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Molecular characterization and antibiotic resistance of Acinetobacter baumannii in cerebrospinal fluid and blood. PLoS One 2021; 16:e0247418. [PMID: 33617547 PMCID: PMC7899338 DOI: 10.1371/journal.pone.0247418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 02/07/2021] [Indexed: 01/22/2023] Open
Abstract
The increasing prevalence of carbapenem-resistant Acinetobacter baumannii (CRAB) caused nosocomial infections generate significant comorbidity and can cause death among patients. Current treatment options are limited. These infections pose great difficulties for infection control and clinical treatment. To identify the antimicrobial resistance, carbapenemases and genetic relatedness of Acinetobacter baumannii isolates from cerebrospinal fluid (CSF) and blood, a total of 50 nonrepetitive CSF isolates and 44 blood isolates were collected. The resistance phenotypes were determined, and polymerase chain reaction (PCR) was performed to examine the mechanisms of carbapenem resistance. Finally, multilocus sequence typing (MLST) was conducted to determine the genetic relatedness of these isolates. It was observed that 88 of the 94 collected isolates were resistant to imipenem or meropenem. Among them, the blaOXA-23 gene was the most prevalent carbapenemase gene, with an observed detection rate of 91.5% (86/94), followed by the blaOXA-24 gene with a 2.1% detection rate (2/94). Among all carbapenem-resistant Acinetobacter baumannii (CRAB) observations, isolates with the blaOXA-23 gene were resistant to both imipenem and meropenem. Interestingly, isolates positive for the blaOXA-24 gene but negative for the blaOXA-23 gene showed an imipenem-sensitive but meropenem-resistant phenotype. The MLST analysis identified 21 different sequence types (STs), with ST195, ST540 and ST208 most frequently detected (25.5%, 12.8% and 11.7%, respectively). 80 of the 94 isolates (85.1%) were clustered into CC92 which showed a carbapenem resistance phenotype (except AB13). Five novel STs were detected, and most of them belong to CRAB. In conclusion, these findings provide additional observations and epidemiological data of CSF and blood A. baumannii strains, which may improve future infection-control measures and aid in potential clinical treatments in hospitals and other clinical settings.
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Advancing pediatric antimicrobial stewardship: Has pharmacodynamic dosing for gram-negative infections taken effect? ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e61. [PMID: 36168509 PMCID: PMC9495429 DOI: 10.1017/ash.2021.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022]
Abstract
Objective: To characterize pharmacodynamic dosing strategies used at children’s hospitals using a national survey. Design: Survey. Setting: Children’s hospitals. Participants: Volunteer sample of antimicrobial stewardship program (ASP) respondents. Methods: A nationwide survey was conducted to gain greater insight into the current adoption of nontraditional dosing methods and monitoring of select β-lactam and fluoroquinolone antibiotics used to treat serious gram-negative infections in pediatric populations. The survey was performed through the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Results: Of the 75 children’s hospitals that responded, 68% of programs reported adoption of pharmacodynamically optimized dosing using prolonged β-lactam infusions and 35% using continuous β-lactam infusions, although use was infrequent. Factors including routine MIC monitoring and formal postgraduate training and board certification of ASP pharmacists were associated with increased utilization of pharmacodynamic dosing. In addition, 60% of programs reported using pharmacodynamically optimized ciprofloxacin and 14% reported using pharmacodynamically optimized levofloxacin. Only 20% of programs monitored β-lactam levels; they commonly cited lack of published guidance, practitioner experience, and laboratomory support as reasons for lack of utilization. Less physician time dedicated to ASP programs was associated with lower adoption of optimized dosing. Conclusions: Use of pharmacodynamic dosing through prolonged and continuous infusions of β-lactams have not yet been routinely adopted at children’s hospitals. Further guidance from trials and literature are needed to continue to guide pediatric pharmacodynamic dosing efforts. Children’s hospitals should utilize these data to compare practices and to prioritize further research and education efforts.
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Corcione S, Lupia T, Maraolo AE, Mornese Pinna S, Gentile I, De Rosa FG. Carbapenem-sparing strategy: carbapenemase, treatment, and stewardship. Curr Opin Infect Dis 2020; 32:663-673. [PMID: 31599774 DOI: 10.1097/qco.0000000000000598] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW describing the current role of carbapenems and carbapenem-sparing strategies in the setting of antimicrobial stewardship programs. RECENT FINDINGS sparing carbapenems with other drugs appears to be an interesting perspective for a variety of reasons in the current context of the multidrug-resistant (MDR) pandemic. Specific algorithms should also be precisely investigated to define better how to spare carbapenems within empiric and targeted regimens, with combination treatment or monotherapies, aiming at the best use of the new drugs and improving de-escalation as soon as possible for most of the patients. SUMMARY stewardship programs may be useful in reducing probable misuse and overuse of antibiotics, which has probably contributed to the emergence of carbapenem-resistant bacteria worldwide. The proposal of carbapenem-sparing strategies has then generated substantial scientific debate and, overall, the concept of sparing these drugs is well advocated together with judicious use of novel drugs, appropriate measures of infection control and prevention as well as in stewardship programs to curb the spread of MDR and XDR-strains in healthcare facilities.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
| | - Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
| | - Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Disease, University of Naples Federico II, Naples, Italy
| | | | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Disease, University of Naples Federico II, Naples, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin
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Huang C, Shi Q, Zheng B, Ji J, Ying C, Yu X, Wang H, Xiao Y. Simulating moxalactam dosage for extended-spectrum β-lactamase-producing Enterobacteriaceae using blood antimicrobial surveillance network data. Infect Drug Resist 2019; 12:1199-1208. [PMID: 31190908 PMCID: PMC6522843 DOI: 10.2147/idr.s193712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/11/2019] [Indexed: 11/28/2022] Open
Abstract
Objectives: Monte Carlo simulation (MCS) was used to evaluate optimal dosage for cefepime (FEP), moxalactam (MOX), and cefperazone/sulbactam (CFZ/SBT) against extended-spectrum β-lactamase (ESBL) producers isolated from the Blood Bacterial Resistant Investigation Collaborative System. Methods: Minimum inhibitory concentration (MIC) was tested by agar dilution, and ESBL producers were identified by modified Clinical and Laboratory Standards Institute tests. Pharmacokinetic parameters were derived from data on healthy individuals, and probability of target attainment (PTA) and cumulative fraction of response (CFR) %fT >MIC values were estimated by MCS. Results: A total of 2032 Escherichia coli (875 ESBL-producing) and Klebsiella pneumoniae (157 ESBL-producing) strains, and 371 other Enterobacteriaceae strains, were isolated from patients with bloodstream infections (BSIs). MIC90 values for FEP, MOX, and CFZ/SBT against ESBL-producing E. coli and K. pneumoniae were 64/64 mg/L, 2/32 mg/L, and 64/128 mg/L, respectively. Conventional MOX and CFZ/SBT doses failed to reach 90% PTA against isolates with MICs ≥8 mg/L and ≥4 mg/L, respectively. Against ESBL producers, neither FEP nor CFZ/SBT achieved ≥90% CFR, while CFRs for MOX (1 g iv q6h, 2 g iv q12h, and 2 g iv q8h) exceeded 90% against ESBL-producing E. coli. Simulated CFRs for FEP and MOX were similar (>90%) against non-ESBL-producing Enterobacteriaceae, and higher than CFRs for CFZ/SBT. Conclusion: ESBL producers from BSIs were highly susceptible to MOX, and PTA values were generally higher for MOX than FEP or CFZ/SBT for conventional dosing regimens. This large MCS analysis shows that MOX but not FEP or CFZ/SBT can be used empirically to treat BSIs caused by ESBL-producing E. coli strains.
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Affiliation(s)
- Chen Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China.,Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo, People's Republic of China
| | - Qingyi Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Beiwen Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Jinru Ji
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Chaoqun Ying
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Xiao Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
| | - Hui Wang
- Department of Respiratory Medicine, Lihuili Hospital, Ningbo Medical Center, Ningbo, People's Republic of China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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5
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Current opinions in the infection control of carbapenem-resistant Enterobacteriaceae species and Pseudomonas aeruginosa. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/mrm.0000000000000107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wilby KJ, Nasr ZG, Elazzazy S, Lau TTY, Hamad A. A Review of Clinical Outcomes Associated with Two Meropenem Dosing Strategies. Drugs R D 2017; 17:73-78. [PMID: 28101836 PMCID: PMC5318341 DOI: 10.1007/s40268-017-0173-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Meropenem is a carbapenem antibiotic that exhibits time-dependent bactericidal activity, traditionally dosed intravenously at 1 g every 8 h. In order to maximize its pharmacodynamic activity and reduce costs, an alternative regimen employed by many institutions is 500 mg every 6 h. The objective of this review was to summarize and evaluate published literature comparing clinical outcomes associated with these two meropenem dosing regimens. The literature was searched up to October 2016 using the MEDLINE, EMBASE, and Google Scholar databases. Three retrospective cohort studies were identified that compared clinical outcomes in general infectious disease patients (two studies) and patients with febrile neutropenia (one study). All studies reported no difference in clinical outcomes (clinical success, time to defervescence, sign or symptom resolution, length of stay, mortality, need for other antibiotics, and seizure rates). One study reported reduced economic costs with the alternative dosing. Interpretation of findings was primarily limited by small sample sizes and generalizability. Based on the data reviewed, the alternative dosing regimen of meropenem 500 mg intravenously every 6 h could be considered a therapeutic option. Future studies are needed to confirm the findings of this review, especially in high-risk populations such as immunocompromised patients or those with severe infections.
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Affiliation(s)
- Kyle John Wilby
- College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar.
| | | | - Shereen Elazzazy
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
| | - Tim T Y Lau
- Pharmaceutical Sciences, Vancouver General Hospital, 899 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, PO Box 3050, Doha, Qatar
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O’Donnell JN, Miglis CM, Lee JY, Tuvell M, Lertharakul T, Scheetz MH. Carbapenem susceptibility breakpoints, clinical implications with the moving target. Expert Rev Anti Infect Ther 2016; 14:389-401. [DOI: 10.1586/14787210.2016.1159131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Monogue ML, Kuti JL, Nicolau DP. Optimizing Antibiotic Dosing Strategies for the Treatment of Gram-negative Infections in the Era of Resistance. Expert Rev Clin Pharmacol 2016; 9:459-76. [DOI: 10.1586/17512433.2016.1133286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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9
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Schuck EL, Derendorf H. Pharmacokinetic/ pharmacodynamic evaluation of anti-infective agents. Expert Rev Anti Infect Ther 2014; 3:361-73. [PMID: 15954853 DOI: 10.1586/14787210.3.3.361] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pharmacokinetic/pharmacodynamic modeling has become an extremely important tool in evaluating and optimizing anti-infective therapy. By systematically linking the pharmacokinetic and pharmacodynamic properties of the anti-infective agent, it is possible to make educated decisions about the correct drug to be used, correct dosing regimen and to estimate the probability of success with the selected dose regimen. This article gives an overview of the current pharmacokinetic/pharmacodynamic approaches for anti-infective agents and discusses their use in optimizing drug therapy.
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Affiliation(s)
- Edgar L Schuck
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA.
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10
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Mazzei T. The pharmacokinetics and pharmacodynamics of the carbapanemes: focus on doripenem. J Chemother 2010; 22:219-25. [PMID: 20685624 DOI: 10.1179/joc.2010.22.4.219] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Carbapenems are the most potent group of beta-lactam agents, having a broad spectrum of bactericidal activity against both Gram-negative and Gram-positive bacteria including anaerobes. Doripenem is a new carbapenem endowed with excellent bactericidal activity, a wide spectrum of antibacterial activity against difficult nosocomial pathogens, including extended-spectrum beta-lactamase producers. Its high stability in solution render it extremely flexible for dosing and infusion time. It is the only carbapenem which has been registered officially for administration as an extended infusion of more than 4 hours, which can thus enhance its potential clinical efficacy against difficult bacterial pathogens with MICs of 4-8 mg/L.
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Affiliation(s)
- T Mazzei
- Department of Pharmacology, University of Florence, Florence, Italy.
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11
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Soga Y, Ohge H, Ikawa K, Morikawa N, Ikeda K, Sueda T. Peritoneal pharmacokinetics and pharmacodynamic target attainment of meropenem in patients undergoing abdominal surgery. J Chemother 2010; 22:98-102. [PMID: 20435568 DOI: 10.1179/joc.2010.22.2.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Although meropenem is commonly used for intra-abdominal infections, its penetration into the abdominal cavity is not well understood. Meropenem (500 mg) was administered intravenously to 8 patients with inflammatory bowel diseases undergoing laparotomy. The drug concentrations were analyzed and used for a Monte Carlo simulation with minimum inhibitory concentration (MIC) data. Meropenem concentrations in peritoneal fluid (PF) and plasma were similar at 1 h after the end of a 0.5-h infusion. The probabilities of target achievement of drug concentrations over the MIC in PF for 40% of the dosing interval with 500 mg every 8 h and 1000 mg every 8 h, were 84% and 90% against Bacteroides spp., 98% and 99% against Escherichia coli , and 76% and 83% against Pseudomonas aeruginosa, respectively. In conclusion, meropenem penetrated PF well, and 500 mg every 8 h or 1000 mg every 8 h would be suitable for the therapy for intraabdominal infections.
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Affiliation(s)
- Y Soga
- Department of Surgery, Graduate school of Biomedical Sciences, Hiroshima University, Japan
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12
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Frei CR, Burgess DS. Pharmacokinetic/pharmacodynamic modeling to predict in vivo effectiveness of various dosing regimens of piperacillin/tazobactam and piperacillin monotherapy against gram-negative pulmonary isolates from patients managed in intensive care units in 2002. Clin Ther 2008; 30:2335-41. [DOI: 10.1016/j.clinthera.2008.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
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13
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Slama TG. Clinical review: balancing the therapeutic, safety, and economic issues underlying effective antipseudomonal carbapenem use. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:233. [PMID: 18983709 PMCID: PMC2592734 DOI: 10.1186/cc6994] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antipseudomonal carbapenems have played a useful role in our antimicrobial armamentarium for 20 years. However, a review of their use during that period creates concern that their clinical effectiveness is critically dependent on attainment of an appropriate dosing range. Unfortunately, adequate carbapenem dosing is missed for many reasons, including benefit/risk misconceptions, a narrow therapeutic window for imipenem and meropenem (due to an increased rate of seizures at higher doses), increasingly resistant pathogens requiring higher doses than are typically given, and cost containment issues that may limit their use. To improve the use of carbapenems, several initiatives should be considered: increase awareness about appropriate treatment with carbapenems across hospital departments; determine optimal dosing regimens for settings where multidrug resistant organisms are more likely encountered; use of, or combination with, an alternative antimicrobial agent having more favorable pharmacokinetic, pharmacodynamic, or adverse event profile; and administer a newer carbapenem with lower propensity for resistance development (for example, reduced expression of efflux pumps or greater stability against carbapenemases).
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Affiliation(s)
- Thomas G Slama
- Department of Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana 46260, USA.
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14
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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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15
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Cheatham SC, Kays MB, Smith DW, Wack MF, Sowinski KM. Steady-State Pharmacokinetics and Pharmacodynamics of Meropenem in Hospitalized Patients. Pharmacotherapy 2008; 28:691-8. [DOI: 10.1592/phco.28.6.691] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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Ikawa K, Morikawa N, Sakamoto K, Ikeda K, Ohge H, Takesue Y, Sueda T. Pharmacokinetics and Pharmacodynamic Assessment of Imipenem in the Intraperitoneal Fluid of Abdominal Surgery Patients. Chemotherapy 2008; 54:131-9. [DOI: 10.1159/000118665] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 06/03/2007] [Indexed: 11/19/2022]
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Schmidt S, Schuck E, Kumar V, Burkhardt O, Derendorf H. Integration of pharmacokinetic/pharmacodynamic modeling and simulation in the development of new anti-infective agents – minimum inhibitory concentration versus time-kill curves. Expert Opin Drug Discov 2007; 2:849-60. [DOI: 10.1517/17460441.2.6.849] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Lodise TP, Lomaestro BM, Drusano GL. Application of antimicrobial pharmacodynamic concepts into clinical practice: focus on beta-lactam antibiotics: insights from the Society of Infectious Diseases Pharmacists. Pharmacotherapy 2007; 26:1320-32. [PMID: 16945055 DOI: 10.1592/phco.26.9.1320] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In recent years there have been tremendous strides in understanding the relationship between the pharmacodynamics of beta-lactams and microbiologic response. For beta-lactams, in vitro and animal studies suggest that the amount of time in which free or non-protein-bound antimicrobial concentration exceeds the minimum inhibitory concentration (MIC) of the organism (fT>MIC) is the best predictor of bacterial killing and microbiologic response. Using population pharmacokinetic modeling and Monte Carlo simulation, it is possible to integrate pharmacokinetics, a pharmacodynamic target, and microbiologic surveillance data to generate empiric beta-lactam dosing strategies that maximize the likelihood of achieving fT>MIC associated with near maximal bactericidal effect against the range of pathogens encountered in clinical practice. At Albany Medical Center Hospital, these mathematical modeling techniques were used to devise alternative dosing schemes for piperacillin-tazobactam, meropenem, and cefepime. These alternative schemes optimized fT>MIC at a lower total daily dose than would be employed with traditional dosing methods. Moreover, they achieved the targeted fT>MIC with less administration time/day than would be needed for continuous infusion.
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19
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Frei CR, Hampton SL, Burgess DS. Influence of culture site-specific MIC distributions on the pharmacokinetic and pharmacodynamic properties of piperacillin/tazobactam and piperacillin: a data analysis. Clin Ther 2006; 28:1035-40. [PMID: 16990081 DOI: 10.1016/j.clinthera.2006.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Investigators who perform pharmacokinetic/pharmacodynamic (PK-PD) modeling with Monte Carlo simulation have historically not stratified microbiological data by culture site. This lack of stratification might be problematic if susceptibility patterns differ among sites and might lead to differences in PK-PD. OBJECTIVE This study compared the PK-PD of 2 antimicrobial regimens against 5 gram-negative bacterial species form 3 culture sites. METHODS This data analysis was performed at the Department of Pharmacology, The University of Texas Health Science Center, San Antonio, Texas. Blood, pulmonary (ie, bronchial, endotracheal, lung, respiratory, sputum, and tracheal secretions), and wound distributions of MICs were extracted from the 2002 Intensive Care Unit Surveillance System database. Bacteria included Acinetobacter baumannii, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. The PK properties of piperacillin/tazobactam (3.375 g every 4 hours) and piperacillin (3 g every 4 hours) were obtained from studies in healthy volunteers. Monte Carlo simulation was used in 10,000 patients for each antimicrobial-bacteria-culture site combination. The cumulative fraction of response (CFR) for a free percentage time above the MIC of > or =50% was determined for each combination, and a clinically significant difference was defined a priori as > or =10%. RESULTS Data from 2408 pulmonary, 490 blood, and 242 wound isolates were included. For piperacillin/tazobactam, the CFR varied <10% by culture site in all 5 bacterial species. Site-specific differences were noted in MIC50 for piperacillin versus E cloacae and E coli and MIC90 for piperacillin/tazobactam versus K pneumoniae and P aeruginosa. Likewise, for piperacillin, the CFR was similar among the 3 culture sites for P aeruginosa. However, the CFR for piperacillin varied by > or =10% for A baumannii (blood > wound), E cloacae (pulmonary > blood), E coli (pulmonary and blood > wound), and K pneumoniae (wound > blood). CONCLUSIONS The PK-PD models based on PK properties found in healthy humans and site-specific MIC distributions in this study suggest that for piperacillin, culture-site differences subsequently resulted in CFR differences that exceeded a predetermined level of clinical significance. Furthermore, these data suggest that traditional reporting strategies for microbiological data (ie, MIC50 and MIC90) might fail to adequately characterize the MIC population.
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20
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Tam VH, Kabbara S. Comparative performance of different stochastic methods to simulate drug exposure and variability in a population. Diagn Microbiol Infect Dis 2006; 56:185-8. [PMID: 16930922 DOI: 10.1016/j.diagmicrobio.2006.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Revised: 06/17/2006] [Accepted: 06/20/2006] [Indexed: 12/01/2022]
Abstract
Monte Carlo simulations (MCSs) are increasingly being used to predict the pharmacokinetic variability of antimicrobials in a population. However, various MCS approaches may differ in the accuracy of the predictions. We compared the performance of 3 different MCS approaches using a data set with known parameter values and dispersion. Ten concentration-time profiles were randomly generated and used to determine the best-fit parameter estimates. Three MCS methods were subsequently used to simulate the AUC(0-infinity) of the population, using the central tendency and dispersion of the following in the subject sample: 1) K and V; 2) clearance and V; 3) AUC(0-infinity). In each scenario, 10000 subject simulations were performed. Compared to true AUC(0-infinity) of the population, mean biases by various methods were 1) 58.4, 2) 380.7, and 3) 12.5 mg h L(-1), respectively. Our results suggest that the most realistic MCS approach appeared to be based on the variability of AUC(0-infinity) in the subject sample.
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Affiliation(s)
- Vincent H Tam
- Department of Clinical Sciences and Administration, University of Houston College of Pharmacy, Houston, TX 77030, USA
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21
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Ellis JM, Kuti JL, Nicolau DP. Pharmacodynamic evaluation of meropenem and cefotaxime for pediatric meningitis: a report from the OPTAMA program. Paediatr Drugs 2006; 8:131-8. [PMID: 16608373 DOI: 10.2165/00148581-200608020-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To determine the probability of meropenem (Merrem, AstraZeneca Pharmaceuticals L.P., Wilmington, DE, USA) and cefotaxime (Claforan, Aventis Pharmaceuticals Inc., Bridgewater, NJ, USA) achieving bactericidal exposures in the cerebrospinal fluid against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. METHODS A 5,000-patient Monte Carlo simulation in a population of 10-year-old children with meningitis was conducted. Pediatric pharmacokinetic data were derived from the literature. Pathogen minimum inhibitory concentrations (MICs) were obtained from common bacteria that had caused meningitis collected during pediatric clinical trials. Time above the MIC exposures in the cerebrospinal fluid was calculated. Bactericidal exposure or probability of target attainment was defined as 40% and 50% time above the MIC for meropenem and cefotaxime, respectively. High cumulative fractions of responses were defined as >90% probability of target attainment against the populations of bacteria. RESULTS Meropenem was calculated to achieve 94.7%, 94.3%, and 96.1% cumulative fractions of response against S. pneumoniae, H. influenzae, and N. meningitidis, respectively. Cefotaxime only achieved a high likelihood of bactericidal attainment against N. meningitidis (91.6%). Against S. pneumoniae and H. influenzae, cefotaxime was only calculated to achieve 84.3% and 84.8% cumulative fractions of response, respectively. CONCLUSION In a simulated population of 10-year-old children, meropenem had a high likelihood of attaining bactericidal exposures in the cerebrospinal fluid. Cefotaxime had a >90% cumulative fraction of response against only N. meningitidis. Therefore, at the doses simulated, meropenem may be a more appropriate empiric choice for the treatment of bacterial meningitis in pediatric patients presumed to be caused by these pathogens until culture and susceptibility data are available.
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Affiliation(s)
- Jennifer M Ellis
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, USA
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Tam VH, Kabbara S, Yeh RF, Leary RH. Impact of sample size on the performance of multiple-model pharmacokinetic simulations. Antimicrob Agents Chemother 2006; 50:3950-2. [PMID: 16954312 PMCID: PMC1635223 DOI: 10.1128/aac.00337-06] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Monte Carlo simulations are increasingly used to predict pharmacokinetic variability of antimicrobials in a population. We investigated the sample size necessary to provide robust pharmacokinetic predictions. To obtain reasonably robust predictions, a nonparametric model derived from a sample population size of >/=50 appears to be necessary as the input information.
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Affiliation(s)
- Vincent H Tam
- University of Houston College of Pharmacy, 1441 Moursund Street, Houston, TX 77030, USA.
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Kuti JL, Horowitz S, Nightingale CH, Nicolau DP. Comparison of pharmacodynamic target attainment between healthy subjects and patients for ceftazidime and meropenem. Pharmacotherapy 2005; 25:935-41. [PMID: 16006272 DOI: 10.1592/phco.2005.25.7.935] [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] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To compare the pharmacodynamics of two beta-lactams--ceftazidime and meropenem--in healthy subjects versus patients. DESIGN Monte Carlo simulation based on published pharmacokinetic studies. SUBJECTS One hundred and ninety-seven participants (75 healthy volunteers and 122 patients) from published pharmacokinetic studies of ceftazidime or meropenem. MEASUREMENTS AND MAIN RESULTS Data on total body clearance and volume of distribution for ceftazidime and meropenem in healthy subjects and patients were obtained from published studies. Monte Carlo simulations were performed based on the pharmacokinetics from each study for ceftazidime 1000 mg every 8 hours and meropenem 1000 mg every 8 hours against isolates of Escherichia coli , Klebsiella pneumoniae , Acinetobacter baumannii , and Pseudomonas aeruginosa collected from North and South America. We calculated the likelihood of obtaining bactericidal exposures (50% time above the minimum inhibitory concentration [MIC] for ceftazidime and 40% time above the MIC for meropenem) for each combination of pharmacokinetic study data and MIC distribution. Linear regression was used to compare target attainments for healthy subjects versus patients. Only three drug-pathogen combinations differed in target attainment between healthy subjects and patients: ceftazidime against P. aeruginosa in North America and meropenem against E. coli and P. aeruginosa in South America. The regression line of target attainment for patients versus healthy subjects had a slope of 1.04 (95% confidence interval [CI] 0.983-1.093) and a y intercept of -3.73 (95% CI -8.265-0.827, r2 = 0.992). The beta values for slope and intercept did not differ to a statistically significant extent between the regression line and the line of identity (p=0.264). CONCLUSION The pharmacodynamic target attainment calculated with healthy subject pharmacokinetic data was predictive of patient target target attainment for ceftazidime and meropenem.
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Affiliation(s)
- Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut 06102, USA
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Tellado JM, Wilson SE. Empiric Treatment of Nosocomial Intra-Abdominal Infections: A Focus on the Carbapenems. Surg Infect (Larchmt) 2005; 6:329-43. [PMID: 16201943 DOI: 10.1089/sur.2005.6.329] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Serious nosocomial intra-abdominal infections are associated with high morbidity and mortality and represent a substantial drain on healthcare resources. Effective management of this type of infection requires the early use of appropriate, broad-spectrum empiric antimicrobial therapy. The consequences of delayed or inappropriate antimicrobial treatment can be severe-leading to an increased risk of death, re-operation, or prolonged hospitalization. Therefore, it is necessary to begin treatment as soon as possible with the most appropriate regimen, in terms of spectrum, timing, and duration. METHODS Review of pertinent English-language literature. RESULTS Serious nosocomial intra-abdominal infections require broad-spectrum coverage because of the wide range of possible pathogens, which include difficult-to-treat organisms such as Pseudomonas aeruginosa and Bacteroides spp., and resistant strains of Klebsiella spp., Escherichia coli, and methicillin-resistant Staphylococcus aureus acquired from the hospital flora. The early use of appropriate, broad-spectrum empiric antimicrobial therapy for treating high-risk patients with intra-abdominal infections is considered, and appropriate use of the carbapenems, meropenem, and imipenem/cilastatin, is described. CONCLUSION The carbapenems meropenem and imipenem/cilastatin have a spectrum of antimicrobial activity that covers the majority of expected pathogens, including anaerobes, as well as difficult-to-treat and resistant gram-negative strains. Early and appropriate use can reduce mortality and morbidity. Data from published clinical trials support the clinical effectiveness of these two carbapenems in intra-abdominal infections.
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Affiliation(s)
- Jose M Tellado
- Department of Surgery CGI, Hospital Universitario Gregorio Marañon, Madrid, Spain. jtellado.hgugm@salud
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Lodise TP, Lomaestro B, Rodvold KA, Danziger LH, Drusano GL. Pharmacodynamic profiling of piperacillin in the presence of tazobactam in patients through the use of population pharmacokinetic models and Monte Carlo simulation. Antimicrob Agents Chemother 2005; 48:4718-24. [PMID: 15561849 PMCID: PMC529233 DOI: 10.1128/aac.48.12.4718-4724.2004] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The primary objectives of this analysis were to determine which pharmacokinetic model most accurately describes the elimination pathways for piperacillin in the presence of tazobactam through population pharmacokinetic modeling and to characterize its pharmacodynamic profile. Once the optimal pharmacokinetic model was identified, Monte Carlo simulation of 10,000 subjects with ADAPT II was performed to estimate the probability of attaining a target free-piperacillin concentration greater than the MIC for 50% of the dosing interval for 3.375 g every 6 h or every 4 h given as a 0.5-h infusion at each MIC between 0.25 and 32 microg/ml. In the population pharmacokinetic analysis, measurements of bias and precision, observed-predicted plots, and r2 values were highly acceptable for all three models and all three models were appropriate candidates for the Monte Carlo simulation evaluation. Visual comparison of the distribution of the piperacillin concentrations at the pharmacodynamic endpoint--h 3 concentrations of a 6-h dosing interval--between the simulated populations and raw data revealed that the linear model was most reflective of the raw data at the pharmacodynamic endpoint, and the linear model was therefore selected for the target attainment analysis. In the target attainment analysis, administration of 3 g of piperacillin every 6 h resulted in a robust target attainment rate that exceeded 95% for MICs of < or =8 mg/liter. The 4-h piperacillin administration interval had a superior pharmacodynamic profile and provided target attainment rates exceeding 95% for MICs of < or =16 mg/liter. This study indicates that piperacillin-tazobactam should have utility for empirical therapy of hospital-onset infections.
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Kuti JL, Nightingale CH, Nicolau DP. Optimizing pharmacodynamic target attainment using the MYSTIC antibiogram: data collected in North America in 2002. Antimicrob Agents Chemother 2004; 48:2464-70. [PMID: 15215095 PMCID: PMC434188 DOI: 10.1128/aac.48.7.2464-2470.2004] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The OPTAMA Program is intended to examine typical antimicrobial regimens used in the treatment of common nosocomial pathogens and the likelihood of these regimens attaining appropriate pharmacodynamic exposure in different parts of the world. A 5,000-subject Monte Carlo simulation was used to estimate pharmacodynamic target attainment for meropenem, imipenem, ceftazidime, cefepime, piperacillin-tazobactam, and ciprofloxacin against Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. Standard dosing regimens from North America were used. Pharmacokinetic parameter variability was derived from existing healthy volunteer data, and MIC data came from the 2002 MYSTIC Program. Ciprofloxacin displayed the lowest target attainment against all bacterial species (41 to 46% for A. baumannii, 53 to 59% for P. aeruginosa, and 80 to 85% for the Enterobacteriaceae). Increasing the dose to 400 mg every 8 h did not significantly increase target attainment against nonfermenters. Piperacillin-tazobactam target attainments were similar to that of ceftazidime against all pathogens. Higher doses of both compounds were needed to achieve better target attainments against P. aeruginosa. Overall, meropenem, imipenem, and cefepime attained the highest probabilities of attainment against the Enterobacteriaceae (99 to 100%). The carbapenems appear to be the most useful agents against A. baumannii (88 to 92%), and these agents, along with higher doses of any of the beta-lactams, would be the most appropriate choices for empirical therapy for P. aeruginosa infection. Given the lack of agreement between percent susceptibility and probability of target attainment for certain antimicrobial regimens, a methodology employing stochastic pharmacodynamic analyses may be a more useful tool for differentiating the most-optimal compounds and dosing regimens in the clinical setting of initial empirical therapy.
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Affiliation(s)
- Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, 80 Seymour St., P.O. Box 5037, Hartford, CT 06102, USA
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Mattoes HM, Kuti JL, Drusano GL, Nicolau DP. Optimizing antimicrobial pharmacodynamics: dosage strategies for meropenem. Clin Ther 2004; 26:1187-98. [PMID: 15476901 DOI: 10.1016/s0149-2918(04)80001-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2004] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Carbapenems are broad-spectrum antibiotics that are often employed as the last line of therapy for patients with nonresponsive nosocomial infections. Consideration of pharmacodynamic principles in dosage regimens for these agents can maximize their antibacterial effectiveness and reduce the number of bacterial strains that survive to mutate or continue infection. OBJECTIVE The objectives of this review were to highlight examples of the application of pharmacodynamics to the carbapenems (particularly meropenem) and to comment on clinical utility of these dosage regimens. METHODS Relevant information was identified through a MEDLINE search of the literature (1980-present) using the terms carbapenem, pharmacodynamic, pharmacokinetic, pharmacoeconomic, meropenem, imipenem, ertapenem, biapenem, and panipenem. Additionally, meeting posters were identified from the International Conference of Antimicrobial Agents and Chemotherapy (years 2001-2003) and the International Conference of the American Thoracic Society (years 2002-2003). All studies demonstrating the pharmacodynamics of the carbapenems by incorporating changes in dosage strategies were included. RESULTS Only relevant data for meropenem were identified in our literature search. The dosage scheme for meropenem may be modified to maximize the percentage of the dosage interval that drug concentrations remain above the minimum inhibitory concentration, an important parameter related to the bacterial kill rate. Only relevant data for meropenem were identified in our literature search. Human volunteer and Monte Carlo simulation studies suggested that in the treatment of susceptible pathogens, higher meropenem doses, increased frequency of administration, or prolonged duration of infusion resulted in improved pharmacodynamics. CONCLUSION When proper pharmacodynamic principles are applied to dosage strategies for meropenem, clinical and microbiological outcomes can be optimized.
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Affiliation(s)
- Holly M Mattoes
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut 06102, USA
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