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Estradé O, Vozmediano V, Carral N, Isla A, González M, Poole R, Suarez E. Key Factors in Effective Patient-Tailored Dosing of Fluoroquinolones in Urological Infections: Interindividual Pharmacokinetic and Pharmacodynamic Variability. Antibiotics (Basel) 2022; 11:antibiotics11050641. [PMID: 35625285 PMCID: PMC9137891 DOI: 10.3390/antibiotics11050641] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Fluoroquinolones (FQs) are a critical group of antimicrobials prescribed in urological infections as they have a broad antimicrobial spectrum of activity and a favorable tissue penetration at the site of infection. However, their clinical practice is not problem-free of treatment failure, risk of emergence of resistance, and rare but important adverse effects. Due to their critical role in clinical improvement, understanding the dose-response relation is necessary to optimize the effectiveness of FQs therapy, as it is essential to select the right antibiotic at the right dose for the right duration in urological infections. The aim of this study was to review the published literature about inter-individual variability in pharmacological processes that can be responsible for the clinical response after empiric dose for the most commonly prescribed urological FQs: ciprofloxacin, levofloxacin, and moxifloxacin. Interindividual pharmacokinetic (PK) variability, particularly in elimination, may contribute to treatment failure. Clearance related to creatinine clearance should be specifically considered for ciprofloxacin and levofloxacin. Likewise, today, undesired interregional variability in FQs antimicrobial activity against certain microorganisms exists. FQs pharmacology, patient-specific characteristics, and the identity of the local infecting organism are key factors in determining clinical outcomes in FQs use.
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Affiliation(s)
- Oskar Estradé
- Department of Urology, Cruces University Hospital, 48903 Barakaldo, Spain;
| | - Valvanera Vozmediano
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Nerea Carral
- Department of Pharmacology, Faculty of Medicine and Nursey, University of Basque Country UPV/EHU, 48940 Leioa, Spain;
- Biocruces Health Research Institute, 48903 Barakaldo, Spain
| | - Arantxa Isla
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, 01006 Vitoria-Gasteiz, Spain;
- Instituto de Investigación Sanitaria Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, 01006 Vitoria-Gasteiz, Spain
| | - Margarita González
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Rachel Poole
- Center for Pharmacometrics and Systems Pharmacology, Department of Pharmaceutics, University of Florida, Gainesville, FL 32612, USA; (V.V.); (M.G.); (R.P.)
| | - Elena Suarez
- Department of Pharmacology, Faculty of Medicine and Nursey, University of Basque Country UPV/EHU, 48940 Leioa, Spain;
- Biocruces Health Research Institute, 48903 Barakaldo, Spain
- Correspondence:
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Farrar JE, Mueller SW, Stevens V, Kiser TH, Taleb S, Reynolds PM. Correlation of antimicrobial fraction unbound and sieving coefficient in critically ill patients on continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2021; 77:310-319. [DOI: 10.1093/jac/dkab396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Fraction unbound has been used as a surrogate for antimicrobial sieving coefficient (SC) to predict extracorporeal clearance in critically ill patients on continuous renal replacement therapy (CRRT), but this is based largely on expert opinion.
Objectives
To examine relationships between package insert-derived fraction unbound (Fu-P), study-specific fraction unbound (Fu-S), and SC in critically ill patients receiving CRRT.
Methods
English-language studies containing patient-specific in vivo pharmacokinetic parameters for antimicrobials in critically ill patients requiring CRRT were included. The primary outcome included correlations between Fu-S, Fu-P, and SC. Secondary outcomes included correlations across protein binding quartiles, serum albumin, and predicted in-hospital mortality, and identification of predictors for SC through multivariable analysis.
Results
Eighty-nine studies including 32 antimicrobials were included for analysis. SC was moderately correlated to Fu-S (R2 = 0.55, P < 0.001) and Fu-P (R2 = 0.41, P < 0.001). SC was best correlated to Fu-S in first (<69%) and fourth (>92%) quartiles of fraction unbound and above median albumin concentrations of 24.5 g/L (R2 = 0.71, P = 0.07). Conversely, correlation was weaker in patients with mortality estimates greater than the median of 55% (R2 = 0.06, P = 0.84). SC and Fu-P were also best correlated in the first quartile of antimicrobial fraction unbound (R2 = 0.66, P < 0.001). Increasing Fu-P, flow rate, membrane surface area, and serum albumin, and decreasing physiologic charge significantly predicted increasing SC.
Conclusions
Fu-S and Fu-P were both reasonably correlated to SC. Caution should be taken when using Fu-S to calculate extracorporeal clearance in antimicrobials with 69%–92% fraction unbound or with >55% estimated in-hospital patient mortality. Fu-P may serve as a rudimentary surrogate for SC when Fu-S is unavailable.
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Affiliation(s)
- Julie E. Farrar
- Auburn University Harrison School of Pharmacy, 650 Clinic Dr, Mobile, AL 36688, USA
| | - Scott W. Mueller
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Victoria Stevens
- University of Colorado Hospital, 12505 E 16th Ave, Aurora, CO 80045, USA
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Sim Taleb
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
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Jang SM, Awdishu L. Drug dosing considerations in continuous renal replacement therapy. Semin Dial 2021; 34:480-488. [PMID: 33939855 DOI: 10.1111/sdi.12972] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/23/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, which is associated with increased in-hospital mortality. Delivering effective antibiotics to treat patients with sepsis receiving continuous renal replacement therapy (RRT) is complicated by variability in pharmacokinetics, dialysis delivery, lack of primary literature, and therapeutic drug monitoring. Pharmacokinetic alterations include changes in absorption, distribution, protein binding (PB), metabolism, and renal elimination. Drug absorption may be significantly changed due to alterations in gastric pH, perfusion, gastrointestinal motility, and intestinal atrophy. Volume of distribution for hydrophilic drugs may be increased due to volume overload. Estimation of renal clearance is challenged by the effective delivery of RRT. Drug characteristics such as PB, volume of distribution, and molecular weight impact removal of the drug by RRT. The totality of these alterations leads to reduced exposure. Despite our best knowledge, therapeutic drug monitoring of patients receiving continuous RRT demonstrates wide variability in antimicrobial concentrations, highlighting the need for expanded monitoring of all drugs. This review article will focus on changes in drug pharmacokinetics in AKI and dosing considerations to attain antibiotic pharmacodynamic targets in critically ill patients receiving continuous RRT.
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Affiliation(s)
- Soo Min Jang
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Linda Awdishu
- Clinical Pharmacy, UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
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Kalaria S, Williford S, Guo D, Shu Y, Medlin C, Li M, Yeung SYA, Ali F, Jean W, Gopalakrishnan M, Heavner M. Optimizing ceftaroline dosing in critically ill patients undergoing continuous renal replacement therapy. Pharmacotherapy 2021; 41:205-211. [PMID: 33438291 DOI: 10.1002/phar.2502] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Currently, no dosing information exists for ceftaroline fosamil in patients undergoing continuous renal replacement therapy (CRRT). The objectives of this study are to characterize the pharmacokinetics of ceftaroline in critically ill patients undergoing CRRT modalities and to derive individualized dosing recommendations. METHODS This pharmacokinetic study aimed to enroll critically ill patients receiving ceftaroline fosamil and any CRRT modality from adult intensive care units. Selection of the specific CRRT modality and dosing regimen was based on clinical discretion. Pre-filter, post-filter, and ultrafiltrate samples were obtained before the administration of the fourth dose, after the completion of the infusion, and up to five additional time points post-infusion. Plasma concentrations were measured using a validated ultra-high performance liquid chromatography assay. Individual pharmacokinetic parameters were calculated using non-compartmental analysis. RESULTS Four patients were enrolled to investigate the need for dosing adjustments. The average sieving coefficient for ceftaroline was 0.81 ± 0.1, indicating high filter efficiency. The average volume of distribution was 41.8 L (0.48 L/kg) and is within the previously reported range in patients with normal renal function. Non-renal clearance accounted for more than 50% of the total clearance observed in patients. The observed pharmacokinetic profiles suggest that the pharmacodynamic target for 2-log10 CFU reduction from baseline (%fT >1 mg/L of 50%) was met for each patient. Due to the impact of CRRT and non-renal clearance, dosing recommendations were derived for different ranges of effluent flow rates and adjusted body weights. For a patient with an adjusted body weight of 70 kg and receiving CRRT at an effluent flow rate of 3 L/h, a ceftaroline fosamil dosing regimen of 400 mg every 12 h is proposed. CONCLUSION Ceftaroline is cleared extensively in critically ill patients receiving CRRT and may impact pharmacodynamic target achievement. Dose adjustments should be based on the intensity of the CRRT regimen, patient weight, and the clinical status of the patient.
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Affiliation(s)
- Shamir Kalaria
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Sarah Williford
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dong Guo
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Yan Shu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Christopher Medlin
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Matthew Li
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Siu Yan Amy Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Farhan Ali
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Wisna Jean
- Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Mojdeh Heavner
- Department of Pharmacy Practice and Science, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Optimal levofloxacin dosing regimens in critically ill patients with acute kidney injury receiving continuous renal replacement therapy. J Crit Care 2020; 63:154-160. [PMID: 33012583 DOI: 10.1016/j.jcrc.2020.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 12/29/2022]
Abstract
PURPOSES To determine appropriate dosing of levofloxacin in critically ill patients receiving continuous renal replacement therapy (CRRT). METHODS All necessary pharmacokinetic and pharmacodynamic parameters from critically ill patients were obtained to develop mathematical models with first order elimination. Levofloxacin concentration-time profiles were calculated to determine the efficacy based on the probability of target attainment (PTA) of AUC24h/MIC ≥50 for Gram-positive and AUC24h/MIC ≥125 for Gram-negative infections. A group of 5000 virtual patients was simulated and tested using Monte Carlo simulations for each dose in the models. The optimal dosing regimens were defined as the dose achieved target PTA at least 90% of the virtual patients. RESULTS No conventional, FDA approved regimens achieved at least 90% of PTA for Gram-negative infection with Pseudomonas aeruginosa at MIC of 2 mg/L. The successful dose (1750 mg on day 1, then 1500 mg q 24 h) was far exceeded the maximum FDA-approved doses. For Gram-positive infections, a levofloxacin 750 mg q 24 h was sufficient to attain PTA target of ~90% at the MIC of 2 mg/L for Streptococcus pneumoniae. CONCLUSIONS Levofloxacin cannot be recommended as an empiric monotherapy for serious Gram-negative infections in patients receiving CRRT due to suboptimal efficacy.
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Broeker A, Vossen MG, Thalhammer F, Wallis SC, Lipman J, Roberts JA, Wicha SG. An Integrated Dialysis Pharmacometric (IDP) Model to Evaluate the Pharmacokinetics in Patients Undergoing Renal Replacement Therapy. Pharm Res 2020; 37:96. [PMID: 32409892 PMCID: PMC7225193 DOI: 10.1007/s11095-020-02832-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/22/2020] [Indexed: 01/27/2023]
Abstract
PURPOSE Clearance via renal replacement therapy (RRT) can significantly alter the pharmacokinetic profile of drugs. The aim of this study was (i) to improve the use of clinical trial data and (ii) to provide a model that allows quantification of all aspects of drug elimination via RRT including adsorption to dialysis membranes and/or degradation of the drug in the dialysate. METHODS An integrated dialysis pharmacometric (IDP) model was developed to simultaneously incorporate all available RRT information. The sensitivity, accuracy and precision of the IDP model was compared to conventional approaches in clinical trial simulations and applied to clinical datasets of teicoplanin and doripenem. RESULTS The IDP model was more accurate, precise and sensitive than conventional plasma-concentration-based approaches when estimating the clearanceRRT (relative bias <1%). In contrast to conventional approaches, adsorption and degradation were quantifiable using the IDP model (relative bias: -1.1% and - 1.9%, respectively). Applied to clinical data, clearanceRRT, drug degradation (effluent-half-lifedoripenem: 13.5 h-1) and adsorption (polysulphone adsorption capacityteicoplanin: 31.2 mg) were assessed. CONCLUSION The IDP model allows accurate, precise and sensitive characterization of clearanceRRT, adsorption and degradation. Successful quantification of all aspects of clearanceRRT in clinical data demonstrated the benefit of the IDP model as compared to conventional approaches.
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Affiliation(s)
- Astrid Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - Matthias G Vossen
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Thalhammer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Steven C Wallis
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany.
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A Guide to Understanding Antimicrobial Drug Dosing in Critically Ill Patients on Renal Replacement Therapy. Antimicrob Agents Chemother 2019; 63:AAC.00583-19. [PMID: 31109983 DOI: 10.1128/aac.00583-19] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
A careful management of antimicrobials is essential in the critically ill with acute kidney injury, especially if renal replacement therapy is required. Acute kidney injury may lead per se to clinically significant modifications of drugs' pharmacokinetic parameters, and the need for renal replacement therapy represents a further variable that should be considered to avoid inappropriate antimicrobial therapy. The most important pharmacokinetic parameters, useful to determine the significance of extracorporeal removal of a given drug, are molecular weight, protein binding, and distribution volume. In many cases, the extracorporeal removal of antimicrobials can be relevant, with a consistent risk of underdosing-related treatment failure and/or potential onset of bacterial resistance. It should also be taken into account that renal replacement therapies are often not standardized in critically ill patients, and their impact on plasma drug concentrations may substantially vary in relation to membrane characteristics, treatment modality, and delivered dialysis dose. Thus, in this clinical scenario, the knowledge of the pharmacokinetic and pharmacodynamic properties of different antimicrobial classes is crucial to tailor maintenance dose and/or time interval according to clinical needs. Finally, especially for antimicrobials known for a tight therapeutic range, therapeutic drug monitoring is strongly suggested to guide dosing adjustment in complex clinical settings, such as septic patients with acute kidney injury undergoing renal replacement therapy.
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Wang Q, Wang G, Xie S, Zhao X, Zhang Y. Comparison of high-performance liquid chromatography and ultraviolet-visible spectrophotometry to determine the best method to assess Levofloxacin released from mesoporous silica microspheres/nano-hydroxyapatite composite scaffolds. Exp Ther Med 2019; 17:2694-2702. [PMID: 30906459 PMCID: PMC6425260 DOI: 10.3892/etm.2019.7238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/22/2019] [Indexed: 12/28/2022] Open
Abstract
An assessment of Levofloxacin by high-performance liquid chromatography (HPLC) or ultraviolet-visible spectrophotometry (UV-Vis) and its pharmacokinetics in serum or plasma was made in a previous study by the present authors. Levofloxacin-loaded mesoporous silica microspheres/nano-hydroxyapatite (n-HA) composite scaffolds comprise a novel synthetic composite scaffold that may be utilized as a drug-delivery system for clinical usage. However, few studies have been published concerning a comparison of HPLC with UV-Vis, which is the preferred method for determination of Levofloxacin. In the present study, an HPLC method was first established, and subsequently a comparison of HPLC with the UV-Vis method was performed. The standard curve was established, and recovery rate from simulated body fluid was calculated. The linear concentration range for Levofloxacin was 0.05–300 µg/ml. The regression equation for HPLC was y=0.033x+0.010, with R2=0.9991, whereas that for UV-Vis was y=0.065x+0.017, with R2=0.9999. The recovery rates of low, medium and high (5, 25 and 50 µg/ml) concentrations of Levofloxacin determined by HPLC were 96.37±0.50, 110.96±0.23 and 104.79±0.06%, respectively, whereas those for low, medium and high concentrations according to UV-Vis were 96.00±2.00, 99.50±0.00 and 98.67±0.06%, respectively. Taken together, these findings demonstrated that it is not accurate to measure the concentration of drugs loaded on the biodegradable composite composites by UV-Vis. HPLC is the preferred method to evaluate sustained release characteristics of Levofloxacin released from mesoporous silica microspheres/n-HA composite scaffolds. The present study also provides guidance on which methods should be selected for investigating the sustained release properties of drugs in tissue engineering. The accurate determination of drug concentration in the drug delivery system provides guidance for the treatment of infectious diseases.
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Affiliation(s)
- Qi Wang
- Department of Orthopedics, The Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Guodong Wang
- Department of Orthopedics, The Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Shicheng Xie
- Department of Orthopedics, The Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Xiaowei Zhao
- Department of Orthopedics, The Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
| | - Yuanmin Zhang
- Department of Orthopedics, The Affiliated Hospital of Jining Medical University, Jining, Shandong 272000, P.R. China
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Abstract
Appropriate antibiotic dosing is critical to improve outcomes in critically ill patients with sepsis. The addition of continuous renal replacement therapy makes achieving appropriate antibiotic dosing more difficult. The lack of continuous renal replacement therapy standardization results in treatment variability between patients and may influence whether appropriate antibiotic exposure is achieved. The aim of this study was to determine if continuous renal replacement therapy effluent flow rate impacts attaining appropriate antibiotic concentrations when conventional continuous renal replacement therapy antibiotic doses were used. This study used Monte Carlo simulations to evaluate the effect of effluent flow rate variance on pharmacodynamic target attainment for cefepime, ceftazidime, levofloxacin, meropenem, piperacillin, and tazobactam. Published demographic and pharmacokinetic parameters for each antibiotic were used to develop a pharmacokinetic model. Monte Carlo simulations of 5000 patients were evaluated for each antibiotic dosing regimen at the extremes of Kidney Disease: Improving Global Outcomes guidelines recommended effluent flow rates (20 and 35 mL/kg/h). The probability of target attainment was calculated using antibiotic-specific pharmacodynamic targets assessed over the first 72 hours of therapy. Most conventional published antibiotic dosing recommendations, except for levofloxacin, reach acceptable probability of target attainment rates when effluent rates of 20 or 35 mL/kg/h are used.
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Lewis SJ, Chaijamorn W, Shaw AR, Mueller BA. In silico trials using Monte Carlo simulation to evaluate ciprofloxacin and levofloxacin dosing in critically ill patients receiving prolonged intermittent renal replacement therapy. RENAL REPLACEMENT THERAPY 2016. [DOI: 10.1186/s41100-016-0055-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gorman SK. Presence and accuracy of drug dosage recommendations for continuous renal replacement therapy in tertiary drug information references. Can J Hosp Pharm 2012; 65:188-95. [PMID: 22783029 PMCID: PMC3379825 DOI: 10.4212/cjhp.v65i3.1141] [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: 11/10/2022]
Abstract
BACKGROUND Clinicians commonly rely on tertiary drug information references to guide drug dosages for patients who are receiving continuous renal replacement therapy (CRRT). It is unknown whether the dosage recommendations in these frequently used references reflect the most current evidence. OBJECTIVE To determine the presence and accuracy of drug dosage recommendations for patients undergoing CRRT in 4 drug information references. METHODS Medications commonly prescribed during CRRT were identified from an institutional medication inventory database, and evidence-based dosage recommendations for this setting were developed from the primary and secondary literature. The American Hospital Formulary System-Drug Information (AHFS-DI), Micromedex 2.0 (specifically the DRUGDEX and Martindale databases), and the 5th edition of Drug Prescribing in Renal Failure (DPRF5) were assessed for the presence of drug dosage recommendations in the CRRT setting. The dosage recommendations in these tertiary references were compared with the recommendations derived from the primary and secondary literature to determine concordance. RESULTS Evidence-based drug dosage recommendations were developed for 33 medications administered in patients undergoing CRRT. The AHFS-DI provided no dosage recommendations specific to CRRT, whereas the DPRF5 provided recommendations for 27 (82%) of the medications and the Micromedex 2.0 application for 20 (61%) (13 [39%] in the DRUGDEX database and 16 [48%] in the Martindale database, with 9 medications covered by both). The dosage recommendations were in concordance with evidence-based recommendations for 12 (92%) of the 13 medications in the DRUGDEX database, 26 (96%) of the 27 in the DPRF5, and all 16 (100%) of those in the Martindale database. CONCLUSIONS One prominent tertiary drug information resource provided no drug dosage recommendations for patients undergoing CRRT. However, 2 of the databases in an Internet-based medical information application and the latest edition of a renal specialty drug information resource provided recommendations for a majority of the medications investigated. Most dosage recommendations were similar to those derived from the primary and secondary literature. The most recent edition of the DPRF is the preferred source of information when prescribing dosage regimens for patients receiving CRRT.
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Affiliation(s)
- Sean K Gorman
- Sean K Gorman, BScPharm, ACPR, PharmD, is Clinical Coordinator—Critical Care, Pharmacy Department, Capital District Health Authority, and Associate Professor, College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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12
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Suzuki F, Hanada K, Motoki M, Ogata H. [Study of factors affecting drug extraction during continuous hemofiltration and hemodiafiltration, and the contribution of extraction to systemic clearance]. YAKUGAKU ZASSHI 2012; 132:517-23. [PMID: 22465930 DOI: 10.1248/yakushi.132.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to elucidate the factors affecting dialysis clearance and the need for additional doses of drugs during and after continuous hemofiltration (CHF) and hemodiafiltration (CHDF). We performed a literature search of MEDLINE using the terms hemofiltration OR hemodiafiltration AND pharmacokinetics to obtain the clearances of CHF and CHDF in a clinical setting. The relationships between molecular weight, the unbound fraction (fuB), ultrafiltration flow rate (UFR) and dialysis flow rate were analyzed. The need for additional doses of certain drugs was also discussed based on the ratio of dialysis and systemic clearances. The clearance of CHF for 32 reported drugs was significantly correlated with the product of fuB×UFR (r=0.841, p<0.001), and furthermore the plots obtained lay on a line of y=x. The clearance of CHDF also showed good correlation with the product of fuB×UFR (r=0.795, p<0.001), but the plots were higher than the line for y=x, suggesting that additional clearance by dialysis was not negligible. The elimination by both forms of dialysis for drugs excreted mainly via the kidneys, and with a higher fuB, was considerable. The extent of drug clearance by both CHF and CHDF is determined mainly by fuB and UFR. The ratio of dialysis clearance to systemic clearance should be estimated to determine the contribution of CHF and CHDF.
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Affiliation(s)
- Fumi Suzuki
- Course of Clinical Pharmacy, Graduate School of Pharmaceutical Science, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
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13
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VAARA S, PETTILA V, KAUKONEN KM. Quality of pharmacokinetic studies in critically ill patients receiving continuous renal replacement therapy. Acta Anaesthesiol Scand 2012; 56:147-57. [PMID: 22092254 DOI: 10.1111/j.1399-6576.2011.02571.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2011] [Indexed: 11/30/2022]
Abstract
Continuous renal replacement therapy (CRRT) is the preferred renal replacement therapy modality in the critically ill. We aimed to reveal the literature on the pharmacokinetic studies in critically ill patients receiving CRRT with special reference to quality assessment of these studies and the CRRT dose. We conducted a systematic review by searching the MEDLINE, EMBASE, and the Cochrane databases to December 2009 and bibliographies of relevant review articles. We included original studies reporting from critically ill adult subjects receiving CRRT because of acute kidney injury with a special emphasis on drug pharmacokinetics. We used the minimum reporting criteria for CRRT studies by Acute Dialysis Quality Initiative (ADQI) and, second, the Downs and Black checklist to assess the quality of the studies. We calculated the CRRT dose per study. We included pharmacokinetic parameters, residual renal function, and recommendations on drug dosing. Of 182 publications, 95 were considered relevant and 49 met the inclusion criteria. The median [interquartile range (IQR)] number of reported criteria by ADQI was 7.0 (5.0-8.0) of 12. The median (IQR) Downs and Black quality score was 15 (14-16) of 32. None of the publications reported CRRT dose directly. The median (IQR) weighted CRRT dose was 23.7 (18.8-27.9) ml/kg/h. More attention should be paid both to standardizing the CRRT dose and reporting of the CRRT parameters in pharmacokinetic studies. The general quality of the studies during CRRT in the critically ill was only moderate and would be greatly improved by reports in concordant with the ADQI recommendations.
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Affiliation(s)
- S. VAARA
- Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki; Finland
| | - V. PETTILA
- Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki; Finland
| | - K.-M. KAUKONEN
- Division of Anaesthesia and Intensive Care Medicine; Department of Surgery; Helsinki University Central Hospital; Helsinki; Finland
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Eyler RF, Mueller BA. Antibiotic dosing in critically ill patients with acute kidney injury. Nat Rev Nephrol 2011; 7:226-35. [PMID: 21343897 DOI: 10.1038/nrneph.2011.12] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A common cause of acute kidney injury (AKI) is sepsis, which makes appropriate dosing of antibiotics in these patients essential. Drug dosing in critically ill patients with AKI, however, can be complicated. Critical illness and AKI can both substantially alter pharmacokinetic parameters as compared with healthy individuals or patients with end-stage renal disease. Furthermore, drug pharmacokinetic parameters are highly variable within the critically ill population. The volume of distribution of hydrophilic agents can increase as a result of fluid overload and decreased binding of the drug to serum proteins, and antibiotic loading doses must be adjusted upwards to account for these changes. Although renal elimination of drugs is decreased in patients with AKI, residual renal function in conjunction with renal replacement therapies (RRTs) result in enhanced drug clearance, and maintenance doses must reflect this situation. Antibiotic dosing decisions should be individualized to take into account patient-related, RRT-related, and drug-related factors. Efforts must also be made to optimize the attainment of antibiotic pharmacodynamic goals in this population.
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Affiliation(s)
- Rachel F Eyler
- Department of Clinical, Social, and Administrative Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, MI 48109-1065, USA
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15
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A systematic review of antibiotic dosing regimens for septic patients receiving continuous renal replacement therapy: do current studies supply sufficient data? J Antimicrob Chemother 2009; 64:929-37. [DOI: 10.1093/jac/dkp302] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Pharmacokinetics of levofloxacin after single and multiple oral doses in patients undergoing intermittent haemodialysis. Int J Antimicrob Agents 2008; 32:46-9. [DOI: 10.1016/j.ijantimicag.2008.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Revised: 02/18/2008] [Accepted: 02/19/2008] [Indexed: 11/18/2022]
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Bouman CSC. Dosing of antimicrobial agents in critically-ill patients with acute kindey injury and continuous venvenous haemofiltration. Acta Clin Belg 2008; 62 Suppl 2:365-70. [PMID: 18284001 DOI: 10.1179/acb.2007.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To summarize the general guidelines for drug dosing in critically-ill patients with acute kidney injury and continuous venovenous haemofiltration (CVVH), and to discuss whether the predicted dose adjustment is an as reliable estimate than one based on observed data, considering the recent literature. METHODS Literature search was done in PubMed database for human studies. CONCLUSIONS In critically-ill patients receiving CVVH, dosing of antibiotics based on the predicted clearances yield rough estimates. Because of interpatient variability observed in the clearance of many antibiotics, monitoring of plasma concentration is highly recommended whenever possible, and especially for those antibiotics that are eliminated predominantly by the kidney, and that have a low therapeutic threshold such as aminoglycosides and glycopeptides, or in patients requiring protracted treatment. However, for many antibiotics, monitoring of blood concentrations is not routinely available and adequate concentrations can only be inferred from clinical response. Therefore, it is important to realize that among many other causes, failure to respond within the first few days of antibiotic treatment may be due to inadequate dosing.
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Affiliation(s)
- C S C Bouman
- Academic Medical Center, University of Amsterdam, Department of Intensive Care, Amsterdam, Netherlands.
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Siewert S, Drewelow B, Mueller SC. Clearance of levofloxacin by an in vitro model of continuous venovenous hemodialysis (CVVHD). Int J Artif Organs 2008; 30:889-95. [PMID: 17992649 DOI: 10.1177/039139880703001005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Information about the elimination and the adequate dosing of levofloxacin during renal replacement therapy is scarce. The aim of this study was to characterize in vitro the elimination of levofloxacin during continuous venovenous hemodialysis (CVVHD) and to investigate whether the CVVHD clearances of creatinine and urea are correlated with the levofloxacin clearance in order to facilitate dosage adjustments. An in vitro model of CVVHD was established using five dialyzer membranes at varying dialysate flow rates applied in the clinical setting (8, 16, 25, 33 and 41 ml/min). Plasma and dialysate samples were drawn for determination of levofloxacin, creatinine and urea concentrations to evaluate clearances by CVVHD. During CVVHD, the clearance of levofloxacin varied between 9.02 and 33.30 ml/min, depending on the chosen setup. Positive correlations (p<0.001) were received for: dialysate flow rate (QD) and creatinine/ urea clearances (R(2)>0.93); QD and levofloxacin clearance (R(2) 0.59-0.71); levofloxacin and creatinine clearance (R(2) 0.69-0.75); and levofloxacin and urea clearance (R(2) 0.56-0.75) as well. When dosing critically ill patients, therefore, extracorporeal as well as total clearance of levofloxacin should be considered.
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Affiliation(s)
- S Siewert
- Institute of Clinical Pharmacology, University of Rostock, Rostock, Germany.
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20
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Abstract
BACKGROUND Fluoroquinolones, including ciprofloxacin, levofloxacin, gemifloxacin, and moxifloxacin, represent a major advance in the development of antimicrobial agents. They offer significant activity against Gram-negative pathogens, while more advanced generation fluoroquinolones including levofloxacin, gemifloxacin, and moxifloxacin are significantly active against Gram-positive (e.g., Streptococcus pneumoniae for some members of the class), typical, atypical, and anaerobic pathogens. Fluoroquinolones have a pharmacokinetic/pharmacodynamic profile that exhibits concentration-dependent killing and good oral absorption, allowing for once-daily dosing. OBJECTIVE Review of data from fluoroquinolone studies, with an emphasis on the associated rare, but potentially clinically important, adverse events in specific patient populations. Review of clinical efficacy is included where relevant to the topic under discussion. METHODS A literature search was conducted using terms including fluoroquinolones, moxifloxacin, ciprofloxacin, levofloxacin, gatifloxacin, gemifloxacin, safety, adverse events, drug interactions, and pharmacokinetic parameters to identify literature providing information regarding the safety profile of specified fluoroquinolones in special patient populations (i.e., the elderly, patients with liver disease, kidney disease, glycemic disorder, those at risk for cardiovascular events). Although specific date criteria were not applied to the search, preference was given to more recent publications. Online databases searched include MEDLINE and EMBASE and relevant textbooks were utilized as well. FINDINGS Fluoroquinolones, when used either as monotherapy or as combination therapy depending on their individual indications, attain adequate concentrations for treating infections in different target sites, including epithelial lining fluid, alveolar macrophages, skin, and gastrointestinal tissues. Overall, fluoroquinolones have predictable and mild-to-moderate adverse-event profiles and are generally well tolerated. Findings of this review are limited by the availability of publications and case reports. CONCLUSIONS Fluoroquinolones, are associated with rare, but clinically important, adverse events in special patient populations (including the elderly; those with hepatic, renal, or glycemic disorders; and those at risk for cardiovascular events). Recognition of differences in the clinical efficacy and safety profiles of fluoroquinolones in special patient populations should lead to better antimicrobial agent selection.
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Affiliation(s)
- Paul B Iannini
- Department of Medicine, Danbury Hospital, Danbury, CT 06810, USA.
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21
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Pea F, Viale P, Pavan F, Furlanut M. Pharmacokinetic Considerations for Antimicrobial Therapy in Patients Receiving Renal Replacement Therapy. Clin Pharmacokinet 2007; 46:997-1038. [DOI: 10.2165/00003088-200746120-00003] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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22
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Choi G, Gomersall CD, Lipman J, Wong A, Joynt GM, Leung P, Ramsay SJ, Ho OM. The effect of adsorption, filter material and point of dilution on antibiotic elimination by haemofiltration an in vitro study of levofloxacin. Int J Antimicrob Agents 2005; 24:468-72. [PMID: 15519479 DOI: 10.1016/j.ijantimicag.2004.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 06/04/2004] [Indexed: 11/16/2022]
Abstract
We studied an in vitro model of continuous venous-venous haemofiltration (CVVH), into which levofloxacin 100 mg was infused, to determine levofloxacin adsorption and to determine the effect of filter material and point of dilution (pre- or post-filter) on sieving coefficient. Mean (standard deviation; S.D.) adsorption was 18.7 (5.3) mg for the polyamide filter and 40.2 (2.0) mg for the polyacrylonitrile (PAN) filter (P < 0.001). Post-dilution resulted in a minor, but statistically significant, decrease in sieving coefficient (pre-dilution 0.96 (S.D. 0.10), post-dilution 0.88 (S.D. 0.11) with the PAN filter. These data indicate that the variability in published values for levofloxacin sieving coefficient are not due to variation in point of dilution or membrane type (PAN or polyamide). Significant adsorption of levofloxacin onto PAN filters occurs.
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Affiliation(s)
- Gordon Choi
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Mueller BA, Pasko DA, Sowinski KM. Ofloxacin clearance during continuous hemofiltration. Am J Kidney Dis 2003; 42:1326-7; author reply 1327-8. [PMID: 14655211 DOI: 10.1053/j.ajkd.2003.08.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fuhrmann V, Schenk P, Thalhammer F. In Reply. Am J Kidney Dis 2003. [DOI: 10.1053/j.ajkd.2003.09.008] [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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Sowinski KM, Lucksiri A, Kays MB, Scott MK, Mueller BA, Hamburger RJ. Levofloxacin pharmacokinetics in ESRD and removal by the cellulose acetate high performance-210 hemodialyzer. Am J Kidney Dis 2003; 42:342-9. [PMID: 12900817 DOI: 10.1016/s0272-6386(03)00660-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND No published data are available describing the pharmacokinetics of intravenous levofloxacin in patients with end-stage renal disease (ESRD). Objectives of this study are to determine the pharmacokinetics and dialytic clearance of levofloxacin and develop dosing strategies in these patients. METHODS Eight noninfected subjects receiving long-term thrice-weekly hemodialysis, with no measurable residual renal function, were administered intravenous levofloxacin, 250 mg, over 1 hour after a scheduled hemodialysis session. Blood samples were collected serially during the interdialytic period, during the next intradialytic period, and immediately after the next hemodialysis session. Serum concentrations of levofloxacin were determined by high-performance liquid chromatography. Differential equations describing a 2-compartment open-infusion pharmacokinetic model were fit to each individual subject's serum concentration-time data by iterative nonlinear weighted least-squares regression analysis using Adapt II (Biomedical Simulations Resource, University of Southern California, Los Angeles, CA). Ratios of maximum serum concentration (C(max)) to minimum inhibitory concentration (MIC) were calculated for common respiratory pathogens by using MIC for 90% of isolates (MIC90) data from published studies. RESULTS All subjects completed the study, and no adverse events were reported. Median systemic clearance, volume of distribution at steady state, elimination half-life, and C(max) were 37.0 mL/min (range, 12.8 to 42.7 mL/min), 103.3 L (range, 39.8 to 139.3 L), 34.4 hours (range, 28.4 to 39.3 hours), and 5.2 microg/mL (range, 4.1 to 11.3 microg/mL), respectively. Median dialytic clearance and levofloxacin reduction ratios were 84.4 mL/min (range, 61.8 to 107.6 mL/min) and 0.244 (range, 0.181 to 0.412), respectively. Median C(max)-MIC90 ratios were 10 or greater for Haemophilus influenzae, Moraxella catarrhalis, Enterobacter cloacae, and Klebsiella pneumoniae, approximately 5 for Streptococcus pneumoniae, and less than 1 for Pseudomonas aeruginosa. CONCLUSION The administration of levofloxacin to patients with ESRD as 500 mg initially, followed by 250 mg every 48 hours, will provide adequate C(max)-MIC ratios after the first and subsequent doses for most patients with respiratory tract infections caused by organisms with levofloxacin MICs of 1 microg/mL or less.
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Affiliation(s)
- Kevin M Sowinski
- Department of Pharmacy Practice, School of Pharmacy and Pharmacal Sciences, Purdue University, Indianapolis, IN 46202-2879, USA.
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Fuhrmann V, Schenk P, Mittermayer C, El Menyawi I, Ratheiser K, Thalhammer F. Single-dose pharmacokinetics of ofloxacin during continuous venovenous hemofiltration in critical care patients. Am J Kidney Dis 2003; 42:310-4. [PMID: 12900813 DOI: 10.1016/s0272-6386(03)00656-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Ofloxacin is a quinolone administered to patients with severe infections. Pharmacokinetic data on ofloxacin in critically ill patients on renal replacement therapy are sparse and conflicting. METHODS Eight patients with anuric acute renal failure were administered 400 mg of ofloxacin intravenously. The pharmacokinetics of ofloxacin was analyzed during continuous venovenous hemofiltration (CVVH) with a high-flux polysulfone membrane. Serum and ultrafiltrate levels of ofloxacin were measured by means of high-performance liquid chromatography. RESULTS Mean serum ofloxacin concentration peak was 5.5 +/- 0.7 mg/L. Elimination half-life, hemofiltration clearance, and total removal were 2.8 +/- 0.5 hours, 89.9 +/- 4.5 mL/min, and 76.9% +/- 7.1%, respectively. CONCLUSION Ofloxacin is significantly and rapidly eliminated by CVVH with a high-flux polysulfone membrane.
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Affiliation(s)
- Valentin Fuhrmann
- Department of Internal Medicine 4, Intensive Care Unit, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel, Vienna, Austria
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