverse event for ertapenem, especially in patients with advanced age, renal insufficiency, pre-existing neurological disease, and hypoalbuminemia. This adverse reaction usually resolves with medication interruption, or antiepileptic administration and hemodialysis.
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Affiliation(s)
- Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Yulu Zhou
- Department of Pharmacy, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, 410028, People’s Republic of China
| | - Ya Zhou
- Department of Pharmacy, People’s Hospital of Ningxiang City Affiliated to Hunan University of Chinese Medicine, Changsha, Hunan, 410600, People’s Republic of China
| | - Chao Ye
- Department of Pharmacy, The Third Hospital of Changsha, Changsha, Hunan, 410015, People’s Republic of China
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In Vitro Activity of Ertapenem against Neisseria gonorrhoeae Clinical Isolates with Decreased Susceptibility or Resistance to Extended-Spectrum Cephalosporins in Nanjing, China (2013 to 2019). Antimicrob Agents Chemother 2022; 66:e0010922. [PMID: 35491832 PMCID: PMC9112910 DOI: 10.1128/aac.00109-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Neisseria gonorrhoeae isolates collected in Nanjing, China, that possessed decreased susceptibility (or resistance) to extended-spectrum cephalosporins (ESCs) were examined for susceptibility to ertapenem, and their sequence types were determined. Ceftriaxone and cefixime MICs of ≥0.125 mg/L and ≥0.25 mg/L, respectively, were first determined in 259 strains isolated between 2013 and 2019, and then MICs of ertapenem were measured using the antimicrobial gradient Epsilometer test (Etest). Also, genetic determinants of ESC resistance were identified and N. gonorrhoeae multiantigen sequence typing (NG-MAST) was performed to analyze associations with ertapenem susceptibility. All isolates displayed ertapenem MICs between 0.006 mg/L and 0.38 mg/L; the overall MIC50 and MIC90 were 0.032 mg/L and 0.125 mg/L, respectively. Forty-four (17.0%) isolates displayed ertapenem MICs of ≥0.125 mg/L; 10 (3.9%) had MICs of ≥0.25 mg/L. The proportion of isolates with ertapenem MICs of ≥0.125 mg/L increased from 4.0% in 2013 to 20.0% in 2019 (χ2 = 24.144, P < 0.001; chi-square test for linear trend). The penA mosaic allele was present in a significantly higher proportion of isolates with ertapenem MICs of ≥0.125 mg/L than of isolates with MICs of ≤0.094 mg/L) (97.7% versus 34.9%, respectively; χ2 = 58.158, P < 0.001). ST5308 was the most prevalent NG-MAST type (8.5%); ST5308 was also significantly more common among isolates with ertapenem MICs of ≥0.125 mg/L than isolates with MICs of ≤0.094 mg/L (22.7% and 5.6%, respectively; χ2 = 13.815, P = 0.001). Ertapenem may be effective therapy for gonococcal isolates with decreased susceptibility or resistance to ESCs and isolates with identifiable genetic resistance determinants.
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El Nekidy WS, Elrefaei H, St John TJL, Attallah NM, Kablaoui F, Nusair A, Piechowski-Jozwiak B, Phillips J, Ghazi IM. Ertapenem Neurotoxicity in Hemodialysis Patients-Safe and Effective Dosing Is Still Needed: A Retrospective Study and Literature Review. Ann Pharmacother 2020; 55:52-58. [PMID: 32618479 DOI: 10.1177/1060028020938059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The approved dosing of ertapenem in patients with chronic kidney disease stage 5 utilizing dialysis (CKD-5D) is 0.5 g intravenous daily. Several reports associated this dosing strategy with neurotoxicity. OBJECTIVE The purpose of this study is to identify the incidence of neurotoxicity in this population and the risk factors associated with this toxicity. The secondary objective was to review the literature and discuss a safer/cost-effective dosing strategy based on available data. METHODS A retrospective study was conducted screening all patients who received ertapenem and hemodialysis at our quaternary hospital between May 2015 and March 2019. Patients' demographics, comorbidities, concomitant drugs (known to induce neurotoxicity), and seizure history were collected. RESULTS A total of 99 eligible patients were identified; 10 of them (10%) developed neurotoxicity. The patients who developed neurotoxicity were all male; mean age was 74 ± 9 years as compared with 68.9 ± 13 years in the sample. Bivariate relationships between all predictors and the seizures (dichotomously coded) were estimated to investigate the risk factors. The following were the significant predictors of seizures: male sex (17%; P = 0.014), dementia (27%; P = 0.012), and concomitant use of β-lactams, aminoglycosides, or fluoroquinolones (19.6%; P = 0.042). CONCLUSION AND RELEVANCE The currently approved ertapenem dose imposes a risk of developing neurotoxicity in patients with CKD-5D. Utilizing the published data in this population, alternative post-dialysis dosing strategies administered through dialysis access such as 1 g loading dose, followed by either 0.5 g (for the 48 hours interdialytic time) or 1 g (for the 72 hours interdialytic time) might warrant further investigation for efficacy and safety.
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Affiliation(s)
- Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | | | | | | | | | | | | | - Islam M Ghazi
- Philadelphia College of Pharmacy at University of the Sciences, Philadelphia, PA, USA
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Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
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García-Souto F, Cases-Mérida S, Sosa-Moreno F, Escudero-Ordoñez J. Ertapenem-induced vasculitis with striking targetoid lesions. Int J Dermatol 2019; 59:e28-e29. [PMID: 31566270 DOI: 10.1111/ijd.14656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 08/14/2019] [Accepted: 08/29/2019] [Indexed: 11/27/2022]
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8
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A practical thrice weekly ertapenem in hemodialysis patients. Antimicrob Agents Chemother 2019:AAC.01427-19. [PMID: 31527026 DOI: 10.1128/aac.01427-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Change of ertapenem dosage from 500 mg daily to thrice weekly after each hemodialysis session can maintain the plasma concentration above 2 mg/L, and be practical in hemodialysis patients.
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Sanroma P, Muñoz P, Mirón-Rubio M, Aguilera A, Estrada O, García D, González-Ramallo VJ, Pajarón M, Sgaramella GA, González CR, Mujal A, Abad A, Solé A, González S, Escalada C, Vitoria I, Gómez MJ, Parra JJ, Sampedro I, Pereda I. Effectiveness and safety of ertapenem used in hospital-at-home units: data from Spanish Outpatient Parenteral Antimicrobial Therapy Registry. Future Microbiol 2018; 13:1363-1373. [PMID: 30238769 DOI: 10.2217/fmb-2018-0065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
AIM To evaluate the effectiveness and safety of ertapenem in patients hospitalized at home. PATIENTS & METHODS Retrospective analysis of data from Spanish Outpatient Parenteral Antimicrobial Therapy (OPAT) registry. RESULTS Data from 1428 patients (median age 70 years; 5.4% institutionalized) and 1547 infectious processes (24% self-administration) were analyzed. Clinical cure or improvement was achieved in 93.8% of cases. Rate of related readmissions was 4.2%, of clinically important complications -3.9%, and of adverse drug reactions -3.2%. High comorbidity burden, contagion in nursing home and certain types of infection were associated with worse prognosis. Self-administration was effective and safe, except in case of nursing home-acquired infections. CONCLUSION Ertapenem OPAT was effective and safe. Caregivers in nursing homes should be better trained in OPAT-related procedures.
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Affiliation(s)
- Pedro Sanroma
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | - Pedro Muñoz
- Teaching unit, Cantabria Health Care Service, Santander, Spain
| | - Manuel Mirón-Rubio
- Hospital-at-Home unit, Torrejon Hospital, Torreján de Ardoz, Madrid, Spain
| | - Ana Aguilera
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | - Oriol Estrada
- Germans Trias i Pujol Hospital, Badalona, Barcelona, Spain
| | - Dora García
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | | | - Marcos Pajarón
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | | | | | - Abel Mujal
- Hospital-at-Home unit. Department of Internal Medicine. Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Aquilino Abad
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | - Anna Solé
- Arnau de Vilanova University Hospital, Lleida, Spain
| | | | - Carmen Escalada
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | | | | | - Juan J Parra
- Family Medicine Resident, Valdecilla Hospital, Santander, Spain
| | - Isabel Sampedro
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
| | - Iliana Pereda
- Hospital-at-Home unit, Valdecilla Hospital, Santander, Spain
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10
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Cooper TW, Pass SE, Brouse SD, Hall RG. Can Pharmacokinetic and Pharmacodynamic Principles Be Applied to the Treatment of Multidrug-Resistant Acinetobacter? Ann Pharmacother 2017; 45:229-40. [DOI: 10.1345/aph.1p187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE: To discuss treatment options that can be used for treatment of Acinetobacter infections. DATA SOURCES: A MEDLINE search (1966-November 2010) was conducted to identify English-language literature on pharmacotherapy of Acinetobacter and the bibliographies of pertinent articles. Programs and abstracts from infectious diseases meetings were also searched. Search terms included Acinetobacter, multidrug resistance, pharmacokinetics, pharmacodynamics, Monte Carlo simulation, nosocomial pneumonia, carbapenems, polymyxins, sulbactam, aminoglycosides, tetracyclines, tigecycline, rifampin, and fluoroquinolones. DATA SELECTION AND DATA EXTRACTION: All articles were critically evaluated and all pertinent information was included in this review. DATA SYNTHESIS: Multidrug resistant (MDR) Acinetobacter, defined as resistance to 3 or more antimicrobial classes, has increased over the past decade. The incidence of carbapenem-resistant Acinetobacter is also increasing, leading to an increased use of dose optimization techniques and/or alternative antimicrobials, which is driven by local susceptibility patterns. However, Acinetobacter infections that are resistant to all commercially available antibiotics have been reported. General principles are available to guide dose optimization of aminoglycosides, β-lactams, fluoroquinolones, and tigecycline for infections due to gram-negative pathogens. Unfortunately, data specific to patients with Acinetobacter infections are limited. Recent pharmacokinetic-pharmacodynamic information has shed light on colistin dosing. The dilemma with colistin is its concentration-dependent killing, which makes once-daily dosing seem like an attractive option, but its short postantibiotic effect limits a clinician's ability to extend the dosing interval. Localized delivery of antimicrobials is also an attractive option due to the ability to increase drug concentration at the infection site while minimizing systemic adverse events, but more data are needed regarding this approach. CONCLUSIONS: Increased reliance on dosage optimization, combination therapy, and localized delivery of antimicrobials are methods to pursue positive clinical outcomes in MDR Acinetobacter infections since novel antimicrobials will not be available for several years. Well-designed clinical trials with MDR Acinetobacter are needed to define the best treatment options for these patients.
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Population Pharmacokinetics and Target Attainment of Ertapenem in Plasma and Tissue Assessed via Microdialysis in Morbidly Obese Patients after Laparoscopic Visceral Surgery. Antimicrob Agents Chemother 2016; 61:AAC.00952-16. [PMID: 27795367 DOI: 10.1128/aac.00952-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/07/2016] [Indexed: 11/20/2022] Open
Abstract
Ertapenem provides broad-spectrum activity against many pathogens, and its use is relevant for the prophylaxis and treatment of infections in morbidly obese patients undergoing surgery. However, its pharmacokinetics and tissue penetration in these patients are not well defined. We assessed the population pharmacokinetics and target attainment for ertapenem in the plasma, subcutaneous tissue, and peritoneal fluid of morbidly obese patients. Six female patients (body mass index, 43.7 to 55.9 kg/m2) received 1,000 mg ertapenem as 15-min infusions at 0 and 26 h. On day 2, the unbound ertapenem concentrations in plasma, subcutaneous tissue, and peritoneal fluid were measured by microdialysis; total plasma concentrations were additionally quantified. The probability of attaining a target of an unbound ertapenem concentration above the MIC for at least 40% of the dosing interval was predicted via Monte Carlo simulations. The population pharmacokinetic model contained two disposition compartments and simultaneously described all concentrations. For unbound ertapenem, total clearance was 12.3 liters/h (coefficient of variation, 21.6% for between-patient variability) and the volume of distribution at steady state was 57.8 liters in patients with a 53-kg fat-free mass. The area under the concentration-time curve (AUC) for ertapenem was 49% lower in subcutaneous tissue and 25% lower in peritoneal fluid than the unbound AUC in plasma. Tissue penetration was rapid (equilibration half-life, <15 min) and was variable in subcutaneous tissue. Short-term ertapenem infusions (1,000 mg every 24 h) achieved robust (>90%) target attainment probabilities for MICs of up to 1 mg/liter in plasma, 0.25 to 0.5 mg/liter in subcutaneous tissue, and 0.5 mg/liter in peritoneal fluid. Ertapenem presents an attractive choice for many pathogens relevant to morbidly obese patients undergoing surgery. (This study has been registered at ClinicalTrials.gov under identifier NCT01407965.).
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Baker MA, Schneider EK, X. Huang J, Cooper MA, Li J, Velkov T. The Plasma Protein Binding Proteome of Ertapenem: A Novel Compound-Centric Proteomic Approach for Elucidating Drug-Plasma Protein Binding Interactions. ACS Chem Biol 2016; 11:3353-3364. [PMID: 27682196 DOI: 10.1021/acschembio.6b00700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ertapenem is an important first-line carbapenem antibiotic used for the treatment of aerobic Gram-negative bacterial infections. It is the only marketed carbapenem that is highly bound to plasma proteins and displays a concentration-dependent and saturable plasma protein binding profile. To date, the plasma components responsible for sequestering ertapenems antibacterial activity remain uncharacterized. In the present study, we have employed an orthogonal, multiplatform approach, including novel compound-centric displacement proteomics and surface plasmon resonance to characterize the plasma protein binding proteome of ertapenem. In proof-of-concept, the capacity of physiological cocktails of the identified plasma proteins to inhibit the antibacterial activity of ertapenem was assessed with in vitro microbiological assays. We show that fibrinogen, complement C4, haptoglobulin, α-1-antitrypsin, fibronectin, transferrin, immunoglobulin G, hemopexin, and humans serum albumin are responsible for the majority of the sequestering activity in plasma. No binding was observed to α-1-acid-glycoprotein. The findings of this study have broad reaching implications for antibiotic drug design and for dose tailoring to suit the plasma protein levels of individual patients in order to maximize the clinical efficacy of important first-line antibiotics such as ertapenem.
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Affiliation(s)
- Mark A. Baker
- Priority
Research Centre in Reproductive Science, School of Environmental and
Life Sciences, University of Newcastle, Callaghan, New South Wales 2308, Australia
| | - Elena K. Schneider
- Facility
for Drug Development and Innovation, Drug Delivery, Disposition and
Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Johnny X. Huang
- Institute
for Molecular Bioscience, The University of Queensland, 306 Carmody
Road, St Lucia, Queensland 4072, Australia
| | - Matthew A. Cooper
- Institute
for Molecular Bioscience, The University of Queensland, 306 Carmody
Road, St Lucia, Queensland 4072, Australia
| | - Jian Li
- Facility
for Drug Development and Innovation, Drug Delivery, Disposition and
Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
- Monash
Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
| | - Tony Velkov
- Facility
for Drug Development and Innovation, Drug Delivery, Disposition and
Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
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van Rijn SP, van Altena R, Akkerman OW, van Soolingen D, van der Laan T, de Lange WC, Kosterink JG, van der Werf TS, Alffenaar JWC. Pharmacokinetics of ertapenem in patients with multidrug-resistant tuberculosis. Eur Respir J 2016; 47:1229-34. [DOI: 10.1183/13993003.01654-2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/15/2015] [Indexed: 02/04/2023]
Abstract
Treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) is becoming more challenging because of increased levels of drug resistance against second-line TB drugs. One promising group of antimicrobial drugs is carbapenems. Ertapenem is an attractive carbapenem for the treatment of MDR- and XDR-TB because its relatively long half-life enables once-daily dosing.A retrospective study was performed for all patients with suspected MDR-TB at the Tuberculosis Center Beatrixoord of the University Medical Center Groningen (Haren, the Netherlands) who received ertapenem as part of their treatment regimen between December 1, 2010 and March 1, 2013. Safety and pharmacokinetics were evaluated.18 patients were treated with 1000 mg ertapenem for a mean (range) of 77 (5–210) days. Sputum smear and culture were converted in all patients. Drug exposure was evaluated in 12 patients. The mean (range) area under the concentration–time curve up to 24 h was 544.9 (309–1130) h·mg·L−1. The mean (range) maximum observed plasma concentration was 127.5 (73.9–277.9) mg·L−1.In general, ertapenem treatment was well tolerated during MDR-TB treatment and showed a favourable pharmacokinetic/pharmacodynamic profile in MDR-TB patients. We conclude that ertapenem is a highly promising drug for the treatment of MDR-TB that warrants further investigation.
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Jain JG, Sutherland C, Nicolau DP, Kuti JL. Stability of ertapenem 100 mg/mL in polypropylene syringes stored at 25, 4, and -20 °C. Am J Health Syst Pharm 2015; 71:1480-4. [PMID: 25147172 DOI: 10.2146/ajhp130664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The stability of ertapenem solution in syringes at room, refrigerator, and freezer temperatures was determined to establish options for extended storage. METHODS Six replicate solutions of ertapenem (100 mg/mL) in 0.9% sodium chloride injection were prepared in 20-mL polypropylene syringes and stored at 25, 4, or -20 °C. Syringe samples were collected immediately after preparation and at preselected time points and assayed by a validated high-performance liquid chromatography (HPLC) method. The ertapenem solution was considered stable if at least 90% of the mean initial concentration remained at the time of HPLC analysis. RESULTS The mean±S.D. baseline ertapenem concentration across all stability studies was 109.9±9.2 mg/mL. One hour after preparation, the mean±S.D. ertapenem concentration of samples kept at room temperature was 87.8±4.6% of the initial concentration. After 24 and 48 hours of refrigeration, mean±S.D. drug concentrations had declined to 93.6±5.9% and 86.2±4.3% of the respective baseline concentrations. Frozen syringes required 1 hour to thaw at room temperature; after 14 and 28 days of frozen storage, the mean±S.D. ertapenem concentrations of these samples 4 hours after thawing were 93.4±3.5% and 86.4±2.6% of the respective baseline values. CONCLUSION Ertapenem 100 mg/mL prepared in 20-mL polypropylene syringes was stable at room temperature for approximately 30 minutes. Room-temperature stability was extended to 4 hours after 24 hours of refrigeration. After being frozen for 14 or 28 days, ertapenem was stable for 3-5 hours after removal from the freezer.
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Affiliation(s)
- Jami G Jain
- Jami G. Jain, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow; Christina Sutherland, B.S., is Research Technologist; David P. Nicolau, Pharm.D., FCCP, FIDSA, is Director; and Joseph L. Kuti, Pharm.D., is Associate Director, Clinical and Economic Studies, Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - Christina Sutherland
- Jami G. Jain, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow; Christina Sutherland, B.S., is Research Technologist; David P. Nicolau, Pharm.D., FCCP, FIDSA, is Director; and Joseph L. Kuti, Pharm.D., is Associate Director, Clinical and Economic Studies, Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - David P Nicolau
- Jami G. Jain, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow; Christina Sutherland, B.S., is Research Technologist; David P. Nicolau, Pharm.D., FCCP, FIDSA, is Director; and Joseph L. Kuti, Pharm.D., is Associate Director, Clinical and Economic Studies, Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
| | - Joseph L Kuti
- Jami G. Jain, Pharm.D., BCPS, is Infectious Diseases Pharmacotherapy Fellow; Christina Sutherland, B.S., is Research Technologist; David P. Nicolau, Pharm.D., FCCP, FIDSA, is Director; and Joseph L. Kuti, Pharm.D., is Associate Director, Clinical and Economic Studies, Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT.
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Lee KH, Ueng YF, Wu CW, Chou YC, Ng YY, Yang WC. The recommended dose of ertapenem poses a potential risk for central nervous system toxicity in haemodialysis patients - case reports and literature reviews. J Clin Pharm Ther 2014; 40:240-4. [PMID: 25487647 DOI: 10.1111/jcpt.12239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 11/10/2014] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Dosage adjustment of 500 mg ertapenem daily is recommended for patients with advanced kidney disease. 30% of ertapenem is cleared by a session of haemodialysis (HD). However, because most published carbapenems studies have excluded patients on dialysis, little is known about the dosing of ertapenem to avoid central nervous system (CNS) toxicity in regular HD patients. We report of four patients who developed CNS toxicity in such patients. CASE SUMMARY The 4 HD patients developed unexplained CNS toxicity manifested as seizures, hallucination and cognitive dysfunction after receiving 3-7 consecutive recommended doses of ertapenem. Their symptoms of CNS toxicity were completely resolved within 8 days after discontinuation of ertapenem. In one of our presented cases, we demonstrated the very high level of plasma ertapenem accumulating with several consecutive doses. Cognitive function gradually recovered in line with a corresponding decline in blood level of ertapenem. WHAT IS NEW AND CONCLUSIONS This is the first report of ertapenem-associated CNS toxicity in patients on regular HD and utilizing the plasma ertapenem concentration to demonstrate the causal relationship. The recommended dosage of 500 mg ertapenem daily may be still too high in regular HD patients, especially in Asians, owing to their relatively small body size. An increased awareness of ertapenem-associated CNS toxicity would avoid unnecessary examinations, hospitalization, and potentially catastrophic complications.
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Affiliation(s)
- K-H Lee
- Division of Nephrology, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
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16
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Grau S, Lozano V, Valladares A, Cavanillas R, Xie Y, Nocea G. Antibiotic expected effectiveness and cost under real life microbiology: evaluation of ertapenem and ceftriaxone in the treatment of community-acquired pneumonia for elderly patients in Spain. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:83-92. [PMID: 24611019 PMCID: PMC3928454 DOI: 10.2147/ceor.s55265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Clinical efficacy of antibiotics may be affected by changes in the susceptibility of microorganisms to antimicrobial agents. The purpose of this study is to assess how these changes could affect the initial efficacy of ertapenem and ceftriaxone in the treatment of community-acquired pneumonia (CAP) in elderly patients and the potential consequences this may have in health care costs. Methods Initial efficacy in elderly was obtained from a combined analysis of two multicenter, randomized studies. An alternative scenario was carried out using initial efficacy data according to the pneumonia severity index (PSI). Country-specific pathogens distribution was obtained from a national epidemiological study, and microbiological susceptibilities to first- and second-line therapies were obtained from Spanish or European surveillance studies. A decision analytic model was used to compare ertapenem versus ceftriaxone for CAP inpatient treatment. Inputs of the model were the expected effectiveness previously estimated and resource use considering a Spanish national health system perspective. Outcomes include difference in proportion of successfully treated patients and difference in total costs between ertapenem and ceftriaxone. The model performed one-way and probabilistic sensitivity analyses. Results First-line treatment of CAP with ertapenem led to a higher proportion of successfully treated patients compared with ceftriaxone in Spain. One-way sensitivity analysis showed that length of stay was the key parameter of the model. Probabilistic sensitivity analysis showed that ertapenem can be a cost-saving strategy compared with ceftriaxone, with a 59% probability of being dominant (lower costs with additional health benefits) for both, elderly patients (>65 years) and patients with PSI >3. Conclusion The incorporation of the current antimicrobial susceptibility into the initial clinical efficacy has a significant impact in outcomes and costs in CAP treatment. The treatment with ertapenem compared with ceftriaxone resulted in better clinical outcomes and lower treatment costs for two segments of the Spanish population: elderly patients and patients with severe pneumonia (PSI >3).
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Affiliation(s)
| | - Virginia Lozano
- Pharmacoeconomics and Outcomes Research Iberia, Madrid, Spain
| | | | | | - Yang Xie
- Global Health Outcomes, Merck Sharp and Dohme Ltd, Whitehouse Station, NJ, USA
| | - Gonzalo Nocea
- Outcomes Research Merck Sharp and Dohme Ltd, Madrid, Spain
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Pharmacokinetics of ertapenem in critically ill patients receiving continuous venovenous hemodialysis or hemodiafiltration. Antimicrob Agents Chemother 2013; 58:1320-6. [PMID: 24323468 DOI: 10.1128/aac.02090-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study characterizes the pharmacokinetics of ertapenem, a carbapenem antibiotic, in critically ill adult subjects receiving continuous renal replacement therapy (CRRT). Eight critically ill patients with suspected/known Gram-negative infections receiving continuous venovenous hemodialysis (CVVHD) or continuous venovenous hemodiafiltration (CVVHDF) and ertapenem were enrolled. One gram of ertapenem was infused over 30 min. Predialyzer blood samples were drawn with the first dose of ertapenem from the hemodialysis tubing at time zero, 30 min, and 1, 2, 4, 8, 12, 18, and 24 h after the start of the ertapenem infusion. Effluent was collected at the same time points. Ertapenem total serum, unbound serum, and effluent concentrations from all eight subjects were used simultaneously to perform a population compartmental pharmacokinetic modeling procedure using NONMEM. Monte Carlo simulations were performed to evaluate the ability of several ertapenem dosing regimens (500 mg once daily, 750 mg once daily, 500 mg twice daily, and 1,000 mg once daily) to obtain effective unbound serum concentrations above 0.5, 1, and 2 μg/ml. For our simulated patients, all regimens produced unbound ertapenem concentrations above 2 μg/ml for 40% of the dosing interval for at least 96% of simulated patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT00877370.).
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18
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Wiskirchen DE, Housman ST, Quintiliani R, Nicolau DP, Kuti JL. Comparative pharmacokinetics, pharmacodynamics, and tolerability of ertapenem 1 gram/day administered as a rapid 5-minute infusion versus the standard 30-minute infusion in healthy adult volunteers. Pharmacotherapy 2013; 33:266-74. [PMID: 23400916 DOI: 10.1002/phar.1197] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
STUDY OBJECTIVE To compare ertapenem pharmacokinetics, pharmacodynamics, and tolerability when administered as a rapid 5-minute infusion to the standard 30-minute infusion. DESIGN Prospective, randomized, crossover pharmacokinetic study. SETTING Clinical research center. SUBJECTS Twelve healthy adult volunteers. INTERVENTION Each subject received ertapenem 1 g intravenously, administered either as a rapid 5-minute infusion or the standard 30-minute infusion, every 24 hours for 3 days (first phase); after a 4-day washout period, each subject then received the other infusion every 24 hours for 3 days (second phase). MEASUREMENTS AND MAIN RESULTS Plasma samples were collected after the first and third (steady-state) doses of each study phase, and protein binding was assessed by use of ultrafiltration. Pharmacokinetic analyses were conducted using noncompartmental and compartmental methods. A 5000-subject Monte Carlo simulation was used to assess the probability of target attainment for free drug concentration remaining above the minimum inhibitory concentration (MIC) for 40% or greater of the dosing interval (40% fT > MIC) over an MIC range. Ertapenem was well tolerated and adverse events were similar for both infusions. The ertapenem steady-state mean ± SD maximum concentrations were 193.3 ± 43.3 and 165.7 ± 20.4 mg/L for the 5- and 30-minute infusions, respectively; the mean ± SD areas under the concentration-time curves from 0-24 hours were 561.2 ± 77.0 and 531.3 ± 56.9 μg · hr/ml (geometric mean ratio 1.008, 90% confidence interval 0.999-1.017), respectively. Protein binding was concentration dependent (range 87.9-98.9%). A two-compartment model best described ertapenem pharmacokinetics with the following parameter estimates: clearance 1.89 ± 0.19 L/hr, volume of central compartment 5.04 ± 0.56 L, and transfer constants k12 0.43 ± 0.08/hr and k21 0.44 ± 0.07/hr. The probabilities of target attainment for 5- and 30-minute infusions were 97.0% and 97.9% at an MIC of 0.25 mg/L and 1.7% and 2.8% at an MIC of 0.5 mg/L, respectively. CONCLUSION Ertapenem administered as a rapid 5-minute infusion provides a well tolerated, bioequivalent, and pharmacodynamically equivalent regimen to the 30-minute infusion at clinically relevant MICs.
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Affiliation(s)
- Dora E Wiskirchen
- Center for Anti-Infective Research and Development , Hartford Hospital, Hartford, CT 06102, USA
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19
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Unemo M, Nicholas RA. Emergence of multidrug-resistant, extensively drug-resistant and untreatable gonorrhea. Future Microbiol 2012; 7:1401-22. [PMID: 23231489 PMCID: PMC3629839 DOI: 10.2217/fmb.12.117] [Citation(s) in RCA: 320] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The new superbug Neisseria gonorrhoeae has retained resistance to antimicrobials previously recommended for first-line treatment and has now demonstrated its capacity to develop resistance to the extended-spectrum cephalosporin, ceftriaxone, the last remaining option for first-line empiric treatment of gonorrhea. An era of untreatable gonorrhea may be approaching, which represents an exceedingly serious public health problem. Herein, we review the evolution, origin and spread of antimicrobial resistance and resistance determinants (with a focus on extended-spectrum cephalosporins) in N. gonorrhoeae, detail the current situation regarding verified treatment failures with extended-spectrum cephalosporins and future treatment options, and highlight essential actions to meet the large public health challenge that arises with the possible emergence of untreatable gonorrhea. Essential actions include: implementing action/response plans globally and nationally; enhancing surveillance of gonococcal antimicrobial resistance, treatment failures and antimicrobial use/misuse; and improving prevention, early diagnosis and treatment of gonorrhea. Novel treatment strategies, antimicrobials (or other compounds) and, ideally, a vaccine must be developed.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea & Other STIs, National Reference Laboratory for Pathogenic Neisseria, Örebro University Hospital, SE-701 85 Örebro, Sweden.
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Sime FB, Roberts MS, Peake SL, Lipman J, Roberts JA. Does Beta-lactam Pharmacokinetic Variability in Critically Ill Patients Justify Therapeutic Drug Monitoring? A Systematic Review. Ann Intensive Care 2012; 2:35. [PMID: 22839761 PMCID: PMC3460787 DOI: 10.1186/2110-5820-2-35] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 06/28/2012] [Indexed: 01/05/2023] Open
Abstract
The pharmacokinetics of beta-lactam antibiotics in intensive care patients may be profoundly altered due to the dynamic, unpredictable pathophysiological changes that occur in critical illness. For many drugs, significant increases in the volume of distribution and/or variability in drug clearance are common. When “standard” beta-lactam doses are used, such pharmacokinetic changes can result in subtherapeutic plasma concentrations, treatment failure, and the development of antibiotic resistance. Emerging data support the use of beta-lactam therapeutic drug monitoring (TDM) and individualized dosing to ensure the achievement of pharmacodynamic targets associated with rapid bacterial killing and optimal clinical outcomes. The purpose of this work was to describe the pharmacokinetic variability of beta-lactams in the critically ill and to discuss the potential utility of TDM to optimize antibiotic therapy through a structured literature review of all relevant publications between 1946 and October 2011. Only a few studies have reported the utility of TDM as a tool to improve beta-lactam dosing in critically ill patients. Moreover, there is little agreement between studies on the pharmacodynamic targets required to optimize antibiotic therapy. The impact of TDM on important clinical outcomes also remains to be established. Whereas TDM may be theoretically rational, clinical studies to assess utility in the clinical setting are urgently required.
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Affiliation(s)
- Fekade Bruck Sime
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.
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21
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Unemo M, Golparian D, Limnios A, Whiley D, Ohnishi M, Lahra MM, Tapsall JW. In vitro activity of ertapenem versus ceftriaxone against Neisseria gonorrhoeae isolates with highly diverse ceftriaxone MIC values and effects of ceftriaxone resistance determinants: ertapenem for treatment of gonorrhea? Antimicrob Agents Chemother 2012; 56:3603-9. [PMID: 22547617 PMCID: PMC3393402 DOI: 10.1128/aac.00326-12] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/23/2012] [Indexed: 12/24/2022] Open
Abstract
Clinical resistance to the currently recommended extended-spectrum cephalosporins (ESCs), the last remaining treatment options for gonorrhea, is being reported. Gonorrhea may become untreatable, and new treatment options are crucial. We investigated the in vitro activity of ertapenem, relative to ceftriaxone, against N. gonorrhoeae isolates and the effects of ESC resistance determinants on ertapenem. MICs were determined using agar dilution technique or Etest for international reference strains (n = 17) and clinical N. gonorrhoeae isolates (n = 257), which included the two extensively drug-resistant (XDR) strains H041 and F89 and additional isolates with high ESC MICs, clinical ESC resistance, and other types of clinical high-level and multidrug resistance (MDR). Genetic resistance determinants for ESCs (penA, mtrR, and penB) were sequenced. In general, the MICs of ertapenem (MIC(50) = 0.032 μg/ml; MIC(90) = 0.064 μg/ml) paralleled those of ceftriaxone (MIC(50) = 0.032 μg/ml; MIC(90) = 0.125 μg/ml). The ESC resistance determinants mainly increased the ertapenem MIC and ceftriaxone MIC at similar levels. However, the MIC ranges for ertapenem (0.002 to 0.125 μg/ml) and ceftriaxone (<0.002 to 4 μg/ml) differed, and the four (1.5%) ceftriaxone-resistant isolates (MIC = 0.5 to 4 μg/ml) had ertapenem MICs of 0.016 to 0.064 μg/ml. Accordingly, ertapenem had in vitro advantages over ceftriaxone for isolates with ceftriaxone resistance. These in vitro results suggest that ertapenem might be an effective treatment option for gonorrhea, particularly for the currently identified ESC-resistant cases and possibly in a dual antimicrobial therapy regimen. However, further knowledge regarding the genetic determinants (and their evolution) conferring resistance to both antimicrobials, and clear correlates between genetic and phenotypic laboratory parameters and clinical treatment outcomes, is essential.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Daniel Golparian
- WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | - Athena Limnios
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - David Whiley
- Queensland Paediatric Infectious Diseases Laboratory, Queensland Children's Medical Research Institute, Children's Health Service District, Brisbane, Queensland, Australia
| | | | - Monica M. Lahra
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - John W. Tapsall
- WHO Collaborating Centre for STD, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Kim YJ, Han SH, Jeon JY, Hwang MH, Im YJ, Chae SW, Kim MG. Validation of LC-MS/MS method for determination of ertapenem in human plasma and urine. ANALYTICAL SCIENCE AND TECHNOLOGY 2012. [DOI: 10.5806/ast.2012.25.1.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Impact of derepressed AmpC beta-lactamase ACT-9 on the clinical efficacy of ertapenem. Antimicrob Agents Chemother 2011; 55:4440-2. [PMID: 21690276 DOI: 10.1128/aac.00271-11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
An in vivo development of Pantoea agglomerans mutants (isolates PA2 to PA4) with reduced ertapenem susceptibility from that of isolate PA1 was associated with an inadequate clinical response to ertapenem therapy. All four isolates harbored the bla(ACT-9) AmpC β-lactamase gene. However, a loss-of-function mutation in the ampD gene in PA2 to PA4, but not PA1, led to derepressed ACT-9. The reduced ertapenem susceptibility caused by derepressed ACT-9 was confirmed with an ampD knockout mutant of PA1.
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Wu DC, Chan WW, Metelitsa AI, Fiorillo L, Lin AN. Pseudomonas skin infection: clinical features, epidemiology, and management. Am J Clin Dermatol 2011; 12:157-69. [PMID: 21469761 DOI: 10.2165/11539770-000000000-00000] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Pseudomonas aeruginosa is a Gram-negative bacillus that is most frequently associated with opportunistic infection, but which can also present in the otherwise healthy patient. The range of P. aeruginosa infections varies from localized infections of the skin to life-threatening systemic disease. Many P. aeruginosa infections are marked by characteristic cutaneous manifestations. The aim of this article is to provide a comprehensive synthesis of the current knowledge of cutaneous manifestations of P. aeruginosa infection with specific emphasis on clinical features and management. The ability of P. aeruginosa to rapidly acquire antibacterial resistance is an increasingly well recognized phenomenon, and the correct application of antipseudomonal therapy is therefore of the utmost importance. A detailed discussion of currently available anti-pseudomonal agents is included, and the benefits of antimicrobial combination therapy versus monotherapy are explored. Rapid clinical recognition of P. aeruginosa infection aided by the identification of characteristic cutaneous manifestations can play a critical role in the successful management of potentially life-threatening disease.
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Affiliation(s)
- Douglas C Wu
- Division of Dermatology, University of Alberta, Edmonton, Alberta, Canada
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Abstract
PURPOSE OF REVIEW Antibiotic resistance continues to rise, whereas development of new agents to counter it has slowed. A heightened need exists to maintain the effectiveness of currently available agents. This review focuses on the need for better antimicrobial stewardship, expected benefits of well designed antimicrobial stewardship programs (ASPs), and provides suggestions for development of an effective ASP. RECENT FINDINGS Healthcare-associated infections (HAIs) are a significant cause of poor treatment outcomes and elevated healthcare and societal costs worldwide. HAIs are often caused by antibiotic-resistant pathogens; overuse of antibiotics has been linked with antibiotic resistance. Benefits of improved antimicrobial stewardship include reduced emergence of antibiotic resistance, limitation of drug-related adverse events, minimization of other consequences of antibiotic use (e.g., superinfection), and reduction of societal and healthcare-related costs. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) provided guidelines for the development of institutional programs to enhance antimicrobial stewardship. Experiences at The Ohio State University Medical Center (OSUMC) reinforce this message, while providing specific examples of ways to optimize ASP development and implementation. The focus of an ASP should be on improving quality of care, reducing drug resistance, and cost savings. When implementing an ASP, it is important to identify those most likely to resist the ASP, understand their concerns, and develop easy-to-understand messages that address these concerns and highlight the benefits of the proposed changes. Antibiograms play a key role in identifying local and interdepartmental trends in antibiotic susceptibility or resistance. These data are important not only in devising best-treatment practices for the institution, but also in evaluating the impact of a recently implemented ASP. Other measures of the impact of an ASP should include patient outcomes and overall costs or savings. SUMMARY Better antimicrobial stewardship is needed to limit the emergence of antibiotic resistance, prolong the effectiveness of currently available agents, improve patient outcomes, and reduce healthcare and societal costs associated with HAIs. Guidelines from the IDSA/SHEA and experiences at OSUMC provide examples of how best to develop an institutional ASP to accomplish these goals.
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Prolonged Use of Ertapenem to Treat Infected Diabetic Foot Ulcers. Case Rep Med 2010; 2010. [PMID: 20936155 PMCID: PMC2948897 DOI: 10.1155/2010/149591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 09/12/2010] [Accepted: 09/13/2010] [Indexed: 12/01/2022] Open
Abstract
We present the case of a diabetic man who was successfully treated with ertapenem for over 4 months for severe infection of his foot ulcers. After initial unsuccessful treatment with empirical intravenous antibiotics, ertapenem was started on microbiology advice and led to a marked improvement in the soft-tissue infection. Ertapenem was continued for a total of 137 days under close clinical and biochemical monitoring and produced a complete resolution of the foot infection. This is the first documented case that we know of in which ertapenem has been safely used for this duration of time.
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Burkhardt O, Kumar V, Schmidt S, Kielstein JT, Welte T, Derendorf H. Underdosing of ertapenem in critically ill patients with pneumonia confirmed by Monte Carlo simulations. Int J Antimicrob Agents 2010; 35:96-7. [DOI: 10.1016/j.ijantimicag.2009.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Accepted: 09/02/2009] [Indexed: 10/20/2022]
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[Update on antimicrobial chemotherapy]. Med Mal Infect 2009; 40:135-54. [PMID: 19959306 DOI: 10.1016/j.medmal.2009.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 09/02/2009] [Accepted: 10/28/2009] [Indexed: 11/21/2022]
Abstract
There is a constant need for new antibacterial agents because of the unavoidable development of bacterial resistance that follows the introduction of antibiotics in clinical practice. As observed in many fields, innovation generally comes by series. For instance, a wide variety of broad-spectrum antibacterial agents became available between the 1970s and the 1990s, such as cephalosporins, penicillin/beta-lactamase inhibitor combinations, carbapenems, and fluoroquinolones. Over the last 2 decades, the arrival of new antibacterial drugs on the market has dramatically slowed, leaving a frequent gap between isolation of resistant pathogens and effective treatment options. In fact, many pharmaceutical companies focused on the development of narrow-spectrum antibiotics targeted at multidrug-resistant Gram-positive bacteria (e.g. methicillin-resistant Staphylococcus aureus, penicillin resistant Streptococcus pneumoniae, and vancomycin-resistant Enterococcus faecium). Therefore, multidrug-resistant Gram-negative bacteria (e.g. extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter baumannii) recently emerged and rapidly spread worldwide. Even if some molecules were developed, new molecules for infections caused by these multidrug-resistant Gram-negative bacteria remain remarkably scarce compared to those for Gram-positive infections. This review summarises the major microbiological, pharmacological, and clinical properties of systemic antibiotics recently marketed in France (i.e. linezolid, daptomycin, tigecycline, ertapenem, and doripenem) as well as those of antibacterial drugs currently in development (i.e. ceftobiprole, ceftaroline, dalbavancin, telavancin, oritavancin, iclaprim, and ramoplanin) or available in other countries (i.e. garenoxacin, sitafloxacin, and temocillin).
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Pharmacokinetics of ertapenem following intravenous and subcutaneous infusions in patients. Antimicrob Agents Chemother 2009; 54:924-6. [PMID: 19933804 DOI: 10.1128/aac.00836-09] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Steady-state pharmacokinetics of ertapenem were compared in patients after 1-g intravenous and subcutaneous (s.c.) infusions. Bioavailability was 99%+/-18% after s.c. administration, but peaks were reduced by about (43+/-29 versus 115+/-28 microg/ml) and times to peak were delayed. Simulations based on unbound concentrations show that time over the MIC should always be longer than 30% to 40% of the dosing interval, suggesting that s.c. infusion could be an alternative in patients with reduced vascular access.
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Siempos II, Michalopoulos A, Falagas ME. Treatment of acute bacterial exacerbations of chronic bronchitis. Expert Opin Pharmacother 2009; 10:1173-82. [PMID: 19405791 DOI: 10.1517/14656560902907734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Controversies persist regarding the optimal management of patients with acute exacerbations of chronic bronchitis (AECB). OBJECTIVE To evaluate the available evidence on relevant issues, namely the need for administering antimicrobials in patients with AECB, the identification of the subgroup of patients with AECB needing antibiotics, the antimicrobial regimen of choice and its optimal duration, the existence of new agents, and the value of non-antimicrobial regimens for AECB. METHODS Data from various sources of evidence, including recent relevant meta-analyses, were appraised. CONCLUSION Administration of antimicrobial agents, combined with bronchodilators and systemic corticosteroids, is warranted in approximately half of AECBs (i.e., in bacterial exacerbations) to achieve a survival benefit. Simple clinical parameters, mainly sputum purulence, and biomarkers, such as procalcitonin, are useful in identifying patients requiring antibiotics. Advanced antibiotics (quinolones, macrolides, or amoxicillin/clavulanic acid) are more effective than 'old' antibiotics in AECB; regimens of short duration (for 5 days) are preferred. There is no difference between several classes of advanced antibiotics regarding their short-term effectiveness; however, quinolones are associated with better long-term outcomes than macrolides. Newer quinolones and new formulations of macrolides enrich clinicians' armamentarium against AECB.
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Affiliation(s)
- Ilias I Siempos
- Alfa Institute of Biomedical Sciences, 9 Neapoleos Street, 151 23 Marousi, Greece
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Reddy P, Chadaga S, Noskin GA. Antibiotic considerations in the treatment of multidrug-resistant (MDR) pathogens: a case-based review. J Hosp Med 2009; 4:E8-15. [PMID: 19670375 DOI: 10.1002/jhm.505] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The recent rise in antimicrobial resistance among health-care associated pathogens is a growing public health concern. According to the National Nosocomial Infections Surveillance System, rates of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units have nearly doubled over the last decade. Of equal importance, gram-negative agents such as Pseudomonas aeruginosa, Acinetobacter baumannii, and extended-spectrum beta lactamase-producing Enterobacteriaceae demonstrate increasing resistance to third-generation cephalosporins, fluoroquinolones, and, in some cases, carbapenems. As a consequence, hospitalists may find themselves utilizing new antibiotics in the treatment of bacterial infections. This case-based review will highlight 8 antibiotics that have emerging clinical indications in treating these multidrug-resistant (MDR) pathogens.
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Affiliation(s)
- Pavani Reddy
- Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Brink A, Richards G, Schillack V, Kiem S, Schentag J. Pharmacokinetics of once-daily dosing of ertapenem in critically ill patients with severe sepsis. Int J Antimicrob Agents 2009; 33:432-6. [DOI: 10.1016/j.ijantimicag.2008.10.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 10/01/2008] [Accepted: 10/02/2008] [Indexed: 11/29/2022]
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Matthews S, Lancaster JW. Doripenem monohydrate, a broad-spectrum carbapenem antibiotic. Clin Ther 2009; 31:42-63. [DOI: 10.1016/j.clinthera.2009.01.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2008] [Indexed: 11/30/2022]
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Burkhardt O, Hafer C, Langhoff A, Kaever V, Kumar V, Welte T, Haller H, Fliser D, Kielstein JT. Pharmacokinetics of ertapenem in critically ill patients with acute renal failure undergoing extended daily dialysis. Nephrol Dial Transplant 2008; 24:267-71. [DOI: 10.1093/ndt/gfn472] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Scaglione F, Paraboni L. Pharmacokinetics/pharmacodynamics of antibacterials in the Intensive Care Unit: setting appropriate dosing regimens. Int J Antimicrob Agents 2008; 32:294-301. [PMID: 18621508 DOI: 10.1016/j.ijantimicag.2008.03.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/26/2008] [Indexed: 12/18/2022]
Abstract
Patients admitted to Intensive Care Units (ICUs) are at very high risk of developing severe nosocomial infections. Consequently, antimicrobials are among the most important and commonly prescribed drugs in the management of these patients. Critically ill patients in ICUs include representatives of all age groups with a range of organ dysfunction related to severe acute illness that may complicate long-term illness. The range of organ dysfunction, together with drug interactions and other therapeutic interventions (e.g. haemodynamically active drugs and continuous renal replacement therapies), may strongly impact on antimicrobial pharmacokinetics in critically ill patients. In the last decade, it has become apparent that the intrinsic pharmacokinetic (PK) and pharmacodynamic (PD) properties are the major determinants of in vivo efficacy of antimicrobial agents. PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. In this review, we analyse the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach of the antimicrobial agent classes commonly utilised in the ICU setting.
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Affiliation(s)
- Francesco Scaglione
- Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, University of Milan, Milan, Italy.
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Joseph J, Rodvold KA. The role of carbapenems in the treatment of severe nosocomial respiratory tract infections. Expert Opin Pharmacother 2008; 9:561-75. [PMID: 18312158 DOI: 10.1517/14656566.9.4.561] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The prevalence of antibiotic-resistant bacteria continues to increase, particularly in patients in the intensive care unit with nosocomial pneumonia. The intention of this review is to provide an overview of severe nosocomial pneumonia, carbapenems and the problem of bacterial resistance to antimicrobial agents. Attention was focused on the efficacy, safety and pharmacodynamics of imipenem, meropenem, ertapenem and doripenem. Issues on the impact of appropriate empiric antibiotic therapy for nosocomial pneumonia patients considered at risk for resistant pathogens are discussed. Critical decision making regarding the use of carbapenems for treating severe nosocomial pneumonia requires careful consideration of the four Ds of optimal antimicrobial therapy: right Drug, right Dose, De-escalated to pathogen-directed therapy and right Duration of therapy.
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Affiliation(s)
- Jomy Joseph
- University of Illinois at Chicago, College of Medicine, Chicago, IL 60612, USA
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Abstract
Anaerobic bacteria are the predominant flora in the normal human skin and mucous membranes and are, therefore, a common cause of endogenous infections. Since anaerobic infections are generally polymicrobial, where anaerobes are mixed with aerobic organisms, therapy should provide coverage of both types of pathogens. The isolation of anaerobes requires appropriate methods of collection, transportation and cultivation of specimens. The lack of use of any of these methods can lead to inadequate recovery of anaerobes and inappropriate therapy. Treatment of anaerobic infection is complicated by the slow growth of these organisms and the growing resistance of anaerobic bacteria to antimicrobials. The primary role of antimicrobials is to limit the local and systemic spread of infection. Surgical drainage is of primary importance. This includes debriding of necrotic tissue, draining the pus, improving circulation, alleviating obstruction and increasing tissue oxygenation. The most effective antimicrobials against anaerobic organisms are metronidazole, the carbapenems (imipenem, meropenem and ertapenem), chloramphenicol, the combinations of a penicillin and a beta-lactamase inhibitor (ampicillin or ticarcillin plus clavulanate, amoxicillin plus sulbactam, and piperacillin plus tazobactam), tigecycline and clindamycin.
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Affiliation(s)
- Itzhak Brook
- Georgetown University School of Medicine, Department of Pediatrics, 4431 Albemarle St NW, Washington, DC 20016, USA.
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