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Junior RM, Hosawi A, Girdwood ST, Dong M, Juodinis VD, Romano P, Ebner PDAR, Duarte NJC, de Souza DC, Santos SRCJ. Optimizing Piperacillin Dosing in Pediatric Liver Transplant Recipients: A Case Series. Pediatr Transplant 2024; 28:e14860. [PMID: 39319995 PMCID: PMC11433544 DOI: 10.1111/petr.14860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 08/12/2024] [Accepted: 09/06/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Pathophysiological changes post-liver transplantation impact the pharmacokinetics and pharmacodynamics of antibiotics. Piperacillin, often used in combination with tazobactam, is a key antibiotic after transplantation to its broad-spectrum activity, but there is a lack of specific pharmacokinetic data in this population. This study aims to describe the pharmacokinetic parameters and target attainment of piperacillin in pediatric liver transplant recipients. METHODS Patients with preserved renal function (estimated glomerular filtration rate > 50 mL/min/1.73 m2) receiving intravenous piperacillin-tazobactam at 112.5 mg/kg every 8 h (100 mg piperacillin/12.5 mg tazobactam), with a rapid infusion (0.5-1 h), were included. Two blood samples per child were collected during the same interval within 48 h of starting therapy. A Bayesian approach was applied to estimate individual pharmacokinetic parameters and perform dosing recommendations against Enterococcus spp., Enterobacterales and Pseudomonas aeruginosa. RESULTS Eight patients with median age of 8 months were included. Median piperacillin clearance and central volume of distribution for the cohort were 11.11 L/h/70 kg and 9.80 L/70 kg, respectively. Seven patients (87.5%) presented with concentrations below the target of 100% fT > MIC. Simulations suggested that these patients required more frequent dosing and extended duration of infusion to ensure target attainment. One patient (12.5%) had trough concentrations that exceed 16 mg/L and could receive a lower daily dose. CONCLUSIONS This case series highlights the importance of personalized therapy in pediatric liver transplant recipients due to the unpredictable and highly variable piperacillin pharmacokinetics in this population.
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Affiliation(s)
- Ronaldo Morales Junior
- Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, SP, Brazil
- Pediatric Unit, Hospital Sírio-libanês, São Paulo, SP, Brazil
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Anhar Hosawi
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pharmacology and Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - Sonya Tang Girdwood
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Min Dong
- Division of Translational and Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | - Paschoalina Romano
- Central Laboratory Division & Medical Investigation Laboratory, Medical School, University of Sao Paulo, São Paulo, SP, Brazil
| | - Pérsio de Almeida Rezende Ebner
- Central Laboratory Division & Medical Investigation Laboratory, Medical School, University of Sao Paulo, São Paulo, SP, Brazil
| | - Nilo José Coelho Duarte
- Central Laboratory Division & Medical Investigation Laboratory, Medical School, University of Sao Paulo, São Paulo, SP, Brazil
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Butler DA, Patel N, O'Donnell JN, Lodise TP. Combination therapy with IV fosfomycin for adult patients with serious Gram-negative infections: a review of the literature. J Antimicrob Chemother 2024:dkae253. [PMID: 39215642 DOI: 10.1093/jac/dkae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Treatment of patients with serious infections due to resistant Gram-negative bacteria remains highly problematic and has prompted clinicians to use existing antimicrobial agents in innovative ways. One approach gaining increased therapeutic use is combination therapy with IV fosfomycin. This article reviews the preclinical pharmacokinetic/pharmacodynamic (PK/PD) infection model and clinical data surrounding the use of combination therapy with IV fosfomycin for the treatment of serious infections caused by resistant Gram-negative bacteria. Data from dynamic in vitro and animal infection model studies of highly resistant Enterobacterales and non-lactose fermenters are positive and suggest IV fosfomycin in combination with a β-lactam, polymyxin or aminoglycoside produces a synergistic effect that rivals or surpasses that of other aminoglycoside- or polymyxin-containing regimens. Clinical studies performed to date primarily have involved patients with pneumonia and/or bacteraemia due to Klebsiella pneumoniae, Pseudomonas aeruginosa or Acinetobacter baumannii. Overall, the observed success rates with fosfomycin combination regimens were consistent with those reported for other combination regimens commonly used to treat these patients. In studies in which direct treatment comparisons can be derived, the results suggest that patients who received fosfomycin combination therapy had similar or improved outcomes compared with other therapies and combinations, especially when it was used in combination with a β-lactam that (1) targets PBP-3 and (2) has exceptional stability in the presence of β-lactamases. Collectively, the data indicate that combination therapy with IV fosfomycin should be considered as a potential alternative to aminoglycoside or polymyxin combinations for patients with antibiotic-resistant Gram-negative infections when benefits outweigh risks.
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Affiliation(s)
- David A Butler
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY 12208, USA
| | - Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, 9255 Pharmacy Lane, La Jolla, CA, USA
| | - J Nicholas O'Donnell
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY 12208, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, 106 New Scotland Avenue, Albany, NY 12208, USA
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3
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Carson AA, Bowker KE, Attwood M, Noel AR, MacGowan AP. Pharmacodynamics of piperacillin/tazobactam against Pseudomonas aeruginosa: antibacterial effect and risk of emergence of resistance. JAC Antimicrob Resist 2024; 6:dlae108. [PMID: 39005592 PMCID: PMC11242448 DOI: 10.1093/jacamr/dlae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Affiliation(s)
- Amy A Carson
- Infection Sciences, Pathology Quarter, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Karen E Bowker
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Severn Infection Sciences, Pathology Quarter, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Marie Attwood
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Severn Infection Sciences, Pathology Quarter, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Alan R Noel
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Severn Infection Sciences, Pathology Quarter, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Alasdair P MacGowan
- Bristol Centre for Antimicrobial Research & Evaluation (BCARE), Severn Infection Sciences, Pathology Quarter, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
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Huynh D, Tung N, Dam Q, Tran T, Hulten KG, Harrison CJ, Kaplan SL, Nguyen A, Do TH, Setty A, Le J. Amoxicillin and penicillin G dosing in pediatric community-acquired pneumococcal pneumonia in the era of conjugate pneumococcal vaccines. Pharmacotherapy 2024; 44:606-614. [PMID: 36571459 DOI: 10.1002/phar.2756] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Parenteral penicillin G (PENG) and oral amoxicillin (AMOX) are recommended as treatment for pediatric community-acquired pneumonia (CAP). With recent epidemiologic penicillin susceptibility data for Streptococcus pneumoniae, the most common etiology of CAP, the objective of this study was to evaluate optimal dosing regimens of PENG and AMOX based on population pharmacokinetics linked to current susceptibility data. METHODS Using NONMEM v7.3, Monte Carlo simulations (N = 10,000) were conducted for AMOX 15 mg/kg/dose PO every 8 h (standard-dose), AMOX 45 mg/kg/dose PO every 12 h (high-dose), and PENG 62,500 units/kg/day IV every 6 h using six virtual subjects with ages spanning 3 months to 15 years old. The probability of target attainment (PTA) was determined for both serum and epithelial lining fluid (ELF) to achieve free drug concentrations above the minimum inhibitory concentration (%fT>MIC) across the population of pneumococci for 30%-50% of the dosing interval. RESULTS In 2018, all 21 (100%) pneumococcal isolates were susceptible to both PENG and AMOX based on Clinical and Laboratory Standards Institute (CLSI; MIC at 2 mg/L) breakpoints, and 15 of 21 (71%) were susceptible based on EUCAST (MIC at 0.5 mg/L) breakpoints. As compared to CLSI, EUCAST breakpoints consistently achieved higher PTA for all antibiotic regimens. At 50% fT>MIC in the serum at the susceptible MICs, standard-dose AMOX achieved >4% PTA (CLSI) and >86% PTA (EUCAST); high-dose AMOX achieved >73% PTA (CLSI) and >99% PTA (EUCAST); and PENG achieved 0% PTA (using CLSI) and 100% PTA (using EUCAST). Standard-dose AMOX, high-dose AMOX, and PENG achieved >71%, >93%, and 100% PTA, respectively, in the serum at 30%-50% fT>MIC when each patient was stochastically linked to an MIC based on the frequency distribution of national susceptibility data. The PTA was consistently lower in ELF as compared with serum for all regimens. CONCLUSION Based on the recent rates of resistance, antibiotic doses evaluated provide appropriate exposure for pediatric CAP based on the serum and ELF data associated with predicted clinical and microbiologic success for pneumococcus. High-dose AMOX may still be required to treat pediatric CAP, especially if using CLSI breakpoints. Ongoing surveillance for resistance is essential.
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Affiliation(s)
- Dustin Huynh
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
| | - Norint Tung
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
| | - Quang Dam
- Miller Children's and Women's Hospital of Long Beach, Long Beach, California, USA
| | - Tri Tran
- School of Medicine, University of California Riverside, Riverside, California, USA
| | - Kristina G Hulten
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher J Harrison
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Sheldon L Kaplan
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Allison Nguyen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
| | - Tyler H Do
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
| | - Amartya Setty
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, San Diego, California, USA
- Miller Children's and Women's Hospital of Long Beach, Long Beach, California, USA
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Collignon C, Benaboud S, Gana I, Bendavid M, Fournier B, Oualha M, de Marcellus C. Pharmacokinetic of ceftazidime-avibactam in a critically ill patient under high-volume continuous venovenous haemodiafiltration: A first paediatric case report. Br J Clin Pharmacol 2024; 90:890-894. [PMID: 38178624 DOI: 10.1111/bcp.15993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/01/2023] [Accepted: 12/16/2023] [Indexed: 01/06/2024] Open
Abstract
Ceftazidime-avibactam is a novel cephalosporin/B-lactamase inhibitor developed in the context of increasing resistance. This case reports the pharmacokinetics of ceftazidime-avibactam in a critically ill child under continuous renal replacement (CRRT) therapy for fluid overload. The patient was a 6-month-old female with sepsis due to bloodstream infection to Stenotrophomonas maltophilia following stem cell transplantation for severe combined immunodeficiency. CRRT was started on Day 2. Concentrations have been monitored using liquid chromatography-tandem mass spectrometry. Treatment was given every 8 h with a 2 h infusion of 30-7,5 mg/kg and did not reach pharmacokinetic/pharmacodynamic targets. Total clearance was respectively 1.7 and 3.02 L/h, with CRRT clearance respectively 28.8%-60% for ceftazidime and 14%-33% for avibactam. Those clearances are higher than reported in adult literature leading to a risk of treatment failure and emerging resistance. This supports the benefit of monitoring antimicrobial therapy under CRRT and the necessity to assess higher dosing or continuous infusion of ceftazidime-avibactam.
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Affiliation(s)
- Charlotte Collignon
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, Paris, France
| | - Sihem Benaboud
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Department of Clinical Pharmacology, Cochin Hospital, Paris Descartes University, Paris Descartes University, Paris, France
| | - Inès Gana
- Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Department of Clinical Pharmacology, Cochin Hospital, Paris Descartes University, Paris Descartes University, Paris, France
| | - Matthieu Bendavid
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, Paris, France
| | - Benjamin Fournier
- Pediatric Hematology-Immunology and Rheumatology Unit, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Charles de Marcellus
- Pediatric Intensive Care Unit, APHP University Hospital Necker-Enfants Malades, Paris, France
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6
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Garavaglia J, Hardigan T, Turner R, Monachello G, Khan MB, Hodge JO, Brandmeir NJ. Continuous Intrathecal Medication Delivery With the IRRA flow Catheter: Pearls and Early Experience. Oper Neurosurg (Hagerstown) 2024; 26:293-300. [PMID: 37819074 DOI: 10.1227/ons.0000000000000940] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intrathecal (IT) medications are routinely introduced through catheterization of the intraventricular space or subarachnoid space. There has been sporadic use of IT medications delivered directly to the ventricle either by intermittent injection through an external ventricular drain (EVD) or by an Ommaya reservoir with a ventricular catheter. IT medication delivery through EVD has many drawbacks, including the necessary opening of a sterile system, delivery of medication in a bolus form, and requirements to clamp the EVD after medication delivery. Despite these setbacks, IT medications delivered through EVD have been used across a wide range of applications, including antibiotic delivery treatment of vasospasm with nicardipine and delivery of tissue plasminogen activator. METHODS We used a newly developed active fluid exchange device to treat various severe conditions involved in the cerebral ventricles. Here, we present our treatment protocols and advice on the techniques related to successful active fluid exchange therapy. RESULTS Seventy patients have been treated with our system with various conditions, including subarachnoid hemorrhage, intraventricular hemorrhage, ventriculitis, and cerebral abscess. Total complication rate was 14% with only 1 catheter occlusion and low rates of hemorrhage, infection, and spinal fluid leak. CONCLUSION Current continuous IT medication dosages and protocols are based on reports and consensus statements evaluating intermittent instillation of medication boluses. The pharmacokinetics of continuous dosing and the therapeutic and safety profiles of the medications need to be studied in a prospective manner to evaluate the true optimal dosing standards. Furthermore, the ability to deliver continuous, sterile medications directly through an IT route will open new avenues of pharmacotherapy that were previously closed. This report serves as a basic guide for the safe and effective use of the IRRA flow active fluid exchange catheter to deliver IT medications.
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Affiliation(s)
- Jeffrey Garavaglia
- Department of Pharmacy, Ruby Memorial Hospital, West Virginia University, Morgantown , West Virginia, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Mt. Sinai Hospital, New York City , New York , USA
| | - Ryan Turner
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Gracie Monachello
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Muhammad Babar Khan
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Johnie O Hodge
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Rockefeller Neuroscience Institute, West Virginia University, Morgantown , West Virginia , USA
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7
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Andrianopoulou A, Sokolowski K, Wenzler E, Bulman ZP, Gemeinhart RA. Assessment of antibiotic release and antibacterial efficacy from pendant glutathione hydrogels using ex vivo porcine skin. J Control Release 2024; 365:936-949. [PMID: 38070603 PMCID: PMC10843833 DOI: 10.1016/j.jconrel.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/22/2023] [Accepted: 12/03/2023] [Indexed: 12/22/2023]
Abstract
Acute bacterial skin and skin structure infections (ABSSSIs) confer a substantial burden on the healthcare system. Local antibiotic delivery systems can provide controlled drug release directly to the site of infection to maximize efficacy and minimize systemic toxicity. The purpose of this study was to examine the antibacterial activity of antibiotic-loaded glutathione-conjugated poly(ethylene glycol) hydrogels (GSH-PEG) against ABSSSIs utilizing an ex vivo porcine dermal explant model. Vancomycin- or meropenem-loaded GSH-PEG hydrogels at 3 different dose levels were loaded over 1 h. Drug release was monitored in vitro under submerged conditions, by the Franz cell diffusion method, and ex vivo utilizing a porcine dermis model. Antibacterial activity was assessed ex vivo on porcine dermis explants inoculated with Staphylococcus aureus or Pseudomonas aeruginosa isolates treated with vancomycin- or meropenem-loaded GSH-PEG hydrogels, respectively. Histological assessment of the explants was conducted to evaluate tissue integrity and viability in the context of the experimental conditions. A dose-dependent release was observed from vancomycin and meropenem hydrogels, with in vitro Franz cell diffusion data closely representing ex vivo vancomycin release, but not high dose meropenem release. High dose vancomycin-loaded hydrogels resulted in a >3 log10 clearance against all S. aureus isolates at 48 h. High dose meropenem-loaded hydrogels achieved 6.5, 4, and 2 log10 reductions in CFU/ml against susceptible, intermediate, and resistant P. aeruginosa isolates, respectively. Our findings demonstrate the potential application of GSH-PEG hydrogels for flexible, local antibiotic delivery against bacterial skin infections.
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Affiliation(s)
| | - Karol Sokolowski
- Department of Pharmaceutical Sciences, University of Illinois Chicago, Chicago, IL, USA
| | - Eric Wenzler
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
| | - Zackery P Bulman
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL, USA
| | - Richard A Gemeinhart
- Department of Pharmaceutical Sciences, University of Illinois Chicago, Chicago, IL, USA; Department of Biomedical Engineering, University of Illinois Chicago, Chicago, IL, USA; Department of Chemical Engineering, University of Illinois Chicago, Chicago, IL, USA; Department of Ophthalmology and Visual Sciences, University of Illinois Chicago, Chicago, IL, USA.
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Gras E, Vu TTT, Nguyen NTQ, Tran VG, Mao Y, Tran ND, Mai NH, Dong OX, Jung DH, Iorio NLPP, Povoa HCC, Pinheiro MG, Aguiar-Alves F, Weiss WJ, Zheng B, Cheng LI, Stover CK, Sellman BR, DiGiandomenico A, Gibault L, Valour F, Diep BA. Development and validation of a rabbit model of Pseudomonas aeruginosa non-ventilated pneumonia for preclinical drug development. Front Cell Infect Microbiol 2023; 13:1297281. [PMID: 38149013 PMCID: PMC10750358 DOI: 10.3389/fcimb.2023.1297281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023] Open
Abstract
Background New drugs targeting antimicrobial resistant pathogens, including Pseudomonas aeruginosa, have been challenging to evaluate in clinical trials, particularly for the non-ventilated hospital-acquired pneumonia and ventilator-associated pneumonia indications. Development of new antibacterial drugs is facilitated by preclinical animal models that could predict clinical efficacy in patients with these infections. Methods We report here an FDA-funded study to develop a rabbit model of non-ventilated pneumonia with Pseudomonas aeruginosa by determining the extent to which the natural history of animal disease reproduced human pathophysiology and conducting validation studies to evaluate whether humanized dosing regimens of two antibiotics, meropenem and tobramycin, can halt or reverse disease progression. Results In a rabbit model of non-ventilated pneumonia, endobronchial challenge with live P. aeruginosa strain 6206, but not with UV-killed Pa6206, caused acute respiratory distress syndrome, as evidenced by acute lung inflammation, pulmonary edema, hemorrhage, severe hypoxemia, hyperlactatemia, neutropenia, thrombocytopenia, and hypoglycemia, which preceded respiratory failure and death. Pa6206 increased >100-fold in the lungs and then disseminated from there to infect distal organs, including spleen and kidneys. At 5 h post-infection, 67% of Pa6206-challenged rabbits had PaO2 <60 mmHg, corresponding to a clinical cut-off when oxygen therapy would be required. When administered at 5 h post-infection, humanized dosing regimens of tobramycin and meropenem reduced mortality to 17-33%, compared to 100% for saline-treated rabbits (P<0.001 by log-rank tests). For meropenem which exhibits time-dependent bactericidal activity, rabbits treated with a humanized meropenem dosing regimen of 80 mg/kg q2h for 24 h achieved 100% T>MIC, resulting in 75% microbiological clearance rate of Pa6206 from the lungs. For tobramycin which exhibits concentration-dependent killing, rabbits treated with a humanized tobramycin dosing regimen of 8 mg/kg q8h for 24 h achieved Cmax/MIC of 9.8 ± 1.4 at 60 min post-dose, resulting in 50% lung microbiological clearance rate. In contrast, rabbits treated with a single tobramycin dose of 2.5 mg/kg had Cmax/MIC of 7.8 ± 0.8 and 8% (1/12) microbiological clearance rate, indicating that this rabbit model can detect dose-response effects. Conclusion The rabbit model may be used to help predict clinical efficacy of new antibacterial drugs for the treatment of non-ventilated P. aeruginosa pneumonia.
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Affiliation(s)
- Emmanuelle Gras
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Université François Rabelais, Tours, France
| | - Trang T. T. Vu
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Nhu T. Q. Nguyen
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Vuvi G. Tran
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Yanjie Mao
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Nguyen D. Tran
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nam H. Mai
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Oliver X. Dong
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - David H. Jung
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Natalia L. P. P. Iorio
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Basic Science, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | - Helvecio C. C. Povoa
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Basic Science, Fluminense Federal University, Nova Friburgo, Rio de Janeiro, Brazil
| | - Marcos Gabriel Pinheiro
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Fabio Aguiar-Alves
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Pathology Program, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
| | - William J. Weiss
- Pre-Clinical Services at UNT Health Science Center, Fort Worth, TX, United States
| | - Bo Zheng
- Clinical Pharmacology & DMPK, AstraZeneca, Gaithersburg, MD, United States
| | - Lily I. Cheng
- Early Vaccines and Immune Therapies, AstraZeneca, Gaithersburg, MD, United States
| | - Charles K. Stover
- Early Vaccines and Immune Therapies, AstraZeneca, Gaithersburg, MD, United States
| | - Bret R. Sellman
- Early Vaccines and Immune Therapies, AstraZeneca, Gaithersburg, MD, United States
| | | | - Laure Gibault
- Pathology Department, George Pompidou European Hospital, Paris, France
| | - Florent Valour
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
- Department of Infectious Diseases, Hospices Civils de Lyon, Lyon, France
- CIRI – Centre International de Recherche en Infectiologie, Inserm, U1111, University of Lyon, Lyon, France
- Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, University of Lyon, Lyon, France
| | - Binh An Diep
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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9
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Morales Junior R, Juodinis VD, Telles JP, Romano P, Duarte NJC, De Souza DC, Santos SRCJ. Pharmacokinetics and Therapeutic Target Attainment of Meropenem in Pediatric Post-Liver Transplant Patients: Extended vs Intermittent Infusion. Transplant Proc 2023; 55:2456-2461. [PMID: 37923571 DOI: 10.1016/j.transproceed.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/16/2023] [Accepted: 09/22/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The aim of this study is to characterize the concentration-time profile, pharmacokinetics parameters, and therapeutic target attainment of meropenem in pediatric post-liver transplant patients according to the duration of infusion. METHODS This is a prospective cohort of pediatric transplant recipients with preserved renal function receiving meropenem 40 mg/kg every 8 hours. The patients were stratified into 2 groups based on infusion duration: G1 (15 minutes of intermittent infusion) and G1 (3 hours of extended infusion). Two blood samples per child were collected during the same interval within 48 hours of starting the antimicrobial. Meropenem concentrations were determined by high-performance liquid chromatography with tandem mass spectrometry. Pharmacokinetic parameters were assessed using a noncompartmental analysis. The therapeutic target was defined as 100% of the time above the minimum inhibitory concentration. FINDINGS Fourteen patients with 28 measured meropenem concentrations were included. Lower values of volume of distribution and meropenem clearance compared with other critically ill pediatric populations were found. All patients achieved the therapeutic target against gram-negative pathogens with a minimum inhibitory concentration of ≤8 mg/L. Patients receiving a 15-minute infusion had higher values of peak and trough concentrations, resulting in unnecessary increased total drug exposure when compared to patients receiving a 3-hour infusion (P < .05). CONCLUSIONS Meropenem at 120 mg/kg/d attained the therapeutic target against sensitive microorganisms in pediatric liver transplant recipients. The extended infusion should be preferred for patient safety. Because of the pharmacokinetic changes resulting from liver transplantation, individualized meropenem dosing regimens may be necessary.
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Affiliation(s)
- Ronaldo Morales Junior
- Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil; Pediatric Unit, Hospital Sírio-Libanês, São Paulo, Brazil.
| | | | - João Paulo Telles
- Ac Camargo Cancer Center, Infectious Diseases Department, São Paulo, Brazil
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Tamma PD, Harris PNA, Mathers AJ, Wenzler E, Humphries RM. Breaking Down the Breakpoints: Rationale for the 2022 Clinical and Laboratory Standards Institute Revised Piperacillin-Tazobactam Breakpoints Against Enterobacterales. Clin Infect Dis 2023; 77:1585-1590. [PMID: 36001445 DOI: 10.1093/cid/ciac688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/11/2022] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Abstract
Piperacillin-tazobactam (PTZ) is one of the most common antibiotics administered to hospitalized patients. Its broad activity against gram-negative, gram-positive, and anaerobic pathogens; efficacy in clinical trials across diverse infection types and patient populations; and generally favorable toxicity profile make it a particularly appealing antibiotic agent. PTZ susceptibility interpretive criteria (ie, breakpoints) for the Enterobacterales were initially established in 1992, as the drug was undergoing approval by the US Food and Drug Administration. In the ensuing 30 years, changes in the molecular epidemiology of the Enterobacterales and its impact on PTZ susceptibility testing, mounting pharmacokinetic/pharmacodynamic data generated from sophisticated techniques such as population pharmacokinetic modeling and Monte Carlo simulation, and disturbing safety signals in a large clinical trial prompted the Clinical Laboratory and Standards Institute (CLSI) to review available evidence to determine the need for revision of the PTZ breakpoints for Enterobacterales. After an extensive literature review and formal voting process, the susceptibility criteria were revised in the 2022 CLSI M100 document to the following: ≤8/4 µg/mL (susceptible), 16/4 µg/mL (susceptible dose-dependent), and ≥32/4 µg/mL (resistant). Herein, we provide a brief overview of the CLSI process of antibiotic breakpoint revisions and elaborate on the available data that ultimately led to the decision to revise the PTZ breakpoints.
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Affiliation(s)
- Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Patrick N A Harris
- Faculty of Medicine, UQ Center for Clinical Research, Royal Brisbane and Women's Hospital Campus, University of Queensland, Brisbane, Australia
| | - Amy J Mathers
- Department of Medicine and Pathology, University of Virginia, Charlottesville, Virginia, USA
| | - Eric Wenzler
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Romney M Humphries
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Rungkitwattanakul D, Charoensareerat T, Chaichoke E, Rakamthong T, Srisang P, Pattharachayakul S, Srisawat N, Chaijamorn W. Piperacillin-tazobactam dosing in anuric acute kidney injury patients receiving continuous renal replacement therapy. Semin Dial 2023; 36:468-476. [PMID: 36807546 DOI: 10.1111/sdi.13148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/26/2022] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION To determine appropriate dosing of piperacillin-tazobactam in critically ill patients receiving continuous renal replacement therapy (CRRT). METHODS The databases of PubMed, Embase, and ScienceDirect were searched. We used the Medical Subject Headings of "piperacillin-tazobactam," "CRRT," and "pharmacokinetics" or related terms or synonym to identify the studies for reviews. A one-compartment pharmacokinetic model was conducted to predict piperacillin levels for the initial 48 h of therapy. The pharmacodynamic target was 50% of free drug level above the minimum inhibitory concentration (MIC) and 4 times of the MIC. The dose that achieved at least 90% of the probability of target attainment was defined as an optimal dose. RESULTS Our simulation study reveals that the dosing regimen of piperacillin-tazobactam 12 g/day is appropriate for treating Pseudomonal infection with KDIGO recommended effluent rate of 25-35 mL/kg/h. The MIC values of each setting were an important factor to design piperacillin-tazobactam dosing regimens. CONCLUSION The Monte Carlo simulation can be a useful tool to evaluate drug dosing in critically ill acute kidney injury patients receiving CRRT when limited pharmacokinetic data are a concern. Clinical validation of these results is needed.
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Affiliation(s)
- Dhakrit Rungkitwattanakul
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, District of Columbia, USA
| | | | | | | | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Songkhla, Thailand
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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12
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Hamad MA, Williams A, Kneebusch J, Butala N. Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital. Ment Health Clin 2023; 13:233-238. [PMID: 38131054 PMCID: PMC10732127 DOI: 10.9740/mhc.2023.10.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/27/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Urinary tract infections (UTIs) are one of the most common indications for antibiotic use; patients with psychiatric disorders have a greater risk for UTI compared with patients without these disorders. However, there is little guidance on how best to manage antibiotic therapy in psychiatric hospitals. This study assessed the impact of a Board Certified Psychiatric Pharmacist (BCPP)-driven guideline on managing UTI treatment in an acute psychiatric hospital. Methods The guideline was developed by the psychiatric pharmacy team and distributed to internists, psychiatrists, and pharmacists. Preintervention data were assessed for patients admitted between November 30, 2019, and February 23, 2020; postintervention data were assessed from February 25, 2020, to April 24, 2020. All patients ages 13 years and older who were admitted and had orders for an antibiotic to treat a UTI were included in this study. Appropriate UTI management was defined as an appropriate agent, dose, route, and frequency per the treatment guideline. Additionally, the following criteria were to be ordered and assessed to be deemed appropriate: urinalysis, urine culture, complete blood count, basic or complete metabolic panel, temperature, and subjective symptoms. Results Before intervention, 19.0% of antibiotic orders were appropriate; after intervention, 46.7% of antibiotic orders were appropriate (P = .048). Conclusion The implementation of a BCPP-driven treatment algorithm was associated with a significant increase in appropriate antibiotic regimens for the treatment of UTIs in patients admitted to a psychiatric hospital.
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Affiliation(s)
- Mohammad Adam Hamad
- Clinical Pharmacist, Western University of Health Sciences College of Pharmacy, Pomona, California; Clinical Pharmacist, Riverside University Health Systems Medical Center, Moreno Valley, California
| | - Andrew Williams
- Clinical Pharmacist, Western University of Health Sciences College of Pharmacy, Pomona, California; Clinical Pharmacist, Riverside University Health Systems Medical Center, Moreno Valley, California
- Health Sciences Assistant Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California
- Clinical Pharmacist III, Behavioral Health, Riverside University Health Systems Medical Center, Moreno Valley, California
| | - Jamie Kneebusch
- Health Sciences Assistant Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California
| | - Niyati Butala
- Clinical Pharmacist III, Behavioral Health, Riverside University Health Systems Medical Center, Moreno Valley, California
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13
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Barker CIS, Kipper K, Lonsdale DO, Wright K, Thompson G, Kim M, Turner MA, Johnston A, Sharland M, Standing JF. The Neonatal and Paediatric Pharmacokinetics of Antimicrobials study (NAPPA): investigating amoxicillin, benzylpenicillin, flucloxacillin and piperacillin pharmacokinetics from birth to adolescence. J Antimicrob Chemother 2023; 78:2148-2161. [PMID: 37531085 PMCID: PMC10477139 DOI: 10.1093/jac/dkad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 06/09/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK) data underlying paediatric penicillin dosing remain limited, especially in critical care. OBJECTIVES The primary objective of the Neonatal and Paediatric Pharmacokinetics of Antimicrobials study (NAPPA) was to characterize PK profiles of commonly used penicillins using data obtained during routine care, to further understanding of PK variability and inform future evidence-based dosing. METHODS NAPPA was a multicentre study of amoxicillin, co-amoxiclav, benzylpenicillin, flucloxacillin and piperacillin/tazobactam. Patients were recruited with informed consent. Antibiotic dosing followed standard of care. PK samples were obtained opportunistically or at optimal times, frozen and analysed using UPLC with tandem MS. Pharmacometric analysis was undertaken using NONMEM software (v7.3). Model-based simulations (n = 10 000) tested PTA with British National Formulary for Children (BNFC) and WHO dosing. The study had ethical approval. RESULTS For the combined IV PK model, 963 PK samples from 370 participants were analysed simultaneously incorporating amoxicillin, benzylpenicillin, flucloxacillin and piperacillin data. BNFC high-dose regimen simulations gave these PTA results (median fT>MIC at breakpoints of specified pathogens): amoxicillin 100% (Streptococcus pneumoniae); benzylpenicillin 100% (Group B Streptococcus); flucloxacillin 48% (MSSA); and piperacillin 100% (Pseudomonas aeruginosa). Oral population PK models for flucloxacillin and amoxicillin enabled estimation of first-order absorption rate constants (1.16 h-1 and 1.3 h-1) and bioavailability terms (62.7% and 58.7%, respectively). CONCLUSIONS NAPPA represents, to our knowledge, the largest prospective combined paediatric penicillin PK study undertaken to date, and the first paediatric flucloxacillin oral PK model. The PTA results provide evidence supportive of BNFC high-dose IV regimens for amoxicillin, benzylpenicillin and piperacillin.
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Affiliation(s)
- Charlotte I S Barker
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Medical & Molecular Genetics, King’s College London, London, UK
| | - Karin Kipper
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Analytical Services International, St George’s, University of London, London, UK
- Analytical Chemistry Department, Epilepsy Society, Chesham Lane, Chalfont St Peter, Buckinghamshire, UK
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Dagan O Lonsdale
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Kirstie Wright
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
| | - Georgina Thompson
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
| | - Min Kim
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mark A Turner
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Atholl Johnston
- Analytical Services International, St George’s, University of London, London, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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14
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Monti G, Bradić N, Marzaroli M, Konkayev A, Fominskiy E, Kotani Y, Likhvantsev VV, Momesso E, Nogtev P, Lobreglio R, Redkin I, Toffoletto F, Bruni A, Baiardo Redaelli M, D’Andrea N, Paternoster G, Scandroglio AM, Gallicchio F, Ballestra M, Calabrò MG, Cotoia A, Perone R, Cuffaro R, Montrucchio G, Pota V, Ananiadou S, Lembo R, Musu M, Rauch S, Galbiati C, Pinelli F, Pasin L, Guarracino F, Santarpino G, Agrò FE, Bove T, Corradi F, Forfori F, Longhini F, Cecconi M, Landoni G, Bellomo R, Zangrillo A. Continuous vs Intermittent Meropenem Administration in Critically Ill Patients With Sepsis: The MERCY Randomized Clinical Trial. JAMA 2023; 330:141-151. [PMID: 37326473 PMCID: PMC10276329 DOI: 10.1001/jama.2023.10598] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
Importance Meropenem is a widely prescribed β-lactam antibiotic. Meropenem exhibits maximum pharmacodynamic efficacy when given by continuous infusion to deliver constant drug levels above the minimal inhibitory concentration. Compared with intermittent administration, continuous administration of meropenem may improve clinical outcomes. Objective To determine whether continuous administration of meropenem reduces a composite of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria compared with intermittent administration in critically ill patients with sepsis. Design, Setting, and Participants A double-blind, randomized clinical trial enrolling critically ill patients with sepsis or septic shock who had been prescribed meropenem by their treating clinicians at 31 intensive care units of 26 hospitals in 4 countries (Croatia, Italy, Kazakhstan, and Russia). Patients were enrolled between June 5, 2018, and August 9, 2022, and the final 90-day follow-up was completed in November 2022. Interventions Patients were randomized to receive an equal dose of the antibiotic meropenem by either continuous administration (n = 303) or intermittent administration (n = 304). Main Outcomes and Measures The primary outcome was a composite of all-cause mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. There were 4 secondary outcomes, including days alive and free from antibiotics at day 28, days alive and free from the intensive care unit at day 28, and all-cause mortality at day 90. Seizures, allergic reactions, and mortality were recorded as adverse events. Results All 607 patients (mean age, 64 [SD, 15] years; 203 were women [33%]) were included in the measurement of the 28-day primary outcome and completed the 90-day mortality follow-up. The majority (369 patients, 61%) had septic shock. The median time from hospital admission to randomization was 9 days (IQR, 3-17 days) and the median duration of meropenem therapy was 11 days (IQR, 6-17 days). Only 1 crossover event was recorded. The primary outcome occurred in 142 patients (47%) in the continuous administration group and in 149 patients (49%) in the intermittent administration group (relative risk, 0.96 [95% CI, 0.81-1.13], P = .60). Of the 4 secondary outcomes, none was statistically significant. No adverse events of seizures or allergic reactions related to the study drug were reported. At 90 days, mortality was 42% both in the continuous administration group (127 of 303 patients) and in the intermittent administration group (127 of 304 patients). Conclusions and Relevance In critically ill patients with sepsis, compared with intermittent administration, the continuous administration of meropenem did not improve the composite outcome of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. Trial Registration ClinicalTrials.gov Identifier: NCT03452839.
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Affiliation(s)
- Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Nikola Bradić
- Clinical Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
- University North, Varazdin, Croatia
| | - Matteo Marzaroli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aidos Konkayev
- National Scientific Center of Traumatology and Orthopedia named acad NBatpenov, Astana Medical University, Astana, Kazakhstan
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Kameda Medical Center, Kamogawa, Japan
| | | | - Elena Momesso
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Pavel Nogtev
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Ivan Redkin
- Federal Research and Clinical Center of Resuscitation and Rehabilitation, Moscow, Russia
| | - Fabio Toffoletto
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Natascia D’Andrea
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | | | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Romina Perone
- Department of Cardio Thoracic and Vascular Surgery, Pineta Grande Hospital, Pineta Grande, Italy
| | - Raffaele Cuffaro
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgia Montrucchio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Vincenzo Pota
- Università della Campania L. Vanvitelli, Napoli, Italy
| | | | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Musu
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy
- Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Simon Rauch
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of Merano, Merano, Italy
| | - Carola Galbiati
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fulvio Pinelli
- Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Laura Pasin
- Azienda Ospedale Università Padova, Padua, Italy
| | - Fabio Guarracino
- Dipartimento Anestesia e Rianimazione, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giuseppe Santarpino
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
- GVM Care and Research, Department of Cardiac Surgery, Città di Lecce Hospital, Lecce, Italy
- Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Felice Eugenio Agrò
- Research Unit of Anesthesia and Intensive Care, Department of Medicine and Surgery, Università Campus Bio-Medico, Rome, Italy
- Operative Research Unit of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Khole AV, Dionne E, Zitek-Morrison E, Campion M. Cefepime extended infusion versus intermittent infusion: Clinical and cost evaluation. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e119. [PMID: 37502254 PMCID: PMC10369431 DOI: 10.1017/ash.2023.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 07/29/2023]
Abstract
Background Extended infusion cefepime (1 gram every 6 hours administered over 3 hours) achieves pharmacodynamic efficacy against bacteria with a MIC of ≤8 mg/L in Monte Carlo simulations. This regimen has not been evaluated in clinical practice. Objective Compare clinical and economic outcomes for cefepime by intermittent infusion and by extended infusion in the acute-care setting. Design Single-center, retrospective cohort study. Setting Tertiary-care academic medical center. Patients Hospitalized adults who received cefepime between August 2016 and July 2018 with a diagnosis of sepsis or pneumonia. Methods Clinical and economic outcomes were compared for patients who received empiric cefepime via intermittent infusion (30-minute infusion of 2 g every 8 hours) or extended infusion (3-hour infusion of 1 g every 6 hours). Clinical outcomes analyses were carried out using appropriate statistical methods. Results Overall, 111 patients received intermittent infusion and 93 patients received extended infusion. Approximately half of the included patients had a positive culture for a bacterial pathogen (intermittent infusion 45.9% vs extended infusion 47.3%). Median hospital length of stay (intermittent infusion 6 days vs extended infusion 6 days; P = .67) and 90-day readmission rates (intermittent infusion 61.3% vs extended infusion 67.7%; P = .34) did not differ between the groups. Mortality was infrequent in both groups (intermittent infusion 2.9% vs extended infusion 1.5%; P = .45). Cefepime cost per patient was lower with cefepime by extended infusion: average total daily cost $86.06 for intermittent infusion versus $43.39 for extended infusion. Conclusions Cefepime via extended infusion (4 grams/day) did not differ in clinical outcomes compared to intermittent infusion (6 grams/day) but reduced drug expenditure. Prospective, multicenter, high-quality studies should be conducted to evaluate a mortality difference between these regimens.
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Affiliation(s)
- Aalok V. Khole
- Division of Infectious Diseases and International Health, Cheshire Medical Center/Dartmouth Health, Keene, New Hampshire
| | - Emily Dionne
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Emily Zitek-Morrison
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Maureen Campion
- Department of Pharmacy, Tufts Medical Center, Boston, Massachusetts
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Abbasi MY, Chaijamorn W, Wiwattanawongsa K, Charoensareerat T, Doungngern T. Recommendations of Gentamicin Dose Based on Different Pharmacokinetic/Pharmacodynamic Targets for Intensive Care Adult Patients: A Redefining Approach. Clin Pharmacol 2023; 15:67-76. [PMID: 37427084 PMCID: PMC10329437 DOI: 10.2147/cpaa.s417298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
Background In addition to the maximum plasma concentration (Cmax) to the minimum inhibitory concentration (MIC) ratio, the 24-hour area under the concentration-time curve (AUC24h) to MIC has recently been suggested as pharmacokinetic/pharmacodynamic (PK/PD) targets for efficacy and safety in once-daily dosing of gentamicin (ODDG) in critically ill patients. Purpose This study aimed to predict the optimal effective dose and risk of nephrotoxicity for gentamicin in critically ill patients for two different PK/PD targets within the first 3 days of infection. Methods The gathered pharmacokinetic and demographic data in critically ill patients from 21 previously published studies were used to build a one-compartment pharmacokinetic model. The Monte Carlo Simulation (MCS) method was conducted with the use of gentamicin once-daily dosing ranging from 5-10 mg/kg. The percentage target attainment (PTA) for efficacy, Cmax/MIC ~8-10 and AUC24h/MIC ≥110 targets, were studied. The AUC24h >700 mg⋅h/L and Cmin >2 mg/L were used to predict the risk of nephrotoxicity. Results Gentamicin 7 mg/kg/day could achieve both efficacy targets for more than 90% when the MIC was <0.5 mg/L. When the MIC increased to 1 mg/L, gentamicin 8 mg/kg/day could reach the PK/PD and safety targets. However, for pathogens with MIC ≥2 mg/L, no studied gentamicin doses were sufficient to reach the efficacy target. The risk of nephrotoxicity using AUC24h >700 mg⋅h/L was small, but the risk was greater when applying a Cmin target >2 mg/L. Conclusion Considering both targets of Cmax/MIC ~8-10 and AUC24h/MIC ≥110, an initial gentamicin dose of 8 mg/kg/day should be recommended in critically ill patients for pathogens with MIC of ≤1 mg/L. Clinical validation of our results is essential.
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Affiliation(s)
- Mohammad Yaseen Abbasi
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, 90110Thailand
| | - Weerachai Chaijamorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Pathum Wan, Bangkok, 10330, Thailand
| | - Kamonthip Wiwattanawongsa
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, 90110Thailand
| | | | - Thitima Doungngern
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince Songkla University, Hat Yai, Songkhla, 90110Thailand
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17
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Ishikawa K, Shibutani K, Kawai F, Ota E, Takahashi O, Mori N. Effectiveness of Extended or Continuous vs. Bolus Infusion of Broad-Spectrum Beta-Lactam Antibiotics for Febrile Neutropenia: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2023; 12:1024. [PMID: 37370343 DOI: 10.3390/antibiotics12061024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
This systematic review aimed to compare extended infusion or continuous infusion with bolus infusion for febrile neutropenia (FN). We included clinical trials comparing extended or continuous infusion with bolus infusion of beta-lactam antibiotics as empirical treatment for FN and evaluated the clinical failure, all-cause mortality, and adverse event rates. Five articles (three randomized controlled trials (RCTs) and two retrospective studies) from 2014 to 2022 were included. Clinical failure was assessed with a risk ratio (RR) (95% coincident interval (CI)) of 0.74 (0.53, 1.05) and odds ratio (OR) (95% CI) of 0.14 (0.02, 1.17) in the 2 RCTs and retrospective studies, respectively. All-cause mortality was assessed with an RR (95% CI) of 1.25 (0.44, 3.54) and OR (95% CI) of 1.00 (0.44, 2.23) in the RCTs and retrospective studies, respectively. Only 1 RCT evaluated adverse events (with an RR (95% CI) of 0.46 (0.13, 1.65)). The quality of evidence was "low" for clinical failure and all-cause mortality in the RCTs. In the retrospective studies, the clinical failure and all-cause mortality evidence qualities were considered "very low" due to the study design. Extended or continuous infusion of beta-lactam antibiotics did not reduce mortality better than bolus infusion but was associated with shorter fever durations and fewer adverse events.
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Affiliation(s)
- Kazuhiro Ishikawa
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
| | - Koko Shibutani
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
| | - Fujimi Kawai
- Library, Center for Academic Resources, St. Luke's International University, Tokyo 104-0044, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Sciences, St. Luke's International University, Tokyo 104-0044, Japan
- Tokyo Foundation for Policy Research, Tokyo 106-0032, Japan
| | - Osamu Takahashi
- Graduate School of Public Health, St. Luke's International University, Tokyo 104-0045, Japan
| | - Nobuyoshi Mori
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
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Smith SE, Halbig Z, Fox NR, Bland CM, Branan TN. Outcomes of Intravenous Push versus Intermittent Infusion Administration of Cefepime in Critically Ill Patients. Antibiotics (Basel) 2023; 12:996. [PMID: 37370315 DOI: 10.3390/antibiotics12060996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The equivalence of intravenous push (IVP) and piggyback (IVPB) administration has not been evaluated in the critically ill population for most medications, but it is especially relevant for antibiotics, such as cefepime, that exhibit time-dependent bactericidal activity. A single center, retrospective, observational pre/post-protocol change study included critically ill adults who received cefepime as empiric therapy between August 2015 and 2021. The primary outcome was treatment failure, which was defined as a composite of escalation of antibiotic regimen or all-cause mortality. Secondary outcomes included adverse drug events, days of cefepime therapy, total days of antibiotic therapy, and ICU and hospital length of stay. Outcomes were compared using Chi-squared, Mann Whitney U, and binary logistic regression as appropriate. A total of 285 patients were included: 87 IVPB and 198 IVP. Treatment failure occurred in 18% (n = 16) of the IVPB group and 27% (n = 54) of the IVP group (p = 0.109). There were no significant differences in secondary outcomes. Longer duration of antibiotics (odds ratio [OR] 1.057, 95% confidence interval [CI] 1.013-1.103), SOFA score (OR 1.269, 95% CI 1.154-1.397) and IVP administration of cefepime (OR 2.370, 95% CI 1.143-4.914) were independently associated with treatment failure. Critically ill patients who received IVP cefepime were more likely to experience treatment failure in an adjusted analysis. The current practice of IVP cefepime should be reevaluated, as it may not provide similar clinical outcomes in the critically ill population.
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Affiliation(s)
- Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA 30602, USA
| | - Zachary Halbig
- Department of Pharmacy, Piedmont Athens Regional, Athens, GA 30606, USA
| | - Nicholas R Fox
- Athens Pulmonary, Piedmont Athens Regional, Athens, GA 30606, USA
| | - Christopher M Bland
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, GA 31405, USA
| | - Trisha N Branan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA 30602, USA
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19
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An G, Creech CB, Wu N, Nation RL, Gu K, Nalbant D, Jimenez-Truque N, Fissell W, Patel PC, Fishbane N, Watanabe A, Rolsma S, Kirkpatrick CMJ, Landersdorfer CB, Winokur P. Population pharmacokinetics and target attainment analyses to identify a rational empirical dosing strategy for cefepime in critically ill patients. J Antimicrob Chemother 2023; 78:1460-1470. [PMID: 37071586 PMCID: PMC10474939 DOI: 10.1093/jac/dkad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/22/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES We aimed to identify rational empirical dosing strategies for cefepime treatment in critically ill patients by utilizing population pharmacokinetics and target attainment analysis. PATIENTS AND METHODS A prospective and opportunistic pharmacokinetic (PK) study was conducted in 130 critically ill patients in two ICU sites. The plasma concentrations of cefepime were determined using a validated LC-MS/MS method. All cefepime PK data were analysed simultaneously using the non-linear mixed-effects modelling approach. Monte Carlo simulations were performed to evaluate the PTA of cefepime at different MIC values following different dose regimens in subjects with different renal functions. RESULTS The PK of cefepime in critically ill patients was best characterized by a two-compartment model with zero-order input and first-order elimination. Creatinine clearance and body weight were identified to be significant covariates. Our simulation results showed that prolonged 3 h infusion does not provide significant improvement on target attainment compared with the traditional intermittent 0.5 h infusion. In contrast, for a given daily dose continuous infusion provided much higher breakpoint coverage than either 0.5 h or 3 h intermittent infusions. To balance the target attainment and potential neurotoxicity, cefepime 3 g/day continuous infusion appears to be a better dosing regimen than 6 g/day continuous infusion. CONCLUSIONS Continuous infusion may represent a promising strategy for cefepime treatment in critically ill patients. With the availability of institution- and/or unit-specific cefepime susceptibility patterns as well as individual patients' renal function, our PTA results may represent useful references for physicians to make dosing decisions.
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Affiliation(s)
- Guohua An
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nan Wu
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Roger L Nation
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Kenan Gu
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Demet Nalbant
- Department of Pharmaceutical Sciences and Experimental Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Natalia Jimenez-Truque
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William Fissell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratish C Patel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Stephanie Rolsma
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carl M J Kirkpatrick
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | | | - Patricia Winokur
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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20
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Kıran P, Nadir Y, Gencer S. Clinical efficacy and safety of prolonged versus intermittent administration of antipseudomonal beta-lactam antibiotics in adults with severe acute infections: A meta-analysis of randomized controlled trials. J Infect Chemother 2023:S1341-321X(23)00118-6. [PMID: 37169223 DOI: 10.1016/j.jiac.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/20/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION In order to compare the clinical efficacy and safety of prolonged versus intermittent antipseudomonal beta-lactam antibiotic infusion for the treatment of severe acute infections in adult patients, a meta-analysis of randomized controlled trials (RCTs) was performed. METHODS We systematically searched MEDLINE and Cochrane Library databases until December 2022. The outcomes were all-cause mortality, clinical success, microbiological eradication and adverse events. The pooled risk ratios (RR) were estimated by the fixed or random effect methods according to heterogeneity statistics. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence for each outcome. RESULTS Twenty eligible RCTs with 2081 participants were included in the meta-analysis. The risk of all-cause mortality was significantly lower in the prolonged infusion group than in the intermittent infusion group (RR 0.77, 95% confidence interval [CI] 0.63-0.95, p = 0.01, I2 = 0%; moderate certainty). Treatment with prolonged infusion showed significant benefit in clinical success (RR 1.09, 95% CI 1.02-1.17, p = 0.008, I2 = 19%; moderate certainty). There were no significant differences in microbiological eradication (RR 1.12, 95% CI 0.99-1.28, p = 0.07, I2 = 49%; low certainty), any adverse events (RR 0.96, 95% CI 0.86-1.08, p = 0.50, I2 = 27%; moderate certainty) and serious adverse events (RR 0.99, 95%CI 0.70-1.39 p = 0.95, I2 = 0%; low certainty). CONCLUSIONS Prolonged antipseudomonal beta-lactam infusion probably decreases all-cause mortality. Additionally, it probably increases clinical success in adults with severe acute infections. This infusion strategy may result in little to no difference in microbiological eradication and is probably not associated with a rise in any adverse events.The evidence suggests that prolonged infusion may not increase serious adverse events.
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Affiliation(s)
- Pınar Kıran
- Department of Infectious Diseases and Clinical Microbiology, Epidemiology Subsection, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey.
| | - Yasemin Nadir
- Department of Infectious Diseases and Clinical Microbiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Serap Gencer
- Department of Infectious Diseases and Clinical Microbiology, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
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21
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Caniff KE, Rebold N, Rybak MJ. Oral stepdown in Gram-positive bloodstream infections: A step in the right direction. Pharmacotherapy 2023; 43:247-256. [PMID: 36727285 DOI: 10.1002/phar.2775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 02/03/2023]
Abstract
Bloodstream infections (BSIs) due to Gram-positive organisms have traditionally been treated with prolonged courses of intravenous antimicrobials. However, this dogma is associated with substantial burden to the patient and health care system. Consequently, there is growing interest in the utilization of oral stepdown therapy, defined as the transition of intravenous therapy to an active oral agent, for this indication. This review highlights available literature examining oral stepdown in adult patients with BSI due to commonly encountered Gram-positive pathogens, including Staphylococcus aureus, Streptococcus spp., and Enterococcus spp. Support for oral stepdown in this setting is primarily derived from observational studies subject to selection bias. Nevertheless, this treatment strategy exhibits promising potential in carefully selected patients as it is consistently associated with reductions in hospital length of stay without jeopardizing clinical cure or survivability. Prospective, randomized trials are needed for validation of oral stepdown in Gram-positive BSI and to identify the optimal patient population and regimen.
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Affiliation(s)
- Kaylee E Caniff
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Nicholas Rebold
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Department of Clinical & Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, District of Columbia, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA.,Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, Michigan, USA.,Department of Pharmacy, Detroit Receiving Hospital, Detroit, Michigan, USA
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22
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McAlister MJ, Rose DT, Hudson FP, Padilla-Tolentino E, Jaso TC. Oral β-lactams vs fluoroquinolones and trimethoprim/sulfamethoxazole for step-down therapy for Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae bacteremia. Am J Health Syst Pharm 2023; 80:S33-S41. [PMID: 35868628 DOI: 10.1093/ajhp/zxac202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To compare rates of treatment failure for patients with bloodstream infections (BSIs) due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis who received oral step-down antibiotic therapy with either a fluoroquinolone (FQ) or trimethoprim/sulfamethoxazole (SXT) to rates for those who received an oral β-lactam (BL). METHODS This retrospective, multicenter, cohort study included 397 unique adult hospitalized patients with a BSI due to E. coli, K. pneumoniae, or P. mirabilis at 6 hospitals in central Texas between July 11, 2016, and July 11, 2018. The primary outcome was a composite of treatment failure comprising 30-day readmission due to recurrence, 30-day all-cause mortality, and change in oral antibiotic. Secondary outcomes included 90-day development of Clostridioides difficile infection, 90-day colonization with a multidrug-resistant organism, 90-day all-cause readmission, hospital length of stay, and the individual components of the primary outcome. RESULTS Of the 397 patients included, 200 received oral step-down therapy with a BL while 197 received an FQ or SXT. Most patients had an infection due to E. coli (82.8%) and a urinary source of infection (85%). Median total duration of therapy was 14 days in both groups. No difference in treatment failure was identified between the groups treated with a BL and FQ/SXT (7% vs 5.8%, P = 0.561). Median hospital length of stay was the only secondary endpoint in which there was an observed difference (6 vs 5 days, P = 0.04). CONCLUSION We observed no difference in treatment failure rates for patients receiving an oral BL compared to an oral FQ or SXT for step-down therapy of BSIs due to E. coli, K. pneumoniae, and P. mirabilis.
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Affiliation(s)
- Michael J McAlister
- Department of Pharmacy, Dr. P. Phillips Hospital/Orlando Health, Orlando, FL, USA
| | - Dusten T Rose
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Austin, TX, USA
| | - F Parker Hudson
- Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | | | - Theresa C Jaso
- Department of Pharmacy, Ascension Seton Medical Center Austin, Austin, TX, USA
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23
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Population pharmacokinetics and pharmacodynamics of cefazolin using total and unbound serum concentrations in patients with high body weight. Int J Antimicrob Agents 2023; 61:106751. [PMID: 36758780 DOI: 10.1016/j.ijantimicag.2023.106751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 01/04/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
The objective of this study was to evaluate the steady state pharmacokinetics and pharmacodynamics of cefazolin in patients with a high body weight. Cefazolin was administered by 0.5-h infusions to 11 patients with total body weight (TBW) ≥120 kg receiving 3 g q8h, and 12 patients with TBW <120 kg receiving 2 g q8h. Total and unbound serum concentration-time data obtained from serial blood samples were analysed simultaneously by population pharmacokinetic modelling using NONMEM. Probability of target attainment (PTA) was calculated for various dosing regimens through Monte Carlo simulations based on the cumulative percentage of the dosing interval that the unbound concentration exceeds the minimum inhibitory concentration (MIC) value for the pathogen at steady state (fTMIC) ≥40%, ≥60% and 100%. A two-compartment model with non-linear protein binding and allometric scaling of the central volume of distribution using TBW best characterized both total and unbound concentration-time data. Unbound clearance was significantly associated with creatinine clearance, and maximum protein binding constant was significantly associated with serum albumin concentration and body mass index (P <0.05). Based on unbound concentration-time profiles, all simulated regimens achieved PTA >90% at MIC values ≤2 mg/L using fTMIC ≥40%, at MIC values ≤1 mg/L using fTMIC ≥60%, and at MIC values ≤0.5 mg/L using fTMIC of 100%. At fTMIC ≥60%, 0.5-h infusion of cefazolin 1 g q8h achieved PTA <90% at MIC values ≥2 mg/L in patients with TBW≥120 kg; however, prolonged-infusion and higher-dose regimens improved PTA to >90%. Overall, cefazolin pharmacokinetics are altered considerably in obese patients. Higher-dose and/or prolonged-infusion cefazolin regimens should be considered in patients with TBW ≥120 kg, particularly those with less-susceptible Gram-negative infections.
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24
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Effectiveness and Safety of Beta-Lactam Antibiotics with and without Therapeutic Drug Monitoring in Patients with Pseudomonas aeruginosa Pneumonia or Bloodstream Infection. Antimicrob Agents Chemother 2022; 66:e0064622. [PMID: 36073943 PMCID: PMC9578394 DOI: 10.1128/aac.00646-22] [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: 11/20/2022] Open
Abstract
This objective of this study was to compare clinical outcomes in hospitalized patients with Pseudomonas aeruginosa pneumonia (PNA) or bloodstream infection (BSI) receiving beta-lactam antibiotic (BLA) infusions with and without the guidance of therapeutic drug monitoring (TDM). A retrospective, parallel cohort study was conducted at two academic medical centers between December 2015 and January 2020, UF Shands Gainesville, which uses BLA TDM for select patients (BLA TDM), and UF Health Jacksonville, which does not use BLA TDM (No-BLA TDM). All hospitalized adult patients with respiratory or blood culture positive for P. aeruginosa who met diagnosis criteria for lower respiratory tract infection with a positive P. aeruginosa respiratory culture and who received ≥48 h of intravenous BLA with in vitro susceptibility within 72 h of positive culture collection were included. The primary outcome was a composite of presumed treatment failure defined as the presence of any of the following from index-positive P. aeruginosa culture collection to the end of BLA therapy: all-cause mortality, escalation of and/or additional antimicrobial therapy for P. aeruginosa infection after 48 h of treatment with susceptible BLA due to worsening clinical status, or transfer to a higher level of care (i.e., the intensive care unit [ICU]). Analyses were adjusted for possible confounding with inverse probability of treatment weighting (IPTW). Two-hundred patients were included (BLA TDM, n = 95; No-BLA TDM, n = 105). In IPTW-adjusted analysis of the primary composite endpoint, BLA TDM demonstrated a significant decrease in presumed treatment failure compared to No-BLA TDM (adjusted odds ratio [aOR] 0.037, 95% confidence interval [CI] [0.013 to 0.107]; P < 0.001). BLA TDM had more 30-, 60- and 90-day infection-related readmissions ([aOR], 11.301, 95% CI (3.595 to 35.516); aOR 10.389, 95% CI [2.496 to 43.239], and aOR 24.970, 95% CI [6.703 to 93.028]) in IPTW analyses. For both unadjusted and IPTW-adjusted cohorts, there was no significant difference in hospital and ICU length of stay, adverse effects while on BLA, or microbiological eradication between BLA TDM and No-BLA TDM. In hospitalized adult patients with P. aeruginosa PNA or BSI, the use of TDM-guided BLA infusions decreased the odds of presumed treatment failure compared to patients receiving BLA infusions without TDM guidance. Future studies should evaluate BLA TDM impact on readmission.
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25
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Venugopalan V, Hamza M, Santevecchi B, DeSear K, Cherabuddi K, Peloquin CA, Al-Shaer MH. Implementation of a β-lactam therapeutic drug monitoring program: Experience from a large academic medical center. Am J Health Syst Pharm 2022; 79:1586-1591. [PMID: 35704702 DOI: 10.1093/ajhp/zxac171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the implementation and operationalization of a β-lactam (BL) therapeutic drug monitoring(TDM) program at a large academic center. SUMMARY BLs are the most used class of antibiotics. Suboptimal antibiotic exposure is a significant concern in hospitalized patients, particularly in those with altered pharmacokinetics. BL-TDM provides clinicians the opportunity to optimize drug concentrations to ensure maximal therapeutic efficacy while minimizing toxicity. However, BL-TDM has not been widely adopted due to the lack of access to assays. The University of Florida Shands Hospital developed a BL-TDM program in 2015. This is a consultative service primarily run by pharmacists and is conducted in all patient care areas. An analysis was performed on the first BL-TDM encounter for 1,438 patients. BL-TDM was most frequently performed for cefepime (61%, n = 882), piperacillin (15%, n = 218), and meropenem (11%, n = 151). BL-TDM was performed a median of 3 days (interquartile range, 1-5 days) from BL initiation. Among patients with available minimum inhibitory concentration (MIC) values and trough concentrations, the pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT>MIC was attained in 308 patients (88%). BL-TDM resulted in a dosage adjustment in 25% (n = 361) of patients. CONCLUSION Implementation of a BL-TDM program requires the concerted efforts of physicians, pharmacists, nursing staff, phlebotomists, and personnel in the analytical laboratory. Standard antibiotic dosing failed to achieve optimal PK/PD targets in all patients; utilizing BL-TDM, dose adjustments were made in 1 of every 4 patients.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Malva Hamza
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Barbara Santevecchi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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26
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Zhou J, Jiang L, Zhang ZL, Wang ZR, Zhang YX, Lin X, Tang BH, Yao BF, Guo ZX, Yang JJ, Van Den Anker J, Wu YE, Zhao W. Population pharmacokinetics and dosing optimization of mezlocillin in neonates and young infants. J Antimicrob Chemother 2022; 77:2238-2244. [PMID: 35662337 DOI: 10.1093/jac/dkac176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/07/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Mezlocillin is used in the treatment of neonatal infectious diseases. However, due to the absence of population pharmacokinetic studies in neonates and young infants, dosing regimens differ considerably in clinical practice. Hence, this study aimed to describe the pharmacokinetic characteristics of mezlocillin in neonates and young infants, and propose the optimal dosing regimen based on the population pharmacokinetic model of mezlocillin. METHODS A prospective, open-label pharmacokinetic study of mezlocillin was carried out in newborns. Blood samples were collected using an opportunistic sampling method. HPLC was used to measure the plasma drug concentrations. A population pharmacokinetic model was developed using NONMEM software. RESULTS Ninety-five blood samples from 48 neonates and young infants were included. The ranges of postmenstrual age and birth weight were 29-40 weeks and 1200-4000 g, respectively, including term and preterm infants. A two-compartment model with first-order elimination was developed to describe the population pharmacokinetics of mezlocillin. Postmenstrual age, current weight and serum creatinine concentration were the most important covariates. Monte Carlo simulation results indicated that the current dose of 50 mg/kg q12h resulted in 89.2% of patients achieving the therapeutic target, when the MIC of 4 mg/L was used as the breakpoint. When increasing the dosing frequency to q8h, a dose of 20 mg/kg resulted in 74.3% of patients achieving the therapeutic target. CONCLUSIONS A population pharmacokinetic model of mezlocillin in neonates and young infants was established. Optimal dosing regimens based on this model were provided for use in neonatal infections.
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Affiliation(s)
- Jing Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Li Jiang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhi-Ling Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhao-Rui Wang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Yan-Xiu Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Xu Lin
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zi-Xuan Guo
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing-Jing Yang
- Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - John Van Den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, Qilu Hospital of Shandong University, Shandong University, Jinan, China
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27
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Stereoselective synthesis of new β-lactams from the main functional group of indomethacin. JOURNAL OF THE IRANIAN CHEMICAL SOCIETY 2022. [DOI: 10.1007/s13738-021-02466-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen C, Seabury RW, Steele JM, Parsels KA, Darko W, Miller CD, Kufel WD. Evaluation of β-lactam therapeutic drug monitoring among US health systems with postgraduate year 2 infectious diseases pharmacy residency programs. Am J Health Syst Pharm 2022; 79:1273-1280. [PMID: 35439284 DOI: 10.1093/ajhp/zxac117] [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: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE While some guidelines recognize the need for β-lactam therapeutic drug monitoring (TDM), there is still a paucity of data regarding the prevalence of and barriers to performing β-lactam TDM in the United States. We sought to estimate the prevalence of β-lactam TDM, describe monitoring practices, and identify actual and perceived barriers to implementation among health systems in the US. METHODS A multicenter, cross-sectional, 40-item electronic survey was distributed to all postgraduate year 2 (PGY2) infectious diseases (ID) pharmacy residency program directors (RPDs) listed in the American Society of Health-System Pharmacists pharmacy residency directory. The primary outcome was the percentage of institutions with established β-lactam TDM. Secondary outcomes included assessing β-lactam TDM methods and identifying potential barriers to implementation. RESULTS The survey was distributed to 126 PGY2 ID RPDs, with a response rate of 31.7% (40 of 126). Only 7.7% of respondents (3 of 39) performed β-lactam TDM. Patient populations, therapeutic targets, and frequency and timing of obtaining repeat β-lactam concentration measurements varied among institutions. The greatest barrier to implementation was lack of access to testing with a rapid turnaround time. Institutions were unlikely to implement β-lactam TDM within the next year but were significantly more inclined to do so within 5 years (P < 0.001). CONCLUSION Β-lactam TDM was infrequently performed at the surveyed US health systems. Lack of access to serum concentration testing with rapid turnaround and lack of US-specific guidelines appear to be considerable barriers to implementing β-lactam TDM. Among institutions that have implemented β-lactam TDM, there is considerable variation in monitoring approaches.
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Affiliation(s)
- Chieh Chen
- State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Robert W Seabury
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Katie A Parsels
- State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - William Darko
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Christopher D Miller
- State University of New York Upstate University Hospital, Syracuse, NY, and State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Wesley D Kufel
- State University of New York Upstate University Hospital, Syracuse, NY, State University of New York Upstate Medical University, Syracuse, NY, and Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
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Yagnik KJ, Brown LS, Saad HA, Alvarez K, Mang N, Bird CE, Cerise F, Bhavan KP. Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria. Open Forum Infect Dis 2022; 9:ofac117. [PMID: 35493115 PMCID: PMC9045948 DOI: 10.1093/ofid/ofac117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Prior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a syringe bolus push. However, intravenous drip infusions subsequently became the standard of care. Puerto Rico is the largest supplier of IV fluid bags and in the aftermath of Hurricane Maria, there was a nationwide fluid bag shortage. This shortage required stewardship measures to maintain the operation of the self-administered outpatient parenteral antimicrobial therapy (OPAT) program at Parkland Health. Methods Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV syringe bolus push (IVP) instead of an IV-drip infusion. Medications deemed appropriate were transitioned to IVP. The hospital EMR was used to identify patients discharged to the OPAT clinic using all methods of parenteral drug delivery. Data was collected for patient demographics, patient satisfaction, and clinical outcomes. Finally cost of care was calculated for IVP and IV drip administration. Results One-hundred and thirteen self-administered IVP and 102 self-administered IV drip treatment courses were identified during the study period. Individuals using IVP had a statistically significant decrease in hospital length of stay. Patient satisfaction was greater with IVP and IVP saved 504 liters of normal saline resulting in a savings of $43,652 over 6 months. The 30-day readmission rate and mortality were similar. Conclusion The abrupt IV fluid shortage following a natural disaster led to implementation of a high value care model that improved efficiency, reduced costs, and did not affect safety or efficacy.
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Affiliation(s)
- Kruti J Yagnik
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - L Steven Brown
- Parkland Health, Office of Research Administration, Dallas, Texas, USA
| | - Hala A Saad
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kristin Alvarez
- Parkland Health, Center of Innovation and Value at Parkland, Dallas, Texas, USA
| | - Norman Mang
- Parkland Health, Pharmacy Department, Dallas, Texas, USA
| | - Cylaina E Bird
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Fred Cerise
- Parkland Health, Office of Research Administration, Dallas, Texas, USA
- Parkland Health, Center of Innovation and Value at Parkland, Dallas, Texas, USA
- Parkland Health, Pharmacy Department, Dallas, Texas, USA
| | - Kavita P Bhavan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Parkland Health, Center of Innovation and Value at Parkland, Dallas, Texas, USA
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Berry AV, Kuti JL. Pharmacodynamic Thresholds for Beta-Lactam Antibiotics: A Story of Mouse Versus Man. Front Pharmacol 2022; 13:833189. [PMID: 35370708 PMCID: PMC8971958 DOI: 10.3389/fphar.2022.833189] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/24/2022] [Indexed: 01/20/2023] Open
Abstract
Beta-lactams remain a critical member of our antibiotic armamentarium and are among the most commonly prescribed antibiotic classes in the inpatient setting. For these agents, the percentage of time that the free concentration remains above the minimum inhibitory concentration (%fT > MIC) of the pathogen has been shown to be the best predictor of antibacterial killing effects. However, debate remains about the quantity of fT > MIC exposure needed for successful clinical response. While pre-clinical animal based studies, such as the neutropenic thigh infection model, have been widely used to support dosing regimen selection for clinical development and susceptibility breakpoint evaluation, pharmacodynamic based studies in human patients are used validate exposures needed in the clinic and for guidance during therapeutic drug monitoring (TDM). For the majority of studied beta-lactams, pre-clinical animal studies routinely demonstrated the fT > MIC should exceed approximately 40–70% fT > MIC to achieve 1 log reductions in colony forming units. In contrast, clinical studies tend to suggest higher exposures may be needed, but tremendous variability exists study to study. Herein, we will review and critique pre-clinical versus human-based pharmacodynamic studies aimed at determining beta-lactam exposure thresholds, so as to determine which targets may be best suited for optimal dosage selection, TDM, and for susceptibility breakpoint determination. Based on our review of murine and clinical literature on beta-lactam pharmacodynamic thresholds, murine based targets specific to each antibiotic are most useful during dosage regimen development and susceptibility breakpoint assessment, while a range of exposures between 50 and 100% fT > MIC are reasonable to define the beta-lactam TDM therapeutic window for most infections.
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Silva CM, Baptista JP, Santos I, Martins P. Recommended Antibiotic Dosage Regimens in Critically Ill Patients with Augmented Renal Clearance: A Systematic Review. Int J Antimicrob Agents 2022; 59:106569. [DOI: 10.1016/j.ijantimicag.2022.106569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 02/15/2022] [Accepted: 03/06/2022] [Indexed: 12/17/2022]
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Pierce VM, Mathers AJ. Setting Antimicrobial Susceptibility Testing Breakpoints: A Primer for Pediatric Infectious Diseases Specialists on the Clinical and Laboratory Standards Institute Approach. J Pediatric Infect Dis Soc 2022; 11:73-80. [PMID: 34888640 DOI: 10.1093/jpids/piab106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/22/2021] [Indexed: 01/22/2023]
Abstract
Breakpoints are the values used by clinical microbiology laboratories to interpret the results of antimicrobial susceptibility testing (AST) and classify isolates as susceptible or resistant. Whether the breakpoints applied by laboratories accurately predict the likelihood of successful treatment with a particular antimicrobial is an issue of critical importance to quality clinical care. In the United States, the Food and Drug Administration (FDA) sets breakpoints, and globally, breakpoints are also set by 2 standards development organizations, the Clinical and Laboratory Standards Institute (CLSI) and the European Committee on Antimicrobial Susceptibility Testing (EUCAST); individual laboratories may choose which breakpoints to implement. Many CLSI breakpoints are recognized by FDA, facilitating their incorporation into widely used commercial AST devices. The CLSI Subcommittee on AST's consensus approach to establishing (and as needed, revising) breakpoints involves integration of currently available microbiological, pharmacokinetic-pharmacodynamic, and clinical data. Here, an overview of the CLSI process for establishing breakpoints is provided.
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Affiliation(s)
- Virginia M Pierce
- Clinical Microbiology Laboratory, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Pediatric Infectious Disease Unit, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - Amy J Mathers
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.,Clinical Microbiology Laboratory, Department of Pathology, University of Virginia Health System, Charlottesville, Virginia, USA
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Andreev SS, Ryazantseva E, Maltseva N, Mutovina Z, Fomina D, Lysenko M. Corynebacterium amycolatum infective endocarditis in a patient with severe COVID-19: a case report. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2022. [DOI: 10.36488/cmac.2022.3.261-266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective.
To present a case of successful treatment of a secondary bacterial infection caused by nondiphtheritic corynebacterium in a patient with severe COVID-19 and known beta-lactam intolerance.
Materials and Methods.
A clinical case of infective endocarditis (IE) caused by Corynebacterium amycolatum in a 74-year-old patient hospitalized with severe COVID-19 is presented. Comorbidity (secondary immune deficiency due to active malignancy, chemotherapy courses; previous heart disease) and the need for immunosuppressive therapy were triggers for infection caused by a rare Gram-positive bacterium which is usually considered as clinically non-significant. The choice of empiric antimicrobial treatment was limited by the patient’s history of beta-lactam intolerance.
Results.
A multidisciplinary approach to medical care of the patient and alertness to secondary infections helped to diagnose IE in a timely manner and to choose effective antimicrobial therapy. Combination therapy with vancomycin and amikacin helped to make blood flow free from infection. The further switch to oral doxycycline in outpatient settings resulted in the patient recovery from the infection.
Conclusions.
Under conditions of limited choice of drug therapy, it is critical to have access to modern microbiological diagnostics which make it possible to diagnose rare pathogens. A dialogue between treating physician and clinical pharmacologist helps to choose an empirical and targeted antimicrobial therapy with the best efficacy-safety ratio. There is a need to be alert to secondary infections, including those of atypical locations and courses and caused by rare or opportunistic pathogens.
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Affiliation(s)
| | | | | | - Z.Yu. Mutovina
- City Clinical Hospital No. 52; Central State Medical Academy (Moscow, Russia)
| | - D.S. Fomina
- City Clinical Hospital No. 52; I.M. Sechenov First Moscow State Medical University (Moscow, Russia)
| | - M.A. Lysenko
- City Clinical Hospital No. 52; Pirogov Russian National Research Medical University (Moscow, Russia)
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Morales Junior R, Pereira GO, Tiguman GMB, Juodinis VD, Telles JP, de Souza DC, Santos SRCJ. Beta-Lactams Therapeutic Monitoring in Septic Children-What Target Are We Aiming for? A Scoping Review. Front Pediatr 2022; 10:777854. [PMID: 35359889 PMCID: PMC8960241 DOI: 10.3389/fped.2022.777854] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/31/2022] [Indexed: 01/25/2023] Open
Abstract
The antimicrobial therapy of sepsis and septic shock should be individualized based on pharmacokinetic/pharmacodynamic (PK/PD) parameters to deliver effective and timely treatment of life-threatening infections. We conducted a literature scoping review to identify therapeutic targets of beta-lactam antibiotics in septic pediatric patients and the strategies that have been applied to overcome sepsis-related altered pharmacokinetics and increase target attainment against susceptible pathogens. A systematic search was conducted in the MEDLINE, EMBASE and Web of Science databases to select studies conducted since 2010 with therapeutic monitoring data of beta-lactams in septic children. Last searches were performed on 02 September 2021. Two independent authors selected the studies and extracted the data. A narrative and qualitative approach was used to summarize the findings. Out of the 118 identified articles, 21 met the eligibility criteria. Population pharmacokinetic modeling was performed in 12 studies, while nine studies reported data from bedside monitoring of beta-lactams. Most studies were conducted in the United States of America (n = 9) and France (n = 5) and reported PK/PD data of amoxicillin, ampicillin, azlocillin, aztreonam, cefazolin, cefepime, cefotaxime, ceftaroline, ceftazidime, doripenem, meropenem and piperacillin/tazobactam. Therapeutic targets ranged from to 40% fT> MIC to 100% fT> 6 × MIC. Prolonging the infusion time and frequency were most described strategies to increase target attainment. Monitoring beta-lactam serum concentrations in clinical practice may potentially maximize therapeutic target attainment. Further studies are required to define the therapeutic target associated with the best clinical outcomes.
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Affiliation(s)
- Ronaldo Morales Junior
- Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil.,Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Gabriela Otofuji Pereira
- Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | | | - Vanessa D'Amaro Juodinis
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês, São Paulo, Brazil
| | - João Paulo Telles
- Department of Infectious Diseases, AC Camargo Cancer Center, São Paulo, Brazil
| | - Daniela Carla de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês, São Paulo, Brazil.,Pediatric Intensive Care Unit, University Hospital, University of São Paulo, São Paulo, Brazil
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Population Pharmacokinetics and Dosing Optimization of Piperacillin-Tazobactam in Critically Ill Patients on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy. Microbiol Spectr 2021; 9:e0063321. [PMID: 34937189 PMCID: PMC8694146 DOI: 10.1128/spectrum.00633-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Critical illness and extracorporeal circulation, such as extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), may alter the pharmacokinetics of piperacillin-tazobactam. We aimed to develop a population pharmacokinetic model of piperacillin-tazobactam in critically ill patients during ECMO or CRRT and investigate the optimal dosage regimen needed to achieve ≥90% of patients attaining the piperacillin pharmacodynamic target of 100% of dosage time above MIC of 16 mg/L. This prospective observational study included 26 ECMO patients, of which 13 patients received continuous venovenous hemodiafiltration (CVVHDF). A population pharmacokinetic model was developed using nonlinear mixed-effects models, and Monte Carlo simulations were performed to evaluate creatinine clearance (CrCL) and infusion method in relation to the probability of target attainment (PTA) in four patient groups according to combination of ECMO and CVVHDF. A total of 244 plasma samples were collected. In a two-compartment model, clearance decreased during ECMO and CVVHDF contributed to an increase in the volume of distribution. The range of PTA reduction as CrCL increased was greater in the order of intermittent bolus, extended infusion, and continuous infusion method. Continuous infusion should be considered in critically ill patients with CrCL of ≥60 mL/min, and at least 12, 16, and 20 g/day was required for CrCL of <40, 40 to 60, and 60 to 90 mL/min, respectively, regardless of ECMO or CVVHDF. In patients with CrCL of ≥90 mL/min, even a continuous infusion of 24 g/day was insufficient to achieve adequate PTA. Therefore, further research on permissible high continuous infusion dose focused on the risk of toxicity is required. (This trial has been registered at ClinicalTrials.gov under registration no. NCT02581280, December 1, 2014.) IMPORTANCE To the best of our knowledge, this is the first large prospective pharmacokinetic/pharmacodynamic (PK/PD) study of piperacillin-tazobactam in ECMO patients. We used piperacillin-tazobactam plasma concentration data from four different cases (concomitant use of ECMO and CVVHDF, receiving ECMO only, weaned from ECMO and receiving CVVHDF, and weaned from ECMO and not receiving CVVHDF) to provide preliminary insights into the incremental effects of critical illness, ECMO, and CVVHDF on PK. Our analysis revealed that volume of distribution increased in patients on CVVHDF and clearance decreased during ECMO and as creatinine clearance was reduced. When targeting 100% fT>MIC (16 mg/L, clinical breakpoint for Pseudomonas aeruginosa), continuous infusions would have achieved the highest percentage of target attainment compared to intermittent bolus or extended infusion if the total daily dose was the same. Continuous infusion should be considered in critically ill patients with creatinine clearance of ≥60 mL/min, regardless of ECMO or CVVHDF.
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Busse D, Simon P, Schmitt L, Petroff D, Dorn C, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Comparative Plasma and Interstitial Tissue Fluid Pharmacokinetics of Meropenem Demonstrate the Need for Increasing Dose and Infusion Duration in Obese and Non-obese Patients. Clin Pharmacokinet 2021; 61:655-672. [PMID: 34894344 PMCID: PMC9095536 DOI: 10.1007/s40262-021-01070-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES A quantitative evaluation of the PK of meropenem, a broad-spectrum β-lactam antibiotic, in plasma and interstitial space fluid (ISF) of subcutaneous adipose tissue of obese patients is lacking as of date. The objective of this study was the characterisation of meropenem population pharmacokinetics in plasma and ISF in obese and non-obese patients for identification of adequate dosing regimens via Monte-Carlo simulations. METHODS We obtained plasma and microdialysate concentrations after administration of meropenem 1000 mg to 15 obese and 15 non-obese surgery patients from a prospective clinical trial. After characterizing plasma- and microdialysis-derived ISF pharmacokinetics via population pharmacokinetic analysis, we simulated thrice-daily (TID) meropenem short-term (0.5 h), prolonged (3.0 h), and continuous infusions. Adequacy of therapy was assessed by the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) analysis based on time unbound concentrations exceeded minimum inhibitory concentrations (MIC) on treatment day 1 (%fT > MIC) and the sum of PTA weighted by relative frequency of MIC values for infections by pathogens commonly treated with meropenem. To avoid interstitial tissue fluid concentrations below MIC for the entire dosing interval during continuous infusions, a more conservative PK/PD index was selected (%fT > 4 × MIC). RESULTS Adjusted body weight (ABW) and calculated creatinine clearance (CLCRCG_ABW) of all patients (body mass index [BMI] = 20.5-81.5 kg/m2) explained a considerable proportion of the between-patient pharmacokinetic variability (15.1-31.0% relative reduction). The ISF:plasma ratio of %fT > MIC was relatively similar for MIC ≤ 2 mg/L but decreased for MIC = 8 mg/L over ABW = 60-120 kg (0.50-0.20). Steady-state concentrations were 2.68 times (95% confidence interval [CI] = 2.11-3.37) higher in plasma than in ISF, supporting PK/PD targets related to four times the MIC during continuous infusions to avoid suspected ISF concentrations constantly below the MIC. A 3000 mg/24 h continuous infusion was sufficient at MIC = 2 mg/L for patients with CLCRCG_ABW ≤ 100 mL/min and ABW < 90 kg, whereas 2000 mg TID prolonged infusions were adequate for those with CLCRCG_ABW ≤ 100 mL/min and ABW > 90 kg. For MIC = 2 mg/L and %fT> MIC = 95, PTA was adequate in patients over the entire investigated range of body mass and renal function using a 6000 mg continuous infusion. A prolonged infusion of meropenem 2000 mg TID was sufficient for MIC ≤ 8 mg/L and all investigated ABW and CLCRCG_ABW when employing the PK/PD target %fT > MIC = 40. Short-term infusions of 1000 mg TID were sufficient for CLCRCG_ABW ≤ 130 mL/min and distributions of MIC values for Escherichia coli, Citrobacter freundii, and Klebsiella pneumoniae but not for Pseudomonas aeruginosa. CONCLUSIONS This analysis indicated a need for higher doses (≥ 2000 mg) and prolonged infusions (≥ 3 h) for obese and non-obese patients at MIC ≥ 2 mg/L. Higher PTA was achieved with prolonged infusions in obese patients and with continuous infusions in non-obese patients. TRIAL REGISTRATION EudraCT: 2012-004383-22.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
- Graduate Research Training Program PharMetrX, Berlin, Germany
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Maarbjerg SF, Thorsted A, Friberg LE, Nielsen EI, Wang M, Schrøder H, Albertsen BK. Continuous infusion of piperacillin-tazobactam significantly improves target attainment in children with cancer and fever. Cancer Rep (Hoboken) 2021; 5:e1585. [PMID: 34796702 PMCID: PMC9575485 DOI: 10.1002/cnr2.1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/07/2022] Open
Abstract
Background Children with febrile neutropenia commonly exhibit alterations of pharmacokinetic (PK) parameters, leading to decreased β‐lactam concentrations. Aims This study evaluated piperacillin PK and probability of target attainment (PTA) with continuous infusion of piperacillin‐tazobactam, in order to optimize the dosing regimen. Methods This prospective PK study included children with cancer, aged 1–17 years, who were treated with piperacillin‐tazobactam for suspected or verified infection. A piperacillin‐tazobactam loading dose (100 mg/kg) was administered followed by continuous infusion (300 mg/kg/day). The unbound fraction of piperacillin was quantified by high‐performance liquid chromatography and PK were described using population PK modeling. PK data was used to update and extend a previous PK model built on data following intermittent administration. Monte Carlo simulations were performed to assess PTA for targets of 100% time above the minimum inhibitory concentration (100% fT > MIC) and 50% fT > 4xMIC. Results We included 68 fever episodes among 38 children with a median (IQR) age of 6.5 years and body weight of 27.4 kg (15.1–54.0). A three‐compartment model adequately described the concentration‐time data. Median (95% confidence interval) estimates for clearance and piperacillin concentration at steady state were 14.2 L/h/70 kg (13.0; 15.3) and 47.6 mg/L (17.2; 129.5), respectively. Body weight or lean body weight was significantly associated with the PK parameters, and body weight was integrated in the final PK model. Based on piperacillin exposure, continuous infusion was the only dosing regimen to achieve optimal PTA for the P. aeruginosa breakpoint (16 mg/L) with the target of 100% fT > MIC, and a daily dose of 300 mg/kg reached optimal PTA. The strict target of 50% fT > 4xMIC (64 mg/L) was not feasibly attained by any dosing regimen at recommended doses. Conclusion Unlike conventional piperacillin intermittent administration and extended infusion regimens, continuous infusion allows the target of 100% fT > MIC to be reached for children with febrile neutropenia.
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Affiliation(s)
- Sabine F Maarbjerg
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Mikala Wang
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte K Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Population Pharmacokinetics of Piperacillin and Tazobactam in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation: an ASAP ECMO Study. Antimicrob Agents Chemother 2021; 65:e0143821. [PMID: 34460303 DOI: 10.1128/aac.01438-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Our study aimed to describe the population pharmacokinetics (PK) of piperacillin and tazobactam in patients on extracorporeal membrane oxygenation (ECMO), with and without renal replacement therapy (RRT). We also aimed to use dosing simulations to identify the optimal dosing strategy for these patient groups. Serial piperacillin and tazobactam plasma concentrations were measured with data analyzed using a population PK approach that included staged testing of patient and treatment covariates. Dosing simulations were conducted to identify the optimal dosing strategy that achieved piperacillin target exposures of 50% and 100% fraction of time free drug concentration is above MIC (%fT>MIC) and toxic exposures of greater than 360 mg/liter. The tazobactam target of percentage of time free concentrations of >2 mg/liter was also assessed. Twenty-seven patients were enrolled, of which 14 patients were receiving concurrent RRT. Piperacillin and tazobactam were both adequately described by two-compartment models, with body mass index, creatinine clearance, and RRT as significant predictors of PK. There were no substantial differences between observed PK parameters and published parameters from non-ECMO patients. Based on dosing simulations, a 4.5-g every 6 hours regimen administered over 4 hours achieves high probabilities of efficacy at a piperacillin MIC of 16 mg/liter while exposing patients to a <3% probability of toxic concentrations. In patients receiving ECMO and RRT, a frequency reduction to every 12 hours dosing lowers the probability of toxic concentrations, although this remains at 7 to 9%. In ECMO patients, piperacillin and tazobactam should be dosed in line with standard recommendations for the critically ill.
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Zylbersztajn B, Parker S, Navea D, Izquierdo G, Ortiz P, Torres JP, Fajardo C, Diaz R, Valverde C, Roberts J. Population Pharmacokinetics of Vancomycin and Meropenem in Pediatric Extracorporeal Membrane Oxygenation Support. Front Pharmacol 2021; 12:709332. [PMID: 34483917 PMCID: PMC8411703 DOI: 10.3389/fphar.2021.709332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: Describe primary pharmacokinetic/pharmacodynamic (PK/PD) parameters of vancomycin and meropenem in pediatric patients undergoing ECMO and analyze utilized dosing to reach PK/PD target. Design: Prospective, multicentric, population PK analysis. Setting: Two hospitals with pediatric intensive care unit. Patients: Pediatric patients (1 month - 15 years old) receiving vancomycin and meropenem for empiric or definitive infection treatment while ECMO support. Measurements and Main Results: Four serum concentration were obtained for patients receiving vancomycin (n = 9) and three for meropenem (n = 9). The PK/PD target for vancomycin was a ratio of the area under the curve to the minimal inhibitory concentration (AUC/MIC) of >400, and for meropenem was 4 times above MIC for 50% of the dosing interval (fT50% > 4xMIC). Pharmacokinetic modeling was performed using PMetrics 1.5.0. We included nine patients, with 11 PK profiles for each antimicrobial. The median age of patients was 4 years old (2 months - 13 years) and 45% were male. Creatinine clearance (CL) was 183 (30–550) ml/min/1.73 m2. The median dose was 13.6 (range 10–15) mg/kg every 6–12 h and 40 mg/kg every 8–12 h for vancomycin and meropenem, respectively. Two compartment models were fitted. Weight was included as a covariate on volume of the central compartment (Vc) for meropenem. Weight was included as a covariate on both Vc and clearance (CL) and serum creatinine was also included as a covariate on CL for vancomycin. The pharmacokinetic parameters CL and Vc were 0.139 ± 0.102 L/h/kg and 0.289 ± 0.295 L/kg for meropenem and 0.060 ± 0.055 L/h/kg and 0.419 ± 0.280 L/kg for vancomycin, respectively. Across each dosing interval 91% of patients achieved the PK/PD targets for adequate exposure for meropenem and 63.6% for vancomycin. Conclusion: Pharmacokinetic/pharmacodynamic objectives for vancomycin were achieved partially with conventional doses and higher dosing with extended infusion were needed in the case of meropenem.
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Affiliation(s)
| | - Suzanne Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | | | | | - Paula Ortiz
- Pediatric Intensive Care Unit, Roberto Del Rio Hospital, SantiagoChile
| | - Juan Pablo Torres
- Department of Infectious Disease, Clinica Las Condes, Santiago, Chile
| | | | - Rodrigo Diaz
- Intensive Care Unit, Clinica Las Condes, Santiago, Chile
| | | | - Jason Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia
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40
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Busse D, Simon P, Petroff D, Dorn C, Schmitt L, Bindellini D, Kratzer A, Dietrich A, Zeitlinger M, Huisinga W, Michelet R, Wrigge H, Kloft C. Similar Piperacillin/Tazobactam Target Attainment in Obese versus Nonobese Patients despite Differences in Interstitial Tissue Fluid Pharmacokinetics. Pharmaceutics 2021; 13:1380. [PMID: 34575456 PMCID: PMC8464843 DOI: 10.3390/pharmaceutics13091380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/17/2022] Open
Abstract
Precision dosing of piperacillin/tazobactam in obese patients is compromised by sparse information on target-site exposure. We aimed to evaluate the appropriateness of current and alternative piperacillin/tazobactam dosages in obese and nonobese patients. Based on a prospective, controlled clinical trial in 30 surgery patients (15 obese/15 nonobese; 0.5-h infusion of 4 g/0.5 g piperacillin/tazobactam), piperacillin pharmacokinetics were characterized in plasma and at target-site (interstitial fluid of subcutaneous adipose tissue) via population analysis. Thereafter, multiple 3-4-times daily piperacillin/tazobactam short-term/prolonged (recommended by EUCAST) and continuous infusions were evaluated by simulation. Adequacy of therapy was assessed by probability of pharmacokinetic/pharmacodynamic target-attainment (PTA ≥ 90%) based on time unbound piperacillin concentrations exceed the minimum inhibitory concentration (MIC) during 24 h (%fT>MIC). Lower piperacillin target-site maximum concentrations in obese versus nonobese patients were explained by the impact of lean (approximately two thirds) and fat body mass (approximately one third) on volume of distribution. Simulated steady-state concentrations were 1.43-times, 95%CI = (1.27; 1.61), higher in plasma versus target-site, supporting targets of %fT>2×MIC instead of %fT>4×MIC during continuous infusion to avoid target-site concentrations constantly below MIC. In all obesity and renally impairment/hyperfiltration stages, at MIC = 16 mg/L, adequate PTA required prolonged (thrice-daily 4 g/0.5 g over 3.0 h at %fT>MIC = 50) or continuous infusions (24 g/3 g over 24 h following loading dose at %fT>MIC = 98) of piperacillin/tazobactam.
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Affiliation(s)
- David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Philipp Simon
- Department of Anesthesiology, Intensive Care, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (P.S.); (A.D.)
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
- Clinical Trial Centre Leipzig, University of Leipzig, 04109 Leipzig, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053 Regensburg, Germany;
| | - Lisa Schmitt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Davide Bindellini
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Arne Dietrich
- Department of Anesthesiology, Intensive Care, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (P.S.); (A.D.)
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, University Medical University of Vienna, 1090 Vienna, Austria;
| | - Wilhelm Huisinga
- Institute of Mathematics, University of Potsdam, 14469 Potsdam, Germany;
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (H.W.)
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, 06112 Halle, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (L.S.); (D.B.); (R.M.)
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Hosmann A, Ritscher L, Burgmann H, Al Jalali V, Wulkersdorfer B, Wölfl-Duchek M, Sanz Codina M, Jäger W, Poschner S, Plöchl W, Reinprecht A, Rössler K, Gruber A, Zeitlinger M. Meropenem concentrations in brain tissue of neurointensive care patients exceed CSF levels. J Antimicrob Chemother 2021; 76:2914-2922. [PMID: 34392352 DOI: 10.1093/jac/dkab286] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inadequate antibiotic exposure in cerebral infections might have detrimental effects on clinical outcome. Commonly, antibiotic concentrations within the CSF were used to estimate cerebral target levels. However, the actual pharmacological active unbound drug concentration beyond the blood-brain barrier is unknown. OBJECTIVES To compare meropenem concentrations in blood, CSF and cerebral microdialysate of neurointensive care patients. PATIENTS AND METHODS In 12 patients suffering subarachnoid haemorrhage, 2000 mg of meropenem was administered every 8 h due to an extracerebral infection. Meropenem concentrations were determined in blood, CSF and cerebral microdialysate at steady state (n = 11) and following single-dose administration (n = 5). RESULTS At steady state, the free AUC0-8 was 233.2 ± 42.7 mg·h/L in plasma, 7.8 ± 1.9 mg·h/L in CSF and 26.6 ± 14.0 mg·h/L in brain tissue. The brain tissue penetration ratio (AUCbrain/AUCplasma) was 0.11 ± 0.06, which was more than 3 times higher than in CSF (0.03 ± 0.01), resulting in an AUCCSF/AUCbrain ratio of 0.41 ± 0.16 at steady state. After single-dose administration similar proportions were achieved (AUCbrain/AUCplasma = 0.09 ± 0.08; AUCCSF/AUCplasma = 0.02 ± 0.00). Brain tissue concentrations correlated well with CSF concentrations (R = 0.74, P < 0.001), but only moderately with plasma concentrations (R = 0.51, P < 0.001). Bactericidal thresholds were achieved in both plasma and brain tissue for MIC values ≤16 mg/L. In CSF, bactericidal effects were only reached for MIC values ≤1 mg/L. CONCLUSIONS Meropenem achieves sufficient bactericidal concentrations for the most common bacterial strains of cerebral infections in both plasma and brain tissue, even in non-inflamed brain tissue. CSF concentrations would highly underestimate the target site activity of meropenem beyond the blood-brain barrier.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Lavinia Ritscher
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Heinz Burgmann
- Department of Internal Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Vienna, Austria
| | - Valentin Al Jalali
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Michael Wölfl-Duchek
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Maria Sanz Codina
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Walter Jäger
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Stefan Poschner
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Walter Plöchl
- Department of Anaesthesia, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Johannes Kepler University, Linz, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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42
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Timsit JF, Huntington JA, Wunderink RG, Shime N, Kollef MH, Kivistik Ü, Nováček M, Réa-Neto Á, Martin-Loeches I, Yu B, Jensen EH, Butterton JR, Wolf DJ, Rhee EG, Bruno CJ. Ceftolozane/tazobactam versus meropenem in patients with ventilated hospital-acquired bacterial pneumonia: subset analysis of the ASPECT-NP randomized, controlled phase 3 trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:290. [PMID: 34380538 PMCID: PMC8356211 DOI: 10.1186/s13054-021-03694-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 07/18/2021] [Indexed: 11/17/2022]
Abstract
Background Ceftolozane/tazobactam is approved for treatment of hospital-acquired/ventilator-associated bacterial pneumonia (HABP/VABP) at double the dose approved for other infection sites. Among nosocomial pneumonia subtypes, ventilated HABP (vHABP) is associated with the lowest survival. In the ASPECT-NP randomized, controlled trial, participants with vHABP treated with ceftolozane/tazobactam had lower 28-day all-cause mortality (ACM) than those receiving meropenem. We conducted a series of post hoc analyses to explore the clinical significance of this finding. Methods ASPECT-NP was a multinational, phase 3, noninferiority trial comparing ceftolozane/tazobactam with meropenem for treating vHABP and VABP; study design, efficacy, and safety results have been reported previously. The primary endpoint was 28-day ACM. The key secondary endpoint was clinical response at test-of-cure. Participants with vHABP were a prospectively defined subgroup, but subgroup analyses were not powered for noninferiority testing. We compared baseline and treatment factors, efficacy, and safety between ceftolozane/tazobactam and meropenem in participants with vHABP. We also conducted a retrospective multivariable logistic regression analysis in this subgroup to determine the impact of treatment arm on mortality when adjusted for significant prognostic factors. Results Overall, 99 participants in the ceftolozane/tazobactam and 108 in the meropenem arm had vHABP. 28-day ACM was 24.2% and 37.0%, respectively, in the intention-to-treat population (95% confidence interval [CI] for difference: 0.2, 24.8) and 18.2% and 36.6%, respectively, in the microbiologic intention-to-treat population (95% CI 2.5, 32.5). Clinical cure rates in the intention-to-treat population were 50.5% and 44.4%, respectively (95% CI − 7.4, 19.3). Baseline clinical, baseline microbiologic, and treatment factors were comparable between treatment arms. Multivariable regression identified concomitant vasopressor use and baseline bacteremia as significantly impacting ACM in ASPECT-NP; adjusting for these two factors, the odds of dying by day 28 were 2.3-fold greater when participants received meropenem instead of ceftolozane/tazobactam. Conclusions There were no underlying differences between treatment arms expected to have biased the observed survival advantage with ceftolozane/tazobactam in the vHABP subgroup. After adjusting for clinically relevant factors found to impact ACM significantly in this trial, the mortality risk in participants with vHABP was over twice as high when treated with meropenem compared with ceftolozane/tazobactam. Trial registration clinicaltrials.gov, NCT02070757. Registered 25 February, 2014, clinicaltrials.gov/ct2/show/NCT02070757. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03694-3.
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Affiliation(s)
| | | | - Richard G Wunderink
- Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ülo Kivistik
- Pulmonology Centre, North Estonia Medical Centre, Tallinn, Estonia
| | - Martin Nováček
- Department of Anaesthesia and Intensive Care, General Hospital of Kolin, Kolin, Czech Republic
| | - Álvaro Réa-Neto
- Departamento de Clínica Médica, Universidade Federal do Paraná, Curitiba, Brazil
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, Dublin, Ireland.,Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, Barcelona, Spain
| | - Brian Yu
- MRL, Merck & Co., Inc., Kenilworth, NJ, USA
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Lodise TP, Smith NM, O'Donnell N, Eakin AE, Holden PN, Boissonneault KR, Zhou J, Tao X, Bulitta JB, Fowler VG, Chambers HF, Bonomo RA, Tsuji BT. Determining the optimal dosing of a novel combination regimen of ceftazidime/avibactam with aztreonam against NDM-1-producing Enterobacteriaceae using a hollow-fibre infection model. J Antimicrob Chemother 2021; 75:2622-2632. [PMID: 32464664 DOI: 10.1093/jac/dkaa197] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND MBL-producing strains of Enterobacteriaceae are a major public health concern. We sought to define optimal combination regimens of ceftazidime/avibactam with aztreonam in a hollow-fibre infection model (HFIM) of MBL-producing strains of Escherichia coli and Klebsiella pneumoniae. METHODS E. coli ARLG-1013 (blaNDM-1, blaCTX-M, blaCMY, blaTEM) and K. pneumoniae ARLG-1002 (blaNDM-1, blaCTXM-15, blaDHA, blaSHV, blaTEM) were studied in the HFIM using simulated human dosing regimens of ceftazidime/avibactam and aztreonam. Experiments were designed to evaluate the effect of staggered versus simultaneous administration, infusion duration and aztreonam daily dose (6 g/day versus 8 g/day) on bacterial killing and resistance suppression. Prospective validation experiments for the most active combination regimens were performed in triplicate to ensure reproducibility. RESULTS Staggered administration of the combination (ceftazidime/avibactam followed by aztreonam) was found to be inferior to simultaneous administration. Longer infusion durations (2 h and continuous infusion) also resulted in enhanced bacterial killing relative to 30 min infusions. The rate of killing was more pronounced with 8 g/day versus 6 g/day aztreonam combination regimens for both tested strains. In the prospective validation experiments, ceftazidime/avibactam with aztreonam dosed every 8 and 6 h, respectively (ceftazidime/avibactam 2/0.5 g every 8 h + aztreonam 2 g every 6 h), or ceftazidime/avibactam with aztreonam as continuous infusions resulted in maximal bacterial killing and resistance suppression over 7 days. CONCLUSIONS Simultaneous administration of aztreonam 8 g/day given as a continuous or 2 h infusion with ceftazidime/avibactam resulted in complete bacterial eradication and resistance suppression. Further study of this combination is needed with additional MBL-producing Gram-negative pathogens. The safety of this double β-lactam strategy also warrants further study in Phase 1 clinical trials.
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Affiliation(s)
- Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Nicolas M Smith
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | - Nick O'Donnell
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Ann E Eakin
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Patricia N Holden
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
| | | | - Jieqiang Zhou
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Xun Tao
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Jürgen B Bulitta
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Orlando, FL, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Henry F Chambers
- University of California, San Francisco, and San Francisco General Hospital, San Francisco, CA, USA
| | - Robert A Bonomo
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, Biochemistry, and Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Brian T Tsuji
- Laboratory for Antimicrobial Pharmacodynamics, University at Buffalo, Buffalo, NY, USA
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Parsels KA, Mastro KA, Steele JM, Thomas SJ, Kufel WD. Cefiderocol: a novel siderophore cephalosporin for multidrug-resistant Gram-negative bacterial infections. J Antimicrob Chemother 2021; 76:1379-1391. [PMID: 33532823 DOI: 10.1093/jac/dkab015] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cefiderocol is a novel siderophore cephalosporin that forms a complex with extracellular free ferric iron, which leads to transportation across the outer cell membrane to exert its bactericidal activity through cell wall synthesis inhibition. This pharmacological property has rendered cefiderocol active against several clinically relevant MDR Gram-negative bacteria as evidenced by several in vitro and in vivo studies. Cefiderocol was first approved by the US FDA on 14 November 2019 for the treatment of complicated urinary tract infections. On 28 September 2020, cefiderocol was approved for the treatment of hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia. The FDA-approved indications are based on clinical data from the APEKS-cUTI, APEKS-NP and CREDIBLE-CR trials. In APEKS-cUTI, cefiderocol demonstrated non-inferiority to imipenem/cilastatin for the treatment of complicated urinary tract infection caused by MDR Gram-negative bacteria. In APEKS-NP, cefiderocol demonstrated non-inferiority to meropenem for treatment of nosocomial pneumonia. However, in CREDIBLE-CR, higher all-cause mortality was observed with cefiderocol compared with best available therapy for the treatment of severe infections caused by Gram-negative bacteria, primarily in the subset of patients with Acinetobacter spp. infections. Several case reports/series have demonstrated clinical success with cefiderocol for a variety of severe infections. The purpose of this article is to review available data on the mechanism of action, in vitro and in vivo data, pharmacokinetics, pharmacodynamics, susceptibility testing, efficacy and safety of cefiderocol to address its role in therapy.
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Affiliation(s)
- Katie A Parsels
- State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Keri A Mastro
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate University Hospital, Syracuse, NY, USA
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Stephen J Thomas
- State University of New York Upstate University Hospital, Syracuse, NY, USA
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Wesley D Kufel
- State University of New York Upstate University Hospital, Syracuse, NY, USA
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
- State University of New York Upstate Medical University, Syracuse, NY, USA
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45
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Abstract
BACKGROUND The mortality rate of patients with a drug-resistant bacterial infection is high, as are the associated treatment costs. To overcome these issues, optimization of the available therapeutic options is required. Beta-lactams are time-dependent antibiotics and their efficacy is determined by the amount of time the free concentration remains above the minimum inhibitory concentration. Therefore, the aim of this study was to assess the extent and variability of protein binding for meropenem, cefepime, and piperacillin. METHODS Plasma samples for the analysis of meropenem, cefepime, and piperacillin were collected from patients admitted to a tertiary care hospital as part of the standard care. The bound and unbound drug fractions in the samples were separated by ultrafiltration. Validated liquid chromatography-tandem mass spectrometry assays were used to quantify the total and free plasma concentrations, and the protein binding was determined. RESULTS Samples from 95 patients were analyzed. The median (range) age of patients was 56 years (17-87) and the median (range) body mass index was 25.7 kg/m (14.7-74.2). Approximately 59% of the patients were men. The median (range) unbound fraction (fu) was 62.5% (41.6-99.1) for meropenem, 61.4% (51.6-99.2) for cefepime, and 48.3% (39.4-71.3) for piperacillin. In the bivariate analysis, as the total meropenem concentration increased, the fu increased (r = 0.37, P = 0.045). A decrease in piperacillin fu was observed as the albumin concentration increased (r = -0.56, P = 0.005). CONCLUSIONS The average fu values were lower than those reported in the literature. There was also a large variability in fu; hence, it should be considered when managing patients administered with these drugs through direct measurements of free drug concentrations.
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46
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Cusumano JA, Klinker KP, Huttner A, Luther MK, Roberts JA, LaPlante KL. Towards precision medicine: Therapeutic drug monitoring-guided dosing of vancomycin and β-lactam antibiotics to maximize effectiveness and minimize toxicity. Am J Health Syst Pharm 2021; 77:1104-1112. [PMID: 32537644 DOI: 10.1093/ajhp/zxaa128] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The goal of this review is to explore the role of antimicrobial therapeutic drug monitoring (TDM), especially in critically ill, obese, and older adults, with a specific focus on β-lactams and vancomycin. SUMMARY The continued rise of antimicrobial resistance prompts the need to optimize antimicrobial dosing. The aim of TDM is to individualize antimicrobial dosing to achieve antibiotic exposures associated with improved patient outcomes. Initially, TDM was developed to minimize adverse effects during use of narrow therapeutic index agents. Today, patient and organism complexity are expanding the need for precision dosing through TDM services. Alterations of pharmacokinetics and pharmacodynamics (PK/PD) in the critically ill, obese, and older adult populations, in conjunction with declining organism susceptibility, complicate attainment of therapeutic targets. Over the last decade, antimicrobial TDM has expanded with the emergence of literature supporting β-lactam TDM and a shift from monitoring vancomycin trough concentrations to monitoring of the ratio of area under the concentration (AUC) curve to minimum inhibitory concentration (MIC). PK/PD experts should be at the forefront of implementing precision dosing practices. CONCLUSION Precision dosing through TDM is expanding and is especially important in populations with altered PK/PD, including critically ill, obese, and older adults. Due to wide PK/PD variability in these populations, TDM is vital to maximize antimicrobial effectiveness and decrease adverse event rates. However, there is still a need for studies connecting TDM to patient outcomes. Providing patient-specific care through β-lactam TDM and transitioning to vancomycin AUC/MIC monitoring may be challenging, but with experts at the forefront of this initiative, PK-based optimization of antimicrobial therapy can be achieved.
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Affiliation(s)
- Jaclyn A Cusumano
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | | | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Megan K Luther
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, University of Queensland, Brisbane, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Veterans Affairs Medical Center, Providence, RI.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI
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El-Haffaf I, Caissy JA, Marsot A. Piperacillin-Tazobactam in Intensive Care Units: A Review of Population Pharmacokinetic Analyses. Clin Pharmacokinet 2021; 60:855-875. [PMID: 33876381 DOI: 10.1007/s40262-021-01013-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 12/15/2022]
Abstract
Piperacillin-tazobactam is a potent β-lactam/β-lactamase inhibitor antibiotic commonly prescribed in the intensive care unit setting. Admitted patients often show large variability in treatment response due to multiple pathophysiological changes present in this population that alter the drug's pharmacokinetics. This review summarizes the population pharmacokinetic models developed for piperacillin-tazobactam and provides comprehensive data on current dosing strategies while identifying significant covariates in critically ill patients. A literature search on the PubMed database was conducted, from its inception to July 2020. Relevant articles were retained if they met the defined inclusion/exclusion criteria. A total of ten studies, published between 2009 and 2020, were eligible. One- and two-compartment models were used in two and eight studies, respectively. The lowest estimated piperacillin clearance value was 3.12 L/h, and the highest value was 19.9 L/h. The estimations for volume of distribution varied between 11.2 and 41.2 L. Tazobactam clearance values ranged between 5.1 and 6.78 L/h, and tazobactam volume of distribution values ranged between 17.5 and 76.1 L. The most frequent covariates were creatinine clearance and body weight, each present in four studies. Almost all studies used an exponential approach for the interindividual variability. The highest variability was observed in piperacillin central volume of distribution, at a value of 75.0%. Simulations showed that continuous or extended infusion methods performed better than intermittent administration to achieve appropriate pharmacodynamic targets. This review synthesizes important pharmacokinetic elements for piperacillin-tazobactam in an intensive care unit setting. This will help clinicians better understand changes in the drug's pharmacokinetic parameters in this specific population.
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Affiliation(s)
- Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
| | - Jean-Alexandre Caissy
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.,Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.,Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
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Riccobene TA, Carrothers TJ, Knebel W, Raber S, Chan PL. Pharmacokinetic and Pharmacodynamic Target Attainment in Adult and Pediatric Patients Following Administration of Ceftaroline Fosamil as a 5-Minute Infusion. Clin Pharmacol Drug Dev 2021; 10:420-427. [PMID: 33465279 PMCID: PMC8048922 DOI: 10.1002/cpdd.907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 12/17/2020] [Indexed: 12/15/2022]
Abstract
The key pharmacokinetic/pharmacodynamic (PK/PD) efficacy index for β-lactam antibiotics is the percentage of time that free drug concentrations exceed the minimum inhibitory concentration (MIC) of bacteria during each dosing interval (fT>MIC). Ceftaroline fosamil, the prodrug of the β-lactam ceftaroline, was initially approved for administration as 60-minute intravenous (IV) infusions. Population PK analyses comparing exposure and PK/PD target attainment for 5-minute and 60-minute IV infusions, described here, have supported ceftaroline fosamil labeling updates to include variable infusion durations of 5 to 60 minutes in adults and children aged ≥2 months. A 2-compartment disposition PK model for ceftaroline fosamil and ceftaroline was used to predict steady-state ceftaroline exposures (maximum plasma concentrations [Cmax,ss ] and area under the plasma concentration-time curve over 24 hours [AUCss,0-24 ]) and probability of target attainment in simulated adult and pediatric patients with various degrees of renal function receiving standard doses of ceftaroline fosamil as 5-minute or 60-minute IV infusions. Across age groups and renal function categories, median ceftaroline AUCss,0-24 values were similar for 5-minute and 60-minute infusions, whereas Cmax,ss was up to 42% higher for 5-minute infusions. Both infusion durations achieved >99% probability of target attainment based on PK/PD targets for Staphylococcus aureus (35% fT>MIC) and Streptococcus pneumoniae (44% fT>MIC) at European Committee on Antimicrobial Susceptibility Testing/Clinical and Laboratory Standards Institute MIC breakpoints (1 mg/L and 0.25/0.5 mg/L, respectively). These findings support administration of standard ceftaroline fosamil doses over 5 to 60 minutes for adults and children aged ≥2 months, providing added flexibility to clinicians and patients.
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Short and long term impact of combining restrictive and enabling interventions to reduce aztreonam consumption in a community hospital. Int J Clin Pharm 2021; 43:1345-1351. [PMID: 33677793 PMCID: PMC7937360 DOI: 10.1007/s11096-021-01257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/22/2021] [Indexed: 10/28/2022]
Abstract
Background Antimicrobial stewardship initiatives combining restrictive and enabling components may be an effective strategy to achieve short- and long-term objectives. Aztreonam, a relatively high-cost antipseudomonal antibiotic, is an appropriate target for stewardship initiatives based on propensity for overuse in penicillin allergy, an activity profile often warranting additional empiric gram-negative and gram-positive coverage, and a unique durability to Ambler class B metallo-beta-lactamases. Objective Analyze the immediate and long-term impact on aztreonam prescribing of combining restrictive and enabling interventions. Setting Single 233-bed community hospital with 45 adult intensive care unit beds in Nashville, Tennessee. Method Retrospective, interrupted time series analysis comparing all patients receiving aztreonam prior to intervention between January 1, 2010 and September 30, 2011 and following intervention between October 1, 2011 and September 30, 2019. Quarterly defined daily doses/1000 adjusted patient days and microbiology laboratory annual surveillance data were utilized for analysis. Main outcome measure Post-intervention change in trend of aztreonam consumption. Results Following intervention, a significant decline in aztreonam consumption was observed (- 1.97 defined daily doses/1000 adjusted patient days; p = 0.003) resulting in a sustained decrease in aztreonam consumption from 2011 (3rd quarter) to 2019 (3rd quarter) from 15.2 to 0.26 defined daily doses/1000 adjusted patient days. Short-term group 2 carbapenem consumption increased (p = 0.044). Pseudomonas aeruginosa susceptibility to aztreonam improved from 2011 to 2018 (72% vs. 84%; p = 0.0004) without deleterious effects to alternative antipseudomonal beta-lactams. Conclusion Combining restrictive and enabling interventions had immediate and sustained impact on aztreonam consumption with P. aeruginosa susceptibility improvement.
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Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy 2021; 41:220-233. [PMID: 33480024 DOI: 10.1002/phar.2505] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/13/2022]
Abstract
Therapeutic drug monitoring (TDM) opens the door to personalized medicine, yet it is infrequently applied to β-lactam antibiotics, one of the most commonly prescribed drug classes in the hospital setting. As we continue to understand more about β-lactam pharmacodynamics (PD) and wide inter- and intra-patient variability in pharmacokinetics (PK), the utility of TDM has become increasingly apparent. For β-lactams, the time that free concentrations remain above the minimum inhibitory concentration (MIC) as a function of the dosing interval (%fT>MIC) has been shown to best predict antibacterial effect. Many studies have shown that β-lactam %fT>MIC exposures are often suboptimal across a wide variety of disease states and clinical settings. A limitation to implementing this practice is the general lack of understanding on how to best operationalize this intervention and interpret the results. The instrumentation and expertise needed to quantify β-lactams for TDM is rarely available locally, but certain laboratories advertise these services and perform them regularly. Familiarity with the modalities and nuances of antimicrobial susceptibility testing is crucial to establishing β-lactam concentration targets that meet the relevant exposure thresholds. Evaluation of these concentrations is best accomplished using population PK software and Bayesian modeling, for which a multitude of programs are available. While TDM of β-lactams has shown an ability to increase the rate of target attainment, there is currently limited evidence to suggest that it leads to improved clinical outcomes. Although consensus guidelines for β-lactam TDM do not exist in the United States, guidance would help to promote this important practice and better standardize the approach across institutions. Herein, we discuss the basis for β-lactam TDM, review supporting evidence, and provide guidance for implementation in specific patient populations.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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