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Pehlivanli A, Yanik Yalçin T, Yeşiler Fİ, Şahintürk H, Kurt Azap Ö, Zeyneloğlu P, Başgut B. Antimicrobial dosing recommendations during continuous renal replacement therapy: different databases, different doses. J Chemother 2024:1-9. [PMID: 38409748 DOI: 10.1080/1120009x.2024.2321015] [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: 09/12/2023] [Accepted: 02/14/2024] [Indexed: 02/28/2024]
Abstract
Meticulous antimicrobial management is essential among critically ill patients with acute kidney injury, particularly if renal replacement therapy is needed. Many factors affect drug removal in patients undergoing continuous renal replacement therapy CRRT. In this study, we aimed to compare current databases that are frequently used to adjust CRRT dosages of antimicrobial drugs with the gold standard. The dosage recommendations from various databases for antimicrobial drugs eliminated by CRRT were investigated. The book 'Renal Pharmacotherapy: Dosage Adjustment of Medications Eliminated by the Kidneys' was chosen as the gold standard. There were variations in the databases. Micromedex, UpToDate, and Sanford had similar rates to the gold standard of 45%, 35%, and 30%, respectively. The Micromedex database shows the most similar results to the gold standard source. In addition, a consensus was reached as a result of the expert panel meetings established to discuss the different antimicrobial dose recommendations of the databases.
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Affiliation(s)
- Aysel Pehlivanli
- Pharmacology Department, Faculty of Pharmacy, Başkent University
- Clinical Pharmacy and Drug Information Center, Ankara Hospital, Başkent University
| | - Tuğba Yanik Yalçin
- Infectious Diseases and Clinical Microbiology Department, Faculty of Medicine, Başkent University
| | - Fatma İrem Yeşiler
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Helin Şahintürk
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Özlem Kurt Azap
- Infectious Diseases and Clinical Microbiology Department, Faculty of Medicine, Başkent University
| | - Pınar Zeyneloğlu
- Anesthesiology and Critical Care Unit Department, Faculty of Medicine, Başkent University
| | - Bilgen Başgut
- Pharmacology Department, Faculty of Pharmacy, Başkent University
- Clinical Pharmacy and Drug Information Center, Ankara Hospital, Başkent University
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2
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Cusack R, Little E, Martin-Loeches I. Practical Lessons on Antimicrobial Therapy for Critically Ill Patients. Antibiotics (Basel) 2024; 13:162. [PMID: 38391547 PMCID: PMC10886263 DOI: 10.3390/antibiotics13020162] [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: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis stands as a formidable global health challenge, with persistently elevated mortality rates in recent decades. Each year, sepsis not only contributes to heightened morbidity but also imposes substantial healthcare costs on survivors. This narrative review aims to highlight the targeted measures that can be instituted to alleviate the incidence and impact of sepsis in intensive care. Here we discuss measures to reduce nosocomial infections and the prevention of equipment and patient colonisation by resilient pathogens. The overarching global crisis of bacterial resistance to newly developed antimicrobial agents intensifies the imperative for antimicrobial stewardship and de-escalation. This urgency has been accentuated in recent years, notably during the COVID-19 pandemic, as high-dose steroids and opportunistic infections presented escalating challenges. Ongoing research into airway colonisation's role in influencing disease outcomes among critically ill patients underscores the importance of tailoring treatments to disease endotypes within heterogeneous populations, which are important lessons for intensivists in training. Looking ahead, the significance of novel antimicrobial delivery systems and drug monitoring is poised to increase. This narrative review delves into the multifaceted barriers and facilitators inherent in effectively treating critically ill patients vulnerable to nosocomial infections. The future trajectory of intensive care medicine hinges on the meticulous implementation of vigilant stewardship programs, robust infection control measures, and the continued exploration of innovative and efficient technological solutions within this demanding healthcare landscape.
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Affiliation(s)
- Rachael Cusack
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Elizabeth Little
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James' Hospital, D08 NHY1 Dublin, Ireland
- Hospital Clinic, Universitat de Barcelona, IDIBAPS, CIBERES, 08180 Barcelona, Spain
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3
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Friedel M, Thompson IAP, Kasting G, Polsky R, Cunningham D, Soh HT, Heikenfeld J. Opportunities and challenges in the diagnostic utility of dermal interstitial fluid. Nat Biomed Eng 2023; 7:1541-1555. [PMID: 36658344 DOI: 10.1038/s41551-022-00998-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/06/2022] [Indexed: 01/21/2023]
Abstract
The volume of interstitial fluid (ISF) in the human body is three times that of blood. Yet, collecting diagnostically useful ISF is more challenging than collecting blood because the extraction of dermal ISF disrupts the delicate balance of pressure between ISF, blood and lymph, and because the triggered local inflammation further skews the concentrations of many analytes in the extracted fluid. In this Perspective, we overview the most meaningful differences in the make-up of ISF and blood, and discuss why ISF cannot be viewed generally as a diagnostically useful proxy for blood. We also argue that continuous sensing of small-molecule analytes in dermal ISF via rapid assays compatible with nanolitre sample volumes or via miniaturized sensors inserted into the dermis can offer clinically advantageous utility, particularly for the monitoring of therapeutic drugs and of the status of the immune system.
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Affiliation(s)
- Mark Friedel
- Novel Device Laboratory, Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Ian A P Thompson
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Gerald Kasting
- The James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Ronen Polsky
- Nano and Micro Sensors, Sandia National Laboratories, Albuquerque, NM, USA
| | - David Cunningham
- Department of Chemistry and Physics, Southeast Missouri State University, Cape Girardeau, MO, USA
| | - Hyongsok Tom Soh
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA.
- Department of Radiology, Stanford University, Stanford, CA, USA.
| | - Jason Heikenfeld
- Novel Device Laboratory, Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA.
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Ashino T, Nakamura Y, Ohtaki H, Iwakura Y, Numazawa S. Downregulation of the gene expression of Cyp2c29 and Cyp3a11 by cecal ligation and puncture-induced sepsis is associated with interleukin-6. Int Immunopharmacol 2023; 117:110039. [PMID: 36944277 DOI: 10.1016/j.intimp.2023.110039] [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: 01/29/2023] [Revised: 03/07/2023] [Accepted: 03/12/2023] [Indexed: 03/22/2023]
Abstract
Sepsis is a pathological condition that affects the metabolism of administered drugs, leading to changes in the duration and intensity of their intended efficacies. Proinflammatory cytokines downregulate the expression of cytochrome P450s (P450s). The effects of P450 expression under inflammatory conditions have been studied using prophlogistic substances such as lipopolysaccharide; however, few studies have focused on clinical models of sepsis. Here, we show that cecal ligation and puncture (CLP), an approach for the study of human polymicrobial sepsis, leads to the expression of interleukin-1β (IL-1β), IL-6, and tumor necrosis factor α (TNFα) at 24 h after the CLP operation. Following CLP, IL-6-/- mice exhibited markedly lower survival than WT mice. In addition, CLP led to the significant downregulation of Cyp2c29 and Cyp3a11 gene expression in IL-1α-/-/β-/- (IL-1-/-) and TNFα-/- mice as well as in WT mice. In contrast, CLP elicited no significant effect on Cyp3a11 expression in IL-6-/- mice. Although CLP reduced the Cyp2c29 expression level in IL-6-/- mice, the expression of Cyp2c29 was lower in CLP-operated WT mice than in CLP-operated IL-6-/- mice. The reduction in the respective P450 protein levels and activities due to CLP-induced sepsis, reflected in the mRNA expression levels, was abolished by IL-6 depletion. Thus, CLP-induced sepsis downregulates P450 gene expression, particularly Cyp2c expression, and this effect is associated with IL-6 without affecting resistance to CLP-induced sepsis. These findings demonstrate the usefulness of CLP for studying the regulation of P450s and highlight IL-6 as a potential indicator of drug-metabolizing capacity under septic conditions.
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Affiliation(s)
- Takashi Ashino
- Division of Toxicology, Department of Pharmacology, Toxicology and Therapeutics, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan; Pharmacological Research Center, Showa University, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan.
| | - Yuki Nakamura
- Division of Toxicology, Department of Pharmacology, Toxicology and Therapeutics, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan; Center for Pharmaceutical Education, Faculty of Pharmacy, Yokohama University of Pharmacy, 601 Matano, Totsuka, Yokohama, Kanagawa 245-0066, Japan
| | - Hirokazu Ohtaki
- Department of Functional Neurobiology, School of Pharmacy, Tokyo University of Pharmacy and Life Science, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Yoichiro Iwakura
- Center for Animal Disease Models, Research Institute for Biomedical Sciences, Tokyo University of Science, 2669 Yamazaki, Noda, Chiba 278-0022, Japan
| | - Satoshi Numazawa
- Division of Toxicology, Department of Pharmacology, Toxicology and Therapeutics, Showa University School of Pharmacy, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan; Pharmacological Research Center, Showa University, 1-5-8 Hatanodai, Shinagawa, Tokyo 142-8555, Japan
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5
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Mercer MA, Davis JL, McKenzie HC, Messenger KM, Schaefer E, Council-Troche RM, Werre SR. Pharmacokinetics and efficacy of orally administered acetaminophen (paracetamol) in adult horses with experimentally induced endotoxemia. J Vet Intern Med 2023; 37:718-727. [PMID: 36840424 DOI: 10.1111/jvim.16663] [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: 09/13/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Acetaminophen has been evaluated in horses for treatment of musculoskeletal pain but not as an antipyretic. OBJECTIVES To determine the pharmacokinetics and efficacy of acetaminophen compared to placebo and flunixin meglumine in adult horses with experimentally induced endotoxemia. ANIMALS Eight university owned research horses with experimentally induced endotoxemia. METHODS Randomized placebo controlled crossover study. Horses were treated with acetaminophen (30 mg/kg PO; APAP), flunixin meglumine (1.1 mg/kg, PO; FLU), and placebo (PO; PLAC) 2 hours after administration of LPS. Plasma APAP was analyzed via LC-MS/MS. Serial CBC, lactate, serum amyloid A, heart rate and rectal temperature were evaluated. Serum IL-1β, IL-6, IL-8, IL-10, and TNF-α were evaluated by an equine-specific multiplex assay. RESULTS Mean maximum plasma APAP concentration was 13.97 ± 2.74 μg/mL within 0.6 ± 0.3 hour after administration. At 4 and 6 hours after treatment, both APAP (P = <.001, P = .03, respectively) and FLU (P = .0045 and P < .001, respectively) had a significantly greater decrease in rectal temperature compared to placebo. FLU caused greater heart rate reduction than APAP at 4 and 6 hours (P = .004 and P = .04), and PLAC at 4 hours (P = .05) after treatment. CONCLUSIONS AND CLINICAL IMPORTANCE The pharmacokinetics of acetaminophen in endotoxemic horses differ from those reported by previous studies in healthy horses. Acetaminophen is an option for antipyresis in clinical cases, particularly when administration of traditional NSAIDs is contraindicated.
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Affiliation(s)
- Melissa A Mercer
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
| | - Jennifer L Davis
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
| | - Harold C McKenzie
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
| | - Kristen M Messenger
- Department of Molecular Biomedical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, USA
| | - Emily Schaefer
- Department of Large Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
| | - R McAlister Council-Troche
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
| | - Stephen R Werre
- Department of Population Health Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, USA
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Morales Junior R, Telles JP, Kwiatkowski SYC, Juodinis VD, de Souza DC, Santos SRCJ. Pharmacokinetic and pharmacodynamic considerations of antibiotics and antifungals in liver transplantation recipients. Liver Transpl 2023; 29:91-102. [PMID: 35643926 DOI: 10.1002/lt.26517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 01/14/2023]
Abstract
The liver plays a major role in drug metabolism. Liver transplantation impacts the intrinsic metabolic capability and extrahepatic mechanisms of drug disposition and elimination. Different levels of inflammation and oxidative stress during transplantation, the process of liver regeneration, and the characteristics of the graft alter the amount of functional hepatocytes and activity of liver enzymes. Binding of drugs to plasma proteins is affected by the hyperbilirubinemia status and abnormal synthesis of albumin and alpha-1-acid glycoproteins. Postoperative intensive care complications such as biliary, circulatory, and cardiac also impact drug distribution. Renally eliminated antimicrobials commonly present reduced clearance due to hepatorenal syndrome and the use of nephrotoxic immunosuppressants. In addition, liver transplantation recipients are particularly susceptible to multidrug-resistant infections due to frequent manipulation, multiple hospitalizations, invasive devices, and frequent use of empiric broad-spectrum therapy. The selection of appropriate anti-infective therapy must consider the pathophysiological changes after transplantation that impact the pharmacokinetics and pharmacodynamics of antibiotics and antifungal drugs.
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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
| | - João Paulo Telles
- Department of Infectious Diseases , AC Camargo Cancer Center , São Paulo , Brazil
| | | | - Vanessa D'Amaro Juodinis
- Pediatric Intensive Care Unit, Department of Pediatrics , Hospital Sírio-Libanês , São Paulo , Brazil
| | - Daniela Carla de Souza
- Pediatric Intensive Care Unit, Department of Pediatrics , Hospital Sírio-Libanês , São Paulo , Brazil
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7
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Ewoldt TMJ, Abdulla A, Hunfeld N, Li L, Smeets TJL, Gommers D, Koch BCP, Endeman H. The impact of sepsis on hepatic drug metabolism in critically ill patients: a narrative review. Expert Opin Drug Metab Toxicol 2022; 18:413-421. [PMID: 35912845 DOI: 10.1080/17425255.2022.2106215] [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: 11/04/2022]
Abstract
INTRODUCTION Hepatic drug metabolism is important in improving drug dosing strategies in sepsis. Pharmacokinetics in the critically ill population are severely altered due to changes in absorption, distribution, excretion and metabolization. Hepatic drug metabolism might be altered due to changes in hepatic blood flow, drug metabolizing protein availability, and protein binding. The purpose of this review is to examine evidence on whether hepatic drug metabolism is significantly affected in septic patients, and to provide insights in the need for future research. AREAS COVERED This review describes the effect of sepsis on hepatic drug metabolism in humans. Clinical trials, pathophysiological background information and example drug groups are further discussed. The literature search has been conducted in Embase, Medline ALL Ovid, and Cochrane CENTRAL register of trials. EXPERT OPINION Limited research has been conducted on drug metabolism in the sepsis population, with some trials having researched healthy individuals using endotoxin injections. Notwithstanding this limitation, hepatic drug metabolism seems to be decreased for certain drugs in sepsis. More research on the pharmacokinetic behavior of hepatic metabolized drugs in sepsis is warranted, using inflammatory biomarkers, hemodynamic changes, mechanical ventilation, organ support, and catecholamine infusion as possible confounders.
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Affiliation(s)
- Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole Hunfeld
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
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8
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Towards Improved Management of Tuberculous Bloodstream Infections: Pharmacokinetic Considerations with Suggestions for Better Treatment Outcomes. Antibiotics (Basel) 2022; 11:antibiotics11070895. [PMID: 35884149 PMCID: PMC9311525 DOI: 10.3390/antibiotics11070895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
Mycobacterium tuberculosis is the leading cause of sepsis among HIV-infected adults, yet effective treatment remains a challenge. Efficacy of antituberculous drugs is optimized by high Area Under Curve to Minimum Inhibitory Concentration (AUC/MIC) ratios, suggesting that both the drug concentration at the disease site and time above MIC are critical to treatment outcomes. We elaborate on sepsis pathophysiology and show how it adversely affects antituberculous drug kinetics. Expanding distribution volumes secondary to an increased vascular permeability prevents the attainment of target Cmax concentrations for nearly all drugs. Furthermore, sepsis-induced metabolic acidosis promotes protonation, which increases renal clearance of basic drugs such as isoniazid and ethambutol, and hence AUCs are substantially reduced. Compared with the treatment of non-sepsis TB disease, these distorted kinetics underlie the poor treatment outcomes observed with bloodstream infections. In addition to aggressive hemodynamic management, an increase in both the dose and frequency of drug administration are warranted, at least in the early phase of treatment.
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9
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Hughes S, Heard KL, Mughal N, Moore LSP. Optimization of antimicrobial dosing in patients with acute kidney injury: a single-centre observational study. JAC Antimicrob Resist 2022; 4:dlac080. [PMID: 35898430 PMCID: PMC9311788 DOI: 10.1093/jacamr/dlac080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Acute kidney injury (AKI) is a potential complication of systemic infection. Optimizing antimicrobial dosing in this dynamic state can be challenging with sub- or supra-therapeutic dosing risking treatment failure or toxicity, respectively. Locally, unadjusted renal dosing for the first 48 h of infection is recommended. Objectives To determine the outcomes associated with this dosing strategy. Methods A retrospective cohort analysis was undertaken in patients treated for Gram-negative bacteraemia with concurrent non-filtration dependent AKI from a single-centre NHS acute hospital (April 2016–March 2020). Patient demographics, microbiology data, antimicrobial treatment and patient outcome (in-hospital mortality and kidney function) were analysed. Results In total, 647 episodes of Gram-negative bacteraemia (608 patients) were included; 305/608 (50.2%) were male with median age 71 years (range 18–100). AKI was present in 235/647 (36.3%); 78/647 (12.1%) and 45/647 (7.0%) having Kidney Disease Improving Global Outcomes-defined injury (stage 2) or failure (stage 3), respectively. In-hospital 30 day mortality was 25/352 (7.1%), 14/112 (12.5%), 26/123 (21.1%) and 11/60(18.3%) in patients with normal renal function, AKI stage 1, AKI stage ≥2 and established chronic kidney disease, respectively. Recovery of renal function at Day 21 or discharge was present in 105/106 surviving patients presenting with AKI stage ≥2. Time to recovery of AKI was similar in patients receiving full, low or no aminoglycoside (3 versus 4 versus 3 days, P = 0.612) and those receiving full- and low-dose β-lactam (3 versus 5 days, P = 0.077). Conclusions There is a high burden of AKI in patients with Gram-negative bacteraemia. Dose adjustments of β-lactams may not be necessary in the first 48 h of infection-induced AKI and single-dose aminoglycosides may be considered for early empirical coverage.
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Affiliation(s)
- Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust , 369 Fulham Road, London SW10 9NH , UK
| | - Katie L Heard
- Chelsea and Westminster NHS Foundation Trust , 369 Fulham Road, London SW10 9NH , UK
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust , 369 Fulham Road, London SW10 9NH , UK
- North West London Pathology, Imperial College Healthcare NHS Trust , Fulham Palace Road, London W6 8RF , UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus , Du Cane Road, London W12 0NN , UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust , 369 Fulham Road, London SW10 9NH , UK
- North West London Pathology, Imperial College Healthcare NHS Trust , Fulham Palace Road, London W6 8RF , UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus , Du Cane Road, London W12 0NN , UK
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Dale GH, Holmaas G, Berg JA, Riedel B, Schjøtt J, Bjånes TK. A Patient With Sepsis-Induced Multiorgan Failure and Increasing Serum Methadone Concentration: A Case Study. Ther Drug Monit 2022; 44:366-368. [PMID: 35067668 DOI: 10.1097/ftd.0000000000000963] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/29/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The authors describe a patient with substance use disorder admitted to the hospital with septic shock and multiorgan failure, in whom the serum concentration of methadone kept increasing despite discontinuation of the drug. Therapeutic drug monitoring was performed to monitor the methadone serum concentration during treatment of the underlying diseases.
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Affiliation(s)
- Gro Helen Dale
- Departments of Medical Biochemistry and Pharmacology and
| | - Gunhild Holmaas
- Anesthesia and Intensive Care, Haukeland University Hospital
| | - Jon A Berg
- Departments of Medical Biochemistry and Pharmacology and
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen; and
| | - Bettina Riedel
- Departments of Medical Biochemistry and Pharmacology and
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen; and
| | - Jan Schjøtt
- Departments of Medical Biochemistry and Pharmacology and
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen; and
- Regional Medicines Information and Pharmacovigilance Centre (RELIS Vest), Haukeland University Hospital, Bergen, Norway
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11
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Badin RC, Martins CSM, Manaças LRA. Pharmacological profile and potential drug interactions in ovarian cancer hospitalized patients. J Oncol Pharm Pract 2022:10781552221091298. [DOI: 10.1177/10781552221091298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to identify the main therapeutic classes prescribed to ovarian cancer patients and the potential drug interactions (PDI) during hospitalization. This descriptive retrospective work was carried out in a referral gynecological cancer hospital from the Brazilian public health system. The first 24 h inpatients’ prescriptions were evaluated to obtain the pharmacological profile data. Clinical and epidemiological characteristics were collected through the analysis of electronic medical records. A total of 236 patients were included in the study, of which 154 (65.25%) had PDI, with a mean of 1.43 ± 1.76 interactions per patient. The main therapeutic classes prescribed were analgesics and antiemetics (35%), compatible with the oncologic supportive care. All PDI identified (n = 331) were categorized by severity, using the Micromedex database, resulting in: 1.51% contraindicated, 67.67% major, 24.77% moderate, and 6.04% minor. The more prevalent PDI were ondansetron/tramadol (22.05%) and metoclopramide/tramadol (7.25%), both major. An association between PDI and polypharmacy was observed, which did not occur between age or length of stay. Ongoing prescription review by the pharmaceutical team is necessary to identify, monitor, and manage PDI-related adverse events and carry out required interventions with patients, physicians, and nurses. Taken together the data showed that even in a specialized hospital, the complexity of the pharmacotherapy can cause harm to the ovarian cancer patient. The clinical pharmacist acting in a multidisciplinary team is important for improving patient safety in oncology services.
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Affiliation(s)
- Rebeka Caribé Badin
- Pharmacy Service, National Cancer Institute José Alencar Gomes da Silva - Cancer Hospital II, Rio de Janeiro, RJ, Brazil
| | - Carolina Souza Machado Martins
- Pharmacy Service, National Cancer Institute José Alencar Gomes da Silva - Cancer Hospital II, Rio de Janeiro, RJ, Brazil
| | - Liliane Rosa Alves Manaças
- Pharmacy Service, National Cancer Institute José Alencar Gomes da Silva - Cancer Hospital II, Rio de Janeiro, RJ, Brazil
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12
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Ghasemiyeh P, Mohammadi-Samani S, Firouzabadi N, Vazin A, Zand F. A brief ICU residents’ guide: Pharmacotherapy, pharmacokinetic aspects and dose adjustments in critically ill adult patients admitted to ICU. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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13
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Dao K, Fuchs A, André P, Giannoni E, Decosterd LA, Marchetti O, Asner SA, Pfister M, Widmer N, Buclin T, Csajka C, Guidi M. Dosing strategies of imipenem in neonates based on pharmacometric modelling and simulation. J Antimicrob Chemother 2021; 77:457-465. [PMID: 34791295 DOI: 10.1093/jac/dkab394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Imipenem is a broad-spectrum antibacterial agent used in critically ill neonates after failure of first-line treatments. Few studies have described imipenem disposition in this population. The objectives of our study were: (i) to characterize imipenem population pharmacokinetics (PK) in a cohort of neonates; and (ii) to conduct model-based simulations to evaluate the performance of six different dosing regimens aiming at optimizing PK target attainment. METHODS A total of 173 plasma samples from 82 neonates were collected over 15 years at the Lausanne University Hospital, Switzerland. The majority of study subjects were preterm neonates with a median gestational age (GA) of 27 weeks (range: 24-41), a postnatal age (PNA) of 21 days (2-153) and a body weight (BW) of 1.16 kg (0.5-4.1). PK data were analysed using non-linear mixed-effect modelling (NONMEM). RESULTS A one-compartment model best characterized imipenem disposition. Population PK parameters estimates of CL and volume of distribution were 0.21 L/h and 0.73 L, with an interpatient variability (CV%) of 20.1% on CL in a representative neonate (GA 27 weeks, PNA 21 days, BW 1.16 kg, serum creatinine, SCr 46.6 μmol/L). GA and PNA exhibited the greatest impact on PK parameters, followed by SCr. These covariates explained 36% and 15% of interindividual variability in CL, respectively.Simulated regimens using a dose of 20-25 mg/kg every 6-12 h according to postnatal age led to the highest PTA (T>MIC over 100% of time). CONCLUSIONS Dosing adjustment according to BW, GA and PNA optimizes imipenem exposure in neonates.
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Affiliation(s)
- Kim Dao
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aline Fuchs
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pascal André
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Innovation and Development Laboratory, Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Oscar Marchetti
- Service of Infectious Disease, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Medicine, Ensemble Hospitalier de la Côte, Morges, Switzerland
| | - Sandra A Asner
- Pediatric Infectious Disease and Vaccinology Unit, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, UKBB, Basel, Switzerland
| | - Nicolas Widmer
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Pharmacy of the Eastern Vaud Hospitals, Rennaz, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Lausanne, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Chantal Csajka
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Lausanne, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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14
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Dose Optimization of Vancomycin for Critically Ill Patients Undergoing CVVH: A Prospective Population PK/PD Analysis. Antibiotics (Basel) 2021; 10:antibiotics10111392. [PMID: 34827330 PMCID: PMC8614878 DOI: 10.3390/antibiotics10111392] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/02/2021] [Accepted: 11/09/2021] [Indexed: 12/27/2022] Open
Abstract
The optimal dose of vancomycin in critically ill patients receiving continuous venovenous hemofiltration (CVVH) remains unclear. The objective of this study was to identify factors that significantly affect pharmacokinetic profiles and to further investigate the optimal dosage regimens for critically ill patients undergoing CVVH based on population pharmacokinetics and pharmacodynamic analysis. A prospective population pharmacokinetic analysis was performed at the surgical intensive care unit in a level A tertiary hospital. We included 11 critically ill patients undergoing CVVH and receiving intravenous vancomycin. Serial blood samples were collected from each patient, with a total of 131 vancomycin concentrations analyzed. Nonlinear mixed effects models were developed using NONMEM software. Monte Carlo Simulation was used to optimize vancomycin dosage regimens. A two-compartment model with first-order elimination was sufficient to characterize vancomycin pharmacokinetics for CVVH patients. The population typical vancomycin clearance (CL) was 1.15 L/h and the central volume of distribution was 16.9 L. CL was significantly correlated with ultrafiltration rate (UFR) and albumin level. For patients with normal albumin and UFR between 20 and 35 mL/kg/h, the recommended dosage regimen was 10 mg/kg qd. When UFR was between 35 and 40 mL/kg/h, the recommended dosage regimen was 5 mg/kg q8h. For patients with hypoalbuminemia and UFR between 20 and 25 mL/kg/h, the recommended dosage regimen was 5 mg/kg q8h. When UFR was between 25 and 40 mL/kg/h, the recommended dosage regimen was 10 mg/kg q12h. We recommend clinicians choosing the optimal initial vancomycin dosage regimens for critically ill patients undergoing CVVH based on these two covariates.
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Santiago-Llorente I, López-San Román FJ, Villalba-Orero M. Demographic, preoperative and anaesthesia-related risk factors for unsatisfactory recovery quality in horses undergoing emergency abdominal surgery. Vet Anaesth Analg 2021; 48:882-890. [PMID: 34642100 DOI: 10.1016/j.vaa.2021.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/26/2021] [Accepted: 04/28/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine demographic, preoperative and anaesthesia-related variables that may be associated with unsatisfactory recovery quality in horses undergoing emergency abdominal surgery (colic) in an equine teaching hospital. STUDY DESIGN Retrospective case series. ANIMALS A total of 313 horses. METHODS The anaesthetic records of horses admitted for surgical treatment of colic between 2005 and 2018 were examined. Overall quality of recovery was assessed as dangerous, poor, fair, good or excellent. The following categories were constructed as a dichotomic variable: unsatisfactory recovery (poor and dangerous recoveries) and satisfactory recovery (excellent, good and fair recoveries). Univariable and multivariable analyses were performed to evaluate the association between all studied variables and recovery. RESULTS All recoveries were unassisted. Unsatisfactory recovery quality totalled 17.2% (3.5% and 13.7% were dangerous and poor recoveries, respectively), whereas satisfactory recoveries totalled 82.8% (26.2%, 40.9% and 15.7% were fair, good and excellent recoveries, respectively). Univariable analysis showed that unsatisfactory recoveries were associated with high preoperative packed cell volume, pain behaviour, poor premedication and induction quality, high intraoperative mean heart rate, low mean arterial blood pressure, dobutamine dose ≥1.5 μg kg-1 minute-1, non-administration of romifidine, long anaesthesia time and prolonged time to stand. The multivariable model showed that factors strongly associated with unsatisfactory recovery quality were dobutamine dose ≥1.5 μg kg-1 minute-1 [adjusted odds ratio (AOR) = 6.60; 95% confidence interval (CI), 2.91-14.96], poor premedication quality (AOR=4.60; 95% CI, 1.73-12.23) and a time to stand > 70 minutes (AOR=2.59; 95% CI, 1.13-5.91). CONCLUSIONS AND CLINICAL RELEVANCE Our study shows that high dobutamine requirements, poor premedication quality and a prolonged time to stand are risk factors for unsatisfactory recovery quality in horses undergoing anaesthesia for colic surgery. Addressing these factors may enable clinicians to improve the quality of recovery phase.
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Affiliation(s)
- Isabel Santiago-Llorente
- Hospital Clínico Veterinario Complutense, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Javier López-San Román
- Hospital Clínico Veterinario Complutense, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain; Departamento de Medicina y Cirugía Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain
| | - María Villalba-Orero
- Hospital Clínico Veterinario Complutense, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain; Departamento de Medicina y Cirugía Animal, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain.
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Population Pharmacokinetic Modeling and Dose Optimization of Vancomycin in Chinese Patients with Augmented Renal Clearance. Antibiotics (Basel) 2021; 10:antibiotics10101238. [PMID: 34680818 PMCID: PMC8532702 DOI: 10.3390/antibiotics10101238] [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: 08/28/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with augmented renal clearance (ARC) have been described as having low vancomycin concentration. However, the pharmacokinetic model that best describes vancomycin in patients with ARC has not been clarified. The purpose of this study is to determine the pharmacokinetic of vancomycin in Chinese adults and the recommend dosage for patients with different renal function, including patients with ARC. We retrospectively collected 424 vancomycin serum concentrations from 209 Chinese patients and performed a population pharmacokinetic model using NONMEM 7.4.4. The final model indicated that the clearance rate of vancomycin increased together with the creatinine clearance, and exhibited a nearly saturated curve at higher creatinine clearance. The estimated clearance of vancomycin was between 3.46 and 5.58 L/h in patients with ARC, with 5.58 being the maximum theoretical value. The central volume of distribution increased by more than three times in patients admitted to Intensive Care Unit. Monte Carlo simulations were conducted to explore the probability of reaching the target therapeutic range (24-h area under the curve: 400–650 mg·h/L, trough concentration: 10–20 mg/L) when various dose regimens were administered. The simulations indicated that dose should increase together with the creatinine clearance until 180 mL/min. These findings may contribute to improving the efficacy and safety of vancomycin in patients with ARC.
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17
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Ural MN, Uney K. Pharmacokinetic Behavior and Pharmacokinetic/Pharmacodynamic Integration of Danofloxacin Following Single or Co-Administration with Meloxicam in Healthy Lambs and Lambs with Respiratory Infections. Antibiotics (Basel) 2021; 10:antibiotics10101190. [PMID: 34680771 PMCID: PMC8532679 DOI: 10.3390/antibiotics10101190] [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: 06/28/2021] [Revised: 08/18/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to determine the pharmacokinetics and pharmacodynamics of danofloxacin (DAN; 6 mg/kg) following subcutaneous administration alone or co-administration with meloxicam (MLX; 1 mg/kg) in healthy lambs and lambs with respiratory infections. The study was carried out using a total of four groups: HD (healthy; n = 6) and ID (infected; n = 7) groups who were administered DAN only, and HDM (healthy; n = 6) and IDM (infected; n = 7) groups who were administered DAN and MLX simultaneously. The plasma concentrations of DAN were determined using high-performance liquid chromatography–UV and analyzed by the non-compartmental method. DAN exhibited a similar elimination half-life in all groups, including both the healthy and infected lambs. The total clearance in the HDM, ID and IDM groups and volume of distribution in the HDM and IDM groups were significantly reduced. MLX in the IDM group significantly increased the area under the curve (AUC) and peak concentration (Cmax) of DAN compared to the HD group. The Mannheimia haemolytica, Escherichia coli, and Streptococcus spp. strains were isolated from bronchoalveolar lavage fluid samples of the infected lambs. When co-administration with meloxicam, DAN at a 6 mg/kg dose can provide optimum values of ƒAUC0–24/MIC (>56 h) and ƒCmax/MIC (>8) for susceptible M. haemolytica isolates with an MIC90 value of 0.25 µg/mL and susceptible E. coli isolates with an MIC value of ≤0.125 µg/mL.
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Affiliation(s)
- Mehmet Nihat Ural
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, 42031 Konya, Turkey;
- Pendik Veterinary Control Institute, Bati Mah. Yunus Cad. 2/1, Pendik, 34890 Istanbul, Turkey
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, 42031 Konya, Turkey;
- Correspondence: ; Tel.: +90-332-223-2733
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18
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Song X, Liu P, Liu X, Wang Y, Wei H, Zhang J, Yu L, Yan X, He Z. Dealing with MDR bacteria and biofilm in the post-antibiotic era: Application of antimicrobial peptides-based nano-formulation. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 128:112318. [PMID: 34474869 DOI: 10.1016/j.msec.2021.112318] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023]
Abstract
The rapid development of multidrug-resistant (MDR) bacteria due to the improper and overuse of antibiotics and the ineffective performance of antibiotics against the difficult-to-treat biofilm-related infections (BRIs) have urgently called for alternative antimicrobial agents and strategies in combating bacterial infections. Antimicrobial peptides (AMPs), owing to their compelling antimicrobial activity against MDR bacteria and BRIs without causing bacteria resistance, have attracted extensive attention in the research field. With the development of nanomaterial-based drug delivery strategies, AMPs-based nano-formulations have significantly improved the therapeutic effects of AMPs by ameliorating their hydrolytic stability, half-life in vivo, and solubility as well as reducing the cytotoxicity and hemolysis, etc. This review has comprehensively summarized the application AMPs-based nano-formulation in various bacterial infections models, including bloodstream infections (specifically sepsis), pulmonary infections, chronic wound infections, gastrointestinal infections, among others. The design of the nanomaterial-based drug delivery systems and the therapeutic effects of the AMPs-based nano-formulations in literature have been categorized and in details discussed. Overall, this review provides insights into the advantages and disadvantages of the current developed AMPs-based nano-formulations in literature for the treatment of bacterial infections, bringing inspirations and suggestions for their future design in the way towards clinical translation.
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Affiliation(s)
- Xinyu Song
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Pengyan Liu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Xiaohu Liu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Yanan Wang
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Huichao Wei
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Jingwen Zhang
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Liangmin Yu
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China.
| | - Xuefeng Yan
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China
| | - Zhiyu He
- Key Laboratory of Marine Chemistry Theory and Technology, Ministry of Education, College of Chemistry and Chemical Engineering, Ocean University of China, Qingdao 266100, China.
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A pilot study on the melatonin treatment in patients with early septic shock: results of a single-center randomized controlled trial. Ir J Med Sci 2021; 191:1913-1924. [PMID: 34468959 PMCID: PMC8408361 DOI: 10.1007/s11845-021-02758-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND We assessed the potential impact of a high dose of melatonin treatment in patients with early septic shock. METHODS Forty patients with early septic shock were randomly allocated to the melatonin or placebo groups. Besides standard-of-care treatment, melatonin and placebo were administered at a dose of 50 mg for five consecutive nights. The efficacy outcomes were severity of organ dysfunction based on the Sequential Organ Failure Assessment (SOFA) score, the number of patients requiring mechanical ventilation and ventilator-free days, the mean required vasopressor dose and vasopressor-free days, and 28 days all-cause mortality. RESULTS After 5-day treatment, the mean SOFA scores decreased 4.05 ± 4.75 score in the melatonin group and 2.25 ± 4.87 in the placebo group. On day 28, 60% of the melatonin-treated patients and 35% of the placebo-treated patients had a SOFA score below six. Thirteen cases in the placebo group and nine cases in the melatonin group required mechanical ventilation; however, there was no statistically significant difference between the groups regarding these outcomes. The melatonin-treated patients had more ventilator-free days than placebo-treated patients over the 28-day (16.90 ± 9.24 vs. 10.00 ± 10.94; p value = 0.035). The mean reduction in the required dose of vasopressor was 6.2 ± 5.12 in the melatonin-treated patients compared to 3.20 ± 3.95 in the placebo-treated patients (p value = 0.045). Vasopressor-free days in the melatonin-treated group were also significantly more than the placebo-treated group (12.75 ± 7.43 days vs. 10.15 ± 6.12 days; p value = 0.046). CONCLUSIONS Our pilot study supported the potential benefits of melatonin in treating septic shock. Further clinical evidence is required for expanding and confirming these findings. TRIAL REGISTRATION The trial was registered at Clinicaltrials.gov (ID code: IRCT20120215009014N296). Registration date: 15/09/2019.
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20
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Schroepf S, Burau D, Muench HG, Derendorf H, Zeitlinger M, Genzel-Boroviczény O, Adam D, Kloft C. Microdialysis sampling to monitor target-site vancomycin concentrations in septic infants: a feasible way to close the knowledge gap. Int J Antimicrob Agents 2021; 58:106405. [PMID: 34289402 DOI: 10.1016/j.ijantimicag.2021.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
This work is dedicated to the memory of Hartmut Derendorf (1953-2020), a pioneer of modern pharmacokinetics and valued mentor of this project. OBJECTIVES Septic infants/neonates need effective antibiotic exposure, but dosing recommendations are challenging as the pharmacokinetics in this age are highly variable. For vancomycin, which is used as a standard treatment, comprehensive pharmacokinetic knowledge especially at the infection site is lacking. Hence, an exploratory clinical study was conducted to assess the feasibility and safety of microdialysis sampling for vancomycin monitoring at the target site. METHODS Nine infants/neonates with therapeutic indications for vancomycin treatment were administered 15 mg/kg as 1-hour infusions every 8-24 hours. Microdialysis catheters were implanted in the subcutaneous interstitial space fluid of the lateral thigh. Samples were collected every 30 minutes over 24 hours, followed by retrodialysis for catheter calibration. Prior in vitro investigations have evaluated impact factors on relative recovery and retrodialysis. RESULTS In vitro investigations showed the applicability of microdialysis for vancomycin monitoring. Microdialysis sampling was well tolerated in all infants/neonates (23-255 days) without major bleeding or other adverse events. Pharmacokinetic profiles were obtained and showed plausible vancomycin concentration-time courses. CONCLUSIONS Microdialysis as a minimally invasive technique for continuous longer-term sampling is feasible and safe in infants/neonates. Interstitial space fluid profiles were plausible and showed substantial interpatient variation. Hence, a larger microdialysis trial is warranted to further characterise the pharmacokinetics and variability of vancomycin at the target site and ultimately improve vancomycin dosing in these vulnerable patients.
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Affiliation(s)
- Sebastian Schroepf
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany.
| | - Daniela Burau
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Hans-Georg Muench
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | | | | | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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Rao PS, Moore CC, Mbonde AA, Nuwagira E, Orikiriza P, Nyehangane D, Al-Shaer MH, Peloquin CA, Gratz J, Pholwat S, Arinaitwe R, Boum Y, Mwanga-Amumpaire J, Houpt ER, Kagan L, Heysell SK, Muzoora C. Population Pharmacokinetics and Significant Under-Dosing of Anti-Tuberculosis Medications in People with HIV and Critical Illness. Antibiotics (Basel) 2021; 10:antibiotics10060739. [PMID: 34207312 PMCID: PMC8235594 DOI: 10.3390/antibiotics10060739] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 12/18/2022] Open
Abstract
Critical illness from tuberculosis (TB) bloodstream infection results in a high case fatality rate for people living with human immunodeficiency virus (HIV). Critical illness can lead to altered pharmacokinetics and suboptimal drug exposures. We enrolled adults living with HIV and hospitalized with sepsis, with and without meningitis, in Mbarara, Uganda that were starting first-line anti-TB therapy. Serum was collected two weeks after enrollment at 1-, 2-, 4-, and 6-h post-dose and drug concentrations quantified by validated LC-MS/MS methods. Non-compartmental analyses were used to determine total drug exposure, and population pharmacokinetic modeling and simulations were performed to determine optimal dosages. Eighty-one participants were enrolled. Forty-nine completed pharmacokinetic testing: 18 (22%) died prior to testing, 13 (16%) were lost to follow-up and one had incomplete testing. Isoniazid had the lowest serum attainment, with only 4.1% achieving a target exposure over 24 h (AUC0–24) of 52 mg·h/L despite appropriate weight-based dosing. Simulations to reach target AUC0–24 found necessary doses of rifampin of 1800 mg, pyrazinamide of 2500–3000 mg, and for isoniazid 900 mg or higher. Given the high case fatality ratio of TB-related critical illness in this population, an early higher dose anti-TB therapy should be trialed.
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Affiliation(s)
- Prakruti S. Rao
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
| | - Christopher C. Moore
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
| | - Amir A. Mbonde
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda; (A.A.M.); (E.N.); (R.A.); (J.M.-A.); (C.M.)
| | - Edwin Nuwagira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda; (A.A.M.); (E.N.); (R.A.); (J.M.-A.); (C.M.)
| | - Patrick Orikiriza
- Department of Microbiology, University of Global Health Equity, Kigali 6955, Rwanda;
| | - Dan Nyehangane
- Epicentre Mbarara Research Center, Mbarara 1956, Uganda; (D.N.); (Y.B.)
| | - Mohammad H. Al-Shaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (M.H.A.-S.); (C.A.P.)
| | - Charles A. Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL 32610, USA; (M.H.A.-S.); (C.A.P.)
| | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
| | - Suporn Pholwat
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
| | - Rinah Arinaitwe
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda; (A.A.M.); (E.N.); (R.A.); (J.M.-A.); (C.M.)
- Epicentre Mbarara Research Center, Mbarara 1956, Uganda; (D.N.); (Y.B.)
| | - Yap Boum
- Epicentre Mbarara Research Center, Mbarara 1956, Uganda; (D.N.); (Y.B.)
| | - Juliet Mwanga-Amumpaire
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda; (A.A.M.); (E.N.); (R.A.); (J.M.-A.); (C.M.)
- Epicentre Mbarara Research Center, Mbarara 1956, Uganda; (D.N.); (Y.B.)
| | - Eric R. Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
| | - Leonid Kagan
- Department of Pharmaceutics and Center of Excellence for Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA;
| | - Scott K. Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA 22908, USA; (P.S.R.); (C.C.M.); (J.G.); (S.P.); (E.R.H.)
- Correspondence:
| | - Conrad Muzoora
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda; (A.A.M.); (E.N.); (R.A.); (J.M.-A.); (C.M.)
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Hernandis V, Escudero E, Pareja A, Marín P. A fast, cost-saving and sensitive method for determination of cefuroxime in plasma by HPLC with ultraviolet detection. Biomed Chromatogr 2021; 35:e5188. [PMID: 34081795 DOI: 10.1002/bmc.5188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/16/2021] [Accepted: 06/01/2021] [Indexed: 11/08/2022]
Abstract
Cefuroxime (CFX) is a broad-spectrum second-generation cephalosporin and one of the best choices for antibiotic prophylaxis. However, when used in critically ill patients, it may present changes in its pharmacokinetic properties. Therefore, therapeutic drug monitoring of CFX is necessary for effective dosing strategies. A simple, rapid and sensitive liquid chromatographic method with UV detection was developed and validated for the quantification of CFX in plasma. The method involved a single-step precipitation of proteins with methanol and trifluoroacetic acid. Cefuroxime was analyzed on a Brisa LC2 C18 column in isocratic mode consisting of 0.1% trifluoroacetic acid in water and acetonitrile (75:25) with UV detection at a wavelength of 280 nm. The retention times of CFX and cephazolin (internal standard) were 9.8 and 7.4 min, respectively. The calibration curve was linear over a concentration range of 0.25-50 μg/ml. The limits of detection and quantification were 0.1 μg/ml and 0.25 μg/ml, respectively. The accuracy and precision were always <10%. The mean recovery was 93.52%. This fast and simple method could be applied in routine analysis and pharmacokinetic studies.
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Affiliation(s)
- Verónica Hernandis
- Department of Pharmacology, Faculty of Veterinary Medicine, University of Murcia, Murcia, Spain
| | - Elisa Escudero
- Department of Pharmacology, Faculty of Veterinary Medicine, University of Murcia, Murcia, Spain
| | - Ana Pareja
- Pharmacy Service, Arrixaca University Hospital, Murcia, Spain
| | - Pedro Marín
- Department of Pharmacology, Faculty of Veterinary Medicine, University of Murcia, Murcia, Spain
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23
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Roberts JA, Joynt GM, Lee A, Choi G, Bellomo R, Kanji S, Mudaliar MY, Peake SL, Stephens D, Taccone FS, Ulldemolins M, Valkonen MM, Agbeve J, Baptista JP, Bekos V, Boidin C, Brinkmann A, Buizen L, Castro P, Cole CL, Creteur J, De Waele JJ, Deans R, Eastwood GM, Escobar L, Gomersall C, Gresham R, Jamal JA, Kluge S, König C, Koulouras VP, Lassig-Smith M, Laterre PF, Lei K, Leung P, Lefrant JY, Llauradó-Serra M, Martin-Loeches I, Mat Nor MB, Ostermann M, Parker SL, Rello J, Roberts DM, Roberts MS, Richards B, Rodríguez A, Roehr AC, Roger C, Seoane L, Sinnollareddy M, Sousa E, Soy D, Spring A, Starr T, Thomas J, Turnidge J, Wallis SC, Williams T, Wittebole X, Zikou XT, Paul SK, Lipman J. The Effect of Renal Replacement Therapy and Antibiotic Dose on Antibiotic Concentrations in Critically Ill Patients: Data From the Multinational Sampling Antibiotics in Renal Replacement Therapy Study. Clin Infect Dis 2021; 72:1369-1378. [PMID: 32150603 DOI: 10.1093/cid/ciaa224] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The optimal dosing of antibiotics in critically ill patients receiving renal replacement therapy (RRT) remains unclear. In this study, we describe the variability in RRT techniques and antibiotic dosing in critically ill patients receiving RRT and relate observed trough antibiotic concentrations to optimal targets. METHODS We performed a prospective, observational, multinational, pharmacokinetic study in 29 intensive care units from 14 countries. We collected demographic, clinical, and RRT data. We measured trough antibiotic concentrations of meropenem, piperacillin-tazobactam, and vancomycin and related them to high- and low-target trough concentrations. RESULTS We studied 381 patients and obtained 508 trough antibiotic concentrations. There was wide variability (4-8-fold) in antibiotic dosing regimens, RRT prescription, and estimated endogenous renal function. The overall median estimated total renal clearance (eTRCL) was 50 mL/minute (interquartile range [IQR], 35-65) and higher eTRCL was associated with lower trough concentrations for all antibiotics (P < .05). The median (IQR) trough concentration for meropenem was 12.1 mg/L (7.9-18.8), piperacillin was 78.6 mg/L (49.5-127.3), tazobactam was 9.5 mg/L (6.3-14.2), and vancomycin was 14.3 mg/L (11.6-21.8). Trough concentrations failed to meet optimal higher limits in 26%, 36%, and 72% and optimal lower limits in 4%, 4%, and 55% of patients for meropenem, piperacillin, and vancomycin, respectively. CONCLUSIONS In critically ill patients treated with RRT, antibiotic dosing regimens, RRT prescription, and eTRCL varied markedly and resulted in highly variable antibiotic concentrations that failed to meet therapeutic targets in many patients.
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Affiliation(s)
- Jason A Roberts
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Gavin M Joynt
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Anna Lee
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gordon Choi
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg and School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - M Yugan Mudaliar
- Intensive Care Unit, Westmead Hospital, Sydney, Australia.,Medical School, University of Sydney, Sydney, Australia
| | - Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dianne Stephens
- Intensive Care Unit, Royal Darwin Hospital, Darwin, Australia.,Flinders University, Adelaide, Australia.,National Critical Care and Trauma Response Centre, Darwin, Australia
| | | | - Marta Ulldemolins
- Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Fundació Privada Clínic per la Recerca Biomèdica, Barcelona, Spain.,Infectious Diseases-Internal Medicine Departments, Bellvitge University Hospital, l'Hospitalet de Llobregat, Spain
| | - Miia Maaria Valkonen
- Intensive Care Medicine, Department of Perioperative, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Julius Agbeve
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Herston, Australia
| | - João P Baptista
- Intensive Care Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Vasileios Bekos
- Intensive Care Unit, Naval and Veterans Hospital of Athens, Athens, Greece
| | - Clement Boidin
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Lyon, France.,Hôpital Pierre Garraud, Hospices Civils de Lyon, Lyon, France
| | - Alexander Brinkmann
- Department of Anesthesia and Critical Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Luke Buizen
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
| | - Pedro Castro
- Medical Intensive Care Unit, ICMiD. Hospital Clínic de Barcelona, Barcelona, Spain.,IDIBAPS, University of Barcelona, Barcelona, Spain
| | - C Louise Cole
- Medical School, University of Sydney, Sydney, Australia.,Intensive Care Unit, Nepean Hospital, Sydney, Australia
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Brussels, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine; Ghent University Hospital, Ghent, Belgium
| | - Renae Deans
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg and School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Leslie Escobar
- Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Charles Gomersall
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Janattul Ain Jamal
- Department of Pharmacy, Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Vasilios P Koulouras
- Intensive Care Unit Department, University Hospital of Ioannina, Ioannina, Greece
| | - Melissa Lassig-Smith
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Katie Lei
- Guy's and St Thomas Hospital, London, United Kingdom
| | - Patricia Leung
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jean-Yves Lefrant
- Intensive Care Unit, Nîmes University Hospital (Centre Hospitalo Universitaire Nimes), Nimes, France
| | - Mireia Llauradó-Serra
- Department of Nursing, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ignacio Martin-Loeches
- Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Multidisciplinary Intensive Care Research Organization (MICRO), St James Hospital, Dublin, Ireland
| | - Mohd Basri Mat Nor
- Department of Anesthesiology and Intensive Care, School of Medicine, International Islamic University Malaysia, Selangor, Malaysia
| | | | - Suzanne L Parker
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jordi Rello
- CIBERES, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Darren M Roberts
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia.,Translational Research Institute, The University of Queensland, Buranda, Australia
| | - Brent Richards
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Australia
| | - Alejandro Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Tarragona, Spain.,Rovira i Virgili University, IISPV/CIBERES, Tarragona, Spain
| | - Anka C Roehr
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Claire Roger
- Intensive Care Unit, Nîmes University Hospital (Centre Hospitalo Universitaire Nimes), Nimes, France
| | - Leonardo Seoane
- Faculty of Medicine, An University of Queensland, New Orleans, Louisiana, USA.,Intensive Care Unit, Ochsner Health System, New Orleans, Louisiana, USA
| | - Mahipal Sinnollareddy
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.,Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Eduardo Sousa
- Intensive Care Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dolors Soy
- IDIBAPS, University of Barcelona, Barcelona, Spain.,Pharmacy Department, Division of Medicines. Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Spring
- Intensive Care Unit, Naval and Veterans Hospital of Athens, Athens, Greece
| | - Therese Starr
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jane Thomas
- Intensive Care Unit, Royal Darwin Hospital, Darwin, Australia
| | - John Turnidge
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Steven C Wallis
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Tricia Williams
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.,School of Medicine, University of Adelaide, Adelaide, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Xavier Wittebole
- Intensive Care Unit, Clinique Universitaire St Luc UCL, Brussels, Belgium
| | - Xanthi T Zikou
- Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Sanjoy K Paul
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
| | - Jeffrey Lipman
- The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
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24
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van den Broek AK, Prins JM, Visser CE, van Hest RM. Systematic review: the bioavailability of orally administered antibiotics during the initial phase of a systemic infection in non-ICU patients. BMC Infect Dis 2021; 21:285. [PMID: 33743592 PMCID: PMC7981967 DOI: 10.1186/s12879-021-05919-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background The systemic response to an infection might influence the pharmacokinetics of antibiotics. To evaluate the desired possibility of an earlier (< 24 h) IV-to-oral switch therapy in febrile non-ICU, hospitalized patients, a systematic review was performed to assess the effect of the initial phase of a systemic infection on the bioavailability of orally administered antibiotics in such patients. Methods An electronic search was conducted in MEDLINE and Embase up to July 2020. Studies were selected when outcome data were collected during the initial stage of a febrile disease. Outcome data were (maximum) serum concentrations, time of achieving maximum serum concentration, and the area-under-the-plasma-concentration-time curve or bioavailability of orally administered antibiotics. Risk of bias was assessed. Results We identified 9 studies on 6 antibiotics. Ciprofloxacin was the most frequently studied drug. Outcomes of the studies were heterogeneous and generally had a high risk of bias. Three small studies, two on ciprofloxacin and one on clarithromycin, compared the pharmacokinetics of febrile patients with those of clinically recovered patients and suggested that bioavailability was not altered in these patients. Other studies either compared the pharmacokinetics in febrile patients with reported pharmacokinetic values from earlier studies in healthy volunteers (n = 2), or provided no comparison at all and were non-conclusive (n = 4). Conclusion There is a clear knowledge gap regarding the bioavailability of orally administered antibiotics in non-ICU patients during the initial phase of a systemic infection. Well-designed studies on this topic are necessary to elucidate whether patients can benefit from the advantages of an earlier IV-to-oral switch. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05919-w.
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Affiliation(s)
- Annemieke K van den Broek
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Caroline E Visser
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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25
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Lepage MA, Rozza N, Kremer R, Grunbaum A. Safety and effectiveness concerns of lopinavir/ritonavir in COVID-19 affected patients: a retrospective series. Clin Toxicol (Phila) 2021; 59:644-647. [PMID: 33641562 PMCID: PMC7919102 DOI: 10.1080/15563650.2020.1842882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Context Originally developed for treatment of human immunodeficiency virus (HIV), the antiviral combination lopinavir/ritonavir (LPV/r) is being repurposed for treating the novel coronavirus disease (COVID-19) despite minimal experience in this markedly different population and an in-vitro derived EC50 against SARS-CoV-2 several hundred-fold greater than for HIV. We present a case series including a case of severe hyponatremia and a 32-fold overdose raising safety and effectiveness concerns in COVID-19 patients. Methods We measured LPV trough concentrations in 12 patients and reviewed their clinical charts for side effects known to occur in HIV patients. Findings Compared to established LPV trough concentrations in HIV patients, concentrations in COVID-19 patients were 3-fold greater (19.37 ± 10.12 mcg/mL versus 6.25 mcg/mL). In addition, cholestasis and dyslipidemia toxicity thresholds were exceeded in 12/12 and 11/12 patients respectively. No patients achieved the presumed therapeutic concentration. Side effects included gastrointestinal symptoms (5/12), electrolyte imbalances (4/12), liver enzyme disturbances (5/12) and triglyceride elevations (2/12). Conclusion No patients reached presumed therapeutic LPV concentrations despite experiencing side effects and exceeding cholestasis and dyslipidemia toxicity thresholds. This raises concerns for the safety and effectiveness of LPV/r. Clinicians should consider closely monitoring for side effects and not necessarily attribute them to COVID-19.
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Affiliation(s)
- Marc-Antoine Lepage
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Nicholas Rozza
- McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Richard Kremer
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
| | - Ami Grunbaum
- McGill University Health Centre, Montreal, Canada.,McGill Faculty of Medecine and Health Sciences, Montreal, Canada
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26
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Affiliation(s)
- H.D. O'Reilly
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - K. Menon
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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27
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Papafilippou L, Claxton A, Dark P, Kostarelos K, Hadjidemetriou M. Nanotools for Sepsis Diagnosis and Treatment. Adv Healthc Mater 2021; 10:e2001378. [PMID: 33236524 DOI: 10.1002/adhm.202001378] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/07/2020] [Indexed: 12/12/2022]
Abstract
Sepsis is one of the leading causes of death worldwide with high mortality rates and a pathological complexity hindering early and accurate diagnosis. Today, laboratory culture tests are the epitome of pathogen recognition in sepsis. However, their consistency remains an issue of controversy with false negative results often observed. Clinically used blood markers, C reactive protein (CRP) and procalcitonin (PCT) are indicators of an acute-phase response and thus lack specificity, offering limited diagnostic efficacy. In addition to poor diagnosis, inefficient drug delivery and the increasing prevalence of antibiotic-resistant microorganisms constitute significant barriers in antibiotic stewardship and impede effective therapy. These challenges have prompted the exploration for alternative strategies that pursue accurate diagnosis and effective treatment. Nanomaterials are examined for both diagnostic and therapeutic purposes in sepsis. The nanoparticle (NP)-enabled capture of sepsis causative agents and/or sepsis biomarkers in biofluids can revolutionize sepsis diagnosis. From the therapeutic point of view, currently existing nanoscale drug delivery systems have proven to be excellent allies in targeted therapy, while many other nanotherapeutic applications are envisioned. Herein, the most relevant applications of nanomedicine for the diagnosis, prognosis, and treatment of sepsis is reviewed, providing a critical assessment of their potentiality for clinical translation.
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Affiliation(s)
- Lana Papafilippou
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
| | - Andrew Claxton
- Department of Critical Care Salford Royal Foundation Trust Stott Lane Salford M6 8HD UK
| | - Paul Dark
- Manchester NIHR Biomedical Research Centre Division of Infection Immunity and Respiratory Medicine University of Manchester Manchester M13 9PT UK
| | - Kostas Kostarelos
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
- Catalan Institute of Nanoscience and Nanotechnology (ICN2) Campus UAB Bellaterra Barcelona 08193 Spain
| | - Marilena Hadjidemetriou
- Nanomedicine Lab Faculty of Biology Medicine and Health AV Hill Building The University of Manchester Manchester M13 9PT UK
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28
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D'Agate S, Musuamba FT, Della Pasqua O. Dose Rationale for Amoxicillin in Neonatal Sepsis When Referral Is Not Possible. Front Pharmacol 2020; 11:521933. [PMID: 33117151 PMCID: PMC7549385 DOI: 10.3389/fphar.2020.521933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/24/2020] [Indexed: 01/17/2023] Open
Abstract
Background Despite the widespread use of amoxicillin in young children, efforts to establish the feasibility of simplified dosing regimens in resource-limited settings have relied upon empirical evidence of efficacy. Given the antibacterial profile of beta-lactams, understanding of the determinants of pharmacokinetic variability may provide a more robust guidance for the selection of a suitable regimen. Here we propose a simplified dosing regimen based on pharmacokinetic-pharmacodynamic principles, taking into account the impact of growth, renal maturation and disease processes on the systemic exposure to amoxicillin. Materials and Methods A meta-analytical modeling approach was applied to allow the adaptation of an existing pharmacokinetic model for amoxicillin in critically ill adults. Model parameterization was based on allometric concepts, including a maturation function. Clinical trial simulations were then performed to characterize exposure, as defined by secondary pharmacokinetic parameters (AUC, Cmax, Cmin) and T>MIC. The maximization of the T>MIC was used as criterion for the purpose of this analysis and results compared to current WHO guidelines. Results A two-compartment model with first order absorption and elimination was found to best describe the pharmacokinetics of amoxicillin in the target population. In addition to the changes in clearance and volume distribution associated with demographic covariates, our results show that sepsis alters drug distribution, leading to lower amoxicillin levels and longer half-life as compared to non-systemic disease conditions. In contrast to the current WHO guidelines, our analysis reveals that amoxicillin can be used as a fixed dose regimen including two weight bands: 125 mg b.i.d. for patients with body weight < 4.0 kg and 250 mg b.i.d. for patients with body weight ≥ 4.0 kg. Conclusions In addition to the effect of developmental growth and renal maturation, sepsis also alters drug disposition. The use of a model-based approach enabled the integration of these factors when defining the dose rationale for amoxicillin. A simplified weight-banded dosing regimen should be considered for neonates and young infants with sepsis when referral is not possible.
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Affiliation(s)
- Salvatore D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Flora Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
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29
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Jennaro TS, Puskarich MA, McCann MR, Gillies CE, Pai MP, Karnovsky A, Evans CR, Jones AE, Stringer KA. Using l-Carnitine as a Pharmacologic Probe of the Interpatient and Metabolic Variability of Sepsis. Pharmacotherapy 2020; 40:913-923. [PMID: 32688453 DOI: 10.1002/phar.2448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this review is to discuss the therapeutic use and differential treatment response to Levo-carnitine (l-carnitine) treatment in septic shock, and to demonstrate common lessons learned that are important to the advancement of precision medicine approaches to sepsis. We propose that significant interpatient variability in the metabolic response to l-carnitine and clinical outcomes can be used to elucidate the mechanistic underpinnings that contribute to sepsis heterogeneity. METHODS A narrative review was conducted that focused on explaining interpatient variability in l-carnitine treatment response. Relevant biological and patient-level characteristics considered include genetic, metabolic, and morphomic phenotypes; potential drug interactions; and pharmacokinetics (PKs). MAIN RESULTS Despite promising results in a phase I study, a recent phase II clinical trial of l-carnitine treatment in septic shock showed a nonsignificant reduction in mortality. However, l-carnitine treatment induces significant interpatient variability in l-carnitine and acylcarnitine concentrations over time. In particular, administration of l-carnitine induces a broad, dynamic range of serum concentrations and measured peak concentrations are associated with mortality. Applied systems pharmacology may explain variability in drug responsiveness by using patient characteristics to identify pretreatment phenotypes most likely to derive benefit from l-carnitine. Moreover, provocation of sepsis metabolism with l-carnitine offers a unique opportunity to identify metabolic response signatures associated with patient outcomes. These approaches can unmask latent metabolic pathways deranged in the sepsis syndrome and offer insight into the pathophysiology, progression, and heterogeneity of the disease. CONCLUSIONS The compiled evidence suggests there are several potential explanations for the variability in carnitine concentrations and clinical response to l-carnitine in septic shock. These serve as important confounders that should be considered in interpretation of l-carnitine clinical studies and broadly holds lessons for future clinical trial design in sepsis. Consideration of these factors is needed if precision medicine in sepsis is to be achieved.
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Affiliation(s)
- Theodore S Jennaro
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael A Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.,Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Marc R McCann
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Institute for Data Science, Office of Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alla Karnovsky
- Department of Computational Medicine and Bioinformatics, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Charles R Evans
- Michigan Regional Comprehensive Metabolomics Resource Core (MRC2), University of Michigan, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), School of Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
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30
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Brunsdon P, Saluja B, Sahajwalla C. Clinical Pharmacology Considerations for Developing Small-Molecule Treatments for COVID-19. J Clin Pharmacol 2020; 60:1147-1154. [PMID: 32579707 PMCID: PMC7361784 DOI: 10.1002/jcph.1697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
Numerous drugs are being investigated for the treatment of COVID‐19, including antivirals and therapies targeting complications related to COVID‐19. The clinical presentation of COVID‐19 varies from mild fever, cough, and dyspnea in the early stages of disease to severe complications such as acute respiratory distress syndrome, systemic hyperinflammation, and sepsis. A thorough understanding of the disease pathogenesis and the disease complications is essential to developing effective therapies to treat this potentially life‐threatening disease. This review offers key clinical pharmacology considerations involved in the development of small molecules for the treatment of COVID‐19. They are based on the major observed disease complications that impact drug absorption, distribution, metabolism, and elimination. We also address considerations regarding potential drug interactions, alternative routes and methods of administration, and dosing in patients on hemodialysis.
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Affiliation(s)
- Priya Brunsdon
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bhawana Saluja
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Huang Y, Xu K, Zhan Y, Zha X, Liu S, Xie J, Liu L, Li Q, Shao H, Yang Y. Comparable Effect of Two-Step Versus Extended Infusions on the Pharmacokinetics of Imipenem in Patients with Sepsis and Septic Shock. Adv Ther 2020; 37:2246-2255. [PMID: 32277344 PMCID: PMC7223128 DOI: 10.1007/s12325-020-01339-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The present study aimed to compare the pharmacokinetic/pharmacodynamic (PK/PD) parameters of imipenem administered by two-step (50% delivered in a 30-min bolus, 50% for the following 90 min) or extended (administered continuously for 2 h) infusion. METHODS Patients with sepsis and septic shock were prospectively enrolled and randomized into four groups. Subjects in the two-step or extended groups were given two doses of imipenem (0.5 g q6h and 1.0 g q8h). The plasma imipenem concentrations were measured at given time points after the fifth dose. The PK/PD target was defined as the achievement of a fractional time above the minimal inhibitory concentration (MIC) of > 40%. RESULTS Thirty-five patients were eventually enrolled. No significant difference was observed in the percentage of patients achieving 40% T > MIC between the different infusion modes with the same dosage, although the two-step groups exhibited a significantly shorter Tmax compared with the extended groups (0.5 g q6h: 1.5 ± 0.8 vs. 2.0 ± 0.0 h; 1.0 g q8h: 1.0 ± 0.6 vs. 2.0 ± 0.0 h; both, p < 0.05). All four groups achieved 40% T > MIC when MIC was 0.5-4.0 μg/ml, but only regimens with a higher dose (1.0 g q8h) achieved target when MIC was 8 μg/ml. CONCLUSION The two-step and extended regimens of imipenem are comparable to the PK/PD target in the treatment of sepsis and septic shock. A higher dose (1.0 g q8h) should be considered for target achievement at an MIC of > 8 μg/ml. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02616354.
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Affiliation(s)
- Yingzi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Kang Xu
- Pharmacy Department, Hospital for Skin Diseases, Chinese Academy of Medical Sciences, Nanjing, China
| | - Ying Zhan
- Pharmacy Department, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xian Zha
- Pharmacy Department, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lin Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Qing Li
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Hua Shao
- Pharmacy Department, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China.
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Raffaeli G, Pokorna P, Allegaert K, Mosca F, Cavallaro G, Wildschut ED, Tibboel D. Drug Disposition and Pharmacotherapy in Neonatal ECMO: From Fragmented Data to Integrated Knowledge. Front Pediatr 2019; 7:360. [PMID: 31552205 PMCID: PMC6733981 DOI: 10.3389/fped.2019.00360] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. As the survival and the overall outcome of patients rely on the treatment and reversal of the underlying disease, effective and preferentially evidence-based pharmacotherapy is crucial to target recovery. Currently limited data exist to support the clinicians in their every-day intensive care prescribing practice with the contemporary ECMO technology. Indeed, drug dosing to optimize pharmacotherapy during neonatal ECMO is a major challenge. The impact of the maturational changes of the organ function on both pharmacokinetics (PK) and pharmacodynamics (PD) has been widely established over the last decades. Next to the developmental pharmacology, additional non-maturational factors have been recognized as key-determinants of PK/PD variability. The dynamically changing state of critical illness during the ECMO course impairs the achievement of optimal drug exposure, as a result of single or multi-organ failure, capillary leak, altered protein binding, and sometimes a hyperdynamic state, with a variable effect on both the volume of distribution (Vd) and the clearance (Cl) of drugs. Extracorporeal membrane oxygenation introduces further PK/PD perturbation due to drug sequestration and hemodilution, thus increasing the Vd and clearance (sequestration). Drug disposition depends on the characteristics of the compounds (hydrophilic vs. lipophilic, protein binding), patients (age, comorbidities, surgery, co-medications, genetic variations), and circuits (roller vs. centrifugal-based systems; silicone vs. hollow-fiber oxygenators; renal replacement therapy). Based on the potential combination of the above-mentioned drug PK/PD determinants, an integrated approach in clinical drug prescription is pivotal to limit the risks of over- and under-dosing. The understanding of the dose-exposure-response relationship in critically-ill neonates on ECMO will enable the optimization of dosing strategies to ensure safety and efficacy for the individual patient. Next to in vitro and clinical PK data collection, physiologically-based pharmacokinetic modeling (PBPK) are emerging as alternative approaches to provide bedside dosing guidance. This article provides an overview of the available evidence in the field of neonatal pharmacology during ECMO. We will identify the main determinants of altered PK and PD, elaborate on evidence-based recommendations on pharmacotherapy and highlight areas for further research.
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Affiliation(s)
- Genny Raffaeli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Pavla Pokorna
- Department of Pediatrics—ICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Enno D. Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Nowak H, Weidemann C, Martini S, Oesterreicher ZA, Dorn C, Adamzik M, Kees F, Zeitlinger M, Rahmel T. Repeated determination of moxifloxacin concentrations in interstitial space fluid of muscle and subcutis in septic patients. J Antimicrob Chemother 2019; 74:2681-2689. [PMID: 31299075 DOI: 10.1093/jac/dkz259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/07/2019] [Accepted: 05/22/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For an effective antimicrobial treatment, it is crucial that antibiotics reach sufficient concentrations in plasma and tissue. Currently no data exist regarding moxifloxacin plasma concentrations and exposure levels in tissue under septic conditions. OBJECTIVES To determine the pharmacokinetics of moxifloxacin in plasma and interstitial space fluid over a prolonged period. PATIENTS AND METHODS Ten septic patients were treated with 400 mg of moxifloxacin once a day; on days 1, 3 and 5 of treatment plasma sampling and microdialysis in the subcutis and muscle of the upper thigh were performed to determine concentrations of moxifloxacin in different compartments. This trial was registered in the German Clinical Trials Register (DRKS, register number DRKS00012985). RESULTS Mean unbound fraction of moxifloxacin in plasma was 85.5±3.4%. On day 1, Cmax in subcutis and muscle was 2.8±1.8 and 2.5±1.3 mg/L, respectively, AUC was 24.8±15.1 and 21.3±10.5 mg·h/L, respectively, and fAUC0-24/MIC was 100.9±62.9 and 86.5±38.3 h, respectively. Cmax for unbound moxifloxacin in plasma was 3.5±0.9 mg/L, AUC was 23.5±7.5 mg·h/L and fAUC0-24/MIC was 91.6±24.8 h. Key pharmacokinetic parameters on days 3 and 5 showed no significant differences. Clearance was higher than in healthy adults, but tissue concentrations were comparable, most likely due to a lower protein binding. CONCLUSIONS Surprisingly, the first dose already achieved exposure comparable to steady-state conditions. The approved daily dose of 400 mg was adequate in our patient population. Thus, it seems that in septic patients a loading dose on the first day of treatment with moxifloxacin is not required.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Caroline Weidemann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Stefan Martini
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Zoe Anne Oesterreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Michael Adamzik
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
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Continuous infusion of physostigmine in patients with perioperative septic shock: A pharmacokinetic/pharmacodynamic study with population pharmacokinetic modeling. Pharmacotherapy 2019; 118:109318. [PMID: 31398669 DOI: 10.1016/j.biopha.2019.109318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/27/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND In the context of the cholinergic anti-inflammatory pathway, the clinical trial Anticholium® per Se (EudraCT Number: 2012-001650-26, ClinicalTrials.gov NCT03013322) addressed the possibility of taking adjunctive physostigmine salicylate treatment in septic shock from bench to bedside. Pharmacokinetics (PK) are likely altered in critically ill patients; data on physostigmine PK and target concentrations are sparse, particularly for continuous infusion. Our objective was to build a population PK (popPK) model for physostigmine, and further evaluate pharmacodynamics (PD) and concentration-response relationship in this setting. METHODS In the randomized, double-blind, placebo-controlled trial, 20 patients with perioperative septic shock either received an initial dose of 0.04 mg/kg physostigmine salicylate, followed by continuous infusion of 1 mg/h for up to 120 h, or equivalent volumes of 0.9% sodium chloride (placebo group). Physostigmine plasma concentrations and acetylcholinesterase (AChE) activity were measured; concentration-response associations were evaluated, and popPK and PD modeling was performed with NONMEM. RESULTS Steady state physostigmine plasma concentrations reached 7.60 ± 2.81 ng/mL (mean ± standard deviation [SD]). PK was best described by a two-compartment model with linear clearance. Significant covariate effects were detected for body weight and age on clearance, as well as a high inter-individual variability of the central volume of distribution. AChE activity was significantly reduced to 30.5%-50.6% of baseline activity during physostigmine salicylate infusion. A sigmoidal direct effect PD model best described enzyme inhibition by physostigmine, with an estimated half maximal effective concentration (EC50) of 5.99 ng/mL. CONCLUSIONS PK of physostigmine in patients with septic shock displayed substantial inter-individual variability with body weight and age influencing the clearance. Physostigmine inhibited AChE activity with a sigmoidal concentration-response effect.
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Mzyk DA, Bublitz CM, Martinez MN, Davis JL, Baynes RE, Smith GW. Impact of bovine respiratory disease on the pharmacokinetics of danofloxacin and tulathromycin in different ages of calves. PLoS One 2019; 14:e0218864. [PMID: 31233558 PMCID: PMC6590872 DOI: 10.1371/journal.pone.0218864] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/11/2019] [Indexed: 12/16/2022] Open
Abstract
Pneumonia is one of the most economically important respiratory diseases of calves and knowledge of the impact of clinical disease on pharmacokinetics (PK) in young calves is limited. This study was undertaken to investigate the efficacy and PK of two antibiotics, tulathromycin and danofloxacin, in two age groups of calves experimentally infected with Pasteurella multocida. Both danofloxacin, a fluoroquinolone antibiotic, and tulathromycin, a macrolide antibiotic is approved for the treatment of bovine respiratory disease (BRD). To evaluate potential influences of age and disease on drug distribution and elimination in calves, plasma, interstitial fluid (ISF), and pulmonary epithelial lining fluid (PELF) were analyzed for drug concentrations. Concentrations for both drugs in the PELF were estimated by a urea dilution assay of the collected bronchoalveolar lavage fluids. Age was determined to be a significant covariate for calves administered danofloxacin and tulathromycin for plasma PK parameters. For calves administered danofloxacin, the area under the curve (AUC) in the plasma was lower in 6-month old calves (18.9 ± 12.6 hr* μg/mL) vs. 3-week old calves (32.0 ± 8.2 hr* μg/mL). Clearance (CL/F) of danofloxacin was higher in 6-month old calves. In contrast, tulathromycin plasma concentrations were higher in 6 month old calves and CL/F was higher in 3-week old calves. Age did not significantly influence the ISF concentrations of danofloxacin or tulathromycin in calves with respiratory disease, unlike previous studies which reported higher ISF concentrations of danofloxacin and tulathromycin in 6-month old calves when compared to younger calves. PELF concentrations were higher than plasma and ISF for both danofloxacin and tulathromycin, but did not differ between age groups. Potential reasons for age-related differences on plasma concentration–time profiles and the impact of disease on the partitioning of the drug from the blood to the lungs and ISF as a function of age are explored.
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Affiliation(s)
- Danielle A. Mzyk
- Department of Population Health and Pathobiology, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, United States of America
| | - Claire M. Bublitz
- Department of Population Health and Pathobiology, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, United States of America
| | - Marilyn N. Martinez
- Office of New Animal Drug Evaluation, Center for Veterinary Medicine, Rockville, Maryland, United States of America
| | - Jennifer L. Davis
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, Virginia, United States of America
| | - Ronald E. Baynes
- Department of Population Health and Pathobiology, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, United States of America
| | - Geof W. Smith
- Department of Population Health and Pathobiology, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, United States of America
- * E-mail:
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Fleuren LM, Roggeveen LF, Guo T, Waldauf P, van der Voort PHJ, Bosman RJ, Swart EL, Girbes ARJ, Elbers PWG. Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient: a cross-sectional study. Crit Care 2019; 23:185. [PMID: 31118061 PMCID: PMC6532162 DOI: 10.1186/s13054-019-2438-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antibiotic exposure in intensive care patients with sepsis is frequently inadequate and is associated with poorer outcomes. Antibiotic dosing is challenging in the intensive care, as critically ill patients have altered and fluctuating antibiotic pharmacokinetics that make current one-size-fits-all regimens unsatisfactory. Real-time bedside dosing software is not available yet, and therapeutic drug monitoring is typically used for few antibiotic classes and only allows for delayed dosing adaptation. Thus, adequate and timely antibiotic dosing continues to rely largely on the level of pharmacokinetic expertise in the ICU. Therefore, we set out to assess the level of knowledge on antibiotic pharmacokinetics among these intensive care professionals. METHODS In May 2018, we carried out a cross-sectional study by sending out an online survey on antibiotic dosing to more than 20,000 intensive care professionals. Questions were designed to cover relevant topics in pharmacokinetics related to intensive care antibiotic dosing. The preliminary pass mark was set by members of the examination committee for the European Diploma of Intensive Care using a modified Angoff approach. The final pass mark was corrected for clinical relevance as assessed for each question by international experts on pharmacokinetics. RESULTS A total of 1448 respondents completed the survey. Most of the respondents were intensivists (927 respondents, 64%) from 97 countries. Nearly all questions were considered clinically relevant by pharmacokinetic experts. The pass mark corrected for clinical relevance was 52.8 out of 93.7 points. Pass rates were 42.5% for intensivists, 36.1% for fellows, 24.8% for residents, and 5.8% for nurses. Scores without correction for clinical relevance were worse, indicating that respondents perform better on more relevant topics. Correct answers and concise clinical background are provided. CONCLUSIONS Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient. This should be addressed given the importance of adequate antibiotic exposure in critically ill patients with sepsis. Solutions include improved education, intensified pharmacy support, therapeutic drug monitoring, or the use of real-time bedside dosing software. Questions may provide useful for teaching purposes.
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Affiliation(s)
- Lucas M. Fleuren
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Luca F. Roggeveen
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tingjie Guo
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, Kralovske Vinohrady University Hospital and The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Eleonora L. Swart
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Świerczek A, Wyska E, Pociecha K, Baś S, Mlynarski J. Influence of inflammatory disorders on pharmacokinetics of lisofylline in rats: implications for studies in humans. Xenobiotica 2018; 49:1209-1220. [PMID: 30526201 DOI: 10.1080/00498254.2018.1542516] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
1. Despite the number of favourable properties of lisofylline (LSF), clinical trials on this compound have not yielded the expected results yet. 2. The aims of this study were to evaluate the pharmacokinetics of LSF enantiomers in rats following intravenous, oral and subcutaneous administration of (±)-LSF and to assess the influence of experimental inflammatory disorders, such as multiple organ dysfunction syndrome and severe sepsis on LSF pharmacokinetics. 3. In addition, based on the results obtained an attempt was made to elucidate the possible reasons for the failure of LSF therapy in clinical trials carried out in patients with severe inflammatory disorders. 4. A subcutaneous route of (±)-LSF administration to rats is more favourable than an oral one due to a high bioavailability and a fast absorption of both LSF enantiomers. Pharmacokinetics of LSF in rats is significantly influenced by inflammatory diseases. Too low LSF serum levels might have been one of the reasons for clinical trial failures. A long-term i.v. infusion of LSF seems to be more effective compared to short-term multiple infusions that were used in clinical trials, as it may provide concentrations above IC50 for inhibition of both TNF-alpha release and cAMP degradation in serum for a longer period of time.
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Affiliation(s)
- Artur Świerczek
- a Department of Pharmacokinetics and Physical Pharmacy , Jagiellonian University Medical College , Cracow , Poland
| | - Elżbieta Wyska
- a Department of Pharmacokinetics and Physical Pharmacy , Jagiellonian University Medical College , Cracow , Poland
| | - Krzysztof Pociecha
- a Department of Pharmacokinetics and Physical Pharmacy , Jagiellonian University Medical College , Cracow , Poland
| | - Sebastian Baś
- b Faculty of Chemistry , Jagiellonian University , Cracow , Poland
| | - Jacek Mlynarski
- b Faculty of Chemistry , Jagiellonian University , Cracow , Poland
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Kovacevic MP, Szumita PM, Dube KM, DeGrado JR. Transition From Continuous Infusion Fentanyl to Hydromorphone in Critically Ill Patients. J Pharm Pract 2018; 33:129-135. [PMID: 29996718 DOI: 10.1177/0897190018786832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The 2013 Society of Critical Care Medicine guidelines for the management of pain, agitation, and delirium in adult intensive care unit (ICU) patients recommend intravenous opioids as first-line therapy to treat nonneuropathic pain. There is a paucity of literature describing possible benefits of utilizing specific opioids over others in ICU patients. OBJECTIVE The objective was to identify rationales for the transition from continuous infusion fentanyl to continuous infusion hydromorphone in critically ill patients. METHODS This was a single-center, prospective, observational analysis of adult ICU patients who were transitioned from fentanyl to hydromorphone. The major end point was to characterize the primary reason for transition. Minor end points included secondary reason(s) for transition, transition dosing, changes in continuous sedative requirements, and level of sedation. RESULTS Forty-six patients were included in the analysis. The primary rationale for transition was ventilator compliance (28.3%), followed by tachyphylaxis or better pain control (19.6%), and reduction in sedatives (13.0%). The most common secondary reason(s) for transition included reduction in sedatives (47.8%), opioid rotation (32.6%), and obesity (30.4). Median fentanyl rate of 100 µg/h was transitioned to 1 mg/h of hydromorphone. The percentage of patients requiring the use of continuous sedatives was decreased in the 24 hours following transition (P = .005); however, patients were more deeply sedated (P = .02). CONCLUSION Rationales for transition were to improve ventilator compliance, optimize patient-specific pharmacokinetics, and limit overall sedative exposure.
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Affiliation(s)
- Mary P Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin M Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
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Development of a Physiologically Based Pharmacokinetic Modelling Approach to Predict the Pharmacokinetics of Vancomycin in Critically Ill Septic Patients. Clin Pharmacokinet 2018; 56:759-779. [PMID: 28039606 DOI: 10.1007/s40262-016-0475-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Sepsis is characterised by an excessive release of inflammatory mediators substantially affecting body composition and physiology, which can be further affected by intensive care management. Consequently, drug pharmacokinetics can be substantially altered. This study aimed to extend a whole-body physiologically based pharmacokinetic (PBPK) model for healthy adults based on disease-related physiological changes of critically ill septic patients and to evaluate the accuracy of this PBPK model using vancomycin as a clinically relevant drug. METHODS The literature was searched for relevant information on physiological changes in critically ill patients with sepsis, severe sepsis and septic shock. Consolidated information was incorporated into a validated PBPK vancomycin model for healthy adults. In addition, the model was further individualised based on patient data from a study including ten septic patients treated with intravenous vancomycin. Models were evaluated comparing predicted concentrations with observed patient concentration-time data. RESULTS The literature-based PBPK model correctly predicted pharmacokinetic changes and observed plasma concentrations especially for the distribution phase as a result of a consideration of interstitial water accumulation. Incorporation of disease-related changes improved the model prediction from 55 to 88% within a threshold of 30% variability of predicted vs. observed concentrations. In particular, the consideration of individualised creatinine clearance data, which were highly variable in this patient population, had an influence on model performance. CONCLUSION PBPK modelling incorporating literature data and individual patient data is able to correctly predict vancomycin pharmacokinetics in septic patients. This study therefore provides essential key parameters for further development of PBPK models and dose optimisation strategies in critically ill patients with sepsis.
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Lelièvre B, Briet M, Godon C, Legras P, Riou J, Vandeputte P, Diquet B, Bouchara JP. Impact of Infection Status and Cyclosporine on Voriconazole Pharmacokinetics in an Experimental Model of Cerebral Scedosporiosis. J Pharmacol Exp Ther 2018; 365:408-412. [PMID: 29491040 DOI: 10.1124/jpet.117.245449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/15/2018] [Indexed: 11/22/2022] Open
Abstract
Cerebral Scedosporium infections usually occur in lung transplant recipients as well as in immunocompetent patients in the context of near drowning. Voriconazole is the first-line treatment. The diffusion of voriconazole through the blood-brain barrier in the context of cerebral infection and cyclosporine administration is crucial and remains a matter of debate. To address this issue, the pharmacokinetics of voriconazole was assessed in the plasma, cerebrospinal fluid (CSF), and brain in an experimental model of cerebral scedosporiosis in rats receiving or not receiving cyclosporine. A single dose of voriconazole (30 mg/kg, i.v.) was administered to six groups of rats randomized according to the infection status and the cyclosporine dosing regimen (no cyclosporine, a single dose, or three doses; 15 mg/kg each). Voriconazole concentrations in plasma, CSF, and brain samples were quantified using ultra-performance liquid chromatography-tandem mass spectrometry and high-performance liquid chromatography UV methods and were documented up to 48 hours after administration. Pharmacokinetic parameters were estimated using a noncompartmental approach. Voriconazole pharmacokinetic profiles were similar for plasma, CSF, and brain in all groups studied. The voriconazole Cmax and area under the curve (AUC) (AUC0 ≥ 48 hours) values were significantly higher in plasma than in CSF [CSF/plasma ratio, median (range) = 0.5 (0.39-0.55) for AUC0 ≥ 48 hours and 0.47 (0.35 and 0.75) for Cmax]. Cyclosporine administration was significantly associated with an increase in voriconazole exposure in the plasma, CSF, and brain. In the plasma, but not in the brain, an interaction between the infection and cyclosporine administration reduced the positive impact of cyclosporine on voriconazole exposure. Together, these results emphasize the impact of cyclosporine on brain voriconazole exposure.
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Affiliation(s)
- Bénédicte Lelièvre
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Marie Briet
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Charlotte Godon
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Pierre Legras
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Jérémie Riou
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Patrick Vandeputte
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Bertrand Diquet
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
| | - Jean-Philippe Bouchara
- Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d'Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066-CNRS 6021, Université d'Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d'Etude des Interactions Hôte-Pathogène (EA 3142), Université d'Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.-P.B., B.D.); and Service Commun de l'Animalerie Hospitalo-Universitaire, Université d'Angers, Angers, France (P.L.)
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Abstract
Sepsis is a leading cause of maternal morbidity and mortality in developed and developing nations. Obstetric practitioners should be familiar with guidelines that promote the safe and expeditious recovery of those affected. This article will provide the reader with rational steps to aid in the recovery of such a patient.
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Affiliation(s)
- Arthur Jason Vaught
- John Hopkins School of Medicine, 600 N. Wolfe St, Phipps 228, Baltimore, MD 21287.
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Model based population PK-PD analysis of furosemide for BP lowering effect: A comparative study in primary and secondary hypertension. Eur J Pharm Sci 2017; 109:253-261. [PMID: 28821435 DOI: 10.1016/j.ejps.2017.08.009] [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: 05/01/2017] [Revised: 07/05/2017] [Accepted: 08/14/2017] [Indexed: 11/20/2022]
Abstract
Though numerous reports have demonstrated multiple mechanisms by which furosemide can exert its anti-hypertensive response. However, lack of studies describing PK-PD relationship for furosemide featuring its anti-hypertensive property has limited its usage as a blood pressure (BP) lowering agent. Serum concentrations and mean arterial BP were monitored following 40 and 80mgkg-1 multiple oral dose of furosemide in spontaneously hypertensive rats (SHR) and DOCA-salt induced hypertensive (DOCA-salt) rats. A simultaneous population PK-PD relationship using Emax model with effect compartment was developed to compare the anti-hypertensive efficacy of furosemide in these rat models. A two-compartment PK model with Weibull-type absorption and first-order elimination best described the serum concentration-time profile of furosemide. In the present study, post dose serum concentrations of furosemide were found to be lower than the EC50. The EC50 predicted in DOCA-salt rats was found to be lower (4.5-fold), whereas the tolerance development was higher than that in SHR model. The PK-PD parameter estimates, particularly lower values of EC50, Ke and Q in DOCA-salt rats as compared to SHR, pinpointed the higher BP lowering efficacy of furosemide in volume overload induced hypertensive conditions. Insignificantly altered serum creatinine and electrolyte levels indicated a favorable side effect profile of furosemide. In conclusion, the final PK-PD model described the data well and provides detailed insights into the use of furosemide as an anti-hypertensive agent.
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Zimmermann JB, Pinder N, Bruckner T, Lehmann M, Motsch J, Brenner T, Hoppe-Tichy T, Swoboda S, Weigand MA, Hofer S. Adjunctive use of physostigmine salicylate (Anticholium®) in perioperative sepsis and septic shock: study protocol for a randomized, double-blind, placebo-controlled, monocentric trial (Anticholium® per Se). Trials 2017; 18:530. [PMID: 29126416 PMCID: PMC5681758 DOI: 10.1186/s13063-017-2231-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 10/05/2017] [Indexed: 11/24/2022] Open
Abstract
Background Severe sepsis and septic shock remain a major challenge, even in modern intensive care. In Germany, about 68,000 patients die annually because of septic diseases, characterized by a complex systemic inflammatory response. Causal treatment of the underlying infection is essential for successful management of sepsis, but the course can be positively influenced by supportive and adjuvant measures. The cholinergic anti-inflammatory pathway (CAP) represents a new approach to adjunctive therapy of septic diseases and can be pharmacologically activated by the acetylcholinesterase inhibitor physostigmine (Anticholium®). Promising effects can be found in several in vitro and in vivo models of sepsis, such as a reduction in pro-inflammatory cytokines and improved survival. Methods Anticholium® per Se is a randomized, double-blind, placebo-controlled, monocentric trial to assess whether the CAP can be transferred from bench to bedside. In this pilot study, 20 patients with perioperative sepsis and septic shock as a result of intra-abdominal infection are enrolled. According to randomization, participants are treated with physostigmine salicylate (verum group) or 0.9% sodium chloride (placebo group) for up to 5 days. The mean Sequential Organ Failure Assessment (SOFA) score during treatment and subsequent intensive care of up to 14 days is used as surrogate outcome (primary endpoint). Secondary outcome measures include 30- and 90-day mortality. An embedded pharmacokinetics and pharmacodynamics study investigates plasma concentrations of physostigmine and its metabolite eseroline. Further analyses will contribute to our understanding of the role of various cytokines in the pathophysiology of human sepsis. A computer-generated list is used for block randomization. Discussion This randomized, controlled, monocentric trial investigates for the first time the adjunctive use of physostigmine (Anticholium®) in patients with perioperative sepsis and septic shock and may be a pivotal step toward the clinical use in this indication. Trial registration EudraCT Number: 2012-001650-26 (entered 14 August 2012), ClinicalTrials.gov identifier: NCT03013322 (registered on 1 Jan 2017). Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2231-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes B Zimmermann
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Nadine Pinder
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.,Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Monika Lehmann
- Coordination Centre for Clinical Trials, University Hospital Heidelberg, Marsilius-Arkaden, Tower West, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Johann Motsch
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Torsten Hoppe-Tichy
- Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Stefanie Swoboda
- Pharmacy Department, University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anaesthesiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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44
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Ehmann L, Zoller M, Minichmayr IK, Scharf C, Maier B, Schmitt MV, Hartung N, Huisinga W, Vogeser M, Frey L, Zander J, Kloft C. Role of renal function in risk assessment of target non-attainment after standard dosing of meropenem in critically ill patients: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:263. [PMID: 29058601 PMCID: PMC5651591 DOI: 10.1186/s13054-017-1829-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/29/2017] [Indexed: 12/31/2022]
Abstract
Background Severe bacterial infections remain a major challenge in intensive care units because of their high prevalence and mortality. Adequate antibiotic exposure has been associated with clinical success in critically ill patients. The objective of this study was to investigate the target attainment of standard meropenem dosing in a heterogeneous critically ill population, to quantify the impact of the full renal function spectrum on meropenem exposure and target attainment, and ultimately to translate the findings into a tool for practical application. Methods A prospective observational single-centre study was performed with critically ill patients with severe infections receiving standard dosing of meropenem. Serial blood samples were drawn over 4 study days to determine meropenem serum concentrations. Renal function was assessed by creatinine clearance according to the Cockcroft and Gault equation (CLCRCG). Variability in meropenem serum concentrations was quantified at the middle and end of each monitored dosing interval. The attainment of two pharmacokinetic/pharmacodynamic targets (100%T>MIC, 50%T>4×MIC) was evaluated for minimum inhibitory concentration (MIC) values of 2 mg/L and 8 mg/L and standard meropenem dosing (1000 mg, 30-minute infusion, every 8 h). Furthermore, we assessed the impact of CLCRCG on meropenem concentrations and target attainment and developed a tool for risk assessment of target non-attainment. Results Large inter- and intra-patient variability in meropenem concentrations was observed in the critically ill population (n = 48). Attainment of the target 100%T>MIC was merely 48.4% and 20.6%, given MIC values of 2 mg/L and 8 mg/L, respectively, and similar for the target 50%T>4×MIC. A hyperbolic relationship between CLCRCG (25–255 ml/minute) and meropenem serum concentrations at the end of the dosing interval (C8h) was derived. For infections with pathogens of MIC 2 mg/L, mild renal impairment up to augmented renal function was identified as a risk factor for target non-attainment (for MIC 8 mg/L, additionally, moderate renal impairment). Conclusions The investigated standard meropenem dosing regimen appeared to result in insufficient meropenem exposure in a considerable fraction of critically ill patients. An easy- and free-to-use tool (the MeroRisk Calculator) for assessing the risk of target non-attainment for a given renal function and MIC value was developed. Trial registration Clinicaltrials.gov, NCT01793012. Registered on 24 January 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1829-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa Ehmann
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin/Potsdam, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Barbara Maier
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian V Schmitt
- Institute of Pharmacy and Molecular Biotechnology, University of Heidelberg, Heidelberg, Germany
| | - Niklas Hartung
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.,Institute of Mathematics, Universitaet Potsdam, Potsdam, Germany
| | - Wilhelm Huisinga
- Institute of Mathematics, Universitaet Potsdam, Potsdam, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Lorenz Frey
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Zander
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstrasse 31, 12169, Berlin, Germany.
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45
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Bainum TB, Fike DS, Mechelay D, Haase KK. Effect of Abrupt Discontinuation of Antidepressants in Critically Ill Hospitalized Adults. Pharmacotherapy 2017; 37:1231-1240. [PMID: 28730691 DOI: 10.1002/phar.1992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To determine whether discontinuation of chronic antidepressant therapy is associated with a higher risk of antidepressant discontinuation syndrome (ADS) symptoms in patients admitted to the intensive care unit (ICU) when compared with those who were continued on therapy and to identify factors associated with increased risk of ADS in this population. DESIGN Single-center retrospective observational cohort study. SETTING ICUs in a tertiary care hospital. PATIENTS A total of 106 adult patients, admitted to the ICU between September 2013 and August 2014, who had a length of stay of 72 hours or longer and who were receiving chronic selective serotonin inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) before admission. MEASUREMENTS AND MAIN RESULTS Patients were classified as continued or discontinued from therapy based on initiation of home SSRI/SNRI therapy within 48 hours of admission. The primary end point was incidence of ADS symptoms. Type of symptoms, receipt of symptom-related therapies, and length of stay were also assessed. Sequential logistic regression analysis was used to determine the impact of discontinuation while controlling for other risk factors. Therapy was discontinued in 38.7% of patients. The risk of developing ADS symptoms was higher in discontinued patients (unadjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.12-6.07, p=0.024). After adjusting for covariates, the odds of ADS increased (adjusted OR 3.8, 95% CI 1.3-11.7, p=0.018). Female sex was associated with an increase in risk of ADS (OR 3.4, 95% CI 1.2-10.0, p=0.026). Affective symptoms were the most prevalent type reported (34.1% vs 10.8%, p=0.005). Use of symptom-related therapies and length of stay did not differ between groups. CONCLUSION Abrupt discontinuation of SSRI/SNRI therapy increases the risk of ADS symptoms in critically ill patients, particularly in females. These results underscore the importance of continuation of home antidepressant therapy even in the setting of critical illness.
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Affiliation(s)
- Taryn B Bainum
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
| | - David S Fike
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Dallas, Texas
| | - Diana Mechelay
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
| | - Krystal K Haase
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
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46
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Smuszkiewicz P, Wiczling P, Przybyłowski K, Borsuk A, Trojanowska I, Paterska M, Matysiak J, Kokot Z, Grześkowiak E, Bienert A. The pharmacokinetics of propofol in ICU patients undergoing long-term sedation. Biopharm Drug Dispos 2016; 37:456-466. [DOI: 10.1002/bdd.2028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 08/08/2016] [Accepted: 08/17/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Piotr Smuszkiewicz
- Department of Anaesthesiology and Intensive Therapy; Karol Marcinkowski University of Medical Sciences; ul. Przybyszewskiego 49 60-355 Poznań Poland
| | - Paweł Wiczling
- Department of Biopharmacy and Pharmacodynamics; Medical University of Gdansk; ul. Hallera 107 80-416 Gdańsk Poland
| | - Krzysztof Przybyłowski
- Department of Clinical Pharmacy and Biopharmacy; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
| | - Agnieszka Borsuk
- Department of Biopharmacy and Pharmacodynamics; Medical University of Gdansk; ul. Hallera 107 80-416 Gdańsk Poland
| | - Iwona Trojanowska
- Department of Anaesthesiology and Intensive Therapy; Karol Marcinkowski University of Medical Sciences; ul. Przybyszewskiego 49 60-355 Poznań Poland
| | - Marta Paterska
- Department of Clinical Pharmacy and Biopharmacy; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
| | - Jan Matysiak
- Department of Inorganic and Analytical Chemistry; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
| | - Zenon Kokot
- Department of Inorganic and Analytical Chemistry; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
| | - Edmund Grześkowiak
- Department of Clinical Pharmacy and Biopharmacy; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
| | - Agnieszka Bienert
- Department of Clinical Pharmacy and Biopharmacy; Karol Marcinkowski University of Medical Sciences; ul. Grunwaldzka 6 60-780 Poznań Poland
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47
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Irikuchi J, Imai T, Yoshida Y, Orii T. [Influence of systemic inflammatory response syndrome on the pharmacokinetics of vancomycin]. YAKUGAKU ZASSHI 2016; 135:745-51. [PMID: 25948312 DOI: 10.1248/yakushi.14-00214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Therapeutic drug monitoring (TDM) of vancomycin (VCM) is recommended to minimize its nephrotoxicity and maximize efficacy. Recently, the concept of systemic inflammatory response syndrome (SIRS) has been introduced to describe a clinical state resulting from the actions of complex intrinsic mediators in an acute-phase systemic response. However, there are few reports on the pharmacokinetics of VCM in patients with SIRS. This study investigated the effect of SIRS on the pharmacokinetics of VCM by analyzing the predictability of TDM and pharmacokinetic parameters in 31 non-SIRS patients and 52 SIRS patients, with stratification by SIRS score. The mean prediction error (ME) and mean absolute prediction error in SIRS score 2 and 3 patients differed from those in non-SIRS patients. The ME in the score 4 group showed a negative value. In the comparison of pharmacokinetic parameters by SIRS score, a significantly lower CL(vcm) value was observed at score 4 compared with scores 2 and 3, a higher Vd value was observed at score 4 compared with non-SIRS and at score 3, and a longer T1/2 was observed at score 2. In the comparison of patient characteristics by SIRS score, albumin, aspartate aminotransferase, and alanine aminotransferase levels showed differences among the scores. However, no correlation was observed between VCM pharmacokinetics and these three laboratory parameters. These findings suggest that the pharmacokinetics of VCM may be affected by the pathology of SIRS rather than by patient characteristics.
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48
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Abstract
Critical illness is accompanied by multiple physiologic alterations that affect the pharmacokinetics of antimicrobials. Although the pharmacokinetics of a number of antimicrobials have been studied in critically ill individuals, an understanding of the physiological alterations in critical illness and general pharmacokinetic principles of antimicrobials is imperative for appropriate selection, dosing, and prediction of toxicity.
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Affiliation(s)
- Aaron M. Cook
- Neurosurgery/Critical Care, University of Kentucky Chandler Medical Center, Lexington,
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49
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[Strategies for antifungal treatment failure in intensive care units]. Anaesthesist 2016; 64:643-58. [PMID: 26349425 DOI: 10.1007/s00101-015-0072-0] [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: 10/23/2022]
Abstract
Recent epidemiologic studies reveal both an increasing incidence and an escalation in resistance of invasive fungal infections in intensive care units. Primary therapy fails in 70 % of cases, depending on the underlying pathogens and diseases. The purpose of this review is to raise awareness for the topic of antifungal therapy failure, describe the clinical conditions in which it occurs, and suggest a possible algorithm for handling the situation of suspected primary therapy failure.
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